1
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Serena TE, Snyder RJ, Bowler PG. Use of fluorescence imaging to optimize location of tissue sampling in hard-to-heal wounds. Front Cell Infect Microbiol 2023; 12:1070311. [PMID: 36710976 PMCID: PMC9878329 DOI: 10.3389/fcimb.2022.1070311] [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: 10/18/2022] [Accepted: 12/20/2022] [Indexed: 01/14/2023] Open
Abstract
Introduction Wound microflora in hard-to-heal wounds is invariably complex and diverse. Determining the interfering organisms(s) is therefore challenging. Tissue sampling, particularly in large wounds, is subjective and, when performed, might involve swabbing or biopsy of several locations. Fluorescence (FL) imaging of bacterial loads is a rapid, non-invasive method to objectively locate microbial hotspots (loads >104 CFU/gr). When sampling is deemed clinically necessary, imaging may indicate an optimal site for tissue biopsy. This study aimed to investigate the microbiology of wound tissue incisional biopsies taken from sites identified by FL imaging compared with sites selected by clinical judgment. Methods A post hoc analysis of the 350-patient FLAAG wound trial was conducted; 78 wounds were included in the present study. All 78 wounds were biopsied at two sites: one at the center of the wound per standard of care (SoC) and one site guided by FL-imaging findings, allowing for comparison of total bacterial load (TBL) and species present. Results The comparison between the two biopsy sites revealed that clinical uncertainty was higher as wound surface area increased. The sensitivity of a FL-informed biopsy was 98.7% for accurately finding any bacterial loads >104 CFU/g, compared to 87.2% for SoC (p=0.0059; McNemar test). Regarding species detected, FL-informed biopsies detected an average of 3 bacterial species per biopsy versus 2.2 species with SoC (p < 0.001; t-test). Microbial hotspots with a higher number of pathogens also included the CDC's pathogens of interest. Conclusions & perspective FL imaging provides a more accurate and relevant microbiological profile that guides optimal wound sampling compared to clinical judgment. This is particularly interesting in large, complex wounds, as evidenced in the wounds studied in this post hoc analysis. In addition, fluorescence imaging enables earlier bacterial detection and intervention, guiding early and appropriate wound hygiene and potentially reducing the need for antibiotic use. When indicated, this diagnostic partnership with antibiotic stewardship initiatives is key to ameliorating the continuing threat of antibiotic resistance.
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Affiliation(s)
- Thomas E. Serena
- SerenaGroup Research Foundation, Cambridge, MA, United States,*Correspondence: Thomas E. Serena,
| | - Robert J. Snyder
- Foot and Ankle Institute, Barry University, Miami, FL, United States
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2
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Caputo WJ, Monterosa P, Beggs D. Antibiotic Misuse in Wound Care: Can Bacterial Localization through Fluorescence Imaging Help? Diagnostics (Basel) 2022; 12:diagnostics12123207. [PMID: 36553214 PMCID: PMC9778012 DOI: 10.3390/diagnostics12123207] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/07/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
(1) Background: Systemic antibiotic use in chronic wounds is alarmingly high worldwide. Between 53% to 71% of patients are prescribed at least one course per chronic wound. Systemic antibiotic use should follow antibiotic stewardship guidelines and ought to be reserved for situations where their use is deemed supported by clinical indications. Unfortunately, in the field of wound care, indiscriminate and often inadequate use of systemic antibiotics is leading to both patient complications and worsening antibiotic resistance rates. Implementing novel tools that help clinicians prevent misuse or objectively determine the true need for systemic antibiotics is essential to reduce prescribing rates. (2) Methods: We present a compendium of available systemic antibiotic prescription rates in chronic wounds. The impact of various strategies used to improve these rates, as well as preliminary data on the impact of implementing fluorescence imaging technology to finesse wound status diagnosis, are presented. (3) Results: Interventions including feedback from wound care surveillance and treatment data registries as well as better diagnostic strategies can ameliorate antibiotic misuse. (4) Conclusions: Interventions that mitigate unnecessary antibiotic use are needed. Effective strategies include those that raise awareness of antibiotic overprescribing and those that enhance diagnosis of infection, such as fluorescence imaging.
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Affiliation(s)
- Wayne J. Caputo
- Director of the Wound Care Center at Clara Maass Medical Center, Belleville, NJ 07109, USA
- Correspondence:
| | | | - Donald Beggs
- Infectious Disease, Clara Maass Medical Center, Belleville, NJ 07109, USA
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3
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Serena TE, Gould L, Ousey K, Kirsner RS. Reliance on Clinical Signs and Symptoms Assessment Leads to Misuse of Antimicrobials: Post hoc Analysis of 350 Chronic Wounds. Adv Wound Care (New Rochelle) 2022; 11:639-649. [PMID: 34714159 PMCID: PMC9527054 DOI: 10.1089/wound.2021.0146] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Objectives: Bacteria frequently impede wound healing and cause infection. Clinicians rely on clinical signs and symptoms (CSS) to assess for bacteria at the point of care, and inform prescription of antibiotics and other antimicrobials. Yet, robust evidence suggests that CSS has poor sensitivity for detection of problematic bacterial burden and infection, hindering antimicrobial stewardship efforts. This study evaluated CSS-based antimicrobial prescribing practices across 14 wound care centers. Approach: Data were analyzed from the fluorescence assessment and guidance (FLAAG) trial, a study of 350 chronic wounds across 20 clinicians. Clinicians reviewed patient history and assessed for CSS using the International Wound Infection Institute infection checklist. Wounds with >3 criteria or any overwhelming symptom were considered CSS+. Bacterial levels were confirmed with quantitative tissue culture of wound biopsies. Results: Antimicrobials (including dressings, topicals, and systemic antibiotics) were prescribed at a similar rate for wounds identified as CSS+ (75.0%) and CSS- (72.8%, p = 0.76). Antimicrobial dressings, the most frequently prescribed antimicrobial, were prescribed at a similar rate for CSS+ (83.3%) and CSS- (89.5%, p = 0.27) wounds. In 33.3% of patients prescribed systemic antibiotics, no CSS were present. Prescribing patterns did not correlate with bacterial load. Innovation: This study is the first to evaluate antimicrobial prescribing trends in a large, multisite cohort of chronic wound patients. Conclusions: Reliance on CSS to diagnose clinically significant bacterial burden in chronic wounds leads to the haphazard use of antimicrobials. Improved methods of identifying bacterial burden and infection are needed to enhance antimicrobial stewardship efforts in wound care. Clinicaltrials.gov ID. NCT03540004.
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Affiliation(s)
- Thomas E. Serena
- SerenaGroup® Research Foundation, Cambridge, Massachusetts, USA.,Correspondence: SerenaGroup Research Foundation, 125 Cambridge Park Drive, Cambridge, MA 02140, USA.
| | - Lisa Gould
- South Shore Health Department of Surgery (or Brown Alpert Department of Medicine), Weymouth, Massachusetts, USA
| | - Karen Ousey
- School of Human and Health Sciences, University of Huddersfield, West Yorkshire, United Kingdom
| | - Robert S. Kirsner
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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4
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Amin AN, Dellinger EP, Harnett G, Kraft BD, LaPlante KL, LoVecchio F, McKinnell JA, Tillotson G, Valentine S. It's about the patients: Practical antibiotic stewardship in outpatient settings in the United States. Front Med (Lausanne) 2022; 9:901980. [PMID: 35966853 PMCID: PMC9363693 DOI: 10.3389/fmed.2022.901980] [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: 03/22/2022] [Accepted: 06/27/2022] [Indexed: 12/01/2022] Open
Abstract
Antibiotic-resistant pathogens cause over 35,000 preventable deaths in the United States every year, and multiple strategies could decrease morbidity and mortality. As antibiotic stewardship requirements are being deployed for the outpatient setting, community providers are facing systematic challenges in implementing stewardship programs. Given that the vast majority of antibiotics are prescribed in the outpatient setting, there are endless opportunities to make a smart and informed choice when prescribing and to move the needle on antibiotic stewardship. Antibiotic stewardship in the community, or "smart prescribing" as we suggest, should factor in antibiotic efficacy, safety, local resistance rates, and overall cost, in addition to patient-specific factors and disease presentation, to arrive at an appropriate therapy. Here, we discuss some of the challenges, such as patient/parent pressure to prescribe, lack of data or resources for implementation, and a disconnect between guidelines and real-world practice, among others. We have assembled an easy-to-use best practice guide for providers in the outpatient setting who lack the time or resources to develop a plan or consult lengthy guidelines. We provide specific suggestions for antibiotic prescribing that align real-world clinical practice with best practices for antibiotic stewardship for two of the most common bacterial infections seen in the outpatient setting: community-acquired pneumonia and skin and soft-tissue infection. In addition, we discuss many ways that community providers, payors, and regulatory bodies can make antibiotic stewardship easier to implement and more streamlined in the outpatient setting.
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Affiliation(s)
- Alpesh N. Amin
- Department of Medicine, University of California, Irvine, Irvine, CA, United States
| | | | - Glenn Harnett
- No Resistance Consulting, Birmingham, AL, United States
| | - Bryan D. Kraft
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Kerry L. LaPlante
- College of Pharmacy, University of Rhode Island, Kingston, RI, United States
| | - Frank LoVecchio
- Department of Emergency Medicine, Valleywise Health, Arizona State University, Phoenix, AZ, United States
| | - James A. McKinnell
- Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Disease, Lundquist Research Institute at Harbor-UCLA, Torrance, CA, United States
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5
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Trottier ED, Farley St-Amand B, Vincent M, Chevalier I, Autmizguine J, Tremblay S, Gouin S. Outpatient management of moderate cellulitis in children using high-dose oral cephalexin. Paediatr Child Health 2022; 27:213-219. [PMID: 35859686 PMCID: PMC9291389 DOI: 10.1093/pch/pxac031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 02/25/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
To evaluate the effectiveness of a high-dose (HD) oral cephalexin treatment guideline for children with moderate cellulitis treated as outpatients.
