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Brinkmann A, Röhr AC, Frey OR, Krüger WA, Brenner T, Richter DC, Bodmann KF, Kresken M, Grabein B. [S2k guidelines of the PEG on calculated parenteral initial treatment of bacterial diseases in adults : Focussed summary and supplementary information on antibiotic treatment of critically ill patients]. Anaesthesist 2019; 67:936-949. [PMID: 30511110 DOI: 10.1007/s00101-018-0512-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In January 2018 the recent revision of the S2k guidelines on calculated parenteral initial treatment of bacterial diseases in adults-update 2018 (Editor: Paul Ehrlich Society for Chemotherapy, PEG) was realized. It is a helpful tool for the complex infectious disease setting in an intensive care unit. The present summary of the guidelines focuses on the topics of anti-infective agents, including new substances, pharmacokinetics and pharmacodynamics as well as on microbiology, resistance development and recommendations for calculated drug therapy in septic patients. As in past revisions the recent resistance situation and results of new clinical studies are considered and anti-infective agents are summarized in a table.
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Affiliation(s)
- A Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Schlosshaustraße 100, 89522, Heidenheim, Deutschland.
| | - A C Röhr
- Apotheke, Klinikum Heidenheim, Heidenheim, Deutschland
| | - O R Frey
- Apotheke, Klinikum Heidenheim, Heidenheim, Deutschland
| | - W A Krüger
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Konstanz, Konstanz, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D C Richter
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - K-F Bodmann
- Klinik für Internistische Intensiv- und Notfallmedizin und Klinische Infektiologie, Klinikum Barnim GmbH, Werner Forßmann Krankenhaus, Eberswalde, Deutschland
| | - M Kresken
- Antiinfectives Intelligence GmbH, Campus Rheinbach, Hochschule Bonn-Rhein-Sieg, Rheinbach, Deutschland.,Rheinische Fachhochschule Köln gGmbH, Köln, Deutschland
| | - B Grabein
- Stabsstelle Klinische Mikrobiologie und Krankenhaushygiene, Klinikum der Universität München, Campus Großhadern, München, Deutschland
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102
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Tabah A, Bassetti M, Kollef MH, Zahar JR, Paiva JA, Timsit JF, Roberts JA, Schouten J, Giamarellou H, Rello J, De Waele J, Shorr AF, Leone M, Poulakou G, Depuydt P, Garnacho-Montero J. Antimicrobial de-escalation in critically ill patients: a position statement from a task force of the European Society of Intensive Care Medicine (ESICM) and European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Critically Ill Patients Study Group (ESGCIP). Intensive Care Med 2019; 46:245-265. [PMID: 31781835 DOI: 10.1007/s00134-019-05866-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/12/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antimicrobial de-escalation (ADE) is a strategy of antimicrobial stewardship, aiming at preventing the emergence of antimicrobial resistance (AMR) by decreasing the exposure to broad-spectrum antimicrobials. There is no high-quality research on ADE and its effects on AMR. Its definition varies and there is little evidence-based guidance for clinicians to use ADE in the intensive care unit (ICU). METHODS A task force of 16 international experts was formed in November 2016 to provide with guidelines for clinical practice to develop questions targeted at defining ADE, its effects on the ICU population and to provide clinical guidance. Groups of 2 experts were assigned 1-2 questions each within their field of expertise to provide draft statements and rationale. A Delphi method, with 3 rounds and an agreement threshold of 70% was required to reach consensus. RESULTS We present a comprehensive document with 13 statements, reviewing the evidence on the definition of ADE, its effects in the ICU population and providing guidance for clinicians in subsets of clinical scenarios where ADE may be considered. CONCLUSION ADE remains a topic of controversy due to the complexity of clinical scenarios where it may be applied and the absence of evidence to the effects it may have on antimicrobial resistance.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe and Caboolture Hospitals, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Santa Maria Misericordia University Hospital, Udine, Italy
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Jean-Ralph Zahar
- Hygiène Hospitalière Et Prévention du Risque Infectieux, CHU Avicenne, AP-HP, 125 rue de Stalingrad, 93000, Bobigny, France
| | - José-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar Universitário São João, Faculty of Medicine and University of Porto, Grupo de Infecçao e Sépsis, Porto, Portugal
| | - Jean-Francois Timsit
- Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard University Hospital, Paris, France
- University of Paris, INSERM IAME, U1137, Team DesCID, Paris, France
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, and Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- Departments of Pharmacy and 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
| | - Jeroen Schouten
- Department of Intensive Care, Radboudumc, Nijmegen, The Netherlands
| | - Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Jordi Rello
- CIBERES and Vall d'Hebron Institute of Research, Barcelona, Spain
- Clinical Research in ICU, CHU Nîmes, University Montpellier, Montpellier, France
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Marc Leone
- Department of Anesthesiology and Intensive Care Medicine, Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | - Garyphallia Poulakou
- 3rd Department of Medicine, National and Kapodistrian University of Athens, Medical School, Sotiria General Hospital, Athens, Greece
| | - Pieter Depuydt
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jose Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
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103
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Lanckohr C, Bracht H. [Antibiotic stewardship : Measures for optimizing prescription of anti-infective agents]. Anaesthesist 2019; 67:3-8. [PMID: 29313072 DOI: 10.1007/s00101-017-0398-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Antibiotic stewardship (ABS) comprises a bundle of different interventions to improve anti-infective treatment in a hospital setting. An important component of ABS interventions is the interdisciplinary approach to infection management. Besides improving infrastructural aspects on a hospital level, including surveillance of the use of anti-infective agents and nosocomial infections, collation and interpretation of statistics on resistance and formulation of local treatment guidelines, ABS teams go to the wards and advise treating physicians on antibiotic therapy. Frequent approaches for optimization are selection of substances, administration route, dosing of medication and duration of treatment. An important overall objective of ABS is the reduction of resistance induction in order to preserve the therapeutic efficiency of antibiotics. A number of studies have shown that this goal can be achieved in different clinical settings without negatively affecting patient outcome. The strategies of ABS can also be applied with no problems to critically ill patients on the intensive care unit.
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Affiliation(s)
- C Lanckohr
- Antibiotic Stewardship (ABS)-Team, Institut für Hygiene, Universitätsklinikum Münster, Robert-Koch-Str. 41, 48149, Münster, Deutschland. .,Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Geb. A1, 48149, Münster, Deutschland.
| | - H Bracht
- Klinik für Anästhesiologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
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104
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Sadyrbaeva-Dolgova S, Aznarte-Padial P, Jimenez-Morales A, Expósito-Ruiz M, Calleja-Hernández MÁ, Hidalgo-Tenorio C. Pharmacist recommendations for carbapenem de-escalation in urinary tract infection within an antimicrobial stewardship program. J Infect Public Health 2019; 13:558-563. [PMID: 31685404 DOI: 10.1016/j.jiph.2019.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/31/2019] [Accepted: 09/18/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Carbapenem antibiotics are considered the treatment of choice for serious extended-spectrum beta-lactamase-producing Gram-negative bacteria infections. Our objectives were to analyze the results of carbapenem de-escalation therapy in complicated urinary tract infections (UTIs) attended in a third-level Spanish hospital and to evaluate the impact of pharmacist recommendation in this practice, the outcomes obtained, and associated factors. METHODS This prospective observational study of carbapenem prescriptions and de-escalation performance was conducted in a third-level hospital between August 1 2013 and July 31, 2014. Data were gathered on carbapenem treatment duration, de-escalation, length of hospital stay, mortality rate, and associated re-admissions. RESULTS De-escalation, which was only ordered for patients with positive cultures, was conducted in 49.7% of the 163 patients with complicated UTI. More than half (69.1%) of pharmacist interventions were accepted. De-escalation reduced the median hospital stay by five days (p=0.030). Crude hospital mortality was lower in the de-escalation group (7.4% vs. 29.3%, p<0.001), although their exposure to carbapenems was lower (4 vs 6 days, p<0.001). Factors associated with de-escalation were ICU stay for at least 48h, pharmacist recommendation and ESBL or AmpC producing Enterobacteriaceae. Factors associated with in-hospital mortality were age, previous admission and duration of hospital stay, but not pharmacist recommendation. Otherwise, carbapenem de-escalation was associated as a protective factor against in-hospital mortality. CONCLUSIONS Carbapenem de-escalation in accordance with pharmacist recommendation proved to be a safe approach in complicated UTI, reducing the hospital stay of patients without affecting the re-admission rate.
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Affiliation(s)
| | - Pilar Aznarte-Padial
- Department of Pharmacy, University Hospital Virgen de las Nieves, Granada, Spain
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105
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Madaline T, Wadskier Montagne F, Eisenberg R, Mowrey W, Kaur J, Malik M, Gendlina I, Guo Y, White D, Pirofski LA, Sarwar U. Early Infectious Disease Consultation Is Associated With Lower Mortality in Patients With Severe Sepsis or Septic Shock Who Complete the 3-Hour Sepsis Treatment Bundle. Open Forum Infect Dis 2019; 6:ofz408. [PMID: 31687417 PMCID: PMC6821928 DOI: 10.1093/ofid/ofz408] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/11/2019] [Indexed: 12/15/2022] Open
Abstract
Objective Severe sepsis and septic shock (SS/SS) treatment bundles reduce mortality, and early infectious diseases (ID) consultation also improves patient outcomes. We retrospectively examined whether early ID consultation further improves outcomes in Emergency Department (ED) patients with SS/SS who complete the sepsis bundle. Method We included 248 adult ED patients with SS/SS who completed the 3-hour bundle. Patients with ID consultation within 12 hours of ED triage (n = 111; early ID) were compared with patients who received standard care (n = 137) for in-hospital mortality, 30-day readmission, length of hospital stay (LOS), and antibiotic management. A competing risk survival analysis model compared risks of in-hospital mortality and discharge alive between groups. Results In-hospital mortality was lower in the early ID group unadjusted (24.3% vs 38.0%, P = .02) and adjusted for covariates (odds ratio, 0.47; 95% confidence interval (CI), 0.25–0.89; P = .02). There was no significant difference in 30-day readmission (22.6% vs 23.5%, P = .89) or median LOS (10.2 vs 12.1 days, P = .15) among patients who survived. A trend toward shorter time to antibiotic de-escalation in the early ID group (log-rank test P = .07) was observed. Early ID consultation was protective of in-hospital mortality (adjusted subdistribution hazard ratio (asHR), 0.60; 95% CI 0.36–1.00, P = .0497) and predictive of discharge alive (asHR 1.58, 95% CI, 1.11–2.23; P-value .01) after adjustment. Conclusions Among patients receiving the SS/SS bundle, early ID consultation was associated with a 40% risk reduction for in-hospital mortality. The impact of team-based care and de-escalation on SS/SS outcomes warrants further study.
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Affiliation(s)
- Theresa Madaline
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Francis Wadskier Montagne
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Ruth Eisenberg
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Wenzhu Mowrey
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | | | - Maria Malik
- Princeton University, Princeton, New Jersey, USA
| | - Inessa Gendlina
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Yi Guo
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Deborah White
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Liise-Anne Pirofski
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Uzma Sarwar
- Division of Infectious Diseases, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
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106
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van Heijl I, Schweitzer VA, Boel CHE, Oosterheert JJ, Huijts SM, Dorigo-Zetsma W, van der Linden PD, Bonten MJM, van Werkhoven CH. Confounding by indication of the safety of de-escalation in community-acquired pneumonia: A simulation study embedded in a prospective cohort. PLoS One 2019; 14:e0218062. [PMID: 31560686 PMCID: PMC6764693 DOI: 10.1371/journal.pone.0218062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/12/2019] [Indexed: 01/17/2023] Open
Abstract
Observational studies have demonstrated that de-escalation of antimicrobial therapy is independently associated with lower mortality. This most probably results from confounding by indication. Reaching clinical stability is associated with the decision to de-escalate and with survival. However, studies rarely adjust for this confounder. We quantified the potential confounding effect of clinical stability on the estimated impact of de-escalation on mortality in patients with community-acquired pneumonia. Data were used from the Community-Acquired Pneumonia immunization Trial in Adults (CAPiTA). The primary outcome was 30-day mortality. We performed Cox proportional-hazards regression with de-escalation as time-dependent variable and adjusted for baseline characteristics using propensity scores. The potential impact of unmeasured confounding was quantified through simulating a variable representing clinical stability on day three, using data on prevalence and associations with mortality from the literature. Of 1,536 included patients, 257 (16.7%) were de-escalated, 123 (8.0%) were escalated and in 1156 (75.3%) the antibiotic spectrum remained unchanged. Crude 30-day mortality was 3.5% (9/257) and 10.9% (107/986) in the de-escalation and continuation groups, respectively. The adjusted hazard ratio of de-escalation for 30-day mortality (compared to patients with unchanged coverage), without adjustment for clinical stability, was 0.39 (95%CI: 0.19–0.79). If 90% to 100% of de-escalated patients were clinically stable on day three, the fully adjusted hazard ratio would be 0.56 (95%CI: 0.27–1.12) to 1.04 (95%CI: 0.49–2.23), respectively. The simulated confounder was substantially stronger than any of the baseline confounders in our dataset. Quantification of effects of de-escalation on patient outcomes without proper adjustment for clinical stability results in strong negative bias. This study suggests the effect of de-escalation on mortality needs further well-designed prospective research to determine effect size more accurately.
