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Madran B, Keske Ş, Ferhanoğlu B, Mandel NM, Ergönül Ö. The long-term impact of an antimicrobial stewardship program in febrile neutropenia: an 8 years follow up. Eur J Clin Microbiol Infect Dis 2024:10.1007/s10096-024-04939-z. [PMID: 39264372 DOI: 10.1007/s10096-024-04939-z] [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: 07/04/2024] [Accepted: 09/04/2024] [Indexed: 09/13/2024]
Abstract
PURPOSE To describe the long-term effects of an ASP among febrile neutropenia (FN) patients. METHODS A quasi-experimental study was conducted between 2015 and 2023 at a tertiary care hospital in Istanbul, Türkiye. The ASP was implemented for FN patients, and the effects were assessed before and after the ASP interventions, which included FN clinical pathways and regular multi-disciplinary meetings with relevant healthcare workers. RESULTS A total of 489 FN episodes of 290 patients were included, 42% were female, and the mean age was 56 years (SD: 15, range: 18-89 years). After the intervention, the rate of appropriate antimicrobial therapy at the levels of starting (p = 0.005), switching (p < 0.001), and de-escalation/discontinuation, (p < 0.001) significantly increased. Another positive impact of the ASP was a significant reduction in candidemia (from 4.88 to 0.74, p = 0.004), as well as a significant reduction in the 90-day mortality rate (from 19 to 5%, p < 0.001). In multivariate analysis, having a gram-negative bloodstream infection, prolonged days with fever, and a high risk for neutropenia were found to be significant predictors of 90-day mortality, while follow-up with ASP significantly reduced mortality. CONCLUSION Implementation of ASP led to reduced candidemia and LOS without increasing mortality, even in a country with a high rate of antimicrobial resistance. Implementation of sustainable ASP for FN patients is critical in combating antimicrobial resistance.
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Affiliation(s)
- Bahar Madran
- Department of Public Health, Koç University School of Medicine, Istanbul, Türkiye
- Koç University İşbank Center for Infectious Diseases, Istanbul, Türkiye
| | - Şiran Keske
- Koç University İşbank Center for Infectious Diseases, Istanbul, Türkiye
- Department of Infectious Diseases and Clinical Microbiology, Koç University School of Medicine, Istanbul, Türkiye
| | | | - Nil M Mandel
- Medical Oncology Department, American Hospital, Istanbul, Türkiye
| | - Önder Ergönül
- Koç University İşbank Center for Infectious Diseases, Istanbul, Türkiye.
- Department of Infectious Diseases and Clinical Microbiology, Koç University School of Medicine, Istanbul, Türkiye.
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Pérez-Lazo G, Del Valle-Mendoza J, Sandoval-Ahumada R, Soto-Febres F, Castillo-Córdova R, Zárate-Tantaleán M, Morales-Castillo L, Páucar-Miranda CJ, Altamirano-Molina M, Pacheco-Modesto I, Ruiz de Somocurcio-Cruzado C, Arana-Jurado D, Del Villar-Alarcón C, Vargas-Castro O, Díaz-Bardales C, Guerrero-Arismendiz B, Eyzaguirre-Zapata R, Aguilar-Luis MA, Martins-Luna J, Silva-Caso W. Impact of Adding a Rapid PCR-Based Blood Culture Identification Panel to the Antimicrobial Stewardship Program of Patients with Febrile Neutropenia in a Peruvian Referral Hospital. Antibiotics (Basel) 2023; 12:antibiotics12040648. [PMID: 37107010 PMCID: PMC10135419 DOI: 10.3390/antibiotics12040648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
The addition of Biofire® FilmArray® Blood Culture Identification panel 2 (BCID2) to the antimicrobial stewardship program (ASP) could improve outcomes in bloodstream infections (BSI) of patients with febrile neutropenia (FN). A pre- and post-quasi-experimental single-center study was conducted at a reference hospital in Peru. Three groups were considered: patients with BSI before ASP intervention (control group), patients with BSI after ASP intervention (group 1), and patients with BSI after ASP intervention plus BCID2 PCR Panel implementation (group 2). Overall, 93 patients were identified (32 control, 30 group 1, 31 group 2). The median time to effective therapy was significantly shorter in group 2 compared to group 1 and control group, respectively (3.75 vs. 10 h, p = 0.004; 3.75 vs. 19 h, p < 0.001). No significant differences in terms of relapse of bacteremia, in-hospital mortality (all cause), and 30-day-all-cause hospital readmission between the three study periods were found. The appropriateness of empirical antimicrobial use, adding or change, and the following de-escalation or discontinuation was significant when the two intervention periods were compared with the control group (p < 0.001). In addition to the lack of local studies documenting the microbiological profile of FN episodes, adding syndromic panels-based testing could allow for the consolidation of ASP strategies.
