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Rieg S, Küpper MF. Infectious diseases consultations can make the difference: a brief review and a plea for more infectious diseases specialists in Germany. Infection 2016; 44:159-66. [PMID: 26908131 DOI: 10.1007/s15010-016-0883-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 02/08/2016] [Indexed: 01/15/2023]
Abstract
Trained infectious diseases (ID) specialists are an integral part of inpatient and outpatient care in many countries, however, these specialized services are established only in selected tertiary care hospitals in Germany. This review summarises studies that addressed the impact of ID consultation services on patient care and outcome. Extensive data for a clinical benefit is available in the context of Staphylococcus aureus bacteremia (SAB), in which in-hospital or 30-day mortality was significantly reduced by 40-50 % in patients evaluated and treated in cooperation with ID consultants. This effect was associated with improved adherence to quality-of-care standards. Moreover, newer studies show a reduced length of hospital stay due to ID consultations, especially if patients are evaluated early in the course of their hospital stay. Of note, informal consultations do not seem to be equivalent to a formal ID consultation with bedside patient evaluation. Studies in other patient groups (solid organ transplant recipients or intensive care unit patients) or in the context of other infections (infective endocarditis, pneumonia, other bloodstream infections) also revealed positive effects of ID consultations. Higher rates of appropriate empirical and targeted antimicrobial treatments and de-escalation strategies due to successful pathogen identification were documented. These modifications resulted in lower treatment costs and decreased antimicrobial resistance development. Although there are methodological limitations in single studies, we consider the consistent and reproducible positive effects of ID consultations shown in studies in different countries and health care systems as convincing evidence for improved quality-of-care and treatment outcomes in patients with infectious diseases. Thus, we strongly recommend efforts to establish significantly more ID consultation services in hospitals in Germany.
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Affiliation(s)
- Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, University Medical Center, Albert-Ludwigs-University Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Marc Fabian Küpper
- Division of Infectious Diseases, Department of Medicine II, University Medical Center, Albert-Ludwigs-University Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
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Turza KC, Politano AD, Rosenberger LH, Riccio LM, McLeod M, Sawyer RG. De-Escalation of Antibiotics Does Not Increase Mortality in Critically Ill Surgical Patients. Surg Infect (Larchmt) 2016; 17:48-52. [DOI: 10.1089/sur.2014.202] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kristin C. Turza
- Department of Surgery, Division of Acute Care Surgery, University of Virginia, Charlottesville, Virginia
| | - Amani D. Politano
- Department of Surgery, Division of Acute Care Surgery, University of Virginia, Charlottesville, Virginia
| | - Laura H. Rosenberger
- Department of Surgery, Division of Acute Care Surgery, University of Virginia, Charlottesville, Virginia
| | - Lin M. Riccio
- Department of Surgery, Division of Acute Care Surgery, University of Virginia, Charlottesville, Virginia
| | - Matthew McLeod
- Department of Surgery, Division of Acute Care Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert G. Sawyer
- Department of Surgery, Division of Acute Care Surgery, University of Virginia, Charlottesville, Virginia
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203
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Sartelli M, Weber DG, Ruppé E, Bassetti M, Wright BJ, Ansaloni L, Catena F, Coccolini F, Abu-Zidan FM, Coimbra R, Moore EE, Moore FA, Maier RV, De Waele JJ, Kirkpatrick AW, Griffiths EA, Eckmann C, Brink AJ, Mazuski JE, May AK, Sawyer RG, Mertz D, Montravers P, Kumar A, Roberts JA, Vincent JL, Watkins RR, Lowman W, Spellberg B, Abbott IJ, Adesunkanmi AK, Al-Dahir S, Al-Hasan MN, Agresta F, Althani AA, Ansari S, Ansumana R, Augustin G, Bala M, Balogh ZJ, Baraket O, Bhangu A, Beltrán MA, Bernhard M, Biffl WL, Boermeester MA, Brecher SM, Cherry-Bukowiec JR, Buyne OR, Cainzos MA, Cairns KA, Camacho-Ortiz A, Chandy SJ, Che Jusoh A, Chichom-Mefire A, Colijn C, Corcione F, Cui Y, Curcio D, Delibegovic S, Demetrashvili Z, De Simone B, Dhingra S, Diaz JJ, Di Carlo I, Dillip A, Di Saverio S, Doyle MP, Dorj G, Dogjani A, Dupont H, Eachempati SR, Enani MA, Egiev VN, Elmangory MM, Ferrada P, Fitchett JR, Fraga GP, Guessennd N, Giamarellou H, Ghnnam W, Gkiokas G, Goldberg SR, Gomes CA, Gomi H, Guzmán-Blanco M, Haque M, Hansen S, Hecker A, Heizmann WR, Herzog T, Hodonou AM, Hong SK, Kafka-Ritsch R, Kaplan LJ, Kapoor G, Karamarkovic A, Kees MG, Kenig J, Kiguba R, Kim PK, Kluger Y, Khokha V, Koike K, Kok KYY, Kong V, Knox MC, Inaba K, Isik A, Iskandar K, Ivatury RR, Labbate M, Labricciosa FM, Laterre PF, Latifi R, Lee JG, Lee YR, Leone M, Leppaniemi A, Li Y, Liang SY, Loho T, Maegele M, Malama S, Marei HE, Martin-Loeches I, Marwah S, Massele A, McFarlane M, Melo RB, Negoi I, Nicolau DP, Nord CE, Ofori-Asenso R, Omari AH, Ordonez CA, Ouadii M, Pereira Júnior GA, Piazza D, Pupelis G, Rawson TM, Rems M, Rizoli S, Rocha C, Sakakhushev B, Sanchez-Garcia M, Sato N, Segovia Lohse HA, Sganga G, Siribumrungwong B, Shelat VG, Soreide K, Soto R, Talving P, Tilsed JV, Timsit JF, Trueba G, Trung NT, Ulrych J, van Goor H, Vereczkei A, Vohra RS, Wani I, Uhl W, Xiao Y, Yuan KC, Zachariah SK, Zahar JR, Zakrison TL, Corcione A, Melotti RM, Viscoli C, Viale P. Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA). World J Emerg Surg 2016; 11:33. [PMID: 27429642 PMCID: PMC4946132 DOI: 10.1186/s13017-016-0089-y] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 07/04/2016] [Indexed: 02/08/2023] Open
Abstract
Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Dieter G. Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Etienne Ruppé
- Genomic Research Laboratory, Geneva University Hospitals, Geneva, Switzerland
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy
| | - Brian J. Wright
- Department of Emergency Medicine and Surgery, Stony Brook University School of Medicine, Stony Brook, NY USA
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Fausto Catena
- Department of General, Maggiore Hospital, Parma, Italy
| | | | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Raul Coimbra
- Department of Surgery, UC San Diego Medical Center, San Diego, USA
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
| | - Frederick A. Moore
- Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, FL USA
| | - Ronald V. Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Jan J. De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andrew W. Kirkpatrick
- General, Acute Care, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Ewen A. Griffiths
- General and Upper GI Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Christian Eckmann
- Department of General, Visceral, and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Peine, Germany
| | - Adrian J. Brink
- Department of Clinical microbiology, Ampath National Laboratory Services, Milpark Hospital, Johannesburg, South Africa
| | - John E. Mazuski
- Department of Surgery, School of Medicine, Washington University in Saint Louis, Missouri, USA
| | - Addison K. May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN USA
| | - Rob G. Sawyer
- Department of Surgery, University of Virginia Health System, Charlottesville, VA USA
| | - Dominik Mertz
- Departments of Medicine, Clinical Epidemiology and Biostatistics, and Pathology and Molecular Medicine, McMaster University, Hamilton, ON Canada
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | - Anand Kumar
- Section of Critical Care Medicine and Section of Infectious Diseases, Department of Medicine, Medical Microbiology and Pharmacology/Therapeutics, University of Manitoba, Winnipeg, MB Canada
| | - Jason A. Roberts
- Australia Pharmacy Department, Royal Brisbane and Womens’ Hospital; Burns, Trauma, and Critical Care Research Centre, Australia School of Pharmacy, The University of Queensland, Brisbane, QLD Australia
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Richard R. Watkins
- Department of Internal Medicine, Division of Infectious Diseases, Akron General Medical Center, Northeast Ohio Medical University, Akron, OH USA
| | - Warren Lowman
- Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Brad Spellberg
- Division of Infectious Diseases, Los Angeles County-University of Southern California (USC) Medical Center, Keck School of Medicine at USC, Los Angeles, CA USA
| | - Iain J. Abbott
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC Australia
| | | | - Sara Al-Dahir
- Division of Clinical and Administrative Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA USA
| | - Majdi N. Al-Hasan
- Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC USA
| | | | | | - Shamshul Ansari
- Department of Microbiology, Chitwan Medical College, and Department of Environmental and Preventive Medicine, Oita University, Oita, Japan
| | - Rashid Ansumana
- Centre for Neglected Tropical Diseases, Liverpool School of Tropical Medicine, University of Liverpool, and Mercy Hospital Research Laboratory, Njala University, Bo, Sierra Leone
| | - Goran Augustin
- Department of Surgery, University Hospital Center, Zagreb, Croatia
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | | | - Aneel Bhangu
- Academic Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Marcelo A. Beltrán
- Department of General Surgery, Hospital San Juan de Dios de La Serena, La Serena, Chile
| | | | - Walter L. Biffl
- Department of Surgery, University of Colorado, Denver, CO USA
| | | | - Stephen M. Brecher
- Department of Pathology and Laboratory Medicine, VA Boston HealthCare System, and Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA USA
| | - Jill R. Cherry-Bukowiec
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI USA
| | - Otmar R. Buyne
- Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Miguel A. Cainzos
- Department of Surgery, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Kelly A. Cairns
- Pharmacy Department, Alfred Health, Melbourne, VIC Australia
| | - Adrian Camacho-Ortiz
- Hospital Epidemiology and Infectious Diseases, Hospital Universitario Dr Jose Eleuterio Gonzalez, Monterrey, Mexico
| | - Sujith J. Chandy
- Department of Pharmacology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala India
| | - Asri Che Jusoh
- Department of General Surgery, Kuala Krai Hospital, Kuala Krai, Kelantan Malaysia
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Caroline Colijn
- Department of Mathematics, Imperial College London, London, UK
| | - Francesco Corcione
- Department of Laparoscopic and Robotic Surgery, Colli-Monaldi Hospital, Naples, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Daniel Curcio
- Infectología Institucional SRL, Hospital Municipal Chivilcoy, Buenos Aires, Argentina
| | - Samir Delibegovic
- Department of Surgery, University Clinical Center of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Zaza Demetrashvili
- Department General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
| | | | - Sameer Dhingra
- School of Pharmacy, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Eric Williams Medical Sciences Complex, Uriah Butler Highway, Champ Fleurs, Trinidad and Tobago
| | - José J. Diaz
- Division of Acute Care Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - Isidoro Di Carlo
- Department of Surgical Sciences, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Angel Dillip
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Michael P. Doyle
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, Griffin, GA USA
| | - Gereltuya Dorj
- School of Pharmacy and Biomedicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Agron Dogjani
- Department of Surgery, University Hospital of Trauma, Tirana, Albania
| | - Hervé Dupont
- Département d’Anesthésie-Réanimation, CHU Amiens-Picardie, and INSERM U1088, Université de Picardie Jules Verne, Amiens, France
| | - Soumitra R. Eachempati
- Department of Surgery, Division of Burn, Critical Care, and Trauma Surgery (K.P.S., S.R.E.), Weill Cornell Medical College/New York-Presbyterian Hospital, New York, USA
| | - Mushira Abdulaziz Enani
- Department of Medicine, Infectious Disease Division, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Valery N. Egiev
- Department of Surgery, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Mutasim M. Elmangory
- Sudan National Public Health Laboratory, Federal Ministry of Health, Khartoum, Sudan
| | - Paula Ferrada
- Department of Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Joseph R. Fitchett
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA USA
| | - Gustavo P. Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | | | - Helen Giamarellou
- 6th Department of Internal Medicine, Hygeia General Hospital, Athens, Greece
| | - Wagih Ghnnam
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - George Gkiokas
- 2nd Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Carlos Augusto Gomes
- Department of Surgery, Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Juiz de Fora, Brazil
| | - Harumi Gomi
