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Cantón R, Barberán J, Linares M, Molero JM, Rodríguez-González-Moro JM, Salavert M, González Del Castillo J. Decalogue for the selection of oral antibiotics for lower respiratory tract infections. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2022; 35:16-29. [PMID: 35041328 PMCID: PMC8790641 DOI: 10.37201/req/172.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/12/2022] [Indexed: 12/28/2022]
Abstract
Lower respiratory tract infections, including chronic obstructive pulmonary disease exacerbations (COPD-E) and community acquired pneumonia (CAP), are one of the most frequent reasons for consultation in primary care and hospital emergency departments, and are the cause of a high prescription of antimicrobial agents. The selection of the most appropriate oral antibiotic treatment is based on different aspects and includes to first consider a bacterial aetiology and not a viral infection, to know the bacterial pathogen that most frequently cause these infections and the frequency of their local antimicrobial resistance. Treatment should also be prescribed quickly and antibiotics should be selected among those with a quicker mode of action, achieving the greatest effect in the shortest time and with the fewest adverse effects (toxicity, interactions, resistance and/or ecological impact). Whenever possible, antimicrobials should be rotated and diversified and switched to the oral route as soon as possible. With these premises, the oral treatment guidelines for mild or moderate COPD-E and CAP in Spain include as first options beta-lactam antibiotics (amoxicillin and amoxicillin-clavulanate and cefditoren), in certain situations associated with a macrolide, and relegating fluoroquinolones as an alternative, except in cases where the presence of Pseudomonas aeruginosa is suspected.
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Affiliation(s)
- R Cantón
- Rafael Cantón. Servicio de Microbiología. Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS). Madrid. Spain.
| | | | | | | | | | | | - J González Del Castillo
- Juan Gonzalez del Castillo. Servicio de Urgencias, Hospital Clínico San Carlos and Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain.
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52
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Wang J, Pu Y, Zeng Y, Chen Y, Zhao W, Niu L, Chen B, Yang Z, Wu L, Pan K, Jing B, Zeng D, Ni X. Multi-functional Potential of Five Lactic Acid Bacteria Strains Derived from Giant Panda (Ailuropoda melanoleuca). Probiotics Antimicrob Proteins 2022; 15:668-681. [PMID: 35000110 DOI: 10.1007/s12602-021-09881-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
The multi-functional properties of lactic acid bacteria (LAB) on host health have been a popular research topic. The aim of present study was to assess the multi-functional potential of five LAB strains isolated from giant panda. In this study, we analyzed five giant panda LAB strains (Weissella confuse WJ202003 (W3), WJ202009 (W9), WJ202021 (W21), BSP201703 (X3); Lactiplantibacillus plantarum BSGP201683 (G83)) and found that they exhibited rapid growth as well as strong acid production capacity. The five LAB strains possessed high cell surface hydrophobicity to the four tested solvents (xylene, hexadecane, chloroform, ethyl acetate; except strain W9), auto-aggregation ability, co-aggregation ability with three pathogens (Escherichia coli, Enterotoxigenic Escherichia coli, Salmonella), adhesion ability to Caco-2 cell line, and strongly biofilm formation ability, suggesting an adhesion property. As investigated for their antioxidative potential, all the strains showed good tolerance to H2O2, high scavenging ability against 1, 1-diphenyl-2-picrylhydrazyl (DPPH), and hydroxyl (OH-), and reduction ability. Furthermore, the five LAB strains could produce multiple probiotic substances, including exopolysaccharide (EPS), gamma-aminobutyric acid (GABA), bile salt hydrolase (BSH), cellulase (only strain G83), and protease (except strain X3), which was the first to report the production of EPS, GABA, BSH, cellulase, and protease in giant panda-derived LAB strain. These results demonstrated that strains W3, W9, W21, X3, and G83 had multi-functional potential and could be utilized as potential probiotics for giant panda.
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Affiliation(s)
- Jie Wang
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Yang Pu
- Chengdu Wildlife Institute, Chengdu Zoo, Chengdu, 610081, Sichuan, China
| | - Yan Zeng
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Yingyi Chen
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Wei Zhao
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Lili Niu
- Chengdu Wildlife Institute, Chengdu Zoo, Chengdu, 610081, Sichuan, China
| | - Benhao Chen
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Zihan Yang
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Liqian Wu
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Kangcheng Pan
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Bo Jing
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China
| | - Dong Zeng
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China.
| | - Xueqin Ni
- College of Veterinary Medicine, Sichuan Agricultural University, Chengdu, 611130, Sichuan, China.
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53
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Szychowiak P, Villageois-Tran K, Patrier J, Timsit JF, Ruppé É. The role of the microbiota in the management of intensive care patients. Ann Intensive Care 2022; 12:3. [PMID: 34985651 PMCID: PMC8728486 DOI: 10.1186/s13613-021-00976-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/15/2021] [Indexed: 12/13/2022] Open
Abstract
The composition of the gut microbiota is highly dynamic and changes according to various conditions. The gut microbiota mainly includes difficult-to-cultivate anaerobic bacteria, hence knowledge about its composition has significantly arisen from culture-independent methods based on next-generation sequencing (NGS) such as 16S profiling and shotgun metagenomics. The gut microbiota of patients hospitalized in intensive care units (ICU) undergoes many alterations because of critical illness, antibiotics, and other ICU-specific medications. It is then characterized by lower richness and diversity, and dominated by opportunistic pathogens such as Clostridioides difficile and multidrug-resistant bacteria. These alterations are associated with an increased risk of infectious complications or death. Specifically, at the time of writing, it appears possible to identify distinct microbiota patterns associated with severity or infectivity in COVID-19 patients, paving the way for the potential use of dysbiosis markers to predict patient outcomes. Correcting the microbiota disturbances to avoid their consequences is now possible. Fecal microbiota transplantation is recommended in recurrent C. difficile infections and microbiota-protecting treatments such as antibiotic inactivators are currently being developed. The growing interest in the microbiota and microbiota-associated therapies suggests that the control of the dysbiosis could be a key factor in the management of critically ill patients. The present narrative review aims to provide a synthetic overview of microbiota, from healthy individuals to critically ill patients. After an introduction to the different techniques used for studying the microbiota, we review the determinants involved in the alteration of the microbiota in ICU patients and the latter's consequences. Last, we assess the means to prevent or correct microbiota alteration.
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Affiliation(s)
- Piotr Szychowiak
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional Universitaire de Tours, 37000, Tours, France
| | - Khanh Villageois-Tran
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Laboratoire de Bactériologie, AP-HP, Hôpital Beaujon, 92110, Paris, France
| | - Juliette Patrier
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Réanimation Médicale Et Infectieuse, AP-HP, Hôpital Bichat, 75018, Paris, France
| | - Jean-François Timsit
- Université de Paris, IAME, INSERM, 75018, Paris, France
- Service de Réanimation Médicale Et Infectieuse, AP-HP, Hôpital Bichat, 75018, Paris, France
| | - Étienne Ruppé
- Université de Paris, IAME, INSERM, 75018, Paris, France.
- Laboratoire de Bactériologie, AP-HP, Hôpital Bichat-Claude Bernard, 46 rue Henri Huchard, 75018, Paris, France.
