Antimicrobial Stewardship: How the Microbiology Laboratory Can Right the Ship

Diagnostic Bacteriology in District Hospitals in Sub-Saharan Africa: At the Forefront of the Containment of Antimicrobial Resistance

This review provides an update on the factors fuelling antimicrobial resistance and shows the impact of these factors in low-resource settings. We detail the challenges and barriers to integrating clinical bacteriology in hospitals in low-resource settings, as well as the opportunities provided by the recent capacity building efforts of national laboratory networks focused on vertical single-disease programmes. The programmes for HIV, tuberculosis and malaria have considerably improved laboratory medicine in Sub-Saharan Africa, paving the way for clinical bacteriology. Furthermore, special attention is paid to topics that are less familiar to the general medical community, such as the crucial role of regulatory frameworks for diagnostics and the educational profile required for a productive laboratory workforce in low-resource settings. Traditionally, clinical bacteriology laboratories have been a part of higher levels of care, and, as a result, they were poorly linked to clinical practices and thus underused. By establishing and consolidating clinical bacteriology laboratories at the hospital referral level in low-resource settings, routine patient care data can be collected for surveillance, antibiotic stewardship and infection prevention and control. Together, these activities form a synergistic tripartite effort at the frontline of the emergence and spread of multi-drug resistant bacteria. If challenges related to staff, funding, scale, and the specific nature of clinical bacteriology are prioritized, a major leap forward in the containment of antimicrobial resistance can be achieved. The mobilization of resources coordinated by national laboratory plans and interventions tailored by a good understanding of the hospital microcosm will be crucial to success, and further contributions will be made by market interventions and business models for diagnostic laboratories. The future clinical bacteriology laboratory in a low-resource setting will not be an "entry-level version" of its counterparts in high-resource settings, but a purpose-built, well-conceived, cost-effective and efficient diagnostic facility at the forefront of antimicrobial resistance containment.

How to start an antimicrobial stewardship programme in a hospital

BACKGROUND

Antimicrobial stewardship (AMS) describes a coherent set of actions that ensure optimal use of antimicrobials to improve patient outcomes, while limiting the risk of adverse events (including antimicrobial resistance (AMR)). Introduction of AMS programmes in hospitals is part of most national action plans to mitigate AMR, yet the optimal components and actions of such a programme remain undetermined.

OBJECTIVES

To describe how health-care professionals can start an AMS programme in their hospital, the components of such a programme and the evidence base for its implementation.

SOURCES

National and society-led guidelines on AMS, peer-reviewed publications and experience of AMS experts conducting AMS programmes.

CONTENT

We provide a step-by-step pragmatic guide to setting up and implementing a hospital AMS programme in high-income or low-and-middle-income countries.

IMPLICATIONS

Antimicrobial stewardship programmes in hospitals are a vital component of national action plans for AMR, and have been shown to significantly reduce AMR, particularly when coupled with infection prevention and control interventions. This step-by-step guide of 'how to' set up an AMS programme will help health-care professionals involved in AMS to optimally design and implement their actions.

Challenges and research priorities to progress the impact of antimicrobial stewardship

Antimicrobial stewardship programmes have been playing an important role in patient care and hospital policies. These programmes are now recognised as formal strategies for curbing the upward trend in antibiotic resistance and for improving the appropriate antimicrobial and antifungal use. The role of such programs in the era of antimicrobial resistance presents several unique challenges and opportunities, most notably in the diagnostic and therapeutic setting. Controversies remain regarding the most effective interventions and the appropriate design to evaluate their impact. In this review, based on rounds of discussion, we explain the most important challenges faced by antibiotic stewardship and antifungal stewardship programmes. We also try to suggest areas for further research.

A nationwide survey on involvement of clinical microbiologists in antibiotic stewardship programmes in large French hospitals

Antibiotic stewardship programmes (ASP) are essential to tackle antibiotic resistance. Clinical microbiologists (CMs) play a key role in these programmes; however, few studies describe their actual involvement. Our objective was to explore CMs' involvement in French hospital ASP. In 2018, we conducted a survey among CMs working in large public French hospitals (600 acute care beds or more). The questionnaire focused on the following topics: microbiology department's characteristics, hospital ASP, and CMs' involvement in this programme, including their use of rapid diagnostic tests (RDT). Fifty/74 CMs answered (response rate 68%), with 68% working in a teaching hospital. CMs were leading the ASP in 6% of cases, and 57% of hospitals had a multidisciplinary antibiotic stewardship team. Most microbiology departments (92%) were using specific PCR, processed 24/7 in 74% of hospitals. More than half (58%) were using syndromic panel-based testing, 94% mass spectrometry, and 96% immunochromatographic/colorimetric RDT. Blood cultures were processed 24/7 in 44% of hospitals. CMs were involved in this. Finally, 42% of CMs wished to be more involved in their hospital's ASP, the most frequently reported barrier being lack of time (36%). CMs should be more involved in ASP. RDT are widely used, but not implemented in an optimal way.