- Center for Global Health, Mito Kyodo General Hospital, University of Tsukuba, Mito, Ibaraki Japan
| | - Manuel Guzmán-Blanco
- Hospital Privado Centro Médico de Caracas and Hospital Vargas de Caracas, Caracas, Venezuela
| | - Mainul Haque
- Unit of Pharmacology, Faculty of Medicine and Defense Health, National Defence University of Malaysia, Kuala Lumpur, Malaysia
| | - Sonja Hansen
- Institute of Hygiene, Charité-Universitätsmedizin Berlin, Hindenburgdamm 27, 12203 Berlin, Germany
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | | | - Torsten Herzog
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Adrien Montcho Hodonou
- Department of Surgery, Faculté de médecine, Université de Parakou, BP 123 Parakou, Bénin
| | - Suk-Kyung Hong
- Division of Trauma and Surgical Critical Care, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Reinhold Kafka-Ritsch
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Lewis J. Kaplan
- Department of Surgery Philadelphia VA Medical Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Garima Kapoor
- Department of Microbiology, Gandhi Medical College, Bhopal, India
| | | | - Martin G. Kees
- Department of Anesthesiology and Intensive Care, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Jakub Kenig
- 3rd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Ronald Kiguba
- Department of Pharmacology and Therapeutics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Peter K. Kim
- Department of Surgery, Albert Einstein College of Medicine and Jacobi Medical Center, Bronx, NY USA
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenneth Y. Y. Kok
- Department of Surgery, The Brunei Cancer Centre, Jerudong Park, Brunei
| | - Victory Kong
- Department of Surgery, Edendale Hospital, Pietermaritzburg, South Africa
| | - Matthew C. Knox
- School of Medicine, Western Sydney University, Campbelltown, NSW Australia
| | - Kenji Inaba
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA USA
| | - Arda Isik
- Department of General Surgery, Erzincan University, Faculty of Medicine, Erzincan, Turkey
| | - Katia Iskandar
- Department of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Rao R. Ivatury
- Department of Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Maurizio Labbate
- School of Life Science and The ithree Institute, University of Technology, Sydney, NSW Australia
| | - Francesco M. Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, UNIVMP, Ancona, Italy
| | - Pierre-François Laterre
- Department of Critical Care Medicine, Cliniques Universitaires Saint Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Rifat Latifi
- Department of Surgery, Division of Trauma, University of Arizona, Tucson, AZ USA
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Ran Lee
- Texas Tech University Health Sciences Center School of Pharmacy, Abilene, TX USA
| | - Marc Leone
- Department of Anaesthesiology and Critical Care, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Yousheng Li
- Department of Surgery, Inling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Stephen Y. Liang
- Division of Infectious Diseases, Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO USA
| | - Tonny Loho
- Division of Infectious Diseases, Department of Clinical Pathology, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Marc Maegele
- Department for Traumatology and Orthopedic Surgery, Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke (UW/H), Cologne, Germany
| | - Sydney Malama
- Health Research Program, Institute of Economic and Social Research, University of Zambia, Lusaka, Zambia
| | - Hany E. Marei
- Biomedical Research Center, Qatar University, Doha, Qatar
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Wellcome Trust-HRB Clinical Research, Department of Clinical Medicine, Trinity Centre for Health Sciences, St James’ University Hospital, Dublin, Ireland
| | - Sanjay Marwah
- Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | - Amos Massele
- Department of Clinical Pharmacology, School of Medicine, University of Botswana, Gaborone, Botswana
| | - Michael McFarlane
- Department of Surgery, Radiology, University Hospital of the West Indies, Kingston, Jamaica
| | - Renato Bessa Melo
- General Surgery Department, Centro Hospitalar de São João, Porto, Portugal
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - David P. Nicolau
- Center of Anti-Infective Research and Development, Hartford, CT USA
| | - Carl Erik Nord
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | | | | | - Carlos A. Ordonez
- Department of Surgery and Critical Care, Universidad del Valle, Fundación Valle del Lili, Cali, Colombia
| | - Mouaqit Ouadii
- Department of Surgery, Hassan II University Hospital, Medical School of Fez, Sidi Mohamed Benabdellah University, Fez, Morocco
| | | | - Diego Piazza
- Division of Surgery, Vittorio Emanuele Hospital, Catania, Italy
| | - Guntars Pupelis
- Department of General and Emergency Surgery, Riga East University Hospital ‘Gailezers’, Riga, Latvia
| | - Timothy Miles Rawson
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
| | - Miran Rems
- Department of General Surgery, Jesenice General Hospital, Jesenice, Slovenia
| | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael’s Hospital, University of Toronto, Toronto, Canada
| | | | - Boris Sakakhushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | | | - Norio Sato
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Helmut A. Segovia Lohse
- II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Gabriele Sganga
- Department of Surgery, Catholic University of Sacred Heart, Policlinico A Gemelli, Rome, Italy
| | - Boonying Siribumrungwong
- Department of Surgery, Faculty of Medicine, Thammasat University Hospital, Thammasat University, Pathum Thani, Thailand
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Tan Tock Seng, Singapore
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Rodolfo Soto
- Department of Emergency Surgery and Critical Care, Centro Medico Imbanaco, Cali, Colombia
| | - Peep Talving
- Department of Surgery, North Estonia Medical Center, Tallinn, Estonia
| | - Jonathan V. Tilsed
- Surgery Health Care Group, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - Gabriel Trueba
- Institute of Microbiology, Biological and Environmental Sciences College, University San Francisco de Quito, Quito, Ecuador
| | - Ngo Tat Trung
- Department of Molecular Biology, Tran Hung Dao Hospital, No 1, Tran Hung Dao Street, Hai Ba Trung Dist, Hanoi, Vietnam
| | - Jan Ulrych
- 1st Department of Surgery - Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Prague, Czech Republic
| | - Harry van Goor
- Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Andras Vereczkei
- Department of Surgery, Medical School University of Pécs, Pécs, Hungary
| | - Ravinder S. Vohra
- Nottingham Oesophago-Gastric Unit, Nottingham University Hospitals, Nottingham, UK
| | - Imtiaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Waldemar Uhl
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affilliated Hospital, Zhejiang University, Zhejiang, China
| | - Kuo-Ching Yuan
- Trauma and Emergency Surgery Department, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | | | - Jean-Ralph Zahar
- Infection Control Unit, Angers University, CHU d’Angers, Angers, France
| | - Tanya L. Zakrison
- Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgry, University of Miami, Miami, FL USA
| | - Antonio Corcione
- Anesthesia and Intensive Care Unit, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Rita M. Melotti
- Anesthesiology and Intensive Care Unit, Sant’Orsola University Hospital, Bologna, Italy
| | - Claudio Viscoli
- Infectious Diseases Unit, University of Genoa (DISSAL) and IRCCS San Martino-IST, Genoa, Italy
| | - Perluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’ Orsola Hospital, University of Bologna, Bologna, Italy
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Tabah A, Cotta MO, Garnacho-Montero J, Schouten J, Roberts JA, Lipman J, Tacey M, Timsit JF, Leone M, Zahar JR, De Waele JJ. A Systematic Review of the Definitions, Determinants, and Clinical Outcomes of Antimicrobial De-escalation in the Intensive Care Unit. Clin Infect Dis 2015; 62:1009-1017. [PMID: 26703860 DOI: 10.1093/cid/civ1199] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 12/04/2015] [Indexed: 12/29/2022] Open
Abstract
Antimicrobial de-escalation (ADE) is a strategy to reduce the spectrum of antimicrobials and aims to prevent the emergence of bacterial resistance. We present a systematic review describing the definitions, determinants and outcomes associated with ADE. We included 2 randomized controlled trials and 12 cohort studies. There was considerable variability in the definition of ADE. It was more frequently performed in patients with broad-spectrum and/or appropriate antimicrobial therapy (P= .05 to .002), when more agents were used (P= .002), and in the absence of multidrug-resistant pathogens (P< .05). Where investigated, lower or improving severity scores were consistently associated with ADE (P= .04 to <.001). The pooled effect of ADE on mortality is protective (relative risk, 0.68; 95% confidence interval, .52-.88). Because the determinants of ADE are markers of clinical improvement and/or of lower risk of treatment failure this effect on mortality cannot be retained as evidence. None of the studies were designed to investigate the effect of ADE on antimicrobial resistance.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Royal Brisbane and Women's Hospital.,Burns, Trauma, and Critical Care Research Centre
| | - Menino Osbert Cotta
- Intensive Care Unit, Royal Brisbane and Women's Hospital.,Burns, Trauma, and Critical Care Research Centre.,School of Pharmacy, The University of Queensland
| | - Jose Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Instituto de Biomedicina de Sevilla, Spain
| | - Jeroen Schouten
- Department of Intensive Care, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Jason A Roberts
- Intensive Care Unit, Royal Brisbane and Women's Hospital.,Burns, Trauma, and Critical Care Research Centre.,School of Pharmacy, The University of Queensland
| | - Jeffrey Lipman
- Intensive Care Unit, Royal Brisbane and Women's Hospital.,Burns, Trauma, and Critical Care Research Centre.,Faculty of Health, Queensland University of Technology, Brisbane
| | - Mark Tacey
- Melbourne EpiCentre, Royal Melbourne Hospital and Department of Medicine, University of Melbourne, Australia
| | - Jean-François Timsit
- APHP - Hopital Bichat - Reanimation Medicale et des Maladies Infectieuses.,UMR 1137 - IAME Team 5 - DeSCID: Decision Sciences in Infectious Diseases, Control and Care; Inserm/Univ Paris Diderot, Sorbonne Paris Cité
| | - Marc Leone
- Service d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université
| | - Jean Ralph Zahar
- Unité de Prévention et de Lutte Contre les Infections Nosocomiales, CHU Angers-Université D'Angers, France
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Belgium
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205
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Rate of blood culture contamination in a teaching hospital: A single center study. J Taibah Univ Med Sci 2015. [DOI: 10.1016/j.jtumed.2015.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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206
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Madaras-Kelly K, Jones M, Remington R, Caplinger CM, Huttner B, Jones B, Samore M. Antimicrobial de-escalation of treatment for healthcare-associated pneumonia within the Veterans Healthcare Administration. J Antimicrob Chemother 2015; 71:539-46. [PMID: 26538501 DOI: 10.1093/jac/dkv338] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 09/17/2015] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES The objective of this study was to measure quantitatively antimicrobial de-escalation utilizing electronic medication administration data based on the spectrum of activity for antimicrobial therapy (i.e. spectrum score) to identify variables associated with de-escalation in a nationwide healthcare system. METHODS A retrospective cohort study of patients hospitalized for healthcare-associated pneumonia was conducted in Veterans Affairs Medical Centers (n = 119). Patients hospitalized for healthcare-associated pneumonia on acute-care wards between 5 and 14 days who received antimicrobials for ≥ 3 days during calendar years 2008-11 were evaluated. The spectrum score method was applied at the patient level to measure de-escalation on day 4 of hospitalization. De-escalation was expressed in aggregate and facility-level proportions. Logistic regression was used to assess variables associated with de-escalation. ORs with 95% CIs were reported. RESULTS Among 9319 patients, the de-escalation proportion was 28.3% (95% CI 27.4-29.2), which varied 6-fold across facilities [median (IQR) facility-level de-escalation proportion 29.1% (95% CI 21.7-35.6)]. Variables associated with de-escalation included initial broad-spectrum therapy (OR 1.5, 95% CI 1.4-1.5 for each 10% increase in spectrum), collection of respiratory tract cultures (OR 1.1, 95% CI 1.0-1.2) and care in higher complexity facilities (OR 1.3, 95% CI 1.1-1.6). Respiratory tract cultures were collected from 35.3% (95% CI 32.7-37.7) of patients. CONCLUSIONS De-escalation of antimicrobial therapy was limited and varied substantially across facilities. De-escalation was associated with respiratory tract culture collection and treatment in a high complexity-level facility.
