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Seo D, Heo I, Moon J, Kwon J, Huh Y, Kang B, Song S, Kim S, Jung K. Impact of a Rounding Checklist Implementation in the Trauma Intensive Care Unit on Clinical Outcomes. Healthcare (Basel) 2024; 12:871. [PMID: 38727427 PMCID: PMC11083085 DOI: 10.3390/healthcare12090871] [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: 03/08/2024] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
We aimed to evaluate the effectiveness of an intensive care unit (ICU) round checklist, FAST HUGS BID (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, Ulcer prophylaxis, Glycemic control, Spontaneous breathing trial, Bowel regimen, Indwelling catheter removal, and De-escalation of antibiotics-abbreviated as FD hereafter), in improving clinical outcomes in patients with severe trauma. We included patients admitted to our trauma ICU from 2016 to 2020 and divided them into two groups: before (before-FD, 2016-2017) and after (after-FD, 2019-2020) implementation of the checklist. We compared patient characteristics and clinical outcomes, including ICU and hospital length of stay (LOS) and in-hospital mortality. Survival analysis was performed using Kaplan-Meier curves and multivariable logistic regression models; furthermore, multiple linear regression analysis was used to identify independent factors associated with ICU and hospital LOS. Compared with the before-FD group, the after-FD group had significantly lower in-hospital mortality and complication rates, shorter ICU and hospital LOS, and reduced duration of mechanical ventilation. Moreover, implementation of the checklist was a significant independent factor in reducing ICU and hospital LOS and in-hospital mortality. Implementation of the FD checklist is associated with decreased ICU and hospital LOS and in-hospital mortality.
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Affiliation(s)
- Dongmin Seo
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Inhae Heo
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
| | - Jonghwan Moon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Yo Huh
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Byunghee Kang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Seoyoung Song
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Sora Kim
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
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Widyasari K, Lee S, Cho OH, Hong SI, Ryu BH, Kim S. The Significance of FilmArray Blood Culture Identification Panel (FA-BCID) for Managing Patients with Positive Blood Cultures. Diagnostics (Basel) 2023; 13:3335. [PMID: 37958231 PMCID: PMC10648013 DOI: 10.3390/diagnostics13213335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/22/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
We analyzed the accuracy and time efficiency of the FilmArray blood culture identification (FA-BCID) panel in identifying the pathogens in positive blood cultures. Two-hundred and seventy-two individuals were randomly assigned as the control (n = 212) and FA-BCID (n = 60) groups participating in this study. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) was used to assess the control group. Meanwhile, the FA-BCID group was evaluated using both FA-BCID and MALDI-TOF, and the results were compared. The identification results from 73% (44/60) of the blood samples demonstrated agreement between FA-BCID and MALDI-TOF. The FA-BCID panel detected mecA genes in seven Staphylococcus species; six cases were confirmed using antimicrobial susceptibility testing. In addition, KPC genes were detected in one Escherichia coli and one Klebsiella pneumoniae, although only the latter corresponded with the result from antimicrobial susceptibility testing. The turnaround time (TAT) for identification through FA-BCID was shorter, with a median of 3.6 [2.4-4.6] hours (p < 0.05). No significant differences in the clinical and microbial outcomes following the ASP were observed between FA-BCID and MALDI-TOF. These results suggest that the FA-BCID panel provides an identification result that is as reliable as that provided by the routine identification procedure but with shorter TAT; thus, the FA-BCID method is considered an effective and beneficial method for therapeutic decision making and the improvement of the ASP for patients with bloodstream infection.