Genetic diversity and antibiotic susceptibility of uropathogenic Escherichia coli isolates from kidney transplant recipients

Purpose

Uropathogenic Escherichia coli (UPEC) strains are a common cause of transplant rejection, morbidity, and mortality among kidney transplant recipients. The virulence of UPEC strains differs based on their pathogenicity islands (PAIs) and susceptibility to antibiotics. The present study evaluates the clonal relationship and antibiotic susceptibility of UPEC PAI-genotypes among Escherichia coli (E. coli) isolates from kidney transplant patients.

Patients and methods

A total of 115 Escherichia coli (E. coli) isolates were collected from kidney transplant recipients with acute urinary tract infections (UTIs). Isolates were typed based on the presence of PAI-markers, and random amplified polymorphic DNA (RAPD). The disk diffusion method was performed for the antibiotic susceptibility pattern of isolates.

Results

According to the PAI-specific virulence markers, 69 (60%), 21 (18.3%), and 25 (21.7%) isolates were identified as genotypes related to UPEC 536, UPEC J96, and UPEC CFT073 strains, respectively. PAI III536 genotypes were the most prevalent genotype in this study. The findings showed a high-sensitivity to imipenem (93.9%) and nitrofurantoin (91.3%) and a low-sensitivity to trimethoprim/sulfamethoxazole (36.5%). Clonal association and similar antibiotic susceptibility pattern were seen in the PAI-related genotypes.

Conclusion

Due to a similar pattern of antibiotic susceptibility of these clonal groups and increased resistance to some important antibiotics such as trimethoprim/sulfamethoxazole in the treatment of urinary tract infections, especially in kidney transplant patients, the spread of these clones should be considered as a serious concern.

Evaluating carbapenem restriction practices at a private hospital in Manila, Philippines as a strategy for antimicrobial stewardship

Background

Hospital antimicrobial stewardship programs are especially critical in countries such as the Philippines, where antibiotic resistant infections are highly prevalent. At the study institution in Manila, Philippines, a Prior Approval for Restricted Antimicrobials (PARA) is required for non-infectious disease specialists to prescribe certain antimicrobials, including carbapenems. PARA request forms include specification of empiric or definitive therapy based on diagnostic tests. Recommended duration of therapy is typically 3 days for empiric use and 7 days for definitive, with possible extension upon specialist approval.

Methods

The study took place at an 800-bed tertiary hospital. We performed a retrospective review of patient medical records and laboratory reports dating from January 1 to December 31, 2016. Information related to patient demographics, carbapenem prescription, laboratory diagnosis, and therapy were compiled. Carbapenem prescriptions were classified as 'adherent' or 'non-adherent' according to clinical guidelines related to infection diagnosis, treatment duration, and de-escalation.

Results

Of the 185 patients on carbapenem therapy, Prescriptions of carbapenems were either definitive (n = 56), empiric (n = 127), or prophylactic (n = 2) as defined by the ordering provider. 69 out of 185 (37%) prescriptions were deemed non-adherent to guidelines, despite receiving approvals for their respective requests. Of these, 72% were non-adherent due to failure to de-escalate the carbapenem and 28% were non-adherent due to an incomplete course of therapy.

Conclusion

Despite initial PARA approval for carbapenem therapy, 37% of prescriptions were non-guideline-adherent, highlighting the ongoing challenges in implementing this type of stewardship strategy. In order to increase the effectiveness of PARA, additional approaches may be warranted, including the application of strict policies which reinforce follow-up of available culture results, justification of therapy extension, or referral to an infectious disease specialist.