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Affiliation(s)
- Giancarlo Pérez-Lazo
- Escuela de Medicina, Universidad César Vallejo, Piura 20001, Peru
- Division of Infectious Diseases, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Juana Del Valle-Mendoza
- Centro de Investigación e Innovación de la Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima 15023, Peru
| | - Roxana Sandoval-Ahumada
- Clinical Pathology Department, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Fernando Soto-Febres
- Division of Infectious Diseases, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Raúl Castillo-Córdova
- Division of Infectious Diseases, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Melissa Zárate-Tantaleán
- Clinical Pathology Department, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Liliana Morales-Castillo
- Clinical Pathology Department, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | | | | | - Iván Pacheco-Modesto
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | | | - Denis Arana-Jurado
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Carmen Del Villar-Alarcón
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Olga Vargas-Castro
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Carol Díaz-Bardales
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Bruno Guerrero-Arismendiz
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Renee Eyzaguirre-Zapata
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Miguel Angel Aguilar-Luis
- Centro de Investigación e Innovación de la Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima 15023, Peru
| | - Johanna Martins-Luna
- Centro de Investigación e Innovación de la Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima 15023, Peru
| | - Wilmer Silva-Caso
- Centro de Investigación e Innovación de la Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima 15023, Peru
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Antimicrobial Stewardship Program for Patients in the Hematological Department Receiving Carbapenem Therapy: A Single-Center and Interrupted Time Series Analysis. Antibiotics (Basel) 2023; 12:antibiotics12020302. [PMID: 36830213 PMCID: PMC9951935 DOI: 10.3390/antibiotics12020302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
As antibiotic resistance has become a global problem, the intervention of an antimicrobial stewardship team (AST) is warranted. In hematological disorders, infectious complications are crucial owing to abnormal neutrophil function and decreased cell-mediated immunity. Despite the widespread implementation of AST intervention, the effectiveness of stewardship practices for immunocompromised patients remains uncertain. We determined the effect of AST interventions on carbapenem therapy in the department of hematology. Patients admitted to the department and undergoing carbapenem therapy were enrolled. We compared carbapenem use between the pre-AST (April 2016-March 2018) and post-AST (April 2018-March 2021) periods. Factors associated with long-term carbapenem therapy were investigated. Overall, 515 episodes of carbapenem therapy in 264 patients in the department were evaluated. According to the interrupted time series analysis, the number of days of therapy decreased with AST intervention (β = -0.263, p = 0.011). In multivariate analysis, predictive factors associated with long-term carbapenem therapy (>8 days) were outpatient onset, chronic obstructive pulmonary disease, acute myeloid leukemia, multiple myeloma, and infection with resistant bacteria (such as extended spectrum β-lactamases and AmpC) (95% confidence interval, 1.030-2.818, 1.067-66.667, 1.057-2.782, 0.168-0.742, and 1.382-5.750, respectively). The AST intervention reduced carbapenem use in patients with hematological disorders.
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Going local: Evaluating guideline adherence and appropriateness of antibiotic prescribing in patients with febrile neutropenia at an academic teaching hospital. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e3. [PMID: 36714288 PMCID: PMC9879896 DOI: 10.1017/ash.2022.353] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/08/2022] [Accepted: 11/08/2022] [Indexed: 01/11/2023]
Abstract
Background Febrile neutropenia (FN) is a medical emergency with significant morbidity and mortality for oncology patients, requiring comprehensive workup and timely antibiotic administration. We evaluated concordance with locally developed FN guidelines and outcomes of cancer patients admitted to general internal medicine at an academic teaching hospital. Methods We conducted a retrospective observational cohort study of patients admitted between July 1, 2016, and June 30, 2017, for FN. Patients were classified as having low-risk or high-risk FN according to their malignancy and chemotherapy. Primary outcome was the proportion of patients receiving guideline-concordant antibiotics within 48 hours of admission to general internal medicine. Secondary outcomes were the proportion of patients in whom empirical antibiotics were active against pathogens isolated, rate of antibiotic-associated adverse events, and in-hospital mortality. We used logistic regression to model relationship between FN risk and guideline-concordant antibiotics. Results Among 100 patients included, 34 (34%) were low-risk FN and 66 (66%) were high-risk. Proportion of guideline-concordant empirical antibiotics was significantly lower among low-risk FN patients than high-risk patients: 12 (35%) of 34 versus 47 (71%) of 66 (P = .001). Empirical antibiotics were active against 17 (94%) of 18 isolated pathogens. The mortality rate was 3%, and 16% of patients experienced antibiotic-associated adverse events. Hematological malignancy and infectious diseases-trained physician involvement were associated with guideline-concordant prescribing, with adjusted odds ratios of 3.76 (95% CI, 1.46-9.70; P = .006) and 3.71 (95% CI, 1.49-9.23; P = .005), respectively. Conclusions Guideline concordance was low compared to published reports. Factors influencing appropriate antimicrobial prescribing in patients with FN warrant further exploration.
