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Huo X, Liu P. An agent-based model on antimicrobial de-escalation in intensive care units: Implications on clinical trial design. PLoS One 2024; 19:e0301944. [PMID: 38626111 PMCID: PMC11020418 DOI: 10.1371/journal.pone.0301944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/21/2024] [Indexed: 04/18/2024] Open
Abstract
Antimicrobial de-escalation refers to reducing the spectrum of antibiotics used in treating bacterial infections. This strategy is widely recommended in many antimicrobial stewardship programs and is believed to reduce patients' exposure to broad-spectrum antibiotics and prevent resistance. However, the ecological benefits of de-escalation have not been universally observed in clinical studies. This paper conducts computer simulations to assess the ecological effects of de-escalation on the resistance prevalence of Pseudomonas aeruginosa-a frequent pathogen causing nosocomial infections. Synthetic data produced by the models are then used to estimate the sample size and study period needed to observe the predicted effects in clinical trials. Our results show that de-escalation can reduce colonization and infections caused by bacterial strains resistant to the empiric antibiotic, limit the use of broad-spectrum antibiotics, and avoid inappropriate empiric therapies. Further, we show that de-escalation could reduce the overall super-infection incidence, and this benefit becomes more evident under good compliance with hand hygiene protocols among health care workers. Finally, we find that any clinical study aiming to observe the essential effects of de-escalation should involve at least ten arms and last for four years-a size never attained in prior studies. This study explains the controversial findings of de-escalation in previous clinical studies and illustrates how mathematical models can inform outcome expectations and guide the design of clinical studies.
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Affiliation(s)
- Xi Huo
- Department of Mathematics, University of Miami, Coral Gables, FL, United States of Ameica
| | - Ping Liu
- LinkedIn Corporation, Mountain View, CA, United States of Ameica
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2
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Chen J, Ma H, Huang X, Cui Y, Peng W, Zhu F, Ma S, Rao M, Zhang P, Yang H, Su L, Niu R, Pan P. Risk factors and mortality of carbapenem-resistant Klebsiella pneumoniae bloodstream infection in a tertiary-care hospital in China: an eight-year retrospective study. Antimicrob Resist Infect Control 2022; 11:161. [PMID: 36536423 PMCID: PMC9761986 DOI: 10.1186/s13756-022-01204-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The prevalence of carbapenem-resistant Klebsiella pneumoniae bloodstream infection (CRKP-BSI) is increasing worldwide. CRKP-BSI is associated with high rates of morbidity and mortality due to limited antibiotic choices. Here, we aim to identify the prevalence and risk factors for infection and mortality of CRKP BSI. METHODS This was a retrospective study of the past data from January 1st, 2012 to December 31st, 2019 of adult patients with KP-BSI in Xiangya Hospital, China. RESULTS Among the 706 incidences included in this study, 27.4% of them (212/753) being CR-KP strains. The occurrence of CRKP-BSI was increased from 20.69 to 37.40% from 2012 to 2019. Hematologic malignancies and ICU acquired infection were identified to be substantial risk factors of carbapenem resistance. The overall 28-day mortality rates of CRKP-BSI patients was significantly higher than that of CSKP-BSI (P < 0.001). Logistic regression analysis identified severe sepsis or septic shock incidents, inadequate empirical antimicrobial therapy and corticosteroids use preceding infection onset as the independent predictors of 28-day mortality of CRKP-BSI patients. However, high dose carbapenem combination therapy was identified as anticipated factors of low 28-day mortality. CONCLUSION The occurrence of CRKP-BSI was significantly increased during the study period. Hematologic malignancies and ICU acquired infection were associated with the development of CRKP BSI. Severe sepsis or septic shock incidents, inadequate empirical antimicrobial therapy and corticosteroids use preceding infection onset caused significant increase of mortality rates in CRKP-BSI patients. High dose carbapenem combination therapy was associated with better outcome.