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54
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Bruns N, Dohna-Schwake C. Antibiotics in critically ill children-a narrative review on different aspects of a rational approach. Pediatr Res 2022; 91:440-446. [PMID: 34873285 PMCID: PMC8816725 DOI: 10.1038/s41390-021-01878-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 11/09/2021] [Accepted: 11/13/2021] [Indexed: 12/19/2022]
Abstract
Especially critically ill children are exposed to antibiotic overtreatment, mainly caused by the fear of missing out a severe bacterial infection. Potential adverse effects and selection of multi-drug resistant bacteria play minor roles in decision making. This narrative review first describes harm from antibiotics and second focuses on different aspects that could help to reduce antibiotic overtreatment without harming the patient: harm from antibiotic treatment, diagnostic approaches, role of biomarkers, timing of antibiotic therapy, empiric therapy, targeted therapy, and therapeutic drug monitoring. Wherever possible, we linked the described evidence to the current Surviving Sepsis Campaign guidelines. Antibiotic stewardship programs should help guiding antibiotic therapy for critically ill children. IMPACT: Critically ill children can be harmed by inadequate or overuse of antibiotics. Hemodynamically unstable children with a suspicion of infection should be immediately treated with broad-spectrum antibiotics. In contrast, in hemodynamically stable children with sepsis and organ dysfunction, a time frame of 3 h for proper diagnostics may be adequate before starting antibiotics if necessary. Less and more targeted antibiotic treatment can be achieved via antibiotic stewardship programs.
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Affiliation(s)
- Nora Bruns
- grid.5718.b0000 0001 2187 5445Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany. .,Westdeutsches Zentrum für Infektiologie, University of Duisburg-Essen, Essen, Germany.
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55
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Hirano Y, Shinmoto K, Okada Y, Suga K, Bombard J, Murahata S, Shrestha M, Ocheja P, Tanaka A. Machine Learning Approach to Predict Positive Screening of Methicillin-Resistant Staphylococcus aureus During Mechanical Ventilation Using Synthetic Dataset From MIMIC-IV Database. Front Med (Lausanne) 2021; 8:694520. [PMID: 34869405 PMCID: PMC8635043 DOI: 10.3389/fmed.2021.694520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 10/22/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Mechanically ventilated patients are susceptible to nosocomial infections such as ventilator-associated pneumonia. To treat ventilated patients with suspected infection, clinicians select appropriate antibiotics. However, decision-making regarding the use of antibiotics for methicillin-resistant Staphylococcus aureus (MRSA) is challenging, because of the lack of evidence-supported criteria. This study aims to derive a machine learning model to predict MRSA as a possible pathogen responsible for infection in mechanically ventilated patients. Methods: Data were collected from the Medical Information Mart for Intensive Care (MIMIC)-IV database (an openly available database of patients treated at the Beth Israel Deaconess Medical Center in the period 2008-2019). Of 26,409 mechanically ventilated patients, 809 were screened for MRSA during the mechanical ventilation period and included in the study. The outcome was positivity to MRSA on screening, which was highly imbalanced in the dataset, with 93.9% positive outcomes. Therefore, after dividing the dataset into a training set (n = 566) and a test set (n = 243) for validation by stratified random sampling with a 7:3 allocation ratio, synthetic datasets with 50% positive outcomes were created by synthetic minority over-sampling for both sets individually (synthetic training set: n = 1,064; synthetic test set: n = 456). Using these synthetic datasets, we trained and validated an XGBoost machine learning model using 28 predictor variables for outcome prediction. Model performance was evaluated by area under the receiver operating characteristic (AUROC), sensitivity, specificity, and other statistical measurements. Feature importance was computed by the Gini method. Results: In validation, the XGBoost model demonstrated reliable outcome prediction with an AUROC value of 0.89 [95% confidence interval (CI): 0.83-0.95]. The model showed a high sensitivity of 0.98 [CI: 0.95-0.99], but a low specificity of 0.47 [CI: 0.41-0.54] and a positive predictive value of 0.65 [CI: 0.62-0.68]. Important predictor variables included admission from the emergency department, insertion of arterial lines, prior quinolone use, hemodialysis, and admission to a surgical intensive care unit. Conclusions: We were able to develop an effective machine learning model to predict positive MRSA screening during mechanical ventilation using synthetic datasets, thus encouraging further research to develop a clinically relevant machine learning model for antibiotics stewardship.
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Affiliation(s)
- Yohei Hirano
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Keito Shinmoto
- Department of Internal Medicine, Tokyo bay Ichikawa Urayasu Medical Center, Chiba, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazuhiro Suga
- Department of Mechanical Engineering, Faculty of Engineering, Kogakuin University, Tokyo, Japan
| | | | | | | | - Patrick Ocheja
- Graduate School of Informatics, Kyoto University, Kyoto, Japan
| | - Aiko Tanaka
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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56
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Tabah A, Buetti N, Barbier F, Timsit JF. Current opinion in management of septic shock due to Gram-negative bacteria. Curr Opin Infect Dis 2021; 34:718-727. [PMID: 34751185 DOI: 10.1097/qco.0000000000000767] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The COVID-19 pandemic has caused multiple challenges to ICUs, including an increased rate of secondary infections, mostly caused by Gram-negative micro-organisms. Worrying trends of resistance acquisition complicate this picture. We provide a review of the latest evidence to guide management of patients with septic shock because of Gram-negative bacteria. RECENT FINDINGS New laboratory techniques to detect pathogens and specific resistance patterns from the initial culture are available. Those may assist decreasing the time to adequate antimicrobial therapy and avoid unnecessary broad-spectrum antibiotic overuse. New antimicrobials, including β-lactam/β-lactamase inhibitor combinations, such as ceftolozane-tazobactam, imipenem-relebactam or meropenem-vaborbactam and cephalosporins, such as cefiderocol targeted to specific pathogens and resistance patterns are available for use in the clinical setting. Optimization of antibiotic dosing and delivery should follow pharmacokinetic and pharmacodynamic principles and wherever available therapeutic drug monitoring. Management of sepsis has brought capillary refill time back to the spotlight along with more reasoned fluid resuscitation and a moderate approach to timing of dialysis initiation. SUMMARY Novel rapid diagnostic tests and antimicrobials specifically targeted to Gram-negative pathogens are available and should be used within the principles of antimicrobial stewardship including de-escalation and short duration of antimicrobial therapy.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Redcliffe.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Niccolò Buetti
- Infection Control Program and World Health Organization Collaborating Centre on Patient Safety, University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.,University of Paris, INSERM U1137, IAME, Team DeSCID, Paris
| | | | - Jean-François Timsit
- University of Paris, INSERM U1137, IAME, Team DeSCID, Paris.,Medical and Infectious Diseases Intensive Care Unit (MI2), Bichat-Claude Bernard Hospital, AP-HP, Paris, France
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57
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Nuutila J, Hohenthal U, Oksi J, Jalava-Karvinen P. Rapid detection of bacterial infection using a novel single-tube, four-colour flow cytometric method: Comparison with PCT and CRP. EBioMedicine 2021; 74:103724. [PMID: 34844193 PMCID: PMC8633870 DOI: 10.1016/j.ebiom.2021.103724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/04/2021] [Accepted: 11/16/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND A key factor behind the unnecessary use of antibiotics is the lack of rapid and accurate diagnostic tests. In this study, we developed a novel and fast flow cytometric single-tube method to detect bacterial infections within 30 minutes. METHODS Quantitative flow cytometric four-colour analysis of host biomarkers CD35, CD64, CD329, and MHC class I expression on neutrophils and lymphocytes was performed on samples taken from 841 febrile patients with suspected infection. Obtained data was incorporated into the four-colour bacterial infection (FCBI)-index, using the developed bacterial infection algorithm. FINDINGS In distinguishing between microbiologically confirmed bacterial (n = 193) and viral (n = 291) infections, the FCBI-index method was superior to serum C-reactive protein (CRP) and procalcitonin (PCT). In 269 confirmed viral respiratory tract infections, 43% (95% CI: 37-49%) of the patients had an increased FCBI-index, suggesting probable bacterial coinfection. INTERPRETATION The proposed FCBI-index test might be a potent additional tool when assessing appropriateness of empiric antibiotic treatment. FUNDING This study has been financially supported by Turku University Hospital (Turku, Finland) and The Finnish Medical Foundation.
