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Teshome BF, Park T, Arackal J, Hampton N, Kollef MH, Micek ST. Preventing New Gram-negative Resistance Through Beta-lactam De-escalation in Hospitalized Patients With Sepsis: A Retrospective Cohort Study. Clin Infect Dis 2024:ciae253. [PMID: 38842541 DOI: 10.1093/cid/ciae253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Whether antibiotic de-escalation reduces the risk of subsequent antibiotic resistance is uncertain. We sought to determine if beta-lactam (BL) antibiotic de-escalation is associated with decreased incidence of new Gram-negative resistance in hospitalized patients with sepsis. METHODS In a retrospective cohort study, patients with sepsis who were treated with at least 3 consecutive days of BL antibiotics, the first 2 days of which were with a broad-spectrum BL agent defined as a spectrum score (SS) of ≥7 were enrolled. Patients were grouped into three categories: (1) de-escalation of beta-lactam spectrum score (BLSS), (2) no change in BLSS, or (3) escalation of BLSS. The primary outcome was the isolation of a new drug-resistant Gram-negative bacteria from a clinical culture within 60 days of cohort entry. Fine-Gray proportional hazards regression modeling while accounting for in-hospital death as a competing risk was performed. FINDINGS Six hundred forty-four patients of 7742 (8.3%) patients developed new gram-negative resistance. The mean time to resistance was 23.7 days yielding an incidence rate of 1.85 (95% confidence interval [CI]: 1.71-2.00) per 1000 patient-days. The lowest incidence rate was observed in the de-escalated group 1.42 (95% CI: 1.16-1.68) per 1000 patient-days. Statistically significant reductions in the development of new gram-negative resistance were associated with BL de-escalation compared to no-change (hazards ratio (HR) 0.59 [95% CI: .48-.73]). CONCLUSIONS De-escalation was associated with a decreased risk of new resistance development compared to no change. This represents the largest study to date showing the utility of de-escalation in the prevention of antimicrobial resistance.
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Affiliation(s)
- Besu F Teshome
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri, USA
- Center for Health Outcomes Research and Education, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri, USA
| | - Taehwan Park
- College of Pharmacy and Health Sciences, St. John's University, Queens, New York, USA
| | - Joel Arackal
- Center for Health Outcomes Research and Education, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri, USA
| | - Nicholas Hampton
- Center for Clinical Excellence, BJC Healthcare, St. Louis, Missouri, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Scott T Micek
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri, USA
- Center for Health Outcomes Research and Education, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri, USA
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2
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Tanzarella ES, Cutuli SL, Lombardi G, Cammarota F, Caroli A, Franchini E, Sancho Ferrando E, Grieco DL, Antonelli M, De Pascale G. Antimicrobial De-Escalation in Critically Ill Patients. Antibiotics (Basel) 2024; 13:375. [PMID: 38667051 PMCID: PMC11047373 DOI: 10.3390/antibiotics13040375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/03/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
Antimicrobial de-escalation (ADE) is defined as the discontinuation of one or more antimicrobials in empirical therapy, or the replacement of a broad-spectrum antimicrobial with a narrower-spectrum antimicrobial. The aim of this review is to provide an overview of the available literature on the effectiveness and safety of ADE in critically ill patients, with a focus on special conditions such as anti-fungal therapy and high-risk categories. Although it is widely considered a safe strategy for antimicrobial stewardship (AMS), to date, there has been no assessment of the effect of de-escalation on the development of resistance. Conversely, some authors suggest that prolonged antibiotic treatment may be a side effect of de-escalation, especially in high-risk categories such as neutropenic critically ill patients and intra-abdominal infections (IAIs). Moreover, microbiological documentation is crucial for increasing ADE rates in critically ill patients with infections, and efforts should be focused on exploring new diagnostic tools to accelerate pathogen identification. For these reasons, ADE can be safely used in patients with infections, as confirmed by high-quality and reliable microbiological samplings, although further studies are warranted to clarify its applicability in selected populations.
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Affiliation(s)
- Eloisa Sofia Tanzarella
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Gianmarco Lombardi
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Fabiola Cammarota
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Alessandro Caroli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Emanuele Franchini
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | | | - Domenico Luca Grieco
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Massimo Antonelli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Gennaro De Pascale
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
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3
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Zhao K, Zhang Z, Liang Y, Wang Y, Cai Y. Effect of antimicrobial de-escalation strategy on 14-day mortality among intensive care unit patients: a retrospective propensity score-matched cohort study with inverse probability-of-treatment weighting. BMC Infect Dis 2023; 23:508. [PMID: 37537526 PMCID: PMC10401733 DOI: 10.1186/s12879-023-08491-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/28/2023] [Indexed: 08/05/2023] Open
Abstract
PURPOSE This study aimed to investigate the prevalence of antimicrobial de-escalation (ADE) strategy and assess its effect on 14-day mortality among intensive care unit patients. METHODS A single-center retrospective cohort study was conducted on patients admitted to the intensive care unit (ICU) with infectious diseases between January 2018 and December 2020. Patients were stratified into three groups based on the initial treatment regimen within 5 days of antimicrobial administration: ADE, No Change, and Other Change. Confounders between groups were screened using one-way ANOVA and Chi-square analysis. Univariate and multivariate analyses were performed to identify risk factors for 14-day mortality. Potential confounders were balanced using propensity score inverse probability of treatment weighting (IPTW), followed by multivariate logistic regression analysis to evaluate the effect of ADE strategy on 14-day mortality. RESULTS A total of 473 patients met the inclusion criteria, with 53 (11.2%) in the ADE group, 173 (36.6%) in the No Change group, and 247 (52.2%) in the Other Change group. The 14-day mortality rates in the three groups were 9.4%, 11.6%, and 21.9%, respectively. After IPTW, the adjusted odds ratio for 14-day mortality comparing No Change with ADE was 1.557 (95% CI 1.078-2.247, P = 0.0181) while comparing Other Change with ADE was 1.282(95% CI 0.884-1.873, P = 0.1874). CONCLUSION The prevalence of ADE strategy was low among intensive care unit patients. The ADE strategy demonstrated a protective effect or no adverse effect on 14-day mortality compared to the No Change or Other Change strategies, respectively. These findings provide evidence supporting the implementation of the ADE strategy in ICU patients.
