[S2k guidelines of the PEG on calculated parenteral initial treatment of bacterial diseases in adults : Focussed summary and supplementary information on antibiotic treatment of critically ill patients]

Quality indicators in intensive care medicine for Germany - fourth edition 2022

The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.

Characteristics of bacterial infections and prevalence of multidrug-resistant bacteria in hospitalized patients with liver cirrhosis in Germany

INTRODUCTION AND OBJECTIVES

Bacterial infections are associated with a dismal prognosis in patients with liver cirrhosis. Data on their prevalence and the associated pathogen spectra in Germany are scarce. This study aimed to evaluate the impact of bacterial infections on mortality in hospitalized patients with liver cirrhosis and to analyze the prevalence of multidrug-resistant (MDR) bacteria in a German tertiary care center.

PATIENTS AND METHODS

Consecutive, non-electively hospitalized patients with liver cirrhosis were enrolled in this study between 03/2019-06/2021. All patients underwent clinical, laboratory and microbiological testing to detect potential bacterial infections. Patients were followed for 30 days regarding the composite endpoint of death or liver transplantation (mortality).

RESULTS

In total, 239 patients were recruited (median MELD 18). Bacterial infection was detected in 81 patients (33.9%) at study inclusion. A total of 70 patients (29.3%) developed a hospital-acquired infection. When comparing community-acquired and hospital-acquired infections, the pathogen pattern shifted from a gram-negative to a more gram-positive spectrum and showed an increase of Staphylococcus spp.. MDR bacteria were detected in seven infected patients (5.8%). 34 patients reached the composite endpoint during 30-days follow-up. In multivariable logistic regression analysis, the presence of infection during hospitalization remained independently associated with higher mortality (OR 2.522, 95% CI 1.044 - 6.091, p = 0.040).

CONCLUSIONS

This study demonstrates that bacterial infections are common in hospitalized patients with liver cirrhosis in Germany and are a major determinant of short-term mortality. Our data highlight the importance of regional differences in MDR bacteria and may guide physicians' decision-making regarding calculated antibiotic treatment.

Advances in the pharmacological management of bacterial peritonitis

Introduction: Bacterial peritonitis is an infection with high mortality if not treated immediately. In the absence of an intraabdominal source of infection, bacterial peritonitis may arise in patients with liver cirrhosis, in patients on peritoneal dialysis (PD) for end-stage renal disease or in patients with tuberculosis. In patients with cirrhosis, bacterial peritonitis may trigger acute on chronic liver failure with substantial mortality despite optimal treatment. In patients on PD, peritonitis may make continuation of PD impossible, necessitating the switch to hemodialysis.Areas covered: Recovery from peritonitis and prevention of complications depend on timely pharmacological management. Challenges are the broad microbiological spectrum with growing rates of antimicrobial resistance, the underlying chronic liver or kidney failure and high rates of relapse. The authors provide a review of predisposing conditions, diagnosis, and prevention of bacterial peritonitis with a particular focus on the pharmacological management.Expert opinion: Diagnosis of the type of bacterial peritonitis is essential to pharmacological management. In patients with spontaneous bacterial peritonitis, broad-spectrum antibiotics should be given intravenously in conjunction with albumin. In patients on PD, antibiotic therapy should be preferably applied intraperitoneally with empirical coverage of gram-positive and gram-negative bacteria. Secondary peritonitis usually requires surgical or interventional treatment.

[Acute Hand Infections - Survey of the Pathogen Spectrum and appropriate Antibiotics]

Acute infections of the hand can be a pathology with severe consequences. Alongside the surgical therapy, it is necessary to establish a systemic antiinfective therapy as well. The most frequent bacteria in acute hand infections are Staphylococcus aureus and, less frequently, different Streptococci. If the infection is the result of a bite wound, the most frequently found bacterium is Pasteurella multocida. Fortunately, the susceptibility to frequently used antibiotics in the (middle-)European area is quite good - according to the literature, resistances are rare. First line antibiotics are 1st and 2nd generation cephalosporins as well as aminopenicillins in combination with beta-lactamase inhibitors. Especially in multi-morbid patients or infections with unusual aetiology, a broader bacterial spectrum is to be expected. It is very effective to collect a tissue sample or swab for microbiological analysis before the establishment of the antiinfective therapy to gain valuable information about the prospective therapy. Ultimately, hand infections are a pathology to be treated with increased attention to avoid severe complications. A close cooperation with the involved specialties and physiotherapists should be sought to guarantee the best possible outcome.