Methods
In this retrospective cohort study, we included children who presented to the emergency department (ED) with moderate cellulitis and treated according to the institution’s HD oral cephalexin guideline over a 2-year period. All children had standardized follow-up at a medical day hospital (MDH). Treatment was considered effective in the absence of treatment failure, defined as admission, switch to IV treatment or ED visit within 2 weeks of discharge from the MDH. Safety was ascertained by recording adverse events and severe complications at follow-up.
Results
A total of 123 children were treated as outlined in the guideline, including 117 treated with HD oral cephalexin. The success rate was 89.7% (105/117). Among 12 (10.3%) children who had treatment failure, 10 (8.5%) required admission, 1 (0.9%) received IV antibiotics at the MDH and 1 (0.9%) had a return visit to the ED without admission. No severe complications were reported; four abscesses required drainage and one patient had a rash. The mean number of visits per child at the MDH was 1.6 (SD 1.0).
Conclusions
With a success rate of 89.7%, HD oral cephalexin seems effective and safe for the treatment of children with moderate cellulitis. Its use potentially reduces hospitalization rates for this condition and decreases the need for IV insertion.
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Affiliation(s)
- Evelyne D Trottier
- Department of Paediatric Emergency Medicine, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Beatrice Farley St-Amand
- Department of Paediatric Emergency Medicine, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Mélanie Vincent
- Department of Paediatrics, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Isabelle Chevalier
- Department of Paediatrics, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Julie Autmizguine
- Department of Paediatrics, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
- Department Pharmacology and Physiology, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Stéphanie Tremblay
- Department of Pharmacy, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Serge Gouin
- Department of Paediatric Emergency Medicine, Université de Montréal, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
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6
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Ebied AM, Antonelli P. Optimization of Antibiotic Selection in the Emergency Department for Adult Skin and Soft Tissue Infections. Hosp Pharm 2022; 57:83-87. [PMID: 35521005 PMCID: PMC9065513 DOI: 10.1177/0018578720985425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objectives: Emergency department (ED) order sets that include skin and soft tissue infections (SSTI) stratification and antimicrobial selection criteria may improve clinical outcomes and appropriateness of initial antibiotic selection. The purpose of this study was to optimize and evaluate antimicrobial prescribing for SSTI in the ED by implementing an institution specific Infectious Diseases Society of America (IDSA) guideline directed computerized provider order entry (CPOE) order set. The primary outcome was the rate of appropriate antibiotic prescribing for SSTI in the ED before and after order set revision. Secondary outcomes were length of hospital stay, rate of continuity of antibiotics from the ED to hospital admission orders, and frequency of order set utilization. Methods: This was a single-centered, retrospective, cohort study. The ED SSTI order set revision reflected current IDSA guidelines, institution formulary, and institution antibiogram. Results: A total of 180 patients were included in the study. The rate of appropriate antibiotic prescribing was 74.4% and 78.9% (P = .60) in the pre-revision and post-revision groups, respectively. Length of hospital stay of admitted patients was 4.93 and 4.32 days (P = .61). Rate of antibiotics continued from the ED to admission was 62.1% and 59.4% (P = .99). Order set utilization was 17.8% and 24.4% (P = .36). A subgroup analysis found appropriateness increased with order set use in admitted patients (50% vs 88.2%; P = .0382) and total patients (50% vs 81.8%; P = .037). Conclusion: An order set reflective of current IDSA guidelines and institution specific antibiogram showed a similar rate of appropriate antibiotic selection compared to provider's clinical judgment. Provider awareness of SSTI management could have been a limitation to the study.
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Affiliation(s)
- Alex M. Ebied
- Department of Clinical Sciences, Fred Wilson School of Pharmacy, High Point University, NC, USA,Alex M. Ebied, Department of Clinical Sciences, Fred Wilson School of Pharmacy, High Point University, One University Parkway, High Point, NC 27268, USA.
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7
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Meyer AF, Borkovskiy N, Hessedal T, Murray M. Does This Bite Need an Antibiotic? J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Vazquez Deida AA, Shihadeh KC, Aragon D, Knepper BC, Jenkins TC. Factors Associated With Longer Than Recommended Durations of Antibiotic Therapy for Uncomplicated Ambulatory Infections in an Integrated Healthcare System. Open Forum Infect Dis 2021; 8:ofab324. [PMID: 34631924 PMCID: PMC8495728 DOI: 10.1093/ofid/ofab324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/15/2021] [Indexed: 11/14/2022] Open
Abstract
Across the ambulatory care network of an integrated health care system, durations
of antibiotic therapy prescribed for uncomplicated infections were longer than
recommended in 39% of cases. By logistic regression, site of care, prescriber
characteristics, and type of infection were independently associated with longer
than recommended durations of therapy.
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Affiliation(s)
| | | | - Deborah Aragon
- Department of Patient Safety and Quality, Denver Health Medical Center, Denver, Colorado, USA
| | - Bryan C Knepper
- Department of Patient Safety and Quality, Denver Health Medical Center, Denver, Colorado, USA
| | - Timothy C Jenkins
- Division of Infectious Diseases, Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA.,Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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9
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Beatty N, August J, Saenz JA, Nix DE, Matthias KR, Mohajer MA. Knowledge, attitude, and practices associated with the diagnosis and management of skin and soft-tissue infections among medical students, residents, and attending physicians. Avicenna J Med 2021; 8:104-106. [PMID: 30090749 PMCID: PMC6057159 DOI: 10.4103/ajm.ajm_200_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Skin and soft-tissue infections (SSTIs) are commonly encountered by medical students, residents, and trainees. The Infectious Diseases Society of America (IDSA) has updated its recommendations regarding SSTI diagnosis and management in June 2014. We assessed knowledge, attitude, and practices toward diagnosis and management of SSTIs using an online survey. We disseminated the survey to medical students, residents, and attending physicians practicing in family and internal medicine department at a university-based hospital. A total of 103 surveys were completed out of 121 sent (85.1%) between July 2015 and March 2016. There were nine medical questions in the survey. The mean of correct answers was 4.5/9 ± 2.0. Medical knowledge correlated with the level of education (P < 0.001) but not with subspecialty (P = 0.97). Around 35% were familiar with the updated IDSA guidelines pertaining to SSTIs. The majority (85%) responded that the hospital staff would benefit from additional training and 75% agreed that more antibiotic stewardship education is needed. Our study shows that there are significant opportunities for development among students and physicians who encounter SSTIs.
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Affiliation(s)
- Norman Beatty
- Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Jessica August
- Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Joe Anthony Saenz
- Department of Family and Community Medicine, University of Arizona, Tucson, AZ, USA
| | - David E Nix
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | - Kathryn R Matthias
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | - Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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10
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Frost HM, Knepper BC, Shihadeh KC, Jenkins TC. A Novel Approach to Evaluate Antibiotic Utilization Across the Spectrum of Inpatient and Ambulatory Care and Implications for Prioritization of Antibiotic Stewardship Efforts. Clin Infect Dis 2021; 70:1675-1682. [PMID: 31162539 DOI: 10.1093/cid/ciz466] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 06/03/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Antibiotic overuse remains a significant problem. The objective of this study was to develop a methodology to evaluate antibiotic use across inpatient and ambulatory care sites in an integrated healthcare system to prioritize antibiotic stewardship efforts. METHODS We conducted an epidemiologic study of antibiotic use across an integrated healthcare system on 12 randomly selected days from 2017 to 2018. For inpatients and perioperative patients, administrations of antibiotics were recorded, whereas prescriptions were recorded for outpatients. RESULTS On the study days, 10.9% (95% confidence interval [CI], 10.6%-11.3%) of patients received antibiotics. Of all antibiotics, 54.1% were from ambulatory care (95% CI, 52.6%-55.7%), 38.0% were from the hospital (95% CI, 36.6%-39.5%), and 7.8% (95% CI, 7.1%-8.7%) were perioperative. The emergency department/urgent care centers, adult outpatient clinics, and adult non-critical care inpatient wards accounted for 26.4% (95% CI, 25.0%-27.7%), 23.8% (95% CI, 22.6%-25.2%), and 23.9% (95% CI, 22.7%-25.3%) of antibiotic use, respectively. Only 9.2% (95% CI, 8.3%-10.1%) of all antibiotics were administered in critical care units. Antibiotics with a broad spectrum of gram-negative activity accounted for 30.4% (95% CI, 29.0%-31.9%) of antibiotics. Infections of the respiratory tract were the leading indication for antibiotics. CONCLUSIONS In an integrated healthcare system, more than half of antibiotic use occurred in the emergency department/urgent care centers and outpatient clinics. Antibiotics with a broad spectrum of gram-negative activity accounted for a large portion of antibiotic use. Analysis of antibiotic utilization across the spectrum of inpatient and ambulatory care is useful to prioritize antibiotic stewardship efforts.