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Affiliation(s)
- Kai Zhao
- Department of Pharmacy, the Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, China
- Department of Pharmacy, Northwest Women's and Children's Hospital, Shaanxi, 710061, Xi'an, China
| | - Zhengliang Zhang
- Emergency Department, the Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, China
| | - Ying Liang
- Department of Medical Statistics, Air Force Medical University, Shaanxi, 710032, Xi'an, China
| | - Yan Wang
- Department of Pharmacy, the Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, China
| | - Yan Cai
- Department of Pharmacy, the Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, 710004, Xi'an, China.
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Roper S, Wingler MJB, Cretella DA. Antibiotic De-Escalation in Critically Ill Patients with Negative Clinical Cultures. PHARMACY 2023; 11:104. [PMID: 37368430 DOI: 10.3390/pharmacy11030104] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/11/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023] Open
Abstract
(1) Background: Antibiotics are received by a majority of adult intensive care unit (ICU) patients. Guidelines recommend antibiotic de-escalation (ADE) when culture results are available; however, there is less guidance for patients with negative cultures. The purpose of this study was in investigate ADE rates in an ICU population with negative clinical cultures. (2) Methods: This single-center, retrospective, cohort study evaluated ICU patients who received broad-spectrum antibiotics. The definition of de-escalation was antibiotic discontinuation or narrowing of the spectrum within 72 h of initiation. The outcomes evaluated included the rate of antibiotic de-escalation, mortality, rates of antimicrobial escalation, AKI incidence, new hospital acquired infections, and lengths of stay. (3) Results: Of the 173 patients included, 38 (22%) underwent pivotal ADE within 72 h, and 82 (47%) had companion antibiotics de-escalated. Notable differences in patient outcomes included shorter durations of therapy (p = 0.003), length of stay (p < 0.001), and incidence of AKI (p = 0.031) in those that underwent pivotal ADE; no difference in mortality was found. (4) Conclusions: The results from this study show the feasibility of ADE in patients with negative clinical cultures without a negative impact on the outcomes. However, further investigation is needed to determine its effect on the development of resistance and adverse effects.
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Affiliation(s)
- Spencer Roper
- Department of Pharmacy, University of Tennessee Medical Center, Knoxville, TN 37920, USA
| | - Mary Joyce B Wingler
- Department of Antimicrobial Stewardship, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - David A Cretella
- Department of Antimicrobial Stewardship, University of Mississippi Medical Center, Jackson, MS 39216, USA
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Mokrani D, Chommeloux J, Pineton de Chambrun M, Hékimian G, Luyt CE. Antibiotic stewardship in the ICU: time to shift into overdrive. Ann Intensive Care 2023; 13:39. [PMID: 37148398 PMCID: PMC10163585 DOI: 10.1186/s13613-023-01134-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/20/2023] [Indexed: 05/08/2023] Open
Abstract
Antibiotic resistance is a major health problem and will be probably one of the leading causes of deaths in the coming years. One of the most effective ways to fight against resistance is to decrease antibiotic consumption. Intensive care units (ICUs) are places where antibiotics are widely prescribed, and where multidrug-resistant pathogens are frequently encountered. However, ICU physicians may have opportunities to decrease antibiotics consumption and to apply antimicrobial stewardship programs. The main measures that may be implemented include refraining from immediate prescription of antibiotics when infection is suspected (except in patients with shock, where immediate administration of antibiotics is essential); limiting empiric broad-spectrum antibiotics (including anti-MRSA antibiotics) in patients without risk factors for multidrug-resistant pathogens; switching to monotherapy instead of combination therapy and narrowing spectrum when culture and susceptibility tests results are available; limiting the use of carbapenems to extended-spectrum beta-lactamase-producing Enterobacteriaceae, and new beta-lactams to difficult-to-treat pathogen (when these news beta-lactams are the only available option); and shortening the duration of antimicrobial treatment, the use of procalcitonin being one tool to attain this goal. Antimicrobial stewardship programs should combine these measures rather than applying a single one. ICUs and ICU physicians should be at the frontline for developing antimicrobial stewardship programs.
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Affiliation(s)
- David Mokrani
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Juliette Chommeloux
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Hékimian
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
- Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
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Abstract
PURPOSE OF REVIEW Ventilator-associated pneumonia (VAP) is a common nosocomial infection in critically ill patients requiring endotracheal intubation and mechanical ventilation. Recently, the emergence of multidrug-resistant Gram-negative bacteria, including carbapenem-resistant Enterobacterales, multidrug-resistant Pseudomonas aeruginosa and Acinetobacter species, has complicated the selection of appropriate antimicrobials and contributed to treatment failure. Although novel antimicrobials are crucial to treating VAP caused by these multidrug-resistant organisms, knowledge of how to optimize their efficacy while minimizing the development of resistance should be a requirement for their use. RECENT FINDINGS Several studies have assessed the efficacy of novel antimicrobials against multidrug-resistant organisms, but high-quality studies focusing on optimal dosing, infusion time and duration of therapy in patients with VAP are still lacking. Antimicrobial and diagnostic stewardship should be combined to optimize the use of these novel agents. SUMMARY Improvements in diagnostic tests, stewardship practices and a better understanding of dosing, infusion time, duration of treatment and the effects of combining various antimicrobials should help optimize the use of novel antimicrobials for VAP and maximize clinical outcomes while minimizing the development of resistance.