Personalized ß-lactam dosing in patients with coronavirus disease 2019 (COVID-19) and pneumonia: A retrospective analysis on pharmacokinetics and pharmacokinetic target attainment

ABSTRACT

Pathophysiological changes are important risk factors for critically ill patients with pneumonia manifesting sub-therapeutic antibiotic exposures during empirical treatment. The effect of coronavirus disease 2019 (COVID-19) on antibiotic dosing requirements is uncertain. We aimed to determine the effect of COVID-19 on ß-lactam pharmacokinetics (PK) and PK target attainment in critically ill patients with a personalized dosing strategy.Retrospective, single-center analysis of COVID-19 ± critically ill patients with pneumonia (community-acquired pneumonia or hospital-acquired pneumonia) who received continuous infusion of a ß-lactam antibiotic with dosing personalized through dosing software and therapeutic drug monitoring. A therapeutic exposure was defined as serum concentration between (css) 4 to 8 times the EUCAST non-species related breakpoint).Data from 58 patients with pneumonia was analyzed. Nineteen patients were tested COVID-19-positive before the start of the antibiotic therapy for community-acquired pneumonia or hospital-acquired pneumonia. Therapeutic exposure was achieved in 71% of COVID-19 patients (68% considering all patients). All patients demonstrated css above the non-species-related breakpoint. Twenty percent exceeded css above the target range (24% of all patients). The median ß-lactam clearance was 49% compared to ß-lactam clearance in a standard patient without a significant difference regarding antibiotic, time of sampling or present COVID-19 infection. Median daily doses were 50% lower compared to standard bolus dosing.COVID-19 did not significantly affect ß-lactam pharmacokinetics in critically ill patients. Personalized ß-lactam dosing strategies were safe in critically ill patients and lead to high PK target attainment with less resources.

Personalized Piperacillin Dosing for the Critically Ill: A Retrospective Analysis of Clinical Experience with Dosing Software and Therapeutic Drug Monitoring to Optimize Antimicrobial Dosing

Optimization of antibiotic dosing is a treatment intervention that is likely to improve outcomes in severe infections. The aim of this retrospective study was to describe the therapeutic exposure of steady state piperacillin concentrations (c_PIP) and clinical outcome in critically ill patients with sepsis or septic shock who received continuous infusion of piperacillin with dosing personalized through software-guided empiric dosing and therapeutic drug monitoring (TDM). Therapeutic drug exposure was defined as c_PIP of 32–64 mg/L (2–4× the ‘MIC breakpoint’ of Pseudomonas aeruginosa). Of the 1544 patients screened, we included 179 patients (335 serum concentrations), of whom 89% achieved the minimum therapeutic exposure of >32 mg/L and 12% achieved potentially harmful c_PIP > 96 mg/L within the first 48 h. Therapeutic exposure was achieved in 40% of the patients. Subsequent TDM-guided dose adjustments significantly enhanced therapeutic exposure to 65%, and significantly reduced c_PIP > 96 mg/L to 5%. Mortality in patients with c_PIP > 96 mg/L (13/21; 62%) (OR 5.257, 95% CI 1.867–14.802, p = 0.001) or 64–96 mg/L (30/76; 45%) (OR 2.696, 95% CI 1.301–5.586, p = 0.007) was significantly higher compared to patients with therapeutic exposure (17/72; 24%). Given the observed variability in critically ill patients, combining the application of dosing software and consecutive TDM increases therapeutic drug exposure of piperacillin in patients with sepsis and septic shock.

