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Sánchez Yebra W, Obelleiro Campos AX, Del Gigia Aguirre L, Cabezas Fernández T, Sánchez Gómez J, de Lamo Sevilla C, Gutiérrez Fernández J, Rodríguez Maresca M. Preliminary readings of antimicrobial susceptibility panels: A simple, fast and inexpensive way to detect bacterial resistance and enhance antibiotic treatment of bloodstream infections. Diagn Microbiol Infect Dis 2019; 94:398-402. [PMID: 30929996 DOI: 10.1016/j.diagmicrobio.2019.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 02/18/2019] [Accepted: 03/01/2019] [Indexed: 01/19/2023]
Abstract
Increasing incidence of resistant bacteria needs faster identification (ID) and antibiotic susceptibility testing (AST) in order to improve antimicrobial treatment of severe infections. We propose a preliminary reading of the AST MicroScan® panels coupled with mass spectrometry ID. A total of 157 bacterial clinical isolates were processed for routine ID and AST (in 22 cases, ID and AST were performed directly from positive blood culture bottles). For gram-negatives, data from the initial and final readings were recorded and compared [89.9% category agreement (CA), 6.9% very major errors (VME)]. In adition all the 32 ESBL producers were detected at 5.3-8.6 hours. For Staphylococcus aureus, all the 16 MRSA isolates were detected at 4.5 to 7.5 hours. Thus, we find our preliminary readings approach as a simple, inexpensive and reliable way to detect and identify the most prevalent resistant bacteria in our institution on the same day that ID/AST is performed.
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Affiliation(s)
- Waldo Sánchez Yebra
- UGC Biotecnología, Complejo Hospitalario Torrecárdenas, Servicio Andaluz de Salud, Almería, Spain
| | | | - Laura Del Gigia Aguirre
- UGC Biotecnología, Complejo Hospitalario Torrecárdenas, Servicio Andaluz de Salud, Almería, Spain
| | - Teresa Cabezas Fernández
- UGC Biotecnología, Complejo Hospitalario Torrecárdenas, Servicio Andaluz de Salud, Almería, Spain
| | - Juan Sánchez Gómez
- UGC Biotecnología, Complejo Hospitalario Torrecárdenas, Servicio Andaluz de Salud, Almería, Spain
| | - Cristina de Lamo Sevilla
- UGC Biotecnología, Complejo Hospitalario Torrecárdenas, Servicio Andaluz de Salud, Almería, Spain
| | | | - Manuel Rodríguez Maresca
- UGC Biotecnología, Complejo Hospitalario Torrecárdenas, Servicio Andaluz de Salud, Almería, Spain
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Nadaraia NS, Amiranashvili LS, Merlani M, Kakhabrishvili ML, Barbakadze NN, Geronikaki A, Petrou A, Poroikov V, Ciric A, Glamoclija J, Sokovic M. Novel antimicrobial agents' discovery among the steroid derivatives. Steroids 2019; 144:52-65. [PMID: 30776376 DOI: 10.1016/j.steroids.2019.02.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 02/12/2019] [Indexed: 02/07/2023]
Abstract
Fourteen steroid compounds were in silico evaluated using computer program PASS as antimicrobial agents. The experimental studies evaluation revealed that all compounds have good antibacterial activity with MIC at range of 0.003-0.96 mg/mL and MBC 0.06-1.92 mg/mL. Almost all compounds except of compound 4 (3β-acetoxy-1/-p-chlorophenyl-3/-methyl-5α-androstano[17,16-d]pyrazoline) were more potent than Ampicillin, and they were equipotent or more potent than Streptomycine. All compounds exhibited good antifungal activity with MIC at 0.003-0.96 mg/mL and MFC at 0.006-1.92 mg/mL but with different sensitivity against fungi tested. According to docking studies 14-alpha demethylase inhibition may be responsible for antifungal activity. Prediction of toxicity by PROTOX and GUSAR revealed that compounds have low toxicity and can be considered as potential lead compounds for the further studies.
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Affiliation(s)
- Nanuli Sh Nadaraia
- TSMU I.Kutateladze Institute of Pharmacochemistry, Tbilisi 0159, Georgia
| | | | - Maia Merlani
- TSMU I.Kutateladze Institute of Pharmacochemistry, Tbilisi 0159, Georgia
| | | | - Nana N Barbakadze
- TSMU I.Kutateladze Institute of Pharmacochemistry, Tbilisi 0159, Georgia
| | - Athina Geronikaki
- Aristotle University, School of Pharmacy, Thessaloniki 54124, Greece.
| | - Anthi Petrou
- Aristotle University, School of Pharmacy, Thessaloniki 54124, Greece
| | | | - Ana Ciric
- Mycological Laboratory, Department of Plant Physiology, Institute for Biological Research, Siniša Stanković, University of Belgrade, Bulevar Despota Stefana, Serbia
| | - Jarmila Glamoclija
- Mycological Laboratory, Department of Plant Physiology, Institute for Biological Research, Siniša Stanković, University of Belgrade, Bulevar Despota Stefana, Serbia
| | - Marina Sokovic
- Mycological Laboratory, Department of Plant Physiology, Institute for Biological Research, Siniša Stanković, University of Belgrade, Bulevar Despota Stefana, Serbia
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Nadjm B, Dat VQ, Campbell JI, Dung VTV, Torre A, Tu NTC, Van NTT, Trinh DT, Lan NPH, Trung NV, Hang NTT, Hoi LT, Baker S, Wolbers M, Chau NVV, Van Kinh N, Thwaites GE, van Doorn HR, Wertheim HFL. A randomised controlled trial of matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDITOF-MS) versus conventional microbiological methods for identifying pathogens: Impact on optimal antimicrobial therapy of invasive bacterial and fungal infections in Vietnam. J Infect 2019; 78:454-460. [PMID: 30914268 PMCID: PMC6529875 DOI: 10.1016/j.jinf.2019.03.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 03/19/2019] [Accepted: 03/19/2019] [Indexed: 11/28/2022]
Abstract
MALDITOF MS provided more rapid identification of invasive bacterial and fungal pathogens than conventional microbiology. MALDITOF MS did not increase the proportion of patients on optimal therapy at 24 or 48 hours after positive culture. MALDITOF MS did not increase the proportion of patients receiving adequate therapy at 24 hours after positive culture. The most common reason for therapy being sub-optimal was use of overly broad spectrum or unnecessary multiple antibiotics.
Objectives We assessed the impact of MALDITOF-MS on the timeliness of optimal antimicrobial therapy through a parallel-arm randomised controlled trial in two hospitals in Vietnam. Methods We recruited patients with a pathogen (bacterial or fungal) cultured from a normally sterile sample. Samples were randomly assigned (1:1) to identification by MALDITOF-MS or conventional diagnostics. The primary outcome was the proportion on optimal antimicrobial therapy within 24 h of positive culture, determined by a blinded independent review committee. Trial registered at ClinicalTrials.gov (NCT02306330). Results Among 1005 randomised patients, pathogens were isolated from 628 (326 intervention, 302 control), with 377 excluded as likely contaminants or discharged/died before positive culture. Most isolates were cultured from blood (421/628, 67.0%). The proportion receiving optimal antimicrobial therapy within 24 h (the primary outcome) or 48 h of growth was not significantly different between MALDITOF-MS and control arms (135/326, 41.4% vs 120/302, 39.7%; Adjusted Odds ration (AOR) 1.17, p = 0.40 and 151/326, 46.3% vs 141/302, 46.7%; AOR 1.05 p = 0.79, respectively). Conclusions MALDITOF-MS, in the absence of an antimicrobial stewardship programme, did not improve the proportion on optimal antimicrobial therapy at 24 or 48 h after first growth in a lower-middle income setting with high rates of antibiotic resistance.
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Affiliation(s)
- Behzad Nadjm
- Oxford University Clinical Research Unit, Hanoi & Ho Chi Minh City, Viet Nam; Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom.
| | - Vu Quoc Dat
- Oxford University Clinical Research Unit, Hanoi & Ho Chi Minh City, Viet Nam; Department of Infectious Diseases, Hanoi Medical University, Hanoi, Viet Nam
| | - James I Campbell
- Oxford University Clinical Research Unit, Hanoi & Ho Chi Minh City, Viet Nam; Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Vu Tien Viet Dung
- Oxford University Clinical Research Unit, Hanoi & Ho Chi Minh City, Viet Nam
| | - Alessandro Torre
- Oxford University Clinical Research Unit, Hanoi & Ho Chi Minh City, Viet Nam
| | - Nguyen Thi Cam Tu
- Oxford University Clinical Research Unit, Hanoi & Ho Chi Minh City, Viet Nam
| | - Ninh Thi Thanh Van
- Oxford University Clinical Research Unit, Hanoi & Ho Chi Minh City, Viet Nam
| | | | | | | | | | - Le Thi Hoi
- National Hospital for Tropical Diseases, Hanoi, Viet Nam
| | - Stephen Baker
- Oxford University Clinical Research Unit, Hanoi & Ho Chi Minh City, Viet Nam; Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Marcel Wolbers
- Oxford University Clinical Research Unit, Hanoi & Ho Chi Minh City, Viet Nam
| | | | | | - Guy E Thwaites
- Oxford University Clinical Research Unit, Hanoi & Ho Chi Minh City, Viet Nam; Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Hanoi & Ho Chi Minh City, Viet Nam; Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Heiman F L Wertheim
- Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom; Department of Medical Microbiology, RadboudUMC, Nijmegen, The Netherlands
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Fernández J, Prado V, Trebicka J, Amoros A, Gustot T, Wiest R, Deulofeu C, Garcia E, Acevedo J, Fuhrmann V, Durand F, Sánchez C, Papp M, Caraceni P, Vargas V, Bañares R, Piano S, Janicko M, Albillos A, Alessandria C, Soriano G, Welzel TM, Laleman W, Gerbes A, De Gottardi A, Merli M, Coenraad M, Saliba F, Pavesi M, Jalan R, Ginès P, Angeli P, Arroyo V. Multidrug-resistant bacterial infections in patients with decompensated cirrhosis and with acute-on-chronic liver failure in Europe. J Hepatol 2019; 70:398-411. [PMID: 30391380 DOI: 10.1016/j.jhep.2018.10.027] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 10/23/2018] [Accepted: 10/28/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Antibiotic resistance has been increasingly reported in patients with decompensated cirrhosis in single-center studies. Prospective investigations reporting broad epidemiological data are scarce. We aimed to analyze epidemiological changes in bacterial infections in patients with decompensated cirrhosis. METHODS This was a prospective evaluation of 2 series of patients hospitalized with decompensated cirrhosis. The Canonic series included 1,146 patients from Northern, Southern and Western Europe in 2011. Data on epidemiology, clinical characteristics of bacterial infections, microbiology and empirical antibiotic schedules were assessed. A second series of 883 patients from Eastern, Southern and Western Europe was investigated between 2017-2018. RESULTS A total of 455 patients developed 520 infections (39.7%) in the first series, with spontaneous bacterial peritonitis, urinary tract infections and pneumonia the most frequent infections. Nosocomial episodes predominated in this series. Nearly half of the infections were culture-positive, of which 29.2% were caused by multidrug-resistant organisms (MDROs). MDR strains were more frequently isolated in Northern and Western Europe. Extended-spectrum beta-lactamase-producing Enterobacteriaceae were the most frequent MDROs isolated in this series, although prevalence and type differed markedly among countries and centers. Antibiotic resistance was associated with poor prognosis and failure of antibiotic strategies, based on third-generation cephalosporins or quinolones. Nosocomial infection (odds ratio [OR] 2.74; p < 0.001), intensive care unit admission (OR 2.09; p = 0.02), and recent hospitalization (OR 1.93; p = 0.04) were identified as independent predictors of MDR infection. The prevalence of MDROs in the second series (392 infections/284 patients) was 23%; 38% in culture-positive infections. A mild increase in the rate of carbapenem-resistant Enterobacteriaceae was observed in this series. CONCLUSIONS MDR bacterial infections constitute a prevalent, growing and complex healthcare problem in patients with decompensated cirrhosis and acute-on-chronic liver failure across Europe, negatively impacting on prognosis. Strategies aimed at preventing the spread of antibiotic resistance in cirrhosis should be urgently evaluated. LAY SUMMARY Infections caused by bacteria resistant to the main antibiotic families are prevalent in patients with cirrhosis. This study demonstrates that this healthcare problem is increasing and extends through all European regions. Infections caused by these difficult to treat bacteria resolve less frequently and often cause the death of the patient. The type of resistant bacteria varies markedly among different hospitals.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain.