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Affiliation(s)
- Jari Nuutila
- Department of Life Technologies, University of Turku, Turku, Finland.
| | - Ulla Hohenthal
- Turku University Hospital, Department of Medicine, Turku, Finland; Faculty of Medicine, University of Turku, Turku, Finland
| | - Jarmo Oksi
- Turku University Hospital, Department of Medicine, Turku, Finland; Faculty of Medicine, University of Turku, Turku, Finland
| | - Päivi Jalava-Karvinen
- Turku University Hospital, Department of Medicine, Turku, Finland; Faculty of Medicine, University of Turku, Turku, Finland
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58
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 880] [Impact Index Per Article: 293.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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59
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Shappell CN, Klompas M, Ochoa A, Rhee C. Likelihood of Bacterial Infection in Patients Treated With Broad-Spectrum IV Antibiotics in the Emergency Department. Crit Care Med 2021; 49:e1144-e1150. [PMID: 33967206 PMCID: PMC8516665 DOI: 10.1097/ccm.0000000000005090] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Best practice guidelines and quality metrics recommend immediate antibiotic treatment for all patients with suspected sepsis. However, little is known about how many patients given IV antibiotics in the emergency department are ultimately confirmed to have bacterial infection. DESIGN, SETTING, AND PATIENTS We performed a retrospective study of adult patients who presented to four Massachusetts emergency departments between June 2015 and June 2018 with suspected serious bacterial infection, defined as blood cultures drawn and broad-spectrum IV antibiotics administered. Structured medical record reviews were performed on a random sample of 300 cases to determine the post hoc likelihood of bacterial infection, categorized as definite, likely, unlikely, or definitely none. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among the 300 patients with suspected serious bacterial infections, mean age was 68 years (sd 18), median hospital length of stay was 5 days (interquartile range, 3-8 d), 45 (15%) were admitted directly to ICU, and 14 (5%) died in hospital. Overall, 196 (65%) had definite (n = 115; 38%) or likely (n = 81; 27%) bacterial infection, whereas 104 (35%) were unlikely (n = 55; 18%) or definitely not infected (n = 49; 16%). Antibiotic treatment durations differed by likelihood of infection (median 15 days for definite, 9 for likely, 7 for unlikely, and 3 for definitely not infected). The most frequent post hoc diagnoses in patients with unlikely or definitely no bacterial infection included viral infections (28%), volume overload or cardiac disease (9%), drug effects (9%), and hypovolemia (7%). The likelihoods of infection were similar in the subset of 96 cases in whom emergency department providers explicitly documented possible or suspected sepsis and in the 45 patients admitted from the emergency department to the ICU. CONCLUSIONS One third of patients empirically treated with broad-spectrum antibiotics in the emergency department are ultimately diagnosed with noninfectious or viral conditions. These findings underscore the difficulty diagnosing serious infections in the emergency department and have important implications for guidelines and quality measures that compel immediate empiric antibiotics for all patients with possible sepsis.
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Affiliation(s)
- Claire N Shappell
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Aileen Ochoa
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA
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60
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Ramanan M, Shorr A, Lipman J. Ventriculitis: Infection or Inflammation. Antibiotics (Basel) 2021; 10:antibiotics10101246. [PMID: 34680826 PMCID: PMC8532926 DOI: 10.3390/antibiotics10101246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
Ventriculitis, or infection of the cerebrospinal fluid, in the presence of external ventricular drains (EVD), is an important complication and associated with substantial mortality, morbidity, and healthcare costs. Further, the conditions that require the insertion of an EVD, such as neurotrauma and subarachnoid hemorrhage, are themselves associated with inflammation of the cerebrospinal fluid. Phenotypically, patients with inflammation of the cerebrospinal fluid can present with very similar symptoms, signs, and laboratory findings to those with infection. This review examines various controversies relating to the definitions, diagnosis, challenges of differentiating infection from inflammation, prevention, and treatment of ventriculitis in patients with EVDs.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD 4510, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- School of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia;
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Newtown, NSW 1466, Australia
- Correspondence:
| | - Andrew Shorr
- Washington Hospital Center, Medical Intensive Care Unit, Washington, DC 20010, USA;
| | - Jeffrey Lipman
- School of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia;
- Jamieson Trauma Institute and Intensive Care Services, Royal Brisbane and Women’s Hospital, Herston, QLD 4029, Australia
- Nimes University Hospital, University of Montpellier, 30029 Nimes, France
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61
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Navapurkar V, Bartholdson Scott J, Maes M, Hellyer TP, Higginson E, Forrest S, Pereira-Dias J, Parmar S, Heasman-Hunt E, Polgarova P, Brown J, Titti L, Smith WPW, Scott J, Rostron A, Routledge M, Sapsford D, Török ME, McMullan R, Enoch DA, Wong V, Curran MD, Brown NM, Simpson AJ, Herre J, Dougan G, Conway Morris A. Development and implementation of a customised rapid syndromic diagnostic test for severe pneumonia. Wellcome Open Res 2021; 6:256. [PMID: 36337362 PMCID: PMC9617073 DOI: 10.12688/wellcomeopenres.17099.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2021] [Indexed: 02/02/2023] Open
Abstract
Background: The diagnosis of pneumonia has been hampered by a reliance on bacterial cultures which take several days to return a result, and are frequently negative. In critically ill patients this leads to the use of empiric, broad-spectrum antimicrobials and compromises good antimicrobial stewardship. The objective of this study was to establish the performance of a syndromic molecular diagnostic approach, using a custom TaqMan array card (TAC) covering 52 respiratory pathogens, and assess its impact on antimicrobial prescribing. Methods: The TAC was validated against a retrospective multi-centre cohort of broncho-alveolar lavage samples. The TAC was assessed prospectively in patients undergoing investigation for suspected pneumonia, with a comparator cohort formed of patients investigated when the TAC laboratory team were unavailable. Co-primary outcomes were sensitivity compared to conventional microbiology and, for the prospective study, time to result. Metagenomic sequencing was performed to validate findings in prospective samples. Antibiotic free days (AFD) were compared between the study cohort and comparator group. Results: 128 stored samples were tested, with sensitivity of 97% (95% confidence interval (CI) 88-100%). Prospectively, 95 patients were tested by TAC, with 71 forming the comparator group. TAC returned results 51 hours (interquartile range 41-69 hours) faster than culture and with sensitivity of 92% (95% CI 83-98%) compared to conventional microbiology. 94% of organisms identified by sequencing were detected by TAC. There was a significant difference in the distribution of AFDs with more AFDs in the TAC group (p=0.02). TAC group were more likely to experience antimicrobial de-escalation (odds ratio 2.9 (95%1.5-5.5)). Conclusions: Implementation of a syndromic molecular diagnostic approach to pneumonia led to faster results, with high sensitivity and impact on antibiotic prescribing.