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Antibiotic Stewardship Program Experience in a Training and Research Hospital. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2021; 55:253-261. [PMID: 34349604 PMCID: PMC8298082 DOI: 10.14744/semb.2020.96337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 12/02/2020] [Indexed: 11/20/2022]
Abstract
Objectives Antibiotic Stewardship Programs (ASP) have been developed for the spread of rational antibiotic use. Our hospital is one of the first centers where ASP applications were launched in Turkey. In this study, we aimed to share our experience with ASP which has been applied in our hospital since 2013. Methods We adapted ASP to our hospital program from Centers for Disease Control and Prevention's ASP checklist. Revisions on surgical prophylaxis guidelines and practices were performed. Surgical prophylaxis was evaluated from hospital infection surveillance and antibiotic usage by point prevalence surveys. Antibiotic consumption indexes (ACI) were calculated from hospital pharmacy records. Rapid antigen detection test (RADT) for Group A beta-hemolytic streptococcus and influenza rapid antigen test were started to be used. Cumulative antibiotic susceptibility results were prepared annually. Results Surgical prophylaxis was started to be administered in the operating room within 60 min of incision. Third-generation cephalosporin usage for surgical prophylaxis could be restricted in all clinics but the duration could only be shortened in neurosurgery and general surgery. There was no statistically significant change in antibiotic usage rates and appropriateness between 2014 and 2018. ACI for the class J01 in adult wards was 80.5 daily defined doses (DDD) per 100 patient days in 2014 and reduced to 64.8 DDD per 100 patient days in 2018. 22.445 pediatric patients presenting with complaints of the upper respiratory tract were evaluated with RADT and 75.1% were treated without antibiotics. Conclusion In this global antimicrobial resistance era, all hospitals should have motivated antimicrobial stewardship teams. Each hospital should establish its own stewardship program and often revise it. Improvement in rational antibiotic use is hard to achieve without multidisciplinary involvement.
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Dunnack HJ, Montano ARL. Interprofessional clinical pathway program effects on patient outcomes in the setting of neutropenic fever: An integrative review. Eur J Oncol Nurs 2021; 52:101974. [PMID: 33991870 DOI: 10.1016/j.ejon.2021.101974] [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: 11/30/2020] [Revised: 02/11/2021] [Accepted: 04/27/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Neutropenic fever (NF) is an oncologic emergency linked to substantial healthcare costs, treatment delays, and increased patient mortality. Clinical pathways have emerged as a coordinated, interprofessional approach to NF management. The aim of this review was to examine the research question: What is the effect of an interprofessional clinical pathway program on outcomes (time-to-antibiotic, mortality, cost, readmissions and length of stay) in patients presenting with NF? METHODS Using the integrative review method of Whittemore and Knafl, the databases PubMed, CINAHL and Scopus were searched for articles published in English between 1997 to present that met the following criteria: (1) reported clinical pathway implementation, and (2) reported outcome data on patients 18 years or older who were diagnosed with NF. RESULTS Of the 17 included articles, 13 demonstrated improvement in reducing time-to-antibiotic following clinical pathway implementation. Three studies reported a reduction in mortality and two studies reported no change in patient mortality after NF clinical pathway integration. One study demonstrated a reduction in hospital readmissions, while three studies showed improvement in length of stay. None of the included studies reported data on cost reduction. Half of the articles articulated the different members of the interprofessional teams. CONCLUSION The implementation of interprofessional clinical pathway programs for NF had positive effects on patient outcomes in this review. Measuring patient and institutional outcomes is necessary to evaluate the effectiveness of interprofessional clinical pathways in NF care. Future research should incorporate these measurements to improve the development and implementation of NF clinical pathways.