| | - Verónica Prado
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jonel Trebicka
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; University of Bonn, Germany
| | - Alex Amoros
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Thierry Gustot
- Liver Transplant Unit, Erasme Hospital, Brussels, Belgium
| | - Reiner Wiest
- Department of Medicine and Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Carme Deulofeu
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Elisabet Garcia
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | | | | | | | - Cristina Sánchez
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Maria Papp
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Hungary
| | | | - Victor Vargas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital Vall d'Hebron, Barcelona, Spain
| | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital Gregorio Marañon, Madrid, Spain
| | | | | | | | | | - German Soriano
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital of Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Alexander Gerbes
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU Munich, Germany
| | - Andrea De Gottardi
- Department of Medicine and Surgery, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Faouzi Saliba
- Centre Hepato-Biliare, Hòpital Paul Brousse, Paris, France
| | - Marco Pavesi
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Rajiv Jalan
- ILDH, Division of Medicine, University College London Medical School, London, United Kingdom
| | - Pere Ginès
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain
| | | | - Vicente Arroyo
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
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Lam SW, Bass SN. Advancing Infectious Diseases Diagnostic Testing and Applications to Antimicrobial Therapy in the ICU. J Pharm Pract 2019; 32:327-338. [PMID: 30808257 DOI: 10.1177/0897190019831162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Treatment of suspected infections in critically ill patients requires the timely initiation of appropriate antimicrobials and rapid de-escalation of unnecessary broad-spectrum coverage. New advances in rapid diagnostic tests can now offer earlier detection of pathogen and potential resistance mechanisms within hours of initial culture growth. These technologies, combined with pharmacist antimicrobial stewardship efforts, may result in shorten time to adequate coverage or earlier de-escalation of unnecessary broad spectrum antimicrobials, which could improve patient outcomes and lower overall treatment cost. Furthermore, de-escalation of antimicrobials may lead to decreased emergence of resistant organisms and adverse events associated with antimicrobials. Clinical pharmacists should be aware of new rapid diagnostic tests, including their application, clinical evidence, and limitations, in order to implement the most appropriate clinical treatment strategy when patients have positive cultures. This review will focus on commercially available rapid diagnostic tests for infections that are routinely encountered by critically ill patients, including gram-positive and gram-negative bacterial blood stream infections, Candida, and Clostridioides difficile.
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Affiliation(s)
- Simon W Lam
- 1 Department of Pharmacy, Pharmacoeconomics and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Stephanie N Bass
- 2 Department of Pharmacy, Medical Intensive Care Unit, Cleveland Clinic, Cleveland, OH, USA
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Mach KE, Kaushik AM, Hsieh K, Wong PK, Wang TH, Liao JC. Optimizing peptide nucleic acid probes for hybridization-based detection and identification of bacterial pathogens. Analyst 2019; 144:1565-1574. [PMID: 30656297 PMCID: PMC7039532 DOI: 10.1039/c8an02194e] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Point-of-care (POC) diagnostics for infectious diseases have the potential to improve patient care and antibiotic stewardship. Nucleic acid hybridization is at the core of many amplification-free molecular diagnostics and detection probe configuration is key to diagnostic performance. Modified nucleic acids such as peptide nucleic acid (PNA) offer advantages compared to conventional DNA probes allowing for faster hybridization, better stability and minimal sample preparation for direct detection of pathogens. Probes with tethered fluorophore and quencher allow for solution-based assays and eliminate the need for washing steps thereby facilitating integration into microfluidic devices. Here, we compared the sensitivity and specificity of double stranded PNA probes (dsPNA) and PNA molecular beacons targeting E. coli and P. aeruginosa for direct detection of bacterial pathogens. In bulk fluid assays, the dsPNAs had an overall higher fluorescent signal and better sensitivity and specificity than the PNA beacons for pathogen detection. We further designed and tested an expanded panel of dsPNA probes for detection of a wide variety of pathogenic bacteria including probes for universal detection of eubacteria, Enterobacteriaceae family, and P. mirablis. To confirm that the advantage translated to other assay types we compared the PNA beacon and dsPNA in a prototype droplet microfluidic device. Beyond the bulk fluid assay and droplet devices, use of dsPNA probes may be advantageous in a wide variety of assays that employ homogenous nucleic acid hybridization.
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Affiliation(s)
- Kathleen E Mach
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA.
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Nathwani D, Varghese D, Stephens J, Ansari W, Martin S, Charbonneau C. Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review. Antimicrob Resist Infect Control 2019; 8:35. [PMID: 30805182 PMCID: PMC6373132 DOI: 10.1186/s13756-019-0471-0] [Citation(s) in RCA: 221] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/11/2019] [Indexed: 12/21/2022] Open
Abstract
Background Hospital antimicrobial stewardship programs (ASPs) aim to promote judicious use of antimicrobials to combat antimicrobial resistance. For ASPs to be developed, adopted, and implemented, an economic value assessment is essential. Few studies demonstrate the cost-effectiveness of ASPs. This systematic review aimed to evaluate the economic and clinical impact of ASPs. Methods An update to the Dik et al. systematic review (2000–2014) was conducted on EMBASE and Medline using PRISMA guidelines. The updated search was limited to primary research studies in English (30 September 2014–31 December 2017) that evaluated patient and/or economic outcomes after implementation of hospital ASPs including length of stay (LOS), antimicrobial use, and total (including operational and implementation) costs. Results One hundred forty-six studies meeting inclusion criteria were included. The majority of these studies were conducted within the last 5 years in North America (49%), Europe (25%), and Asia (14%), with few studies conducted in Africa (3%), South America (3%), and Australia (3%). Most studies were conducted in hospitals with 500–1000 beds and evaluated LOS and change in antibiotic expenditure, the majority of which showed a decrease in LOS (85%) and antibiotic expenditure (92%). The mean cost-savings varied by hospital size and region after implementation of ASPs. Average cost savings in US studies were $732 per patient (range: $2.50 to $2640), with similar trends exhibited in European studies. The key driver of cost savings was from reduction in LOS. Savings were higher among hospitals with comprehensive ASPs which included therapy review and antibiotic restrictions. Conclusions Our data indicates that hospital ASPs have significant value with beneficial clinical and economic impacts. More robust published data is required in terms of implementation, LOS, and overall costs so that decision-makers can make a stronger case for investing in ASPs, considering competing priorities. Such data on ASPs in lower- and middle-income countries is limited and requires urgent attention.
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Affiliation(s)
- Dilip Nathwani
- 1Ninewells Hospital and Medical School, Dundee, DD19SY UK
| | - Della Varghese
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
| | - Jennifer Stephens
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
| | | | - Stephan Martin
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
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Ideal and Actual Impact of Rapid Diagnostic Testing and Antibiotic Stewardship on Antibiotic Prescribing and Clinical Outcomes in Children With Positive Blood Cultures. Pediatr Infect Dis J 2019; 38:131-137. [PMID: 29750765 DOI: 10.1097/inf.0000000000002102] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Implementing matrix-assisted laser desorption ionization-time of flight and multiplex polymerase chain reaction has been associated with decreased mortality and hospital length of stay in adults, but the impact in pediatrics is less understood. METHODS This pre-post quasi-experimental study compared antibiotic prescribing for positive blood cultures in patients ≤21 years of age collected in 2012 (preintervention) and in 2015 (after matrix-assisted laser desorption ionization-time of flight/multiplex polymerase chain reaction). Time to effective and optimal antimicrobial therapy was evaluated using Cox proportional hazards regression. Time to ideal optimal therapy was estimated as the earliest potential initiation of optimal therapy. Antibiotic use and clinical outcomes were measured. RESULTS There were 242 and 192 positive monomicrobial blood cultures in 2012 and 2015, respectively. Postintervention, time to optimal therapy (73.8 vs. 48.8 hours; P < 0.001) and organism identification (55.6 vs. 29.5 hours; P < 0.001) were reduced, and patients were more likely to receive optimal therapy by 7 days (hazard ratio, 1.85; P < 0.001). In the ideal scenario in 2015, there was an 8.8-hour delay in initiating optimal therapy based on the time that sufficient microbiologic data were available. Postintervention, time to effective therapy (2.8 vs. 2.7 hours; P = 0.782) and clinical outcomes did not differ. Unnecessary antibiotic duration for probable contaminants (skin flora) (43.1 vs. 29.7 hours; P = 0.027), vancomycin for methicillin-sensitive Staphylococcus aureus (54.0 vs. 41.3 hours; P = 0.008) and nonpenicillin/ampicillin antibiotics for group A Streptococcus, group B Streptococcus and Enterococcus faecalis (87.2 vs. 33.4 hours; P < 0.001) were reduced postintervention. CONCLUSIONS Rapid diagnostics reduced time to optimal antimicrobial therapy and unnecessary antibiotic use without worse clinical outcomes.
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109
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Sprigg K, Pietrangeli CE. Bacterial Antibiotic Resistance: on the Cusp of a Post-antibiotic World. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-0181-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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110
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De Waele JJ, Dhaese S. Antibiotic stewardship in sepsis management: toward a balanced use of antibiotics for the severely ill patient. Expert Rev Anti Infect Ther 2019; 17:89-97. [DOI: 10.1080/14787210.2019.1568239] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jan J. De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Gent, Belgium
| | - Sofie Dhaese
- Department of Critical Care Medicine, Ghent University Hospital, Gent, Belgium
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111
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Microplate-based surface area assay for rapid phenotypic antibiotic susceptibility testing. Sci Rep 2019; 9:237. [PMID: 30659207 PMCID: PMC6338723 DOI: 10.1038/s41598-018-35916-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/08/2018] [Indexed: 11/08/2022] Open
Abstract
Rapid delivery of proper antibiotic therapies to infectious disease patients is essential for improving patient outcomes, decreasing hospital lengths-of-stay, and combating the antibiotic resistance epidemic. Antibiotic stewardship programs are designed to address these issues by coordinating hospital efforts to rapidly deliver the most effective antibiotics for each patient, which requires bacterial identification and antimicrobial susceptibility testing (AST). Despite the clinical need for fast susceptibility testing over a wide range of antibiotics, conventional phenotypic AST requires overnight incubations, and new rapid phenotypic AST platforms restrict the number of antibiotics tested for each patient. Here, we introduce a novel approach to AST based on signal amplification of bacterial surfaces that enables phenotypic AST within 5 hours for non-fastidious bacteria. By binding bacterial surfaces, this novel method allows more accurate measurements of bacterial replication in instances where organisms filament or swell in response to antibiotic exposure. Further, as an endpoint assay performed on standard microplates, this method should enable parallel testing of more antibiotics than is currently possible with available automated systems. This technology has the potential to revolutionize clinical practice by providing rapid and accurate phenotypic AST data for virtually all available antibiotics in a single test.