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Affiliation(s)
- Karl Madaras-Kelly
- Boise Veterans Affairs Medical Center, T111, 500 W. Fort Street, Boise, ID 83702, USA College of Pharmacy, Idaho State University, Meridian, ID, USA
| | - Makoto Jones
- George E. Whalen Veterans Affairs Medical Center, Salt Lake City, UT, USA Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Richard Remington
- Boise Veterans Affairs Medical Center, T111, 500 W. Fort Street, Boise, ID 83702, USA Quantified Inc., Boise, ID, USA
| | - Christina M Caplinger
- Boise Veterans Affairs Medical Center, T111, 500 W. Fort Street, Boise, ID 83702, USA College of Pharmacy, Idaho State University, Meridian, ID, USA
| | - Benedikt Huttner
- Division of Infectious Diseases and Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Barbara Jones
- George E. Whalen Veterans Affairs Medical Center, Salt Lake City, UT, USA Division of Pulmonology and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Matthew Samore
- George E. Whalen Veterans Affairs Medical Center, Salt Lake City, UT, USA Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
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207
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Abstract
PURPOSE OF REVIEW An antimicrobial policy consisting of the initial use of wide-spectrum antimicrobials followed by a reassessment of treatment when culture results are available is termed de-escalation therapy. Our aim is to examine the safety and feasibility of antibiotic de-escalation in critically ill patients providing practical tips about how to accomplish this strategy in the critical care setting. RECENT FINDINGS Numerous studies have assessed the rates of de-escalation therapy (range from 10 to 60%) in patients with severe sepsis or ventilator-associated pneumonia as well as the factors associated with de-escalation. De-escalation generally refers to a reduction in the spectrum of administered antibiotics through the discontinuation of antibiotics or switching to an agent with a narrower spectrum. Diverse studies have identified the adequacy of initial therapy as a factor independently associated with de-escalation. Negative impact on different outcome measures has not been reported in the observational studies. Two randomized clinical trials have evaluated this strategy in patients with ventilator-associated pneumonia or severe sepsis. These trials alert us about the possibility that this strategy may be linked to a higher rate of reinfections but without an impact on mortality. SUMMARY Antibiotic de-escalation is a well tolerated management strategy in critically ill patients but unfortunately is not widely adopted.
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208
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[Impact of an infectious diseases consultation service on the quality of care and the survival of patients with infectious diseases]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2015; 109:500-10. [PMID: 26593765 DOI: 10.1016/j.zefq.2015.09.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 09/03/2015] [Accepted: 09/03/2015] [Indexed: 11/20/2022]
Abstract
While trained infectious diseases (ID) specialists are regularly involved in inpatient and outpatient care in the United States and Canada, these specialized services are only rarely established in Germany. This article aims to summarize the findings of numerous studies that investigated the impact of ID consultation services on patient care and outcome in patients suffering from infectious diseases. The strongest evidence for a clinical benefit is found in the context of Staphylococcus aureus bacteremia (SAB), where in-hospital- and day-30 mortality was significantly and consistently reduced by about 40% in patients that were evaluated and treated in cooperation with an ID physician. Furthermore, studies revealed that this effect was associated with an improved adherence to standards of care. Newer studies show a reduced length of hospital stay due to ID consultations, especially if patients are evaluated early in the course of their hospital stay. Of note, informal or curbside consultations do not seem to be equivalent to a formal ID consultation with bedside patient evaluation. Studies in other patient groups (solid organ transplant recipients or intensive care unit patients) or in the context of other infections (infective endocarditis, pneumonia, other bloodstream infections) also revealed positive effects of ID consultations. Higher rates of appropriate empirical and targeted antimicrobial treatments and de-escalation strategies due to successful pathogen identification were documented. These modifications resulted in lower treatment costs and decreased antimicrobial resistance development. Although there are methodological limitations in single studies, we consider the consistent and reproducible positive effects of ID consultations shown in studies in different countries and health care systems as convincing evidence for the improved quality of care and treatment outcomes in patients with infectious diseases. Thus, strong consideration should be given to establish ID consultation services in small and medium sized hospitals as well.
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209
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Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) infections: are carbapenem alternatives achievable in daily practice? Int J Infect Dis 2015; 39:62-7. [DOI: 10.1016/j.ijid.2015.08.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 07/27/2015] [Accepted: 08/22/2015] [Indexed: 02/04/2023] Open
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210
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Jakkinaboina S, Swarna Deepak K. De-escalation of empiric antibiotic therapy in sepsis - an indian observational study. Intensive Care Med Exp 2015. [PMCID: PMC4798267 DOI: 10.1186/2197-425x-3-s1-a405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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211
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Estella Á, Marchante C, Cobos J, Navarro C. [Infection in the elderly patient. Consensus recommendations for management in the Emergency Department]. Rev Esp Geriatr Gerontol 2015; 51:120-1. [PMID: 26388250 DOI: 10.1016/j.regg.2015.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 07/30/2015] [Accepted: 07/30/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Ángel Estella
- Urgencias Hospital SAS de Jerez, Jerez, Cádiz, España.
| | | | - Jose Cobos
- Urgencias Hospital Universitario Ciudad de Jaén, Jaén, España
| | - Carmen Navarro
- Urgencias Hospital Universitario Virgen Macarena, Sevilla, España
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212
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Roger PM, Courjon J, Léotard S, Déchamp C, Négrin N, Vassallo M. Antimicrobial stewardship policy: time to revisit the strategy? Eur J Clin Microbiol Infect Dis 2015; 34:2167-70. [PMID: 26387088 DOI: 10.1007/s10096-015-2483-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 08/25/2015] [Indexed: 11/28/2022]
Abstract
Recent data indicate that both the overall numbers of antibiotic prescription and the frequency of multidrug-resistant bacteria are increasing significantly. These threatening features are observed, despite national antimicrobial stewardship (AMS) policies aimed at decreasing antibiotic use. AMS should also focus on the initial steps leading to antibiotic prescription. Physicians and their patients should benefit from the structured clinical pathways, the latter being adapted to regional epidemiological data and resources. Continuous evaluation of these predefined clinical paths through a computerized medical dashboard will allow a critical review and finally the optimization of medical practices. These innovative behavioural approaches for clinicians will supply precise information on the relationship among the diagnosis, therapeutics and outcome. This changing environment will carry out the adapted therapeutic procedures, and appropriate antibiotic use will inherently improve.
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Affiliation(s)
- P-M Roger
- Infectiologie, Centre Hospitalier Universitaire de Nice, Université de Nice Sophia-Antipolis, Hôpital de l'Archet 1, BP 3079, 06202, Nice, France.
| | - J Courjon
- Infectiologie, Centre Hospitalier Universitaire de Nice, Université de Nice Sophia-Antipolis, Hôpital de l'Archet 1, BP 3079, 06202, Nice, France
| | - S Léotard
- Laboratoire de Bactériologie, Centre Hospitalier de Grasse, Grasse, France
| | - C Déchamp
- Pharmacie, Centre Hospitalier d'Antibes, Antibes, France
| | - N Négrin
- Service d'Hygiène Hospitalière, Centre Hospitalier de Grasse, Grasse, France
| | - M Vassallo
- Service de Médecine Interne et Infectiologie, Centre Hospitalier de Cannes, Cannes, France
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213
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Garnacho-Montero J, Gutiérrez-Pizarraya A, Escoresca-Ortega A, Fernández-Delgado E, López-Sánchez JM. Adequate antibiotic therapy prior to ICU admission in patients with severe sepsis and septic shock reduces hospital mortality. Crit Care 2015; 19:302. [PMID: 26307060 PMCID: PMC4549859 DOI: 10.1186/s13054-015-1000-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/10/2015] [Indexed: 11/13/2022] Open
Abstract
Introduction In patients with severe sepsis and septic shock as cause of Intensive Care Unit (ICU) admission, we analyze the impact on mortality of adequate antimicrobial therapy initiated before ICU admission. Methods We conducted a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock from January 2008 to September 2013. The primary end-point was in-hospital mortality. We considered two groups for comparisons: patients who received adequate antibiotic treatment before or after the admission to the ICU. Results A total of 926 septic patients were admitted to ICU, and 638 (68.8%) had available microbiological isolation: 444 (69.6%) received adequate empirical antimicrobial treatment prior to ICU and 194 (30.4%) after admission. Global hospital mortality in patients that received treatment before ICU admission, between 0-6h ICU, 6–12h ICU, 12–24h ICU and after 24 hours since ICU admission were 31.3, 53.2, 57.1, 50 and 50.8% (p<0.001). The multivariate analysis showed that urinary focus (odds ratio (OR) 0.20; 0.09–0.42; p<0.001) and adequate treatment prior to ICU admission (OR 0.37; 0.24–0.56; p<0.001) were protective factors whereas APACHE II score (OR 1.10; 1.07–1.14; p<0.001), septic shock (OR 2.47; 1.57–3.87; p<0.001), respiratory source (OR 1.91; 1.12–3.21; p=0.016), cirrhosis (OR 3.74; 1.60–8.76; p=0.002) and malignancy (OR 1.65; 1.02–2.70; p=0.042) were variables independently associated with in-hospital mortality. Adequate treatment prior to ICU was a protective factor for mortality in patients with severe sepsis (n=236) or in septic shock (n=402). Conclusions The administration of adequate antimicrobial therapy before ICU admission is decisive for the survival of patients with severe sepsis and septic shock. Our efforts should be directed to assure the correct administration antibiotics before ICU admission in patients with sepsis.