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Affiliation(s)
- Jie Chen
- grid.452223.00000 0004 1757 7615Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, No. 28 Xiangya Road, Kai-Fu District, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008 Hunan People’s Republic of China ,Clinical Research Center for Respiratory Diseases in Hunan Province, Changsha, 410008 Hunan People’s Republic of China ,Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, 410008 Hunan People’s Republic of China
| | - Hua Ma
- Department of Infectious Disease, People’s Hospital of Liuyang City, Liuyang, 410300 Hunan People’s Republic of China
| | - Xiaoming Huang
- Department of Respiratory Medicine, Traditional Chinese Medicine Hospital of Leiyang City, Hengyang, Hunan People’s Republic of China
| | - Yanhui Cui
- grid.452223.00000 0004 1757 7615Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, No. 28 Xiangya Road, Kai-Fu District, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008 Hunan People’s Republic of China ,Clinical Research Center for Respiratory Diseases in Hunan Province, Changsha, 410008 Hunan People’s Republic of China ,Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, 410008 Hunan People’s Republic of China
| | - Wenzhong Peng
- grid.452223.00000 0004 1757 7615Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, No. 28 Xiangya Road, Kai-Fu District, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008 Hunan People’s Republic of China ,Clinical Research Center for Respiratory Diseases in Hunan Province, Changsha, 410008 Hunan People’s Republic of China ,Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, 410008 Hunan People’s Republic of China
| | - Fei Zhu
- grid.452223.00000 0004 1757 7615Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, No. 28 Xiangya Road, Kai-Fu District, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008 Hunan People’s Republic of China ,Clinical Research Center for Respiratory Diseases in Hunan Province, Changsha, 410008 Hunan People’s Republic of China ,Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, 410008 Hunan People’s Republic of China
| | - Shiyang Ma
- grid.452223.00000 0004 1757 7615Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, No. 28 Xiangya Road, Kai-Fu District, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008 Hunan People’s Republic of China ,Clinical Research Center for Respiratory Diseases in Hunan Province, Changsha, 410008 Hunan People’s Republic of China ,Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, 410008 Hunan People’s Republic of China
| | - Minjun Rao
- grid.452223.00000 0004 1757 7615Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, No. 28 Xiangya Road, Kai-Fu District, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008 Hunan People’s Republic of China ,Clinical Research Center for Respiratory Diseases in Hunan Province, Changsha, 410008 Hunan People’s Republic of China ,Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, 410008 Hunan People’s Republic of China
| | - Peipei Zhang
- grid.452223.00000 0004 1757 7615Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, No. 28 Xiangya Road, Kai-Fu District, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008 Hunan People’s Republic of China ,Clinical Research Center for Respiratory Diseases in Hunan Province, Changsha, 410008 Hunan People’s Republic of China ,Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, 410008 Hunan People’s Republic of China
| | - Hang Yang
- grid.452223.00000 0004 1757 7615Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, No. 28 Xiangya Road, Kai-Fu District, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008 Hunan People’s Republic of China ,Clinical Research Center for Respiratory Diseases in Hunan Province, Changsha, 410008 Hunan People’s Republic of China ,Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, 410008 Hunan People’s Republic of China
| | - Longxiang Su
- grid.413106.10000 0000 9889 6335Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 1st Shuaifuyuan, Dongcheng District, Beijing, 100730 People’s Republic of China
| | - Ruichao Niu
- grid.452223.00000 0004 1757 7615Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, No. 28 Xiangya Road, Kai-Fu District, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008 Hunan People’s Republic of China ,Clinical Research Center for Respiratory Diseases in Hunan Province, Changsha, 410008 Hunan People’s Republic of China ,Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, 410008 Hunan People’s Republic of China ,grid.512482.8Department of Respiratory Medicine, The Second Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region People’s Republic of China
| | - Pinhua Pan