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112
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Hogan CA, Watz N, Budvytiene I, Banaei N. Rapid antimicrobial susceptibility testing by VITEK®2 directly from blood cultures in patients with Gram-negative rod bacteremia. Diagn Microbiol Infect Dis 2019; 94:116-121. [PMID: 30711413 DOI: 10.1016/j.diagmicrobio.2019.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/28/2018] [Accepted: 01/01/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Optimizing therapy for bacteremia is currently limited by the 1-2-day turnaround time required for antimicrobial susceptibility testing (AST). Here, we assess a rapid AST method with VITEK®2 (bioMérieux, France) directly from positive blood cultures. METHODS Patient-derived positive blood cultures with Gram-negative rods identified as Enterobacteriaceae and Pseudomonas aeruginosa were prospectively tested, and other blood culture bottles were spiked with carbapenem-resistant Enterobacteriaceae (CRE). Positive cultures were subjected to red blood cell lysis and centrifugation, and setup on VITEK®2. RESULTS A total of 109 patient blood cultures and 52 spiked blood cultures were tested. Overall, essential agreement was 97.7% [95% confidence interval (CI) 96.4-99.0], and categorical agreement was 96.8% (95% CI 95.0-98.6). Mean turnaround time from setup to susceptibility results for Enterobacteriaceae in the clinical cultures was 9.0 (±1.3) h. CONCLUSIONS Direct susceptibility testing of blood cultures by VITEK®2 for Enterobacteriaceae is an accurate, practical, and inexpensive diagnostic strategy for rapid automated AST.
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Affiliation(s)
- C A Hogan
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA; Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, CA, USA
| | - N Watz
- Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, CA, USA
| | - I Budvytiene
- Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, CA, USA
| | - N Banaei
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA; Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, CA, USA; Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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Beganovic M, Timbrook TT, Wieczorkiewicz SM. Predictors of Time to Effective and Optimal Antimicrobial Therapy in Patients With Positive Blood Cultures Identified via Molecular Rapid Diagnostic Testing. Open Forum Infect Dis 2019; 6:ofy350. [PMID: 30631795 PMCID: PMC6324550 DOI: 10.1093/ofid/ofy350] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/21/2018] [Indexed: 12/16/2022] Open
Abstract
Antimicrobial stewardship (AMS) programs integrated with rapid diagnostic tests optimize patient outcomes and reduce time to effective therapy (TTET) and time to optimal therapy (TTOT). This study identifies predictors of TTET and TTOT among patients with positive blood cultures and identifies limitations to current TTOT definitions and outcomes.
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Affiliation(s)
- Maya Beganovic
- Department of Pharmacy, Advocate Lutheran General Hospital, Park Ridge, Illinois
| | - Tristan T Timbrook
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah.,Salt Lake City Veteran's Affairs Medical Center, Salt Lake City, Utah
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114
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Schneider JG, Wood JB, Schmitt BH, Emery CL, Davis TE, Smith NW, Blevins S, Hiles J, Desai A, Wrin J, Bocian B, Manaloor JJ. Susceptibility Provision Enhances Effective De-escalation (SPEED): utilizing rapid phenotypic susceptibility testing in Gram-negative bloodstream infections and its potential clinical impact. J Antimicrob Chemother 2019; 74:i16-i23. [PMID: 30690542 PMCID: PMC6382035 DOI: 10.1093/jac/dky531] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objectives We evaluated the performance and time to result for pathogen identification (ID) and antimicrobial susceptibility testing (AST) of the Accelerate Pheno™ system (AXDX) compared with standard of care (SOC) methods. We also assessed the hypothetical improvement in antibiotic utilization if AXDX had been implemented. Methods Clinical samples from patients with monomicrobial Gram-negative bacteraemia were tested and compared between AXDX and the SOC methods of the VERIGENE® and Bruker MALDI Biotyper® systems for ID and the VITEK® 2 system for AST. Additionally, charts were reviewed to calculate theoretical times to antibiotic de-escalation, escalation and active and optimal therapy. Results ID mean time was 21 h for MALDI-TOF MS, 4.4 h for VERIGENE® and 3.7 h for AXDX. AST mean time was 35 h for VITEK® 2 and 9.0 h for AXDX. For ID, positive percentage agreement was 95.9% and negative percentage agreement was 99.9%. For AST, essential agreement was 94.5% and categorical agreement was 93.5%. If AXDX results had been available to inform patient care, 25% of patients could have been put on active therapy sooner, while 78% of patients who had therapy optimized during hospitalization could have had therapy optimized sooner. Additionally, AXDX could have reduced time to de-escalation (16 versus 31 h) and escalation (19 versus 31 h) compared with SOC. Conclusions By providing fast and reliable ID and AST results, AXDX has the potential to improve antimicrobial utilization and enhance antimicrobial stewardship.
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Affiliation(s)
- Jack G Schneider
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - James B Wood
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bryan H Schmitt
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christopher L Emery
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas E Davis
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Sarah Blevins
- Indiana University Health, Methodist and University Hospitals, Indianapolis, IN, USA
| | - Jon Hiles
- Indiana University Health, Methodist and University Hospitals, Indianapolis, IN, USA
| | - Armisha Desai
- Indiana University Health, Methodist and University Hospitals, Indianapolis, IN, USA
| | - Justin Wrin
- Indiana University Health, Methodist and University Hospitals, Indianapolis, IN, USA
| | - Brittany Bocian
- Indiana University Health, Methodist and University Hospitals, Indianapolis, IN, USA
| | - John J Manaloor
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
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115
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Jiménez-Aguilar P, López-Cortés LE, Rodríguez-Baño J. Impact of infectious diseases consultation on the outcome of patients with bacteraemia. Ther Adv Infect Dis 2019; 6:2049936119893576. [PMID: 31839942 PMCID: PMC6900613 DOI: 10.1177/2049936119893576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 11/15/2019] [Indexed: 12/29/2022] Open
Abstract
Bacteraemia or bloodstream infections (BSI) are associated with much morbidity and mortality. Management of patients with bacteraemia is complex, and the increase in immunosuppressed patients and multidrug-resistant organisms poses additional challenges. The objective of this review is to assess the available published information about the impact of different aspects of management on the outcome of patients with BSI, and, specifically, the importance of infectious diseases specialists (IDS) consultation. The impact of management by IDS on different aspects, including interpretation of newer rapid techniques, early evaluation and treatment, and follow up, are reviewed. Overall, the available data suggest that IDS intervention improves the management and outcome of patients with BSI, either through consultation or structured unsolicited interventions in the context of multidisciplinary bacteraemia programmes.
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Affiliation(s)
- Patricia Jiménez-Aguilar
- Unidad Clínica de Enfermedades Infecciosas,
Hospital Universitario Puerto Real, Puerto Real, Cádiz, Spain
- Instituto de Investigación e Innovación
Biomédica de Cádiz (INiBICA), Cádiz, Spain
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas,
Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena,
Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas,
Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena,
Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
- Departamento de Medicina, Universidad de
Sevilla, Sevilla, Spain
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116
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Abstract
Antibiotic resistance in common bacterial pathogens, such as Staphylococcus aureus, Escherichia coli, and Klebsiella pneumoniae, has significantly limited the therapeutic options available for management of infectious diseases. While the indiscriminant use of broad spectrum antibiotics is a significant contributing factor, a more fundamental problem exists. Diagnostic microbiology test results have historically been available too late to be useful. This is, in part, due to the nature of the test methods and in part due to workflow practices in the laboratory. Thus, patients remain on empiric treatments that are frequently ineffective or unnecessarily too broad spectrum1,2. Microscopy and bacterial cultures are mainstays in the microbiology lab, using techniques developed more than 100 years ago. Although microbiologists speak with pride about the ‘art' of their science, the clinical value of the diagnostic tests is frequently lost because of the delays in reporting results with these ‘traditional' approaches. Fortunately, the practice of clinical microbiology is undergoing a dramatic transformation with the introduction of molecular diagnostics, primarily for rapid diagnosis of infections caused by viruses and difficult to grow bacteria, MALDI-TOF mass spectrometry for identification of bacteria, mycobacteria and fungi, and automation of all practices in bacteriology.
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117
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Wolk DM, Johnson JK. Rapid Diagnostics for Blood Cultures: Supporting Decisions for Antimicrobial Therapy and Value-Based Care. J Appl Lab Med 2018; 3:686-697. [PMID: 31639736 DOI: 10.1373/jalm.2018.028159] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/07/2018] [Indexed: 01/05/2023]
Abstract
Bacteremia and sepsis are critically important syndromes with high mortality, morbidity, and associated costs. Bloodstream infections and sepsis are among the top causes of mortality in the US, with >600 deaths each day. Most septic patients can be found in emergency medicine departments or critical care units, settings in which rapid administration of targeted antibiotic therapy can reduce mortality. Unfortunately, routine blood cultures are not rapid enough to aid in the decision of therapeutic intervention at the onset of bacteremia. As a result, empiric, broad-spectrum treatment is common-a costly approach that may fail to target the correct microbe effectively, may inadvertently harm patients via antimicrobial toxicity, and may contribute to the evolution of drug-resistant microbes. To overcome these challenges, laboratorians must understand the complexity of diagnosing and treating septic patients, focus on creating algorithms that rapidly support decisions for targeted antibiotic therapy, and synergize with existing emergency department and critical care clinical practices put forth in the Surviving Sepsis Guidelines.