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Affiliation(s)
- Holly M Frost
- Department of Pediatrics, Denver Health Medical Center.,University of Colorado School of Medicine
| | - Bryan C Knepper
- Department of Patient Safety and Quality, Denver Health Medical Center, Colorado
| | | | - Timothy C Jenkins
- University of Colorado School of Medicine.,Division of Infectious Diseases and Department of Medicine, Denver Health Medical Center, Colorado
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11
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Abstract
Skin and soft tissue infections (SSTIs) frequently are encountered in clinical practice, and gram-negative bacilli (GNB) constitute an underrated portion of their etiology. The rate of GNB-causing SSTIs is increasing, especially with the rise in antimicrobial resistance. Although the diagnosis of SSTIs mostly is clinical, rapid diagnostic modalities can shorten the time to initiating proper therapy and improving outcomes. Novel antibiotics are active against GNB SSTIs and can be of great value in the management. This review provides an overview of the role of GNB in SSTIs and summarizes their epidemiology, risk factors, outcome, and clinical management.
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Affiliation(s)
- Jean-Francois Jabbour
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh, Beirut 1107 2020, Lebanon
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El Solh, Beirut 1107 2020, Lebanon.
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12
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Cross ELA, Jordan H, Godfrey R, Onakpoya IJ, Shears A, Fidler K, Peto TEA, Walker AS, Llewelyn MJ. Route and duration of antibiotic therapy in acute cellulitis: A systematic review and meta-analysis of the effectiveness and harms of antibiotic treatment. J Infect 2020; 81:521-531. [PMID: 32745638 DOI: 10.1016/j.jinf.2020.07.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Compared with guideline recommendations, antibiotic overuse is common in treating cellulitis. We conducted a systematic review and meta-analyses on antibiotic route and duration of treatment for cellulitis in adults and children. METHODS We searched MEDLINE, EMBASE and trial registries from inception to Dec 11, 2019 for interventional and observational studies of antibiotic treatment for cellulitis. Exclusions included case series/reports, pre-septal/orbital cellulitis and non-English language articles. Random-effects meta-analyses were used to produce summary relative risk (RR) estimates for our primary outcome of clinical response. PROSPERO CRD42018100602. RESULTS We included 47/8423 articles, incorporating data from eleven trials (1855 patients) in two meta-analyses. The overall risk of bias was moderate. Only two trials compared the same antibiotic agent in each group. We found no evidence of difference in clinical response rates for antibiotic route or duration (RR(oral:IV)=1.12, 95%CI 0.98-1.27, I2=32% and RR(shorter:longer)=0.99, 95%CI 0•96-1.03, I2 = 0%, respectively). Findings were consistent in observational studies. Follow-up data beyond 30 days were sparse. CONCLUSIONS The evidence base for antibiotic treatment decisions in cellulitis is flawed by biased comparisons, short follow-up and lack of data around harms of antibiotic overuse. Future research should focus on developing patient-tailored antibiotic prescribing for cellulitis to reduce unnecessary antibiotic use.
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Affiliation(s)
- Elizabeth L A Cross
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Harriet Jordan
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Rebecca Godfrey
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Igho J Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Annalie Shears
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Katy Fidler
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Timothy E A Peto
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - A Sarah Walker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Biomedical Centre, Oxford, UK
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer, East Sussex BN1 9PS, UK; Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
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13
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Daneman N, Rishu AH, Pinto RL, Arabi YM, Cook DJ, Hall R, McGuinness S, Muscedere J, Parke R, Reynolds S, Rogers B, Shehabi Y, Fowler RA. Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness (BALANCE) randomised clinical trial: study protocol. BMJ Open 2020; 10:e038300. [PMID: 32398341 PMCID: PMC7223357 DOI: 10.1136/bmjopen-2020-038300] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Bloodstream infections are a leading cause of mortality and morbidity; the duration of treatment for these infections is understudied. METHODS AND ANALYSIS We will conduct an international, multicentre randomised clinical trial of shorter (7 days) versus longer (14 days) antibiotic treatment among hospitalised patients with bloodstream infections. The trial will include 3626 patients across 60 hospitals and 6 countries. We will include patients with blood cultures confirming a pathogenic bacterium after hospital admission. Exclusion criteria will include patient factors (severe immunosuppression), infection site factors (endocarditis, osteomyelitis, undrained abscesses, infected prosthetic material) and pathogen factors (Staphylococcus aureus, Staphylococcus lugdunensis, Candida and contaminant organisms). We will leave the selection of specific antibiotics, doses and route of delivery to the discretion of treating physicians; no placebo control will be used given the diversity of pathogens and sources of bacteraemia. The intervention will be assignment of treatment duration to be 7 versus 14 days. We will minimise selection bias via central randomisation with variable block sizes, with concealed allocation until day 7 of adequate antibiotic treatment. The primary outcome is 90-day survival; we will test whether 7 days is non-inferior to 14 days of treatment, with a non-inferiority margin of 4% absolute mortality. Secondary outcomes include hospital and intensive care unit (ICU) mortality, relapse rates of bacteraemia, hospital and ICU length of stay, mechanical ventilation and vasopressor duration, antibiotic-free days, Clostridium difficile infection, antibiotic allergy and adverse events and colonisation/infection with antibiotic-resistant organisms. ETHICS AND DISSEMINATION The study has been approved by the ethics review board at each participating site. Sunnybrook Health Sciences Centre is the central ethics committee. We will disseminate study results via the Canadian Critical Care Trials Group and other collaborating networks to set the global paradigm for antibiotic treatment duration for non-staphylococcal Gram-positive, Gram-negative and anaerobic bacteraemia, among patients admitted to hospital. TRIAL REGISTRATION NUMBER The BALANCE (Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness) trial was registered at www.clinicaltrials.gov (registration number: NCT03005145).
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Affiliation(s)
- Nick Daneman
- Division of Infectious Diseases & Clinical Epidemiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Asgar H Rishu
- Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ruxandra L Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yaseen M Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Richard Hall
- Departments of Critical Care Medicine and Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | | | | | - Steven Reynolds
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Benjamin Rogers
- Centre for Inflammatory Diseases, Monash University School of Clinical Sciences, Melborne, Victoria, Australia
| | - Yahya Shehabi
- Critical Care and Perioperative Medicine, School of Clinical Sciences, Monash University and Monash Health, Melbourne, Victoria, Australia
| | - Robert A Fowler
- Departments of Medicine and Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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14
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Mahyudin F, Edward M, Basuki MH, Basrewan Y, Rahman A. Modern and Classic Wound Dressing Comparison in Wound Healing, Comfort and Cost. JURNAL NERS 2020. [DOI: 10.20473/jn.v15i1.16597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction: Wound care has also developed rapidly after the dissemination of the concept of TIME (Tissue, Infection, Moisture, and Wound Edge) in modern dressing (MD). The aim of this study was to compare modern dressings (MDs) and classic dressings (CDs) in terms of patient comfort, cost effectiveness and wound healing.Methods: A prospective study design with total of 25 participants. The sampling technique used was consecutive sampling. Patient comfort was assessed through the frequency of wound care and pain scale using the Visual Analogue Scale (VAS). Cost-effectiveness was assessed using direct and indirect costs. Wound healing was assessed using the Bates-Jensen Wound Assessment Tool (BWAT) score. The data was analyzed using the independent t and Mann-Whitney tests.Results: In terms of comfort, the mean for the number of times that wound care was performed and the pain scale in the participants using MD was (3.07 ± 0.88 times and VAS 4.59 ± 0.72, respectively), which is less compared to using CD (4.60 ± 1.84 times each and VAS 5.43 ± 0.75). Referring to the indirect and direct costs, MD (13.67 ± 6.09 and 527.63 ± 84.47, respectively) has the same cost-effectiveness as CD (14.00 ± 7.64 and 482.68 ± 98.08, respectively). In terms of healing, the mean of the BWAT score in MD (31.26 ± 1.69) was better compared to CD (33.07 ± 1.65).Conclusion: The application of MD has the same cost-effectiveness as CD with a more satisfactory outcome for the wounds in terms of comfort and healing.
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van den Broek AK, van Hest RM, Lettinga KD, Jimmink A, Lauw FN, Visser CE, Prins JM. The appropriateness of antimicrobial use in the outpatient clinics of three hospitals in the Netherlands. Antimicrob Resist Infect Control 2020; 9:40. [PMID: 32087756 PMCID: PMC7036246 DOI: 10.1186/s13756-020-0689-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/28/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Antimicrobial Stewardship Programs commonly have an in-hospital focus. Little is known about the quality of antimicrobial use in hospital outpatient clinics. We investigated the extent and appropriateness of antimicrobial prescriptions in the outpatient clinics of three hospitals. METHODS From June 2018 to January 2019, we performed ten point prevalence surveys in outpatient clinics of one university hospital and two large teaching hospitals. All prophylactic and therapeutic prescriptions were retrieved from the electronic medical records. Appropriateness was defined as being in accordance with guidelines. Furthermore, we investigated the extent to which the dose was adjusted to renal function and documentation of an antibiotic plan in the case notes. RESULTS We retrieved 720 prescriptions for antimicrobial drugs, of which 173 prescriptions (24%) were prophylactic. A guideline was present for 95% of prescriptions, of which the guideline non-adherence rate was 25.6% (n = 42/164) for prophylaxis and 43.1% (n = 224/520) for therapy. Of all inappropriate prescriptions (n = 266), inappropriate prescriptions for skin and soft tissue infections (n = 60/226) and amoxicillin-clavulanic acid (n = 67/266) made up the largest proportion. In only 13 of 138 patients with impaired or unknown renal function the dosage regimen was adjusted. Amoxicillin-clavulanic acid was the drug for which most often renal function was not taken into account. In 94.6% of prescriptions the antibiotic plan was documented. CONCLUSIONS In hospital outpatient clinics, a substantial part of therapeutics were inappropriately prescribed. Amoxicillin-clavulanic acid was the most inappropriately prescribed drug, due to non-adherence to the guidelines and because dose adjustment to renal function was often not considered.