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Affiliation(s)
- José Garnacho-Montero
- Unidad Clínica de Cuidados Críticos, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain. .,Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain. .,Red Española de Investigación en Patología infecciosa (REIPI), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain.
| | - Antonio Gutiérrez-Pizarraya
- Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain. .,Red Española de Investigación en Patología infecciosa (REIPI), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain. .,Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain.
| | - Ana Escoresca-Ortega
- Unidad Clínica de Cuidados Críticos, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain.
| | - Esperanza Fernández-Delgado
- Unidad Clínica de Cuidados Críticos, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain.
| | - José María López-Sánchez
- Unidad Clínica de Cuidados Críticos, Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Avda. Manuel Siurot s/n, 41013, Sevilla, Spain.
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Pros and cons of using biomarkers versus clinical decisions in start and stop decisions for antibiotics in the critical care setting. Intensive Care Med 2015; 41:1739-51. [PMID: 26194026 DOI: 10.1007/s00134-015-3978-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 07/09/2015] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Patients in the intensive care unit (ICU) frequently receive prolonged or even unnecessary antibiotic therapy, which selects for antibiotic-resistant bacteria. Over the last decade there has been great interest in biomarkers, particularly procalcitonin, to reduce antibiotic exposure. METHODS In this narrative review, we discuss the value of biomarkers and provide additional information beyond clinical evaluation in order to be clinically useful and review the literature on sepsis biomarkers outside the neonatal period. Both benefits and limitations of biomarkers for clinical decision-making are reviewed. RESULTS Several randomized controlled trials (RCTs) have shown the safety and efficacy of procalcitonin to discontinue antibiotic therapy in patients with severe sepsis or septic shock. In contrast, there is limited utility of procalcitonin for treatment initiation or withholding therapy initially. In addition, an algorithm using procalcitonin for treatment escalation has been ineffective and is probably associated with poorer outcomes. Little data from interventional studies are available for other biomarkers for antibiotic stewardship, except for C-reactive protein (CRP), which was recently found to be similarly effective and safe as procalcitonin in a randomized controlled trial. We finally briefly discuss biomarker-unrelated approaches to reduce antibiotic duration in the ICU, which have shown that even without biomarker guidance, most patients with sepsis can be treated with relatively short antibiotic courses of approximately 7 days. CONCLUSIONS In summary, there is an ongoing unmet need for biomarkers which can reliably and early on identify patients who require antibiotic therapy, distinguish between responders and non-responders and help to optimize antibiotic treatment decisions among critically ill patients. Available evidence needs to be better incorporated in clinical decision-making.
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215
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Banerjee R, Teng CB, Cunningham SA, Ihde SM, Steckelberg JM, Moriarty JP, Shah ND, Mandrekar JN, Patel R. Randomized Trial of Rapid Multiplex Polymerase Chain Reaction-Based Blood Culture Identification and Susceptibility Testing. Clin Infect Dis 2015. [PMID: 26197846 DOI: 10.1093/cid/civ447] [Citation(s) in RCA: 348] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The value of rapid, panel-based molecular diagnostics for positive blood culture bottles (BCBs) has not been rigorously assessed. We performed a prospective randomized controlled trial evaluating outcomes associated with rapid multiplex PCR (rmPCR) detection of bacteria, fungi, and resistance genes directly from positive BCBs. METHODS A total of 617 patients with positive BCBs underwent stratified randomization into 3 arms: standard BCB processing (control, n = 207), rmPCR reported with templated comments (rmPCR, n = 198), or rmPCR reported with templated comments and real-time audit and feedback of antimicrobial orders by an antimicrobial stewardship team (rmPCR/AS, n = 212). The primary outcome was antimicrobial therapy duration. Secondary outcomes were time to antimicrobial de-escalation or escalation, length of stay (LOS), mortality, and cost. RESULTS Time from BCB Gram stain to microorganism identification was shorter in the intervention group (1.3 hours) vs control (22.3 hours) (P < .001). Compared to the control group, both intervention groups had decreased broad-spectrum piperacillin-tazobactam (control 56 hours, rmPCR 44 hours, rmPCR/AS 45 hours; P = .01) and increased narrow-spectrum β-lactam (control 42 hours, rmPCR 71 hours, rmPCR/AS 85 hours; P = .04) use, and less treatment of contaminants (control 25%, rmPCR 11%, rmPCR/AS 8%; P = .015). Time from Gram stain to appropriate antimicrobial de-escalation or escalation was shortest in the rmPCR/AS group (de-escalation: rmPCR/AS 21 hours, control 34 hours, rmPCR 38 hours, P < .001; escalation: rmPCR/AS 5 hours, control 24 hours, rmPCR 6 hours, P = .04). Groups did not differ in mortality, LOS, or cost. CONCLUSIONS rmPCR reported with templated comments reduced treatment of contaminants and use of broad-spectrum antimicrobials. Addition of antimicrobial stewardship enhanced antimicrobial de-escalation. CLINICAL TRIALS REGISTRATION NCT01898208.
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Affiliation(s)
- Ritu Banerjee
- Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, Minnesota
| | - Christine B Teng
- Department of Pharmacy, National University of Singapore and Tan Tock Seng Hospital, Singapore
| | | | | | | | | | | | | | - Robin Patel
- Division of Laboratory Medicine and Pathology Division of Infectious Diseases
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216
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Abstract
PURPOSE OF REVIEW To highlight the clinical importance of ventilator-associated pneumonia (VAP) in an era of escalating antimicrobial resistance. RECENT FINDINGS VAP continues to be an important infection in the critically ill. The development of rapid microbiologic diagnostics and new antimicrobial agents offer opportunities for improved treatment strategies for VAP balancing the need to treat effectively in a timely manner and antimicrobial stewardship. Additionally, the new surveillance definitions for assessing the quality of care in critically ill patients (ventilator-associated events, ventilator-associated conditions, and infection-related ventilator-associated conditions) do not appear to be adequate surrogates for the identification of VAP. SUMMARY Clinicians caring for critically ill patients should be aware of the importance of correctly treating VAP. As new diagnostic technologies and antimicrobials become available for VAP, their incorporation into routine patient management should occur in a way that optimizes patient outcomes wherein minimizing further emergence of antimicrobial resistance.
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217
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Weiss E, Zahar JR, Lesprit P, Ruppe E, Leone M, Chastre J, Lucet JC, Paugam-Burtz C, Brun-Buisson C, Timsit JF, Brun-Buisson C, Bruneel F, Chastre J, Lasocki S, Leone M, Montravers P, Nseir S, Paugam-Burtz C, Pease S, Timsit JF, Weiss E, Wolff M, Alfandari S, Fantin B, Gachot B, Lesprit P, Lucet JC, Potel G, Pulcini C, Rabaud C, Tattevin P, Armand-Lefevre L, Cavallo JD, Jarlier V, Joint-Lambert O, Robert J, Ruppé E, Woerther PL. Elaboration of a consensual definition of de-escalation allowing a ranking of β-lactams. Clin Microbiol Infect 2015; 21:649.e1-10. [DOI: 10.1016/j.cmi.2015.03.013] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 01/05/2015] [Accepted: 03/05/2015] [Indexed: 01/22/2023]
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218
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Liang SY, Kumar A. Empiric antimicrobial therapy in severe sepsis and septic shock: optimizing pathogen clearance. Curr Infect Dis Rep 2015; 17:493. [PMID: 26031965 PMCID: PMC4581522 DOI: 10.1007/s11908-015-0493-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Mortality and morbidity in severe sepsis and septic shock remain high despite significant advances in critical care. Efforts to improve outcome in septic conditions have focused on targeted, quantitative resuscitation strategies utilizing intravenous fluids, vasopressors, inotropes, and blood transfusions to correct disease-associated circulatory dysfunction driven by immune-mediated systemic inflammation. This review explores an alternate paradigm of septic shock in which microbial burden is identified as the key driver of mortality and progression to irreversible shock. We propose that clinical outcomes in severe sepsis and septic shock hinge upon the optimized selection, dosing, and delivery of highly potent antimicrobial therapy.
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Affiliation(s)
- Stephen Y. Liang
- Division of Infectious Diseases, Division of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8051, St. Louis, MO 63110, USA,
| | - Anand Kumar
- Section of Critical Care Medicine, Section of Infectious Diseases, JJ399d, Health Sciences Centre, 700 William Street, Winnipeg, Manitoba, Canada R3A-1R9,
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219
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Casaroto E, Marra AR, Camargo TZS, de Souza ARA, de Almeida CES, Pedroti EP, Victor EDS, dos Santos OFP, Edmond MB, Campos AH. Agreement on the prescription of antimicrobial drugs. BMC Infect Dis 2015; 15:248. [PMID: 26123222 PMCID: PMC4484637 DOI: 10.1186/s12879-015-0992-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 06/19/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is universal awareness of the difficulties faced by doctors when prescribing antimicrobials. METHODS Over a six-month period patients hospitalized in the ICU and under treatment with antibiotics and/or antifungals were eligible to participate in the study. The data were assessed by two infectious diseases specialists. Once completed, all case forms were sent independently to both evaluators (TZSC and ARM) by e-mail. Based on the data received, the evaluator completed a form automatically generated on the e-mail and returned it to the original mailbox for further analysis. We assessed the level of agreement between infectious disease specialists and the physicians directly responsible for the decision to begin antimicrobial therapy, as well as to assess the appropriateness of the regimen prescribed. RESULTS Among the antimicrobial regimens prescribed to the 177 patients, 36% were considered inappropriate by specialist #1 and 38% were considered inappropriate by specialist #2. We found 78% agreement by at least one of the infectious disease specialists with the prescribed antimicrobial regimen, and in 49% of cases both specialists agreed with the prescribed regimen. Both disagreed with the prescribed regimen in 22% of the cases and they disagreed between themselves in 29% of the cases. CONCLUSION This study highlights the difficulties in prescribing effective empirical antimicrobial therapy--they are of such magnitude that even two specialists in infectious diseases, well acquainted with our hospital's resistance patterns and our patients' profiles have considerable disagreement.