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Affiliation(s)
- Vilas Navapurkar
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Josefin Bartholdson Scott
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Ellen Higginson
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Joana Pereira-Dias
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Surendra Parmar
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Emma Heasman-Hunt
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Petra Polgarova
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Joanne Brown
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Lissamma Titti
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - William PW Smith
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Anthony Rostron
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Matthew Routledge
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - David Sapsford
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - M. Estée Török
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
| | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Vanessa Wong
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - VAP-Rapid investigators
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Nicholas M Brown
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - A John Simpson
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Jurgen Herre
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
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62
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1436] [Impact Index Per Article: 478.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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63
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Scott J, Ruchaud-Sparagano MH, Musgrave K, Roy AI, Wright SE, Perry JD, Conway Morris A, Rostron AJ, Simpson AJ. Phosphoinositide 3-Kinase δ Inhibition Improves Neutrophil Bacterial Killing in Critically Ill Patients at High Risk of Infection. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2021; 207:1776-1784. [PMID: 34497151 DOI: 10.4049/jimmunol.2000603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/20/2021] [Indexed: 11/19/2022]
Abstract
Acquired neutrophil dysfunction frequently develops during critical illness, independently increasing the risk for intensive care unit-acquired infection. PI3Kδ is implicated in driving neutrophil dysfunction and can potentially be targeted pharmacologically. The aims of this study were to determine whether PI3Kδ inhibition reverses dysfunction in neutrophils from critically ill patients and to describe potential mechanisms. Neutrophils were isolated from blood taken from critically ill patients requiring intubation and mechanical ventilation, renal support, or blood pressure support. In separate validation experiments, neutrophil dysfunction was induced pharmacologically in neutrophils from healthy volunteers. Phagocytosis and bacterial killing assays were performed, and activity of RhoA and protein kinase A (PKA) was assessed. Inhibitors of PI3Kδ, 3-phosphoinositide-dependent protein kinase-1 (PDK1), and PKA were used to determine mechanisms of neutrophil dysfunction. Sixty-six patients were recruited. In the 27 patients (40.9%) with impaired neutrophil function, PI3Kδ inhibition consistently improved function and significantly increased bacterial killing. These findings were validated in neutrophils from healthy volunteers with salbutamol-induced dysfunction and extended to demonstrate that PI3Kδ inhibition restored killing of clinical isolates of nine pathogens commonly associated with intensive care unit-acquired infection. PI3Kδ activation was associated with PDK1 activation, which in turn phosphorylated PKA, which drove phosphorylation and inhibition of the key regulator of neutrophil phagocytosis, RhoA. These data indicate that, in a significant proportion of critically ill patients, PI3Kδ inhibition can improve neutrophil function through PDK1- and PKA-dependent processes, suggesting that therapeutic use of PI3Kδ inhibitors warrants investigation in this setting.
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Affiliation(s)
- Jonathan Scott
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Marie-Hélène Ruchaud-Sparagano
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kathryn Musgrave
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - Stephen E Wright
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - John D Perry
- Microbiology Department, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; and
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Anthony J Rostron
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - A John Simpson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom;
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64
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Niederman MS, Baron RM, Bouadma L, Calandra T, Daneman N, DeWaele J, Kollef MH, Lipman J, Nair GB. Initial antimicrobial management of sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:307. [PMID: 34446092 PMCID: PMC8390082 DOI: 10.1186/s13054-021-03736-w] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 02/08/2023]
Abstract
Sepsis is a common consequence of infection, associated with a mortality rate > 25%. Although community-acquired sepsis is more common, hospital-acquired infection is more lethal. The most common site of infection is the lung, followed by abdominal infection, catheter-associated blood steam infection and urinary tract infection. Gram-negative sepsis is more common than gram-positive infection, but sepsis can also be due to fungal and viral pathogens. To reduce mortality, it is necessary to give immediate, empiric, broad-spectrum therapy to those with severe sepsis and/or shock, but this approach can drive antimicrobial overuse and resistance and should be accompanied by a commitment to de-escalation and antimicrobial stewardship. Biomarkers such a procalcitonin can provide decision support for antibiotic use, and may identify patients with a low likelihood of infection, and in some settings, can guide duration of antibiotic therapy. Sepsis can involve drug-resistant pathogens, and this often necessitates consideration of newer antimicrobial agents.
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Affiliation(s)
- Michael S Niederman
- Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, 425 East 61st St, New York, NY, 10065, USA.
| | - Rebecca M Baron
- Harvard Medical School; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Lila Bouadma
- AP-HP, Bichat Claude Bernard, Medical and Infectious Diseas ICU, University of Paris, Paris, France
| | - Thierry Calandra
- Infectious Diseases Service, Department of Medicine, Lusanne University Hospital, University of Lusanne, Lusanne, Switzerland
| | - Nick Daneman
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Jan DeWaele
- Department of Critical Care Medicine, Surgical Intensive Care Unit, Ghent University, Ghent, Belgium
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffrey Lipman
- Royal Brisbane and Women's Hospital and Jamieson Trauma Institute, The University of Queensland, Brisbane, Australia.,Nimes University Hospital, University of Montpelier, Nimes, France
| | - Girish B Nair
- Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
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65
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Aulin LB, de Lange DW, Saleh MA, van der Graaf PH, Völler S, van Hasselt JC. Biomarker-Guided Individualization of Antibiotic Therapy. Clin Pharmacol Ther 2021; 110:346-360. [PMID: 33559152 PMCID: PMC8359228 DOI: 10.1002/cpt.2194] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/02/2021] [Indexed: 12/11/2022]
Abstract
Treatment failure of antibiotic therapy due to insufficient efficacy or occurrence of toxicity is a major clinical challenge, and is expected to become even more urgent with the global rise of antibiotic resistance. Strategies to optimize treatment in individual patients are therefore of crucial importance. Currently, therapeutic drug monitoring plays an important role in optimizing antibiotic exposure to reduce treatment failure and toxicity. Biomarker-based strategies may be a powerful tool to further quantify and monitor antibiotic treatment response, and reduce variation in treatment response between patients. Host response biomarkers, such as CRP, procalcitonin, IL-6, and presepsin, could potentially carry significant information to be utilized for treatment individualization. To achieve this, the complex interactions among immune system, pathogen, drug, and biomarker need to be better understood and characterized. The purpose of this tutorial is to discuss the use and evidence of currently available biomarker-based approaches to inform antibiotic treatment. To this end, we also included a discussion on how treatment response biomarker data from preclinical, healthy volunteer, and patient-based studies can be further characterized using pharmacometric and system pharmacology based modeling approaches. As an illustrative example of how such modeling strategies can be used, we describe a case study in which we quantitatively characterize procalcitonin dynamics in relation to antibiotic treatments in patients with sepsis.