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Affiliation(s)
- Kristin Widyasari
- Institute of Medical Science, Gyeongsang National University, Jinju 52828, Republic of Korea;
| | - Seungjun Lee
- Department of Laboratory Medicine, Gyeongsang National University Changwon Hospital, Changwon 51472, Republic of Korea;
- Department of Laboratory Medicine, College of Medicine, Gyeongsang National University, Jinju 52828, Republic of Korea
| | - Oh-Hyun Cho
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan 31151, Republic of Korea;
| | - Sun-In Hong
- Division of Infectious Diseases, College of Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University, Cheonan 31151, Republic of Korea;
| | - Byung-Han Ryu
- Department of Internal Medicine, Anyang SAM Hospital, Anyang 14030, Republic of Korea;
| | - Sunjoo Kim
- Institute of Medical Science, Gyeongsang National University, Jinju 52828, Republic of Korea;
- Department of Laboratory Medicine, Gyeongsang National University Changwon Hospital, Changwon 51472, Republic of Korea;
- Department of Laboratory Medicine, College of Medicine, Gyeongsang National University, Jinju 52828, Republic of Korea
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Sun J, Shi Y, Ding Y, Wang S, Qian L, Luan X, Li G, Chen Y, Li X, Lv H, Zheng G, Zhang G. Effect of Follow-Up Cerebrospinal Fluid Cultures in Post-Neurosurgical Patients' Outcome with Gram-Negative Bacterial Meningitis/Encephalitis. Infect Drug Resist 2023; 16:6285-6295. [PMID: 37771842 PMCID: PMC10522782 DOI: 10.2147/idr.s425799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023] Open
Abstract
Background To investigate the factors associated with follow-up CSF cultures (FUCCs) in post-neurosurgical patients with gram-negative bacterial meningitis/encephalitis and the effect of FUCCs on treatment management and patient outcomes. Methods This single-centered retrospective cohort study enrolled post-neurosurgical patients with gram-negative bacterial meningitis/encephalitis at a tertiary-care university hospital between 2012 and 2022. The risk factors for 28-day mortality were evaluated using multivariate Cox analysis. FUCC-related risk factors were also analyzed. Results Among the 844 enrolled patients, 504 (59.7%) underwent FUCC, and FUCC was found to be associated with lower rates of both all-cause (hazard ratio (HR) 0.391; 95% confidence interval (CI), 0.235-0.651; p<0.001) and attributable mortality (HR 0.463; 95% CI, 0.239-0.897; p=0.023) in Post-neurosurgical patients diagnosed with Gram-negative bacterial meningitis/encephalitis. Moreover, the results of the study underscored that patients with persistent gram-negative bacterial meningitis/encephalitis had a lower all-cause/attributable short-term survival rate according to 28-day mortality Kaplan-Meier analysis (P=0.001/0.006). Conclusion Performing FUCC has been demonstrated to lower mortality rates in Post-neurosurgical patients suffering from Gram-negative bacterial meningitis/encephalitis. The higher mortality rate observed in patients with persistent gram-negative bacterial meningitis/encephalitis suggests that performing FUCC is a crucial component of proper patient care and management, and is therefore recommended for use by clinicians as a standard practice. This finding underscores the significance of consistent implementation of FUCC in the management and prognosis of patients with Post-neurosurgical infections.
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Affiliation(s)
- Jialu Sun
- Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yijun Shi
- Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yaowei Ding
- Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Siqi Wang
- Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Lingye Qian
- Laboratory, Beijing An Zhen Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xin Luan
- Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Guoge Li
- Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yuxin Chen
- Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xiaotong Li
- Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hong Lv
- Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- NMPA Key Laboratory for Quality Control of in vitro Diagnostics, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Beijing Engineering Research Center of Immunological Reagents Clinical Research, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Guanghui Zheng
- Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- NMPA Key Laboratory for Quality Control of in vitro Diagnostics, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Beijing Engineering Research Center of Immunological Reagents Clinical Research, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Guojun Zhang
- Laboratory, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- NMPA Key Laboratory for Quality Control of in vitro Diagnostics, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Beijing Engineering Research Center of Immunological Reagents Clinical Research, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
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Aldardeer N, Qushmaq I, AlShehail B, Ismail N, AlHameed A, Damfu N, Al Musawa M, Nadhreen R, Kalkatawi B, Saber B, Nasser M, Ramdan A, Thabit A, Aldhaeefi M, Al Shukairi A. Effect of Broad-Spectrum Antibiotic De-escalation on Critically Ill Patient Outcomes: A Retrospective Cohort Study. J Epidemiol Glob Health 2023; 13:444-452. [PMID: 37296351 PMCID: PMC10255942 DOI: 10.1007/s44197-023-00124-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
PURPOSE Antibiotic de-escalation (ADE) in critically ill patients is controversial. Previous studies mainly focused on mortality; however, data are lacking about superinfection. Therefore, we aimed to identify the impact of ADE versus continuation of therapy on superinfections rate and other outcomes in critically ill patients. METHODS This was a two-center retrospective cohort study of adults initiated on broad-spectrum antibiotics in the intensive care unit (ICU) for ≥ 48 h. The primary outcome was the superinfection rate. Secondary outcomes included 30-day infection recurrence, ICU and hospital length of stay, and mortality. RESULTS 250 patients were included, 125 in each group (ADE group and continuation group). Broad spectrum antibiotic discontinuation occurred at a mean of 7.2 ± 5.2 days in the ADE arm vs. 10.3 ± 7.7 in the continuation arm (P value = 0.001). Superinfection was numerically lower in the ADE group (6.4% vs. 10.4%; P = 0.254), but the difference was not significant. Additionally, the ADE group had shorter days to infection recurrence (P = 0.045) but a longer hospital stay (26 (14-46) vs. 21 (10-36) days; P = 0.016) and a longer ICU stay (14 (6-23) vs. 8 (4-16) days; P = 0.002). CONCLUSION No significant differences were found in superinfection rates among ICU patients whose broad-spectrum antibiotics were de-escalated versus patients whose antibiotics were continued. Future research into the association between rapid diagnostics with antibiotic de-escalation in the setting of high resistance is warranted.