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Affiliation(s)
- Eduardo Casaroto
- Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Alexandre R Marra
- Division of Medical Practice, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701 - 1st floor - Bloco A1 - Room 108 Morumbi, 05651-901, São Paulo, Brazil.
| | | | | | | | | | - Elivane da Silva Victor
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Oscar Fernando Pavão dos Santos
- Division of Medical Practice, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701 - 1st floor - Bloco A1 - Room 108 Morumbi, 05651-901, São Paulo, Brazil.
| | - Michael B Edmond
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | - Alexandre Holthausen Campos
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil.
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Carugati M, Franzetti F, Wiemken T, Kelley RR, Kelly R, Peyrani P, Blasi F, Ramirez J, Aliberti S. De-escalation therapy among bacteraemic patients with community-acquired pneumonia. Clin Microbiol Infect 2015; 21:936.e11-8. [PMID: 26115864 DOI: 10.1016/j.cmi.2015.06.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 06/05/2015] [Accepted: 06/12/2015] [Indexed: 10/23/2022]
Abstract
There is no evidence supporting the use of de-escalation therapy (DET) among patients with community-acquired pneumonia (CAP). We assessed the outcomes associated with DET among bacteraemic CAP patients. We performed a secondary analysis of the Community-Acquired Pneumonia Organization database, which contains data on 660 bacteraemic patients hospitalized because of CAP in 35 countries (2001-2013). Exclusion criteria were death within 72 h from admission and an inappropriate empirical antibiotic regimen. DET was defined as changing an appropriate empirical broad-spectrum regimen to a narrower-spectrum regimen according to culture results within 7 days from hospital admission. Two study groups were identified: patients whose antibiotic therapy was de-escalated (the DET group), and patients whose antibiotic therapy was not de-escalated (the N-DET group). The primary study outcome was 30-day mortality. Two hundred and sixty-one bacteraemic CAP patients were included. Gram-positive bacteria were responsible for 88.1% of the cases (Streptococcus pneumoniae, 75.9%). Gram-negative bacteria were responsible for for 7.3% of the cases. DET was performed in 165 patients (63.2%). The N-DET group was characterized by a more severe presentation at admission. After adjustment for confounders, DET was not associated with an increased risk of 30-day mortality. DET seems to be safe among bacteraemic patients with CAP. Randomized clinical trials are warranted to further explore these findings.
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Affiliation(s)
- M Carugati
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, Milan, Italy.
| | - F Franzetti
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, Milan, Italy
| | - T Wiemken
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | | | - R Kelly
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - P Peyrani
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - F Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - J Ramirez
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - S Aliberti
- Department of Health Sciences, University of Milano - Bicocca, Respiratory Unit, AO San Gerardo, Monza, Italy
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221
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Strategies to reduce curative antibiotic therapy in intensive care units (adult and paediatric). Intensive Care Med 2015; 41:1181-96. [PMID: 26077053 DOI: 10.1007/s00134-015-3853-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 04/28/2015] [Indexed: 02/07/2023]
Abstract
Emerging resistance to antibiotics shows no signs of decline. At the same time, few new antibacterials are being discovered. There is a worldwide recognition regarding the danger of this situation. The urgency of the situation and the conviction that practices should change led the Société de Réanimation de Langue Française (SRLF) and the Société Française d'Anesthésie et de Réanimation (SFAR) to set up a panel of experts from various disciplines. These experts met for the first time at the end of 2012 and have since met regularly to issue the following 67 recommendations, according to the rigorous GRADE methodology. Five fields were explored: i) the link between the resistance of bacteria and the use of antibiotics in intensive care; ii) which microbiological data and how to use them to reduce antibiotic consumption; iii) how should antibiotic therapy be chosen to limit consumption of antibiotics; iv) how can antibiotic administration be optimized; v) review and duration of antibiotic treatments. In each institution, the appropriation of these recommendations should arouse multidisciplinary discussions resulting in better knowledge of local epidemiology, rate of antibiotic use, and finally protocols for improving the stewardship of antibiotics. These efforts should contribute to limit the emergence of resistant bacteria.
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222
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A Simulation Study Reveals Lack of Pharmacokinetic/Pharmacodynamic Target Attainment in De-escalated Antibiotic Therapy in Critically Ill Patients. Antimicrob Agents Chemother 2015; 59:4689-94. [PMID: 26014946 DOI: 10.1128/aac.00409-15] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 05/19/2015] [Indexed: 01/08/2023] Open
Abstract
De-escalation of empirical antibiotic therapy is often included in antimicrobial stewardship programs in critically ill patients, but differences in target attainment when antibiotics are switched are rarely considered. The primary objective of this study was to compare the fractional target attainments of contemporary dosing of empirical broad-spectrum β-lactam antibiotics and narrower-spectrum antibiotics for a number pathogens for which de-escalation may be considered. The secondary objective was to determine whether alternative dosing strategies improve target attainment. We performed a simulation study using published population pharmacokinetic (PK) studies in critically ill patients for a number of broad-spectrum β-lactam antibiotics and narrower-spectrum antibiotics. Simulations were undertaken using a data set obtained from critically ill patients with sepsis without absolute renal failure (n = 49). The probability of target attainment of antibiotic therapy for different microorganisms for which de-escalation was applied was analyzed. EUCAST MIC distribution data were used to calculate fractional target attainment. The probability that therapeutic exposure will be achieved was lower for the narrower-spectrum antibiotics with conventional dosing than for the broad-spectrum alternatives and could drastically be improved with higher dosages and different modes of administrations. For a selection of microorganisms, the probability that therapeutic exposure will be achieved was overall lower for the narrower-spectrum antibiotics using conventional dosing than for the broad-spectrum antibiotics.
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223
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Shehabi Y, Rachakonda KS, Bailey MJ, Peake S. Reply: No significant reduction in antibiotic treatment using a procalcitonin algorithm with low cutoff value in the intensive care unit? Am J Respir Crit Care Med 2015; 191:859-60. [PMID: 25830525 DOI: 10.1164/rccm.201501-0057le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Yahya Shehabi
- 1 University of New South Wales Sydney, New South Wales, Australia
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Cohen J, Vincent JL, Adhikari NKJ, Machado FR, Angus DC, Calandra T, Jaton K, Giulieri S, Delaloye J, Opal S, Tracey K, van der Poll T, Pelfrene E. Sepsis: a roadmap for future research. THE LANCET. INFECTIOUS DISEASES 2015; 15:581-614. [DOI: 10.1016/s1473-3099(15)70112-x] [Citation(s) in RCA: 658] [Impact Index Per Article: 73.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Rapid identification of pathogens in positive blood culture of patients with sepsis: review and meta-analysis of the performance of the sepsityper kit. Int J Microbiol 2015; 2015:827416. [PMID: 26000017 PMCID: PMC4426779 DOI: 10.1155/2015/827416] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 03/26/2015] [Accepted: 03/30/2015] [Indexed: 01/16/2023] Open
Abstract
Sepsis is one of the leading causes of deaths, and rapid identification (ID) of blood stream infection is mandatory to perform adequate antibiotic therapy. The advent of MALDI-TOF Mass Spectrometry for the rapid ID of pathogens was a major breakthrough in microbiology. Recently, this method was combined with extraction methods for pathogens directly from positive blood cultures. This review summarizes the results obtained so far with the commercial Sepsityper sample preparation kit, which is now approved for in vitro diagnostic use. Summarizing data from 21 reports, the Sepsityper kit allowed a reliable ID on the species level of 80% of 3320 positive blood culture bottles. Gram negative bacteria resulted consistently in higher ID rates (90%) compared to Gram positive bacteria (76%) or yeast (66%). No relevant misidentifications on the genus level were reported at a log(score)cut-off of 1.6. The Sepsityper kit is a simple and reproducible method which extends the MALDI-TOF technology to positive blood culture specimens and shortens the time to result by several hours or even days. In combination with antibiotic stewardship programs, this rapid ID allows a much faster optimization of antibiotic therapy in patients with sepsis compared to conventional workflows.
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227
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Mwaigwisya S, Assiri RAM, O'Grady J. Emerging commercial molecular tests for the diagnosis of bloodstream infection. Expert Rev Mol Diagn 2015; 15:681-92. [PMID: 25866124 DOI: 10.1586/14737159.2015.1029459] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Bloodstream infection (BSI) by microorganisms can lead to sepsis. This condition has a high mortality rate, which rises significantly with delays in initiation of appropriate antimicrobial treatment. Current culture methods for diagnosing BSI have long turnaround times and poor clinical sensitivity. While clinicians wait for culture diagnosis, patients are treated empirically, which can result in inappropriate treatment, undesirable side effects and contribute to drug resistance development. Molecular diagnostics assays that target pathogen DNA can identify pathogens and resistance markers within hours. Early diagnosis improves antibiotic stewardship and is associated with favorable clinical outcomes. Nonetheless, limitations of current molecular diagnostic methods are substantial. This article reviews recent commercially available molecular methods that use pathogen DNA to diagnose BSI, either by testing positive blood cultures or directly testing patient blood. We critically assess these tests and their application in clinical microbiology. A view of future directions in BSI diagnosis is also provided.
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228
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Martin-Loeches I, Levy MM, Artigas A. Management of severe sepsis: advances, challenges, and current status. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:2079-88. [PMID: 25926718 PMCID: PMC4403600 DOI: 10.2147/dddt.s78757] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The complexity of treating severe sepsis and septic shock has been elucidated in myriad studies, particularly in the past 10 years. The development of clinical guidelines, insight into the effect of bundle elements, and results of clinical trials have brought to light further opportunities and questions in the approach to pharmaceutical interventions for the global challenge to save lives and reduce healthcare costs. Therapeutic interventions including fluid resuscitation, hemodynamic monitoring, glycemic control, corticosteroids, and antimicrobial therapy and stewardship inform outcomes. Research on biomarkers, use of mesenchymal stem cells, blood purification, immunoglobulins, and antioxidative treatments apropos the immune response may soon yield viable therapies.