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Affiliation(s)
- Linda B.S. Aulin
- Division of Systems Biomedicine and PharmacologyLeiden Academic Centre for Drug ResearchLeiden UniversityLeidenThe Netherlands
| | - Dylan W. de Lange
- Department of Intensive Care MedicineUniversity Medical CenterUniversity UtrechtUtrechtThe Netherlands
| | - Mohammed A.A. Saleh
- Division of Systems Biomedicine and PharmacologyLeiden Academic Centre for Drug ResearchLeiden UniversityLeidenThe Netherlands
| | - Piet H. van der Graaf
- Division of Systems Biomedicine and PharmacologyLeiden Academic Centre for Drug ResearchLeiden UniversityLeidenThe Netherlands
- CertaraCanterburyUK
| | - Swantje Völler
- Division of Systems Biomedicine and PharmacologyLeiden Academic Centre for Drug ResearchLeiden UniversityLeidenThe Netherlands
- Pharmacy, Leiden Academic Centre for Drug ResearchLeiden UniversityLeidenThe Netherlands
| | - J.G. Coen van Hasselt
- Division of Systems Biomedicine and PharmacologyLeiden Academic Centre for Drug ResearchLeiden UniversityLeidenThe Netherlands
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66
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Barberán J, Barberán LC, de la Cuerda A. [Safety in the selection of oral antibiotic treatment in community infections, beyond COVID-19]. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2021; 34:289-297. [PMID: 34319057 PMCID: PMC8329570 DOI: 10.37201/req/087.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Los antibióticos orales son uno de los fármacos más utilizados en la comunidad. Sus efectos adversos son generalmente poco frecuentes y leves, e incluyen toxicidad e interacciones medicamentosas. El mecanismo de producción es variado y no siempre bien conocido. El conocimiento de los efectos adversos con relevancia clínica puede permitir hacer un uso más juicioso de los antibióticos basados en el principio primero no hacer daño, primun non nocere. En esta revisión exploramos los principales efectos adversos de los antibióticos orales con énfasis en los β-lactámicos, macrólidos y fluoroquinolonas.
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Affiliation(s)
- J Barberán
- José Barberán, Servicio de Medicina Interna - Enfermedades infecciosas Hospital Universitario HM Montepríncipe. Universidad San Pablo CEU, Madrid, Spain.
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67
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Predisposition of COVID-19 patients to secondary infections: set in stone or subject to change? Curr Opin Infect Dis 2021; 34:357-364. [PMID: 34039879 DOI: 10.1097/qco.0000000000000736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW There likely are several predisposing factors to secondary infections in patients with Coronavirus disease 2019 (COVID-19), some of which may be preventable. The aim of this review is to explore the literature, summarize potential predisposing factors to secondary infections and their incidence. It also summarizes a variety of healthcare scenarios in which different kinds of secondary infections occur. RECENT FINDINGS Apart from immune dysregulation, severe resource limitations in healthcare settings have made COVID-19 units conducive to a variety of secondary infections. Long-term effect of excess antibiotic use in COVID-19 patients is yet to be studied. Very few studies have assessed secondary infections as the primary outcome measure making it difficult to know the true incidence. Mortality attributable to secondary infections in COVID-19 patients is also unclear. SUMMARY Incidence of secondary infections in COVID-19 patients is likely higher than what is reported in the literature. Well designed studies are needed to understand the incidence and impact of secondary infections in this patient population. Many of these may be preventable especially now, as personal protective equipment and other healthcare resources are recovering. Infection prevention and control (IPC) and antimicrobial stewardship programmes (ASP) must reassess current situation to correct any breaches that could potentially cause more harm in these already vulnerable patients as we brace for a future surge with another pandemic wave.
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68
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Roger C, Louart B. Beta-Lactams Toxicity in the Intensive Care Unit: An Underestimated Collateral Damage? Microorganisms 2021; 9:microorganisms9071505. [PMID: 34361942 PMCID: PMC8306322 DOI: 10.3390/microorganisms9071505] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/11/2021] [Accepted: 07/13/2021] [Indexed: 12/16/2022] Open
Abstract
Beta-lactams are the most commonly prescribed antimicrobials in intensive care unit (ICU) settings and remain one of the safest antimicrobials prescribed. However, the misdiagnosis of beta-lactam-related adverse events may alter ICU patient management and impact clinical outcomes. To describe the clinical manifestations, risk factors and beta-lactam-induced neurological and renal adverse effects in the ICU setting, we performed a comprehensive literature review via an electronic search on PubMed up to April 2021 to provide updated clinical data. Beta-lactam neurotoxicity occurs in 10-15% of ICU patients and may be responsible for a large panel of clinical manifestations, ranging from confusion, encephalopathy and hallucinations to myoclonus, convulsions and non-convulsive status epilepticus. Renal impairment, underlying brain abnormalities and advanced age have been recognized as the main risk factors for neurotoxicity. In ICU patients, trough concentrations above 22 mg/L for cefepime, 64 mg/L for meropenem, 125 mg/L for flucloxacillin and 360 mg/L for piperacillin (used without tazobactam) are associated with neurotoxicity in 50% of patients. Even though renal complications (especially severe complications, such as acute interstitial nephritis, renal damage associated with drug induced hemolytic anemia and renal obstruction by crystallization) remain rare, there is compelling evidence of increased nephrotoxicity using well-known nephrotoxic drugs such as vancomycin combined with beta-lactams. Treatment mainly relies on the discontinuation of the offending drug but in the near future, antimicrobial optimal dosing regimens should be defined, not only based on pharmacokinetics/pharmacodynamic (PK/PD) targets associated with clinical and microbiological efficacy, but also on PK/toxicodynamic targets. The use of dosing software may help to achieve these goals.
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Affiliation(s)
- Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029 Nîmes, France;
- UR UM 103 IMAGINE, Faculty of Medicine, Montpellier University, 34090 Montpellier, France
- Correspondence:
| | - Benjamin Louart
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029 Nîmes, France;
- UR UM 103 IMAGINE, Faculty of Medicine, Montpellier University, 34090 Montpellier, France
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69
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Optimizing Antimicrobial Drug Dosing in Critically Ill Patients. Microorganisms 2021; 9:microorganisms9071401. [PMID: 34203510 PMCID: PMC8305961 DOI: 10.3390/microorganisms9071401] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 12/23/2022] Open
Abstract
A fundamental step in the successful management of sepsis and septic shock is early empiric antimicrobial therapy. However, for this to be effective, several decisions must be addressed simultaneously: (1) antimicrobial choices should be adequate, covering the most probable pathogens; (2) they should be administered in the appropriate dose, (3) by the correct route, and (4) using the correct mode of administration to achieve successful concentration at the infection site. In critically ill patients, antimicrobial dosing is a common challenge and a frequent source of errors, since these patients present deranged pharmacokinetics, namely increased volume of distribution and altered drug clearance, which either increased or decreased. Moreover, the clinical condition of these patients changes markedly over time, either improving or deteriorating. The consequent impact on drug pharmacokinetics further complicates the selection of correct drug schedules and dosing during the course of therapy. In recent years, the knowledge of pharmacokinetics and pharmacodynamics, drug dosing, therapeutic drug monitoring, and antimicrobial resistance in the critically ill patients has greatly improved, fostering strategies to optimize therapeutic efficacy and to reduce toxicity and adverse events. Nonetheless, delivering adequate and appropriate antimicrobial therapy is still a challenge, since pathogen resistance continues to rise, and new therapeutic agents remain scarce. We aim to review the available literature to assess the challenges, impact, and tools to optimize individualization of antimicrobial dosing to maximize exposure and effectiveness in critically ill patients.