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Affiliation(s)
- Donna M Wolk
- Laboratory Medicine, Geisinger Diagnostic Medicine Institute, Danville, PA;
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
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118
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Tseng AS, Kasule SN, Rice F, Mi L, Chan L, Seville MT, Grys TE. Is It Actionable? An Evaluation of the Rapid PCR-Based Blood Culture Identification Panel on the Management of Gram-Positive and Gram-Negative Blood Stream Infections. Open Forum Infect Dis 2018; 5:ofy308. [PMID: 30555850 PMCID: PMC6288766 DOI: 10.1093/ofid/ofy308] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/03/2018] [Indexed: 01/02/2023] Open
Abstract
Background There is growing interest in the use of rapid blood culture identification (BCID) in antimicrobial stewardship programs (ASPs). Although many studies have looked at its clinical and economic utility, its comparative utility in gram-positive and gram-negative blood stream infections (BSIs) has not been as well characterized. Methods The study was a quasi-experimental retrospective study at the Mayo Clinic in Phoenix, Arizona. All adult patients with positive blood cultures before BCID implementation (June 2015 to December 2015) and after BCID implementation (June 2016 to December 2016) were included. The outcomes of interest included time to first appropriate antibiotic escalation, time to first appropriate antibiotic de-escalation, time to organism identification, length of stay, infectious diseases consultation, discharge disposition, and in-hospital mortality. Results In total, 203 patients were included in this study. There was a significant difference in the time to organism identification between the pre- and post-BCID cohorts (27.1 hours vs 3.3 hours, P < .0001). BCID did not significantly reduce the time to first appropriate antimicrobial escalation or de-escalation for either gram-positive BSIs (GP-BSIs) or gram-negative BSIs (GN-BSIs). Providers were more likely to escalate antimicrobial therapy in GP-BSIs after gram stain and more likely to de-escalate therapy in GN-BSIs after susceptibilities. Although there were no significant differences in changes in antimicrobial therapy for organism identification by BCID vs traditional methods, more than one-quarter of providers (28.1%) made changes after organism identification. There were no differences in hospital length of stay or in-hospital mortality comparing pre- vs post-BCID. Conclusions Although BCID significantly reduced the time to identification for both GP-BSIs and GN-BSIs, BCID did not reduce the time to first appropriate antimicrobial escalation and de-escalation.
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Affiliation(s)
- Andrew S Tseng
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Sabirah N Kasule
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Felicia Rice
- Division of Laboratory Medicine, Mayo Clinic, Phoenix, Arizona
| | - Lanyu Mi
- Division of Health Sciences Research, Department of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, Arizona
| | - Lynn Chan
- Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona
| | - Maria T Seville
- Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona
| | - Thomas E Grys
- Division of Laboratory Medicine, Mayo Clinic, Phoenix, Arizona
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119
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Tabak YP, Vankeepuram L, Ye G, Jeffers K, Gupta V, Murray PR. Blood Culture Turnaround Time in U.S. Acute Care Hospitals and Implications for Laboratory Process Optimization. J Clin Microbiol 2018; 56:e00500-18. [PMID: 30135230 PMCID: PMC6258864 DOI: 10.1128/jcm.00500-18] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/08/2018] [Indexed: 01/03/2023] Open
Abstract
The rapid identification of blood culture isolates and antimicrobial susceptibility test (AST) results play critical roles for the optimal treatment of patients with bloodstream infections. Whereas others have looked at the time to detection in automated culture systems, we examined the overall time from specimen collection to actionable test results. We examined four points of time, namely, blood specimen collection, Gram stain, organism identification (ID), and AST reports, from electronic data from 13 U.S. hospitals for the 11 most common, clinically significant organisms in septic patients. We compared the differences in turnaround times and the times from when specimens were collected and the results were reported in the 24-h spectrum. From January 2015 to June 2016, 165,593 blood specimens were collected, of which, 9.5% gave positive cultures. No matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry was used during the study period. Across the 10 common bacterial isolates (n = 6,412), the overall median (interquartile range) turnaround times were 0.80 (0.64 to 1.08), 1.81 (1.34 to 2.46), and 2.71 (2.46 to 2.99) days for Gram stain, organism ID, and AST, respectively. For all positive cultures, approximately 25% of the specimens were collected between 6:00 a.m. and 11:59 a.m. In contrast, more of the laboratory reporting times were concentrated between 6:00 a.m. and 11:59 a.m. for Gram stain (43%), organism ID (78%), and AST (82%), respectively (P < 0.001). The overall average turnaround times from specimen collection for Gram stain, organism ID, and AST were approximately 1, 2, and 3 days, respectively. The laboratory results were reported predominantly in the morning hours. Laboratory automation and work flow optimization may play important roles in reducing the microbiology result turnaround time.
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Affiliation(s)
- Ying P Tabak
- Becton, Dickenson and Co., Medical Affairs, Franklin Lakes, New Jersey, USA
| | - Latha Vankeepuram
- Becton, Dickenson and Co., Medical Affairs, Franklin Lakes, New Jersey, USA
| | - Gang Ye
- Becton, Dickenson and Co., Medical Affairs, Franklin Lakes, New Jersey, USA
| | - Kay Jeffers
- Becton, Dickenson and Co., Technology Solution, San Diego, California, USA
| | - Vikas Gupta
- Becton, Dickenson and Co., Digital Health, Franklin Lakes, New Jersey, USA
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120
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She RC, Bender JM. Advances in Rapid Molecular Blood Culture Diagnostics: Healthcare Impact, Laboratory Implications, and Multiplex Technologies. J Appl Lab Med 2018; 3:617-630. [PMID: 31639730 DOI: 10.1373/jalm.2018.027409] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 09/28/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND For far too long, the diagnosis of bloodstream infections has relied on time-consuming blood cultures coupled with traditional organism identification and susceptibility testing. Technologies to define the culprit in bloodstream infections have gained sophistication in recent years, notably by application of molecular methods. CONTENT In this review, we summarize the tests available to clinical laboratories for molecular rapid identification and resistance marker detection in blood culture bottles that have flagged positive. We explore the cost-benefit ratio of such assays, covering aspects that include performance characteristics, effect on patient care, and relevance to antibiotic stewardship initiatives. SUMMARY Rapid blood culture diagnostics represent an advance in the care of patients with bloodstream infections, particularly those infected with resistant organisms. These diagnostics are relatively easy to implement and appear to have a positive cost-benefit balance, particularly when fully incorporated into a hospital's antimicrobial stewardship program.
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Affiliation(s)
- Rosemary C She
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA;
| | - Jeffrey M Bender
- Division of Infectious Diseases of the Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA
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121
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Beganovic M, McCreary EK, Mahoney MV, Dionne B, Green DA, Timbrook TT. Interplay between Rapid Diagnostic Tests and Antimicrobial Stewardship Programs among Patients with Bloodstream and Other Severe Infections. J Appl Lab Med 2018; 3:601-616. [PMID: 31639729 DOI: 10.1373/jalm.2018.026450] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/04/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) aim to provide optimal antimicrobial therapy to patients quickly to improve the likelihood of overcoming infection while reducing the risk of adverse effects. Rapid diagnostic tests (RDTs) for infectious diseases have become an integral tool for ASPs to achieve these aims. CONTENT This review explored the demonstrated clinical value of longer-standing technologies and implications of newer RDTs from an antimicrobial stewardship perspective. Based on available literature, the focus was on the use of RDTs in bloodstream infections (BSIs), particularly those that perform organism identification and genotypic resistance detection, phenotypic susceptibility testing, and direct specimen testing. Clinical implications of rapid testing among respiratory, central nervous system, and gastrointestinal infections are also reviewed. SUMMARY Coupling RDTs with ASPs facilitates the appropriate and timely use of test results, translating into improved patient outcomes through optimization of antimicrobial use. These benefits are best demonstrated in the use of RDT in BSIs. Rapid phenotypic susceptibility testing offers the potential for early pharmacokinetic/pharmacodynamic optimization, and direct specimen testing on blood may allow ASPs to initiate appropriate therapy and/or tailor empiric therapy even sooner than other RDTs. RDTs for respiratory, central nervous system, and gastrointestinal illnesses have also shown significant promise, although more outcome studies are needed to evaluate their full impact.
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Affiliation(s)
- Maya Beganovic
- Advocate Lutheran General Hospital, Department of Pharmacy, Park Ridge, IL
| | - Erin K McCreary
- University of Pittsburgh Medical Center, Department of Pharmacy, Pittsburgh, PA
| | - Monica V Mahoney
- Beth Israel Deaconess Medical Center, Department of Pharmacy, Boston, MA
| | - Brandon Dionne
- Northeastern University, School of Pharmacy, Bouvé College of Health Sciences, Boston, MA.,Brigham and Women's Hospital, Department of Pharmacy, Boston, MA
| | - Daniel A Green
- Columbia University College of Physicians and Surgeons, New York, NY
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122
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Implementation of Rapid Diagnostic Testing without Active Stewardship Team Notification for Gram-Positive Blood Cultures in a Community Teaching Hospital. Antimicrob Agents Chemother 2018; 62:AAC.01334-18. [PMID: 30150472 DOI: 10.1128/aac.01334-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 08/17/2018] [Indexed: 11/20/2022] Open
Abstract
In community hospitals, antimicrobial stewardship team notification of rapid diagnostic testing (RDT) results may not be feasible. A retrospective quasi-experimental study was conducted evaluating 252 adult inpatients with blood cultures positive for Gram-positive cocci in clusters (pre-RDT, n = 143; post-RDT, n = 109). The median time to appropriate therapy was significantly shorter in the post-RDT group (15 versus 0 h, P < 0.001), and the mean length of stay for patients with coagulase-negative staphylococcus was significantly shorter (10.5 versus 7.7 days; P = 0.015).
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123
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Wu F, Bethke JH, Wang M, You L. Quantitative and synthetic biology approaches to combat bacterial pathogens. CURRENT OPINION IN BIOMEDICAL ENGINEERING 2018; 4:116-126. [PMID: 30263975 DOI: 10.1016/j.cobme.2017.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Antibiotic resistance is one of the biggest threats to public health. The rapid emergence of resistant bacterial pathogens endangers the efficacy of current antibiotics and has led to increasing mortality and economic burden. This crisis calls for more rapid and accurate diagnosis to detect and identify pathogens, as well as to characterize their response to antibiotics. Building on this foundation, treatment options also need to be improved to use current antibiotics more effectively and develop alternative strategies that complement the use of antibiotics. We here review recent developments in diagnosis and treatment of bacterial pathogens with a focus on quantitative biology and synthetic biology approaches.
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Affiliation(s)
- Feilun Wu
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, 27708, USA
| | - Jonathan H Bethke
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, NC 27710, USA
| | - Meidi Wang
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, 27708, USA
| | - Lingchong You
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, 27708, USA.,Department of Molecular Genetics and Microbiology, Duke University School of Medicine, NC 27710, USA.,Center for Genomic and Computational Biology, Duke University, Durham, North Carolina, 27708, USA
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124
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deBoer TR, Tarlton NJ, Yamaji R, Adams-Sapper S, Wu TZ, Maity S, Vesgesna GK, Sadlowski CM, DePaola P, Riley LW, Murthy N. An Enzyme-Mediated Amplification Strategy Enables Detection of β-Lactamase Activity Directly in Unprocessed Clinical Samples for Phenotypic Detection of β-Lactam Resistance. Chembiochem 2018; 19:2173-2177. [PMID: 30079487 DOI: 10.1002/cbic.201800443] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Indexed: 11/09/2022]
Abstract
Biochemical assays that can identify β-lactamase activity directly from patient samples have the potential to significantly improve the treatment of bacterial infections. However, current β-lactamase probes do not have the sensitivity needed to measure β-lactam resistance directly from patient samples. Here, we report the development of an instrument-free signal amplification technology, DETECT, that connects the activity of two enzymes in series to effectively amplify the activity of β-lactamase 40 000-fold, compared to the standard β-lactamase probe nitrocefin.