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Affiliation(s)
- Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland
| | | | - Antonio Artigas
- Critical Care Center, CIBER Enfermedades Respiratorias, Sabadell Hospital, Corporació Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Barcelona, Spain
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229
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Evaluation of restricted antibiotic use in a hospital in Romania. Int J Clin Pharm 2015; 37:452-6. [PMID: 25832678 DOI: 10.1007/s11096-015-0096-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Antibiotics are the most frequently used drugs among hospitalised patients. Antimicrobial resistance is a major health issue and therefore antibiotic consumption should be under strict surveillance. OBJECTIVE To evaluate the use of restricted antibiotics in an academic hospital in Romania. METHODS Retrospective evaluation of the use of 11 restricted antibiotics issued based on the antibiotics formularies for the year 2012. Therapeutic guidelines and the summary of product characteristics were used for the evaluation. The appropriateness antibiotics use was verified, according to three main criteria: appropriate indication (type of treatment, localization and type of infection), dose and duration of treatment. Descriptive statistics and multiple logistic regression analysis were performed. Results 664 prescribing formularies were analyzed, of these 319 were from the intensive care unit (48.04 %). The most prescribed antibiotics were vancomycin (171, 25.75 %), imipenem (151, 22.74 %) and meropenem (116, 17.47 %). Overall, 285 prescriptions (42.92 %) were considered inappropriate. Vancomycin, meropenem and imipenem were prescribed inappropriate in 49.71, 46.55 and 44.06 % of such cases. Of the total 285 prescriptions deemed as inappropriate, for 49.82 % the dose was incorrect, 20 % were inadequate in terms of treatment duration and 15.44 % were wrongly indicated. Inappropriate use was significantly higher among empirical prescriptions than the documented ones (69.75 vs. 30.25 %, p < 0.001). Multiple stepwise logistic regression identified that the duration of the treatment was significant for inappropriate antibiotic use (p < 0.05). The risk of inappropriate use in the case of empirical prescriptions is higher than for documented prescriptions (OR 5.78, p < 0.001, CI 3.65-9.15). CONCLUSIONS the results suggest the need to intensify the control of the use of restricted antibiotics. The implementation of drug formularies in hospitals and the involvement of the clinical pharmacist may ensure rational antibiotic therapy.
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Timsit JF, Perner A, Bakker J, Bassetti M, Benoit D, Cecconi M, Curtis JR, Doig GS, Herridge M, Jaber S, Joannidis M, Papazian L, Peters MJ, Singer P, Smith M, Soares M, Torres A, Vieillard-Baron A, Citerio G, Azoulay E. Year in review in Intensive Care Medicine 2014: III. Severe infections, septic shock, healthcare-associated infections, highly resistant bacteria, invasive fungal infections, severe viral infections, Ebola virus disease and paediatrics. Intensive Care Med 2015; 41:575-88. [PMID: 25810214 PMCID: PMC4491096 DOI: 10.1007/s00134-015-3755-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/12/2015] [Indexed: 01/09/2023]
Affiliation(s)
- Jean-François Timsit
- APHP-Hopital Bichat-Medical and Infectious Diseases ICU, UMR 1137-IAME Team 5-DeSCID: Decision Sciences in Infectious Diseases, Control and Care Inserm/Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France,
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Bassetti M, De Waele JJ, Eggimann P, Garnacho-Montero J, Kahlmeter G, Menichetti F, Nicolau DP, Paiva JA, Tumbarello M, Welte T, Wilcox M, Zahar JR, Poulakou G. Preventive and therapeutic strategies in critically ill patients with highly resistant bacteria. Intensive Care Med 2015; 41:776-95. [PMID: 25792203 PMCID: PMC7080151 DOI: 10.1007/s00134-015-3719-z] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 02/24/2015] [Indexed: 01/06/2023]
Abstract
The antibiotic pipeline continues to diminish and the majority of the public remains unaware of this critical situation. The cause of the decline of antibiotic development is multifactorial and currently most ICUs are confronted with the challenge of multidrug-resistant organisms. Antimicrobial multidrug resistance is expanding all over the world, with extreme and pandrug resistance being increasingly encountered, especially in healthcare-associated infections in large highly specialized hospitals. Antibiotic stewardship for critically ill patients translated into the implementation of specific guidelines, largely promoted by the Surviving Sepsis Campaign, targeted at education to optimize choice, dosage, and duration of antibiotics in order to improve outcomes and reduce the development of resistance. Inappropriate antimicrobial therapy, meaning the selection of an antibiotic to which the causative pathogen is resistant, is a consistent predictor of poor outcomes in septic patients. Therefore, pharmacokinetically/pharmacodynamically optimized dosing regimens should be given to all patients empirically and, once the pathogen and susceptibility are known, local stewardship practices may be employed on the basis of clinical response to redefine an appropriate regimen for the patient. This review will focus on the most severely ill patients, for whom substantial progress in organ support along with diagnostic and therapeutic strategies markedly increased the risk of nosocomial infections.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy,
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232
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Weese JS, Giguère S, Guardabassi L, Morley PS, Papich M, Ricciuto DR, Sykes JE. ACVIM consensus statement on therapeutic antimicrobial use in animals and antimicrobial resistance. J Vet Intern Med 2015; 29:487-98. [PMID: 25783842 PMCID: PMC4895515 DOI: 10.1111/jvim.12562] [Citation(s) in RCA: 167] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/21/2015] [Accepted: 01/27/2015] [Indexed: 12/22/2022] Open
Abstract
The epidemic of antimicrobial resistant infections continues to challenge, compromising animal care, complicating food animal production and posing zoonotic disease risks. While the overall role of therapeutic antimicrobial use in animals in the development AMR in animal and human pathogens is poorly defined, veterinarians must consider the impacts of antimicrobial use in animal and take steps to optimize antimicrobial use, so as to maximize the health benefits to animals while minimizing the likelihood of antimicrobial resistance and other adverse effects. This consensus statement aims to provide guidance on the therapeutic use of antimicrobials in animals, balancing the need for effective therapy with minimizing development of antimicrobial resistance in bacteria from animals and humans.
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Affiliation(s)
- J S Weese
- Department of Pathobiology, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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233
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Montero JG, Lerma FÁ, Galleymore PR, Martínez MP, Rocha LÁ, Gaite FB, Rodríguez JÁ, González MC, Moreno IF, Baño JR, Campos J, Andrés JMA, Varela YA, Gay CR, García MS. Combatting resistance in intensive care: the multimodal approach of the Spanish ICU "Zero Resistance" program. Crit Care 2015; 19:114. [PMID: 25880421 PMCID: PMC4361202 DOI: 10.1186/s13054-015-0800-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2015 and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/annualupdate2015. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - José Campos
- Centro Nacional de Microbiología, Majadahonda, Madrid, Spain.
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Impact of antimicrobial strategies on clinical outcomes of adults with septic shock and community-onset Enterobacteriaceae bacteremia: de-escalation is beneficial. Diagn Microbiol Infect Dis 2015; 82:158-64. [PMID: 25796557 DOI: 10.1016/j.diagmicrobio.2015.03.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 02/11/2015] [Accepted: 03/03/2015] [Indexed: 01/24/2023]
Abstract
To investigate the clinical outcomes of patients with septic shock related to community-onset monomicrobial Enterobacteriaceae (CoME) bacteremia as categorized by the strategy of antimicrobial therapy, a retrospective and observational study was conducted. Clinical information on the patients was obtained from medical records. Antibiotic regimens were ranked according to their activity spectrum against Enterobacteriaceae (category IV, highest; I, lowest). De-escalation was defined as a switch to a category with a narrower spectrum of coverage within 5days after the bacteremic onset. Of the 189 eligible patients, 86 (45.5%) patients received de-escalation antibiotic therapy, and most (48, 55.8%) of the patients were empirically treated first with a category IV antibiotic. In a multivariate analysis for 28-day mortality, of several independent predictors, the de-escalation strategy was protective (odds ratio, 0.37; P=0.04). In conclusion, for patients with CoME bacteremia and available susceptibility data, de-escalation of antimicrobial therapy was beneficial for improving clinical outcome.
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235
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Shehabi Y, Sterba M, Garrett PM, Rachakonda KS, Stephens D, Harrigan P, Walker A, Bailey MJ, Johnson B, Millis D, Ding G, Peake S, Wong H, Thomas J, Smith K, Forbes L, Hardie M, Micallef S, Fraser JF. Procalcitonin algorithm in critically ill adults with undifferentiated infection or suspected sepsis. A randomized controlled trial. Am J Respir Crit Care Med 2015; 190:1102-10. [PMID: 25295709 DOI: 10.1164/rccm.201408-1483oc] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
RATIONALE The role of procalcitonin (PCT), a widely used sepsis biomarker, in critically ill patients with sepsis is undetermined. OBJECTIVES To investigate the effect of a low PCT cut-off on antibiotic prescription and to describe the relationships between PCT plasma concentration and sepsis severity and mortality. METHODS This was a multicenter (11 Australian intensive care units [ICUs]), prospective, single-blind, randomized controlled trial involving 400 patients with suspected bacterial infection/sepsis and expected to receive antibiotics and stay in ICU longer than 24 hours. The primary outcome was the cumulative number of antibiotics treatment days at Day 28. MEASUREMENTS AND MAIN RESULTS PCT was measured daily while in the ICU. A PCT algorithm, including 0.1 ng/ml cut-off, determined antibiotic cessation. Published guidelines and antimicrobial stewardship were used in all patients. Primary analysis included 196 (PCT) versus 198 standard care patients. Ninety-three patients in each group had septic shock. The overall median (interquartile range) number of antibiotic treatment days were 9 (6-21) versus 11 (6-22), P = 0.58; in patients with positive pulmonary culture, 11 (7-27) versus 15 (8-27), P = 0.33; and in patients with septic shock, 9 (6-22) versus 11 (6-24), P = 0.64; with an overall 90-day all-cause mortality of 35 (18%) versus 31 (16%), P = 0.54 in the PCT versus standard care, respectively. Using logistic regression, adjusted for age, ventilation status, and positive culture, the decline rate in log(PCT) over the first 72 hours independently predicted hospital and 90-day mortality (odds ratio [95% confidence interval], 2.76 [1.10-6.96], P = 0.03; 3.20 [1.30-7.89], P = 0.01, respectively). CONCLUSIONS In critically ill adults with undifferentiated infections, a PCT algorithm including 0.1 ng/ml cut-off did not achieve 25% reduction in duration of antibiotic treatment. Clinical trial registered with http://www.anzctr.org.au (ACTRN12610000809033).