Which Analysis Approach Is Adequate to Leverage Clinical Microdialysis Data? A Quantitative Comparison to Investigate Exposure and Reponse Exemplified by Levofloxacin

Purpose

Systematic comparison of analysis methods of clinical microdialysis data for impact on target-site drug exposure and response.

Methods

39 individuals received a 500 mg levofloxacin short-term infusion followed by 24-h dense sampling in plasma and microdialysate collection in interstitial space fluid (ISF). ISF concentrations were leveraged using non-compartmental (NCA) and compartmental analysis (CA) via (ii) relative recovery correction at midpoint of the collection interval (midpoint-NCA, midpoint-CA) and (ii) dialysate-based integrals of time (integral-CA). Exposure and adequacy of community-acquired pneumonia (CAP) therapy via pharmacokinetic/pharmacodynamic target-attainment (PTA) analysis were compared between approaches.

Results

Individual AUC_ISF estimates strongly varied for midpoint-NCA and midpoint-CA (≥52.3%CV) versus integral-CA (≤32.9%CV) owing to separation of variability in PK parameters (midpoint-CA = 46.5%–143%CV_PK, integral-CA = 26.4%–72.6%CV_PK) from recovery-related variability only in integral-CA (41.0%–50.3%CV_recovery). This also led to increased variability of AUC_plasma for midpoint-CA (56.0%CV) versus midpoint-NCA and integral-CA (≤33.0%CV), and inaccuracy of predictive model performance of midpoint-CA in plasma (visual predictive check). PTA analysis translated into 33% of evaluated patient cases being at risk of incorrectly rejecting recommended dosing regimens at CAP-related epidemiological cut-off values.

Conclusions

Integral-CA proved most appropriate to characterise clinical pharmacokinetics- and microdialysis-related variability. Employing this knowledge will improve the understanding of drug target-site PK for therapeutic decision-making.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11095-021-02994-1.

Meropenem Plasma and Interstitial Soft Tissue Concentrations in Obese and Nonobese Patients-A Controlled Clinical Trial

BACKGROUND

This controlled clinical study aimed to investigate the impact of obesity on plasma and tissue pharmacokinetics of meropenem.

METHODS

Obese (body mass index (BMI) ≥ 35 kg/m²) and age-/sex-matched nonobese (18.5 kg/m² ≥ BMI ≤ 30 kg/m²) surgical patients received a short-term infusion of 1000-mg meropenem. Concentrations were determined via high performance liquid chromatography-ultraviolet (HPLC-UV) in the plasma and microdialysate from the interstitial fluid (ISF) of subcutaneous tissue up to eight h after dosing. An analysis was performed in the plasma and ISF by noncompartmental methods.

RESULTS

The maximum plasma concentrations in 15 obese (BMI 49 ± 11 kg/m²) and 15 nonobese (BMI 24 ± 2 kg/m²) patients were 54.0 vs. 63.9 mg/L (95% CI for difference: -18.3 to -3.5). The volume of distribution was 22.4 vs. 17.6 L, (2.6-9.1), but the clearance was comparable (12.5 vs. 11.1 L/h, -1.4 to 3.1), leading to a longer half-life (1.52 vs. 1.31 h, 0.05-0.37) and fairly similar area under the curve (AUC)_8h (78.7 vs. 89.2 mg*h/L, -21.4 to 8.6). In the ISF, the maximum concentrations differed significantly (12.6 vs. 18.6 L, -16.8 to -0.8) but not the AUC_8h (28.5 vs. 42.0 mg*h/L, -33.9 to 5.4). Time above the MIC (T > MIC) in the plasma and ISF did not differ significantly for MICs of 0.25-8 mg/L.

CONCLUSIONS

In morbidly obese patients, meropenem has lower maximum concentrations and higher volumes of distribution. However, due to the slightly longer half-life, obesity has no influence on the T > MIC, so dose adjustments for obesity seem unnecessary.

