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Abstract
Multidrug-resistant organisms are creating a challenge for physicians treating the critically ill. As new antibiotics lag behind the emergence of worsening resistance, intensivists in countries with high rates of extensively drug-resistant bacteria are turning to inhaled antibiotics as adjunctive therapy. These drugs can provide high concentrations of drug in the lung that could not be achieved with intravenous antibiotics without significant systemic toxicity. This article summarizes current evidence describing the use of inhaled antibiotics for the treatment of bacterial ventilator-associated pneumonia and ventilator-associated tracheobronchitis. Preliminary data suggest aerosolized antimicrobials may effectively treat resistant pathogens with high minimum inhibitory concentrations.
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102
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Alves J, Alp E, Koulenti D, Zhang Z, Ehrmann S, Blot S, Bassetti M, Conway-Morris A, Reina R, Teran E, Sole-Lleonart C, Ruiz-Rodríguez M, Rello J. Nebulization of antimicrobial agents in mechanically ventilated adults in 2017: an international cross-sectional survey. Eur J Clin Microbiol Infect Dis 2018; 37:785-794. [PMID: 29318460 DOI: 10.1007/s10096-017-3175-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 12/21/2017] [Indexed: 02/07/2023]
Abstract
2017 ESCMID practice guidelines reported safety concerns and weak evidence of benefit supporting use of aerosolized antibiotics in mechanically ventilated patients. Our primary goal was to assess current patterns of aerosolized antibiotic prescription in mechanically ventilated patients. A sequential global survey was performed prior to the release of the ESCMID guidelines, from the 1st of February to the 30th of April 2017, using an electronic platform. Responses were analyzed comparing geographical regions. A total of 410 units responded, with 261 (177 from Europe) being eligible for the full survey. 26.8% of units reported not using aerosolized antibiotics. The two major indications amongst prescribing units were ventilator-associated pneumonia and ventilator-associated tracheobronchitis (74.3% and 49.4%, respectively). 63.6% of units indicated prescription solely in response to multi-drug resistant organisms. In comparison with a survey undertaken in 2014, there was a significant reduction in use of aerosolized antibiotics for prophylaxis (50.6% vs 7.7%, p < 0.05) and colonization (52.9% vs 25.3%, p < 0.05). The large majority of units (91.7%) reported only prescribing in patients with positive pulmonary cultures. Asia appeared to be an outlier, with 53.3% of units reporting empirical use. The most commonly used device was the jet nebulizer. The most commonly prescribed drugs were colistin methanesulfonate (57.6%), colistin base (41.9%) and amikacin (31.4%), although there was considerable heterogeneity across geographical areas. A significant gap exists between ESCMID clinical practice recommendations and the use of aerosolized antibiotics in clinical practice. Our findings indicate an urgent need for high-quality education to bring practice into line with evidence-based guidelines.
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Affiliation(s)
- Joana Alves
- Infectious Diseases Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of University of Porto, Porto, Portugal
| | - Emine Alp
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Despoina Koulenti
- BTCCRC, UQCCR, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- 2nd Critical Care Department, Attikon Univesrity Hospital, Athens, Greece
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CHRU de Tours and CRICS-TriggerSEP Network, Tours, France
- Centre d'étude des pathologies respiratoires, INSERM U1100, Aérosolthérapie et biomédicaments à visée respiratoire, Faculté de médecine de Tours, Université François Rabelais, Tours, France
| | - Stijn Blot
- Department of Internal Medicine, Faculty of Medicine & Health Science, Ghent University, Ghent, Belgium
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - Andrew Conway-Morris
- University Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Rosa Reina
- Terapia Intensiva, Hospital Interzonal de Agudos "General San Martín", La Plata, Argentina
| | - Enrique Teran
- Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador
| | - Candela Sole-Lleonart
- Centre Hospitalier Universitaire Vaudoise, Geneve, Switzerland
- Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Maria Ruiz-Rodríguez
- Department of Clinical Research & Innovation in Pneumonia and Sepsis, Vall d'Hebron Institut of Research, Barcelona, Spain
| | - Jordi Rello
- Critical Care Department, Vall d'Hebron Institut of Research, Barcelona, Spain.