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Affiliation(s)
- Hayley J Dunnack
- University of Connecticut School of Nursing, 231 Glenbrook Road, Unit 4026, Storrs, CT, 06269, USA.
| | - Anna-Rae L Montano
- Brown University School of Public Health, 121 S. Main St, Ste. 6, Providence, RI, 02903, USA; Providence VA Medical Center, 830 Chalkstone Ave, Bld. 32, Providence, RI, 02903, USA
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Jantarathaneewat K, Apisarnthanarak A, Limvorapitak W, Weber DJ, Montakantikul P. Pharmacist-Driven Antibiotic Stewardship Program in Febrile Neutropenic Patients: A Single Site Prospective Study in Thailand. Antibiotics (Basel) 2021; 10:antibiotics10040456. [PMID: 33920541 PMCID: PMC8072986 DOI: 10.3390/antibiotics10040456] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/11/2021] [Accepted: 04/15/2021] [Indexed: 12/11/2022] Open
Abstract
The antibiotic stewardship program (ASP) is a necessary part of febrile neutropenia (FN) treatment. Pharmacist-driven ASP is one of the meaningful approaches to improve the appropriateness of antibiotic usage. Our study aimed to determine role of the pharmacist in ASPs for FN patients. We prospectively studied at Thammasat University Hospital between August 2019 and April 2020. Our primary outcome was to compare the appropriate use of target antibiotics between the pharmacist-driven ASP group and the control group. The results showed 90 FN events in 66 patients. The choice of an appropriate antibiotic was significantly higher in the pharmacist-driven ASP group than the control group (88.9% vs. 51.1%, p < 0.001). Furthermore, there was greater appropriateness of the dosage regimen chosen as empirical therapy in the pharmacist-driven ASP group than in the control group (97.8% vs. 88.7%, p = 0.049) and proper duration of target antibiotics in documentation therapy (91.1% vs. 75.6%, p = 0.039). The multivariate analysis showed a pharmacist-driven ASP and infectious diseases consultation had a favorable impact on 30-day infectious diseases-related mortality in chemotherapy-induced FN patients (OR 0.058, 95%CI:0.005–0.655, p = 0.021). Our study demonstrated that pharmacist-driven ASPs could be a great opportunity to improve antibiotic appropriateness in FN patients.
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Affiliation(s)
- Kittiya Jantarathaneewat
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand;
- Department of Pharmaceutical care, Faculty of Pharmacy, Thammasat University, Pathum Thani 12120, Thailand
| | - Anucha Apisarnthanarak
- Division of Infectious Diseases, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand;
| | - Wasithep Limvorapitak
- Division of Hematology, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand;
| | - David J. Weber
- School of Global Public Health, University of North Carolina, Gillings, Chapel Hill, NC 27599-7400, USA;
| | - Preecha Montakantikul
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand;
- Correspondence: ; Tel.: +66-0-2644-8694
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Guisado-Gil AB, Aguilar-Guisado M, Peñalva G, Lepe JA, Espigado I, Rodríguez-Arbolí E, González-Campos J, Rodríguez-Torres N, Montero-Cuadrado MI, Falantes-González JF, Reguera-Ortega JL, Gil-Navarro MV, Molina J, Pérez-Simón JA, Cisneros JM. Long-Term Impact of an Educational Antimicrobial Stewardship Program on Management of Patients with Hematological Diseases. Antibiotics (Basel) 2021; 10:antibiotics10020136. [PMID: 33573180 PMCID: PMC7911074 DOI: 10.3390/antibiotics10020136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/06/2021] [Accepted: 01/27/2021] [Indexed: 02/01/2023] Open
Abstract
Antimicrobial stewardship programs (ASPs) in hematological patients are especially relevant. However, information about ASPs in this population is scarce. For 11 years, we quarterly assessed antimicrobial consumption and incidence and death rates of multidrug-resistant (MDR) bloodstream infections (BSI) in the hematology Department. Healthcare activity indicators were also monitored yearly. We performed an interrupted time-series analysis. Antimicrobials showed a sustained reduction with a relative effect of −62.3% (95% CI −84.5 to −40.1) nine years after the inception of the ASP, being especially relevant for antifungals (relative effect −80.4%, −90.9 to −69.9), quinolones (relative effect −85.0%, −102.0 to −68.1), and carbapenems (relative effect −68.8%, −126.0 to −10.6). Incidence density of MDR BSI remained low and stable (mean 1.10 vs. 0.82 episodes per 1000 occupied bed days for the pre-intervention and the ASP period, respectively) with a quarterly percentage of change of −0.3% (95% CI −2.0 to 1.4). Early and late mortality of MDR BSI presented a steady trend (quarterly percentage of change −0.7%, 95% CI −1.7 to 0.3 and −0.6%, 95% CI −1.5 to 0.3, respectively). Volume and complexity of healthcare activity increased over the years. The ASP effectively achieved long-term reductions in antimicrobial consumption and improvements in the prescription profile, without increasing the mortality of MDR BSI.