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Affiliation(s)
- Annemieke K van den Broek
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Reinier M van Hest
- Department of Hospital Pharmacy, Division of Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Kamilla D Lettinga
- Department of Internal medicine, Onze lieve vrouwe gasthuis, location West, Jan Tooropstraat 164, 1061, AE, Amsterdam, The Netherlands
| | - Afra Jimmink
- Department of Hospital Pharmacy, Onze lieve vrouwe gasthuis, location West, Jan Tooropstraat 164, 1061, AE, Amsterdam, The Netherlands
| | - Fanny N Lauw
- Department of Internal medicine, MC Slotervaart, Louwesweg 6, 1066, EC, Amsterdam, The Netherlands.,Department of Internal medicine, MC Jan van Goyen, Jan van Goyenkade 1, 1075, HN, Amsterdam, The Netherlands
| | - Caroline E Visser
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
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16
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Clarke MC, Cheng AC, Pollard JG, Birch M, Cowan RU, Linke JA, Walton AL, Friedman ND. Lessons Learned From a Randomized Controlled Trial of Short-Course Intravenous Antibiotic Therapy for Erysipelas and Cellulitis of the Lower Limb (Switch Trial). Open Forum Infect Dis 2019; 6:ofz335. [PMID: 31660410 PMCID: PMC6798252 DOI: 10.1093/ofid/ofz335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/16/2019] [Indexed: 01/22/2023] Open
Abstract
Background The diagnosis of cellulitis is made clinically without a gold standard diagnostic test, and cellulitis has many disease mimics. There is currently no consensus for optimal antimicrobial treatment duration or method of antimicrobial delivery. Methods This was a randomized controlled open-label multicenter trial to determine the safety and efficacy of 24 hours of intravenous (IV) therapy compared with ≥72 hours of IV therapy, both followed by oral therapy to a maximum of 7–10 days’ duration for the treatment of lower limb cellulitis. Results Over 40 months, 80 patients were recruited. Thirty-nine patients were assigned to 24 hours of IV antibiotics and 41 to ≥72 hours of IV antibiotics. The mean duration (range) of IV antibiotics in the 24-hour group was 25.5 (17–40) hours, and in the ≥72-hour group it was 78 (41.5–210) hours. Three patients in the 24-hour arm and 4 patients in the ≥72-hour arm were excluded from the analysis due to withdrawal from the trial. Analysis of the remaining patients revealed that 6 patients (4 in the intervention arm and 2 in the control arm) did not achieve an adequate response to therapy. Only 1 patient experienced self-limiting adverse effects of treatment. Conclusions The noninferiority of short-course IV therapy cannot be determined from this trial. Challenges included resource limitations for recruitment, misdiagnosis, participant withdrawal, and subjective responses to therapy based on visual assessment by treating clinicians. Further studies are needed to determine if short-course IV therapy is a suitable treatment option. Australia Council of Clinical Trials Registry No ACTRN12613001366741.
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Affiliation(s)
- Marcus C Clarke
- Department of Infectious Diseases, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Allen C Cheng
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - James Gd Pollard
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia.,Hospital in the Home Service, Barwon Health, Geelong, Victoria, Australia
| | - Mark Birch
- Department of Infectious Diseases, Christchurch Public Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Raquel U Cowan
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - Jake A Linke
- Deakin University, School of Medicine, Geelong, Victoria, Australia
| | - Aaron L Walton
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
| | - N Deborah Friedman
- Department of Infectious Diseases, Barwon Health, Geelong, Victoria, Australia
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Nonviral Injection-Related Injuries in Persons Who Inject Drugs: Skin and Soft Tissue Infection, Vascular Damage, and Wounds. Adv Skin Wound Care 2019; 32:301-310. [DOI: 10.1097/01.asw.0000559612.06067.55] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Ko LN, Garza-Mayers AC, St John J, Strazzula L, Vedak P, Shah R, Dobry AS, Rao SR, Milne LW, Parry BA, Kroshinsky D. Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis: A Randomized Clinical Trial. JAMA Dermatol 2019; 154:529-536. [PMID: 29453872 DOI: 10.1001/jamadermatol.2017.6196] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Each year, cellulitis leads to 650 000 hospital admissions and is estimated to cost $3.7 billion in the United States. Previous literature has demonstrated a high misdiagnosis rate for cellulitis, which results in unnecessary antibiotic use and health care cost. Objective To determine whether dermatologic consultation decreases duration of hospital stay or intravenous antibiotic treatment duration in patients with cellulitis. Design, Setting, and Participants This randomized clinical trial was conducted in a large urban tertiary care hospital between October 2012 and January 2017, with 1-month follow-up duration. Patients were randomized to the control group, which received the standard of care (ie, treatment by primary medicine team), or the intervention group, which received dermatology consultation. Medical chart review of demographic information and hospital courses was performed. Adult patients hospitalized with presumed diagnosis of cellulitis were eligible. A total of 1300 patients were screened, 1125 were excluded, and 175 were included. Statistical analysis was employed to identify significant outcome differences between the 2 groups. Interventions Dermatology consultation within 24 hours of hospitalization. Main Outcomes and Measures Length of hospital stay and duration of intravenous antibiotic treatment. Results Of 175 participants, 70 (40%) were women and 105 (60%) were men. The mean age was 58.8 years. Length of hospital stay was not statistically different between the 2 groups. The duration of intravenous antibiotic treatment (<4 days: 86.4% vs 72.5%; absolute difference, 13.9%; 95% CI, 1.9%-25.9%; P = .04) and duration of total antibiotic treatment was significantly lower in patients who had early dermatology consultation (<10 days: 50.6% vs 32.5%; absolute difference, 18.1%; 95% CI, 3.7%-32.5%; P = .01). Clinical improvement at 2 weeks was significantly higher for those in the intervention group (79 [89.3%] vs 59 [68.3%]; absolute difference, 21.0%; 95% CI, 9.3%-32.7%; P < .001). There was no significant difference in 1-month readmission rate between the groups (4 [4.5%] vs 6 [6.9%]; absolute difference, -2.4%; 95% CI, -9.3% to 4.5%; P = .54). In the intervention group, the rate of cellulitis misdiagnosis was 30.7% (27 of 88 participants). Among the entire cohort, 101 (57.7%) patients were treated with courses of antibiotics longer than what is recommended by guidelines. Conclusions and Relevance Early dermatologic consultation can improve outcomes in patients with suspected cellulitis by identifying alternate diagnoses, treating modifiable risk factors, and decreasing length of antibiotic treatment. Trial Registration clinicaltrials.gov Identifier: NCT01706913.
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Affiliation(s)
- Lauren N Ko
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anna C Garza-Mayers
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jessica St John
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lauren Strazzula
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Harvard Combined Dermatology Residency, Harvard Medical School, Boston, Massachusetts
| | - Priyanka Vedak
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Harvard Combined Dermatology Residency, Harvard Medical School, Boston, Massachusetts
| | - Radhika Shah
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Allison S Dobry
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sowmya R Rao
- Massachusetts General Hospital Biostatistics Center; Department of Surgery, Boston University, Boston, Massachusetts
| | - Leslie W Milne
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Blair Alden Parry
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniela Kroshinsky
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Common Community-acquired Bacterial Skin and Soft-tissue Infections in Children: an Intersociety Consensus on Impetigo, Abscess, and Cellulitis Treatment. Clin Ther 2019; 41:532-551.e17. [PMID: 30777258 DOI: 10.1016/j.clinthera.2019.01.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/20/2018] [Accepted: 01/16/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE The main objective of this article was to offer practical suggestions, given the existing evidence, for identifying and managing bacterial impetigo, abscess, and cellulitis in ambulatory and hospital settings. METHODS Five Italian pediatric societies appointed a core working group. In selected conditions, specially trained personnel evaluated quality assessment of treatment strategies according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Only randomized controlled trials (RCTs) and observational studies were included for quality assessment according to the GRADE methodology. MEDLINE, Ovid MEDLINE, EMBASE, and Cochrane Library databases were searched with a strategy combining MeSH and free text terms. FINDINGS The literature review included 364 articles focusing on impetigo, skin abscess, and cellulitis/orbital cellulitis. The articles included for quality assessment according to the GRADE methodology for impetigo comprised 5 RCTs and 1 observational study; for skin abscess, 10 RCTs and 3 observational studies were included; for cellulitis and erysipelas, 5 RCTs and 5 observational studies were included; and for orbital cellulitis, 8 observational studies were included. Recommendations were formulated according to 4 grades of strength for each specific topic (impetigo, skin abscesses, cellulitis, and orbital cellulitis). Where controversies arose and expert opinion was considered fundamental due to lack of evidence, agreement according to Delphi consensus recommendations was included. IMPLICATIONS Based on a literature review and on local epidemiology, this article offers practical suggestions for use in both ambulatory and hospital settings for managing the most common bacterial SSTIs.
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20
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Boothe WD, Diven D. Antibiotic stewardship: The treatment of uncomplicated lower limb cellulitis. Am J Emerg Med 2019; 37:1390-1391. [PMID: 30674428 DOI: 10.1016/j.ajem.2019.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 01/12/2019] [Indexed: 10/27/2022] Open
Affiliation(s)
- William David Boothe
- Dell Seton Medical Center, Department of Dermatology, 1701 Trinity St., Stop Z0900, Austin, TX 78712, United States of America.
| | - Dayna Diven
- Dell Seton Medical Center, Department of Dermatology, 1701 Trinity St., Stop Z0900, Austin, TX 78712, United States of America.