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70
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Moragues-Solanas L, Scotti R, O'Grady J. Rapid metagenomics for diagnosis of bloodstream and respiratory tract nosocomial infections: current status and future prospects. Expert Rev Mol Diagn 2021; 21:371-380. [PMID: 33740391 DOI: 10.1080/14737159.2021.1906652] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Nosocomial infections represent a major problem for the health-care systems worldwide. Currently, diagnosis relies on microbiological culture, which is slow and has poor sensitivity. While waiting for a diagnosis, patients are treated with empiric broad spectrum antimicrobials, which are often inappropriate for the infecting pathogen. This results in poor patient outcomes, poor antimicrobial stewardship and increased costs for health-care systems.Areas covered: Clinical metagenomics (CMg), the application of metagenomic sequencing for the diagnosis of infection, has the potential to become a viable alternative to culture that can offer rapid results with high accuracy. In this article, we review current CMg methods for the diagnosis of nosocomial bloodstream (BSI) and lower respiratory-tract infections (LRTI).Expert opinion: CMg approaches are more accurate in LRTI compared to BSI. This is because BSIs are caused by low pathogen numbers in a high background of human cells. To overcome this, most approaches focus on cell-free DNA, but, to date, these tests are not accurate enough yet to replace blood culture. The higher pathogen numbers in LRTI samples make this a more suitable for CMg and accurate approaches have been developed, which are likely to be implemented in hospitals within the next 2-5 years.
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Affiliation(s)
| | - Riccardo Scotti
- Quadram Institute of Bioscience, Norwich Research Park, Norwich, Norfolk, UK
| | - Justin O'Grady
- Quadram Institute of Bioscience, Norwich Research Park, Norwich, Norfolk, UK.,Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
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71
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Lonsdale DO, Lipman J. Global personalization of antibiotic therapy in critically ill patients. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2021. [DOI: 10.1080/23808993.2021.1874823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Dagan O Lonsdale
- Department of Clinical Pharmacology, St George’s, University of London, London, UK
- Department of Critical Care, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Jeffrey Lipman
- Department of Intensive Care, Royal Brisbane and Women’s Hospital, Brisbane, Australia
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Maes M, Higginson E, Pereira-Dias J, Curran MD, Parmar S, Khokhar F, Cuchet-Lourenço D, Lux J, Sharma-Hajela S, Ravenhill B, Hamed I, Heales L, Mahroof R, Soderholm A, Forrest S, Sridhar S, Brown NM, Baker S, Navapurkar V, Dougan G, Bartholdson Scott J, Conway Morris A. Ventilator-associated pneumonia in critically ill patients with COVID-19. Crit Care 2021; 25:25. [PMID: 33430915 PMCID: PMC7797892 DOI: 10.1186/s13054-021-03460-5] [Citation(s) in RCA: 182] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/04/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Pandemic COVID-19 caused by the coronavirus SARS-CoV-2 has a high incidence of patients with severe acute respiratory syndrome (SARS). Many of these patients require admission to an intensive care unit (ICU) for invasive ventilation and are at significant risk of developing a secondary, ventilator-associated pneumonia (VAP). OBJECTIVES To study the incidence of VAP and bacterial lung microbiome composition of ventilated COVID-19 and non-COVID-19 patients. METHODS In this retrospective observational study, we compared the incidence of VAP and secondary infections using a combination of microbial culture and a TaqMan multi-pathogen array. In addition, we determined the lung microbiome composition using 16S RNA analysis in a subset of samples. The study involved 81 COVID-19 and 144 non-COVID-19 patients receiving invasive ventilation in a single University teaching hospital between March 15th 2020 and August 30th 2020. RESULTS COVID-19 patients were significantly more likely to develop VAP than patients without COVID (Cox proportional hazard ratio 2.01 95% CI 1.14-3.54, p = 0.0015) with an incidence density of 28/1000 ventilator days versus 13/1000 for patients without COVID (p = 0.009). Although the distribution of organisms causing VAP was similar between the two groups, and the pulmonary microbiome was similar, we identified 3 cases of invasive aspergillosis amongst the patients with COVID-19 but none in the non-COVID-19 cohort. Herpesvirade activation was also numerically more frequent amongst patients with COVID-19. CONCLUSION COVID-19 is associated with an increased risk of VAP, which is not fully explained by the prolonged duration of ventilation. The pulmonary dysbiosis caused by COVID-19, and the causative organisms of secondary pneumonia observed are similar to that seen in critically ill patients ventilated for other reasons.
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Affiliation(s)
- Mailis Maes
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), University of Cambridge, Cambridge, UK
| | - Ellen Higginson
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), University of Cambridge, Cambridge, UK
| | - Joana Pereira-Dias
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), University of Cambridge, Cambridge, UK
| | - Martin D Curran
- Public Health England, Clinical Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Cambridge, UK
| | - Surendra Parmar
- Public Health England, Clinical Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Cambridge, UK
| | - Fahad Khokhar
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), University of Cambridge, Cambridge, UK
| | - Delphine Cuchet-Lourenço
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Level 4, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Janine Lux
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Level 4, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | | | | | - Islam Hamed
- John Farman ICU, Addenbrookes Hospital, Cambridge, UK
| | - Laura Heales
- John Farman ICU, Addenbrookes Hospital, Cambridge, UK
| | | | - Amelia Soderholm
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), University of Cambridge, Cambridge, UK
| | - Sally Forrest
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), University of Cambridge, Cambridge, UK
| | - Sushmita Sridhar
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), University of Cambridge, Cambridge, UK
- Wellcome Sanger Institute, Hinxton, UK
| | - Nicholas M Brown
- Public Health England, Clinical Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Cambridge, UK
| | - Stephen Baker
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), University of Cambridge, Cambridge, UK
| | | | - Gordon Dougan
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), University of Cambridge, Cambridge, UK
| | - Josefin Bartholdson Scott
- Department of Medicine, Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), University of Cambridge, Cambridge, UK
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Level 4, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
- John Farman ICU, Addenbrookes Hospital, Cambridge, UK.
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73
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Moniz P, Coelho L, Póvoa P. Antimicrobial Stewardship in the Intensive Care Unit: The Role of Biomarkers, Pharmacokinetics, and Pharmacodynamics. Adv Ther 2021; 38:164-179. [PMID: 33216323 PMCID: PMC7677101 DOI: 10.1007/s12325-020-01558-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/31/2020] [Indexed: 02/06/2023]
Abstract
The high prevalence of infectious diseases in the intensive care unit (ICU) and consequently elevated pressure for immediate and effective treatment have led to increased antimicrobial therapy consumption and misuse. Moreover, the emerging global threat of antimicrobial resistance and lack of novel antimicrobials justify the implementation of judicious antimicrobial stewardship programs (ASP) in the ICU. However, even though the importance of ASP is generally accepted, its implementation in the ICU is far from optimal and current evidence regarding strategies such as de-escalation remains controversial. The limitations of clinical guidance for antimicrobial therapy initiation and discontinuation have led to multiple studies for the evaluation of more objective tools, such as biomarkers as adjuncts for ASP. C-reactive protein and procalcitonin can be adequate for clinical use in acute infectious diseases, the latter being the most studied for ASP purposes. Although promising, current evidence highlights challenges in biomarker application and interpretation. Furthermore, the physiological alterations in the critically ill render pharmacokinetics and pharmacodynamics crucial parameters for adequate antimicrobial therapy use. Individual pharmacokinetic and pharmacodynamic targets can reduce antimicrobial therapy misuse and risk of antimicrobial resistance.