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Affiliation(s)
- Yahya Shehabi
- 1 University of New South Wales Clinical School, Randwick, Australia
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Abstract
Pneumonia is a common disease that carries a high mortality. Traditionally, pneumonia has been classified and treated according to the setting where the pneumonia develops, namely community-acquired pneumonia, health-care-associated pneumonia, and hospital-acquired pneumonia. This classification was based on the risk of a patient being infected with a hospital-acquired drug-resistant pathogen. A new treatment paradigm has been proposed based on the risk of the patient being infected with a community-acquired drug-resistant pathogen. The risk factors for infection with a community-acquired drug-resistant pathogen include (1) hospitalization for > 2 days during the previous 90 days, (2) antibiotic use during the previous 90 days, (3) nonambulatory status, (4) tube feeds, (5) immunocompromised status, (6) use of acid-suppressive therapy, (7) chronic hemodialysis during the preceding 30 days, (8) positive methicillin-resistant Staphylococcus aureus history within the previous 90 days, and (9) present hospitalization > 2 days. This article reviews this new treatment paradigm and other issues relevant to the diagnosis and management of pneumonia based on information from MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School , Norfolk, VA , USA
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237
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Nair GB, Niederman MS. Ventilator-associated pneumonia: present understanding and ongoing debates. Intensive Care Med 2015; 41:34-48. [PMID: 25427866 PMCID: PMC7095124 DOI: 10.1007/s00134-014-3564-5] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 11/11/2014] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) is a common cause of nosocomial infection, and is related to significant utilization of health-care resources. In the past decade, new data have emerged about VAP epidemiology, diagnosis, treatment and prevention. RESULTS Classifying VAP strictly based on time since hospitalization (early- and late-onset VAP) can potentially result in undertreatment of drug-resistant organisms in ICUs with a high rate of drug resistance, and overtreatment for patients not infected with resistant pathogens. A combined strategy incorporating diagnostic scoring systems, such as the Clinical Pulmonary Infection Score (CPIS), and either a quantitative or qualitative microbiological specimen, plus serial measurement of biomarkers, leads to responsible antimicrobial stewardship. The newly proposed ventilator-associated events (VAE) surveillance definition, endorsed by the Centers for Disease Control and Prevention, has low sensitivity and specificity for diagnosing VAP and the ability to prevent VAE is uncertain, making it a questionable surrogate for the quality of ICU care. The use of adjunctive aerosolized antibiotic treatment can provide high pulmonary concentrations of the drug and may facilitate shorter durations of therapy for multi-drug-resistant pathogens. A group of preventive strategies grouped as a 'ventilator bundle' can decrease VAP rates, but not to zero, and several recent studies show that there are potential barriers to implementation of these prevention strategies. CONCLUSION The morbidity and mortality related to VAP remain high and, in the absence of a gold standard test for diagnosis, suspected VAP patients should be started on antibiotics based on recommendations per the 2005 ATS guidelines and knowledge of local antibiotic susceptibility patterns. Using a combination of clinical severity scores, biomarkers, and cultures might help with reducing the duration of therapy and achieving antibiotic de-escalation.
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Affiliation(s)
- Girish B. Nair
- Pulmonary and Critical Care Medicine, Winthrop-University Hospital, Mineola, NY USA
- Department of Medicine, SUNY at Stony Brook, Stony Brook, NY USA
| | - Michael S. Niederman
- Department of Medicine, Winthrop-University Hospital, 222 Station Plaza N., Suite 509, Mineola, NY 11501 USA
- Department of Medicine, SUNY at Stony Brook, Stony Brook, NY USA
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Neuberger A, Yahav D, Daitch V, Akayzen Y, Farbman L, Avni T, Leibovici L, Paul M. The significance of persistent fever in the treatment of suspected bacterial infections among inpatients: a prospective cohort study. Eur J Clin Microbiol Infect Dis 2014; 34:805-10. [PMID: 25502509 DOI: 10.1007/s10096-014-2288-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 11/18/2014] [Indexed: 11/29/2022]
Abstract
Antibiotic escalations are frequently guided by fever persistence. Unnecessary antibiotic escalation is associated with resistance induction. We examined whether fever persistence is associated with adverse outcomes among medical inpatients with sepsis. In a single-center prospective cohort study, we included consecutive medical inpatients with suspected or documented bacterial infections. Data were collected on days 0, 2, 4, and 30 days from episode onset. We examined the association between fever persistence at 4 days and 30-day mortality on univariate and multivariate analysis. Inappropriate empirical antibiotic treatment (IAET) was defined for patients with microbiologically documented infections (MDIs). Odds ratios (ORs) are presented with 95% confidence intervals (CIs). A total of 1,621 patients were included. Among patients with MDIs, 38/206 (18.4%) given appropriate empiric therapy had continued fever on day 4, compared to 64/231 (27.7%) of patients receiving IAET, OR 0.59, 95% CI 0.37-0.93. Fever persistence was not associated with mortality after adjustment for other risk factors. Among patients with presumed sepsis who did not have MDIs, persistent fever was significantly associated with 30-day mortality on a multivariate analysis, adjusted OR 2.77 (95% CI 1.78-4.31). Other risk factors for mortality included older age, nosocomial infections, malignancy, dyspnea, shock, decreased albumin, and elevated creatinine. For patients with MDIs, fever persistence for up to 4 days is a marker of IAET, but is not associated with mortality, and should not, in itself, trigger antibiotic escalation. For patients without MDIs, fever persistence should trigger careful re-evaluation, as it is associated with mortality.
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Affiliation(s)
- A Neuberger
- Unit of Infectious Diseases and Internal Medicine B, Rambam Health Care Campus, The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, 8 Haalya Hashnya St., Haifa, 33705, Israel,
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239
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Lew KY, Ng TM, Tan M, Tan SH, Lew EL, Ling LM, Ang B, Lye D, Teng CB. Safety and clinical outcomes of carbapenem de-escalation as part of an antimicrobial stewardship programme in an ESBL-endemic setting. J Antimicrob Chemother 2014; 70:1219-25. [PMID: 25473028 DOI: 10.1093/jac/dku479] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate the safety and clinical outcomes of patients who received carbapenem de-escalation as guided by an antimicrobial stewardship programme (ASP) in a setting where ESBL-producing Enterobacteriaceae are endemic. METHODS Patients receiving meropenem or imipenem underwent a prospective ASP review for eligibility for de-escalation according to defined institutional guidelines. Patients in whom carbapenem was de-escalated or not de-escalated, representing the acceptance and rejection of the ASP recommendation, respectively, were compared. The primary outcome was the clinical success rate; secondary outcomes included the 30 day readmission and mortality rates, the duration of carbapenem therapy, the incidence of adverse drug reactions due to antimicrobials, the acquisition of carbapenem-resistant Gram-negative bacteria and the occurrence of Clostridium difficile-associated diarrhoea (CDAD). RESULTS The de-escalation recommendations for 300 patients were evaluated; 204 (68.0%) were accepted. The patient demographics and disease severity were similar. The clinical success rates were similar [de-escalated versus not de-escalated, 183/204 (89.7%) versus 85/96 (88.5%), P=0.84], as was the survival at hospital discharge [173/204 (84.8%) versus 79/96 (82.3%), P=0.58]. In the de-escalated group, the duration of carbapenem therapy was shorter (6 versus 8 days, P<0.001), the rate of adverse drug reactions was lower [11/204 (5.4%) versus 12/96 (12.5%), P=0.037], there was less diarrhoea [9/204 (4.4%) versus 12/96 (12.5%), P=0.015], there was a lower incidence of carbapenem-resistant Acinetobacter baumannii acquisition [4/204 (2.0%) versus 7/96 (7.3%), P=0.042] and there was a lower incidence of CDAD [2/204 (1.0%) versus 4/96 (4.2%), P=0.081]. CONCLUSIONS This study suggests that the ASP-guided de-escalation of carbapenems led to comparable clinical success, fewer adverse effects and a lower incidence of the development of resistance. This approach is safe and practicable, and should be a key component of an ASP.
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Affiliation(s)
- Kaung Yuan Lew
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, 117543 Singapore
| | - Tat Ming Ng
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Michelle Tan
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Sock Hoon Tan
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Ee Ling Lew
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Li Min Ling
- Communicable Disease Center, Institute of Infectious Diseases and Epidemiology, Department of Infectious Disease, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Brenda Ang
- Communicable Disease Center, Institute of Infectious Diseases and Epidemiology, Department of Infectious Disease, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - David Lye
- Communicable Disease Center, Institute of Infectious Diseases and Epidemiology, Department of Infectious Disease, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road 119228, Singapore
| | - Christine B Teng
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, 117543 Singapore Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
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240
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Braykov NP, Morgan DJ, Schweizer ML, Uslan DZ, Kelesidis T, Weisenberg SA, Johannsson B, Young H, Cantey J, Srinivasan A, Perencevich E, Septimus E, Laxminarayan R. Assessment of empirical antibiotic therapy optimisation in six hospitals: an observational cohort study. THE LANCET. INFECTIOUS DISEASES 2014; 14:1220-7. [PMID: 25455989 PMCID: PMC5525058 DOI: 10.1016/s1473-3099(14)70952-1] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Modification of empirical antimicrobials when warranted by culture results or clinical signs is recommended to control antimicrobial overuse and resistance. We aimed to assess the frequency with which patients were started on empirical antimicrobials, characteristics of the empirical regimen and the clinical characteristics of patients at the time of starting antimicrobials, patterns of changes to empirical therapy at different timepoints, and modifiable factors associated with changes to the initial empirical regimen in the first 5 days of therapy. METHODS We did a chart review of adult inpatients receiving one or more antimicrobials in six US hospitals on 4 days during 2009 and 2010. Our primary outcome was the modification of antimicrobial regimen on or before the 5th day of empirical therapy, analysed as a three-category variable. Bivariate analyses were used to establish demographic and clinical variables associated with the outcome. Variables with p values below 0·1 were included in a multivariable generalised linear latent and mixed model with multinomial logit link to adjust for clustering within hospitals and accommodate a non-binary outcome variable. FINDINGS Across the six study sites, 4119 (60%) of 6812 inpatients received antimicrobials. Of 1200 randomly selected patients with active antimicrobials, 730 (61%) met inclusion criteria. At the start of therapy, 220 (30%) patients were afebrile and had normal white blood cell counts. Appropriate cultures were collected from 432 (59%) patients, and 250 (58%) were negative. By the 5th day of therapy, 12·5% of empirical antimicrobials were escalated, 21·5% were narrowed or discontinued, and 66·4% were unchanged. Narrowing or discontinuation was more likely when cultures were collected at the start of therapy (adjusted OR 1·68, 95% CI 1·05-2·70) and no infection was noted on an initial radiological study (1·76, 1·11-2·79). Escalation was associated with multiple infection sites (2·54, 1·34-4·83) and a positive culture (1·99, 1·20-3·29). INTERPRETATION Broad-spectrum empirical therapy is common, even when clinical signs of infection are absent. Fewer than one in three inpatients have their regimens narrowed within 5 days of starting empirical antimicrobials. Improved diagnostic methods and continued education are needed to guide discontinuation of antimicrobials. FUNDING US Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion; Robert Wood Johnson Foundation; US Department of Veterans Administration; US Department of Homeland Security.