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Antimicrobial Stewardship Program: Reducing Antibiotic's Spectrum of Activity Is not the Solution to Limit the Emergence of Multidrug-Resistant Bacteria. Antibiotics (Basel) 2022; 11:antibiotics11010070. [PMID: 35052947 PMCID: PMC8772858 DOI: 10.3390/antibiotics11010070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/20/2021] [Accepted: 12/30/2021] [Indexed: 12/10/2022] Open
Abstract
Overconsumption of antibiotics in hospitals has led to policy implementation, including the control of antibiotic prescriptions. The impact of these policies on the evolution of antimicrobial resistance remains uncertain. In this work, we review the possible limits of such policies and focus on the need for a more efficient approach. Establishing a causal relationship between the introduction of new antibiotics and the emergence of new resistance mechanisms is difficult. Several studies have demonstrated that many resistance mechanisms existed before the discovery of antibiotics. Overconsumption of antibiotics has worsened the phenomenon of resistance. Antibiotics are responsible for intestinal dysbiosis, which is suspected of being the source of bacterial resistance. The complexity of the intestinal microbiota composition, the impact of the pharmacokinetic properties of antibiotics, and the multiplicity of other factors involved in the acquisition and emergence of multidrug-resistant organisms, lead us to think that de-escalation, in the absence of studies proving its effectiveness, is not the solution to limiting the spread of multidrug-resistant organisms. More studies are needed to clarify the ecological risk caused by different antibiotic classes. In the meantime, we need to concentrate our efforts on limiting antibiotic prescriptions to patients who really need it, and work on reducing the duration of these treatments.
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Routsi C, Gkoufa A, Arvaniti K, Kokkoris S, Tourtoglou A, Theodorou V, Vemvetsou A, Kassianidis G, Amerikanou A, Paramythiotou E, Potamianou E, Ntorlis K, Kanavou A, Nakos G, Hassou E, Antoniadou H, Karaiskos I, Prekates A, Armaganidis A, Pnevmatikos I, Kyprianou M, Zakynthinos S, Poulakou G, Giamarellou H. De-escalation of antimicrobial therapy in ICU settings with high prevalence of multidrug-resistant bacteria: a multicentre prospective observational cohort study in patients with sepsis or septic shock. J Antimicrob Chemother 2021; 75:3665-3674. [PMID: 32865203 DOI: 10.1093/jac/dkaa375] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 08/03/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND De-escalation of empirical antimicrobial therapy, a key component of antibiotic stewardship, is considered difficult in ICUs with high rates of antimicrobial resistance. OBJECTIVES To assess the feasibility and the impact of antimicrobial de-escalation in ICUs with high rates of antimicrobial resistance. METHODS Multicentre, prospective, observational study in septic patients with documented infections. Patients in whom de-escalation was applied were compared with patients without de-escalation by the use of a propensity score matching by SOFA score on the day of de-escalation initiation. RESULTS A total of 262 patients (mean age 62.2 ± 15.1 years) were included. Antibiotic-resistant pathogens comprised 62.9%, classified as MDR (12.5%), extensively drug-resistant (49%) and pandrug-resistant (1.2%). In 97 (37%) patients de-escalation was judged not feasible in view of the antibiotic susceptibility results. Of the remaining 165 patients, judged as patients with de-escalation possibility, de-escalation was applied in 60 (22.9%). These were matched to an equal number of patients without de-escalation. In this subset of 120 patients, de-escalation compared with no de-escalation was associated with lower all-cause 28 day mortality (13.3% versus 36.7%, OR 0.27, 95% CI 0.11-0.66, P = 0.006); ICU and hospital mortality were also lower. De-escalation was associated with a subsequent collateral decrease in the SOFA score. Cox multivariate regression analysis revealed de-escalation as a significant factor for 28 day survival (HR 0.31, 95% CI 0.14-0.70, P = 0.005). CONCLUSIONS In ICUs with high levels of antimicrobial resistance, feasibility of antimicrobial de-escalation was limited because of the multi-resistant pathogens isolated. However, when de-escalation was feasible and applied, it was associated with lower mortality.