Microextraction by Packed Molecularly Imprinted Polymer Combined Ultra-High-Performance Liquid Chromatography for the Determination of Levofloxacin in Human Plasma

Fluoroquinolones are considered as gold standard for the prevention of bacterial infections. To improve assessment of antibacterial efficacy, a novel method for determination of levofloxacin was developed and validated. Deep eutectic solvents (DESs) as only green solvent were used as a porogen for preparation of water-compatible molecularly imprinted polymers (MIPs) with a pseudotemplate. The DESs-MIPs were characterized in detail, including scanning electron microscope, nitrogen sorption porosimetry, and Fourier transform-infrared spectra. Clearly, the maximum binding capacity of levofloxacin on DESs-MIPs in water and methanol was 0.216 and 0.077 μmol g−1, respectively. The DESs-MIPs as adsorbing materials were applied in microextraction by packed sorbent (MEPS), and the DESs-MIPs-MEPS conditions were optimized. The DESs-MIPs-MEPS coupled with ultra-high-performance liquid chromatography (UHPLC) was used to determine levofloxacin in human plasma. The method was found linear over 0.05–10 μg mL−1 with coefficient of correlation equal to 0.9988. The limit of detection and limit of quantification were 0.012 and 0.04 μg mL−1, respectively. At three spiked levels, the precision of proposed method was between 95.3% and 99.7% with intraday and interday relative standard deviations ≤8.9%. Finally, the developed method was used to examine levofloxacin from human plasma of 20 hospitalized patients after transrectal ultrasound-guided prostate biopsy, and the average concentration (±SD) of levofloxacin was 2.35 ± 0.99 μg mL−1 in plasma.

Point prevalence survey of antimicrobial prescription in a tertiary hospital in South East Nigeria: A call for improved antibiotic stewardship

OBJECTIVES

Antimicrobial prescribing practices and use contribute to the growing threat of antimicrobial resistance (AMR) to global health. Information on antimicrobial prescribing and use are lacking in most developing countries, including Nigeria. This information is crucial for antimicrobial stewardship programmes, an effective tool in minimising AMR. This study was performed to gather baseline information on antimicrobial prescribing practices in Nigeria.

METHODS

A cross-sectional survey was conducted on all inpatients of a tertiary hospital in South East Nigeria. All patients on admission on the day of the survey formed the study population. A standardised questionnaire, web-based data entry and validation process designed by the University of Antwerp, Belgium, were adopted. Information on basic patient demographics, antimicrobial agents used, indication for treatment, laboratory data prior to treatment and stop/review date was collected.

RESULTS

Of 220 inpatients surveyed, 78.2% were receiving at least one antimicrobial agent. The highest prevalence of antimicrobial use was in the ICU (100%), adult surgical ward (82.9%) and paediatric medical ward (82.9%). Agents used were mainly third-generation cephalosporins (ceftriaxone 25.1%) and nitroimidazole (metronidazole 24.6%). Antimicrobial prescription was empirical (91.1% in medical wards, 96.8% in surgical wards and 100% in ICU). There was limited use of guidelines but clear documentation of stop/review dates and reasons for antimicrobial use.

CONCLUSION

Although a majority of antimicrobial prescriptions were made with indications, they were mostly prescribed empirically and the majority of prescriptions were parenteral formulations. There is a need to develop antibiotic guidelines, to educate prescribers on antimicrobial stewardship and to encourage targeted prescription.

Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry for the Rapid Detection of Antimicrobial Resistance Mechanisms and Beyond

Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) has been successfully applied in recent years for first-line identification of pathogens in clinical microbiology because it is simple to use, rapid, and accurate and has economic benefits in hospital management. The range of clinical applications of MALDI-TOF MS for bacterial isolates is increasing constantly, from species identification to the two most promising applications in the near future: detection of antimicrobial resistance and strain typing for epidemiological studies. The aim of this review is to outline the contribution of previous MALDI-TOF MS studies in relation to detection of antimicrobial resistance and to discuss potential future challenges in this field. Three main approaches are ready (or almost ready) for clinical use, including the detection of antibiotic modifications due to the enzymatic activity of bacteria, the detection of antimicrobial resistance by analysis of the peak patterns of bacteria or mass peak profiles, and the detection of resistance by semiquantification of bacterial growth in the presence of a given antibiotic. This review provides an expert guide for MALDI-TOF MS users to new approaches in the field of antimicrobial resistance detection, especially possible applications as a routine diagnostic tool in microbiology laboratories.