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21
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Almulhim AS, Alotaibi FM. Comparison of broad-spectrum antibiotics and narrow-spectrum antibiotics in the treatment of lower extremity cellulitis. Int J Health Sci (Qassim) 2018; 12:3-7. [PMID: 30534037 PMCID: PMC6257879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE Cellulitis is a commonly encountered medical illness and is most frequently caused by Group A β-hemolytic Streptococcus species and Staphylococcus aureus. The purpose of this study was to compare clinical outcomes of patients with lower extremity cellulitis treated with broad-spectrum and narrow-spectrum antibiotics. METHODS This was a retrospective cohort study conducted in a community tertiary hospital between January 2016 and May 2016. Patients were included if they were diagnosed with uncomplicated non-purulent lower extremity cellulitis. Patients were divided into two groups: Individuals receiving narrow-spectrum antibiotics or receiving broad-spectrum antibiotics. Logistic regression analysis was used to estimate the odds ratio of repeat visit between the groups. RESULTS A total of 599 patients with uncomplicated cellulitis were identified; of which 120 were included in the study (93 in narrow-spectrum arm and 27 in broad-spectrum arm). Repeat visit due to cellulitis was similar in both Groups 1 (4%) and 3 (3%) (P = 0.89) in the broad-spectrum arm and narrow-spectrum arm, respectively. CONCLUSION Broad-spectrum antibiotic use in uncomplicated cellulitis was common and unjustified given the results of our study. Implementation of clinical practice guidelines is recommended in limiting broad-spectrum antibiotics use in such population.
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Affiliation(s)
- Abdulaziz Saleh Almulhim
- King Faisal University, College of Clinical Pharmacy, Al-Ahsa, Saudi Arabia
- The University of Arizona, College of Pharmacy, Tucson, AZ, United States
| | - Fawaz M. Alotaibi
- Virginia Commonwealth University, School of Pharmacy, Richmond, Virginia
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22
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Llor C, Moragas A, Cordoba G. [Twenty-five myths in infectious diseases in primary care associated with overdiagnosis and overtreatment]. Aten Primaria 2018; 50 Suppl 2:57-64. [PMID: 30270191 PMCID: PMC6836970 DOI: 10.1016/j.aprim.2018.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 11/17/2022] Open
Abstract
Overdiagnosis and overprescribing is common in current clinical practice of infectious diseases in primary care. On the basis of studies published in the medical literature we identify my means of a non-systematic review a total of 25 myths associated with the diagnosis and treatment and present the literature pertaining to each myth. These myths result in extraneous testing (overdiagnosis) and excessive antimicrobial treatment (overtreatment). Most of these myths are ingrained among general practitioners in our country. Not only should these myths be debunked from our clinical practice, but they should also be reversed, and we encourage our readers to critically appraise their practice when it comes down to the misconceptions treated in this manuscript. We attempt to give guidance to clinicians facing these frequent clinical scenarios.
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Affiliation(s)
- Carles Llor
- Centro de Salud Via Roma, Barcelona, España; Grupo de Trabajo de Enfermedades Infecciosas de la semFYC.
| | - Ana Moragas
- Universitat Rovira i Virgili. Centro de Salud Jaume I, Tarragona, España
| | - Gloria Cordoba
- Centro de Investigación y Educación en Medicina Familiar, Instituto de Salud Pública, Universidad de Copenhague, Copenhague, Dinamarca
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23
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Pulia MS, Schwei RJ, Patterson BW, Repplinger MD, Smith MA, Shah MN. Effectiveness of Outpatient Antibiotics After Surgical Drainage of Abscesses in Reducing Treatment Failure. J Emerg Med 2018; 55:512-521. [PMID: 30149998 DOI: 10.1016/j.jemermed.2018.06.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 06/22/2018] [Accepted: 06/24/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND The optimal approach to outpatient antibiotic use after surgical drainage of abscesses is unclear given conflicting clinical trial results. OBJECTIVE Our primary objective was to evaluate the real-world effectiveness of outpatient antibiotic prescribing after surgical drainage of cutaneous abscesses on reducing treatment failure. METHODS We performed a retrospective observational study using data extracted from the electronic health record of a single academic health care system. All emergency department (ED) visits that resulted in discharge with a surgical drainage of a cutaneous abscess procedure code were included in the sample. All visits were categorized into having received or not having received an antibiotic prescription at the index visit. Outcome frequencies were compared using Pearson's chi-squared test. A multivariable logistic regression model was used to estimate the odds of treatment failure among those who did and did not receive an antibiotic prescription at their index ED visit. RESULTS The final sample consisted of 421 index ED visits, of which 303 (72%) received an antibiotic prescription. Treatment with antibiotics after drainage did not significantly reduce the odds of composite treatment failure within 30 days when controlling for sociodemographic and clinical encounter variables (odds ratio 0.52, 95% confidence interval 0.23-1.21). CONCLUSIONS This real-world, comparative effectiveness analysis did not demonstrate any significant reduction in treatment failure with the use of antibiotics after drainage of abscesses in the ED. It is unclear if the clinical benefit observed under controlled trial conditions will carry over to routine clinical practice where varied antibiotic regimens are the norm and local bacterial resistance patterns vary.
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Affiliation(s)
- Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Rebecca J Schwei
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Brian W Patterson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Maureen A Smith
- Health Innovation Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
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Prevalence of Inappropriate Antibiotic Prescribing in Primary Care Clinics within a Veterans Affairs Health Care System. Antimicrob Agents Chemother 2018; 62:AAC.00337-18. [PMID: 29967028 DOI: 10.1128/aac.00337-18] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 06/05/2018] [Indexed: 01/12/2023] Open
Abstract
Data are needed from outpatient settings to better inform antimicrobial stewardship. In this study, a random sample of outpatient antibiotic prescriptions by primary care providers (PCPs) at our health care system was reviewed and compared to consensus guidelines. Over 12 months, 3,880 acute antibiotic prescriptions were written by 76 PCPs caring for 40,734 patients (median panel, 600 patients; range, 33 to 1,547). PCPs ordered a median of 84 antibiotic prescriptions per 1,000 patients per year. Azithromycin (25.8%), amoxicillin-clavulanate (13.3%), doxycycline (12.4%), amoxicillin (11%), fluoroquinolones (11%), and trimethoprim-sulfamethoxazole (10.6%) were prescribed most commonly. Medical records corresponding to 300 prescriptions from 59 PCPs were analyzed in depth. The most common indications for these prescriptions were acute respiratory tract infection (28.3%), urinary tract infection (23%), skin and soft tissue infection (15.7%), and chronic obstructive pulmonary disease (COPD) exacerbation (6.3%). In 5.7% of cases, no reason for the prescription was listed. No antibiotic was indicated in 49.7% of cases. In 12.3% of cases, an antibiotic was indicated, but the prescribed agent was guideline discordant. In another 14% of cases, a guideline-concordant antibiotic was given for a guideline-discordant duration. Therefore, 76% of reviewed prescriptions were inappropriate. Ciprofloxacin and azithromycin were most likely to be prescribed inappropriately. A non-face-to-face encounter prompted 34% of prescriptions. The condition for which an antibiotic was prescribed was not listed in primary or secondary diagnosis codes in 54.5% of clinic visits. In conclusion, there is an enormous opportunity to reduce inappropriate outpatient antibiotic prescriptions.
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25
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Nelson CE, Chen A, McAndrew L, Tay KY, Balamuth F. Management of Skin and Soft-Tissue Infections Before and After Clinical Pathway Implementation. Clin Pediatr (Phila) 2018; 57:660-666. [PMID: 29084435 DOI: 10.1177/0009922817738329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We evaluated if the introduction of a clinical pathway for skin and soft-tissue infections (SSTIs) would reduce methicillin-resistant Staphylococcus aureus (MRSA)-directed therapy for simple cellulitis and antibiotic use for simple abscess after drainage. We compared the treatment of SSTI during a 3-month prepathway and 11-month postpathway period. We included patients 57 days to 18 years old discharged from the emergency department (ED) with a diagnosis of cellulitis or abscess. Balancing measures included 72-hour revisit rate and ED length of stay (LOS). A total of 291 patients prepathway and 781 patients postpathway were included. The proportion of patients with simple cellulitis prescribed MRSA-directed therapy decreased from 81% to 54% postpathway. The proportion of patients with a drained abscess prescribed systemic antibiotics decreased from 88% to 75%. There was no increase in 72-hour revisit rates (3.8% vs 3.2%, P = .64) or ED LOS (2.8 vs 2.7 hours, P = .05).