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Affiliation(s)
- Christina Routsi
- 1st Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Evangelismos' Hospital, Athens, Greece.,Hellenic Society of Antimicrobial Chemotherapy, Greece
| | | | - Kostoula Arvaniti
- Department of Intensive Care, 'Papageorgiou' Hospital, Thessaloniki, Greece
| | - Stelios Kokkoris
- 1st Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Evangelismos' Hospital, Athens, Greece
| | | | - Vassiliki Theodorou
- Department of Intensive Care, Democritus University of Thrace, Alexandroupolis University Hospital, Alexandroupolis, Greece
| | - Anna Vemvetsou
- Department of Intensive Care, 'Papageorgiou' Hospital, Thessaloniki, Greece
| | | | | | - Elisabeth Paramythiotou
- 2nd Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' Hospital, Athens, Greece
| | - Efstathia Potamianou
- 1st Department of Respiratory Medicine, Intensive Care Unit, School of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital, Athens, Greece
| | - Kyriakos Ntorlis
- Department of Intensive Care, 'Konstantopouleio' Hospital, Athens, Greece
| | - Angeliki Kanavou
- Department of Intensive Care, 'Thriassio' Hospital, Elefsina, Greece
| | - Georgios Nakos
- Department of Intensive Care, 'Henry Dunant' Hospital Center, Athens, Greece
| | - Eleftheria Hassou
- Department of Intensive Care, 'Gennimatas' Hospital, Thessaloniki, Greece
| | - Helen Antoniadou
- Department of Intensive Care, 'Gennimatas' Hospital, Thessaloniki, Greece
| | - Ilias Karaiskos
- Hellenic Society of Antimicrobial Chemotherapy, Greece.,Hygeia General Hospital, Athens, Greece
| | | | - Apostolos Armaganidis
- 2nd Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' Hospital, Athens, Greece
| | - Ioannis Pnevmatikos
- Department of Intensive Care, Democritus University of Thrace, Alexandroupolis University Hospital, Alexandroupolis, Greece
| | | | - Spyros Zakynthinos
- 1st Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Evangelismos' Hospital, Athens, Greece
| | - Garyfallia Poulakou
- Hellenic Society of Antimicrobial Chemotherapy, Greece.,School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Helen Giamarellou
- Hellenic Society of Antimicrobial Chemotherapy, Greece.,Hygeia General Hospital, Athens, Greece
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Blood Stream Infections from MDR Bacteria. Life (Basel) 2021; 11:life11060575. [PMID: 34207043 PMCID: PMC8233890 DOI: 10.3390/life11060575] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/13/2021] [Accepted: 06/14/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Bloodstream infections (BSIs) constitute a growing public health concern, are among the most severe nosocomial pathologies, and are considered a worldwide cause of unfaithful outcomes, increasing treatment costs and diagnostic uncertainties. BSIs are one of the most frequent lethal conditions that are managed in intensive care units (ICUs). In the case of septic shock, immune deficiency, and delayed treatment, even with adequate antimicrobial therapy and/or source control, the outcomes are often unfavorable. METHODS this review article summarizes the epidemiological and microbiological characteristics of BSIs with a particular focus on ICU acquired BSIs (ICU-BSIs), which are usually caused by multidrug-resistant (MDR) pathogens. For this reason, their antimicrobial resistance patterns and therapeutic options have also been compiled. RESULTS ICU-acquired BSIs prevail in 5-7% of ICU patients. Klebsiella pneumoniae, Escherichia coli, Acinetobacter baumannii, and Pseudomonas aeruginosae are the pathogens most often responsible for MDR infections. MDR Enterobacteriaceae have seen their prevalence increase from 6.2% (1997-2000) to 15.8% (2013-2016) in recent years. CONCLUSIONS Considering that prevention and treatment of sepsis is nowadays considered a global health priority by the World Health Organization, it is our obligation to invest more resources into solving or reducing the spread of these unfaithful infections. It is relevant to identify patients with risk factors that make them more susceptible to BSIs, to guarantee earlier molecular or microbiological diagnoses, and more rapidly appropriate treatment by using de-escalation strategies where possible.
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Ling L, Joynt GM, Lipman J. A narrative review on antimicrobial therapy in septic shock: updates and controversies. Curr Opin Anaesthesiol 2021; 34:92-98. [PMID: 33470662 DOI: 10.1097/aco.0000000000000954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Antibiotics are an essential treatment for septic shock. This review provides an overview of the key issues in antimicrobial therapy for septic shock. We include a summary of available evidence with an emphasis on data published in the last few years. RECENT FINDINGS We examine apparently contradictory data supporting the importance of minimizing time to antimicrobial therapy in sepsis, discuss approaches to choosing appropriate antibiotics, and review the importance and challenges presented by antimicrobial dosing. Lastly, we evaluate the evolving concepts of de-escalation, and optimization of the duration of antimicrobials. SUMMARY The topics discussed in this review provide background to key clinical decisions in antimicrobial therapy for septic shock: timing, antibiotic choice, dosage, de-escalation, and duration. Although acknowledging some controversy, antimicrobial therapy in septic shock should be delivered early, be of the adequate spectrum, appropriately and individually dosed, rationalized when possible, and of minimal effective duration.
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Affiliation(s)
- Lowell Ling
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Gavin Matthew Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Jeffrey Lipman
- Intensive Care Services, Royal Brisbane and Women's Hospital
- The University of Queensland Centre for Clinical Research, Brisbane, Australia
- Scientific Consultant, Nimes University Hospital, University of Montpellier, Nimes, France
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Antibiotic Stewardship in the Intensive Care Unit. An Official American Thoracic Society Workshop Report in Collaboration with the AACN, CHEST, CDC, and SCCM. Ann Am Thorac Soc 2021; 17:531-540. [PMID: 32356696 PMCID: PMC7193806 DOI: 10.1513/annalsats.202003-188st] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Intensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital’s use of parenteral antibiotics, especially broad-spectrum, occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is “the right drug at the right time and the right dose for the right bug for the right duration.” A major emphasis was that antibiotic stewardship should be a core competency of critical care clinicians. Fear of pathogens that are not covered by empirical antibiotics is a major driver of excessively broad-spectrum therapy in critically ill patients. Better diagnostics and outcome data can address this fear and expand efforts to narrow or shorten therapy. Greater awareness of the substantial adverse effects of antibiotics should be emphasized and is an important counterargument to broad-spectrum therapy in individual low-risk patients. Optimal antibiotic stewardship should not focus solely on reducing antibiotic use or ensuring compliance with guidelines. Instead, it should enhance care both for individual patients (by improving and individualizing their choice of antibiotic) and for the ICU population as a whole. Opportunities for antibiotic stewardship in common ICU infections, including community- and hospital-acquired pneumonia and sepsis, are discussed. Intensivists can partner with antibiotic stewardship programs to address barriers and improve patient care.