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Affiliation(s)
- Namareq Aldardeer
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, MBC J-11, P.O. Box 40047, Jeddah, 21499, Saudi Arabia.
| | - Ismael Qushmaq
- Section of Critical Care Medicine, Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Bashayer AlShehail
- Pharmacy Practice Department, College of Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Nadia Ismail
- Pharmaceutical Care Division, King Fahad Hospital of the University, Al-Khobar, Saudi Arabia
| | - Abrar AlHameed
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Madinah, Saudi Arabia
| | - Nader Damfu
- Infection Prevention and Control Department, King Abdul Aziz Medical City, Jeddah, Saudi Arabia
| | - Mohammad Al Musawa
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, MBC J-11, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Renad Nadhreen
- Section of Critical Care Medicine, Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Bayader Kalkatawi
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, MBC J-11, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Bashaer Saber
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, MBC J-11, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Mohannad Nasser
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, MBC J-11, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Aiman Ramdan
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Abrar Thabit
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Mohammed Aldhaeefi
- Department of Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC, USA
| | - Abeer Al Shukairi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Arain S, Khalawi F, Parakkal SA, AlHamad HS, Thorakkattil SA, Alghashmari FFJ, AlHarbi B, Bakhashwain N, Alzawad WM, AlHomoud A. Drug Utilization Evaluation and Impact of Pharmacist Interventions on Optimization of Piperacillin/Tazobactam Use: A Retrospective Analysis and Prospective Audit. Antibiotics (Basel) 2023; 12:1192. [PMID: 37508288 PMCID: PMC10376400 DOI: 10.3390/antibiotics12071192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/08/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Piperacillin/tazobactam is a broad-spectrum antimicrobial encompassing most Gram-positive and Gram-negative aerobic and anaerobic bacteria. The inappropriate use of such broad-spectrum antibiotics is an important contributor to the rising rates of antimicrobial drug resistance worldwide. Drug utilization evaluation studies and pharmacists' interventions are vital to assess, develop, and promote the rational use of antibiotics. This drug utilization study aimed to evaluate the current utilization practice of piperacillin/tazobactam in a hospital setting and assess the impact of pharmacist intervention in improving its appropriate use. (2) Methodology: In this study, we used a retrospective cohort and a prospective cohort, a cross-sectional, observational method. It included a retrospective (Cycle A/pre-intervention-CycA) phase followed by an educational interventional phase conducted by the pharmacists. During the 2 months of educational intervention, pharmacists used several methods, including workshops, lectures, oral presentations, and the development and reinforcement of clinical pathways to promote the judicious use of piperacillin/tazobactam. This was followed by a prospective (Cycle B/post-intervention-CycB) phase to improve piperacillin/tazobactam usage appropriateness. The appropriateness criteria for this drug utilization evaluation were established based on antimicrobial guidelines, the published literature, the institutional antibiogram, consultation from the antimicrobial stewardship committee, and the product monograph (Tazocin). The appropriateness of CycA and CycB patients was compared using the measurable elements, including indication and dose based on renal function, timely order for cultures, de-escalation, and use of extended infusion protocol. (3) Results: The study population comprised 100 patients in both CycA and CycB. The mean age of the patients was 66.28 ± 16.15 and 67.35 ± 17.98, and the ratios of men to women were found to be 49:51 and 61:39 in CycA and CycB, respectively. It was observed that inappropriate usage was high in CycA patients, and the appropriateness was improved in CycB patients. A total of 31% of inappropriate empirical broad-spectrum use was found in CycA, and it was reduced to 12% in CycB patients. The transition of appropriateness was observed in all measurable criteria, which includes the optimized dose according to the renal function (CycA = 49% to CycB = 94%), timely bacterial culture orders (CycA = 47% to CycB = 74%), prompt de-escalation (CycA = 31% to CycB = 53%), and adherence to extended infusion institutional guidelines (CycA = 34% to CycB = 86%). (4) Conclusions: The study highlighted important aspects of inappropriate piperacillin/tazobactam use. This can be considerably improved by proper education and timely interventions based on the pharmacists' vigilant approach. The study results emphasized the need for surveillance of piperacillin/tazobactam usage by conducting similar drug utilization evaluations and practice to improve quality and safety in healthcare organizations globally.