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Affiliation(s)
- Courtney E Nelson
- 1 Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Aaron Chen
- 2 Children's Hospital of Philadelphia, PA, USA
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26
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Saha SK, Hawes L, Mazza D. Improving antibiotic prescribing by general practitioners: a protocol for a systematic review of interventions involving pharmacists. BMJ Open 2018; 8:e020583. [PMID: 29654036 PMCID: PMC5898351 DOI: 10.1136/bmjopen-2017-020583] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Effective antibiotic options in general practice for patients with infections are declining significantly due to antibiotic over-prescribing and emerging antibiotic resistance. To better improve antibiotic prescribing by general practitioner (GP), pharmacist-GP collaborations have been promoted under antibiotic stewardship programmes. However, there is insufficient information about whether and how pharmacists help GPs to more appropriately prescribe antibiotics. This systematic review aims to determine whether pharmacist-led or pharmacist-involved interventions are effective at improving antibiotic prescribing by GPs. METHODS AND ANALYSIS A systematic review of English language randomised controlled trials (RCTs), cluster RCTs, controlled before-and-after studies and interrupted time series studies cited in MEDLINE, EMBASE, EMCARE, CINAHL Plus, PubMed, PsycINFO, Cochrane Central Register of Controlled Trials and Web of Science databases will be conducted. Studies will be included if a pharmacist is involved as the intervention provider and GPs are the intervention recipients in general practice setting. Data extraction and management will be conducted using Effective Practice and Organisation of Care data abstraction tools and a template for intervention description and replication. The Cochrane and ROBINS-I risk of bias assessment tools will be used to assess the methodological quality of studies. Primary outcome measures include changes (overall, broad spectrum and guidelines concordance) of GP-prescribed antibiotics. Secondary outcomes include quality of antibiotic prescribing, delayed antibiotic use, acceptability and feasibility of interventions. Meta-analysis for combined effect and forest plots, χ2 test and I2 statistics for detailed heterogeneity and sensitivity analysis will be performed if data permit. Grading of Recommendations Assessment, Development and Evaluation and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidance will be used to report findings. ETHICS AND DISSEMINATION No ethics approval is required as no primary, personal or confidential data are being collected in this study. The findings will be disseminated to national and international scientific sessions and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42017078478.
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Affiliation(s)
- Sajal K Saha
- Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Melbourne, Victoria 3168, Australia
| | - Lesley Hawes
- Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Melbourne, Victoria 3168, Australia
| | - Danielle Mazza
- Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Road, Notting Hill, Melbourne, Victoria 3168, Australia
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27
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Jenkins TC, Haukoos JS, Cotton E, Weitzenkamp D, Frank DN, Burman WJ. Time Course of C-Reactive Protein and Procalcitonin Levels During the Treatment of Acute Bacterial Skin Infections. Open Forum Infect Dis 2018. [PMID: 29516022 PMCID: PMC5830966 DOI: 10.1093/ofid/ofy029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In a pilot study of 22 patients with an acute bacterial skin infection, serum levels of C-reactive protein and procalcitonin tended to be elevated at presentation and declined within 3–5 days of treatment. Further study of a biomarker-guided treatment strategy to reduce antibiotic overuse in skin infections is warranted.
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Affiliation(s)
- Timothy C Jenkins
- Department of Medicine, Denver Health, Denver, Colorado
- Division of Infectious Diseases, Denver Health, Denver, Colorado
- Department of Patient Safety and Quality, Denver Health, Denver, Colorado
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado
- Correspondence: T. C. Jenkins, MD, 601 Broadway, Denver, CO 80204 ()
| | - Jason S Haukoos
- Department of Emergency Medicine, Denver Health, Denver, Colorado
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Eleanor Cotton
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - David Weitzenkamp
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Daniel N Frank
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado
| | - William J Burman
- Department of Medicine, Denver Health, Denver, Colorado
- Division of Infectious Diseases, Denver Health, Denver, Colorado
- Denver Public Health, Denver Health, Denver, Colorado
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado
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Kamath RS, Sudhakar D, Gardner JG, Hemmige V, Safar H, Musher DM. Guidelines vs Actual Management of Skin and Soft Tissue Infections in the Emergency Department. Open Forum Infect Dis 2018; 5:ofx188. [PMID: 29354655 PMCID: PMC5767964 DOI: 10.1093/ofid/ofx188] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 12/29/2017] [Indexed: 01/22/2023] Open
Abstract
Background Infections of skin and soft tissue (SSTI) commonly cause visits to hospital emergency departments (EDs). The Infectious Diseases Society of America (IDSA) has published guidelines for the management of SSTI, but it is unclear how closely these guidelines are followed in practice. Methods We reviewed records of patients seen in the ED at a large tertiary care hospital to determine guidelines adherence in 4 important areas: the decision to hospitalize, choice of antibiotics, incision and drainage (I&D) of abscesses, and submission of specimens for culture. Results The decision to hospitalize did not comply with guidelines in 19.6% of cases. Nonrecommended antibiotics were begun in the ED in 71% of patients with nonpurulent infections and 68.4% of patients with purulent infections. Abscesses of mild severity were almost always treated with antibiotics, and I&D was often not done (both against recommendations). Blood cultures were done (against recommendations) in 29% of patients with mild-severity cellulitis. Abscess drainage was almost always sent for culture (recommendations neither favor nor oppose). Overall, treatment fully complied with guidelines in 20.1% of cases. Conclusions Our results show a striking lack of concordance with IDSA guidelines in the ED management of SSTI. Social factors may account for discordant decisions regarding site of care. Use of trimethoprim/sulfamethoxazole (TMP/SMX) in cellulitis was the most common source of discordance; this practice is supported by some medical literature. Excess antibiotics were often used in cellulitis and after I&D of simple abscesses, opposing antibiotic stewardship. Ongoing education of ED doctors and continued review of published guidelines are needed.
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Affiliation(s)
- Rahul S Kamath
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Deepthi Sudhakar
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Vagish Hemmige
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Hossam Safar
- Emergency Medicine Service Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Daniel M Musher
- Department of Medicine, Baylor College of Medicine, Houston, Texas.,Medical Care Line (Infectious Disease Section), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
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Ko HHT, Lareu RR, Dix BR, Hughes JD. Statins: antimicrobial resistance breakers or makers? PeerJ 2017; 5:e3952. [PMID: 29085751 PMCID: PMC5659212 DOI: 10.7717/peerj.3952] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/02/2017] [Indexed: 12/14/2022] Open
Abstract
Introduction The repurposing of non-antibiotic drugs as adjuvant antibiotics may help break antimicrobial resistance (AMR). Statins are commonly prescribed worldwide to lower cholesterol. They also possess qualities of AMR “breakers”, namely direct antibacterial activity, synergism with antibiotics, and ability to stimulate the host immune system. However, statins’ role as AMR breakers may be limited. Their current extensive use for cardiovascular protection might result in selective pressures for resistance, ironically causing statins to be AMR “makers” instead. This review examines statins’ potential as AMR breakers, probable AMR makers, and identifies knowledge gaps in a statin-bacteria-human-environment continuum. The most suitable statin for repurposing is identified, and a mechanism of antibacterial action is postulated based on structure-activity relationship analysis. Methods A literature search using keywords “statin” or “statins” combined with “minimum inhibitory concentration” (MIC) was performed in six databases on 7th April 2017. After screening 793 abstracts, 16 relevant studies were identified. Unrelated studies on drug interactions; antifungal or antiviral properties of statins; and antibacterial properties of mevastatin, cerivastatin, antibiotics, or natural products were excluded. Studies involving only statins currently registered for human use were included. Results Against Gram-positive bacteria, simvastatin generally exerted the greatest antibacterial activity (lowest MIC) compared to atorvastatin, rosuvastatin, and fluvastatin. Against Gram-negative bacteria, atorvastatin generally exhibited similar or slightly better activity compared to simvastatin, but both were more potent than rosuvastatin and fluvastatin. Discussion Statins may serve as AMR breakers by working synergistically with existing topical antibiotics, attenuating virulence factors, boosting human immunity, or aiding in wound healing. It is probable that statins’ mechanism of antibacterial activity involves interference of bacterial cell regulatory functions via binding and disrupting cell surface structures such as wall teichoic acids, lipoteichoic acids, lipopolysaccharides, and/or surface proteins. The widespread use of statins for cardiovascular protection may favor selective pressures or co-selection for resistance, including dysbiosis of the human gut microbiota, sublethal plasma concentrations in bacteremic patients, and statin persistence in the environment, all possibly culminating in AMR. Conclusion Simvastatin appears to be the most suitable statin for repurposing as a novel adjuvant antibiotic. Current evidence better supports statins as potential AMR breakers, but their role as plausible AMR makers cannot be excluded. Elucidating the mechanism of statins’ antibacterial activity is perhaps the most important knowledge gap to address as this will likely clarify statins’ role as AMR breakers or makers.
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Affiliation(s)
- Humphrey H T Ko
- School of Pharmacy, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia.,Curtin Health Innovation Research Institute (CHIRI) Biosciences Research Precinct, Curtin University, Perth, Western Australia, Australia
| | - Ricky R Lareu
- School of Pharmacy, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia.,Curtin Health Innovation Research Institute (CHIRI) Biosciences Research Precinct, Curtin University, Perth, Western Australia, Australia
| | - Brett R Dix
- School of Pharmacy, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Jeffery D Hughes
- School of Pharmacy, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
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No to Pip-Tazo. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2017. [DOI: 10.1097/ipc.0000000000000499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Walsh TL, Bremmer DN, Moffa MA, Chan-Tompkins NH, Murillo MA, Chan L, Burkitt MJ, Konopka CI, Watson C, Trienski TL. Effect of Antimicrobial Stewardship Program Guidance on the Management of Uncomplicated Skin and Soft Tissue Infections in Hospitalized Adults. Mayo Clin Proc Innov Qual Outcomes 2017; 1:91-99. [PMID: 30225405 PMCID: PMC6135010 DOI: 10.1016/j.mayocpiqo.2017.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective To assess the effect of an antimicrobial stewardship program (ASP)–bundled initiative on the appropriate use of antibiotics for uncomplicated skin and soft tissue infections (uSSTIs) at 2 academic medical centers in Pittsburgh, Pennsylvania. Patients and Methods A retrospective preintervention and postintervention study was conducted to compare management of patients admitted with uSSTIs before and after the implementation of the bundled initiative. The preintervention period was from August 1, 2014, through March 31, 2015, and the postintervention period was from August 1, 2015, through March 31, 2016. Results A total of 160 patients were included in the preintervention cohort, and 163 were included in the postintervention cohort. Compared with the preintervention group, the mean duration of therapy decreased (12.5 days vs 8.8 days; P<.001) and an appropriate duration of less than 10 days increased in more patients (20.6% [33 of 160] vs 68.7% [112 of 163]; P<.001) in the postintervention period. Fewer patients were exposed to antimicrobials with extended gram-negative (44.4% [71 of 160] vs 9.2% [15 of 163]; P<.001), anaerobic (39.4% [63 of 160] vs 9.8% [16 of 163]; P<.001), and antipseudomonal (16.3% [26 of 160] vs 1.8% [3 of 163]; P<.001) coverage. The mean length of stay decreased from 3.6 to 2.2 days (P<.001) without an increase in 30-day readmissions (6.3% [10 of 160] vs 4.9% [8 of 163]; P=.64). The ASP made recommendations for 125 patients, and 96% were accepted. Conclusion Implementation of an ASP-bundled approach aimed at optimizing antibiotic therapy in the management of uSSTIs led to shorter durations of narrow-spectrum therapy as well as shorter hospital length of stay without adversely affecting hospital readmissions.