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Affiliation(s)
- Nikolay P Braykov
- Center for Disease Dynamics, Economics and Policy, Washington, DC, USA
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marin L Schweizer
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Daniel Z Uslan
- Infectious Diseases, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Theodoros Kelesidis
- Infectious Diseases, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | | | - Birgir Johannsson
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Heather Young
- Infectious Diseases, Denver Health Medical Center, Denver, CO, USA
| | - Joseph Cantey
- Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Eli Perencevich
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Edward Septimus
- Clinical Services Group, HCA Inc, Nashville, TN, USA; Texas A&M Health Science Center College of Medicine, Houston, TX, USA
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics and Policy, Washington, DC, USA; Public Health Foundation of India, New Delhi, India; Princeton University, Princeton, NJ, USA.
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241
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Zafrani L, Azoulay E. How to treat severe infections in critically ill neutropenic patients? BMC Infect Dis 2014; 14:512. [PMID: 25431154 PMCID: PMC4289060 DOI: 10.1186/1471-2334-14-512] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 09/09/2014] [Indexed: 12/30/2022] Open
Abstract
Severe infections in neutropenic patient often progress rapidly leading to life-threatening organ dysfunction requiring admission to the Intensive Care Unit. Management strategies include early adequate appropriate empirical antimicrobial, early admission to ICU to avoid any delay in the diagnostic and therapeutic management of organ dysfunction. This review discusses the main clinical situations encountered in critically ill neutropenic patients. Specific diagnostic and therapeutic approaches have been proposed for acute respiratory failure, shock, neutropenic enterocolitis, catheter-related infections, cellulitis and primary bacteriemia. Non anti-infectious agents and recent advances will also be discussed. At present, most of large-scale studies and recommendations in neutropenic patients stem from hematological patients and will need further validation in ICU patients.
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Affiliation(s)
| | - Elie Azoulay
- AP-HP, Hôpital Saint-Louis, Medical ICU, Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique (Grrr-OH), Paris, France.
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242
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Timsit JF, Soubirou JF, Voiriot G, Chemam S, Neuville M, Mourvillier B, Sonneville R, Mariotte E, Bouadma L, Wolff M. Treatment of bloodstream infections in ICUs. BMC Infect Dis 2014; 14:489. [PMID: 25431091 PMCID: PMC4289315 DOI: 10.1186/1471-2334-14-489] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 09/03/2014] [Indexed: 11/24/2022] Open
Abstract
Bloodstream infections (BSIs) are frequent in ICU and is a prognostic factor of severe sepsis. Community acquired BSIs usually due to susceptible bacteria should be clearly differentiated from healthcare associated BSIs frequently due to resistant hospital strains. Early adequate treatment is key and should use guidelines and direct examination of samples performed from the infectious source. Previous antibiotic therapy knowledge, history of multi-drug resistant organism (MDRO) carriage are other major determinants of first choice antimicrobials in heathcare-associated and nosocomial BSIs. Initial antimicrobial dose should be adapted to pharmacokinetic knowledge. In general, a high dose is recommended at the beginning of treatment. If MDRO is suspected combination antibiotic therapy is mandatory because it increase the spectrum of treatment. Most of time, combination should be pursued no more than 2 to 5 days. Given the negative impact of useless antimicrobials, maximal effort should be done to decrease the antibiotic selection pressure. De-escalation from a broad spectrum to a narrow spectrum antimicrobial decreases the antibiotic selection pressure without negative impact on mortality. Duration of therapy should be shortened as often as possible especially when organism is susceptible, when the infection source has been totally controlled.
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243
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Cawcutt KA, Peters SG. Severe sepsis and septic shock: clinical overview and update on management. Mayo Clin Proc 2014; 89:1572-8. [PMID: 25444488 DOI: 10.1016/j.mayocp.2014.07.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 07/07/2014] [Accepted: 07/16/2014] [Indexed: 12/30/2022]
Abstract
Sepsis is among the oldest themes in medicine; however, despite modern advances, it remains a leading cause of death in the United States. Every clinician should be able to recognize the signs and symptoms of sepsis, along with early management strategies, to expeditiously provide appropriate care and decrease resultant morbidity and mortality. This review addresses the definitions, pathogenesis, clinical manifestations, management, and outcomes of patients with sepsis, severe sepsis, and septic shock.
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244
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Vitrat V, Hautefeuille S, Janssen C, Bougon D, Sirodot M, Pagani L. Optimizing antimicrobial therapy in critically ill patients. Infect Drug Resist 2014; 7:261-71. [PMID: 25349478 PMCID: PMC4208492 DOI: 10.2147/idr.s44357] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Critically ill patients with infection in the intensive care unit (ICU) would certainly benefit from timely bacterial identification and effective antimicrobial treatment. Diagnostic techniques have clearly improved in the last years and allow earlier identification of bacterial strains in some cases, but these techniques are still quite expensive and not readily available in all institutions. Moreover, the ever increasing rates of resistance to antimicrobials, especially in Gram-negative pathogens, are threatening the outcome for such patients because of the lack of effective medical treatment; ICU physicians are therefore resorting to combination therapies to overcome resistance, with the direct consequence of promoting further resistance. A more appropriate use of available antimicrobials in the ICU should be pursued, and adjustments in doses and dosing through pharmacokinetics and pharmacodynamics have recently shown promising results in improving outcomes and reducing antimicrobial resistance. The aim of multidisciplinary antimicrobial stewardship programs is to improve antimicrobial prescription, and in this review we analyze the available experiences of such programs carried out in ICUs, with emphasis on results, challenges, and pitfalls. Any effective intervention aimed at improving antibiotic usage in ICUs must be brought about at the present time; otherwise, we will face the challenge of intractable infections in critically ill patients in the near future.
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Affiliation(s)
- Virginie Vitrat
- Antimicrobial Stewardship Program, Infectious Diseases Unit, Annecy, France
| | - Serge Hautefeuille
- Intensive Care Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Cécile Janssen
- Antimicrobial Stewardship Program, Infectious Diseases Unit, Annecy, France
| | - David Bougon
- Intensive Care Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Michel Sirodot
- Intensive Care Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Leonardo Pagani
- Antimicrobial Stewardship Program, Infectious Diseases Unit, Annecy, France ; Infectious Diseases Unit, Bolzano Central Hospital, Bolzano, Italy
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De-escalation in severe sepsis: still an important part of our armamentarium against antimicrobial resistance. Intensive Care Med 2014; 40:1618. [PMID: 25236540 DOI: 10.1007/s00134-014-3476-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2014] [Indexed: 10/24/2022]
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Leone M, Bechis C, Baumstarck K. De-escalation in severe sepsis: still an important part of our armamentarium against antimicrobial resistance, of course! Intensive Care Med 2014; 40:1619. [PMID: 25236541 DOI: 10.1007/s00134-014-3479-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2014] [Indexed: 11/21/2022]
Affiliation(s)
- Marc Leone
- Service d'Anesthésie et de Réanimation, Hôpital Nord, Aix Marseille Université, 13015, Marseille, France,
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247
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De Waele JJ, Bassetti M, Martin-Loeches I. Impact of de-escalation on ICU patients' prognosis. Intensive Care Med 2014; 40:1583-5. [PMID: 25217149 DOI: 10.1007/s00134-014-3488-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 09/04/2014] [Indexed: 12/12/2022]
Affiliation(s)
- Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium,
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Stratégies de réduction de l’utilisation des antibiotiques à visée curative en réanimation (adulte et pédiatrique). MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0916-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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249
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De Santis V, Gresoiu M, Corona A, Wilson APR, Singer M. Bacteraemia incidence, causative organisms and resistance patterns, antibiotic strategies and outcomes in a single university hospital ICU: continuing improvement between 2000 and 2013. J Antimicrob Chemother 2014; 70:273-8. [DOI: 10.1093/jac/dku338] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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250
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Leone M, Bechis C, Baumstarck K, Lefrant JY, Albanèse J, Jaber S, Lepape A, Constantin JM, Papazian L, Bruder N, Allaouchiche B, Bézulier K, Antonini F, Textoris J, Martin C. De-escalation versus continuation of empirical antimicrobial treatment in severe sepsis: a multicenter non-blinded randomized noninferiority trial. Intensive Care Med 2014; 40:1399-408. [PMID: 25091790 DOI: 10.1007/s00134-014-3411-8] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 07/17/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND In patients with severe sepsis, no randomized clinical trial has tested the concept of de-escalation of empirical antimicrobial therapy. This study aimed to compare the de-escalation strategy with the continuation of an appropriate empirical treatment in those patients. METHODS This was a multicenter non-blinded randomized noninferiority trial of patients with severe sepsis who were randomly assigned to de-escalation or continuation of empirical antimicrobial treatment. Recruitment began in February 2012 and ended in April 2013 in nine intensive care units (ICUs) in France. Patients with severe sepsis were assigned to de-escalation (n = 59) or continuation of empirical antimicrobial treatment (n = 57). The primary outcome was to measure the duration of ICU stay. We defined a noninferiority margin of 2 days. If the lower boundary of the 95 % confidence interval (CI) for the difference in patients assigned to the de-escalation group was less than 2 days, as compared with that of patients assigned to the continuation group, de-escalation was considered to be noninferior to the continuation strategy. Secondary outcomes included mortality at 90 days, occurrence of organ failure, number of superinfections, and number of days with antibiotics during the ICU stay. RESULTS The median duration of ICU stay was 9 [interquartile range (IQR) 5-22] days in the de-escalation group and 8 [IQR 4-15] days in the continuation group, respectively (P = 0.71). The mean difference was 3.4 (95 % CI -1.7 to 8.5). A superinfection occurred in 16 (27 %) patients in the de-escalation group and six (11 %) patients in the continuation group (P = 0.03). The numbers of antibiotic days were 9 [7-15] and 7.5 [6-13] in the de-escalation group and continuation group, respectively (P = 0.03). Mortality was similar in both groups. CONCLUSION As compared to the continuation of the empirical antimicrobial treatment, a strategy based on de-escalation of antibiotics resulted in prolonged duration of ICU stay. However, it did not affect the mortality rate.
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Affiliation(s)
- Marc Leone
- Service d'anesthésie et de réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France,
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