- Centro de Investigacion Biomedica en Red (CIBERES), Ps Vall d'Hebron 119, AMI- 14a Planta, 08035, Barcelona, Spain.
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103
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Liu C, Zhang YT, Peng ZY, Zhou Q, Hu B, Zhou H, Li JG. Aerosolized Amikacin as Adjunctive Therapy of Ventilator-associated Pneumonia Caused by Multidrug-resistant Gram-negative Bacteria: A Single-center Randomized Controlled Trial. Chin Med J (Engl) 2018; 130:1196-1201. [PMID: 28485320 PMCID: PMC5443026 DOI: 10.4103/0366-6999.205846] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Aerosolized amikacin (AA) is a current option for the management of ventilator-associated pneumonia (VAP) caused by multidrug-resistant Gram-negative bacteria (MDR-GNB), as it is reported that AA could increase the alveolar level of the drug without increasing systemic toxicity. This study aimed to evaluate the efficacy and safety of AA as an adjunctive therapy for VAP caused by MDR-GNB. Methods: In this single-center, double-blind study conducted in a 36-bed general Intensive Care Unit (ICU) in a tertiary hospital from June 2014 to June 2016, 52 ICU patients with confirmed MDR-GNB VAP were randomized to two groups (AA group, n = 27 and placebo group, n = 25). Amikacin (400 mg, q8h) or saline placebo (4 ml, q8h) was aerosolized for 7 days. The attending physician determined the administration of systemic antibiotics for VAP. Patients were followed up for 28 days. Bacteriological eradication, clinical pulmonary infection score (CPIS), and serum creatinine were assessed on day 7 of therapy. New resistance to amikacin, cure rate of VAP, weaning rate, and mortality were assessed on day 28. Results: The baseline characteristics of patients in both groups were similar. At the end of the treatment, 13 of the 32 initially detected bacterial isolates were eradicated in AA group, compared to 4 of 28 in placebo group (41% vs. 14%, P = 0.024). As for patients, 11 of 27 patients treated with AA and 4 of 25 patients treated with placebo have eradication (41% vs. 16%, P = 0.049). The adjunction of AA reduced CPIS (4.2 ± 1.6 vs. 5.8 ± 2.1, P = 0.007). New drug resistance to amikacin and the change in serum creatinine were not detected in AA group. No significant differences in the clinical cure rate in survivors (48% vs. 35%, P = 0.444), weaning rate (48% vs. 32%, P = 0.236), and mortality (22% vs. 32%, P = 0.427) were detected between the two groups on day 28. Conclusions: As an adjunctive therapy of MDR-GNB VAP, AA successfully eradicated existing MDR organisms without inducing new resistance to amikacin or change in serum creatinine. However, the improvement of mortality was not found.
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Affiliation(s)
- Chang Liu
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Yu-Ting Zhang
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Zhi-Yong Peng
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Qing Zhou
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Bo Hu
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Hui Zhou
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Jian-Guo Li
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
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104
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Antimicrobial molecules in the lung: formulation challenges and future directions for innovation. Future Med Chem 2018; 10:575-604. [PMID: 29473765 DOI: 10.4155/fmc-2017-0162] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Inhaled antimicrobials have been extremely beneficial in treating respiratory infections, particularly chronic infections in a lung with cystic fibrosis. The pulmonary delivery of antibiotics has been demonstrated to improve treatment efficacy, reduce systemic side effects and, critically, reduce drug exposure to commensal bacteria compared with systemic administration, reducing selective pressure for antimicrobial resistance. This review will explore the specific challenges of pulmonary delivery of a number of differing antimicrobial molecules, and the formulation and technological approaches that have been used to overcome these difficulties. It will also explore the future challenges being faced in the development of inhaled products and respiratory infection treatment, and identify future directions of innovation, with a particular focus on respiratory infections caused by multiple drug-resistant pathogens.