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Key Words
- AGH, Allegheny General Hospital
- ASP, antimicrobial stewardship program
- ICD-10, International Classification of Diseases, Tenth Revision
- ICD-9, International Classification of Diseases, Ninth Revision
- IDSA, Infectious Diseases Society of America
- SSTI, skin and soft tissue infection
- WPH, Western Pennsylvania Hospital
- uSSTI, uncomplicated skin and skin tissue infection
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Affiliation(s)
- Thomas L Walsh
- Division of Infectious Diseases, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA.,Division of Infectious Diseases, Department of Medicine, Western Pennsylvania Hospital, Pittsburgh, PA
| | - Derek N Bremmer
- Department of Pharmacy, Western Pennsylvania Hospital, Pittsburgh, PA
| | - Matthew A Moffa
- Division of Infectious Diseases, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA.,Division of Infectious Diseases, Department of Medicine, Western Pennsylvania Hospital, Pittsburgh, PA
| | - Noreen H Chan-Tompkins
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA.,School of Pharmacy, Loma Linda University, Loma Linda, CA
| | - Monika A Murillo
- Division of Infectious Diseases, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA.,Division of Infectious Diseases, Department of Medicine, Western Pennsylvania Hospital, Pittsburgh, PA
| | - Lynn Chan
- Department of Pharmacy, Allegheny General Hospital, Pittsburgh, PA.,Department of Pharmacy, Mayo Clinic, Phoenix, AZ
| | - Michael J Burkitt
- Division of Hospital Medicine, Department of Medicine, Allegheny General Hospital, Pittsburgh, PA.,Division of Hospital Medicine, Department of Medicine, Western Pennsylvania Hospital, Pittsburgh, PA
| | | | - Courtney Watson
- Center for Inclusion Health, Allegheny General Hospital, Pittsburgh, PA
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Walsh TL, Chan L, Konopka CI, Burkitt MJ, Moffa MA, Bremmer DN, Murillo MA, Watson C, Chan-Tompkins NH. Appropriateness of antibiotic management of uncomplicated skin and soft tissue infections in hospitalized adult patients. BMC Infect Dis 2016; 16:721. [PMID: 27899072 PMCID: PMC5129241 DOI: 10.1186/s12879-016-2067-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/25/2016] [Indexed: 11/23/2022] Open
Abstract
Background Skin and soft tissue infections (SSTIs) are a leading cause for hospitalizations in the United States. Few studies have addressed the appropriateness of antibiotic therapy in the management of SSTIs without complicating factors. We aimed to determine the appropriateness of antibiotic treatment duration for hospitalized adult patients with uncomplicated SSTIs. Methods This was a retrospective analysis performed at two academic medical centers in Pittsburgh, Pennsylvania on patients aged 18 years and older with primary ICD-9 code for SSTIs admitted August 1st, 2014–March 31st, 2015. The primary outcome was the appropriateness of antibiotic treatment duration for uncomplicated SSTIs. Secondary objectives included the appropriateness of antibiotic agent spectrum, duration of inpatient length of stay (LOS), utilization of blood cultures and advanced imaging modalities, and re-hospitalization for SSTI within 30 days of discharge from the index admission. Results A total of 163 episodes were included in the cohort. The mean duration of total antibiotic therapy was 12.6 days. Appropriate duration was defined as receipt of total antibiotic duration of less than 10 days and occurred in 20.2% of patients. Twenty eight percent of patients received antibiotics for greater than 14 days. Seventy three (44.8%) patients received greater than 24 h of inappropriate extended spectrum gram-negative coverage; 65 (39.9%) received anaerobic coverage. Conclusions In the majority of patients, treatment duration was excessive. Inappropriate broad spectrum antibiotic selection was utilized with regularity for SSTIs without complicating factors. The management of uncomplicated SSTIs represents a significant opportunity for antimicrobial stewardship.
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Affiliation(s)
- Thomas L Walsh
- Department of Medicine and Division of Infectious Diseases, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA. .,Department of Medicine and Division of Infectious Diseases, Western Pennsylvania Hospital, 4800 Friendship Avenue, Pittsburgh, PA, 15224, USA.
| | - Lynn Chan
- Department of Pharmacy, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212, USA
| | - Chelsea I Konopka
- Department of Pharmacy, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212, USA
| | - Michael J Burkitt
- Division of Hospital Medicine, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212, USA.,Division of Hospital Medicine, Western Pennsylvania Hospital, 4800 Friendship Avenue, Pittsburgh, PA, 15224, USA
| | - Matthew A Moffa
- Department of Medicine and Division of Infectious Diseases, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA.,Department of Medicine and Division of Infectious Diseases, Western Pennsylvania Hospital, 4800 Friendship Avenue, Pittsburgh, PA, 15224, USA
| | - Derek N Bremmer
- Department of Pharmacy, Western Pennsylvania Hospital, 4800 Friendship Avenue, Pittsburgh, PA, 15224, USA
| | - Monika A Murillo
- Department of Medicine and Division of Infectious Diseases, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA.,Department of Medicine and Division of Infectious Diseases, Western Pennsylvania Hospital, 4800 Friendship Avenue, Pittsburgh, PA, 15224, USA
| | - Courtney Watson
- Center for Inclusion Health, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212, USA
| | - Noreen H Chan-Tompkins
- Department of Pharmacy, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA, 15212, USA
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Yogo N, Gahm G, Knepper BC, Burman WJ, Mehler PS, Jenkins TC. Clinical Characteristics, Diagnostic Evaluation, and Antibiotic Prescribing Patterns for Skin Infections in Nursing Homes. Front Med (Lausanne) 2016; 3:30. [PMID: 27493938 PMCID: PMC4954810 DOI: 10.3389/fmed.2016.00030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/23/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The epidemiology and management of skin infections in nursing homes has not been adequately described. We reviewed the characteristics, diagnosis, and treatment of skin infections among residents of nursing homes to identify opportunities to improve antibiotic use. METHODS This was a retrospective study involving 12 nursing homes in the Denver metropolitan area. For residents at participating nursing homes diagnosed with a skin infection between July 1, 2013 and June 30, 2014, clinical and demographic information was collected through manual chart review. RESULTS Of 100 cases included in the study, the most common infections were non-purulent cellulitis (n = 55), wound infection (n = 27), infected ulcer (n = 8), and cutaneous abscess (n = 7). In 26 cases, previously published minimum clinical criteria for initiating antibiotics (Loeb criteria) were not met. Most antibiotics (n = 52) were initiated as a telephone order following a call from a nurse, and 41 patients were not evaluated by a provider within 48 h after initiation of antibiotics. Nearly all patients (n = 95) were treated with oral antibiotics alone. The median treatment duration was 7 days (interquartile range 7-10); 43 patients received treatment courses of ≥10 days. CONCLUSION Most newly diagnosed skin infections in nursing homes were non-purulent infections treated with oral antibiotics. Antibiotics were initiated by telephone in over half of cases, and lack of a clinical evaluation within 48 h after starting antibiotics was common. Improved diagnosis through more timely clinical evaluations and decreasing length of therapy are important opportunities for antibiotic stewardship in nursing homes.
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Affiliation(s)
- Norihiro Yogo
- Department of Medicine, Division of Infectious Diseases, University of Colorado, Aurora, CO, USA; University of Colorado School of Medicine, Aurora, CO, USA
| | - Gregory Gahm
- Department of Medicine, Division of Geriatrics, University of Colorado , Aurora, CO , USA
| | - Bryan C Knepper
- Department of Patient Safety and Quality, Denver Health, Denver, CO, USA; Denver Health, Denver, CO, USA
| | - William J Burman
- Department of Medicine, Division of Infectious Diseases, University of Colorado, Aurora, CO, USA; University of Colorado School of Medicine, Aurora, CO, USA; Denver Health, Denver, CO, USA; Denver Public Health, Denver Health, Denver, CO, USA
| | - Philip S Mehler
- University of Colorado School of Medicine, Aurora, CO, USA; Denver Health, Denver, CO, USA
| | - Timothy C Jenkins
- Department of Medicine, Division of Infectious Diseases, University of Colorado, Aurora, CO, USA; University of Colorado School of Medicine, Aurora, CO, USA; Denver Health, Denver, CO, USA
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Dyar OJ, Beović B, Vlahović-Palčevski V, Verheij T, Pulcini C. How can we improve antibiotic prescribing in primary care? Expert Rev Anti Infect Ther 2016; 14:403-13. [PMID: 26853235 DOI: 10.1586/14787210.2016.1151353] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Antibiotic stewardship is a necessity given the worldwide antimicrobial resistance crisis. Outpatient antibiotic use represents around 90% of total antibiotic use, with more than half of these prescriptions being either unnecessary or inappropriate. Efforts to improve antibiotic prescribing need to incorporate two complementary strategies: changing healthcare professionals' behaviour, and modifying the healthcare system. In this review, we present a broad perspective on antibiotic stewardship in primary care in high and high-middle income country settings, focussing on studies published in the last five years. We present the limitations of available literature, discuss perspectives, and provide suggestions for where future work should be concentrated.