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Affiliation(s)
- Patrícia Moniz
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal
| | - Luís Coelho
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal
- Nova Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal.
- Nova Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark.
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74
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Reticker A, Lichvar A, Walsh M, Gross AE, Patel S. The Significance and Impact of Screening Preservation Fluid Cultures in Renal Transplant Recipients. Prog Transplant 2020; 31:40-46. [PMID: 33297862 DOI: 10.1177/1526924820978608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Infectious complications can be a major cause of morbidity and mortality in solid organ transplant recipients. Preservation fluid is necessary to maintain organ viability but may serve as a vector or infection. The utility of screening preservation fluid routinely for microbial growth and the impact of culture-positive preservation fluid is controversial. Research Question: What is the clinical impact of a culture positive preservation fluid in a kidney transplant recipient? DESIGN This retrospective study was performed to define the incidence of post-operative infection related to PF and examine the negative sequelae of culture-positive PF. One hundred and fifty-two deceased donor renal transplant recipients from January 2015 to December 2017 were included for analysis. RESULTS Overall, 67% of patients (102/152) received an allograft from a culture-positive PF. Nearly 80% of microbial growth was consistent with skin flora, and coagulase-negative staphylococci was the most frequently isolated organism (56%). Sixty-seven percent of patients (68/102) with culture-positive PF received antimicrobial treatment for an average duration of 5 days. There was no difference in the incidence of infection between patients with culture positive PF compared to culture-negative PF. Furthermore, there were no cases of infection related to PF regardless of whether culture-positive PF was treated or untreated. The incidence of subsequent C. difficile infection and multidrug-resistant organisms was similar. DISCUSSION This study suggests antimicrobial treatment for culture positive PF may not be necessary with pathogens that are common contaminants and of low virulence. Interventional studies are needed to validate this strategy.
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Affiliation(s)
- Anesia Reticker
- Department of Pharmacy Practice, University of Illinois Hospital and Health Sciences System, 14681University of Illinois at Chicago, Chicago, IL, USA
| | - Alicia Lichvar
- Department of Pharmacy Practice, University of Illinois Hospital and Health Sciences System, 14681University of Illinois at Chicago, Chicago, IL, USA
| | - Meghan Walsh
- Department of Pharmacy Practice, University of Illinois Hospital and Health Sciences System, 14681University of Illinois at Chicago, Chicago, IL, USA
| | - Alan E Gross
- Department of Pharmacy Practice, University of Illinois Hospital and Health Sciences System, 14681University of Illinois at Chicago, Chicago, IL, USA
| | - Shree Patel
- Department of Pharmacy Practice, University of Illinois Hospital and Health Sciences System, 14681University of Illinois at Chicago, Chicago, IL, USA
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75
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Abstract
Pulmonary infection is one of the main complications occurring in patients suffering from acute respiratory distress syndrome (ARDS). Besides traditional risk factors, dysregulation of lung immune defenses and microbiota may play an important role in ARDS patients. Prone positioning does not seem to be associated with a higher risk of pulmonary infection. Although bacteria associated with ventilator-associated pneumonia (VAP) in ARDS patients are similar to those in patients without ARDS, atypical pathogens (Aspergillus, herpes simplex virus and cytomegalovirus) may also be responsible for infection in ARDS patients. Diagnosing pulmonary infection in ARDS patients is challenging, and requires a combination of clinical, biological and microbiological criteria. The role of modern tools (e.g., molecular methods, metagenomic sequencing, etc.) remains to be evaluated in this setting. One of the challenges of antimicrobial treatment is antibiotics diffusion into the lungs. Although targeted delivery of antibiotics using nebulization may be interesting, their place in ARDS patients remains to be explored. The use of extracorporeal membrane oxygenation in the most severe patients is associated with a high rate of infection and raises several challenges, diagnostic issues and pharmacokinetics/pharmacodynamics changes being at the top. Prevention of pulmonary infection is a key issue in ARDS patients, but there is no specific measure for these high-risk patients. Reinforcing preventive measures using bundles seems to be the best option.
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76
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Tauber SC, Djukic M, Gossner J, Eiffert H, Brück W, Nau R. Sepsis-associated encephalopathy and septic encephalitis: an update. Expert Rev Anti Infect Ther 2020; 19:215-231. [PMID: 32808580 DOI: 10.1080/14787210.2020.1812384] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Sepsis-associated encephalopathy (SAE) and septic encephalitis (SE) are associated with increased mortality, long-term cognitive impairment, and focal neurological deficits. AREAS COVERED The PUBMED database was searched 2016-2020. The clinical manifestation of SAE is delirium, SE additionally is characterized by focal neurological symptoms. SAE is caused by inflammation with endothelial/microglial activation, increase of permeability of the blood-brain-barrier, hypoxia, imbalance of neurotransmitters, glial activation, axonal, and neuronal loss. Septic-embolic (SEE) and septic-metastatic encephalitis (SME) are characterized by focal ischemia (SEE) and small abscesses (SME). The continuum between SAE, SME, and SEE is documented by imaging techniques and autopsies. The backbone of treatment is rapid optimum antibiotic therapy. Experimental approaches focus on modulation of inflammation, stabilization of the blood-brain barrier, and restoration of membrane/mitochondrial function. EXPERT OPINION The most promising diagnostic approaches are new imaging techniques. The most important measure to fight delirium remains establishment of daily structure and adequate sensory stimuli. Dexmedetomidine and melatonin appear to reduce the frequency of delirium, their efficacy in SAE and SE remains to be established. Drugs already licensed for other indications or available as food supplements which may be effective in SAE are statins, L-DOPA/benserazide, β-hydroxybutyrate, palmitoylethanolamide, and tetracyclines or other bactericidal non-lytic antibiotics.