- grid.452223.00000 0004 1757 7615Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, No. 28 Xiangya Road, Kai-Fu District, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, 410008 Hunan People’s Republic of China ,Clinical Research Center for Respiratory Diseases in Hunan Province, Changsha, 410008 Hunan People’s Republic of China ,Hunan Engineering Research Center for Intelligent Diagnosis and Treatment of Respiratory Disease, Changsha, 410008 Hunan People’s Republic of China ,grid.452223.00000 0004 1757 7615National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, 410008 Hunan People’s Republic of China
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Giacomini E, Perrone V, Alessandrini D, Paoli D, Nappi C, Degli Esposti L. Evidence of Antibiotic Resistance from Population-Based Studies: A Narrative Review. Infect Drug Resist 2021; 14:849-858. [PMID: 33688220 PMCID: PMC7937387 DOI: 10.2147/idr.s289741] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/11/2021] [Indexed: 12/23/2022] Open
Abstract
The 20th century witnessed the dawn of the antibiotic revolution and is now facing the rising phenomenon of antibiotic resistance. In this narrative review, we aim to describe antibiotic resistance in clinical practice settings through population-based studies from different countries reporting the role of misuse of antibiotics in the development of resistance and the clinical and economic burden associated. The misuse of antibiotics was documented in the wide population as well as in hospitals and care facilities. It was mainly reported as over-use and inappropriate prescribing. Improper dosage regimens and longer treatment duration were regarded as pivotal factors related to antibiotic resistance; the emerging strategy of "antibiotic-de-escalation" could be the key to overcome these issues. The investigation of the self-medication attitude revealed widespread antibiotic use without following medical instructions or medical consultation. Moreover, several studies established the association of antibiotic resistance with increased risk of longer hospitalizations and mortality, highlighting the heavy clinical and economic burden of this phenomenon. In this narrative review, the widespread inappropriate use of antibiotics emerged as one of the main causes of antibiotic resistance, which negative outcomes call for the development of antibiotic stewardship programs and global surveillance networks.
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Affiliation(s)
- Elisa Giacomini
- CliCon S.r.l. Health, Economics & Outcomes Research, Ravenna, Italy
| | | | | | - Daniela Paoli
- CliCon S.r.l. Health, Economics & Outcomes Research, Ravenna, Italy
| | - Carmela Nappi
- CliCon S.r.l. Health, Economics & Outcomes Research, Ravenna, Italy
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Novak F, Hørlück JT, Redder JD, Denton PW, Storgaard M. Poor compliance with an antibiotic directive-A call for intensified monitoring. Int J Infect Dis 2021; 104:474-478. [PMID: 33465487 DOI: 10.1016/j.ijid.2021.01.029] [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: 11/26/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In April 2017, the Central Denmark Region Antibiotic Stewardship Committee issued a directive to reduce the general use of piperacillin-tazobactam and prescribe narrow-spectrum antibiotics for mild and moderate pneumonia. The directive was distributed to all regional hospital clinicians. METHODS Electronic medical records were used to obtain de-identified details of all antibiotics administered (together with diagnosis codes) to all in-hospital patients (pre-directive and post-directive) in the nine regional hospitals. Average moving range statistical process control charts were used to analyze pre-directive and post-directive variation in antibiotic usage patterns. RESULTS Upon the distribution of the directive, a period of decline of the overall usage of piperacillin-tazobactam ensued. Rather than benzylpenicillin, as recommended for pneumonia, the initial decline in piperacillin/tazobactam usage was accompanied by increased use of cefuroxime. CONCLUSIONS A steward-directed reduction in piperacillin-tazobactam usage was accompanied by less desirable usage of a broad-spectrum alternative. Future antibiotic stewardship initiatives will hopefully benefit from close monitoring and timely feedback to clinicians. A dialogue with clinicians based on near real-time data is predicted to improve antibiotic stewardship actions.
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Affiliation(s)
- Frederik Novak
- Department of Infectious Diseases, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | | | - Jacob D Redder
- Business Intelligence Office, Department of Information Technology, Central Denmark Region, Aarhus, Denmark
| | - Paul W Denton
- Department of Infectious Diseases, Aarhus University Hospital, Skejby, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Universityof Nebraska at Omaha, Department of Biology, Omaha, Nebraska, USA
| | - Merete Storgaard
- Department of Infectious Diseases, Aarhus University Hospital, Skejby, Aarhus, Denmark.