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Affiliation(s)
- Oliver J Dyar
- a Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden
| | - Bojana Beović
- b Department of Infectious Diseases, University Medical Centre Ljubljana and Faculty of Medicine , University of Ljubljana , Ljubljana , Slovenia
| | - Vera Vlahović-Palčevski
- c Department of Clinical Pharmacology, University Hospital Rijeka and Medical Faculty , University of Rijeka , Rijeka , Croatia
| | - Theo Verheij
- d Julius Center for Health Sciences and Primary Care , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Céline Pulcini
- e EA 4360 APEMAC , Université de Lorraine and Service de maladies infectieuses et tropicales, CHU de Nancy , Nancy , France
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Conejo-Fernández A, Martínez-Chamorro M, Couceiro J, Moraga-Llop F, Baquero-Artigao F, Alvez F, Vera Casaño A, Piñeiro-Pérez R, Alfayate S, Cilleruelo M, Calvo C. SEIP–AEPAP–SEPEAP consensus document on the aetiology, diagnosis and treatment of bacterial skin infections in out-patients. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.anpede.2015.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Documento de consenso SEIP-AEPAP-SEPEAP sobre la etiología, el diagnóstico y el tratamiento de las infecciones cutáneas bacterianas de manejo ambulatorio. An Pediatr (Barc) 2016; 84:121.e1-121.e10. [DOI: 10.1016/j.anpedi.2015.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 12/30/2014] [Accepted: 01/12/2015] [Indexed: 12/30/2022] Open
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Daneman N, Rishu AH, Xiong W, Bagshaw SM, Cook DJ, Dodek P, Hall R, Kumar A, Lamontagne F, Lauzier F, Marshall JC, Martin CM, McIntyre L, Muscedere J, Reynolds S, Stelfox HT, Fowler RA. Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness (BALANCE): study protocol for a pilot randomized controlled trial. Trials 2015; 16:173. [PMID: 25903783 PMCID: PMC4407544 DOI: 10.1186/s13063-015-0688-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 03/26/2015] [Indexed: 01/05/2023] Open
Abstract
Background Bacteremia is a leading cause of mortality and morbidity in critically ill adults. No previous randomized controlled trials have directly compared shorter versus longer durations of antimicrobial treatment in these patients. Methods/Design This is a multicenter pilot randomized controlled trial in critically ill patients with bacteremia. Eligible patients will be adults with a positive blood culture with pathogenic bacteria identified while in the intensive care unit. Eligible, consented patients will be randomized to either 7 days or 14 days of adequate antimicrobial treatment for the causative pathogen(s) detected on blood cultures. The diversity of pathogens and treatment regimens precludes blinding of patient and clinicians, but allocation concealment will be extended to day 7 and outcome adjudicators will be blinded. The primary outcome for the main trial will be 90-day mortality. The primary outcome for the pilot trial is feasibility defined by (i) rate of recruitment exceeding 1 patient per site per month and (ii) adherence to treatment duration protocol ≥ 90%. Secondary outcomes include intensive care unit, hospital and 90-day mortality rates, relapse rates of bacteremia, antibiotic-related side effects and adverse events, rates of Clostridium difficile infection, rates of secondary infection or colonization with antimicrobial resistant organisms, ICU and hospital lengths of stay, mechanical ventilation and vasopressor duration in intensive care unit, and procalcitonin levels on the day of randomization, and day 7, 10 and 14 after the index blood culture. Discussion The BALANCE pilot trial will inform the design and execution of the subsequent BALANCE main trial, which will evaluate shorter versus longer duration treatment for bacteremia in critically ill patients, and thereby provide an evidence basis for treatment duration decisions for these infections. Trial registration The Pilot Trial was registered on 26 September 2014. Trial registration number: NCT02261506. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0688-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nick Daneman
- Division of Infectious Diseases & Clinical Epidemiology, Sunnybrook Health Sciences Centre, University of Toronto and Adjunct Scientist, Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada.
| | - Asgar H Rishu
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
| | - Wei Xiong
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
| | - Sean M Bagshaw
- Division of Critical Care Medicine, University of Alberta Edmonton, 2-124E 8440-112 ST NW, Edmonton, AB, T6G 2B7, Canada.
| | - Deborah J Cook
- Division of Critical Care Medicine, Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L8, Canada.
| | - Peter Dodek
- Division of Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, St Paul's Hospital and University of B.C, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Richard Hall
- Division of Critical Care Medicine, Department of Anesthesiology, Dalhousie University and the Capital District, Health Authority, 5790 University Avenue, Halifax, NS, B3H 1V7, Canada.
| | - Anand Kumar
- Section of Critical Care Medicine, University of Manitoba, 710 Park Blvd South, Winnipeg, MB, R3P 0X1, Canada.
| | - Francois Lamontagne
- Centre de recherche Clinique Étienne-Le Bel, 2500 boul. de l'Université, Université de Sherbrooke, Sherbrooke, QC, J1K 2R1, Canada.
| | - Francois Lauzier
- Centre de recherche FRQS du Centre hospitalier affilié universitaire de Québec, Axe Traumatologie - urgence - soins intensifs, Division de soins intensifs adultes, départements de médecine et d'anesthésiologie, Université Laval, 1401, 18e Rue, Québec, QC, G1J 1Z4, Canada.
| | - John C Marshall
- Departments of Surgery and Critical Care Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
| | - Claudio M Martin
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, 800 Commissioners Rd. E, London, ON, N6A 4G5, Canada.
| | - Lauralyn McIntyre
- Division of Critical Care, Department of Medicine, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
| | - John Muscedere
- Department of Medicine, Kingston General Hospital, Queen's University, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
| | - Steven Reynolds
- Department of Medicine, Royal Columbian Hospital, University of British Columbia, 260 Sherbrook Street, New Westminster, Vancouver, BC, V3L 3M2, Canada.
| | - Henry T Stelfox
- Department of Critical Care Medicine, Institute of Public Health, University of Calgary, 1403 29 Street NW, Calgary, AB, T2N 2T9, Canada.
| | - Robert A Fowler
- Departments of Medicine and Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
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Zani-Ruttenstock E, Zani A, Bullman E, Lapidus-Krol E, Pierro A. Are paediatric operations evidence based? A prospective analysis of general surgery practice in a teaching paediatric hospital. Pediatr Surg Int 2015; 31:53-9. [PMID: 25367096 DOI: 10.1007/s00383-014-3624-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/07/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND/AIM Paediatric surgical practice should be based upon solid scientific evidence. A study in 1998 (Baraldini et al., Pediatr Surg Int) indicated that only a quarter of paediatric operations were supported by the then gold standard of evidence based medicine (EBM) which was defined by randomized controlled trials (RCTs). The aim of the current study was to re-evaluate paediatric surgical practice 16 years after the previous study in a larger cohort of patients. METHODS A prospective observational study was performed in a tertiary level teaching hospital for children. The study was approved by the local research ethics board. All diagnostic and therapeutic procedures requiring a general anaesthetic carried out over a 4-week period (24 Feb 2014-22 Mar 2014) under the general surgery service or involving a general paediatric surgeon were included in the study. Pubmed and EMBASE were used to search in the literature for the highest level of evidence supporting the recorded procedures. Evidence was classified according to the Oxford Centre for Evidence Based Medicine (OCEBM) 2009 system as well as according to the classification used by Baraldini et al. Results was compared using Χ (2) test. P < 0.05 was considered statistically significant. RESULTS During the study period, 126 operations (36 different types) were performed on 118 patients. According to the OCEBM classification, 62 procedures (49 %) were supported by systematic reviews of multiple homogeneous RCTs (level 1a), 13 (10 %) by individual RCTs (level 1b), 5 (4 %) by systematic reviews of cohort studies (level 2a), 11 (9 %) by individual cohort studies, 1 (1 %) by systematic review of case-control studies (level 3a), 14 (11 %) by case-control studies (level 3b), 9 (7 %) by case series (type 4) and 11 procedures (9 %) were based on expert opinion or deemed self-evident interventions (type 5). High level of evidence (OCEBM level 1a or 1b or level I according to Baraldini et al. PSI 1998) supported 75 (60 %) operations in the current study compared to 18 (26 %) in the study of 1998 (P < 0.0001). CONCLUSION The present study shows that nowadays a remarkable number of paediatric surgical procedures are supported by high level of evidence. Despite this improvement in evidence-based paediatric surgical practice, more than a third of the procedures still lack sufficient evidence-based literature support. More RCTs are warranted to support and direct paediatric surgery practice according to the principals of EBM.
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Affiliation(s)
- Elke Zani-Ruttenstock
- Division of General and Thoracic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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Jenkins TC, Haas MK, Shihadeh KC, Lavonas EJ. Trimethoprim-Sulfamethoxazole for Skin and Soft Tissue Infections—Let Us Not Forget the Risks. Ann Emerg Med 2014; 63:783-4. [DOI: 10.1016/j.annemergmed.2014.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 02/12/2014] [Accepted: 02/18/2014] [Indexed: 11/29/2022]
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