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Affiliation(s)
- Savera Arain
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Fahad Khalawi
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Sainul Abideen Parakkal
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Hassan S AlHamad
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Shabeer Ali Thorakkattil
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | | | - Bader AlHarbi
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Nujud Bakhashwain
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Weaam Mustafa Alzawad
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Ali AlHomoud
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
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Baltogianni M, Giapros V, Kosmeri C. Antibiotic Resistance and Biofilm Infections in the NICUs and Methods to Combat It. Antibiotics (Basel) 2023; 12:antibiotics12020352. [PMID: 36830264 PMCID: PMC9951928 DOI: 10.3390/antibiotics12020352] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Neonatal sepsis is an important cause of neonatal morbidity and mortality. A significant proportion of bacteria causing neonatal sepsis is resistant to multiple antibiotics, not only to the usual empirical first-line regimens, but also to second- and third-line antibiotics in many neonatal intensive care units (NICUs). NICUs have unique antimicrobial stewardship goals. Apart from antimicrobial resistance, NICUs have to deal with another problem, namely biofilm infections, since neonates often have central and peripheral lines, tracheal tubes and other foreign bodies for a prolonged duration. The aim of this review is to describe traditional and novel ways to fight antibiotic-resistant bacteria and biofilm infections in NICUs. The topics discussed will include prevention and control of the spread of infection in NICUs, as well as the wise use of antimicrobial therapy and ways to fight biofilm infections.
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Affiliation(s)
- Maria Baltogianni
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45500 Ioannina, Greece
| | - Vasileios Giapros
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45500 Ioannina, Greece
- Correspondence: ; Tel.: +30-26-5100-7546
| | - Chrysoula Kosmeri
- Department of Pediatrics, University Hospital of Ioannina, 45500 Ioannina, Greece
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Haseeb A, Saleem Z, Altaf U, Batool N, Godman B, Ahsan U, Ashiq M, Razzaq M, Hanif R, E-Huma Z, Amir A, Hossain MA, Raafat M, Radwan RM, Iqbal MS, Kamran SH. Impact of Positive Culture Reports of E. coli or MSSA on De-Escalation of Antibiotic Use in a Teaching Hospital in Pakistan and the Implications. Infect Drug Resist 2023; 16:77-86. [PMID: 36636371 PMCID: PMC9831081 DOI: 10.2147/idr.s391295] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/23/2022] [Indexed: 01/06/2023] Open
Abstract
Background Antibiotic de-escalation is a key element of antimicrobial stewardship programs that restrict the spread and emergence of resistance. This study was performed to evaluate the impact of positive culture sensitivity reports of E. coli or Methicillin sensitive Staphylococcus aureus (MSSA) on de-escalation of antibiotic therapy. Methods This prospective observational study was performed on 256 infected patients. The samples were obtained principally from the pus of infected sites for the identification of pathogens and culture-sensitivity testing. The data were collected from patient medical files, which included their demographic data, sample type, causative microbe and antimicrobial treatment as empiric or definitive treatment based on cultures. Data were analyzed using SPSS. Results Of 256 isolated microbes, 138 (53.9%) were MSSA and 118 were E. coli (46.1%). MSSA showed 100% sensitivity to cefoxitin, oxacillin, vancomycin, fosfomycin, colistin and more than 90% to linezolid (95.3%), tigecycline (93.1%), chloramphenicol (92.2%) and amikacin (90.2%). E. coli showed 100% sensitivity to only fosfomycin and more than 90% to colistin (96.7%), polymyxin-B (95.1%) and tigecycline (92.9%). The high use of cefoperazone+sulbactam (151), amikacin (149), ceftriaxone (33), metronidazole (30) and piperacillin + tazobactam (22) was seen with empiric prescribing. Following susceptibility testing, the most common antibiotics prescribed for E. coli were meropenem IV (34), amikacin (34), ciprofloxacin (29) and cefoperazone+sulbactam (25). For MSSA cases, linezolid (48), clindamycin (30), cefoperazone+ sulbactam IV (16) and amikacin (15) was used commonly. Overall, there was 23% reduction in antibiotic use in case of E. coli and 43% reduction in MSSA cases. Conclusion Culture sensitivity reports helped in the de-escalation of antimicrobial therapy, reducing the prescribing of especially broad-spectrum antibiotics. Consequently, it is recommended that local hospital guidelines be developed based on local antimicrobial susceptibility patterns while preventing the unnecessary use of broad-spectrum antibiotics for empiric treatment.