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Affiliation(s)
- Inger van Heijl
- Department of Clinical Pharmacy, Tergooi hospital, Hilversum, The Netherlands
- Julius Center for Health Sciences and Primary care, University Medical Centre Utrecht, Utrecht, The Netherlands
- * E-mail:
| | - Valentijn A. Schweitzer
- Julius Center for Health Sciences and Primary care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - C. H. Edwin Boel
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine & Infectious Diseases, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Susanne M. Huijts
- Department of Pulmonary Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | | | - Marc J. M. Bonten
- Julius Center for Health Sciences and Primary care, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Cornelis H. van Werkhoven
- Julius Center for Health Sciences and Primary care, University Medical Centre Utrecht, Utrecht, The Netherlands
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107
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Subramanian M, Hirschkorn C, Eyerly-Webb SA, Solomon RJ, Hodgman EI, Sanchez RE, Davare DL, Pigneri DA, Kiffin C, Rosenthal AA, Pedraza Taborda FE, Arenas JD, Hennessy SA, Minei JP, Minshall CT, Hranjec T. Clinical Diagnosis of Infection in Surgical Intensive Care Unit: You're Not as Good as You Think! Surg Infect (Larchmt) 2019; 21:122-129. [PMID: 31553271 DOI: 10.1089/sur.2019.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Because of the everincreasing costs and the complexity of institutional medical reimbursement policies, the necessity for extensive laboratory work-up of potentially infected patients has come into question. We hypothesized that intensivists are able to differentiate between infected and non-infected patients clinically, without the need to pan-culture, and are able to identify the location of the infection clinically in order to administer timely and appropriate treatment. Methods: Data collected prospectively on critically ill patients suspected of having an infection in the surgical intensive care unit (SICU) was obtained over a six-month period in a single tertiary academic medical center. Objective evidence of infection derived from laboratory or imaging data was compared with the subjective answers of the three most senior physicians' clinical diagnoses. Results: Thirty-nine critically ill surgical patients received 52 work-ups for suspected infections on the basis of signs and symptoms (e.g., fever, altered mental status). Thirty patients were found to be infected. Clinical diagnosis differentiated infected and non-infected patients with only 61.5% accuracy (sensitivity 60.3%; specificity 64.4%; p = 0.0049). Concordance between physicians was poor (κ = 0.33). Providers were able to predict the infectious source correctly only 60% of the time. Utilization of culture/objective data and SICU antibiotic protocols led to overall 78% appropriate initiation of antibiotics compared with 48% when treatment was based on clinical evaluation alone. Conclusion: Clinical diagnosis of infection is difficult, inaccurate, and unreliable in the absence of culture and sensitivity data. Infection suspected on the basis of signs and symptoms should be confirmed via objective and thorough work-up.
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Affiliation(s)
- Madhu Subramanian
- Division of Burn/Trauma/Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.,Division of Trauma, Surgical Critical Care and Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Carol Hirschkorn
- Division of Burn/Trauma/Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephanie A Eyerly-Webb
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Rachele J Solomon
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Erica I Hodgman
- Division of Burn/Trauma/Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Medicine, Pediatric Surgery, University of Tennessee Health Science Center College of Medicine Memphis, Memphis, Tennessee
| | - Rafael E Sanchez
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Dafney L Davare
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Danielle A Pigneri
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Chauniqua Kiffin
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Andrew A Rosenthal
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Fernando E Pedraza Taborda
- Division of Solid Organ Transplant, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Juan D Arenas
- Division of Solid Organ Transplant, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
| | - Sara A Hennessy
- Division of Burn/Trauma/Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joseph P Minei
- Division of Burn/Trauma/Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christian T Minshall
- Division of Burn/Trauma/Critical Care, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tjasa Hranjec
- Division of Trauma/Critical Care, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida.,Division of Solid Organ Transplant, Department of Surgery, Memorial Regional Hospital, Hollywood, Florida
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108
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Melling PA, Noto MJ, Rice TW, Semler MW, Stollings JL. Time to First Culture Positivity Among Critically Ill Adults With Methicillin-Resistant Staphylococcus aureus Growth in Respiratory or Blood Cultures. Ann Pharmacother 2019; 54:131-137. [PMID: 31544471 DOI: 10.1177/1060028019877937] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: For critically ill adults receiving empirical vancomycin, the duration of negative cultures after which vancomycin may be discontinued without risking subsequent growth of methicillin-resistant Staphylococcus aureus (MRSA) remains unknown. Objective: We hypothesized that if sputum cultures did not grow MRSA or blood cultures did not grow Gram-positive cocci on Gram stain by 48 hours, those cultures would not subsequently demonstrate MRSA. Methods: We conducted an ancillary analysis from patients enrolled in the Isotonic Solutions and Major Adverse Renal Events Trial (SMART). In this cohort of patients, we collected data on the time of either MRSA identification in culture or Gram-positive cocci identification on Gram stain and rate of vancomycin discontinuation. Results: Of the 15 802 patient admissions in the SMART study, 6553 (41.5%) received empirical intravenous vancomycin. Respiratory sputum cultures demonstrated MRSA during 178 patient admissions. Among respiratory cultures that would ultimately grow MRSA, 85% were positive within 48 hours, and 97% were positive within 72 hours. Cultures demonstrated MRSA bacteremia during 85 patient admissions. In 83 cases (97.6%) of MRSA bacteremia, Gram-positive cocci were identified within 48 hours after the culture was obtained. Conclusion and Relevance: This analysis of a large cohort of critically ill adults receiving empirical vancomycin found that Staphylococcus aureus was present in all but 15% of cases of MRSA-positive respiratory cultures after 48 hours, whereas Gram-positive cocci were identified within 48 hours during nearly all episodes of MRSA bacteremia. These findings may inform the timing of discontinuation of empirical vancomycin among critically ill adults.
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Affiliation(s)
| | - Michael J Noto
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Vanderbilt University Medical Center, Nashville, TN, USA
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109
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Gautam S, Sharma L, Dela Cruz CS. Teaching an Old Intensivist Neutrophil Tricks: Using Alveolar Neutrophilia to Diagnose Ventilator-associated Pneumonia. Am J Respir Crit Care Med 2019; 199:1178-1181. [PMID: 30543457 PMCID: PMC6519853 DOI: 10.1164/rccm.201811-2163ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Samir Gautam
- 1 Section of Pulmonary, Critical Care, and Sleep Medicine Yale University School of Medicine New Haven, Connecticut
| | - Lokesh Sharma
- 1 Section of Pulmonary, Critical Care, and Sleep Medicine Yale University School of Medicine New Haven, Connecticut
| | - Charles S Dela Cruz
- 1 Section of Pulmonary, Critical Care, and Sleep Medicine Yale University School of Medicine New Haven, Connecticut
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110
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Safety of antimicrobial de-escalation for culture-negative severe pneumonia. J Crit Care 2019; 54:14-19. [PMID: 31319347 PMCID: PMC7126337 DOI: 10.1016/j.jcrc.2019.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 12/17/2022]
Abstract
Purpose This study investigated the outcomes of antimicrobial de-escalation (ADE) based on mortality and the incidence of multi-drug resistant (MDR) pathogen occurrence in patients with culture-negative pneumonia presenting with sepsis and septic shock. Materials and Methods We retrospectively analyzed patients diagnosed with severe pneumonia requiring intensive care unit (ICU) admission and possessing negative microbiological culture results at a tertiary referral hospital in South Korea from March 2008 to July 2018. Results We identified 107 patients with culture-negative pneumonia. The Acute Physiologic and Chronic Health Evaluation (APACHE) II and Sepsis-related Organ Failure Assessment (SOFA) mean scores were 20.3 ± 8.6 and 9.6 ± 3.3, respectively. Among the patients, 40 (37.4%) underwent ADE. The APACHE II, SOFA, and follow-up SOFA scores did not differ significantly between the groups, and no differences were found in ICU mortality and MDR pathogen occurrence (27.5% vs 41.8%, P = .137 and 15.0% vs 16.9% P = .794, respectively). Conclusions We observed similar ICU mortality and MDR pathogen occurrence in patients with culture-negative pneumonia presenting with sepsis/shock regardless of whether they received ADE. Additionally, ADE lowered the antimicrobial burden. MDR pathogen occurrence was not reduced in patients who underwent ADE. ADE was not significantly associated with increased ICU mortality. Antimicrobial burden was significantly lower in ADE group.
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111
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt C, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar J, Bruyère R, Chanques G. Pneumonies associées aux soins de réanimation* RFE commune SFAR–SRLF. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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112
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Abstract
Pneumonia is a highly prevalent disease with considerable morbidity and mortality. However, diagnosis and therapy still rely on antiquated methods, leading to the vast overuse of antimicrobials, which carries risks for both society and the individual. Furthermore, outcomes in severe pneumonia remain poor. Genomic techniques have the potential to transform the management of pneumonia through deep characterization of pathogens as well as the host response to infection. This characterization will enable the delivery of selective antimicrobials and immunomodulatory therapy that will help to offset the disorder associated with overexuberant immune responses.
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Affiliation(s)
- Samir Gautam
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University, 300 Cedar Street, TACS441, New Haven, CT 06520-8057, USA
| | - Lokesh Sharma
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University, 300 Cedar Street, TACS441, New Haven, CT 06520-8057, USA
| | - Charles S Dela Cruz
- Pulmonary Critical Care and Sleep Medicine, Center for Pulmonary Infection Research and Treatment, Yale University, 300 Cedar Street, TACS441, New Haven, CT 06520-8057, USA.
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Abstract
Objective: Sepsis is a deadly infection that causes injury to tissues and organs. Infection and anti-infective treatment are the eternal themes of sepsis. The successful control of infection is a key factor of resuscitation for sepsis and septic shock. This review examines evidence for the treatment of sepsis. This evidence is combined with clinical experiments to reveal the rules and a standard flowchart of anti-infection therapy for sepsis. Data Sources: We retrieved information from the PubMed database up to October 2018 using various search terms and their combinations, including sepsis, septic shock, infection, antibiotics, and anti-infection. Study Selection: We included data from peer-reviewed journals printed in English on the relationships between infections and antibiotics. Results: By combining the literature review and clinical experience, we propose a 6Rs rule for sepsis and septic shock management: right patients, right time, right target, right antibiotics, right dose, and right source control. This rule encompasses rational decisions regarding the timing of treatment, the identification of the correct pathogen, the selection of appropriate antibiotics, the formulation of a scientifically based antibiotic dosage regimen, and the adequate control of infectious foci. Conclusions: This review highlights how to recognize and treat sepsis and septic shock and provides rules and a standard flowchart for anti-infection therapy for sepsis and septic shock for use in the clinical setting.
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Sadyrbaeva-Dolgova S, Aznarte-Padial P, Pasquau-Liaño J, Expósito-Ruiz M, Calleja Hernández MÁ, Hidalgo-Tenorio C. Clinical outcomes of carbapenem de-escalation regardless of microbiological results: A propensity score analysis. Int J Infect Dis 2019; 85:80-87. [PMID: 31075508 DOI: 10.1016/j.ijid.2019.04.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/27/2019] [Accepted: 04/30/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the safety and efficacy of de-escalation in patients under treatment with carbapenems and its impact on clinical outcomes. METHODS A prospective observational study was conducted for 1year. Patients administered active carbapenems for at least 24h were included. Primary outcomes were in-hospital mortality, mortality at 30 days after carbapenem prescription, and infection-related readmission within 30 days. De-escalation was defined as the substitution of carbapenem with narrower spectrum antimicrobial agents or its discontinuation during the first 96h of treatment. RESULTS The study included 1161 patients, and de-escalation was performed in 667 (57.5%) of these. In the de-escalation group, 54.9% of cultures were positive. After propensity score matching, 30-day mortality was lower (17.4% vs. 25.7%, p=0.036), carbapenem treatment was 4 days shorter (4 vs. 8 days, p<0.001), total antibiotic therapy duration was 2 days longer (12 vs. 10 days, p=0.003), and length of hospital stay was 5 days shorter (8 vs. 13 days, p=0.008) in the de-escalated versus non-de-escalated patients. In-hospital mortality and 30-day readmission rates did not differ significantly between these groups. CONCLUSION Carbapenem de-escalation is a safe strategy that does not compromise the clinical status of patients.