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Affiliation(s)
- Ana Belén Guisado-Gil
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, 41013 Seville, Spain; (A.B.G.-G.); (G.P.); (J.A.L.); (J.M.); (J.M.C.)
- Department of Pharmacy, University Hospital Virgen del Rocio, 41013 Seville, Spain;
| | - Manuela Aguilar-Guisado
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, 41013 Seville, Spain; (A.B.G.-G.); (G.P.); (J.A.L.); (J.M.); (J.M.C.)
- Correspondence: ; Tel.: +34-670943816
| | - Germán Peñalva
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, 41013 Seville, Spain; (A.B.G.-G.); (G.P.); (J.A.L.); (J.M.); (J.M.C.)
| | - José Antonio Lepe
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, 41013 Seville, Spain; (A.B.G.-G.); (G.P.); (J.A.L.); (J.M.); (J.M.C.)
| | - Ildefonso Espigado
- Department of Hematology, Institute of Biomedicine of Seville (IBiS/CSIC/CIBERONC), University Hospital Virgen del Rocio, University of Seville, 41013 Seville, Spain; (I.E.); (E.R.-A.); (J.G.-C.); (N.R.-T.); (M.I.M.-C.); (J.F.F.-G.); (J.L.R.-O.); (J.-A.P.-S.)
| | - Eduardo Rodríguez-Arbolí
- Department of Hematology, Institute of Biomedicine of Seville (IBiS/CSIC/CIBERONC), University Hospital Virgen del Rocio, University of Seville, 41013 Seville, Spain; (I.E.); (E.R.-A.); (J.G.-C.); (N.R.-T.); (M.I.M.-C.); (J.F.F.-G.); (J.L.R.-O.); (J.-A.P.-S.)
| | - José González-Campos
- Department of Hematology, Institute of Biomedicine of Seville (IBiS/CSIC/CIBERONC), University Hospital Virgen del Rocio, University of Seville, 41013 Seville, Spain; (I.E.); (E.R.-A.); (J.G.-C.); (N.R.-T.); (M.I.M.-C.); (J.F.F.-G.); (J.L.R.-O.); (J.-A.P.-S.)
| | - Nancy Rodríguez-Torres
- Department of Hematology, Institute of Biomedicine of Seville (IBiS/CSIC/CIBERONC), University Hospital Virgen del Rocio, University of Seville, 41013 Seville, Spain; (I.E.); (E.R.-A.); (J.G.-C.); (N.R.-T.); (M.I.M.-C.); (J.F.F.-G.); (J.L.R.-O.); (J.-A.P.-S.)
| | - María Isabel Montero-Cuadrado
- Department of Hematology, Institute of Biomedicine of Seville (IBiS/CSIC/CIBERONC), University Hospital Virgen del Rocio, University of Seville, 41013 Seville, Spain; (I.E.); (E.R.-A.); (J.G.-C.); (N.R.-T.); (M.I.M.-C.); (J.F.F.-G.); (J.L.R.-O.); (J.-A.P.-S.)
| | - José Francisco Falantes-González
- Department of Hematology, Institute of Biomedicine of Seville (IBiS/CSIC/CIBERONC), University Hospital Virgen del Rocio, University of Seville, 41013 Seville, Spain; (I.E.); (E.R.-A.); (J.G.-C.); (N.R.-T.); (M.I.M.-C.); (J.F.F.-G.); (J.L.R.-O.); (J.-A.P.-S.)
| | - Juan Luis Reguera-Ortega
- Department of Hematology, Institute of Biomedicine of Seville (IBiS/CSIC/CIBERONC), University Hospital Virgen del Rocio, University of Seville, 41013 Seville, Spain; (I.E.); (E.R.-A.); (J.G.-C.); (N.R.-T.); (M.I.M.-C.); (J.F.F.-G.); (J.L.R.-O.); (J.-A.P.-S.)
| | | | - José Molina
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, 41013 Seville, Spain; (A.B.G.-G.); (G.P.); (J.A.L.); (J.M.); (J.M.C.)
| | - José-Antonio Pérez-Simón
- Department of Hematology, Institute of Biomedicine of Seville (IBiS/CSIC/CIBERONC), University Hospital Virgen del Rocio, University of Seville, 41013 Seville, Spain; (I.E.); (E.R.-A.); (J.G.-C.); (N.R.-T.); (M.I.M.-C.); (J.F.F.-G.); (J.L.R.-O.); (J.-A.P.-S.)
| | - José Miguel Cisneros
- Department of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospital Virgen del Rocio, 41013 Seville, Spain; (A.B.G.-G.); (G.P.); (J.A.L.); (J.M.); (J.M.C.)