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Affiliation(s)
- Tara R deBoer
- Department of Bioengineering, University of California, Berkeley, University Avenue, Berkeley, CA, 94720, USA
| | - Nicole J Tarlton
- Department of Public Health, University of California, Berkeley, University Avenue, Berkeley, CA, 94720, USA
| | - Reina Yamaji
- Department of Public Health, University of California, Berkeley, University Avenue, Berkeley, CA, 94720, USA
| | - Sheila Adams-Sapper
- Department of Public Health, University of California, Berkeley, University Avenue, Berkeley, CA, 94720, USA
| | - Tiffany Z Wu
- Department of Public Health, University of California, Berkeley, University Avenue, Berkeley, CA, 94720, USA
| | - Santanu Maity
- Department of Bioengineering, University of California, Berkeley, University Avenue, Berkeley, CA, 94720, USA
| | - Giri K Vesgesna
- Department of Bioengineering, University of California, Berkeley, University Avenue, Berkeley, CA, 94720, USA
| | - Corinne M Sadlowski
- Department of Bioengineering, University of California, Berkeley, University Avenue, Berkeley, CA, 94720, USA
| | - Peter DePaola
- Department of Bioengineering, University of California, Berkeley, University Avenue, Berkeley, CA, 94720, USA
| | - Lee W Riley
- Department of Public Health, University of California, Berkeley, University Avenue, Berkeley, CA, 94720, USA
| | - Niren Murthy
- Department of Bioengineering, University of California, Berkeley, University Avenue, Berkeley, CA, 94720, USA
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125
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Rapid Direct Susceptibility Testing from Positive Blood Cultures by the Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry-Based Direct-on-Target Microdroplet Growth Assay. J Clin Microbiol 2018; 56:JCM.00913-18. [PMID: 30093392 DOI: 10.1128/jcm.00913-18] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/02/2018] [Indexed: 12/12/2022] Open
Abstract
The recently developed direct-on-target microdroplet growth assay (DOT-MGA) allows rapid universal antimicrobial susceptibility testing (AST) using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Here, we investigated a direct application of this method on positive blood cultures (BCs) for the acceleration of sepsis diagnostics. Blood samples spiked with meropenem-nonsusceptible and meropenem-susceptible Enterobacterales isolates were inoculated into Bactec Plus Aerobic/F bottles and incubated in the Bactec automated system. Positive-BC broth was processed using four different methods, filtration/dilution, dilution, lysis/centrifugation, and differential centrifugation. For both dilution-based methods, AST was performed from 1:100, 1:1,000, and 1:10,000 dilutions of positive-BC broth in cation-adjusted Mueller-Hinton broth (CA-MHB). For both centrifugation-based methods, a 0.5 McFarland standard turbidity suspension was prepared from a bacterial pellet and adjusted to a final inoculum of 5 × 105 CFU/ml in CA-MHB. Six-microliter microdroplets with or without meropenem at the breakpoint concentration were spotted in triplicate onto a MALDI-TOF MS target, followed by incubation in a humidity chamber for 3 or 4 h and subsequent broth removal. Spectra were evaluated by MALDI Biotyper software. The test was considered valid if the growth control without antibiotic achieved an identification score of ≥1.7. For samples with meropenem, successful identification (score, ≥1.7) was interpreted as a nonsusceptible result, whereas failed identification (score, <1.7) defined susceptibility. The best test performance was achieved with the lysis/centrifugation method after a 4-h incubation. At this time point, 96.3% validity, 91.7% sensitivity, and 100% specificity were reached. This study demonstrated the feasibility and accuracy of a rapid DOT-MGA from positive BCs. Parallel to susceptibility determination, this method provides simultaneous species identification.
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126
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Bennett N, Schulz L, Boyd S, Newland JG. Understanding inpatient antimicrobial stewardship metrics. Am J Health Syst Pharm 2018; 75:230-238. [PMID: 29436469 DOI: 10.2146/ajhp160335] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Nicholas Bennett
- Department of Pharmacy, Saint Luke's Health System, Kansas City, MO
| | - Lucas Schulz
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, WI
| | - Sarah Boyd
- Department of Infectious Diseases, Saint Luke's Health System, Kansas City, MO
| | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.,St. Louis Children's Hospital, St. Louis, MO
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127
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Improving timelines in reporting results from positive blood cultures: simulation of impact of rapid identification on therapy on a real-life cohort. Eur J Clin Microbiol Infect Dis 2018; 37:2253-2260. [DOI: 10.1007/s10096-018-3366-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 08/22/2018] [Indexed: 10/28/2022]
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128
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Towards an improved diagnosis of bloodstream infection: promises and hurdles. Clin Microbiol Infect 2018; 24:933-934. [DOI: 10.1016/j.cmi.2018.02.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/19/2018] [Accepted: 02/21/2018] [Indexed: 10/17/2022]
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129
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Edmiston CE, Garcia R, Barnden M, DeBaun B, Johnson HB. Rapid diagnostics for bloodstream infections: A primer for infection preventionists. Am J Infect Control 2018; 46:1060-1068. [PMID: 29661630 DOI: 10.1016/j.ajic.2018.02.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 01/20/2023]
Abstract
Accurate and rapid antimicrobial susceptibility testing with pathogen identification in bloodstream infections is critical to life results for early sepsis intervention. Advancements in rapid diagnostics have shortened the time to results from days to hours and have had positive effects on clinical outcomes and on efforts to combat antimicrobial resistance when paired with robust antimicrobial stewardship programs. This article provides infection preventionists with a working knowledge of available rapid diagnostics for bloodstream infections.
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Affiliation(s)
| | - Robert Garcia
- Stony Brook University Medical Center, Stony Brook, NY
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Patel R, Fang FC. Diagnostic Stewardship: Opportunity for a Laboratory-Infectious Diseases Partnership. Clin Infect Dis 2018; 67:799-801. [PMID: 29547995 PMCID: PMC6093996 DOI: 10.1093/cid/ciy077] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 01/29/2018] [Indexed: 12/29/2022] Open
Abstract
Recent advances in microbial diagnostics are providing clinicians with information about microbes causing infections and their resistance to antimicrobial agents more rapidly than ever before. Diagnostic stewardship refers to the appropriate use of laboratory testing to guide patient management, including treatment, in order to optimize clinical outcomes and limit the spread of antimicrobial resistance. Fulfilling the promise of diagnostic stewardship requires a seamless partnership between clinical laboratories, pharmacists, and infectious diseases clinicians, so that appropriate tests are ordered and diagnostic information is translated into appropriate management in real time.
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Affiliation(s)
- Robin Patel
- Divisions of Clinical Microbiology and Infectious Diseases, Departments of Laboratory Medicine and Pathology and Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ferric C Fang
- Departments of Laboratory Medicine and Microbiology, University of Washington School of Medicine, Seattle
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Impact of matrix-assisted laser desorption/ionization time of flight mass spectrometric evaluation on the clinical outcomes of patients with bacteremia and fungemia in clinical settings lacking an antimicrobial stewardship program: a pre-post quasi experimental study. BMC Infect Dis 2018; 18:385. [PMID: 30092780 PMCID: PMC6085660 DOI: 10.1186/s12879-018-3299-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/01/2018] [Indexed: 01/14/2023] Open
Abstract
Backgrounds Several studies have evaluated the impact of matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry (MS) combined with antimicrobial stewardship in patients with positive blood cultures; clinical outcomes improved. However, in many hospitals, antimicrobial stewardship is not available because of restricted medical resources. Thus, we investigated the impact of evaluation by MALDI-TOF MS on the clinical outcomes of patients with bacteremia and fungemia treated in a clinical setting lacking an antimicrobial stewardship program (ASP). Methods We designed a pre–post quasi experimental study and retrospectively reviewed the medical records of patients aged > 18 years old with bacteremia and fungemia during two periods: October–December 2012 and October–December 2013. Conventional methods were used to detect microbial pathogens in 2012, and MALDI-TOF MS was employed in 2013. Clinical outcomes compared between periods were the time to pathogen identification, time to effective therapy, 30-day all-cause mortality, time to microbiological clearance, length of ICU stay, and rate of recurrence of the same bloodstream infection (BSI). Results A total of 556 patients were enrolled; 302 patients in 2012, and 254 in 2013. The use of MALDI-TOF MS without an ASP reduced the time to pathogen identification (86.4 vs. 63.5 h, P < 0.001) but did not significantly reduce the time to effective therapy (27.4 vs. 23.2 h, P = 0.187). Also, none of the following differed significantly between the two periods: mortality (17.5 vs. 15.7%, P = 0.571), the time to microbiological clearance (3.6 vs. 3.7 days, P = 0.675), the length of ICU stay (16.8 vs. 14.7 days, P = 0.706), and the recurrence rate of the same BSI (5.0 vs. 2.8%, P = 0.183). Conclusions The use of MALDI-TOF MS alone in a setting lacking an ASP did not afford clinical benefits. An ASP combined with MALDI-TOF MS is necessary to improve clinical outcomes.
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Design and synthesis of oligo-lipidated arginyl peptide (OLAP) dimers with enhanced physicochemical activity, peptide stability and their antimicrobial actions against MRSA infections. Amino Acids 2018; 50:1329-1345. [PMID: 30066172 DOI: 10.1007/s00726-018-2607-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 06/21/2018] [Indexed: 10/28/2022]
Abstract
Multi-drug resistant pathogens have been of increasing concern today. There is an urgent need for the discovery of more potent antibiotics. Cationic antimicrobial peptides (CAMPs) are known to be effective antimicrobial agents against resistant pathogens. However, poor activity under physiological conditions is one of the major limitations of CAMPS in clinical applications. In this study, a series of oligo-lipidated arginyl peptide OLAP dimers comprised of a saturated fatty acid chain (with m number of carbon units) and p repeating units of arginyl fatty acid chains (with n number of carbon units) were designed and studied for their antimicrobial activities as well as their physico-chemical property in various physiological conditions, such as in human serum albumin and high salt conditions. Our results showed that OLAP-11 exhibits potent antimicrobial activity against Gram-positive bacteria with improved physico-chemical activity in various physiological conditions. OLAP-11 is also less susceptible to human serum and trypsin degradation. The HPLC-MS analysis showed that the lipid-arginine bond is very stable. SYTOX Green assay and scanning electron microscopy both show that the OLAP-11 killed bacteria via inner membrane disruption. In addition, OLAP-11 is inner membrane targeting, making it difficult for bacteria to develop resistance. Overall, the design of the OLAP dimers provides an alternative approach to improve the physicochemical activity, peptide stability of CAMPs with potent inner membrane disruption and low in vitro toxicity to increase their potential for clinical applications in the future.