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Affiliation(s)
- Svetlana Sadyrbaeva-Dolgova
- Department of Pharmacy, University Hospital Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria de Granada, Granada, Spain.
| | - Pilar Aznarte-Padial
- Department of Pharmacy, University Hospital Virgen de las Nieves, Granada, Spain
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Niwa T, Yonetamari J, Hayama N, Fujibayashi A, Ito-Takeichi S, Suzuki K, Ohta H, Niwa A, Tsuchiya M, Yamamoto M, Hatakeyama D, Hayashi H, Obara M, Sugiyama T, Baba H, Suzuki A, Murakami N. Clinical impact of matrix-assisted laser desorption ionization-time of flight mass spectrometry combined with antimicrobial stewardship interventions in patients with bloodstream infections in a Japanese tertiary hospital. Int J Clin Pract 2019; 73:e13332. [PMID: 30810264 DOI: 10.1111/ijcp.13332] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/19/2018] [Accepted: 02/24/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) has the potential to permit early organism identification and optimization of antibiotic therapy. However, MALDI-TOF MS combined with antimicrobial stewardship is available at only a limited number of institutions. Here, we evaluated the clinical impact of implementing MALDI-TOF MS combined with antimicrobial stewardship intervention in patients with bloodstream infections. METHODS We conducted a single-centre, prospective cohort study to evaluate the clinical impact of implementing MALDI-TOF MS combined with antimicrobial stewardship intervention in patients with bloodstream infections. Processes and clinical outcomes in patients with bloodstream infections were compared before and after implementation of MALDI-TOF MS. RESULTS Compared with the conventional identification method, MALDI-TOF MS combined with antimicrobial stewardship intervention significantly decreased the time to organism identification (48.6 ± 46.0 hours vs 78.1 ± 38.9 hours, P < 0.001), effective antimicrobial therapy (12.9 ± 19.0 hours vs 26.2 ± 44.8 hours, P < 0.001) and optimal antimicrobial therapy (53.3 ± 55.0 hours vs 91.7 ± 88.7 hours, P < 0.001. Moreover, the rate of clinical failure (14.0% vs 33.3%, P < 0.001) and incidence of adverse events (7.5% vs 23.9%, P < 0.001) was lower in the MALDI-TOF MS group than in the conventional identification group. A multivariate Cox proportional hazard analysis indicated that implementation of MALDI-TOF MS was a protective factor against clinical failure in patients with bloodstream infections (hazard ratio, 0.61; 95% confidence interval, 0.38-0.99; P = 0.047). CONCLUSIONS Implementation of the MALDI-TOF MS combined with antimicrobial stewardship intervention facilitated early optimization of antimicrobial therapy with a remarkable concomitant reduction in clinical failure and adverse events in patients with bloodstream infections.
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Affiliation(s)
- Takashi Niwa
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Jun Yonetamari
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Nozomi Hayama
- Laboratory of Community Healthcare Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Ayasa Fujibayashi
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Syuri Ito-Takeichi
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Keiko Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Hirotoshi Ohta
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Ayumi Niwa
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Mayumi Tsuchiya
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Masayo Yamamoto
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Daijiro Hatakeyama
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Hideki Hayashi
- Laboratory of Community Healthcare Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
- Laboratory of Pharmacy Practice and Social Science, Gifu Pharmaceutical University, Gifu, Japan
| | - Michiko Obara
- Laboratory of Community Healthcare Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Tadashi Sugiyama
- Laboratory of Community Healthcare Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
- Laboratory of Pharmacy Practice and Social Science, Gifu Pharmaceutical University, Gifu, Japan
| | - Hisashi Baba
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Nobuo Murakami
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
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116
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Stewart SD, Allen S. Antibiotic use in critical illness. J Vet Emerg Crit Care (San Antonio) 2019; 29:227-238. [PMID: 31021520 DOI: 10.1111/vec.12842] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 05/17/2017] [Accepted: 06/12/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide a review on the current use of antimicrobials with a discussion on the pharmacokinetic and pharmacodynamic profiles of antimicrobials in critically ill patients, the challenges of drug resistance, the use of diagnostic testing to direct therapy, and the selection of the most likely efficacious antimicrobial protocol. ETIOLOGY Patients in the intensive care unit often possess profound pathophysiologic changes that can complicate antimicrobial therapy. Although many antimicrobials have known pharmacodynamic profiles, critical illness can cause wide variations in their pharmacokinetics. The two principal factors affecting pharmacokinetics are volume of distribution and drug clearance. Understanding the interplay between critical illness, drug pharmacokinetics, and antimicrobial characteristics (ie, time-dependent vs concentration-dependent) may improve antimicrobial efficacy and patient outcome. DIAGNOSIS Utilizing bacterial culture and susceptibility can aid in identifying drug resistant infections, selecting the most appropriate antimicrobials, and hindering the future development of drug resistance. THERAPY Having a basic knowledge of antimicrobial function and how to use diagnostics to direct therapeutic treatment is paramount in managing this patient population. Diagnostic testing is not always available at the time of initiation of antimicrobial therapy, so empiric selections are often necessary. These empiric choices should be made based on the location of the infection and the most likely infecting bacteria. PROGNOSIS Studies have demonstrated the importance of moving away from a "one dose fits all" approach to antimicrobial therapy. Instead there has been a move toward an individualized approach that takes into consideration the pharmacokinetic and pharmacodynamic variabilities that can occur in critically ill patients.
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Affiliation(s)
- Samuel D Stewart
- Emergency and Critical Care Service, Massachusetts Veterinary Referral Hospital, Woburn, MA
| | - Sarah Allen
- Emergency and Critical Care Service, Massachusetts Veterinary Referral Hospital, Woburn, MA
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Mahi-Birjand M, Ziaee M, Bijari B, Khalvati R, Abedini MR, Golboei Mousavi H, Ziaee A. Evaluation of vancomycin use in university-affiliated hospitals in Southern Khorasan Province (East Iran) based on HICPAC guidelines. DRUG HEALTHCARE AND PATIENT SAFETY 2019; 11:29-35. [PMID: 31040721 PMCID: PMC6459150 DOI: 10.2147/dhps.s187732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background Vancomycin resistance has raised concerns about its effectiveness prospect in the treatment of patients with Gram-positive infections. The Healthcare Infection Control Practices Advisory Committee (HICPAC) has recently established guidelines to delineate improper use of vancomycin. In this light, we sought out to determine the appropriateness of vancomycin prescription using the HICPAC guidelines. Setting The study was carried out in two university-affiliated hospitals, Valiasr and Imam Reza, with 297 and 234 beds, respectively, from May 2012 to May 2013. Methods This retrospective study evaluated the vancomycin prescription and usage in the hospitals. Total vancomycin use was determined and expressed as vancomycin courses per 298 admitted patients. The patient information was collected on a data collection sheet as follows: demographic variables, etiology and localization of infection, microbiological data, duration of vancomycin treatment, reasons for vancomycin prescription, prescribed antibiotic dosing, and patient regimen. Results The average age of the patients and vancomycin treatment duration were 55.965 years and 10.5 days, respectively. Septicemia (15.7%) was the most common cause of vancomycin administration. Vancomycin use was documented to be appropriate and inappropriate in 236 (89.4%) and 28 (10.6%) patients, respectively. No statistically significant differences were found among the wards and hospitals (P values =0.66 and 0.54, respectively) in terms of appropriateness of vancomycin use based on the HICPAC criteria. In addition, 29.21% and 62% of all patients exhibited complete and partial recovery, respectively. We found that 90% of the cases showed compliance with the HICPAC recommendations. Conclusion Comprehensive programs are required to improve the vancomycin use in the hospitals. Vancomycin use should be monitored due to its large-scale empiric use. The rate of improper use of vancomycin in the infection and intensive care unit services may be high, and pharmacists must take appropriate action to optimize the use of the drug.
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Affiliation(s)
- Motahare Mahi-Birjand
- Infectious Disease Research Center, Birjand University of Medical Sciences, Birjand, Iran,
| | - Masood Ziaee
- Infectious Disease Research Center, Birjand University of Medical Sciences, Birjand, Iran,
| | - Bita Bijari
- Infectious Disease Research Center, Birjand University of Medical Sciences, Birjand, Iran,
| | - Reza Khalvati
- Food and Drug Administration, Mazandaran University of Medical Sciences, Mazandaran, Iran
| | - Mohammad Reza Abedini
- Department of Pharmacology, Cellular and Molecular Research Center, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran
| | | | - Arash Ziaee
- Mashhad University of Medical Sciences, Mashhad, Iran
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Tsuchiya A, Yasunaga H, Tsutsumi Y, Kawahara T, Matsui H, Fushimi K. Nationwide observational study of mortality from complicated intra-abdominal infections and the role of bacterial cultures. Br J Surg 2019; 106:606-615. [PMID: 30883708 DOI: 10.1002/bjs.11095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/30/2018] [Accepted: 11/26/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The benefit of taking intra-abdominal cultures during source control procedures in patients with complicated intra-abdominal infection (CIAI) is unknown. The aim of this study was to evaluate whether intra-abdominal cultures reduce the mortality rate of CIAI. METHODS The Japanese Diagnosis Procedure Combination database was used to identify adult patients with CIAI who had undergone source control procedures on the first day of admission to hospital between April 2014 and March 2016. In-hospital mortality was compared between patients who did and those who did not have intra-abdominal cultures taken. A generalized linear mixed-effect logistic regression model and a random intercept per hospital were used to adjust for baseline confounders and institutional differences. Subgroup analyses were also performed according to disease cause, site of onset and severity of CIAI. RESULTS Intra-abdominal cultures were taken from 16 303 of 41 495 included patients. Multivariable logistic regression analysis showed that patients with intra-abdominal cultures had a significantly lower mortality than those without (odds ratio 0·85, 95 per cent c.i. 0·77 to 0·95). Subgroup analyses revealed statistically significant differences in mortality between patients with and without cultures among those with lower intestinal perforation, biliary tract infection/perforation, healthcare-associated CIAI and high-risk community-acquired CIAI. CONCLUSIONS Intra-abdominal cultures obtained during source control procedures may reduce in-hospital mortality, especially in patients with lower intestinal perforation, biliary tract infection/perforation, or healthcare-associated or high-risk community-acquired CIAI.
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Affiliation(s)
- A Tsuchiya
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan.,Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Centre, Ibaraki, Japan
| | - H Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Y Tsutsumi
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Centre, Ibaraki, Japan
| | - T Kawahara
- Biostatistics Division, Central Coordinating Unit, Clinical Research Support Centre, University of Tokyo Hospital, Tokyo, Japan
| | - H Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - K Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
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ESTRATEGIAS PARA EL USO DE ANTIBIÓTICOS EN PACIENTES CRÍTICOS. REVISTA MÉDICA CLÍNICA LAS CONDES 2019. [DOI: 10.1016/j.rmclc.2019.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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120
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Garnier M, Gallah S, Vimont S, Benzerara Y, Labbe V, Constant AL, Siami S, Guerot E, Compain F, Mainardi JL, Montil M, Quesnel C. Multicentre randomised controlled trial to investigate usefulness of the rapid diagnostic βLACTA test performed directly on bacterial cell pellets from respiratory, urinary or blood samples for the early de-escalation of carbapenems in septic intensive care unit patients: the BLUE-CarbA protocol. BMJ Open 2019; 9:e024561. [PMID: 30782909 PMCID: PMC6367973 DOI: 10.1136/bmjopen-2018-024561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 11/23/2018] [Accepted: 11/29/2018] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION The dramatic increase of the incidence of infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) has led to an increase of 50% of carbapenem consumption all around Europe in only 5 years. This favours the spread of carbapenem-resistant Gram-negative bacilli (GNB), causing life-threatening infections. In order to limit use of carbapenems for infections actually due to ESBL-PE, health authorities promote the use of rapid diagnostic tests of bacterial resistance. The objective of this work conducted in the intensive care unit (ICU) is to determine whether an early de-escalation of empirical carbapenems guided by the result of the βLACTA test is not inferior to the reference strategy of de-escalating carbapenems after the antibiogram result has been rendered. METHODS AND ANALYSIS This multicentre randomised controlled open-label non-inferiority clinical trial will include patients suffering from respiratory and/or urinary and/or bloodstream infections documented with GNB on direct examination and empirically treated with carbapenems. Empirical carbapenems will be adapted before the second dose depending on the results of the βLACTA test performed directly on the microbiological sample (intervention group) or after 48-72 hours depending on the definite antibiogram (control group). The primary outcome will combine 90-day mortality and percentage of infection recurrence during the ICU stay. The secondary outcomes will include the number of carbapenems defined daily doses and carbapenem-free days after inclusion, the proportion of new infections during ICU stay, new colonisation of patients' digestive tractus with multidrug-resistant GNB, ICU and hospital length of stay and cost-effectiveness ratio. ETHICS AND DISSEMINATION This protocol has been approved by the ethics committee of Paris-Ile-de-France IV, and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03147807.