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105
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Kidd JM, Kuti JL, Nicolau DP. Novel pharmacotherapy for the treatment of hospital-acquired and ventilator-associated pneumonia caused by resistant gram-negative bacteria. Expert Opin Pharmacother 2018; 19:397-408. [DOI: 10.1080/14656566.2018.1438408] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- James M. Kidd
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Joseph L. Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - David P. Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
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La Combe B, Bleibtreu A, Messika J, Fernandes R, Clermont O, Branger C, Billard-Pomares T, Barnaud G, Magdoud F, Eveillard M, Kouatchet A, Lasocki S, Asfar P, Corvec S, Lakhal K, Armand-Lefevre L, Wolff M, Timsit JF, Bourdon S, Reignier J, Martin S, Fihman V, de Prost N, Bador J, Charles PE, Goret J, Boyer A, Wallet F, Jaillette E, Nseir S, Landraud L, Ruimy R, Danin PE, Dellamonica J, Cremniter J, Frat JP, Jauréguy F, Clec’h C, Decré D, Maury E, Dreyfuss D, Denamur E, Ricard JD. Decreased susceptibility to chlorhexidine affects a quarter of Escherichia coli isolates responsible for pneumonia in ICU patients. Intensive Care Med 2018; 44:531-533. [DOI: 10.1007/s00134-018-5061-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2018] [Indexed: 11/30/2022]
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107
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Phillips-Houlbracq M, Ricard JD, Foucrier A, Yoder-Himes D, Gaudry S, Bex J, Messika J, Margetis D, Chatel J, Dobrindt U, Denamur E, Roux D. Pathophysiology of Escherichia coli pneumonia: Respective contribution of pathogenicity islands to virulence. Int J Med Microbiol 2018; 308:290-296. [PMID: 29325882 DOI: 10.1016/j.ijmm.2018.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/28/2017] [Accepted: 01/02/2018] [Indexed: 12/29/2022] Open
Abstract
Ventilator-associated pneumonia (VAP) remains the most frequent life-threatening nosocomial infection. Enterobacteriaceae including Escherichia coli are increasingly involved. If a cumulative effect of pathogenicity islands (PAIs) has been shown for E. coli virulence in urinary tract or systemic infections, very little is known regarding pathophysiology of E. coli pneumonia. This study aimed to determine the role of each of the 7 PAIs present in pathogenic E. coli strain 536 in pneumonia pathophysiology. We used mutant strains to screen pathophysiological role of PAI in a rat pneumonia model. We also test individual gene mutants within PAI identified to be involved in pneumonia pathogenesis. Finally, we determined the prevalence of these genes of interest in E. coli isolates from feces and airways of ventilated patients. Only PAIs I and III were significantly associated with rat pneumonia pathogenicity. Only the antigen-43 (Ag43) gene in PAI III was significantly associated with bacterial pathogenicity. The prevalence of tested genes in fecal and airway isolates of ventilated patients did not differ between isolates. In contrast, genes encoding Ag43, the F17-fimbriae subunits, HmuR and SepA were more prevalent in VAP isolates with statistical significance for hmuR when compared to airway colonizing isolates. The E. coli PAIs involved in lung pathogenicity differed from those involved in urinary tract and bloodstream infections. Overall, extraintestinal E. coli virulence seems to rely on a combination of numerous virulence genes that have a cumulative effect depending on the infection site.
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Affiliation(s)
| | - Jean-Damien Ricard
- IAME, UMR 1137, INSERM, Paris Diderot University, Sorbonne Paris Cité, Paris, France; AP-HP, Louis Mourier Hospital, Intensive Care Unit, Colombes, France.