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Périllaud C, Pilmis B, Diep J, Péan de Ponfilly G, Vidal B, Couzigou C, Mizrahi A, Lourtet-Hascoët J, Le Monnier A, Nguyen Van JC. Prospective evaluation of rapid antimicrobial susceptibility testing by disk diffusion on Mueller-Hinton rapid-SIR directly on blood cultures. Diagn Microbiol Infect Dis 2018; 93:14-21. [PMID: 30149988 DOI: 10.1016/j.diagmicrobio.2018.07.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND With the worldwide spread of antibiotic resistance, delivering antibiotic susceptibility test (AST) results in a timely manner represents a major challenge. In cases of sepsis, rapid AST may facilitate early optimization of empiric antibiotic therapy. Disc diffusion is a well-standardized AST method, however 16 to 24 h are required to achieve an overall AST profile according to antimicrobial societies. METHODS In this prospective pilot study, we evaluated the performance of Mueller-Hinton-Rapid-SIR (MHR-SIR) agar after 6-8 h of incubation in comparison with standard MH agar after 16 h of incubation directly on positive blood cultures caused by Enterobacteriaceae and Staphylococcus aureus from routine clinical microbiology. A total of 133 positive blood samples including 110 Enterobacteriaceae (83%) and 23 Staphylococcus aureus (17%) were tested in parallel by two direct AST methods, each using EUCAST breakpoints. For each combination bacterium and antibiotic, we compared the categorical agreement and the correlation between the diameters obtained by MHR-SIR and by standard MH. RESULTS Our results showed 97.7% categorical agreement for Enterobacteriaceae, with 1.4% minor errors, 0.4% major errors and 0.5% very major errors. For S. aureus, we observed 97.8% categorical agreement, 1.9% minor errors, 0.3% major errors and no very major errors. CONCLUSION Our results showed excellent categorical agreement and correlations between diameters for MHR-SIR and standard MH methods. MHRSIR can predict the result of overall AST profile within 6-8 h with reliable results. AST is obtained on the same day the blood culture becomes positive, with a very moderate cost.
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Affiliation(s)
- Claire Périllaud
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Benoît Pilmis
- Unité Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Julien Diep
- Unité Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | | | - Barbara Vidal
- Unité Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Carine Couzigou
- Unité Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Assaf Mizrahi
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Julie Lourtet-Hascoët
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Alban Le Monnier
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Jean-Claude Nguyen Van
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France.
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Foolad F, Nagel JL, Eschenauer G, Patel TS, Nguyen CT. Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management. J Antimicrob Chemother 2018; 72:3232-3244. [PMID: 29177489 DOI: 10.1093/jac/dkx266] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Although new antimicrobial stewardship programmes (ASPs) often begin by targeting the reduction of antimicrobial use, an increasing focus of ASPs is to improve the management of specific infectious diseases. Disease-based antimicrobial stewardship emphasizes improving patient outcomes by optimizing antimicrobial use and increasing compliance with performance measures. Directing efforts towards the comprehensive management of specific infections allows ASPs to promote the shift in healthcare towards improving quality, safety and patient outcome metrics for specific diseases. This review evaluates published active and passive disease-based antimicrobial stewardship interventions and their impact on antimicrobial use and associated patient outcomes for patients with pneumonia, acute bacterial skin and skin structure infections, bloodstream infections, urinary tract infections, asymptomatic bacteriuria, Clostridium difficile infection and intra-abdominal infections. Current literature suggests that disease-based antimicrobial stewardship effects on medical management and patient outcomes vary based on infectious disease syndrome, resource availability and intervention type.
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Affiliation(s)
- Farnaz Foolad
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Jerod L Nagel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Gregory Eschenauer
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA.,College of Pharmacy, University of Michigan, 428 Church St., Ann Arbor, MI 48109, USA
| | - Twisha S Patel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Cynthia T Nguyen
- Department of Pharmacy, University of Chicago Medicine, 5841 S. Maryland Ave. MC0010, Chicago, IL 60637, USA
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Emberger J, Tassone D, Stevens MP, Markley JD. The Current State of Antimicrobial Stewardship: Challenges, Successes, and Future Directions. Curr Infect Dis Rep 2018; 20:31. [PMID: 29959545 DOI: 10.1007/s11908-018-0637-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The aim of this study is to examine the current state of the field of antimicrobial stewardship (AS) by highlighting key challenges and successes, as well as exciting future directions. RECENT FINDINGS AS mandates from the Centers for Medicare and Medicaid (CMS) and the Joint Commission (TJC) will stimulate increased compliance with current AS standards, but overall compliance is currently poor. Key challenges to progress in the field of AS include insufficient workforce and monetary resources, poorly defined AS metrics, and much needed expansion beyond the inpatient hospital setting. Despite these challenges, massive progress has been made in the last two and a half decades since the field of AS emerged. AS metrics are rapidly evolving and transforming the way antimicrobial stewardship programs (ASPs) measure success. Rapid diagnostics and diagnostic test stewardship are proving to be extremely effective when coupled with an ASP. Telehealth may improve access to ASP expertise in resource poor settings, and the role of bedside nurses as ASP team members has the potential to greatly augment ASP efforts. Allergy testing as an ASP strategy remains largely underutilized. ASPs have made significant gains in the battle against antimicrobial resistance (AR), but considerable advancement is still needed. Awareness of current challenges is critical to ensure progress in the field. The field of AS is expanding and transforming rapidly through integration, technology, and improved processes.
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Affiliation(s)
- Jennifer Emberger
- Virginia Commonwealth University Medical Center, VMI Building, 2nd Floor, Room 204, Richmond, VA, 23298, USA.
| | - Dan Tassone
- Hunter Holmes McGuire Veterans Affairs Medical Center, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Michael P Stevens
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - J Daniel Markley
- Department of Internal Medicine, Division of Infectious Diseases, Hunter Holmes McGuire Veterans Affairs Medical Center, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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Improved rates of antimicrobial stewardship interventions following implementation of the Epic antimicrobial stewardship module. Infect Control Hosp Epidemiol 2018; 39:980-982. [PMID: 29950188 DOI: 10.1017/ice.2018.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We evaluated the impact of the Epic antimicrobial stewardship module (EAM) on the number of interventions, antimicrobial usage, and clinical outcomes. Use of the EAM allowed us to significantly increase the number of ASP antimicrobial reviews and interventions while maintaining a sustained impact on antimicrobial utilization.
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Avdic E, Wang R, Li DX, Tamma PD, Shulder SE, Carroll KC, Cosgrove SE. Sustained impact of a rapid microarray-based assay with antimicrobial stewardship interventions on optimizing therapy in patients with Gram-positive bacteraemia. J Antimicrob Chemother 2018; 72:3191-3198. [PMID: 28961942 DOI: 10.1093/jac/dkx267] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/06/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives To compare antibiotic optimization and outcomes of patients before implementation of the Verigene Gram-Positive Blood Culture (Verigene BC-GP) nucleic acid microarray assay to after implementation with antimicrobial stewardship (AS) interventions and after discontinuation of AS interventions. Methods A retrospective pre-post-post quasi-experimental study was conducted to compare the three periods. AS interventions consisted of real-time guidance to clinicians on antibiotic selection. The primary outcome was median time from Gram stain to optimal therapy. Secondary outcomes included median time to effective therapy, median duration of therapy for contaminant organisms, median length of stay after blood cultures were collected, and all-cause in-hospital mortality. Results Out of a total of 923 patients, 390 (125 baseline, 134 intervention, 131 post-intervention) who were not on optimal therapy at the time of Gram stain or had contaminated blood cultures were assessed. Compared with baseline, only the median time to optimal therapy for MSSA bacteraemia was reduced in both the intervention and post-intervention periods (17 versus 17 versus 50 h; P < 0.001), respectively. In an analysis adjusted for baseline differences among the groups using quantile regression models, use of the Verigene BC-GP assay in both periods significantly reduced time to optimal therapy by 14-22 h in patients who would achieve optimal therapy at ≥ 26 h without the assay. There were no differences in in-hospital mortality or hospital length of stay between study periods. Conclusions A real-time AS intervention implemented alongside introduction of the Verigene BC-GP assay led to improvements in antibiotic therapy for patients with bacteraemia due to Gram-positive cocci, even after the AS intervention was discontinued.
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Affiliation(s)
- Edina Avdic
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ruibin Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David X Li
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Karen C Carroll
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abdul-Aziz MH, Driver E, Lipman J, Roberts JA. New paradigm for rapid achievement of appropriate therapy in special populations: coupling antibiotic dose optimization rapid microbiological methods. Expert Opin Drug Metab Toxicol 2018; 14:693-708. [PMID: 29865877 DOI: 10.1080/17425255.2018.1484452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Some special patient populations (e.g. critically ill, burns, hematological malignancy, post-major surgery, post-major trauma) have characteristics that lead to higher rates of failure and mortality associated with infection. Choice of effective antibiotics and optimized doses are challenging in these patients that are commonly infected by multidrug-resistant pathogens. Areas covered: A review of the importance of diagnosis and the place of newer microbiological methods (e.g. whole-genome sequencing) to ensure rapid transition from empiric to directed antibiotic therapy is provided. The effects of pathophysiological changes on antibiotic pharmacokinetics are also provided. Expert opinion: Product information dosing regimens do not address the pharmacokinetic alterations that can occur in special patient populations and increase the likelihood of therapeutic failure and the emergence of bacterial resistance. Altered dosing approaches, supplemented with the use of dosing software and therapeutic drug monitoring, may be needed to ensure optimal antibiotic exposure and better therapeutic outcomes in these patients with severe infection. Dose optimization needs to be coupled with advanced microbiological techniques that enable rapid microbiological identification and characterization of resistance mechanism to ensure that maximally effective directed therapy can be chosen.
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Affiliation(s)
- Mohd H Abdul-Aziz
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia
| | - Elicia Driver
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia
| | - Jeffrey Lipman
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia.,b Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia
| | - Jason A Roberts
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia.,b Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,c Department of Pharmacy , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,d School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics , The University of Queensland , Brisbane , Queensland , Australia
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Bhavsar SM, Dingle TC, Hamula CL. The impact of blood culture identification by MALDI-TOF MS on the antimicrobial management of pediatric patients. Diagn Microbiol Infect Dis 2018; 92:220-225. [PMID: 29934073 DOI: 10.1016/j.diagmicrobio.2018.05.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/27/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To assess the impact of MALDI-TOF MS coupled with antimicrobial stewardship on clinical outcomes for pediatric inpatients with bloodstream infections. METHODS Outcomes of pediatric inpatients were compared before and after MALDI-TOF MS implementation. Outcomes measured included time until organism identification and susceptibility, duration of antibiotics, patient length of stay (LOS), mortality and hospital costs. RESULTS 210 and 135 patient events were compared pre- and post-intervention. Average time to organism identification decreased from 41 to 11 hours (P = <0.0001). Time to i) susceptibilities decreased from 50.8 to 37.7 hours (P = <0.0001), ii) de-escalation of antibiotics decreased from 58 to 23 hours (P = <0.0001), iii) discontinuation of unnecessary antibiotics decreased from 49 to 20 hours (P = <0.0001). Infection-related LOS decreased from 10.5 to 8.37 days (P = 0.006). No significant differences were seen for other outcomes. CONCLUSIONS MALDI-TOF MS identification of bacteria from blood culture broth improves time to appropriate antibiotic treatment for pediatric inpatients.