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Affiliation(s)
- Marc Garnier
- Anesthesiology and Intensive Care Medicine Department, APHP—Tenon University Hospital, Paris, France
- Medico-surgical Intensive Care Unit, APHP—Tenon University Hospital, Paris, France
- Paris 6 School of Medicine, Sorbonne University, Paris, France
| | - Salah Gallah
- APHP—GHUEP—Microbiology Department, Paris, France
| | - Sophie Vimont
- Paris 6 School of Medicine, Sorbonne University, Paris, France
- APHP—GHUEP—Microbiology Department, Paris, France
| | | | - Vincent Labbe
- Medico-surgical Intensive Care Unit, APHP—Tenon University Hospital, Paris, France
| | - Anne-Laure Constant
- Cardio-thoracic Surgical Intensive Care Unit, APHP—European Georges Pompidou University Hospital, Paris, France
| | - Shidasp Siami
- Polyvalent Intensive Care Unit, Sud Essonne Hospital, Etampes, France
| | - Emmanuel Guerot
- APHP—European Georges Pompidou University Hospital, Medical Intensive Care Unit, Paris, France
| | - Fabrice Compain
- Microbiology Department, APHP—European Georges Pompidou University Hospital, Paris, France
| | - Jean-Luc Mainardi
- Microbiology Department, APHP—European Georges Pompidou University Hospital, Paris, France
| | - Mélissa Montil
- APHP—Clinical Research Platform (URCEst-CRCEst-CRB), St Antoine Hospital, Paris, France
| | - Christophe Quesnel
- Anesthesiology and Intensive Care Medicine Department, APHP—Tenon University Hospital, Paris, France
- Paris 6 School of Medicine, Sorbonne University, Paris, France
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Lambregts MMC, Bernards AT, van der Beek MT, Visser LG, de Boer MG. Time to positivity of blood cultures supports early re-evaluation of empiric broad-spectrum antimicrobial therapy. PLoS One 2019; 14:e0208819. [PMID: 30601829 PMCID: PMC6314566 DOI: 10.1371/journal.pone.0208819] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 11/25/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Blood cultures are considered the gold standard to distinguish bacteremia from non-bacteremic systemic inflammation. In current clinical practice, bacteraemia is considered unlikely if blood cultures have been negative for 48-72 hours. Modern BC systems have reduced this time-to-positivity (TTP), questioning whether the time frame of 48-72 hrs is still valid. This study investigates the distribution of TTP, the probability of blood culture positivity after 24 hours, and identifies clinical predictors of prolonged TTP. METHODS Adult patients with monomicrobial bacteremia in an academic hospital were included retrospectively over a three-year period. Clinical data were retrieved from the medical records. Predictors of TTP >24 hours were determined by uni- and multivariate analyses. The residual probability of bacteremia was estimated for the scenario of negative BCs at 24 hours after bedside collection. RESULTS The cohort consisted of 801 patients, accounting for 897 episodes of bacteremia. Mean age was 65 years (IQR 54-73), 534 (59.5%) patients were male. Median TTP was 15.7 (IQR 13.5-19.3) hours. TTP was ≤24 hours in 85.3% of episodes. Antibiotic pre-treatment (adjusted OR 1.77; 95%CI 1.14-2.74, p<0.01) was independently associated with prolonged TTP. The probability of bacteremia, if BC had remained negative for 24 hours, was 1.8% (95% CI 1.46-2.14). CONCLUSION With adequate hospital logistics, the probability of positive blood cultures after 24 hours of negative cultures was low. Combined with clinical reassessment, knowledge of this low probability may contribute to prioritization of the differential diagnosis and decisions on antimicrobial therapy. As a potential antibiotic stewardship tool, this strategy warrants further prospective investigation.
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Affiliation(s)
- Merel M. C. Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexandra T. Bernards
- Department of Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Leo G. Visser
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G. de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
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Seok H, Park DW. Optimal antimicrobial therapy and antimicrobial stewardship in sepsis and septic shock. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2019. [DOI: 10.5124/jkma.2019.62.12.638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Hyeri Seok
- Division of Infectious Diseases, Department of Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Dae Won Park
- Division of Infectious Diseases, Department of Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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Mathieu C, Pastene B, Cassir N, Martin-Loeches I, Leone M. Efficacy and safety of antimicrobial de-escalation as a clinical strategy. Expert Rev Anti Infect Ther 2018; 17:79-88. [PMID: 30570361 DOI: 10.1080/14787210.2019.1561275] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION De-escalation is a widely recommended strategy in regard to guidelines, with an associated adherence to guidelines being around 50%. This review discusses data supporting de-escalation and possible obstacles for its implementation. Areas covered: Although it does not have a consensual definition, de-escalation consists of reducing the spectrum of empirical antimicrobial treatment based on the microbiological findings. Many observational studies have suggested that this strategy is likely safe and efficient for treating various types of infection. However, randomized controlled trials published as of now have not shown any improvement on the outcomes. Regarding the adverse effects of de-escalation on ecological pressure and multidrug resistance emergence, the data are contradictory. The implementation of new techniques, such as rapid diagnosis, can help guide clinicians. Expert opinion: De-escalation should be included as part of a large antibiotic stewardship program to balance the risk and benefit of each administration, and each physician prescribing antibiotics should be challenged for the quality of her/his prescription on a daily basis. In the future, one of our duties will involve determining whether a delay of antimicrobial treatment - making it possible to improve diagnostic performance and obtain the first laboratory results - is either safe or unsafe for our patients.
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Affiliation(s)
- Calypso Mathieu
- a Assistance Publique Hôpitaux de Marseille, Service d'anesthésie et de réanimation , Aix-Marseille Université , Marseille , France
| | - Bruno Pastene
- a Assistance Publique Hôpitaux de Marseille, Service d'anesthésie et de réanimation , Aix-Marseille Université , Marseille , France
| | - Nadim Cassir
- b IRD, APHM, MEPHI, IHU-Méditerranée Infection , Aix-Marseille Université , Marseille , France
| | - Ignacio Martin-Loeches
- c Multidisciplinary Intensive Care Research Organization (MICRO) , St James's Hospital , Dublin , Ireland
| | - Marc Leone
- a Assistance Publique Hôpitaux de Marseille, Service d'anesthésie et de réanimation , Aix-Marseille Université , Marseille , France.,b IRD, APHM, MEPHI, IHU-Méditerranée Infection , Aix-Marseille Université , Marseille , France
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Dray S, Coiffard B, Persico N, Papazian L, Hraiech S. Are tracheal surveillance cultures useful in the intensive care unit? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:421. [PMID: 30581829 DOI: 10.21037/atm.2018.08.39] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endotracheal aspirate (ETA) surveillance cultures have been used to predict the microorganisms responsible for ventilator associated pneumonia (VAP) in intensive care unit (ICU) patients for 3 decades. However, although more than a dozen studies have been performed, the usefulness and the safety of this strategy are still debated. Tracheobronchial bacterial colonization often precedes the occurrence of VAP, and it has been postulated that the microbes present in the tracheal secretions a few days before VAP might be the same as those retrieved in the lower respiratory tract. A large number of studies, with heterogeneous designs and variable results, have questioned the possibility of predicting, by regular ETA cultures after the 48th hour of mechanical ventilation (MV), the microbiology of VAP and therefore of determining the adequate antibiotic therapy to limit the over-prescription of broad spectrum molecules when following guidelines. Although it has shown some promising results, the strategy has not achieved unanimity because of some discordant data. The aim of this review is to provide an updated overview of the literature available in the field and to attempt to determine the strengths and weaknesses of antibiotic stewardship based on ETA surveillance cultures in VAP, particularly in the global context of drug resistant microorganism emergence and the crucial necessity of broad spectrum molecule preservation.
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Affiliation(s)
- Sandrine Dray
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS - Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Benjamin Coiffard
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS - Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Nicolas Persico
- Service d'Accueil des Urgences Adultes, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France.,Aix-Marseille Université, Assistance Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | - Laurent Papazian
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS - Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Sami Hraiech
- Service de Médecine Intensive - Réanimation, APHM, Hôpital Nord, Marseille, France.,CEReSS - Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
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126
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Li H, Yang CH, Huang LO, Cui YH, Xu D, Wu CR, Tang JG. Antibiotics De-Escalation in the Treatment of Ventilator-Associated Pneumonia in Trauma Patients: A Retrospective Study on Propensity Score Matching Method. Chin Med J (Engl) 2018; 131:1151-1157. [PMID: 29722334 PMCID: PMC5956765 DOI: 10.4103/0366-6999.231529] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: Antimicrobial de-escalation refers to starting the antimicrobial treatment with broad-spectrum antibiotics, followed by narrowing the drug spectrum according to culture results. The present study evaluated the effect of de-escalation on ventilator-associated pneumonia (VAP) in trauma patients. Methods: This retrospective study was conducted on trauma patients with VAP, who received de-escalation therapy (de-escalation group) or non-de-escalation therapy (non-de-escalation group). Propensity score matching method was used to balance the baseline characteristics between both groups. The 28-day mortality, length of hospitalization and Intensive Care Unit stay, and expense of antibiotics and hospitalization between both groups were compared. Multivariable analysis explored the factors that influenced the 28-day mortality and implementation of de-escalation. Results: Among the 156 patients, 62 patients received de-escalation therapy and 94 patients received non-de-escalation therapy. No significant difference was observed in 28-day mortality between both groups (28.6% vs. 23.8%, P = 0.620). The duration of antibiotics treatment in the de-escalation group was shorter than that in the non-de-escalation group (11 [8–13] vs. 14 [8–19] days, P = 0.045). The expenses of antibiotics and hospitalization in de-escalation group were significantly lower than that in the non-de-escalation group (6430 ± 2730 vs. 7618 ± 2568 RMB Yuan, P = 0.043 and 19,173 ± 16,861 vs. 24,184 ± 12,039 RMB Yuan, P = 0.024, respectively). Multivariate analysis showed that high Acute Physiology and Chronic Health Evaluation II (APACHE II) score, high injury severity score, multi-drug resistant (MDR) infection, and inappropriate initial antibiotics were associated with patients' 28-day mortality, while high APACHE II score, MDR infection and inappropriate initial antibiotics were independent factors that prevented the implementation of de-escalation. Conclusions: De-escalation strategy in the treatment of trauma patients with VAP could reduce the duration of antibiotics treatments and expense of hospitalization, without increasing the 28-day mortality and MDR infection.
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Affiliation(s)
- Hu Li
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Chun-Hui Yang
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Li-Ou Huang
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Yu-Hui Cui
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Dan Xu
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Chun-Rong Wu
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Jian-Guo Tang
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
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127
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Antibiotic therapy in the critically ill - expert opinion of the Intensive Care Medicine Scientific Subcommittee of the European Society of Anaesthesiology. Eur J Anaesthesiol 2018; 34:215-220. [PMID: 28248705 DOI: 10.1097/eja.0000000000000595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Antimicrobial treatment is the cornerstone of infection treatment, and the selection of appropriate antibiotic treatment for critically ill patients is challenging. Clinicians working with critically ill patients usually feel a greater obligation towards their patient than towards maintenance of the delicate ecological balance of prevalent microbiological threats and their resistance patterns. Although antibiotic overtreatment is a frequent phenomenon, patient outcomes need not be compromised when antibiotic treatment is driven by informed decision-making.At the 2016 Euro Anaesthesia Conference (London, UK), the European Society of Anaesthesia Intensive Care Scientific Subcommittee convened an expert panel on antibiotic therapy. This article summarises the main conclusions of the panel, namely the principles of antibiotic therapy that all physicians working with critically ill patients must know.
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128
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Septimus EJ. Antimicrobial Resistance: An Antimicrobial/Diagnostic Stewardship and Infection Prevention Approach. Med Clin North Am 2018; 102:819-829. [PMID: 30126573 DOI: 10.1016/j.mcna.2018.04.005] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Antimicrobial resistance (AR) is one of the most serious public health threats today, which has been accelerated by the overuse and misuse of antimicrobials in humans and animals plus inadequate infection prevention. Numerous studies have shown a relationship between antimicrobial use and resistance. Antimicrobial stewardship (AS) programs have been shown to improve patient outcomes, reduce antimicrobial adverse events, and decrease AR. AS programs, when implemented alongside infection control measures, especially hand-hygiene interventions, were more effective than implementation of AS alone. Targeted coordination and prevention strategies are critical to stopping the spread of multidrug-resistant organisms.
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129
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Detection of pathogenic microorganisms from bloodstream infection specimens using TaqMan array card technology. Sci Rep 2018; 8:12828. [PMID: 30150783 PMCID: PMC6110752 DOI: 10.1038/s41598-018-31200-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 08/14/2018] [Indexed: 12/28/2022] Open
Abstract
Bloodstream infections (BSIs) are often life-threatening, and rapid identification is critical. Here, we developed a TaqMan array card (TAC) assay to detect pathogens in BSI specimens. The TAC included 30 primer/probe pairs targeting 27 species and 3 controls. Reverse transcription and 0.1% blue dextran 2000 increased the TAC assay efficiency. The primer/probe pairs had a limit of detection of 100–102 CFU/mL and a specificity of 100%. For whole blood specimens, the TAC assay showed a sensitivity and specificity of 79.4% and 99.69%, respectively. For blood culture samples, the TAC assay showed a sensitivity and specificity of 100% and 99.67%, respectively. The TAC assay could be a promising method for early detection of bloodstream infection.