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Poline J, Postaire M, Parize P, Pilmis B, Bille E, Zahar JR, Frange P, Cohen JF, Lortholary O, Toubiana J. Stewardship program on carbapenem prescriptions in a tertiary hospital for adults and children in France: a cohort study. Eur J Clin Microbiol Infect Dis 2021; 40:1039-1048. [PMID: 33389261 PMCID: PMC7778866 DOI: 10.1007/s10096-020-04103-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/05/2020] [Indexed: 01/31/2023]
Abstract
Antimicrobial stewardship programs aim at reducing the overuse of broad-spectrum antibiotics such as carbapenems, but their impact remains unclear. We compared the use of carbapenems between paediatric and adult subjects admitted to a French tertiary hospital and described the intervention of an antibiotic stewardship team (AST). As part of AST routine activity, all adult and paediatric patients receiving carbapenems are identified in real time using a computer-generated alert system and reviewed by the AST. Data associated with carbapenem prescriptions were extracted for 2 years (2014-2015) and were compared between paediatric and adult wards. Prescription appropriateness (i.e. no clinically suitable narrower spectrum alternative to carbapenem for de-escalation) and AST intervention were analysed. In total, 775 carbapenem prescriptions for 291 children and 262 adults were included. Most patients (95%) had a comordity and 52% had known recent carriage of extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBLE). Most carbapenem prescriptions came from intensive care units (n = 269, 35%) and were initiated for urinary tract (n = 200, 27%), sepsis (n = 181, 25%), and lung (n = 153, 21%) infections. Carbapenems were initiated empirically in 537 (70%) cases, and an organism was isolated in 523 (67%) cases. Among the isolated organisms, 47% (n = 246) were ESBLE and 90% (n = 468) were susceptible to carbapenems, but an alternative existed in 61% (n = 320) of cases according to antibiotic susceptibility testing. Among prescriptions reviewed by the AST, 39% (n = 255) were considered non-appropriate and led to either antibiotic discontinuation (n = 47, 7%) or de-escalation (n = 208, 32%). Non-appropriate prescriptions were more frequent in paediatric wards (p = 0.01) and in microbiologically documented infections (p = 0.013), and less observed in immunocompromised patients (p = 0.009) or with a known ESBLE carriage (p < 0.001). Tailored stewardship programs are essential to better control carbapenem use and subsequent antimicrobial resistance.
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Affiliation(s)
- Julie Poline
- Department of General Paediatrics and Paediatric Infectious Diseases, Hôpital Necker–Enfants Malades, APHP, Université de Paris, 149 rue de Sèvres, 75015 Paris, France ,Department of Gut Inflammation, Center for Research on Inflammation CRI, INSERM 1149, Université de Paris, 75006 Paris, France
| | - Martine Postaire
- Department of Pharmacy, Hôpital Necker–Enfants Malades, APHP, Université de Paris, Paris, France
| | - Perrine Parize
- Department of Infectious Diseases and Tropical Medicine, Necker Enfants-Malades Hospital, Necker-Pasteur Infectious Diseases Center, Université de Paris, IHU Imagine, Paris, France
| | - Benoit Pilmis
- Department of Infectious Diseases and Tropical Medicine, Necker Enfants-Malades Hospital, Necker-Pasteur Infectious Diseases Center, Université de Paris, IHU Imagine, Paris, France
| | - Emmanuelle Bille
- Department of Microbiology, Necker Enfants-Malades Hospital, APHP, Université de Paris, Paris, France
| | - Jean Ralph Zahar
- Department of Microbiology, Necker Enfants-Malades Hospital, APHP, Université de Paris, Paris, France ,Infection Control Unit, IAME, UMR 1137, Université Paris 13, Sorbonne Paris Cité, Paris, France
| | - Pierre Frange
- Department of Microbiology, Necker Enfants-Malades Hospital, APHP, Université de Paris, Paris, France
| | - Jérémie F. Cohen
- Department of General Paediatrics and Paediatric Infectious Diseases, Hôpital Necker–Enfants Malades, APHP, Université de Paris, 149 rue de Sèvres, 75015 Paris, France
| | - Olivier Lortholary
- Department of Infectious Diseases and Tropical Medicine, Necker Enfants-Malades Hospital, Necker-Pasteur Infectious Diseases Center, Université de Paris, IHU Imagine, Paris, France
| | - Julie Toubiana
- Department of General Paediatrics and Paediatric Infectious Diseases, Hôpital Necker–Enfants Malades, APHP, Université de Paris, 149 rue de Sèvres, 75015 Paris, France ,Biodiversity and Epidemiology of Bacterial Pathogens, Institut Pasteur, Paris, France
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13
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Abstract
Antimicrobial de-escalation (ADE) is a component of antimicrobial stewardship (AMS) aimed to reduce exposure to broad-spectrum antimicrobials. In the intensive care unit, ADE is a strong recommendation that is moderately applied in clinical practice. Following a systematic review of the literature, we assessed the studies identified on the topic which included one randomized controlled trial and 20 observational studies. The literature shows a low level of evidence, although observational studies suggested that this procedure is safe. The effects of ADE on the level of resistance of ecological systems and especially on the microbiota are unclear. The reviewers recommend de-escalating antimicrobial treatment in patients requiring long-term antibiotic therapy and considering de-escalation in short-term treatments.