| | - Arnaud Foucrier
- IAME, UMR 1137, INSERM, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | | | - Stéphane Gaudry
- IAME, UMR 1137, INSERM, Paris Diderot University, Sorbonne Paris Cité, Paris, France; AP-HP, Louis Mourier Hospital, Intensive Care Unit, Colombes, France
| | - Julie Bex
- IAME, UMR 1137, INSERM, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Jonathan Messika
- IAME, UMR 1137, INSERM, Paris Diderot University, Sorbonne Paris Cité, Paris, France; AP-HP, Louis Mourier Hospital, Intensive Care Unit, Colombes, France
| | - Dimitri Margetis
- IAME, UMR 1137, INSERM, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Jérémie Chatel
- IAME, UMR 1137, INSERM, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Ulrich Dobrindt
- Institute of Hygiene, University of Münster, Münster, Germany
| | - Erick Denamur
- IAME, UMR 1137, INSERM, Paris Diderot University, Sorbonne Paris Cité, Paris, France; AP-HP, Bichat Hospital, Molecular Biology and Genetics Laboratory, Paris, France
| | - Damien Roux
- IAME, UMR 1137, INSERM, Paris Diderot University, Sorbonne Paris Cité, Paris, France; AP-HP, Louis Mourier Hospital, Intensive Care Unit, Colombes, France.
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108
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Inhaled Antibiotics. Crit Care Med 2018; 46:159-161. [DOI: 10.1097/ccm.0000000000002788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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109
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Use of Calgary and Microfluidic BioFlux Systems To Test the Activity of Fosfomycin and Tobramycin Alone and in Combination against Cystic Fibrosis Pseudomonas aeruginosa Biofilms. Antimicrob Agents Chemother 2017; 62:AAC.01650-17. [PMID: 29084746 DOI: 10.1128/aac.01650-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 10/21/2017] [Indexed: 12/25/2022] Open
Abstract
Pseudomonas aeruginosa is a major cause of morbidity and mortality in chronically infected cystic fibrosis patients. Novel in vitro biofilm models which reliably predict the therapeutic success of antimicrobial therapies against biofilm bacteria should be implemented. The activity of fosfomycin, tobramycin, and the fosfomycin-tobramycin combination against 6 susceptible P. aeruginosa strains isolated from respiratory samples from cystic fibrosis patients was tested by using two in vitro biofilm models: a closed system (Calgary device) and an open model based on microfluidics (BioFlux). All but one of the isolates formed biofilms. The fosfomycin and tobramycin minimal biofilm inhibitory concentrations (MBIC) were 1,024 to >1,024 μg/ml and 8 to 32 μg/ml, respectively. According to fractional inhibitory concentration analysis, the combination behaved synergistically against all the isolates except the P. aeruginosa ATCC 27853 strain. The dynamic formation of the biofilm was also studied with the BioFlux system, and the MIC and MBIC of each antibiotic were tested. For the combination, the lowest tobramycin concentration that was synergistic with fosfomycin was used. The captured images were analyzed by measuring the intensity of the colored pixels, which was proportional to the biofilm biomass. A statistically significant difference was found when the intensity of the inoculum was compared with the intensity of the microchannel in which the MBIC of tobramycin, fosfomycin, or their combination was used (P < 0.01) but not when the MIC was applied (P > 0.01). Fosfomycin-tobramycin was demonstrated to be synergistic against cystic fibrosis P. aeruginosa strains in the biofilm models when both the Calgary and the microfluidic BioFlux systems were tested. These results support the clinical use of this combination.