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130
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Wirz Y, Meier MA, Bouadma L, Luyt CE, Wolff M, Chastre J, Tubach F, Schroeder S, Nobre V, Annane D, Reinhart K, Damas P, Nijsten M, Shajiei A, deLange DW, Deliberato RO, Oliveira CF, Shehabi Y, van Oers JAH, Beishuizen A, Girbes ARJ, de Jong E, Mueller B, Schuetz P. Effect of procalcitonin-guided antibiotic treatment on clinical outcomes in intensive care unit patients with infection and sepsis patients: a patient-level meta-analysis of randomized trials. Crit Care 2018; 22:191. [PMID: 30111341 PMCID: PMC6092799 DOI: 10.1186/s13054-018-2125-7] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 07/10/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The clinical utility of serum procalcitonin levels in guiding antibiotic treatment decisions in patients with sepsis remains unclear. This patient-level meta-analysis based on 11 randomized trials investigates the impact of procalcitonin-guided antibiotic therapy on mortality in intensive care unit (ICU) patients with infection, both overall and stratified according to sepsis definition, severity, and type of infection. METHODS For this meta-analysis focusing on procalcitonin-guided antibiotic management in critically ill patients with sepsis of any type, in February 2018 we updated the database of a previous individual patient data meta-analysis which was limited to patients with respiratory infections only. We used individual patient data from 11 trials that randomly assigned patients to receive antibiotics based on procalcitonin levels (the "procalcitonin-guided" group) or the current standard of care (the "controls"). The primary endpoint was mortality within 30 days. Secondary endpoints were duration of antibiotic treatment and length of stay. RESULTS Mortality in the 2252 procalcitonin-guided patients was significantly lower compared with the 2230 control group patients (21.1% vs 23.7%; adjusted odds ratio 0.89, 95% confidence interval (CI) 0.8 to 0.99; p = 0.03). These effects on mortality persisted in a subgroup of patients meeting the sepsis 3 definition and based on the severity of sepsis (assessed on the basis of the Sequential Organ Failure Assessment (SOFA) score, occurrence of septic shock or renal failure, and need for vasopressor or ventilatory support) and on the type of infection (respiratory, urinary tract, abdominal, skin, or central nervous system), with interaction for each analysis being > 0.05. Procalcitonin guidance also facilitated earlier discontinuation of antibiotics, with a reduction in treatment duration (9.3 vs 10.4 days; adjusted coefficient -1.19 days, 95% CI -1.73 to -0.66; p < 0.001). CONCLUSION Procalcitonin-guided antibiotic treatment in ICU patients with infection and sepsis patients results in improved survival and lower antibiotic treatment duration.
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Affiliation(s)
- Yannick Wirz
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Marc A. Meier
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Lila Bouadma
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, AP-HP, Paris, France
| | - Charles E. Luyt
- Service de Réanimation Médicale, Université Paris 6-Pierre-et-Marie-Curie, Paris, France
| | - Michel Wolff
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, AP-HP, Paris, France
| | - Jean Chastre
- Service de Réanimation Médicale, Université Paris 6-Pierre-et-Marie-Curie, Paris, France
| | - Florence Tubach
- Département d’Epidémiologie Biostatistique et Recherche Clinique, AP-HP, Hôpitaux Universitaires Paris Nord Val de Seine, Paris, France
| | - Stefan Schroeder
- Department of Anesthesiology and Intensive Care Medicine, Krankenhaus Dueren, Dueren, Germany
| | - Vandack Nobre
- Department of Intensive Care, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Djillali Annane
- Critical Care Department, Hôpital Raymond Poincaré, Assistance Publique - Hôpitaux de Paris, Garches, France
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Pierre Damas
- Department of General Intensive Care, University Hospital of Liege, Domaine universitaire de Liège, Liege, Belgium
| | - Maarten Nijsten
- University Medical Centre, University of Groningen, Groningen, The Netherlands
| | - Arezoo Shajiei
- University Medical Centre, University of Groningen, Groningen, The Netherlands
| | | | - Rodrigo O. Deliberato
- Laboratory for Critical Care Research, Critical Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Carolina F. Oliveira
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Yahya Shehabi
- Critical Care and Peri-operative Medicine, Monash Health, Melbourne, Australia
- Faculty of Medicine Nursing and Health Sciences, School of Clinical Sciences, Monash University, Melbourne, Australia
| | | | | | | | | | - Beat Mueller
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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131
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Richter DC, Heininger A, Brenner T, Hochreiter M, Bernhard M, Briegel J, Dubler S, Grabein B, Hecker A, Krüger WA, Mayer K, Pletz MW, Störzinger D, Pinder N, Hoppe-Tichy T, Weiterer S, Zimmermann S, Brinkmann A, Weigand MA, Lichtenstern C. [Bacterial sepsis : Diagnostics and calculated antibiotic therapy]. Anaesthesist 2018; 66:737-761. [PMID: 28980026 DOI: 10.1007/s00101-017-0363-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The mortality of patients with sepsis and septic shock is still unacceptably high. An effective antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed focus and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account for selection of anti-infection treatment. Many pathophysiological alterations influence the pharmacokinetics of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of beta-lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM but for continuous infusion TDM is basically necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug resistant pathogens (MDR) in the intensive care unit. For effective treatment antibiotic stewardship teams (ABS team) are becoming more established. Interdisciplinary cooperation of the ABS team with infectiologists, microbiologists and clinical pharmacists leads not only to a rational administration of antibiotics but also has a positive influence on the outcome. The gold standards for pathogen detection are still culture-based detection and microbiological resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction (PCR)-based procedures for pathogen identification and resistance determination, are currently only an adjunct to routine sepsis diagnostics due to the limited number of studies, high costs and limited availability. In complicated septic courses with multiple anti-infective treatment or recurrent sepsis, PCR-based procedures can be used in addition to therapy monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation).
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Affiliation(s)
- D C Richter
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
| | - A Heininger
- Zentrum für Infektiologie, Sektion für Krankenhaus- und Umwelthygiene, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Hochreiter
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - J Briegel
- Klinik für Anästhesiologie, Klinikum der Universität München, München, Deutschland
| | - S Dubler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - B Grabein
- Stabsstelle "Klinische Mikrobiologie und Krankenhaushygiene", Klinikum der Universität München, München, Deutschland
| | - A Hecker
- Klinik für Allgemein‑, Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland
| | - W A Krüger
- Klinik für Anästhesiologie und operative Intensivmedizin, Gesundheitsverbund Landkreis Konstanz, Klinikum Konstanz, Konstanz, Deutschland
| | - K Mayer
- Apotheke des Universitätsklinikums Heidelberg, Heidelberg, Deutschland
| | - M W Pletz
- Zentrum für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Jena, Deutschland
| | - D Störzinger
- Apotheke des Universitätsklinikums Heidelberg, Heidelberg, Deutschland
| | - N Pinder
- Apotheke des Universitätsklinikums Heidelberg, Heidelberg, Deutschland
| | - T Hoppe-Tichy
- Zentrum für Infektiologie, Sektion für Krankenhaus- und Umwelthygiene, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - S Weiterer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - S Zimmermann
- Zentrum für Infektiologie, Sektion für Krankenhaus- und Umwelthygiene, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - A Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Heidenheim, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - Christoph Lichtenstern
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
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132
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Montrucchio G, Sales G, Corcione S, De Rosa FG, Brazzi L. Choosing wisely: what is the actual role of antimicrobial stewardship in Intensive Care Units? Minerva Anestesiol 2018; 85:71-82. [PMID: 29991221 DOI: 10.23736/s0375-9393.18.12662-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
More than two-thirds of critically ill patients receive an antimicrobial therapy with a percentage between 30% and 50% of all prescribed antibiotics reported to be unnecessary, inappropriate or misused. Since inappropriate prescription of antibiotic drugs concurs to dissemination of the multidrug resistant organisms, a reasoned antibiotics use is crucial especially in Intensive Care Unit (ICU), where up to 60% of the admitted patients develops an infection during their ICU stay. Even if the concept of antimicrobial stewardship (AS) has been clearly described as a series of coordinated interventions designed to improve antimicrobial agents use, few studies are reporting about its effectiveness to improve outcomes, reduce adverse events and costs and decrease resistance rate spread. Moreover, although it is recognized that AS programs are particularly indicated in the critical setting due to the huge number of antimicrobial drugs used, the optimal characteristics of these interventions and the best system to evaluate their effectiveness are still unclear. Specific interventions, designed tacking into account the peculiarities of the ICU setting, are hence necessary to set-up an "in-ICU-stewardship," including prompt identification of infected patients, selection of appropriate empiric treatments, optimization of dosing and route of administration, improvement of diagnostic techniques, early de-escalation to achieve shorter duration and avoid unnecessary therapies. The present narrative review summarizes the "state of art" about AS programmes and discusses the effects of the interventions possibly applied in ICU setting to optimize the patient's treatment, reduce the micro-organisms resistance and contain the hospital resources utilization.
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Affiliation(s)
| | - Gabriele Sales
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Francesco G De Rosa
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy.,Department of Anaesthesia, Intensive Care and Emergency, "Città della Salute e della Scienza" Hospital, Turin, Italy
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133
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Gray ME, Cox HL, Donohue LE, Poulter MD, Eby JC, Mathers AJ. The effect of rapid diagnostic testing with Infectious Diseases fellow consultative intervention on the management of enterococcal bloodstream infection. Diagn Microbiol Infect Dis 2018; 92:319-324. [PMID: 30145036 DOI: 10.1016/j.diagmicrobio.2018.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 06/25/2018] [Accepted: 07/03/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Rapid diagnostics for enterococcal bloodstream infections (E-BSIs) can decrease the time to speciation and determination of vancomycin resistance but may not lead to improved antibiotic stewardship. METHODS Over 3 years, the time to administration of institutionally preferred antibiotics (IPT) for patients with E-BSI was evaluated and compared between 3 intervention groups: before (baseline) and after implementation of a rapid diagnostic (BC-GP), and the use of BC-GP with an Infectious Diseases (ID) fellow-driven consultative intervention (BC-GP + ID). RESULTS A total of 110 patients (63 baseline, 13 BC-GP, 34 BC-GP + ID) with E-BSI were evaluated. Evaluation of Enterococcus faecium BSI showed that the time IPT was significantly reduced with BC-GP + ID by 10.6 h from baseline (P = 0.02) and 5.4 h from BC-GP (P = 0.04). CONCLUSIONS An ID fellow-driven stewardship intervention was associated with a significant improvement in time to IPT for patients with E. faecium but not E. faecalis BSI.
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Affiliation(s)
- Megan E Gray
- Division of Infectious Diseases and International Health, University of Virginia Medical Center, Charlottesville, United States.
| | - Heather L Cox
- Division of Infectious Diseases and International Health, University of Virginia Medical Center, Charlottesville, United States; Department of Pharmacy, University of Virginia Medical Center, Charlottesville, Virginia, United States
| | - Lindsay E Donohue
- Department of Pharmacy, University of Virginia Medical Center, Charlottesville, Virginia, United States
| | - Melinda D Poulter
- Clinical Microbiology Laboratory, University of Virginia Medical Center, Charlottesville, Virginia, United States
| | - Joshua C Eby
- Division of Infectious Diseases and International Health, University of Virginia Medical Center, Charlottesville, United States
| | - Amy J Mathers
- Division of Infectious Diseases and International Health, University of Virginia Medical Center, Charlottesville, United States; Clinical Microbiology Laboratory, University of Virginia Medical Center, Charlottesville, Virginia, United States.
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134
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Russo A, Falcone M, Gutiérrez-Gutiérrez B, Calbo E, Almirante B, Viale PL, Oliver A, Ruiz-Garbajosa P, Gasch O, Gozalo M, Pitout J, Akova M, Peña C, Cisneros JM, Hernández-Torres A, Farcomeni A, Prim N, Origüen J, Bou G, Tacconelli E, Tumbarello M, Hamprecht A, Karaiskos I, de la Calle C, Pérez F, Schwaber MJ, Bermejo J, Lowman W, Hsueh PR, Mora-Rillo M, Rodriguez-Gomez J, Souli M, Bonomo RA, Paterson DL, Carmeli Y, Pascual A, Rodríguez-Baño J, Venditti M. Predictors of outcome in patients with severe sepsis or septic shock due to extended-spectrum β-lactamase-producing Enterobacteriaceae. Int J Antimicrob Agents 2018; 52:577-585. [PMID: 29969692 DOI: 10.1016/j.ijantimicag.2018.06.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/06/2018] [Accepted: 06/18/2018] [Indexed: 11/16/2022]
Abstract
PURPOSE There are few data in the literature regarding sepsis or septic shock due to extended-spectrum β-lactamases (ESBL)-producing Enterobacteriaceae (E). The aim of this study was to assess predictors of outcome in septic patients with bloodstream infection (BSI) caused by ESBL-E. METHODS Patients with severe sepsis or septic shock and BSI due to ESBL-E were selected from the INCREMENT database. The primary endpoint of the study was the evaluation of predictors of outcome after 30 days from development of severe sepsis or septic shock due to ESBL-E infection. Three cohorts were created for analysis: global, empirical-therapy and targeted-therapy cohorts. RESULTS 367 septic patients were analysed. Overall mortality was 43.9% at 30 days. Escherichia coli (62.4%) and Klebsiella pneumoniae (27.2%) were the most frequent isolates. β-lactam/β-lactamase inhibitor (BLBLI) combinations were the most empirically used drug (43.6%), followed by carbapenems (29.4%). Empirical therapy was active in vitro in 249 (67.8%) patients, and escalation of antibiotic therapy was reported in 287 (78.2%) patients. Cox regression analysis showed that age, Charlson Comorbidity Index, McCabe classification, Pitt bacteremia score, abdominal source of infection and escalation of antibiotic therapy were independently associated with 30-day mortality. No differences in survival were reported in patients treated with BLBLI combinations or carbapenems in empirical or definitive therapy. CONCLUSIONS BSI due to ESBL-E in patients who developed severe sepsis or septic shock was associated with high 30-day mortality. Comorbidities, severity scores, source of infection and antibiotic therapy escalation were important determinants of unfavorable outcome.