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Affiliation(s)
- Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan,Correspondence: Zikria Saleem, Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan, Email
| | - Ummara Altaf
- Department of Pharmacy, Ghurki Trust Teaching Hospital, Lahore, Pakistan
| | - Narjis Batool
- Australian Institute of Health Innovation, Center of Health Systems and Safety Research, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK,School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa,Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
| | - Umar Ahsan
- Department of Infection Prevention and Control, Al Noor Specialist Hospital, Ministry of health, Makkah, Kingdom of Saudi Arabia
| | - Mehreen Ashiq
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Mutiba Razzaq
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Rabia Hanif
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Zill E-Huma
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Afreenish Amir
- Department of Microbiology, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Mohammad Akbar Hossain
- Department of Pharmacology and Toxicology, Faculty of Medicine in Al-Qunfudah, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia
| | - Mohamed Raafat
- Department of Pharmacology and Toxicology, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Rozan Mohammad Radwan
- Pharmaceutical Care Department, Al Noor Specialist Hospital, Ministry of Health, Makkah, Saudi Arabia
| | - Muhammad Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
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Spectrum scores: Toward a better definition of de-escalation. Infect Control Hosp Epidemiol 2022:1-3. [DOI: 10.1017/ice.2022.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Spectrum scores measure antimicrobial utilization while also quantifying the spectrum of activity. Accordingly, changes in spectrum score can be used to identify antimicrobial de-escalation. We show that spectrum-score–based de-escalation has a 95.7% positive percentage agreement and 81.6% negative percentage agreement versus de-escalation defined as stopping either antistaphylococcal or antipseudomonal agents.
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Koomanachai P, Srisompong J, Chayangsu S, Ruangkriengsin D, Thamlikitkul V, Wangchinda W, Sirijatuphat R, Rattanaumpawan P. Implementation of Clinical Practice Guidelines for Empirical Antibiotic Therapy of Bacteremia, Urinary Tract Infection, and Pneumonia: A Multi-Center Quasi-Experimental Study. Antibiotics (Basel) 2022; 11:antibiotics11070903. [PMID: 35884157 PMCID: PMC9311984 DOI: 10.3390/antibiotics11070903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 11/16/2022] Open
Abstract
A quasi-experimental study was conducted on the implementation of locally developed clinical practice guidelines (CPGs) for empirical antibiotic (ATB) therapy of common infections (bacteremia, urinary tract infection (UTI), pneumonia) in the hospitals from January 2019 to December 2020. The CPGs were developed using data from patients with these infections at individual hospitals. Relevant CPG data pre- and post-implementation were collected and compared. Of the 1644 patients enrolled in the study, 808 and 836 were in the pre- and post-implementation periods, respectively, and patient outcomes were compared. Significant reductions in the mean durations of intensive care unit stay (3.44 ± 9.08 vs. 2.55 ± 7.89 days; p = 0.035), ventilator use (5.73 ± 12.14 vs. 4.22 ± 10.23 days; p = 0.007), piperacillin/tazobactam administration (0.954 ± 3.159 vs. 0.660 ± 2.217 days, p = 0.029), and cefoperazone/sulbactam administration (0.058 ± 0.737 vs. 0.331 ± 1.803 days, p = 0.0001) occurred. Multivariate analysis demonstrated that CPG-implementation was associated with favorable clinical outcomes (adjusted odds ratio 1.286, 95% confidence interval: 1.004–1.647, p = 0.046). Among patients who provided follow-up cultures (n = 284), favorable microbiological responses were significantly less frequent during the pre-implementation period than the post-implementation period (80.35% vs. 91.89%; p = 0.01). In conclusion, the locally developed CPG implementation is feasible and effective in improving patient outcomes and reducing ATB consumption. Hospital antimicrobial stewardship teams should be able to facilitate CPG development and implementation for antimicrobial therapy for common infections.