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Affiliation(s)
- Sejal Makvana Bhavsar
- Division of Pediatric Infectious Disease, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Tanis C Dingle
- Division of Clinical Microbiology, Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Camille L Hamula
- Division of Clinical Microbiology, Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Florio W, Tavanti A, Barnini S, Ghelardi E, Lupetti A. Recent Advances and Ongoing Challenges in the Diagnosis of Microbial Infections by MALDI-TOF Mass Spectrometry. Front Microbiol 2018; 9:1097. [PMID: 29896172 PMCID: PMC5986882 DOI: 10.3389/fmicb.2018.01097] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 05/08/2018] [Indexed: 12/25/2022] Open
Abstract
Timeliness and accuracy in the diagnosis of microbial infections are associated with decreased mortality and reduced length of hospitalization, especially for severe, life-threatening infections. A rapid diagnosis also allows for early streamlining of empirical antimicrobial therapies, thus contributing to limit the emergence and spread of antimicrobial resistance. The introduction of matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry (MS) for routine identification of microbial pathogens has profoundly influenced microbiological diagnostics, and is progressively replacing biochemical identification methods. Compared to currently used identification methods, MALDI-TOF MS has the advantage of identifying bacteria and yeasts directly from colonies grown on culture plates for primary isolation in a few minutes and with considerable material and labor savings. The reliability and accuracy of MALDI-TOF MS in identification of clinically relevant bacteria and yeasts has been demonstrated by several studies showing that the performance of MALDI-TOF MS is comparable or superior to phenotypic methods currently in use in clinical microbiology laboratories, and can be further improved by database updates and analysis software upgrades. Besides microbial identification from isolated colonies, new perspectives are being explored for MALDI-TOF MS, such as identification of pathogens directly from positive blood cultures, sub-species typing, and detection of drug resistance determinants. In this review, we summarize the state of the art in routine identification of microbial pathogens by MALDI-TOF MS, and highlight recent advancements of this technology in special applications, such as strain typing, assessment of drug susceptibility, and detection of virulence factors.
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Affiliation(s)
- Walter Florio
- Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università di Pisa, Pisa, Italy
| | | | | | - Emilia Ghelardi
- Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università di Pisa, Pisa, Italy
| | - Antonella Lupetti
- Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia, Università di Pisa, Pisa, Italy
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Miano TA, Lautenbach E, Wilson FP, Guo W, Borovskiy Y, Hennessy S. Attributable Risk and Time Course of Colistin-Associated Acute Kidney Injury. Clin J Am Soc Nephrol 2018; 13:542-550. [PMID: 29545383 PMCID: PMC5969457 DOI: 10.2215/cjn.06980717] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 12/19/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite colistin's longstanding reported association with nephrotoxicity, the attributable risk and timing of toxicity onset are still unknown. Whether substantial toxicity occurs during the initial 72 hours of exposure has important implications for early treatment decisions. The objective of this study was to compare colistin-exposed patients with a matched control group given other broad spectrum antibiotics. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective cohort study in patients treated for multidrug-resistant Pseudomonas, Klebsiella, or Acinetobacter spp. Colistin-exposed patients were matched to unexposed controls using propensity scores. AKI was defined according to the Kidney Disease Improving Global Outcomes creatinine criteria. Incidence rate ratios and risk differences of AKI in the matched cohort were estimated with the generalized estimating equation Poisson regression model. Risk factors for AKI were tested for effect modification in the matched cohort. RESULTS The study included 150 propensity-matched pairs with similar types of infection, similar delays to effective treatment, and similar baseline characteristics. Incidence of AKI was 77 of 150 (51%) in the colistin group versus 33 of 150 (22%) in matched controls (risk difference, 29%; 95% confidence interval, 19 to 39), corresponding to a number needed to harm of 3.5. Early toxicity was apparent, because AKI risk was higher in colistin-exposed patients at 72 hours of exposure (incidence rate ratio, 1.9; 95% confidence interval, 1.1 to 3.5). In both groups, hospital mortality in patients who experienced AKI was lower if kidney function returned to baseline during hospitalization. The effect of colistin exposure on AKI risk varied inversely according to baseline hemoglobin concentration. CONCLUSIONS Colistin is associated with substantial excess AKI that is apparent within the first 72 hours of treatment. Colistin's toxicity varied according to baseline hemoglobin concentration. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_03_15_CJASNPodcast_18_4_M.mp3.
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Affiliation(s)
- Todd A Miano
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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The Slow March toward Rapid Phenotypic Antimicrobial Susceptibility Testing: Are We There Yet? J Clin Microbiol 2018; 56:JCM.01999-17. [PMID: 29436417 DOI: 10.1128/jcm.01999-17] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Antimicrobial susceptibility testing (AST) provides critical information for the management of patients with infections. The gold standard methods for assessing organism susceptibility are still based on growth and require incubation over relatively long periods of time. Until now, little progress has been made in developing rapid, growth-based, phenotypic AST systems. This commentary puts the recently FDA-cleared Accelerate PhenoTest (P. Pancholi et al., J Clin Microbiol 56:e01329-17, 2018, https://doi.org/10.1128/JCM.01329-17) in context by providing a historical perspective on attempts to accelerate phenotypic susceptibility results. In addition, some promising new innovations that promise to shorten the turnaround time for phenotypic AST will be briefly reviewed.
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Sofjan AK, Casey BO, Xu BA, Amadio J, Restrepo A, Alam MJ, Garey KW. Accelerate PhenoTest TM BC Kit Versus Conventional Methods for Identification and Antimicrobial Susceptibility Testing of Gram-Positive Bloodstream Isolates: Potential Implications for Antimicrobial Stewardship. Ann Pharmacother 2018; 52:754-762. [PMID: 29557208 DOI: 10.1177/1060028018765486] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The Accelerate PhenoTestTM BC kit (AXDX) provides rapid organism identification (ID) and antimicrobial susceptibility testing (AST) results. Its potential role for antimicrobial stewardship is unknown. OBJECTIVE To compare the diagnostic accuracy of AXDX with conventional methods (CMs) and assess AXDX's potential role for antimicrobial stewardship in patients with Gram-positive bloodstream infections (BSIs). METHODS This retrospective cohort study included adults with Staphylococcus aureus or Enterococcus spp BSIs from July 2014 to January 2016 at a tertiary care medical center. Available isolates were tested on AXDX, and ID and AST results from AXDX were compared with those from CMs (VITEK 2 or ETEST). The following antibiotics were assessed for categorical agreement (CA) and essential agreement (EA) between the methods: ampicillin and daptomycin ( Enterococcus spp only), erythromycin and cefoxitin ( S aureus only), linezolid, and vancomycin. Potential role of AXDX for stewardship was assessed via a retrospective audit by infectious diseases clinicians. RESULTS We included 231 patients with S aureus (n = 112) or Enterococcus spp (n = 119) BSIs, and 106 unique isolates were available for ID and AST performance analyses. Sensitivity and specificity of AXDX for ID were 98.0% and 99.5%, respectively. CA and EA for the tested antibiotics were >97%. In Monte Carlo simulations, AXDX coupled with stewardship personnel (either 24/7 or Monday to Friday) would have allowed unnecessary therapy to be stopped and active/targeted therapy to be started ≥24 hours sooner in >50% of patients. CONCLUSIONS Compared with CMs, AXDX had similar diagnostic accuracy and can potentially optimize therapy sooner in patients with Gram-positive BSIs.
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Affiliation(s)
- Amelia K Sofjan
- 1 University of Houston College of Pharmacy, Houston, TX, USA
| | | | - Boxin A Xu
- 1 University of Houston College of Pharmacy, Houston, TX, USA
| | - Jonathan Amadio
- 1 University of Houston College of Pharmacy, Houston, TX, USA
| | | | - M Jahangir Alam
- 1 University of Houston College of Pharmacy, Houston, TX, USA
| | - Kevin W Garey
- 1 University of Houston College of Pharmacy, Houston, TX, USA
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Luo J, Yu J, Yang H, Wei H. Parallel susceptibility testing of bacteria through culture-quantitative PCR in 96-well plates. Int J Infect Dis 2018; 70:86-92. [PMID: 29559368 DOI: 10.1016/j.ijid.2018.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 03/05/2018] [Accepted: 03/11/2018] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE The methods combining culture and quantitative PCR(qPCR) offer new solutions for rapid antibiotic susceptibility testing(AST). However, the multiple steps of DNA extraction and cold storage of PCR reagents needed make them unsuitable for rapid high throughput AST. In this study, a parallel culture-qPCR method was developed to overcome above problems. METHOD In this method, bacteria culture and DNA extraction automatically and simultaneously completed through using a common PCR instrument as a controllable heating device. A lyophilized 16S rDNA targeted qPCR reagent was also developed, which was stable and could be kept at 4°C for long time and at 37°C for about two months. RESULT Testing of 36 P. aeruginosa isolates and 28 S. aureus isolates showed that the method had good agreements with the standard broth microdilution method, with an overall agreement of 97.22% (95% CI, 85.83-99.51) for P. aeruginosa and 96.43% (95% CI, 79.76-99.81) for S. aureus. This method could test 12 samples against a panel of up to 7 antibiotics simultaneously in two 96-well PCR plates within 4h, which greatly improves the testing efficiency of the culture-qPCR method. CONCLUSION With rapidness to obtain results and the capabilities for automation and multiple-sample testing, the parallel culture-qPCR method would have great potentials in clinical labs.
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Affiliation(s)
- Jun Luo
- Key Laboratory of Special Pathogens and Biosafety, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan 430071, China; University of Chinese Academy of Sciences, Beijing 100039, China
| | - Junping Yu
- Key Laboratory of Special Pathogens and Biosafety, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan 430071, China
| | - Hang Yang
- Key Laboratory of Special Pathogens and Biosafety, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan 430071, China
| | - Hongping Wei
- Key Laboratory of Special Pathogens and Biosafety, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan 430071, China.
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145
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Wang S, Han LZ, Ni YX, Zhang YB, Wang Q, Shi DK, Li WH, Wang YC, Mi CR. Changes in antimicrobial susceptibility of commonly clinically significant isolates before and after the interventions on surgical prophylactic antibiotics (SPAs) in Shanghai. Braz J Microbiol 2018; 49:552-558. [PMID: 29449171 PMCID: PMC6066744 DOI: 10.1016/j.bjm.2017.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/20/2017] [Accepted: 12/01/2017] [Indexed: 12/24/2022] Open
Abstract
Surveillances and interventions on antibiotics use have been suggested to improve serious drug-resistance worldwide. Since 2007, our hospital have proposed many measures for regulating surgical prophylactic antibiotics (carbapenems, third gen. cephalosporins, vancomycin, etc.) prescribing practices, like formulary restriction or replacement for surgical prophylactic antibiotics and timely feedback. To assess the impacts on drug-resistance after interventions, we enrolled infected patients in 2006 (pre-intervention period) and 2014 (post-intervention period) in a tertiary hospital in Shanghai. Proportions of targeted pathogens were analyzed: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE), imipenem-resistant Escherichia coli (IREC), imipenem-resistant Klebsiella pneumoniae (IRKP), imipenem-resistant Acinetobacter baumannii (IRAB) and imipenem-resistant Pseudomonas aeruginosa (IRPA) isolates. Rates of them were estimated and compared between Surgical Department, ICU and Internal Department during two periods. The total proportions of targeted isolates in Surgical Department (62.44%, 2006; 64.09%, 2014) were more than those in ICU (46.13%, 2006; 50.99%, 2014) and in Internal Department (44.54%, 2006; 51.20%, 2014). Only MRSA has decreased significantly (80.48%, 2006; 55.97%, 2014) (p < 0.0001). The percentages of VRE and IREC in 3 departments were all <15%, and the slightest change were also both observed in Surgical Department (VRE: 0.76%, 2006; 2.03%, 2014) (IREC: 2.69%, 2006; 2.63%, 2014). The interventions on surgical prophylactic antibiotics can be effective for improving resistance; antimicrobial stewardship must be combined with infection control practices.