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Affiliation(s)
- A Russo
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, University of Rome La Sapienza, Rome, Italy
| | - M Falcone
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, University of Rome La Sapienza, Rome, Italy
| | - B Gutiérrez-Gutiérrez
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena / Universidad de Sevilla / Instituto de Biomedicina de Sevilla, Seville, Spain
| | - E Calbo
- Hospital Universitari Mútua de Terrassa, Barcelona, Spain
| | - B Almirante
- Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - P L Viale
- Teaching Hospital Policlinico S. Orsola Malpighi, Bologna, Italy
| | - A Oliver
- Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma de Mallorca, Spain
| | | | - O Gasch
- Corporacio Sanitaria Parc Taulí, Sabadell, Barcelona, Spain
| | - M Gozalo
- Hospital Universitario Marqués de Valdecilla - IDIVAL, Santander, Spain
| | - J Pitout
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - M Akova
- Hacettepe University School of Medicine, Ankara, Turkey
| | - C Peña
- Hospital Universitari de Bellvitge, Barcelona, Spain
| | - J M Cisneros
- Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocio, CSIC, University of Seville, Seville, Spain
| | | | - A Farcomeni
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, University of Rome La Sapienza, Rome, Italy
| | - N Prim
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - J Origüen
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | - G Bou
- Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - E Tacconelli
- Universitätsklinikum Tübingen, Tübingen, Germany
| | - M Tumbarello
- Catholic University of the Sacred Heart, Rome, Italy
| | - A Hamprecht
- Institut für Mikrobiologie, Immunologie und Hygiene Universitätsklinikum Köln, Cologne, Germany
| | | | | | - F Pérez
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA
| | - M J Schwaber
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, and National Center for Infection Control, Israel Ministry of Health, Tel Aviv, Israel, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J Bermejo
- Hospital Español, Rosario, Argentina
| | - W Lowman
- Wits Donald Gordon Medical Centre, Johannesburg, South Africa
| | - P-R Hsueh
- National Taiwan University Hospital, National Taiwan University Hospital College of Medicine, Taipei, Taiwan
| | - M Mora-Rillo
- Hospital Universitario La Paz-IdiPAZ, Madrid, Spain
| | - J Rodriguez-Gomez
- Intensive Care Unit. Biomedical Research Institute of Cordoba (IMIBIC)/ Reina Sofia University Hospital/University of Cordoba, Córdoba, Spain
| | - M Souli
- University General Hospital Attikon, Chaidari, Greece
| | - R A Bonomo
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, USA; Departments of Medicine, Pharmacology, Biochemistry, Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland Ohio, USA
| | - D L Paterson
- University of Queensland Centre for Clinical Research, The University of Queensland, Herston, Brisbane, Australia
| | - Y Carmeli
- Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, and National Center for Infection Control, Israel Ministry of Health, Tel Aviv, Israel, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Pascual
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena / Universidad de Sevilla / Instituto de Biomedicina de Sevilla, Seville, Spain
| | - J Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena / Universidad de Sevilla / Instituto de Biomedicina de Sevilla, Seville, Spain
| | - M Venditti
- Department of Public Health and Infectious Diseases, Policlinico Umberto I, University of Rome La Sapienza, Rome, Italy.
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Ferrer R, Martínez ML, Gomà G, Suárez D, Álvarez-Rocha L, de la Torre MV, González G, Zaragoza R, Borges M, Blanco J, Herrejón EP, Artigas A. Improved empirical antibiotic treatment of sepsis after an educational intervention: the ABISS-Edusepsis study. CRITICAL CARE (LONDON, ENGLAND) 2018. [PMID: 29933756 DOI: 10.1186/s13054-18-2091-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early appropriate antibiotic treatment is essential in sepsis. We aimed to evaluate the impact of a multifaceted educational intervention to improve antibiotic treatment. We hypothesized that the intervention would hasten and improve the appropriateness of empirical antibiotic administration, favor de-escalation, and decrease mortality. METHODS We prospectively studied all consecutive patients with sepsis/septic shock admitted to 72 intensive care units (ICUs) throughout Spain in two 4-month periods (before and immediately after the 3-month intervention). We compared process-of-care variables (resuscitation bundle and time-to-initiation, appropriateness, and de-escalation of empirical antibiotic treatment) and outcome variables between the two cohorts. The primary outcome was hospital mortality. We analyzed the intervention's long-term impact in a subset of 50 ICUs. RESULTS We included 2628 patients (age 64.1 ± 15.2 years; men 64.0%; Acute Physiology and Chronic Health Evaluation (APACHE) II, 22.0 ± 8.1): 1352 in the preintervention cohort and 1276 in the postintervention cohort. In the postintervention cohort, the mean (SD) time from sepsis onset to empirical antibiotic therapy was lower (2.0 (2.7) vs. 2.5 (3.6) h; p = 0.002), the proportion of inappropriate empirical treatments was lower (6.5% vs. 8.9%; p = 0.024), and the proportion of patients in whom antibiotic treatment was de-escalated was higher (20.1% vs. 16.3%; p = 0.004); the expected reduction in mortality did not reach statistical significance (29.4% in the postintervention cohort vs. 30.5% in the preintervention cohort; p = 0.544). Gains observed after the intervention were maintained in the long-term follow-up period. CONCLUSIONS Despite advances in sepsis treatment, educational interventions can still improve the delivery of care; further improvements might also improve outcomes.
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Affiliation(s)
- Ricard Ferrer
- Intensive Care Department, Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain. .,CIBER Enfermedades Respiratorias, Madrid, Spain.
| | - María Luisa Martínez
- Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain
| | - Gemma Gomà
- Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - David Suárez
- Epidemiology and Assessment Unit, Fundació Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - Luis Álvarez-Rocha
- Intensive Care Department, Hospital Universitario de la Coruña, A Coruña, Spain
| | | | - Gumersindo González
- Intensive Care Department, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Rafael Zaragoza
- Intensive Care Department, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Marcio Borges
- Intensive Care Department, Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Jesús Blanco
- CIBER Enfermedades Respiratorias, Madrid, Spain.,Intensive Care Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Antonio Artigas
- CIBER Enfermedades Respiratorias, Madrid, Spain.,Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain.,Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
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Ferrer R, Martínez ML, Gomà G, Suárez D, Álvarez-Rocha L, de la Torre MV, González G, Zaragoza R, Borges M, Blanco J, Herrejón EP, Artigas A. Improved empirical antibiotic treatment of sepsis after an educational intervention: the ABISS-Edusepsis study. Crit Care 2018; 22:167. [PMID: 29933756 PMCID: PMC6013897 DOI: 10.1186/s13054-018-2091-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 06/08/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Early appropriate antibiotic treatment is essential in sepsis. We aimed to evaluate the impact of a multifaceted educational intervention to improve antibiotic treatment. We hypothesized that the intervention would hasten and improve the appropriateness of empirical antibiotic administration, favor de-escalation, and decrease mortality. METHODS We prospectively studied all consecutive patients with sepsis/septic shock admitted to 72 intensive care units (ICUs) throughout Spain in two 4-month periods (before and immediately after the 3-month intervention). We compared process-of-care variables (resuscitation bundle and time-to-initiation, appropriateness, and de-escalation of empirical antibiotic treatment) and outcome variables between the two cohorts. The primary outcome was hospital mortality. We analyzed the intervention's long-term impact in a subset of 50 ICUs. RESULTS We included 2628 patients (age 64.1 ± 15.2 years; men 64.0%; Acute Physiology and Chronic Health Evaluation (APACHE) II, 22.0 ± 8.1): 1352 in the preintervention cohort and 1276 in the postintervention cohort. In the postintervention cohort, the mean (SD) time from sepsis onset to empirical antibiotic therapy was lower (2.0 (2.7) vs. 2.5 (3.6) h; p = 0.002), the proportion of inappropriate empirical treatments was lower (6.5% vs. 8.9%; p = 0.024), and the proportion of patients in whom antibiotic treatment was de-escalated was higher (20.1% vs. 16.3%; p = 0.004); the expected reduction in mortality did not reach statistical significance (29.4% in the postintervention cohort vs. 30.5% in the preintervention cohort; p = 0.544). Gains observed after the intervention were maintained in the long-term follow-up period. CONCLUSIONS Despite advances in sepsis treatment, educational interventions can still improve the delivery of care; further improvements might also improve outcomes.
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Affiliation(s)
- Ricard Ferrer
- Intensive Care Department, Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain.
- CIBER Enfermedades Respiratorias, Madrid, Spain.
| | - María Luisa Martínez
- Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain
| | - Gemma Gomà
- Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - David Suárez
- Epidemiology and Assessment Unit, Fundació Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - Luis Álvarez-Rocha
- Intensive Care Department, Hospital Universitario de la Coruña, A Coruña, Spain
| | | | - Gumersindo González
- Intensive Care Department, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Rafael Zaragoza
- Intensive Care Department, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Marcio Borges
- Intensive Care Department, Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Jesús Blanco
- CIBER Enfermedades Respiratorias, Madrid, Spain
- Intensive Care Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Antonio Artigas
- CIBER Enfermedades Respiratorias, Madrid, Spain
- Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain
- Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
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Scheer CS, Fuchs C, Gründling M, Vollmer M, Bast J, Bohnert JA, Zimmermann K, Hahnenkamp K, Rehberg S, Kuhn SO. Impact of antibiotic administration on blood culture positivity at the beginning of sepsis: a prospective clinical cohort study. Clin Microbiol Infect 2018; 25:326-331. [PMID: 29879482 DOI: 10.1016/j.cmi.2018.05.016] [Citation(s) in RCA: 119] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/09/2018] [Accepted: 05/12/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Sepsis guidelines recommend obtaining blood cultures before starting anti-infective therapy in patients with sepsis. However, little is known of how antibiotic treatment before sampling affects bacterial growth. The aim of this study was to compare the results of blood cultures drawn before and during antibiotic therapy. METHODS Prospective clinical cohort study of septic patients. Adult intensive care unit patients with two or three blood culture sets at the beginning of sepsis between 2010 and 2017 were included. Patients with blood culture samples obtained before antibiotic therapy were compared with patients with samples taken during antibiotic therapy. Blood culture positivity, defined as presence of a microbiological pathogen, was compared between the groups. Logistic regression was performed to adjust the impact of different factors with respect to blood culture positivity. RESULTS In total, 559 patients with 1364 blood culture sets at the beginning of sepsis were analysed. Blood culture positivity was 50.6% (78/154) among patients with sepsis who did not receive antibiotics and only 27.7% (112/405) in those who were already receiving antibiotics (p <0.001). Logistic regression revealed antibiotic therapy as an independent factor for less pathogen identification (odds ratio 0.4; 95% CI 0.3-0.6). Gram-positive pathogens (28.3% (111/392) versus 11.9% (116/972); p <0.001) and also Gram-negative pathogens (16.3% (64/392) versus 9.3% (90/972); p <0.001) were more frequent in blood culture sets drawn before antibiotic therapy compared with sets obtained during antibiotic therapy. CONCLUSIONS Obtaining blood cultures during antibiotic therapy is associated with a significant loss of pathogen detection. This strongly emphasizes the current recommendation to obtain blood cultures before antibiotic administration in patients with sepsis.
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Affiliation(s)
- C S Scheer
- Department of Anesthesiology, University Hospital Greifswald, Germany.
| | - C Fuchs
- Department of Anesthesiology, University Hospital Greifswald, Germany
| | - M Gründling
- Department of Anesthesiology, University Hospital Greifswald, Germany
| | - M Vollmer
- Institute of Bioinformatics, University Hospital Greifswald, Germany
| | - J Bast
- Medical Faculty, University of Greifswald, Germany
| | - J A Bohnert
- Friedrich Loeffler Institute of Medical Microbiology, University Hospital Greifswald, Germany
| | - K Zimmermann
- Friedrich Loeffler Institute of Medical Microbiology, University Hospital Greifswald, Germany
| | - K Hahnenkamp
- Department of Anesthesiology, University Hospital Greifswald, Germany
| | - S Rehberg
- Department of Anesthesiology, University Hospital Greifswald, Germany
| | - S-O Kuhn
- Department of Anesthesiology, University Hospital Greifswald, Germany.
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138
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Viale P, Tedeschi S, Scudeller L, Attard L, Badia L, Bartoletti M, Cascavilla A, Cristini F, Dentale N, Fasulo G, Legnani G, Trapani F, Tumietto F, Verucchi G, Virgili G, Berlingeri A, Ambretti S, De Molo C, Brizi M, Cavazza M, Giannella M. Infectious Diseases Team for the Early Management of Severe Sepsis and Septic Shock in the Emergency Department. Clin Infect Dis 2018; 65:1253-1259. [PMID: 28605525 DOI: 10.1093/cid/cix548] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 06/11/2017] [Indexed: 12/27/2022] Open
Abstract
Background The impact on patient survival of an infectious disease (ID) team dedicated to the early management of severe sepsis/septic shock (SS/SS) in Emergency Department (ED) has yet to be assessed. Methods A quasiexperimental pre-post study was performed at the general ED of our hospital. During the pre phase (June 2013-July 2014), all consecutive adult patients with SS/SS were managed according to the standard of care, data were prospectively collected. During the post phase (August 2014-October 2015), patients were managed in collaboration with a dedicated ID team performing a bedside patient evaluation within 1 hour of ED arrival. Results Overall, 382 patients were included, 195 in the pre phase and 187 in the post phase. Median age was 82 years (interquartile range, 70-88). The most common infection sources were lung (43%) and urinary tract (17%); in 22% of cases, infection source remained unknown. During the post phase, overall compliance with the Surviving Sepsis Campaign (SSC) bundle and appropriateness of initial antibiotic therapy improved from 4.6% to 32% (P < .001) and from 30% to 79% (P < .001), respectively. Multivariate analysis showed that predictors of all-cause 14-day mortality were quick sepsis-related organ failure assessment ≥2 (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.15-2.45; P = .007), serum lactate ≥2 mmol/L (HR, 2.13; 95% CI, 1.39-3.25; P < .001), and unknown infection source (HR, 2.07; 95% CI, 1.42-3.02; P < .001); being attended during the post phase was a protective factor (HR, 0.64; 95% CI, 0.43-0.94; P = .026). Conclusion Implementation of an ID team for the early management of SS/SS in the ED improved the adherence to SSC recommendations and patient survival.