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Affiliation(s)
- Pornpan Koomanachai
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (P.K.); (V.T.); (W.W.); (R.S.)
| | | | | | | | - Visanu Thamlikitkul
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (P.K.); (V.T.); (W.W.); (R.S.)
| | - Walaiporn Wangchinda
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (P.K.); (V.T.); (W.W.); (R.S.)
| | - Rujipas Sirijatuphat
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (P.K.); (V.T.); (W.W.); (R.S.)
| | - Pinyo Rattanaumpawan
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (P.K.); (V.T.); (W.W.); (R.S.)
- Correspondence:
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10
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Teitelbaum D, Elligsen M, Katz K, Lam PW, Lo J, MacFadden D, Vermeiren C, Daneman N. Introducing the Escalation Antibiogram: A Simple Tool to Inform Changes in Empiric Antimicrobials in the Non-Responding Patient. Clin Infect Dis 2022; 75:1763-1771. [PMID: 35380628 DOI: 10.1093/cid/ciac256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hospital antibiograms guide initial empiric antibiotic treatment selections, but do not directly inform escalation of treatment among non-responding patients. METHODS Using Gram-negative bacteremia (GNB) as an exemplar condition, we sought to introduce the concept of an Escalation Antibiogram. Among GNBs between 2017-2020 from six hospitals in the Greater Toronto Area, we generated escalation antibiograms for each of 12 commonly used agents. Among organisms resistant to that antibiotic, we calculated the likelihood of susceptibility to each of the other 11 agents. In subgroup analyses, we examined escalation antibiograms across study years, individual hospitals, community versus hospital onset, and pathogen type. RESULTS Among 6577 GNB episodes, the likelihood of coverage was: ampicillin 31.8%, cefazolin 62.7%, ceftriaxone 67.1%, piperacillin-tazobactam 72.5%, ceftazidime 74.1%, trimethoprim-sulfamethoxazole 74.4%, ciprofloxacin 77.1%, tobramycin 88.3%, gentamicin 88.8%, ertapenem 91.0%, amikacin 97.5%, and meropenem 98.2%. The escalation antibiograms revealed marked shifts in likelihood of coverage by the remaining 11 agents. For example, among ceftriaxone-resistant isolates piperacillin-tazobactam susceptibility (21.2%) was significantly lower than trimethoprim-sulfamethoxazole (54.2%, p<0.0001), ciprofloxacin (63.0%, p<0.0001), ertapenem (73.4%, p<0.0001), tobramycin (80.1%, p<0.0001), gentamicin (82.8%, p<0.0001), meropenem (94.3%, p<0.0001), and amikacin (97.1%, p<0.0001). Trimethoprim-sulfamethoxazole was the second ranked agent in the meropenem escalation antibiogram (49.6%), and first in the amikacin escalation antibiogram (86.0%). Escalation antibiograms were consistent across 4 study years and 6 hospitals. CONCLUSION Escalation antibiograms can be generated to inform empiric treatment changes in non-responding patients. These tools can yield important insights such as avoiding the common maneuver of escalating from ceftriaxone to piperacillin-tazobactam in suspected GNB.