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Pillinger KE, Bouchard J, Withers ST, Mediwala K, McGee EU, Gibson GM, Bland CM, Bookstaver PB. Inpatient Antibiotic Stewardship Interventions in the Adult Oncology and Hematopoietic Stem Cell Transplant Population: A Review of the Literature. Ann Pharmacother 2019; 54:594-610. [PMID: 31771337 DOI: 10.1177/1060028019890886] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective: To review the use of antibiotic stewardship interventions in the adult oncology and hematopoietic cell transplantation (HCT) populations. Data Sources: A literature search of PubMed was performed from inception to October 31, 2019. The general search terms used were oncology, cancer, hematologic malignancy, antimicrobial stewardship, antibiotic stewardship, febrile neutropenia, neutropenic fever, de-escalation, discontinuation, prophylaxis, practice guidelines, clinical pathway, rapid diagnostics, Filmarray, Verigene, MALDI-TOF, antibiotic allergy, and antimicrobial resistance. Study Selection and Data Extraction: Relevant English-language studies describing interventions supported by the Infectious Diseases Society of America guidelines on "Implementing an Antibiotic Stewardship Program" were included. Data Synthesis: Antibiotic stewardship publications in the oncology population have increased in recent years. Studies have described the impact of stewardship interventions, including preauthorization, prospective audit and feedback, implementation of clinical pathways, de-escalation of empirical antibiotics for febrile neutropenia (FN) prior to neutrophil recovery, allergy assessments, and use of rapid diagnostic testing. Many of these interventions have been shown to decrease antibiotic use without increased negative consequences, such as affecting length of stay or mortality. Relevance to Patient Care and Clinical Practice: This review synthesizes available evidence for implementing antibiotic stewardship interventions, particularly de-escalation of antibiotics for FN and implementation of clinical pathways for FN and sepsis, in oncology patients and HCT recipients. Summary tables highlight studies and specific research needs for clinicians. Conclusions: Immunocompromised populations, including oncology patients, have often been excluded from stewardship studies. Antibiotic stewardship is effective in reducing antibiotic consumption and improving outcomes in this patient population, although more quality data are needed.
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Antimicrobial Stewardship in Hematological Patients at the intensive care unit: a global cross-sectional survey from the Nine-i Investigators Network. Eur J Clin Microbiol Infect Dis 2019; 39:385-392. [PMID: 31707508 DOI: 10.1007/s10096-019-03736-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 10/03/2019] [Indexed: 01/05/2023]
Abstract
A global cross-sectional survey was performed to gather data on the current treatment of infections caused by multidrug-resistant (MDR) bacteria among hematological patients admitted to ICUs worldwide. The survey was performed in April 2019 using an electronic platform (SurveyMonkey®) being distributed among 83 physicians and completed by 48 (57.8%) responders. ESBL Enterobacteriaceae, carbapenem-resistant K. pneumoniae and carbapenem-resistant P. aeruginosa were the main concerns. Previous MDR infection (34% of responders), MDR colonization (20%) and previous antibiotic exposure within the last 3 months (20.5%) were considered the most relevant risk factors of bloodstream infection (BSI) due to MDR bacteria. In 48.8% of the ICUs, there was no antimicrobial stewardship (AMS) team focused on hematological patients. Updates on local epidemiology of MDR pathogens were provided in 98% of the centers, using phone or verbal communications (56.1% and 53.7%, respectively). In presence of febrile neutropenia, initial therapy consisted of anti-Gram-negative plus anti-Gram-positive antibiotics for 41% of participants. Antibiotic de-escalation and/or discontinuation of therapy were considered as a promising strategy for the prevention of MDR development (32.4%). Factors associated with antibiotic de-escalation were clinical improvement (43.6%) and neutrophil count recovery (12.8%). Infectious Disease consultation and AMS interventions were not determining factors for de-escalation decisions (more than 50% of responders). Infection control and educational programs were valued as necessary measures for implementation by ICU practitioners. These findings should guide future efforts on collaborative team working, improving compliance with adequate treatment protocols, implementing antimicrobial stewardship programs in critically ill hematological patients, and educational activities.
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O'Horo JC, Marcelin JR, Abu Saleh OM, Barwise AK, Odean PM, Rivera CG, Tande AJ, Wilson JW, Osmon DR, Tosh PK. Standardizing Febrile Neutropenia Management: Antimicrobial Stewardship in the Hematologic Malignancy Population. J Oncol Pract 2019; 15:e843-e848. [PMID: 31322989 DOI: 10.1200/jop.18.00775] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Patients with febrile neutropenia (FN) often are subject to antibiotic and diagnostic test overuse. We sought to improve appropriate use of antimicrobials and diagnostic tests for patients with FN. We used a blended quality approach with Lean Six Sigma tools and iterative improvement of a clinical decision aid to guide providers through empirical antimicrobial selection and diagnostic evaluation of patients with FN during a yearlong period. We evaluated the incidence of nonadherence to best practice before, during, and after rollout of a clinical decision aid in conjunction with an educational initiative. At baseline, 71% of patients with FN had at least one critical deviation from best practice. During the project, the percentage decreased to 27.3%; 4 months after the project was completed, the percentage was 33.3% (P = .04). A clinical decision aid can improve adherence to best practices for the empirical management of FN.