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Affiliation(s)
- Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Sara Tedeschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Luigia Scudeller
- Clinical Epidemiology and Biostatistics Unit, Scientific Direction, IRCCS Policlinic San Matteo Foundation, Pavia
| | - Luciano Attard
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Lorenzo Badia
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Alessandra Cascavilla
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Francesco Cristini
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Nicola Dentale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Giovanni Fasulo
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Giorgio Legnani
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Filippo Trapani
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Fabio Tumietto
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Gabriella Verucchi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Giulio Virgili
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
| | - Andrea Berlingeri
- Microbiology, Department of Diagnosis and Prevention, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Simone Ambretti
- Microbiology, Department of Diagnosis and Prevention, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Chiara De Molo
- Microbiology, Department of Diagnosis and Prevention, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Mara Brizi
- Emergency Department, Hospital S. Orsola-Malpighi, University of Bologna, Italy
| | - Mario Cavazza
- Emergency Department, Hospital S. Orsola-Malpighi, University of Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Hospital S. Orsola-Malpighi, University of Bologna
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Frantzeskaki F, Orfanos SE. Treating nosocomial pneumonia: what's new. ERJ Open Res 2018; 4:00058-2018. [PMID: 29978856 PMCID: PMC6018207 DOI: 10.1183/23120541.00058-2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 04/29/2018] [Indexed: 01/08/2023] Open
Abstract
A detailed and comprehensive summary of the ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia, published in ERJ Open Research, will assist clinicians in their tasks http://ow.ly/XC7N30k8Jhu.
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Affiliation(s)
- Frantzeska Frantzeskaki
- 2nd Dept of Critical Care, National and Kapodistrian University of Athens and Attikon Hospital, Athens, Greece
| | - Stylianos E Orfanos
- 2nd Dept of Critical Care, National and Kapodistrian University of Athens and Attikon Hospital, Athens, Greece
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140
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Gustinetti G, Raiola AM, Varaldo R, Galaverna F, Gualandi F, Del Bono V, Bacigalupo A, Angelucci E, Viscoli C, Mikulska M. De-Escalation and Discontinuation of Empirical Antibiotic Treatment in a Cohort of Allogeneic Hematopoietic Stem Cell Transplantation Recipients during the Pre-Engraftment Period. Biol Blood Marrow Transplant 2018; 24:1721-1726. [PMID: 29578073 DOI: 10.1016/j.bbmt.2018.03.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/18/2018] [Indexed: 01/19/2023]
Abstract
To investigate rates and outcomes of antibiotic de-escalation during pre-engraftment neutropenia in allogeneic hematopoietic stem cell transplantation (HSCT) recipients. 110 consecutive HSCTs performed between January 2013 and March 2014 were analyzed. De-escalation was defined as narrowing the spectrum of antibiotic treatment either within (early) or after 96 hours (late) from starting antibiotics. Discontinuation, considered a form of de-escalation, was defined as stopping antibiotics before engraftment. De-escalation failure was defined as restarting/escalating antibiotics within 96 hours after de-escalation. Predictors of de-escalation were analyzed. Among 102 patients who started antibiotics and were included, 68 (67%) received monotherapy (mainly piperacillin-tazobactam, n = 58), whereas 34 (33%) received combination therapy (mainly meropenem plus glycopeptide, n = 24). Median duration of neutropenia was 17 days. Bloodstream infections (BSIs) were diagnosed in 28 patients (20%). Early de-escalation rate was 25.5% (n = 26) and mostly consisted of reducing the spectrum of β-lactams (n = 11, 42%). In comparison with theoretical scenario of continuing therapy until engraftment, the median savings in terms of antibiotic days were 10 for meropenem, 8 for piperacillin-tazobactam, and 7 for vancomycin. Failure rate of early de-escalation was 15% (4/26). Late de-escalation rate was 30.4% (n = 31) and failure rate 19% (6/31). The rate of de-escalation any time before engraftment was 55.9% (n = 57), including discontinuation in 33 patients (32%). Death at day 60 after HSCT occurred in 3 patients who never underwent de-escalation. Acute myeloid disease and BSIs were independent predictors of early de-escalation. De-escalation, including discontinuation, is feasible and safe in pre-engraftment neutropenia after allogeneic HSCT.
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Affiliation(s)
- Giulia Gustinetti
- Division of Infectious Diseases, Department of Health Science (DISSAL), Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Anna Maria Raiola
- Division of Hematology and Hematopoietic Stem Cell Transplantation Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Riccardo Varaldo
- Division of Hematology and Hematopoietic Stem Cell Transplantation Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Federica Galaverna
- Division of Hematology and Hematopoietic Stem Cell Transplantation Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Francesca Gualandi
- Division of Hematology and Hematopoietic Stem Cell Transplantation Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Valerio Del Bono
- Division of Infectious Diseases, Department of Health Science (DISSAL), Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Andrea Bacigalupo
- Istituto di Ematologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Emanuele Angelucci
- Division of Hematology and Hematopoietic Stem Cell Transplantation Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Claudio Viscoli
- Division of Infectious Diseases, Department of Health Science (DISSAL), Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Science (DISSAL), Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa, Genoa, Italy.
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141
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Moreau AS, Martin-Loeches I, Povoa P, Salluh J, Rodriguez A, Thille AW, Diaz Santos E, Vedes E, Lobo SM, Mégarbane B, Molero Silvero E, Coelho L, Argaud L, Sanchez Iniesta R, Labreuche J, Rouzé A, Nseir S. Impact of immunosuppression on incidence, aetiology and outcome of ventilator-associated lower respiratory tract infections. Eur Respir J 2018; 51:13993003.01656-2017. [PMID: 29439020 DOI: 10.1183/13993003.01656-2017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 01/24/2018] [Indexed: 12/15/2022]
Abstract
The aim of this planned analysis of the prospective multinational TAVeM database was to determine the incidence, aetiology and impact on outcome of ventilator-associated lower respiratory tract infections (VA-LRTI) in immunocompromised patients.All patients receiving mechanical ventilation for >48 h were included. Immunocompromised patients (n=663) were compared with non-immunocompromised patients (n=2297).The incidence of VA-LRTI was significantly lower among immunocompromised than among non-immunocompromised patients (16.6% versus 24.2%; sub-hazard ratio 0.65, 95% CI 0.53-0.80; p<0.0001). Similar results were found regarding ventilator-associated tracheobronchitis (7.3% versus 11.6%; sub-hazard ratio 0.61, 95% CI 0.45-0.84; p=0.002) and ventilator-associated pneumonia (9.3% versus 12.7%; sub-hazard ratio 0.72, 95% CI 0.54-0.95; p=0.019). Among patients with VA-LRTI, the rates of multidrug-resistant bacteria (72% versus 59%; p=0.011) and intensive care unit mortality were significantly higher among immunocompromised than among non-immunocompromised patients (54% versus 30%; OR 2.68, 95% CI 1.78-4.02; p<0.0001). In patients with ventilator-associated pneumonia, mortality rates were higher among immunocompromised than among non-immunocompromised patients (64% versus 34%; p<0.001).Incidence of VA-LRTI was significantly lower among immunocompromised patients, but it was associated with a significantly higher mortality rate. Multidrug-resistant pathogens were more frequently found in immunocompromised patients with VA-LRTI.
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Affiliation(s)
| | - Ignacio Martin-Loeches
- Dept of Clinical Medicine, Trinity College, Welcome Trust-HRB Clinical Research Facility, St James Hospital, Dublin, Ireland
| | - Pedro Povoa
- Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CEDOC, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Jorge Salluh
- Dept of Critical Care, D'Or Institute for Research and Education, Rio De Janeiro, Brazil
| | | | - Arnaud W Thille
- CHU de Poitiers, Réanimation Médicale, Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, INSERM, CIC-1402, équipe 5 ALIVE, Poitiers, France
| | - Emilio Diaz Santos
- Critical Care Center, Sabadell Hospital, Corporación Sanitaria Universitaria Parc Taulí, Universitat Autonoma de Barcelona, CIBER de Enfermedades Respiratorias (CIBERES), Sabadell, Spain
| | - Elisa Vedes
- Unidade de Cuidados Intensivos do Hospital da Luz, Lisbon, Portugal
| | | | - Bruno Mégarbane
- Dept of Medical and Toxicological Critical Care, Lariboisière Hospital, Paris-Diderot University, INSERM UMRS-1144, Paris, France
| | | | - Luis Coelho
- Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CEDOC, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Laurent Argaud
- Service de Réanimation Médicale, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | | | - Julien Labreuche
- CHU Lille, Clinique de Santé Publique, Plateforme d'Aide Méthodologique, Lille, France
| | | | - Saad Nseir
- Centre de Réanimation, CHU Lille, Lille, France.,Medical School, Lille University, Lille, France
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Karakuzu Z, Iscimen R, Akalin H, Kelebek Girgin N, Kahveci F, Sinirtas M. Prognostic Risk Factors in Ventilator-Associated Pneumonia. Med Sci Monit 2018; 24:1321-1328. [PMID: 29503436 PMCID: PMC5848715 DOI: 10.12659/msm.905919] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a nosocomial infection commonly seen in patients in intensive care units (ICU). This study aimed to analyze factors affecting prognosis of patients diagnosed with VAP. MATERIAL AND METHODS Critically ill patients with VAP were retrospectively evaluated between June 2002 and June 2011 in the ICU. VAP diagnosis was made according to 2005 ATS/IDSA (Infectious Diseases Society of America/American Thoracic Society) criteria. First pneumonia attacks of patients were analyzed. RESULTS When early- and late-onset pneumonia causes were compared according to ICU and hospital admittance, resistant bacteria were found to be more common in pneumonias classified as early-onset according to ICU admittance. APACHE II score of >21 (p=0.016), SOFA score of >6 (p<0.001) on admission to ICU and SOFA score of >6 (p<0.001) on day of diagnosis are risk factors affecting mortality. Additionally, low PaO2/FIO2 ratio at onset of VAP had a negative effect on prognosis (p<0.001). SOFA score of >6 on the day of VAP diagnosis was an independent risk factor for mortality [(p<0.001; OR (95%CI): 1.4 (1.2-1.6)]. CONCLUSIONS Resistant bacteria might be present in early-onset VAP. Especially, taking LOS into consideration may better estimate the presence of resistant bacteria. Acinetobacter baumannii, Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus (MRSA) were the most frequent causative microorganisms for VAP. SOFA score might be more valuable than APACHE II score. Frequently surveilling SOFA scores may improve predictive performance over time.
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Affiliation(s)
- Ziyaattin Karakuzu
- Department of Anesthesiology and Reanimation, Uludag University, School of Medicine, Bursa, Turkey
| | - Remzi Iscimen
- Department of Anesthesiology and Reanimation, Uludag University, School of Medicine, Bursa, Turkey
| | - Halis Akalin
- Department of Microbiology and Infectious Disease, Uludag University, School of Medicine, Bursa, Turkey
| | - Nermin Kelebek Girgin
- Department of Anesthesiology and Reanimation, Uludag University, School of Medicine, Bursa, Turkey
| | - Ferda Kahveci
- Department of Anesthesiology and Reanimation, Uludag University, School of Medicine, Bursa, Turkey
| | - Melda Sinirtas
- Department of Microbiology and Infectious Disease, Uludag University, School of Medicine, Bursa, Turkey
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143
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Lavrentieva A, Voutsas V, Konoglou M, Karali V, Koukiasa P, Loridas N, Papaioannou M, Vasileiadou G, Bitzani M. Determinants of Outcome in Burn ICU Patients with Septic Shock. J Burn Care Res 2018; 38:e172-e179. [PMID: 27003623 DOI: 10.1097/bcr.0000000000000337] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Infectious complications remain one of the most challenging concerns for the burn team. The goal of this study was to evaluate the diagnostic and therapeutic approaches and prognosis in burn patients with septic shock. This retrospective study included patients with severe burn injury who were admitted to a burn intensive care unit (ICU). Demographic and clinical data were recorded for each patient. The diagnostic and prognostic value of a number of clinical and laboratory parameters and various treatment options were evaluated. Sixty-four of the 378 patients (16.9%) were identified as having experienced a septic shock during ICU stay. The mortality rate of patients with septic shock was 46.9%. The main bacterial strains responsible for infection were Gram-negative bacteria (78.1%). Factors associated with outcome of septic shock on logistic regression analysis were presence of stage III of acute kidney injury (odds ratio [95% confidence interval] 2.03 [1.06-3.84]; P = 0.019), and lactate levels > 4 mmol/L during the first 48 hours of shock (odds ratio 1.92; 95% confidence interval: 1.02-3.62; P = 0.043). Prognosis of septic shock remains poor in burn patients with septic shock. The main causative pathogens of septic shock identified in our burn ICU were Gram-negative species. The main prognostic factors identified in this study were the presence of AKI, stage III, and high lactate levels early after the onset of septic shock.