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Affiliation(s)
- Su Wang
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Clinical Microbiology, Shanghai, China
| | - Li-Zhong Han
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Clinical Microbiology, Shanghai, China.
| | - Yu-Xing Ni
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Clinical Microbiology, Shanghai, China
| | - Yi-Bo Zhang
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Hospital Infection Control, Shanghai, China
| | - Qun Wang
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Hospital Infection Control, Shanghai, China
| | - Da-Ke Shi
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Hospital Infection Control, Shanghai, China
| | - Wen-Hui Li
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Hospital Infection Control, Shanghai, China
| | - Yi-Chen Wang
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Hospital Infection Control, Shanghai, China
| | - Chen-Rong Mi
- Shanghai Jiao Tong University School of Medicine, Ruijin Hospital, Department of Hospital Infection Control, Shanghai, China.
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146
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Stevenson M, Pandor A, Martyn-St James M, Rafia R, Uttley L, Stevens J, Sanderson J, Wong R, Perkins GD, McMullan R, Dark P. Sepsis: the LightCycler SeptiFast Test MGRADE®, SepsiTest™ and IRIDICA BAC BSI assay for rapidly identifying bloodstream bacteria and fungi - a systematic review and economic evaluation. Health Technol Assess 2018; 20:1-246. [PMID: 27355222 DOI: 10.3310/hta20460] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Sepsis can lead to multiple organ failure and death. Timely and appropriate treatment can reduce in-hospital mortality and morbidity. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of three tests [LightCycler SeptiFast Test MGRADE(®) (Roche Diagnostics, Risch-Rotkreuz, Switzerland); SepsiTest(TM) (Molzym Molecular Diagnostics, Bremen, Germany); and the IRIDICA BAC BSI assay (Abbott Diagnostics, Lake Forest, IL, USA)] for the rapid identification of bloodstream bacteria and fungi in patients with suspected sepsis compared with standard practice (blood culture with or without matrix-absorbed laser desorption/ionisation time-of-flight mass spectrometry). DATA SOURCES Thirteen electronic databases (including MEDLINE, EMBASE and The Cochrane Library) were searched from January 2006 to May 2015 and supplemented by hand-searching relevant articles. REVIEW METHODS A systematic review and meta-analysis of effectiveness studies were conducted. A review of published economic analyses was undertaken and a de novo health economic model was constructed. A decision tree was used to estimate the costs and quality-adjusted life-years (QALYs) associated with each test; all other parameters were estimated from published sources. The model was populated with evidence from the systematic review or individual studies, if this was considered more appropriate (base case 1). In a secondary analysis, estimates (based on experience and opinion) from seven clinicians regarding the benefits of earlier test results were sought (base case 2). A NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Scenario analyses were used to assess uncertainty. RESULTS For the review of diagnostic test accuracy, 62 studies of varying methodological quality were included. A meta-analysis of 54 studies comparing SeptiFast with blood culture found that SeptiFast had an estimated summary specificity of 0.86 [95% credible interval (CrI) 0.84 to 0.89] and sensitivity of 0.65 (95% CrI 0.60 to 0.71). Four studies comparing SepsiTest with blood culture found that SepsiTest had an estimated summary specificity of 0.86 (95% CrI 0.78 to 0.92) and sensitivity of 0.48 (95% CrI 0.21 to 0.74), and four studies comparing IRIDICA with blood culture found that IRIDICA had an estimated summary specificity of 0.84 (95% CrI 0.71 to 0.92) and sensitivity of 0.81 (95% CrI 0.69 to 0.90). Owing to the deficiencies in study quality for all interventions, diagnostic accuracy data should be treated with caution. No randomised clinical trial evidence was identified that indicated that any of the tests significantly improved key patient outcomes, such as mortality or duration in an intensive care unit or hospital. Base case 1 estimated that none of the three tests provided a benefit to patients compared with standard practice and thus all tests were dominated. In contrast, in base case 2 it was estimated that all cost per QALY-gained values were below £20,000; the IRIDICA BAC BSI assay had the highest estimated incremental net benefit, but results from base case 2 should be treated with caution as these are not evidence based. LIMITATIONS Robust data to accurately assess the clinical effectiveness and cost-effectiveness of the interventions are currently unavailable. CONCLUSIONS The clinical effectiveness and cost-effectiveness of the interventions cannot be reliably determined with the current evidence base. Appropriate studies, which allow information from the tests to be implemented in clinical practice, are required. STUDY REGISTRATION This study is registered as PROSPERO CRD42015016724. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Matt Stevenson
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Rachid Rafia
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Lesley Uttley
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - John Stevens
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jean Sanderson
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.,Heart of England NHS Foundation Trust, Coventry, UK
| | - Ronan McMullan
- Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK.,Belfast Health and Social Care Trust, The Royal Hospitals, Belfast, UK
| | - Paul Dark
- Institute of Inflammation and Repair, University of Manchester, Manchester, UK.,Salford Royal NHS Foundation Trust, Salford, UK
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147
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Dépret F, Aubry A, Fournier A, Charles-Nelson A, Katsahian S, Compain F, Mainardi JL, Fernandez-Gerlinger MP. β LACTA testing may not improve treatment decisions made with MALDI-TOF MS-informed antimicrobial stewardship advice for patients with Gram-negative bacteraemia: a prospective comparative study. J Med Microbiol 2018; 67:183-189. [DOI: 10.1099/jmm.0.000665] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- F. Dépret
- Service de Microbiologie, Unité Mobile de Microbiologie Clinique, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - A. Aubry
- Service de Microbiologie, Unité Mobile de Microbiologie Clinique, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - A. Fournier
- Service de Microbiologie, Unité Mobile de Microbiologie Clinique, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - A. Charles-Nelson
- Pôle Biostatistique et Santé Publique, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
| | - S. Katsahian
- Pôle Biostatistique et Santé Publique, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
| | - F. Compain
- Service de Microbiologie, Unité Mobile de Microbiologie Clinique, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
| | - J. L. Mainardi
- Service de Microbiologie, Unité Mobile de Microbiologie Clinique, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
| | - M. P. Fernandez-Gerlinger
- Service de Microbiologie, Unité Mobile de Microbiologie Clinique, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France
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148
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Cantón R, Gómez G. de la Pedrosa E. Impacto económico de los métodos de diagnóstico rápido en Microbiología Clínica: precio de la prueba o impacto clínico global. Enferm Infecc Microbiol Clin 2017; 35:659-666. [DOI: 10.1016/j.eimc.2017.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 09/13/2017] [Indexed: 12/19/2022]
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149
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Florio W, Morici P, Ghelardi E, Barnini S, Lupetti A. Recent advances in the microbiological diagnosis of bloodstream infections. Crit Rev Microbiol 2017; 44:351-370. [PMID: 29185372 DOI: 10.1080/1040841x.2017.1407745] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Rapid identification (ID) and antimicrobial susceptibility testing (AST) of the causative agent(s) of bloodstream infections (BSIs) are essential for the prompt administration of an effective antimicrobial therapy, which can result in clinical and financial benefits. Immediately after blood sampling, empirical antimicrobial therapy, chosen on clinical and epidemiological data, is administered. When ID and AST results are available, the clinician decides whether to continue or streamline the antimicrobial therapy, based on the results of the in vitro antimicrobial susceptibility profile of the pathogen. The aim of the present study is to review and discuss the experimental data, advantages, and drawbacks of recently developed technological advances of culture-based and molecular methods for the diagnosis of BSI (including mass spectrometry, magnetic resonance, PCR-based methods, direct inoculation methods, and peptide nucleic acid fluorescence in situ hybridization), the understanding of which could provide new perspectives to improve and fasten the diagnosis and treatment of septic patients. Although blood culture remains the gold standard to diagnose BSIs, newly developed methods can significantly shorten the turnaround time of reliable microbial ID and AST, thus substantially improving the diagnostic yield.
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Affiliation(s)
- Walter Florio
- a Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia , Università di Pisa , Pisa , Italy
| | - Paola Morici
- a Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia , Università di Pisa , Pisa , Italy
| | - Emilia Ghelardi
- a Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia , Università di Pisa , Pisa , Italy
| | - Simona Barnini
- b U.O. Microbiologia Universitaria Azienda Ospedaliero-Universitaria Pisana , Pisa , Italy
| | - Antonella Lupetti
- a Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia , Università di Pisa , Pisa , Italy
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150
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Parsonage B, Hagglund PK, Keogh L, Wheelhouse N, Brown RE, Dancer SJ. Control of Antimicrobial Resistance Requires an Ethical Approach. Front Microbiol 2017; 8:2124. [PMID: 29163414 PMCID: PMC5673829 DOI: 10.3389/fmicb.2017.02124] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 10/18/2017] [Indexed: 01/18/2023] Open
Abstract
Ethical behavior encompasses actions that benefit both self and society. This means that tackling antimicrobial resistance (AMR) becomes an ethical obligation, because the prospect of declining anti-infectives affects everyone. Without preventive action, loss of drugs that have saved lives over the past century, will condemn ourselves, people we know, and people we don't know, to unacceptable risk of untreatable infection. Policies aimed at extending antimicrobial life should be considered within an ethical framework, in order to balance the choice, range, and quality of drugs against stewardship activities. Conserving availability and effectiveness for future use should not compromise today's patients. Practices such as antimicrobial prophylaxis for healthy people 'at risk' should receive full debate. There are additional ethical considerations for AMR involving veterinary care, agriculture, and relevant bio-industries. Restrictions for farmers potentially threaten the quality and quantity of food production with economic consequences. Antibiotics for companion animals do not necessarily spare those used for humans. While low-income countries cannot afford much-needed drugs, pharmaceutical companies are reluctant to develop novel agents for short-term return only. Public demand encourages over-the-counter, internet, black market, and counterfeit drugs, all of which compromise international control. Prescribers themselves require educational support to balance therapeutic choice against collateral damage to both body and environment. Predicted mortality due to AMR provides justification for international co-operation, commitment and investment to support surveillance and stewardship along with development of novel antimicrobial drugs. Ethical arguments for, and against, control of antimicrobial resistance strategies are presented and discussed in this review.
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Affiliation(s)
- Ben Parsonage
- Department of Engineering, University of Strathclyde, Glasgow, United Kingdom
| | - Philip K Hagglund
- Department of Engineering, Luleå University of Technology, Luleå, Sweden
| | - Lloyd Keogh
- Department of Engineering, University of Strathclyde, Glasgow, United Kingdom
| | - Nick Wheelhouse
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Richard E Brown
- Department of Engineering, University of Strathclyde, Glasgow, United Kingdom.,Sophrodyne Ltd., Glasgow, United Kingdom
| | - Stephanie J Dancer
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, United Kingdom.,Department of Microbiology, Hairmyres Hospital, NHS Lanarkshire, Bothwell, United Kingdom
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