[Rational antimicrobial therapy - recommendations for common infections]

Infectious diseases are a frequent reason for medical consultations both in the inpatient and outpatient setting. Inadequate management is associated with increased costs, morbidity and mortality. In times of rising antibiotic resistance rational therapy and antimicrobial stewardship are of utmost importance. While it is crucial to avoid excessively broad antimicrobial coverage and unnecessary therapies, serious conditions must be treated effectively. The article highlights common infections and gives recommendations for empiric and targeted antibiotic treatment. Discussed are pulmonary, abdominal, urinary tract, skin and soft tissue infections, as well as sepsis and staphylococcal bloodstream infections. The recommendations consider national and international guidelines, recent publications and current antimicrobial resistance in Germany.

[New antibiotics for severe infections due to multidrug-resistant pathogens : Definitive treatment and escalation]

Multidrug-resistant pathogens often lead to treatment failure of antimicrobial regimens. After a period of imbalance between the occurrence/spread of resistance mechanisms and the development of new substances, some new substances have meanwhile been approved and many more are currently undergoing clinical testing. They are particularly effective against specific resistance mechanisms/pathogens and should be preserved for definitive treatment of an isolated pathogen. In the absence of alternatives reserve antibiotics, such as aztreonam and colistin have experienced a renaissance. They are again used in special infection scenarios and clinically tested in combination with new substances. Despite the introduction and development of new substances the building of resistance will at some time also render these (at least partially) ineffective. Therefore, their implementation must be carried out according to the antibiotic or infectious diseases stewardship.

[Anti-infective treatment : Treatment strategies for sepsis and septic shock]

Sepsis and septic shock are still associated with a high mortality and morbidity. A decisive factor for improvement of the outcome is the prompt initiation of an effective antibiotic treatment. The early recognition of sepsis within the first hour is here one of the biggest challenges. Effective empirical treatment comprises purposefully selected broad-spectrum antibiotics and also combination treatment or antimycotics in special situations. De-escalation strategies to narrow down or shorten the treatment are safe and can limit the side effects.

[Anti-infective treatment in obesity-"just double it?"]

Adaequate antibiotic therapy is crucial for successful anti-infective therapy. In addition to the choice of the right antibiotic and the duration of therapy, the dose also plays a decisive role. Obesity has an influence on the pharmacokinetics of antibiotics, which can lead to underdosing if previous weight-independent dosing regimes are used. It is therefore necessary to carry out systematic measurements of concentrations in obese patients. Since pharmacokinetic differences between plasma and the interstitial fluid of different target tissues have been observed for different antibiotics, the measurement is also necessary in the target tissue. The technique of microdialysis is best suited for this purpose as it allows concentrations to be measured continuously in the target tissue.

Linezolid Concentrations in Plasma and Subcutaneous Tissue are Reduced in Obese Patients, Resulting in a Higher Risk of Underdosing in Critically Ill Patients: A Controlled Clinical Pharmacokinetic Study

Background: Linezolid is used for the treatment of soft tissue infections in critically ill patients. However, data for characterizing the pharmacokinetics (PK) and assessing whether effective concentrations are reached at the target site are lacking. We hypothesized that current dosing regimens do not lead to effective concentrations in the plasma and interstitial fluid (ISF) of subcutaneous tissue in obese patients. Methods: As a controlled clinical model, critically ill obese and non-obese patients undergoing intra-abdominal surgery received 600 mg linezolid as a single infusion. Concentrations in the plasma and microdialysate from the ISF of subcutaneous tissue were determined up to 8 h after dosing. Pharmacokinetic analysis was performed by non-compartmental methods. As a therapeutic target, we used fAUC/MIC > 80. Results: Fifteen obese (BMI: 48.7 ± 11.2 kg/m²) and 15 non-obese (23.9 ± 2.1 kg/m²) patients were analyzed. AUC_0–8 in ISF decreased by −1.69 mg*h/L (95% CI: −2.59 to −0.79, p < 0.001) for every 10 kg increase in weight. PK in obese patients were characterized by lower maximal plasma concentrations (median 3.8 vs. 8.3 mg/L, p < 0.001) and a higher volume of distribution (41.0 vs. 30.8 L, p < 0.001), and the therapeutic target was not reached for MIC ≥ 1 mg/L in ISF and ≥ 2 mg/L in plasma. Conclusions: Increasing the weight led to a decrease of linezolid concentrations in the plasma and subcutaneous tissue. The current dosing regimen does not seem to produce sufficient concentrations to kill bacteria with MIC ≥ 2 mg/L, especially as empirical antimicrobial therapy in critically ill obese patients.