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144
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt CE, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar JR, Bruyère R, Chanques G. Hospital-acquired pneumonia in ICU. Anaesth Crit Care Pain Med 2018; 37:83-98. [DOI: 10.1016/j.accpm.2017.11.006] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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145
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Abstract
BACKGROUND Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. Early recognition and treatment are the cornerstones of management. METHODS Review of the English-language literature. RESULTS For both sepsis and septic shock "antimicrobials [should be] be initiated as soon as possible and within one hour" (Surviving Sepsis Campaign). The risk of progression from severe sepsis to septic shock increases 8% for each hour before antibiotics are started. Selection of antimicrobial agents is based on a combination of patient factors, predicted infecting organism(s), and local microbial resistance patterns. The initial drugs should have activity against typical gram-positive and gram-negative causative micro-organisms. Anaerobic coverage should be provided for intra-abdominal infections or others where anaerobes are significant pathogens. Empiric antifungal or antiviral therapy may be warranted. For patients with healthcare-associated infections, resistant micro-organisms will further complicate the choice of empiric antimicrobials. Recommendations are given for specific infections. CONCLUSION Early administration of broad-spectrum antimicrobial drugs is one of the most important, if not the most important, treatment for patients with sepsis or septic shock. Drugs should be initiated as soon as possible, and the choice of should take into account patient factors, common local pathogens, hospital antibiograms and resistance patterns, and the suspected source of infection. Antimicrobial agent therapy should be de-escalated as soon as possible.
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Affiliation(s)
- Sara A Buckman
- Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - Isaiah R Turnbull
- Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
| | - John E Mazuski
- Department of Surgery, Washington University School of Medicine in St. Louis , St. Louis, Missouri
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146
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Rudnov VA, Kolotova G, Bagin VA, Nevskaya N, Belsky D, Ivanova N, Gayfutdinov E. The role of antimicrobial therapy stewardship in intensive care service. CLINICAL MICROBIOLOGY AND ANTIMICROBIAL CHEMOTHERAPY 2018. [DOI: 10.36488/cmac.2018.2.132-140] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
An analysis of current trends in the prevalence of nosocomial infections, their etiology and antibiotic resistance in pathogens was performed. Social and economic consequences of antimicrobial resistance as well as a medical community’s response were shown. A role of the AMRmap Internet resource in monitoring antibiotic resistance in Russia was demonstrated. The results of our own approaches to the antimicrobial therapy stewardship in the intensive care service of a large hospital were evaluated.
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Affiliation(s)
- Vladimir A. Rudnov
- Ural State Medical University; City Clinical Hospital №40 (Yekaterinburg, Russia)
| | - G.B. Kolotova
- Ural State Medical University; City Clinical Hospital №40 (Yekaterinburg, Russia)
| | - Vladimir A. Bagin
- Ural State Medical University; City Clinical Hospital №40 (Yekaterinburg, Russia)
| | | | - D.V. Belsky
- Ural State Medical University; City Clinical Hospital №40 (Yekaterinburg, Russia)
| | - N.A. Ivanova
- City Clinical Hospital №40 (Yekaterinburg, Russia)
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147
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Wiens J, Snyder GM, Finlayson S, Mahoney MV, Celi LA. Potential Adverse Effects of Broad-Spectrum Antimicrobial Exposure in the Intensive Care Unit. Open Forum Infect Dis 2017; 5:ofx270. [PMID: 29479546 PMCID: PMC5804637 DOI: 10.1093/ofid/ofx270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 12/18/2017] [Indexed: 12/28/2022] Open
Abstract
Background The potential adverse effects of empiric broad-spectrum antimicrobial use among patients with suspected but subsequently excluded infection have not been fully characterized. We sought novel methods to quantify the risk of adverse effects of broad-spectrum antimicrobial exposure among patients admitted to an intensive care unit (ICU). Methods Among all adult patients admitted to ICUs at a single institution, we selected patients with negative blood cultures who also received ≥1 broad-spectrum antimicrobials. Broad-spectrum antimicrobials were categorized in ≥1 of 5 categories based on their spectrum of activity against potential pathogens. We performed, in serial, 5 cohort studies to measure the effect of each broad-spectrum category on patient outcomes. Exposed patients were defined as those receiving a specific category of broad-spectrum antimicrobial; nonexposed were all other patients in the cohort. The primary outcome was 30-day mortality. Secondary outcomes included length of hospital and ICU stay and nosocomial acquisition of antimicrobial-resistant bacteria (ARB) or Clostridium difficile within 30 days of admission. Results Among the study cohort of 1918 patients, 316 (16.5%) died within 30 days, 821 (42.8%) had either a length of hospital stay >7 days or an ICU length of stay >3 days, and 106 (5.5%) acquired either a nosocomial ARB or C. difficile. The short-term use of broad-spectrum antimicrobials in any of the defined broad-spectrum categories was not significantly associated with either primary or secondary outcomes. Conclusions The prompt and brief empiric use of defined categories of broad-spectrum antimicrobials could not be associated with additional patient harm.
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Affiliation(s)
- Jenna Wiens
- Computer Science and Engineering, University of Michigan, Ann Arbor, Michigan
| | - Graham M Snyder
- Department of Health Care Quality and Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Samuel Finlayson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Leo Anthony Celi
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, Massachusetts
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148
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Wirz Y, Branche A, Wolff M, Welte T, Nobre V, Reinhart K, Falsey AR, Damas P, Beishuizen A, Deliberato RO, Shehabi Y, Jensen JUS, Mueller B, Schuetz P. Management of Respiratory Infections with Use of Procalcitonin: Moving toward More Personalized Antibiotic Treatment Decisions. ACS Infect Dis 2017; 3:875-879. [PMID: 29120606 DOI: 10.1021/acsinfecdis.7b00199] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Due to overlap of clinical findings and low sensitivity of bacterial diagnostic tests, differentiation between bacterial and viral respiratory tract infections remains challenging, ultimately leading to antibiotic overuse in this population of patients. Addition of procalcitonin, a blood biomarker expressed by epithelial cells in response to bacterial infections, to the clinical assessment leads to a reduction in inappropriate antibiotic initiation. Procalcitonin also provides prognostic information about the resolution of illness, and significant decreases over time are a strong signal for the discontinuation of antibiotics. Current evidence from randomized trials indicates that procalcitonin-guided antibiotic stewardship results in a reduction in antibiotic use and antibiotic side effects, which importantly translates into improved survival of patients with respiratory infections. Inclusion of procalcitonin into antibiotic stewardship algorithms thus improves the diagnostic and therapeutic management of patients presenting with respiratory illnesses and holds great promise to mitigate the global bacterial resistance crisis.
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Affiliation(s)
- Yannick Wirz
- Medical University
Department, Kantonsspital Aarau, Tellstrasse, 5000 Aarau, Switzerland
- Faculty of Medicine, University of Basel,
Petersplatz, 4031 Basel, Switzerland
| | - Angela Branche
- National Institute of Allergy and Infectious Diseases
Respiratory Pathogen Research Center, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, New York 14642, United States
| | - Michel Wolff
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, 5 Rue Thomas Mann, 75013 Paris, France
| | - Tobias Welte
- Department of Pulmonary Medicine, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Vandack Nobre
- Department of Intensive Care, Hospital das Clinicas da Universidade Federal de Minas Gerais, 110 Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100, Brasil
| | - Konrad Reinhart
- Department
of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Ann R. Falsey
- National Institute of Allergy and Infectious Diseases
Respiratory Pathogen Research Center, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, New York 14642, United States
| | - Pierre Damas
- Department of General Intensive
Care, University Hospital of Liege, domaine universitaire du Sart Tilman,, 4000 Liège, Belgium
| | - Albertus Beishuizen
- Intensive
Care Center, Medisch Spectrum Twente, Koningsplein 1, 7512KZ, Enschede, The Netherlands
| | - Rodrigo O. Deliberato
- Critical
Care Unit, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701, Morumbi, São Paulo, São Paulo 05652-900, Brazil
| | - Yahya Shehabi
- Critical
Care and Peri-operative Medicine, Monash Health, Clayton Rd., Clayton, Victoria 3171, Australia
- School of Clinical
Sciences, Monash University, E Block, Level 5, Monash Medical Centre, Clayton, Victoria 3168, Australia
| | - Jens-Ulrik S. Jensen
- CHIP & PERSIMUNE, Department of Infectious Diseases, Finsencentret, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 København, Denmark
- Department of Internal Medicine, Respiratory Medicine, Herlev & Gentofte Hospital, Niels Andersens Vej 28, 2900 Hellerup, Denmark
| | - Beat Mueller
- Medical University
Department, Kantonsspital Aarau, Tellstrasse, 5000 Aarau, Switzerland
- Faculty of Medicine, University of Basel,
Petersplatz, 4031 Basel, Switzerland
| | - Philipp Schuetz
- Medical University
Department, Kantonsspital Aarau, Tellstrasse, 5000 Aarau, Switzerland
- Faculty of Medicine, University of Basel,
Petersplatz, 4031 Basel, Switzerland
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149
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Azoulay E, Guigue N, Darmon M, Mokart D, Lemiale V, Kouatchet A, Mayaux J, Vincent F, Nyunga M, Bruneel F, Rabbat A, Bretagne S, Lebert C, Meert AP, Benoit D, Pene F. (1, 3)-β-D-glucan assay for diagnosing invasive fungal infections in critically ill patients with hematological malignancies. Oncotarget 2017; 7:21484-95. [PMID: 26910891 PMCID: PMC5008300 DOI: 10.18632/oncotarget.7471] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 01/19/2016] [Indexed: 11/30/2022] Open
Abstract
Invasive fungal infections (IFIs) are life-threatening complications of hematological malignancies that must be diagnosed early to allow effective treatment. Few data are available on the performance of serum (1–3)-β-D-glucan (BG) assays for diagnosing IFI in patients with hematological malignancies admitted to the intensive care unit (ICU). In this study, 737 consecutive patients with hematological malignancies admitted to 17 ICUs routinely underwent a BG assay at ICU admission. IFIs were diagnosed using standard criteria applied by three independent specialists. Among the 737 patients, 439 (60%) required mechanical ventilation and 273 (37%) died before hospital discharge. Factors known to alter BG concentrations were identified in most patients. IFIs were documented in 78 (10.6%) patients (invasive pulmonary aspergillosis, n = 54; Pneumocystis jirovecii pneumonia, n = 13; candidemia, n = 13; and fusarium infections, n = 3). BG concentrations (pg/mL) were higher in patients with than without IFI (144 (77–510) vs. 50 (30–125), < 0.0001). With 80 pg/mL as the cutoff, sensitivity was 72%, specificity 65%, and area-under-the-curve 0.74 (0.68–0.79). Assuming a prevalence of 10%, the negative and positive predictive values were 94% and 21%. By multivariable analysis, factors independently associated with BG > 80 pg/mL were IFI, admission SOFA score, autologous bone-marrow or hematopoietic stem-cell transplantation, and microbiologically documented bacterial infection. In conclusion, in unselected critically ill hematology patients with factors known to affect serum BG, this biomarker showed only moderate diagnostic performance and rarely detected IFI. However, the negative predictive value was high. Studies are needed to assess whether a negative BG test indicates that antifungal de-escalation is safe.
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Affiliation(s)
- Elie Azoulay
- Medical ICU and Mycology Department, Saint-Louis Hospital, Paris, France
| | - Nicolas Guigue
- Medical ICU and Mycology Department, Saint-Louis Hospital, Paris, France
| | - Michael Darmon
- Medical-Surgical ICU, Saint-Etienne University Hospital, Saint-Étienne, France
| | - Djamel Mokart
- Medical-Surgical ICU Paoli Calmette Cancer Institute, Marseille, France
| | - Virginie Lemiale
- Medical ICU and Mycology Department, Saint-Louis Hospital, Paris, France
| | | | | | | | - Martine Nyunga
- Medical ICU and Mycology Department, Saint-Louis Hospital, Paris, France
| | - Fabrice Bruneel
- Medical ICU and Mycology Department, Saint-Louis Hospital, Paris, France
| | - Antoine Rabbat
- Medical ICU and Pulmonary Department, Cochin Hospital, Paris, France
| | - Stéphane Bretagne
- Medical ICU and Mycology Department, Saint-Louis Hospital, Paris, France
| | - Christine Lebert
- Medical-Surgical ICU, La Roche Sur Yon Hospital, La Roche Sur Yon, France
| | | | | | - Frédéric Pene
- Medical ICU and Pulmonary Department, Cochin Hospital, Paris, France
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150
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Zaragoza Crespo R, Cercos LLetí AC. Antimicrobial stewardship program in critical care medicine: What is going on? Who gives more? Med Intensiva 2017; 42:263-265. [PMID: 29183748 DOI: 10.1016/j.medin.2017.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 10/26/2017] [Indexed: 11/30/2022]
Affiliation(s)
- R Zaragoza Crespo
- Intensive Care Unit, PROA TEAM, Hospital Universitario Dr. Peset, Valencia, Spain.
| | - A C Cercos LLetí
- Pharmacy Department, PROA TEAM, Hospital Universitario Dr. Peset, Valencia, Spain
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