Antimicrobial stewardship for acute-care hospitals: An Asian perspective

Inappropriate use of antibiotics is contributing to a serious antimicrobial resistance problem in Asian hospitals. Despite resource constraints in the region, all Asian hospitals should implement antimicrobial stewardship (AMS) programs to optimize antibiotic treatment, improve patient outcomes, and minimize antimicrobial resistance. This document describes a consensus statement from a panel of regional experts to help multidisciplinary AMS teams design programs that suit the needs and resources of their hospitals. In general, AMS teams must decide on appropriate interventions (eg, prospective audit and/or formulary restriction) for their hospital, focusing on the most misused antibiotics and problematic multidrug-resistant organisms. This focus is likely to include carbapenem use with the goal to reduce carbapenem-resistant gram-negative bacteria. Rather than initially trying to introduce a comprehensive, hospital-wide AMS program, it would be practical to begin by pilot testing a simple program based on 1 achievable core intervention for the hospital. AMS team members must work together to determine the most suitable AMS interventions to implement in their hospitals and how best to put them into practice. Continuous monitoring and feedback of outcomes to the AMS teams, hospital administration, and prescribers will enhance sustainability of the AMS programs.

Role of Education in Antimicrobial Stewardship

The ability to treat infectious diseases with antimicrobials is an essential component of medical management. Antimicrobial therapy is based on the characteristics of the patient, drug, microorganisms causing the infection, and colonizing flora. Prudent antibiotic use is the only option to delay the emergence of resistance. Training in infectious diseases and knowledge of the principles of responsible antibiotic prescribing and uses must be improved. To change practice, health care professionals should be educated at all levels of their training.

The Role of the Hospital Epidemiologist in Antibiotic Stewardship

Antibiotic stewardship programs (ASPs) play a crucial role in controlling the emergence of resistant organisms, reducing rates of Clostridium difficile infections and associated hospital length of stay, promoting judicious use of antibiotics, and minimizing associated adverse events. There is a significant overlap between the goals of infection control programs and ASPs, and both programs can benefit from a synergistic relationship. Hospital epidemiologists can support these programs by providing leadership support, sharing surveillance data, bridging gaps between ASPs and departments such as microbiology, integrating educational programs with ASPs, sharing outbreak alerts, and assisting with the development of treatment algorithms.

Antimicrobial Resistance: An Antimicrobial/Diagnostic Stewardship and Infection Prevention Approach

Antimicrobial resistance (AR) is one of the most serious public health threats today, which has been accelerated by the overuse and misuse of antimicrobials in humans and animals plus inadequate infection prevention. Numerous studies have shown a relationship between antimicrobial use and resistance. Antimicrobial stewardship (AS) programs have been shown to improve patient outcomes, reduce antimicrobial adverse events, and decrease AR. AS programs, when implemented alongside infection control measures, especially hand-hygiene interventions, were more effective than implementation of AS alone. Targeted coordination and prevention strategies are critical to stopping the spread of multidrug-resistant organisms.

Fast track SSTI management program based on a rapid molecular test (GeneXpert® MRSA/SA SSTI) and antimicrobial stewardship

PURPOSE

This study examines the impacts of a skin and soft tissue infection (SSTI) management program involving a rapid diagnostic algorithm (Gram stain plus real-time PCR, GeneXpert® MRSA/SA SSTI) performed directly on clinical samples plus antimicrobial stewardship (AMS) counseling of the responsible physician.

METHODS

Participants were 155 consecutive adult inpatients with SSTI and good quality clinical samples submitted to the microbiology laboratory from April 2016 to January 2017. Results of the rapid test and AMS recommendations were phoned through to the responsible physician. The comparison group was a historical cohort.

RESULTS

Most SSTI were surgical wound infections (41.3% vs 38.1% for the intervention and comparison groups respectively) followed by diabetic foot (14.2% and 18.1%), abscesses (13.5% both) and cellulitis (12.9% both). Isolated microorganisms were mostly Gram-negative bacilli (two-thirds), followed by Staphylococcus aureus (SA). The ratio methicillin-susceptible SA (MSSA) to methicillin-resistant SA (MRSA) was 4:1. Improvements in the intervention cohort were: DOT (22.0 vs. 24.3 days, p = 0.007), treatment duration per SSTI episode (14.1 vs. 15.0 days, p = 0.072), treatment cost (433.1 vs. 533.3 €, p = 0.039), length of stay (18.6 vs 20.7 days, p = 0.031), related mortality (1 vs. 4 patients, p = 0.022) and Clostridium difficile infection (CDI) (4 vs. 8 patients, p = 0.050). In 48 cases (31.4%) in the intervention group, advice was given to improve empiric antibiotic treatment.

CONCLUSION

This type of program could help adjust antibiotic treatment when inappropriate, reducing antibiotic use and costs, length of stay, CDI and related mortality.