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De Bus L, Depuydt P, Steen J, Dhaese S, De Smet K, Tabah A, Akova M, Cotta MO, De Pascale G, Dimopoulos G, Fujitani S, Garnacho-Montero J, Leone M, Lipman J, Ostermann M, Paiva JA, Schouten J, Sjövall F, Timsit JF, Roberts JA, Zahar JR, Zand F, Zirpe K, De Waele JJ. Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure: the DIANA study. Intensive Care Med 2020; 46:1404-1417. [PMID: 32519003 PMCID: PMC7334278 DOI: 10.1007/s00134-020-06111-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 05/11/2020] [Indexed: 01/10/2023]
Abstract
Purpose The DIANA study aimed to evaluate how often antimicrobial de-escalation (ADE) of empirical treatment is performed in the intensive care unit (ICU) and to estimate the effect of ADE on clinical cure on day 7 following treatment initiation. Methods Adult ICU patients receiving empirical antimicrobial therapy for bacterial infection were studied in a prospective observational study from October 2016 until May 2018. ADE was defined as (1) discontinuation of an antimicrobial in case of empirical combination therapy or (2) replacement of an antimicrobial with the intention to narrow the antimicrobial spectrum, within the first 3 days of therapy. Inverse probability (IP) weighting was used to account for time-varying confounding when estimating the effect of ADE on clinical cure. Results Overall, 1495 patients from 152 ICUs in 28 countries were studied. Combination therapy was prescribed in 50%, and carbapenems were prescribed in 26% of patients. Empirical therapy underwent ADE, no change and change other than ADE within the first 3 days in 16%, 63% and 22%, respectively. Unadjusted mortality at day 28 was 15.8% in the ADE cohort and 19.4% in patients with no change [p = 0.27; RR 0.83 (95% CI 0.60–1.14)]. The IP-weighted relative risk estimate for clinical cure comparing ADE with no-ADE patients (no change or change other than ADE) was 1.37 (95% CI 1.14–1.64). Conclusion ADE was infrequently applied in critically ill-infected patients. The observational effect estimate on clinical cure suggested no deleterious impact of ADE compared to no-ADE. However, residual confounding is likely. Electronic supplementary material The online version of this article (10.1007/s00134-020-06111-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liesbet De Bus
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
| | - Pieter Depuydt
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Johan Steen
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, C. Heymanslaan 10, Ghent, Belgium
- Renal Division, Ghent University Hospital, C. Heymanslaan 10, Ghent, Belgium
| | - Sofie Dhaese
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Ken De Smet
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Alexis Tabah
- Intensive Care Unit, Redcliffe and Caboolture Hospitals, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Murat Akova
- Departmant of Infectious Diseases and Clinical Microbiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Menino Osbert Cotta
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Gennaro De Pascale
- Dipartimento Di Scienza Dell'Emergenza, Anestesiologiche e della Rianimazione - UOC Di Anestesia, Rianimazione, Terapia Intensiva e Tossicologia Clinica - Istituto di Anestesia e Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, Athens, Greece
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Shigeki Fujitani
- Emergency Medicine and Critical Care Medicine, St. Marianna University Hospital, Kawasaki-City, Kanagawa, Japan
| | - Jose Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
- Instituto de Biomedicina de Sevilla (IBIS), Seville, Spain
| | - Marc Leone
- Service d'Anesthésie et de Réanimation, Hôpital NordAssistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Jeffrey Lipman
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - José-Artur Paiva
- Emergency and Intensive Care Department, Centro Hospitalar Universitário São João EPE, Porto, Portugal
- Faculdade de Medicina da Universidade Do Porto, Grupo de Infecção E Sépsis, Porto, Portugal
| | - Jeroen Schouten
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare, IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fredrik Sjövall
- Department of Intensive Care and Perioperative Medicine, Skane University Hospital, Malmö, Sweden
- Mitochondrial Medicine, Lund University, Lund, Sweden
| | - Jean-François Timsit
- Sorbonne Paris Cité, IAME, UMR 1137, Université de Paris, Paris, France
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard Hospital, 75018, Paris, France
| | - Jason A Roberts
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jean-Ralph Zahar
- INSERM, IAME UMR 1137, University of Paris, Paris, France
- Microbiology, Infection Control Unit, GH Paris Seine Saint-Denis, APHP, Bobigny, France
| | - Farid Zand
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kapil Zirpe
- Grant Medical Foundation, Ruby Hall Clinic, Pune, Maharashtra, India
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
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Gut Microbiota, Antibiotic Therapy and Antimicrobial Resistance: A Narrative Review. Microorganisms 2020; 8:microorganisms8020269. [PMID: 32079318 PMCID: PMC7074698 DOI: 10.3390/microorganisms8020269] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 02/08/2020] [Accepted: 02/08/2020] [Indexed: 12/13/2022] Open
Abstract
Antimicrobial resistance is a major concern. Epidemiological studies have demonstrated direct relationships between antibiotic consumption and emergence/dissemination of resistant strains. Within the last decade, authors confounded spectrum activity and ecological effects and did not take into account several other factors playing important roles, such as impact on anaerobic flora, biliary elimination and sub-inhibitory concentration. The ecological impact of antibiotics on the gut microbiota by direct or indirect mechanisms reflects the breaking of the resistance barrier to colonization. To limit the impact of antibiotic therapy on gut microbiota, consideration of the spectrum of activity and route of elimination must be integrated into the decision. Various strategies to prevent (antimicrobial stewardship, action on residual antibiotics at colonic level) or cure dysbiosis (prebiotic, probiotic and fecal microbiota transplantation) have been introduced or are currently being developed.