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Affiliation(s)
- John C O'Horo
- Mayo Clinic, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Group, Mayo Clinic, Rochester, MN
| | | | | | - Amelia K Barwise
- Mayo Clinic, Rochester, MN.,Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Group, Mayo Clinic, Rochester, MN
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12
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Molina J, Noguer M, Lepe JA, Pérez-Moreno MA, Aguilar-Guisado M, Lasso de la Vega R, Peñalva G, Crespo-Rivas JC, Gil-Navarro MV, Salvador J, Cisneros JM. Clinical impact of an educational antimicrobial stewardship program associated with infectious diseases consultation targeting patients with cancer: Results of a 9-year quasi-experimental study with an interrupted time-series analysis. J Infect 2019; 79:206-211. [PMID: 31299411 DOI: 10.1016/j.jinf.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 06/17/2019] [Accepted: 07/05/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Antibiotic stewardship programs (ASP) have already demonstrated clinical benefits. However, their effectiveness or safety in immunocompromised hosts needs to be proved. METHODS An ecologic quasi-experimental study was performed from January 2009 to June 2017 in the Oncology department of a tertiary-care hospital. A stable program of Infectious Diseases consultation (IDC) already existed at this unit, and an educational ASP was added in 2011. Its main intervention consisted of face-to-face educational interviews. Antibiotic consumption was assessed through quarterly Defined Daily Doses (DDD) per 100 occupied bed-days. Mortality was evaluated in patients with bloodstream infections through the quarterly incidence density per 1000 admissions, and the annual mortality rates at 7 and 30-days. Time-trends were analysed through segmented-regression analysis, and the impact of the ASP was assessed through before-after interrupted time-series analysis. RESULTS Mortality significantly decreased throughout the study period (-13.3% annual reduction for 7-day mortality rate, p < 0.01; -8.1% annual reduction for 30-day mortality, p = 0.03), parallel to a reduction in antibiotic consumption (quarterly reduction -0.4%, p = 0.01), especially for broader-spectrum antibiotics. The before-after study settled a significant inflexion point on the ASP implementation for the reduction of antibiotic consumption (change in level 0.95 DDD, p = 0.71; change in slope -1.98 DDD per quarter, p < 0.01). The decreasing trend for mortality before the ASP also continued after its implementation. CONCLUSIONS The combination of an ASP with IDC improved antibiotic use among patients with cancer, and was accompanied by a reduction of mortality of bacteraemic infections. Implementation of the ASP was necessary to effectively change antibiotic use.
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Affiliation(s)
- José Molina
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocío/CSIC/University of Seville, Spain
| | - Manuel Noguer
- Clinical Unit of Oncology, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocío/CSIC/University of Seville, Spain
| | - José Antonio Lepe
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocío/CSIC/University of Seville, Spain
| | - María Antonia Pérez-Moreno
- Clinical Unit of Pharmacy, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocío/CSIC/University of Seville, Spain
| | - Manuela Aguilar-Guisado
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocío/CSIC/University of Seville, Spain
| | - Roberto Lasso de la Vega
- Clinical Unit of Oncology, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocío/CSIC/University of Seville, Spain
| | - Germán Peñalva
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocío/CSIC/University of Seville, Spain
| | - Juan Carlos Crespo-Rivas
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocío/CSIC/University of Seville, Spain
| | - María Victoria Gil-Navarro
- Clinical Unit of Pharmacy, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocío/CSIC/University of Seville, Spain
| | - Javier Salvador
- Clinical Unit of Oncology, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocío/CSIC/University of Seville, Spain
| | - José Miguel Cisneros
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBIS), University Hospital Virgen del Rocío/CSIC/University of Seville, Spain.