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110
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Jung SY, Lee SH, Lee SY, Yang S, Noh H, Chung EK, Lee JI. Antimicrobials for the treatment of drug-resistant Acinetobacter baumannii pneumonia in critically ill patients: a systemic review and Bayesian network meta-analysis. Crit Care 2017; 21:319. [PMID: 29262831 PMCID: PMC5738897 DOI: 10.1186/s13054-017-1916-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 12/04/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND An optimal therapy for the treatment of pneumonia caused by drug-resistant Acinetobacter baumannii remains unclear. This study aims to compare various antimicrobial strategies and to determine the most effective therapy for pneumonia using a network meta-analysis. METHODS Systematic search and quality assessment were performed to select eligible studies reporting one of the following outcomes: all-cause mortality, clinical cure, and microbiological eradication. The primary outcome was all-cause mortality. A network meta-analysis was conducted with a Bayesian approach. Antimicrobial treatments were ranked based on surface under the cumulative ranking curve (SUCRA) value along with estimated median outcome rate and corresponding 95% credible intervals (CrIs). Two treatments were considered significantly different if a posterior probability of superiority (P) was greater than 97.5%. RESULTS Twenty-three studies evaluating 15 antimicrobial treatments were included. Intravenous colistin monotherapy (IV COL) was selected as a common comparator, serving as a bridge for developing the network. Five treatments ranked higher than IV COL (SUCRA, 57.1%; median all-cause mortality 0.45, 95% CrI 0.41-0.48) for reducing all-cause mortality: sulbactam monotherapy (SUL, 100.0%; 0.18, 0.04-0.42), high-dose SUL (HD SUL, 85.7%; 0.31, 0.07-0.71), fosfomycin plus IV COL (FOS + IV COL, 78.6%; 0.34, 0.19-0.54), inhaled COL plus IV COL (IH COL + IV COL, 71.4%; 0.39, 0.32-0.46), and high-dose tigecycline (HD TIG, 71.4%; 0.39, 0.16-0.67). Those five treatments also ranked higher than IV COL (SUCRA, 45.5%) for improving clinical cure (72.7%, 72.7%, 63.6%, 81.8%, and 90.9%, respectively). Among the five treatments, SUL (P = 98.1%) and IH COL + IV COL (P = 99.9%) were significantly superior to IV COL for patient survival and clinical cure, respectively. In terms of microbiological eradication, FOS + IV COL (P = 99.8%) and SUL (P = 98.9%) were significantly superior to IV COL. CONCLUSIONS This Bayesian network meta-analysis demonstrated the comparative effectiveness of fifteen antimicrobial treatments for drug-resistant A. baumannii pneumonia in critically ill patients. For survival benefit, SUL appears to be the best treatment followed by HD SUL, FOS + IV COL, IH COL + IV COL, HD TIG, and IV COL therapy, in numerical order.
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Affiliation(s)
- Su Young Jung
- Department of Pharmacy, College of Pharmacy, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826 Republic of Korea
- Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Seung Hee Lee
- Department of Pharmacy, College of Pharmacy, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826 Republic of Korea
| | - Soo Young Lee
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447 Republic of Korea
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Seungwon Yang
- Department of Pharmacy, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Hayeon Noh
- Department of Pharmacy, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Eun Kyoung Chung
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447 Republic of Korea
| | - Jangik I. Lee
- Department of Pharmacy, College of Pharmacy, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826 Republic of Korea
- Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
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111
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Abstract
Ventilator-associated pneumonia (VAP) is the most frequent life-threatening nosocomial infection in intensive care units. The diagnostic is difficult because radiological and clinical signs are inaccurate and could be associated with various respiratory diseases. The concept of infection-related ventilator-associated complication has been proposed as a surrogate of VAP to be used as a benchmark indicator of quality of care. Indeed, bundles of prevention measures are effective in decreasing the VAP rate. In case of VAP suspicion, respiratory secretions must be collected for bacteriological secretions before any new antimicrobials. Quantitative distal bacteriological exams may be preferable for a more reliable diagnosis and therefore a more appropriate use antimicrobials. To improve the prognosis, the treatment should be adequate as soon as possible but should avoid unnecessary broad-spectrum antimicrobials to limit antibiotic selection pressure. For empiric treatments, the selection of antimicrobials should consider the local prevalence of microorganisms along with their associated susceptibility profiles. Critically ill patients require high dosages of antimicrobials and more specifically continuous or prolonged infusions for beta-lactams. After patient stabilization, antimicrobials should be maintained for 7-8 days. The evaluation of VAP treatment based on 28-day mortality is being challenged by regulatory agencies, which are working on alternative surrogate endpoints and on trial design optimization.