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16
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Timsit JF, Ruppé E, Barbier F, Tabah A, Bassetti M. Bloodstream infections in critically ill patients: an expert statement. Intensive Care Med 2020; 46:266-284. [PMID: 32047941 PMCID: PMC7223992 DOI: 10.1007/s00134-020-05950-6] [Citation(s) in RCA: 159] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/23/2020] [Indexed: 02/07/2023]
Abstract
Bloodstream infection (BSI) is defined by positive blood cultures in a patient with systemic signs of infection and may be either secondary to a documented source or primary—that is, without identified origin. Community-acquired BSIs in immunocompetent adults usually involve drug-susceptible bacteria, while healthcare-associated BSIs are frequently due to multidrug-resistant (MDR) strains. Early adequate antimicrobial therapy is a key to improve patient outcomes, especially in those with criteria for sepsis or septic shock, and should be based on guidelines and direct examination of available samples. Local epidemiology, suspected source, immune status, previous antimicrobial exposure, and documented colonization with MDR bacteria must be considered for the choice of first-line antimicrobials in healthcare-associated and hospital-acquired BSIs. Early genotypic or phenotypic tests are now available for bacterial identification and early detection of resistance mechanisms and may help, though their clinical impact warrants further investigations. Initial antimicrobial dosing should take into account the pharmacokinetic alterations commonly observed in ICU patients, with a loading dose in case of sepsis or septic shock. Initial antimicrobial combination attempting to increase the antimicrobial spectrum should be discussed when MDR bacteria are suspected and/or in the most severely ill patients. Source identification and control should be performed as soon as the hemodynamic status is stabilized. De-escalation from a broad-spectrum to a narrow-spectrum antimicrobial may reduce antibiotic selection pressure without negative impact on mortality. The duration of therapy is usually 5–8 days though longer durations may be discussed depending on the underlying illness and the source of infection. This narrative review covers the epidemiology, diagnostic workflow and therapeutic aspects of BSI in ICU patients and proposed up-to-date expert statements.
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Affiliation(s)
- Jean-François Timsit
- AP-HP, Hôpital Bichat, Medical and Infectious Diseases ICU, 75018, Paris, France. .,Université de Paris, IAME, INSERM, 75018, Paris, France.
| | - Etienne Ruppé
- Université de Paris, IAME, INSERM, 75018, Paris, France.,AP-HP, Hôpital Bichat, Bacteriology Laboratory, 75018, Paris, France
| | | | - Alexis Tabah
- ICU, Redcliffe Hospital, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino-IRCCS, Genoa, Italy
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17
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Tabah A, Bassetti M, Kollef MH, Zahar JR, Paiva JA, Timsit JF, Roberts JA, Schouten J, Giamarellou H, Rello J, De Waele J, Shorr AF, Leone M, Poulakou G, Depuydt P, Garnacho-Montero J. Antimicrobial de-escalation in critically ill patients: a position statement from a task force of the European Society of Intensive Care Medicine (ESICM) and European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Critically Ill Patients Study Group (ESGCIP). Intensive Care Med 2019; 46:245-265. [PMID: 31781835 DOI: 10.1007/s00134-019-05866-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/12/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antimicrobial de-escalation (ADE) is a strategy of antimicrobial stewardship, aiming at preventing the emergence of antimicrobial resistance (AMR) by decreasing the exposure to broad-spectrum antimicrobials. There is no high-quality research on ADE and its effects on AMR. Its definition varies and there is little evidence-based guidance for clinicians to use ADE in the intensive care unit (ICU). METHODS A task force of 16 international experts was formed in November 2016 to provide with guidelines for clinical practice to develop questions targeted at defining ADE, its effects on the ICU population and to provide clinical guidance. Groups of 2 experts were assigned 1-2 questions each within their field of expertise to provide draft statements and rationale. A Delphi method, with 3 rounds and an agreement threshold of 70% was required to reach consensus. RESULTS We present a comprehensive document with 13 statements, reviewing the evidence on the definition of ADE, its effects in the ICU population and providing guidance for clinicians in subsets of clinical scenarios where ADE may be considered. CONCLUSION ADE remains a topic of controversy due to the complexity of clinical scenarios where it may be applied and the absence of evidence to the effects it may have on antimicrobial resistance.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe and Caboolture Hospitals, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Santa Maria Misericordia University Hospital, Udine, Italy
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Jean-Ralph Zahar
- Hygiène Hospitalière Et Prévention du Risque Infectieux, CHU Avicenne, AP-HP, 125 rue de Stalingrad, 93000, Bobigny, France
| | - José-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar Universitário São João, Faculty of Medicine and University of Porto, Grupo de Infecçao e Sépsis, Porto, Portugal
| | - Jean-Francois Timsit
- Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard University Hospital, Paris, France
- University of Paris, INSERM IAME, U1137, Team DesCID, Paris, France
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, and Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Jeroen Schouten
- Department of Intensive Care, Radboudumc, Nijmegen, The Netherlands
| | - Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Jordi Rello
- CIBERES and Vall d'Hebron Institute of Research, Barcelona, Spain
- Clinical Research in ICU, CHU Nîmes, University Montpellier, Montpellier, France
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Marc Leone
- Department of Anesthesiology and Intensive Care Medicine, Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | - Garyphallia Poulakou
- 3rd Department of Medicine, National and Kapodistrian University of Athens, Medical School, Sotiria General Hospital, Athens, Greece
| | - Pieter Depuydt
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jose Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
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18
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Timsit JF, Bassetti M, Cremer O, Daikos G, de Waele J, Kallil A, Kipnis E, Kollef M, Laupland K, Paiva JA, Rodríguez-Baño J, Ruppé É, Salluh J, Taccone FS, Weiss E, Barbier F. Rationalizing antimicrobial therapy in the ICU: a narrative review. Intensive Care Med 2019; 45:172-189. [PMID: 30659311 DOI: 10.1007/s00134-019-05520-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/04/2019] [Indexed: 12/13/2022]
Abstract
The massive consumption of antibiotics in the ICU is responsible for substantial ecological side effects that promote the dissemination of multidrug-resistant bacteria (MDRB) in this environment. Strikingly, up to half of ICU patients receiving empirical antibiotic therapy have no definitively confirmed infection, while de-escalation and shortened treatment duration are insufficiently considered in those with documented sepsis, highlighting the potential benefit of implementing antibiotic stewardship programs (ASP) and other quality improvement initiatives. The objective of this narrative review is to summarize the available evidence, emerging options, and unsolved controversies for the optimization of antibiotic therapy in the ICU. Published data notably support the need for better identification of patients at risk of MDRB infection, more accurate diagnostic tools enabling a rule-in/rule-out approach for bacterial sepsis, an individualized reasoning for the selection of single-drug or combination empirical regimen, the use of adequate dosing and administration schemes to ensure the attainment of pharmacokinetics/pharmacodynamics targets, concomitant source control when appropriate, and a systematic reappraisal of initial therapy in an attempt to minimize collateral damage on commensal ecosystems through de-escalation and treatment-shortening whenever conceivable. This narrative review also aims at compiling arguments for the elaboration of actionable ASP in the ICU, including improved patient outcomes and a reduction in antibiotic-related selection pressure that may help to control the dissemination of MDRB in this healthcare setting.