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He G, Huang J, Huang S, Sun J, Zhou Y, Tan H, Shen H, Li Z, Liu J. Risk Factors Affecting Clinical Outcome in Patients with Carbapenem-Resistant K. pneumoniae: A Retrospective Study. Med Sci Monit 2020; 26:e925693. [PMID: 33098640 PMCID: PMC7592427 DOI: 10.12659/msm.925693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background The increased prevalence of carbapenem-resistant K. pneumoniae (CRKP) poses a great threat worldwide. Early identification of CRKP in patients is paramount. Moreover, fully understanding the risk factors affecting clinical outcome and actively providing targeted treatment can improve the cure rate of patients with CRKP. Therefore, our study aimed to describe the clinical characteristics and identify the risk factors affecting clinical outcomes in patients with CRKP. Material/Methods From January 2016 to September 2017, CRKP strains and clinical data from 97 hospitalized patients were collected. We first performed an antibiotic susceptibility test on CRKP strains using the Kirby-Bauer disc agar diffusion method. Logistic regression analysis was then performed to analyze risk factors. Results According to clinical outcome, among the 97 CRKP patients, 67 were in the effective group and 30 patients were in the noneffective group. Risk factors found to correlate with poor clinical outcome in patients with CRKP included ICU admission, arteriovenous catheterization, indwelling gastric tube, indwelling urethral catheter, tracheal intubation, mechanical ventilation, hypoproteinemia, and exposure to carbapenems. Multivariate analysis showed that hypoproteinemia (OR: 2.83, p=0.042), presence of an indwelling gastric tube (OR: 4.54, p=0.005), and exposure to carbapenems (OR: 2.77, p=0.045) negatively affected clinical outcome in patients with CRKP. Conclusions Adverse risk factors correlated with poor clinical outcomes in patients with CRKP were determined. This could be of help in identifying high-risk patients with whom clinicians should take extra precautions and adjust therapeutic strategy to supplement conventional basic treatment with additional measures.
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Affiliation(s)
- Gefei He
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China (mainland)
| | - Juanjuan Huang
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China (mainland)
| | - Shiqiong Huang
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China (mainland)
| | - Ji Sun
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China (mainland)
| | - Yulv Zhou
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China (mainland)
| | - Hong Tan
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan, China (mainland)
| | - Hui Shen
- Medical Laboratory, The First Hospital of Changsha, Changsha, Hunan, China (mainland)
| | - Zhuan Li
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China (mainland)
| | - Jiyang Liu
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, China (mainland)
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The learning hospital: From theory to practice in a hospital infection prevention program. Infect Control Hosp Epidemiol 2020; 41:86-97. [DOI: 10.1017/ice.2019.318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AbstractThe learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.
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Singh R, Azim A, Gurjar M, Poddar B, Baronia AK. Audit of Antibiotic Practices: An Experience from a Tertiary Referral Center. Indian J Crit Care Med 2019; 23:7-10. [PMID: 31065201 PMCID: PMC6481268 DOI: 10.5005/jp-journals-10071-23104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims To estimate the prevalence of antibiotic de-escalation at admission in patients referred to a tertiary hospital in India. The secondary outcomes were the adequacy of empirical antibiotic therapy and culture positivity rates in the de-escalated group. Materials and methods A prospective observational study, in a 20-bedded intensive care unit (ICU) of tertiary care hospital. Patients >18 years, surviving > 48 hours, were included (June– December 2017). Demographic data, previous cultures, and antibiotics from other hospitals, laboratory parameters in the first 24 hours, and severity of illness were noted. Changes made in antibiotic therapy within 48 hours were recorded. Patients were analyzed into three groups: “No change”–empiric therapy was maintained, “Escalation”–switch to or addition of an antibiotic with a broader spectrum, and “De-escalation”–switch to or interruption of a drug class. Results The total number of patients eligible was 75. The mean age of the population is 43.38 (SD + 3.4) and groups were comparable in terms of mean sequential organ failure assessment score (SOFA) and acute physiology, age, chronic health evaluation (APACHE) 2. The prevalence of de-escalation was 60% at admission. The escalation group consisted of 24%. Sixteen percent patients belonged to no change group. Results showed that 38% of patients were on carbapenems, dual gram negative was given to 26%, and empirical methicillin-resistant staphylococcus aureus (MRSA) coverage was 28% on admission. Conclusion Our study aims to provide data about actual practices in the Indian scenario. It highlights the generous use of high-end antibiotics in the community. Indian practices are far cry from theoretical teaching and western data. The need for antibiotic stewardship program in our country for both public and private health sectors is the need of the hour. How to cite this article Singh R, Azim A, Gurjar M, Poddar B, Baronia AK. Audit of Antibiotic Practices: An Experience from a Tertiary Referral Center. Indian Journal of Critical Care Medicine, January 2019;23(1):7-10.