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Effectiveness of clinical pathway for upper respiratory tract infections in emergency department. Int J Infect Dis 2019; 83:154-159. [PMID: 31051280 DOI: 10.1016/j.ijid.2019.04.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 04/22/2019] [Accepted: 04/24/2019] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE We aimed to demonstrate the benefits of implementing a clinical pathway to decrease the inappropriate use of antibiotics in upper respiratory tract infections (URTI) in an emergency department (ED). METHODS The study was performed in a hospital with 300 beds. All patients who applied with URTI from 1st to 30th of April 2017 were included and the appropriateness of the antibiotics were compared with the patients in the same period in 2016. A checklist for the clinical pathway of URTI was completed by the ED physicians. RESULTS 351 patients were included, 176 these patients were in pre-ASP period and 175 patients were in post-ASP period. The rate of prescriptions including antibiotics was 49% in pre-ASP period and has decreased to 29% in post-ASP period (p < 0.001). Adherence to clinical pathway has increased from 50% to 80% (p < 0.001). In the post-ASP period, clinical pathway was used in 133 out of 175 patients (76%) and the consequently rate of appropriate antibiotic use was 82%. CONCLUSION The implementation of clinical pathway for URTI has decreased inappropriate antibiotic use in ED. As the secondary effect, using clinical pathway in ED also has increased the awareness of ED physicians who did not adhere to clinical pathway.
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Van de Wyngaert Z, Berthon C, Debarri H, Bories C, Bonnet S, Nudel M, Carpentier B, Legrand C, Barbieux S, Chauvet P, Simonnet A, Willaume A, Bossard JB, Renaud L, Wattebled KJ, Escure G, Branche N, Arib I, Titecat M, Quesnel B, Alfandari S. Discontinuation of antimicrobial therapy in adult neutropenic haematology patients: A prospective cohort. Int J Antimicrob Agents 2019; 53:781-788. [PMID: 30831232 DOI: 10.1016/j.ijantimicag.2019.02.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/14/2019] [Accepted: 02/26/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Antibiotics for febrile neutropenia (FN) in acute myeloid leukaemia (AML) patients undergoing intensive chemotherapy are usually maintained until neutropenia resolution, because of the risk of uncontrolled sepsis in this vulnerable population. This leads to unnecessarily prolonged antimicrobial therapy. METHODS Based on ECIL-4 recommendations, we modified our management strategy and discontinued antibiotics after a pre-established duration in patients treated for a first episode of FN between August 2014 and October 2017. RESULTS Antibiotics were stopped during 62 FN episodes, and maintained in the control group (n = 13). Median age of patients was 54 years. A total of 39 (63%) patients received induction and 23 (37%) consolidation chemotherapy; 36 (58%) patients had fever of unknown origin. Median neutropenia length was 26 days (IQR 24-30). Antibiotics were started at day 9 (IQR 5-13). Most patients received piperacillin-tazobactam (56%) or cefepime (32%). Antimicrobial therapy was longer in the control group than in the policy compliant group, 10 (IQR 7-16) vs. 19 days (IQR 15-23), P = 0.0001. After antibiotics discontinuation, 20% patients experienced fever recurrence, within 5.5 days (IQR 3-7.5). None of these febrile episodes were severe and 80% patients remained afebrile, with neutrophil recovery occurring within 5 days (IQR 2-8.5). Overall, 287 antibiotics days were spared; this represents 49% of all days with antibiotics. No patient had died at day 30 from intervention; six died during late follow-up, two from graft-versus-host disease and four from relapsed or refractory leukaemia. CONCLUSIONS Discontinuing antibiotics in neutropenic AML patients treated for a first episode of FN is safe, and results in significant antibiotic sparing.
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Affiliation(s)
- Zoé Van de Wyngaert
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France.
| | - Céline Berthon
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France; INSERM, UMR-S 1172; Institut pour la recherche sur le Cancer de Lille, Place de Verdun, F-59000 Lille France
| | - Houria Debarri
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Claire Bories
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Sarah Bonnet
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Morgane Nudel
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Benjamin Carpentier
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Charline Legrand
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Sarah Barbieux
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Paul Chauvet
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Arthur Simonnet
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Alexandre Willaume
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Jean-Baptiste Bossard
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Loic Renaud
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Kevin James Wattebled
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Guillaume Escure
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Nicolas Branche
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Ines Arib
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France
| | - Marie Titecat
- Service de bactériologie, Centre de biologie-pathologie, Rue du Pr Jules LECLERCQ, CHU de Lille, France
| | - Bruno Quesnel
- CHU Lille, Service des Maladies du Sang, Rue Michel Polonovski F-59000 Lille, France; INSERM, UMR-S 1172; Institut pour la recherche sur le Cancer de Lille, Place de Verdun, F-59000 Lille France; Univ. Lille, 2 Avenue Eugène Avinée, F-59000 Lille, France
| | - Serge Alfandari
- Service de réanimation et maladies infectieuses, CH Tourcoing, 59208 Tourcoing, France
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