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Affiliation(s)
- Jean-Francois Timsit
- IAME, Inserm U1137, Paris Diderot University, Paris, F75018, France.,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat University Hospital, Paris, France
| | - Wafa Esaied
- IAME, Inserm U1137, Paris Diderot University, Paris, F75018, France
| | - Mathilde Neuville
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat University Hospital, Paris, France
| | - Lila Bouadma
- IAME, Inserm U1137, Paris Diderot University, Paris, F75018, France.,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat University Hospital, Paris, France
| | - Bruno Mourvllier
- IAME, Inserm U1137, Paris Diderot University, Paris, F75018, France.,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat University Hospital, Paris, France
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112
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Roberts KL, Micek ST, Juang P, Kollef MH. Controversies and advances in the management of ventilator associated pneumonia. Expert Rev Respir Med 2017; 11:875-884. [PMID: 28891372 DOI: 10.1080/17476348.2017.1378574] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Although national surveillance data suggests that the incidence of ventilator associated pneumonia (VAP) is down-trending, it remains one of the most commonly encountered hospital acquired infections in the United States and worldwide. Its association with increased healthcare costs and worsened patient outcomes warrants continued effort to improve the care of patients with VAP. Areas covered: The increasing prevalence of multi-drug resistant bacteria further drives the need to explore advances in diagnostic and treatment options. In this review, controversies pertaining to the definition and diagnosis of VAP as well as empiric treatment strategies will be discussed along with several developments related to rapid microbiologic testing methods and the use of non-traditional antimicrobial agents. Expert commentary: The application of rapid diagnostic techniques to identify microbial pathogens is perhaps one of the most impactful advancements in the treatment of serious nosocomial infections. This technology has the potential to reduce inappropriate initial antimicrobial therapy, unnecessary antimicrobial exposure, and mortality in patients with VAP. In addition, the anticipated approval of new antimicrobial agents within the next several years will provide a much-needed expansion of available treatment options in an era of growing antimicrobial resistance.
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Affiliation(s)
| | - Scott T Micek
- b Division of Pharmacy Practice , St Louis College of Pharmacy , St Louis , MO , USA
| | - Paul Juang
- b Division of Pharmacy Practice , St Louis College of Pharmacy , St Louis , MO , USA
| | - Marin H Kollef
- c Division of Pulmonary and Critical Care Medicine , Washington University School of Medicine , St Louis , MO , USA
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113
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Bassetti M, Giacobbe DR, Giamarellou H, Viscoli C, Daikos GL, Dimopoulos G, De Rosa FG, Giamarellos-Bourboulis EJ, Rossolini GM, Righi E, Karaiskos I, Tumbarello M, Nicolau DP, Viale PL, Poulakou G. Management of KPC-producing Klebsiella pneumoniae infections. Clin Microbiol Infect 2017; 24:133-144. [PMID: 28893689 DOI: 10.1016/j.cmi.2017.08.030] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/17/2017] [Accepted: 08/23/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-KP) has become one of the most important contemporary pathogens, especially in endemic areas. AIMS To provide practical suggestion for physicians dealing with the management of KPC-KP infections in critically ill patients, based on expert opinions. SOURCES PubMed search for relevant publications related to the management of KPC-KP infections. CONTENTS A panel of experts developed a list of 12 questions to be addressed. In view of the current lack of high-level evidence, they were asked to provide answers on the bases of their knowledge and experience in the field. The panel identified several key aspects to be addressed when dealing with KPC-KP in critically ill patients (preventing colonization in the patient, preventing infection in the colonized patient and colonization of his or her contacts, reducing mortality in the infected patient by rapidly diagnosing the causative agent and promptly adopting the best therapeutic strategy) and provided related suggestions that were based on the available observational literature and the experience of panel members. IMPLICATIONS Diagnostic technologies could speed up the diagnosis of KPC-KP infections. Combination treatment should be preferred to monotherapy in cases of severe infections. For non-critically ill patients without severe infections, results from randomized clinical trials are needed for ultimately weighing benefits and costs of using combinations rather than monotherapy. Multifaceted infection control interventions are needed to decrease the rates of colonization and cross-transmission of KPC-KP.