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Affiliation(s)
- Simone C Tauber
- Department of Neurology, Rheinisch-Westfälische Technische Hochschule (RWTH) , Aachen, Germany
| | - Marija Djukic
- Institute of Neuropathology, University Medical Center , Göttingen, Germany.,Department of Geriatrics, Protestant Hospital Göttingen-Weende , Göttingen, Germany
| | - Johannes Gossner
- Department of Diagnostic and Interventional Radiology, Protestant Hospital Göttingen-Weende , Göttingen, Germany
| | - Helmut Eiffert
- Amedes MVZ for Laboratory Medicine, Medical Microbiology and Infectiology , Göttingen, Germany
| | - Wolfgang Brück
- Institute of Neuropathology, University Medical Center , Göttingen, Germany
| | - Roland Nau
- Institute of Neuropathology, University Medical Center , Göttingen, Germany.,Department of Geriatrics, Protestant Hospital Göttingen-Weende , Göttingen, Germany
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77
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Eickelberg G, Sanchez-Pinto LN, Luo Y. Predictive modeling of bacterial infections and antibiotic therapy needs in critically ill adults. J Biomed Inform 2020; 109:103540. [PMID: 32814200 PMCID: PMC7530142 DOI: 10.1016/j.jbi.2020.103540] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/17/2020] [Accepted: 08/12/2020] [Indexed: 12/29/2022]
Abstract
Unnecessary antibiotic regimens in the intensive care unit (ICU) are associated with adverse patient outcomes and antimicrobial resistance. Bacterial infections (BI) are both common and deadly in ICUs, and as a result, patients with a suspected BI are routinely started on broad-spectrum antibiotics prior to having confirmatory microbiologic culture results or when an occult BI is suspected, a practice known as empiric antibiotic therapy (EAT). However, EAT guidelines lack consensus and existing methods to quantify patient-level BI risk rely largely on clinical judgement and inaccurate biomarkers or expensive diagnostic tests. As a consequence, patients with low risk of BI often are continued on EAT, exposing them to unnecessary side effects. Augmenting current intuition-based practices with data-driven predictions of BI risk could help inform clinical decisions to shorten the duration of unnecessary EAT and improve patient outcomes. We propose a novel framework to identify ICU patients with low risk of BI as candidates for earlier EAT discontinuation. For this study, patients suspected of having a community-acquired BI were identified in the Medical Information Mart for Intensive Care III (MIMIC-III) dataset and categorized based on microbiologic culture results and EAT duration. Using structured longitudinal data collected up to 24-, 48-, and 72-hours after starting EAT, our best models identified patients at low risk of BI with AUROCs up to 0.8 and negative predictive values >93%. Overall, these results demonstrate the feasibility of forecasting BI risk in a critical care setting using patient features found in the electronic health record and call for more extensive research in this promising, yet relatively understudied, area.
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Affiliation(s)
- Garrett Eickelberg
- Department of Preventitive Medicine (Health & Biomedical Informatics), Feinberg School of Medicine, 750 N Lake Shore, Chicago, IL 60611, USA
| | - L Nelson Sanchez-Pinto
- Department of Preventitive Medicine (Health & Biomedical Informatics), Feinberg School of Medicine, 750 N Lake Shore, Chicago, IL 60611, USA; Department of Pediatrics (Critical Care), 225 E. Chicago Avenue, Chicago, IL 60611, USA.
| | - Yuan Luo
- Department of Preventitive Medicine (Health & Biomedical Informatics), Feinberg School of Medicine, 750 N Lake Shore, Chicago, IL 60611, USA.
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78
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Dupuis C, Timsit JF. Antibiotics in the first hour: is there new evidence? Expert Rev Anti Infect Ther 2020; 19:45-54. [PMID: 32799580 DOI: 10.1080/14787210.2020.1810567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION International guidelines have recommended for many years to start antimicrobials as early as possible in sepsis and shock. This concept has been challenged by the controversial results of experimental studies and clinical cohorts and resulted in intense debate in the literature. This review aims to summarize the available knowledge on early antimicrobial therapy and to consider perspectives. AREAS COVERED First, after a research using MEDLINE, we reviewed the studies that advocated the implementation of early antimicrobial therapy. We then discussed the drawbacks of these studies. Finally, we suggested possible explanations of the benefit and then absence of the prognostic impact of early antimicrobial therapy i.e. confounding factors, irreversibility of the inflammatory process, non-control of the source of the infection, pharmacodynamic considerations and the harmful effect of antimicrobial drugs. EXPERT OPINION Sepsis is very heterogeneous. The first antimicrobial therapy should be personalized. The sickest patients should be given early antimicrobial therapy, whereas a 'watch and wait process' should be preferred for less severe patients, to allow confirmation of sepsis, identification of pathogens and administration of adequate antimicrobial therapy. We propose steps to personalize the first antimicrobial therapy. New early diagnostic tools will assist the physicians in the future.
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Affiliation(s)
- Claire Dupuis
- Medical Intensive Care Unit, Gabriel Montpied University Hospital , Clermont-Ferrand, France.,Umr 1137, Iame Université De Paris , Paris, France.,APHP, Medical and Infectious Diseases ICU (MI2), Bichat Claude Bernard Hospital , Paris, France
| | - Jean-Francois Timsit
- Umr 1137, Iame Université De Paris , Paris, France.,APHP, Medical and Infectious Diseases ICU (MI2), Bichat Claude Bernard Hospital , Paris, France
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79
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Hurley JC. Antibiotics in the ICU; benefit or harm? Intensive Care Med 2020; 46:1798-1799. [PMID: 32322919 DOI: 10.1007/s00134-020-06060-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Affiliation(s)
- James C Hurley
- Rural Health Academic Center, Melbourne Medical School, University of Melbourne, Melbourne, Australia. .,Division of Internal Medicine, Ballarat Health Services, PO Box 577, Ballarat, VIC, 3353, Australia.
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80
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Diagnosis of ventilator-associated pneumonia in critically ill adult patients-a systematic review and meta-analysis. Intensive Care Med 2020; 46:1170-1179. [PMID: 32306086 PMCID: PMC7223448 DOI: 10.1007/s00134-020-06036-z] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/02/2020] [Indexed: 02/01/2023]
Abstract
The accuracy of the signs and tests that clinicians use to diagnose ventilator-associated pneumonia (VAP) and initiate antibiotic treatment has not been well characterized. We sought to characterize and compare the accuracy of physical examination, chest radiography, endotracheal aspirate (ETA), bronchoscopic sampling cultures (protected specimen brush [PSB] and bronchoalveolar lavage [BAL]), and CPIS > 6 to diagnose VAP. We searched six databases from inception through September 2019 and selected English-language studies investigating accuracy of any of the above tests for VAP diagnosis. Reference standard was histopathological analysis. Two reviewers independently extracted data and assessed study quality. We included 25 studies (1639 patients). The pooled sensitivity and specificity of physical examination findings for VAP were poor: fever (66.4% [95% confidence interval [CI]: 40.7-85.0], 53.9% [95% CI 34.5-72.2]) and purulent secretions (77.0% [95% CI 64.7-85.9], 39.0% [95% CI 25.8-54.0]). Any infiltrate on chest radiography had a sensitivity of 88.9% (95% CI 73.9-95.8) and specificity of 26.1% (95% CI 15.1-41.4). ETA had a sensitivity of 75.7% (95% CI 51.5-90.1) and specificity of 67.9% (95% CI 40.5-86.8). Among bronchoscopic sampling methods, PSB had a sensitivity of 61.4% [95% CI 43.7-76.5] and specificity of 76.5% [95% CI 64.2-85.6]; while BAL had a sensitivity of 71.1% [95% CI 49.9-85.9] and specificity of 79.6% [95% CI 66.2-85.9]. CPIS > 6 had a sensitivity of 73.8% (95% CI 50.6-88.5) and specificity of 66.4% (95% CI 43.9-83.3). Classic clinical indicators had poor accuracy for diagnosis of VAP. Reliance upon these indicators in isolation may result in misdiagnosis and potentially unnecessary antimicrobial use.
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