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Affiliation(s)
- Ritu Singh
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Afzal Azim
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Banani Poddar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arvind K Baronia
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Menichetti F, Falcone M, Lopalco P, Tascini C, Pan A, Busani L, Viaggi B, Rossolini GM, Arena F, Novelli A, De Rosa F, Iannazzo S, Cohen J. The GISA call to action for the appropriate use of antimicrobials and the control of antimicrobial resistance in Italy. Int J Antimicrob Agents 2018; 52:127-134. [PMID: 29802887 DOI: 10.1016/j.ijantimicag.2018.05.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 04/17/2018] [Accepted: 05/12/2018] [Indexed: 12/21/2022]
Abstract
The spread of antibiotic resistance is one of the leading public health problems in Italy. A European Centre for Disease Prevention and Control country visit recently confirmed the major challenges and made important suggestions. In response, the Ministry of Health published the National Plan for Antimicrobial Resistance Containment, and a group of experts belonging to the Italian Group of Antimicrobial Stewardship (GISA) convened to develop a summary of practical recommendations. The GISA document is intended for use by practising physicians; it aims to increase the rational use of antimicrobials in the treatment of infections, and to change the culture of infection control of antibiotic-resistant bacteria, through the translation of theoretical knowledge into priority actions. This document has been endorsed by several national scientific societies, and reflects the particular challenges that are faced in Italy. Nevertheless, it is considered that the general principles and approaches discussed are relevant, particularly to other developed economies.
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Affiliation(s)
- Francesco Menichetti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Marco Falcone
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Pierluigi Lopalco
- Hygiene and Epidemiology Section, Department of Translational Research, New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Carlo Tascini
- Department of Infectious Diseases, Cotugno Hospital, Naples, Italy
| | - Angelo Pan
- Infectious Diseases, Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Luca Busani
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Bruno Viaggi
- NeuroAnesthesia and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, Clinical Microbiology and Virology Unit, Florence Careggi University Hospital, Florence, Italy
| | - Fabio Arena
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Andrea Novelli
- Department of Health Sciences, Clinical Pharmacology and Oncology Section, University of Florence, Florence, Italy
| | | | - Stefania Iannazzo
- Department of Prevention and Innovation, General Direction, Italian Ministry of Health, Rome, Italy
| | - Jonathan Cohen
- Department of Medicine, Brighton & Sussex Medical School, Brighton, UK
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Zheng X, Wang JF, Xu WL, Xu J, Hu J. Clinical and molecular characteristics, risk factors and outcomes of Carbapenem-resistant Klebsiella pneumoniae bloodstream infections in the intensive care unit. Antimicrob Resist Infect Control 2017; 6:102. [PMID: 29026535 PMCID: PMC5625719 DOI: 10.1186/s13756-017-0256-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/04/2017] [Indexed: 11/10/2022] Open
Abstract
Background To analyze the clinical characteristics and outcomes of carbapenem-resistant Klebsiella pneumoniae (CRKp) and carbapenem-susceptible K. pneumoniae (CSKp) bloodstream infections (BSIs), and to study the risk factors for development of CRKp BSI and K. pneumoniae BSI-related mortality. Methods A retrospective case control study of patients with K. pneumoniae BSI was conducted in the intensive care unit of the First Affiliated Hospital, Medical of College, Zhejiang University from January 2013 to December 2014. Carbapenem resistance was defined in accordance with the Clinical and Laboratory Standards Institute 2016 guidelines. Risk factors for the development of CRKp BSI and risk factors for mortality due to K. pneumoniae BSI were assessed. Virulence genes were detected by polymerase chain reaction assay. Results In total, 48 patients were enrolled in the study, including 31 (65%) patients with CRKp BSI and 17 (35%) patients with CSKp BSI. CSKp infection was associated with more severe clinical symptoms, particularly a higher serum creatinine level (165.06 ± 127.01 in the CSKp group vs. 93.77 ± 84.35 μmol/L in the CRKp group, p = 0.039), but there was no significant difference in prognosis between the CSKp and CRKp groups. On multivariate analysis, indwelling central venous catheter (p = 0.045) was the only factor independently associated with CRKp bacteremia. However, the mortality of K. pneumoniae BSI patients was not correlated with carbapenem resistance. In addition, the isolates had diverse clonality and different origins. The frequency of detection of the allS and magA virulence genes was higher in the CSKp group than in the CRKp group (alls p = 0.04; magA p = 0.047). Conclusions Patients in the CSKp group experienced more severe clinical symptoms, although mortality did not differ significantly between the CRKp and CSKp groups. An indwelling central venous catheter was the only factor independently associated with CRKp BSI. The mortality of patients with K. pneumoniae BSI was not associated with carbapenem resistance. The frequency of virulence genes was higher in the CSKp group than in the CRKp group.