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Affiliation(s)
- M Bassetti
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Presidio Ospedaliero Universitario Santa Maria della Misericordia, Udine, Italy.
| | - D R Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa (DISSAL), Genoa, Italy
| | - H Giamarellou
- 6th Department of Internal Medicine, Hygeia General Hospital, 4, Erythrou Stavrou Str & Kifisias, Marousi, Athens, Greece
| | - C Viscoli
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa (DISSAL), Genoa, Italy
| | - G L Daikos
- 1st Department of Propaedeutic Medicine, Laikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - G Dimopoulos
- Department of Critical Care, University Hospital Attikon, Medical School, University of Athens, Athens, Greece
| | - F G De Rosa
- Department of Medical Science, University of Turin, Infectious Diseases Amedeo di Savoia Hospital, Turin, Italy
| | - E J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - G M Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - E Righi
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Presidio Ospedaliero Universitario Santa Maria della Misericordia, Udine, Italy
| | - I Karaiskos
- 6th Department of Internal Medicine, Hygeia General Hospital, 4, Erythrou Stavrou Str & Kifisias, Marousi, Athens, Greece
| | - M Tumbarello
- Institute of Infectious Diseases Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - D P Nicolau
- Center for Anti-infective Research and Development, Hartford, CT, USA; Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
| | - P L Viale
- Clinic of Infectious Diseases, Department of Internal Medicine, Geriatrics and Nephrologic Diseases, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - G Poulakou
- Infectious Diseases Clinic, Department of Medicine University of Udine and Azienda Sanitaria Universitaria Integrata, Presidio Ospedaliero Universitario Santa Maria della Misericordia, Udine, Italy
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Kollef MH, Bassetti M, Francois B, Burnham J, Dimopoulos G, Garnacho-Montero J, Lipman J, Luyt CE, Nicolau DP, Postma MJ, Torres A, Welte T, Wunderink RG. The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship. Intensive Care Med 2017; 43:1187-1197. [PMID: 28160023 PMCID: PMC6204331 DOI: 10.1007/s00134-017-4682-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/06/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE To concisely describe the current standards of care, major recent advances, common beliefs that have been contradicted by recent trials, areas of uncertainty, and clinical studies that need to be performed over the next decade and their expected outcomes with regard to the management of multidrug-resistant (MDR) bacteria, antibiotic use, and antimicrobial stewardship in the intensive care unit (ICU) setting. METHODS Narrative review based on a systematic analysis of the medical literature, national and international guidelines, and expert opinion. RESULTS The prevalence of infection of critically ill patients by MDR bacteria is rapidly evolving. Clinical studies aimed at improving understanding of the changing patterns of these infections in ICUs are urgently needed. Ideal antibiotic utilization is another area of uncertainty requiring additional investigations aimed at better understanding of dose optimization, duration of therapy, use of combination treatment, aerosolized antibiotics, and the integration of rapid diagnostics as a guide for treatment. Moreover, there is an imperative need to develop non-antibiotic approaches for the prevention and treatment of MDR infections in the ICU. Finally, clinical research aimed at demonstrating the beneficial impact of antimicrobial stewardship in the ICU setting is essential. CONCLUSIONS These and other fundamental questions need to be addressed over the next decade in order to better understand how to prevent, diagnose, and treat MDR bacterial infections. Clinical studies described in this research agenda provide a template and set priorities for investigations that should be performed in this field.
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Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St. Louis, MO, 63110, USA.