Modeling a Production Function to Evaluate the Effect of Medical Staffing on Antimicrobial Stewardship Performance in China, 2009-2016: Static and Dynamic Panel Data Analyses

Background: Antimicrobial resistance (AMR) is an international problem. Emergence and spread of AMR are strongly associated with overuse or inappropriate use of antimicrobials. Antimicrobial stewardship ensures the appropriate use of antimicrobials, and is an effective approach to control AMR. This study aims to understand the relationship between medical staffing and antimicrobial stewardship performance in China. Methods: A provincial-level panel dataset from 2009 to 2016 is used. A macro production function is used to quantify the relationship. The output, antimicrobial stewardship performance, is measured by changes in methicillin resistance rates of Staphylococcus. aureus (S. aureus) and coagulase-negative staphylococci (CoNS). The labor input is measured by the numbers of infectious diseases physicians, pharmacists, clinical microbiologists, and nurses in hospitals per 100,000 populations, whereas the capital input is represented by the number of hospital beds per 100,000 populations. The technology is captured by the time index. Both static and dynamic panel data approaches are employed. Results: The increasing number of clinical microbiologists is a significant predictor of lower resistance of CoNS according to dynamic models (Coef. = -0.191, -0.351; p = 0.070, 0.004, respectively). However, a larger number of nurses is significantly associated with higher resistance of S. aureus (Coef. = 0.648; p = 0.044). In addition, the numbers of the other two groups of medical professionals exhibit no significant associations with stewardship performance. Conclusions: The study demonstrates the crucial role of clinical microbiologists in antimicrobial stewardship. The predicted increased risk of resistance with the higher number of nurses may be attributable to their lack of related knowledge and their unrecognized functions in antimicrobial stewardship.

The GISA call to action for the appropriate use of antimicrobials and the control of antimicrobial resistance in Italy

The spread of antibiotic resistance is one of the leading public health problems in Italy. A European Centre for Disease Prevention and Control country visit recently confirmed the major challenges and made important suggestions. In response, the Ministry of Health published the National Plan for Antimicrobial Resistance Containment, and a group of experts belonging to the Italian Group of Antimicrobial Stewardship (GISA) convened to develop a summary of practical recommendations. The GISA document is intended for use by practising physicians; it aims to increase the rational use of antimicrobials in the treatment of infections, and to change the culture of infection control of antibiotic-resistant bacteria, through the translation of theoretical knowledge into priority actions. This document has been endorsed by several national scientific societies, and reflects the particular challenges that are faced in Italy. Nevertheless, it is considered that the general principles and approaches discussed are relevant, particularly to other developed economies.

Multicenter Evaluation of the Accelerate PhenoTest BC Kit for Rapid Identification and Phenotypic Antimicrobial Susceptibility Testing Using Morphokinetic Cellular Analysis

We describe results from a multicenter study evaluating the Accelerate Pheno system, a first of its kind diagnostic system that rapidly identifies common bloodstream pathogens from positive blood cultures within 90 min and determines bacterial phenotypic antimicrobial susceptibility testing (AST) results within ∼7 h. A combination of fresh clinical and seeded blood cultures were tested, and results from the Accelerate Pheno system were compared to Vitek 2 results for identification (ID) and broth microdilution or disk diffusion for AST. The Accelerate Pheno system accurately identified 14 common bacterial pathogens and two Candida spp. with sensitivities ranging from 94.6 to 100%. Of fresh positive blood cultures, 89% received a monomicrobial call with a positive predictive value of 97.3%. Six common Gram-positive cocci were evaluated for ID. Five were tested against eight antibiotics, two resistance phenotypes (methicillin-resistant Staphylococcus aureus and Staphylococcus spp. [MRSA/MRS]), and inducible clindamycin resistance (MLSb). From the 4,142 AST results, the overall essential agreement (EA) and categorical agreement (CA) were 97.6% and 97.9%, respectively. Overall very major error (VME), major error (ME), and minor error (mE) rates were 1.0%, 0.7%, and 1.3%, respectively. Eight species of Gram-negative rods were evaluated against 15 antibiotics. From the 6,331 AST results, overall EA and CA were 95.4% and 94.3%, respectively. Overall VME, ME, and mE rates were 0.5%, 0.9%, and 4.8%, respectively. The Accelerate Pheno system has the unique ability to identify and provide phenotypic MIC and categorical AST results in a few hours directly from positive blood culture bottles and support accurate antimicrobial adjustment.