Linezolid use in German acute care hospitals: results from two consecutive national point prevalence surveys

Background

Linezolid belongs to a reserve group of antibiotics. In recent years, reports on linezolid resistance in gram-positive cocci have become more frequent. Overuse of linezolid is a relevant factor for resistance development. The objective of this study was to describe current prescription practices of linezolid in German hospitals and identify targets for antimicrobial stewardship interventions.

Methods

We analyzed all linezolid prescriptions from the datasets of the consecutive national point prevalence surveys performed in German hospitals in 2011 and 2016. In both surveys, data on healthcare-associated infections and antimicrobial use were collected following the methodology of the European Centre for Disease Prevention and Control.

Results

Overall, the percentage of linezolid among all documented antimicrobials increased significantly from 2011 to 2016 (p < 0.01). In 2011, 0.3% (119 of 41,539) patients received linezolid, in 2016 this proportion was significantly higher (0.4%; 255 of 64,412 patients; p < 0.01). In 2016, intensive care units (ICUs) were the wards most frequently prescribing linezolid. The largest proportion of patients receiving linezolid were non-ICU patients. Roughly 38% of linezolid prescriptions were for treatment of skin/soft tissue and respiratory tract infections. In 2016, linezolid was administered parenterally in 70% (n = 179) of cases. Multivariable analysis showed that the ward specialty ICU posed an independent risk factor, while Northern and Southwestern regions in Germany were independent protective factors for a high rate of linezolid prescriptions.

Conclusions

In conclusion, we detected potentials for improving linezolid prescription practices in German hospitals. Given the emergence of linezolid resistance, optimization of linezolid use must be a target of future antimicrobial stewardship activities.

Clinical relevance of colonization with antimicrobial-resistant bacteria (AMRB) and methicillin susceptible Staphylococcus aureus (MSSA) for mothers during pregnancy

PURPOSE

The impact of colonization with antimicrobial-resistant bacteria (AMRB) and methicillin-sensitive Staphylococcus aureus (MSSA) of healthy pregnant women is not described in detail in Germany. In this study, we screened for MSSA and AMRB, especially for methicillin-resistant S. aureus (MRSA) as well as extended-spectrum beta-lactamase (ESBL)-producing E. coli. Potential risk factors for colonization with AMRB/MSSA and the potential effects of colonization with these on the obstetric population were investigated.

METHODS

From October 2013 until December 2015 pregnant women were screened before birth for colonization with AMRB/MSSA from the mammillae, nose, perianal and vaginal area. Before birth, the expectant mother was administered a standardized interview questionnaire by a trained interviewer. Data from the hospital admission records were also included.

RESULTS

Samples from 651 pregnant women were analyzed. Colonization with MSSA was detected in 14.3% (n = 93), AMRB in 3.5% [(n = 23); MRSA: n = 3/ESBL: n = 20]. Significantly more colonization of AMRB/MSSA could be detected in women who had previously given birth compared to women who were nulliparous (p < 0.05). MSSA colonization was significantly associated with self-reported respiratory diseases during pregnancy (p < 0.05), but AMRB/MSSA colonization was not statistically associated with other types of infection.

CONCLUSION

Our results demonstrate a low overall rate of colonization with AMRB/MSSA, as well as a low percentage of colonized pregnant women who developed infections. Multiparous women are at higher risk for colonization with MSSA/MRSA or ESBL. Because the prevalence of AMRB/MSSA is low, this study suggests that general screening of pregnant women without risk factors is not recommended.