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy
| | - Bruno Francois
- Service de Réanimation Polyvalente, Inserm CIC-1435, CHU Dupuytren, Limoges, France
| | - Jason Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - George Dimopoulos
- Department of Critical Care, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jose Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Seville, Spain
- Institute of Biomedicine of Seville, IBiS/CSIC/University of Seville, Seville, Spain
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Brisbane, QLD, Australia
- Burns, Trauma, and Critical Care Research Centre, The University of Queensland, Herston, Brisbane, QLD, Australia
| | - Charles-Edouard Luyt
- Service de Réanimation, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
- Sorbonne Universités, UPMC Université Paris 06, INSERM, UMRS 1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - David P Nicolau
- Center for Anti-infective Research and Development and Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
| | - Maarten J Postma
- Unit of PharmacoTherapy, Epidemiology & Economics, Department of Pharmacy and Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Antonio Torres
- Department of Pulmonology, Hospital Clinic of Barcelona, CIBERES, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Tobias Welte
- Department of Pulmonology, Hannover Medical School, Hannover, Germany
| | - Richard G Wunderink
- Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Wood GC, Swanson JM. An Update on Aerosolized Antibiotics for Treating Hospital-Acquired and Ventilator-Associated Pneumonia in Adults. Ann Pharmacother 2017; 51:1112-1121. [PMID: 28778127 DOI: 10.1177/1060028017723934] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE A significant percentage of patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) have poor outcomes with intravenous antibiotics. It is not clear if adding aerosolized antibiotics improves treatment. This review is an update on using aerosolized antibiotics for treating HAP/VAP in adults. DATA SOURCES PubMed search using the terms "aerosolized antibiotics pneumonia," "nebulized antibiotics pneumonia," and "inhaled antibiotics pneumonia." Reference lists from identified articles were also searched. STUDY SELECTION AND DATA EXTRACTION Clinical studies of aerosolized antibiotics for treating HAP/VAP in adults from July 2010 to March 2017. This article updates a previous review on this topic written in mid-2010. DATA SYNTHESIS The size and quality of studies have improved dramatically in the recent time period compared to previous studies. However, there still are not large randomized controlled trials available. Colistin and aminoglycosides were the most commonly studied agents, and the most common pathogens were Pseudomonas and Acinetobacter. The clinical efficacy of adding aerosolized antibiotics was mixed. Approximately half of the studies showed better outcomes, and none showed worse outcomes. Aerosolized antibiotics appear to be relatively safe, though pulmonary adverse events can occur. Attention to proper administration technique in mechanically ventilated patients is required, including the use of vibrating plate nebulizers. CONCLUSIONS Adding aerosolized antibiotics to intravenous antibiotics may improve the outcomes of adult patients with HAP/VAP in some settings. It seems reasonable to add aerosolized antibiotics in patients with multidrug-resistant organisms or who appear to be failing therapy. Clinicians should pay attention to potential adverse events and proper administration technique.
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Affiliation(s)
| | - Joseph M Swanson
- 1 University of Tennessee Health Science Center, Memphis, TN, USA
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Nebulized antibiotics in mechanically ventilated patients: a challenge for translational research from technology to clinical care. Ann Intensive Care 2017; 7:78. [PMID: 28766281 PMCID: PMC5539056 DOI: 10.1186/s13613-017-0301-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/17/2017] [Indexed: 01/20/2023] Open
Abstract
Nebulized antibiotic therapy directly targets airways and lung parenchyma resulting in high local concentrations and potentially lower systemic toxicities. Experimental and clinical studies have provided evidence for elevated lung concentrations and rapid bacterial killing following the administration of nebulized antibiotics during mechanical ventilation. Delivery of high concentrations of antibiotics to infected lung regions is the key to achieving efficient nebulized antibiotic therapy. However, current non-standardized clinical practice, the difficulties with implementing optimal nebulization techniques and the lack of robust clinical data have limited its widespread adoption. The present review summarizes the techniques and clinical constraints for optimal delivery of nebulized antibiotics to lung parenchyma during invasive mechanical ventilation. Pulmonary pharmacokinetics and pharmacodynamics of nebulized antibiotic therapy to treat ventilator-associated pneumonia are discussed and put into perspective. Experimental and clinical pharmacokinetics and pharmacodynamics support the use of nebulized antibiotics. However, its clinical benefits compared to intravenous therapy remain to be proved. Future investigations should focus on continuous improvement of nebulization practices and techniques. Before expanding its clinical use, careful design of large phase III randomized trials implementing adequate therapeutic strategies in targeted populations is required to demonstrate the clinical effectiveness of nebulized antibiotics in terms of patient outcomes and reduction in the emergence of antibiotic resistance.
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Dimopoulos G, Akova M. An overview on severe infections in Europe. Intensive Care Med 2016; 43:686-689. [PMID: 27995284 PMCID: PMC7079918 DOI: 10.1007/s00134-016-4650-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 12/08/2016] [Indexed: 02/05/2023]
Affiliation(s)
- George Dimopoulos
- Department of Critical Care, University Hospital Attikon, National and Kapodistrian University of Athens, 1 Rimini Str, Haidari, 12462, Athens, Greece.
| | - Murat Akova
- Department of Infectious Diseases, Hacettepe University School of Medicine, Ankara, Turkey
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