First-year results of an antibiotic stewardship program in a Greek tertiary care hospital

The aim of this study was to investigate the effect of the implementation of an antibiotic stewardship program (ASP) on antibiotic consumption in our 428-bed hospital. The Infection Control Committee implemented an ASP beginning in January 2016, aiming to reduce inappropriate antibiotic use through improved prescribing practices. The ASP included both pre-authorization and prospective audit and feedback strategies. We collected pharmacy and hospital data for the years 2015 (pre-intervention) and 2016 (post-intervention). Consumption data were expressed as daily defined doses (DDDs) per 100 patient-days (PD) and the significance of the differences between 2015 and 2016 was assessed by paired t-test. Antibiotic resistance rates for the most important hospital pathogens were monitored for 2015-2016. The ASP effectively reduced consumption of most antimicrobials; total antibiotic use decreased by 16.7% (from 104.3 in 2015 to 86.9 DDDs/100 patient-days in 2016, p < 0.001) owing to reduction of 19.1% for non-restricted and 13.8% for restricted antibiotics. Important restricted antimicrobials, such as colistin, carbapenems, quinolones and tigecycline showed significantly decreased usage post-intervention. Significant changes in the resistance rates were not observed, except a decreasing trend for colistin and tigecycline (Acinetobacter baumannii and Klebsiella pneumoniae) and also vancomycin (enterococci). The ASP was successful in terms of reducing the antibiotic consumption for the first year of its implementation. Interestingly, antimicrobials requiring pre-authorization exhibited a lower reduction than other antibiotics. Potential effects of the ASP in reducing resistance rates remain to be shown.

Clinical impact of colonization with multidrug-resistant organisms on outcome after allogeneic stem cell transplantation in patients with acute myeloid leukemia

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative treatment option for patients with acute myeloid leukemia (AML). During transplantation, patients undergo a period of severe neutropenia, which puts them at high risk for infectious complications. However, the impact of patient colonization with multidrug-resistant organisms (MDRO) on overall survival remains unclear.

METHODS

In this retrospective, single-center study, the authors analyzed data from 264 patients with AML who underwent a first allo-HSCT between January 2006 and March 2016 at their institution. Primary endpoints were overall survival and nonrelapse-related mortality.

RESULTS

One hundred forty-two of 264 patients (53.8%) were colonized by at least 1 MDRO, mainly with vancomycin-resistant Enterococcus faecalis/faecium (n = 122). The characteristics of colonized patients did not differ from those of MDRO-negative patients with respect to median age (53.5 vs 53 years), cytogenetic risk according to European LeukemiaNet criteria, remission status before allo-HSCT (first or second complete remission: 55.7% vs 60.7%, respectively; active disease: 44.4% vs 39.3%, respectively), donor type, or hematopoietic cell transplantation-comorbidity index (HCT-CI). Compared with noncolonized patients, MDRO-positive patients had an inferior probability of survival at 5 years (43.3% vs 65.5%; P = .002), primarily because of a higher cumulative incidence of nonrelapse-related mortality (33.9% vs 9.4%; P < .001). Death caused by infections occurred in 15.5% of colonized patients versus 4.9% of noncolonized patients. There was no difference in the cumulative incidence of relapse in MDRO-positive versus MDRO-negative patients (33.8% vs 42.1%, respectively; P = .798).

CONCLUSIONS

The current data emphasize the importance of regular MDRO screenings and prompt further investigations into the impact of colonization with MDRO on the immune system after allo-HSCT. Cancer 2018;124:286-96. © 2017 American Cancer Society.

[Antibiotic stewardship : A programmatic approach to improved antimicrobial management]

Due to the increasing selection and prevalence of multidrug-resistant gram-negative bacteria and the insufficient development of novel antibiotics, the responsible and prudent use of the available antimicrobial drugs is of major importance. In Germany the rational use of anti-infectives considering the local antimicrobial resistance situation is defined in the infection protection act of 2011. An important tool to follow legal regulations and to improve the treatment of bacterial infections is the antimicrobial stewardship (AMS) concept. Hospitals implementing an AMS program charge a multidisciplinary team of experts to develop and monitor treatment standards and to establish a system of regular consultations and ward rounds. Objectives of this set of measures are the optimization of the individual treatment outcome and on a longer range the improvement of the epidemiological situation. AMS programs include all clinical disciplines that use antimicrobials. Trauma surgery is also affected in a special way as soon as complicated infections and those with multidrug-resistant bacteria are treated.