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Affiliation(s)
- Jean-François Timsit
- Medical and Infectious Diseases ICU, APHP, Bichat-Claude Bernard Hospital, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France.
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Olaf Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - George Daikos
- Scool of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andre Kallil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric Kipnis
- Surgical Critical Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, CHU Lille, Lille, France
| | - Marin Kollef
- Critical Care Research, Washington University School of Medicine and Respiratory Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Kevin Laupland
- Department of Medicine, Royal Inland Hospital, Kamloops, Canada
| | - Jose-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar São João and Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jesús Rodríguez-Baño
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena, Departament of Medicine, University of Sevilla, Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Étienne Ruppé
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
- Bacteriology Laboratory, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jorge Salluh
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, IDOR, Rio De Janeiro, Brazil
| | | | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, AP-HP, Clichy, France
- INSERM, CRI, UMR 1149, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
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19
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Li H, Yang CH, Huang LO, Cui YH, Xu D, Wu CR, Tang JG. Antibiotics De-Escalation in the Treatment of Ventilator-Associated Pneumonia in Trauma Patients: A Retrospective Study on Propensity Score Matching Method. Chin Med J (Engl) 2018; 131:1151-1157. [PMID: 29722334 PMCID: PMC5956765 DOI: 10.4103/0366-6999.231529] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: Antimicrobial de-escalation refers to starting the antimicrobial treatment with broad-spectrum antibiotics, followed by narrowing the drug spectrum according to culture results. The present study evaluated the effect of de-escalation on ventilator-associated pneumonia (VAP) in trauma patients. Methods: This retrospective study was conducted on trauma patients with VAP, who received de-escalation therapy (de-escalation group) or non-de-escalation therapy (non-de-escalation group). Propensity score matching method was used to balance the baseline characteristics between both groups. The 28-day mortality, length of hospitalization and Intensive Care Unit stay, and expense of antibiotics and hospitalization between both groups were compared. Multivariable analysis explored the factors that influenced the 28-day mortality and implementation of de-escalation. Results: Among the 156 patients, 62 patients received de-escalation therapy and 94 patients received non-de-escalation therapy. No significant difference was observed in 28-day mortality between both groups (28.6% vs. 23.8%, P = 0.620). The duration of antibiotics treatment in the de-escalation group was shorter than that in the non-de-escalation group (11 [8–13] vs. 14 [8–19] days, P = 0.045). The expenses of antibiotics and hospitalization in de-escalation group were significantly lower than that in the non-de-escalation group (6430 ± 2730 vs. 7618 ± 2568 RMB Yuan, P = 0.043 and 19,173 ± 16,861 vs. 24,184 ± 12,039 RMB Yuan, P = 0.024, respectively). Multivariate analysis showed that high Acute Physiology and Chronic Health Evaluation II (APACHE II) score, high injury severity score, multi-drug resistant (MDR) infection, and inappropriate initial antibiotics were associated with patients' 28-day mortality, while high APACHE II score, MDR infection and inappropriate initial antibiotics were independent factors that prevented the implementation of de-escalation. Conclusions: De-escalation strategy in the treatment of trauma patients with VAP could reduce the duration of antibiotics treatments and expense of hospitalization, without increasing the 28-day mortality and MDR infection.
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Affiliation(s)
- Hu Li
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Chun-Hui Yang
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Li-Ou Huang
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Yu-Hui Cui
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Dan Xu
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Chun-Rong Wu
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Jian-Guo Tang
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
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Bluhmki T, Allignol A, Ruckly S, Timsit JF, Wolkewitz M, Beyersmann J. Estimation of adjusted expected excess length-of-stay associated with ventilation-acquired pneumonia in intensive care: A multistate approach accounting for time-dependent mechanical ventilation. Biom J 2018; 60:1135-1150. [DOI: 10.1002/bimj.201700242] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 06/28/2018] [Accepted: 08/06/2018] [Indexed: 12/29/2022]
Affiliation(s)
| | | | | | - Jean-Francois Timsit
- UMR 1137 IAME Inserm/University Paris Diderot; Paris France
- APHP; Bichat Hospital; Intensive Care Unit; Paris France
| | - Martin Wolkewitz
- Institute for Medical Biometry and Statistics; Faculty of Medicine and Medical Center-University of Freiburg; Freiburg Germany
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