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Affiliation(s)
- Xia Zheng
- Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003 People's Republic of China
| | - Jian-Feng Wang
- Department of Respiratory Diseases, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang, No. 126 Wenzhou Road, Hangzhou, 310009 People's Republic of China
| | - Wang-Lan Xu
- Intensive Care Unit, Hospital of Zhejiang General Corps of Armed Police Forces, No. 16 Nanhu Road, Jiaxing, 314000 Zhejiang, People's Republic of China
| | - Jun Xu
- Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003 People's Republic of China
| | - Juan Hu
- Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003 People's Republic of China
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Trupka T, Fisher K, Micek ST, Juang P, Kollef MH. Enhanced antimicrobial de-escalation for pneumonia in mechanically ventilated patients: a cross-over study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:180. [PMID: 28709439 PMCID: PMC5513164 DOI: 10.1186/s13054-017-1772-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 06/26/2017] [Indexed: 12/29/2022]
Abstract
Background Antibiotics are commonly administered to hospitalized patients with infiltrates for possible bacterial pneumonia, often leading to unnecessary treatment and increasing the risk for resistance emergence. Therefore, we performed a study to determine if an enhanced antibiotic de-escalation practice could improve antibiotic utilization in mechanically ventilated patients with suspected pneumonia cared for in an academic closed intensive care unit (ICU). Methods This was a prospective cross-over trial comparing routine antibiotic management (RAM) and enhanced antimicrobial de-escalation (EAD) performed within two medical ICUs (total 34 beds) at Barnes-Jewish Hospital, an academic referral center. Patients in the EAD group had their antibiotic orders and microbiology results reviewed daily by a dedicated team comprised of a second-year critical care fellow, an ICU attending physician and an ICU pharmacist. Antibiotic de-escalation recommendations were made when appropriate based on microbiologic test results and clinical response to therapy. Results There were 283 patients evaluable, with suspected pneumonia requiring mechanical ventilation: 139 (49.1%) patients in the RAM group and 144 (50.9%) in the EAD group. Early treatment failure based on clinical deterioration occurred in 33 (23.7%) and 40 (27.8%) patients, respectively (P = 0.438). In the remaining patients, antimicrobial de-escalation occurred in 70 (66.0%) and 70 (67.3%), respectively (P = 0.845). There was no difference between groups in total antibiotic days ((median (interquartile range)) 7.0 days (4.0, 9.0) versus 7.0 days (4.0, 8.8) (P = 0.616)); hospital mortality (25.2% versus 35.4% (P = 0.061)); or hospital duration (12.0 days (6.0, 20.0) versus 11.0 days (6.0, 22.0) (P = 0.918). Conclusions The addition of an EAD program to a high-intensity daytime staffing model already practicing a high-level of antibiotic stewardship in an academic ICU was not associated with greater antibiotic de-escalation or a reduction in the overall duration of antibiotic therapy. Trial registration ClinicalTrials.gov, NCT02685930. Registered on 26 January 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1772-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tracy Trupka
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Ave, Campus Box 8052, St. Louis, MO, 63110, USA
| | - Kristen Fisher
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Ave, Campus Box 8052, St. Louis, MO, 63110, USA
| | - Scott T Micek
- Division of Pharmacy Practice, St. Louis College of Pharmacy, St. Louis, MO, USA
| | - Paul Juang
- Division of Pharmacy Practice, St. Louis College of Pharmacy, St. Louis, MO, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Ave, Campus Box 8052, St. Louis, MO, 63110, USA.
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