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Affiliation(s)
- Daniel Teitelbaum
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kevin Katz
- Department of Microbiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine, University of Toronto, Ontario, Canada.,Shared Hospital Laboratories, Toronto, Ontario, Canada
| | - Philip W Lam
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jennifer Lo
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Derek MacFadden
- Division of Infectious Diseases, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Christie Vermeiren
- Department of Laboratory Medicine, University of Toronto, Ontario, Canada.,Shared Hospital Laboratories, Toronto, Ontario, Canada
| | - Nick Daneman
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto Ontario Canada
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11
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Abstract
PURPOSE OF REVIEW Ventilator-associated pneumonia (VAP) is a common nosocomial infection in critically ill patients requiring endotracheal intubation and mechanical ventilation. Recently, the emergence of multidrug-resistant Gram-negative bacteria, including carbapenem-resistant Enterobacterales, multidrug-resistant Pseudomonas aeruginosa and Acinetobacter species, has complicated the selection of appropriate antimicrobials and contributed to treatment failure. Although novel antimicrobials are crucial to treating VAP caused by these multidrug-resistant organisms, knowledge of how to optimize their efficacy while minimizing the development of resistance should be a requirement for their use. RECENT FINDINGS Several studies have assessed the efficacy of novel antimicrobials against multidrug-resistant organisms, but high-quality studies focusing on optimal dosing, infusion time and duration of therapy in patients with VAP are still lacking. Antimicrobial and diagnostic stewardship should be combined to optimize the use of these novel agents. SUMMARY Improvements in diagnostic tests, stewardship practices and a better understanding of dosing, infusion time, duration of treatment and the effects of combining various antimicrobials should help optimize the use of novel antimicrobials for VAP and maximize clinical outcomes while minimizing the development of resistance.
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12
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Khan MR, Saleem Z, Batool N, Babar M, Shabbir A. Retrospective drug utilization review of meropenem and role of infectious disease pharmacist in specialized cancer care hospital. J Oncol Pharm Pract 2022; 28:910-915. [DOI: 10.1177/10781552221077929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Carbapenem antimicrobials are considered for the treatment of serious bacterial infections. The objective of this study was to review the use of meropenem in cancer patients and to evaluate the impact of clinical pharmacist's intervention in this practice to reduce possible risks associated with use of meropenem. Methods This retrospective study was conducted among 100 patients who received meropenem at hospital. A structured questionnaire was used to collect data. Descriptive statistics was used to analyze the collected data. Results A total of 100 patients were included in this retrospective study with aim to review rationality and possible side effects associated with meropenem use in our study population. It was revealed that meropenem used was associated with rise in bilirubin in many of our study patients. Pharmacist were found to be instrumental in placing timely interventions for either de-escalation or switch of meropenem to imipenem/cilastatin to reduce that risk. Interventions were accepted by physicians in most of the cases. Conclusion De-escalation and switching were performed in accordance with pharmacist recommendations in more than half of study population with empirically started/ study population in which meropenem was used.
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Affiliation(s)
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, University of Lahore, Lahore, Pakistan
| | - Narjis Batool
- Department of Pharmacology, Punjab University College of Pharmacy, University of the Punjab, Old Campus, Lahore, Pakistan
| | - Mahrukh Babar
- Department of Pharmacy Practice, Faculty of Pharmacy, University of Lahore, Lahore, Pakistan
| | - Aleena Shabbir
- Department of Pharmacy Practice, Faculty of Pharmacy, University of Lahore, Lahore, Pakistan
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13
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Lack of pathogen identification influencing antibiotic de-escalation in hospital-acquired pneumonia. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2022; 2:e181. [PMID: 36386010 PMCID: PMC9641501 DOI: 10.1017/ash.2022.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/09/2022]
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14
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Pliakos EE, Ziakas PD, Mylonakis E. The Cost-effectiveness of Cefazolin Compared With Antistaphylococcal Penicillins for the Treatment of Methicillin-Sensitive Staphylococcus aureus Bacteremia. Open Forum Infect Dis 2021; 8:ofab476. [PMID: 34746331 PMCID: PMC8566905 DOI: 10.1093/ofid/ofab476] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/17/2021] [Indexed: 12/14/2022] Open
Abstract
Background Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia is associated with significant morbidity, mortality, and hospitalization costs. Cefazolin and antistaphylococcal penicillins (ASPs), such as nafcillin, are the preferred treatments for MSSA bacteremia. The aim of this study was to compare the cost-effectiveness of each approach. Methods We constructed a decision-analytic model comparing the use of cefazolin with ASPs for the treatment of MSSA bacteremia. Cost-effectiveness was determined by calculating deaths averted and incremental cost-effectiveness ratios (ICERs). Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. Results In the base-case analysis, the cost associated with the cefazolin strategy was $38 863.1, and the associated probability of survival was 0.91. For the ASP strategy, the cost was $48 578.8, and the probability of survival was 0.81. The incremental difference in cost between the 2 strategies was $9715.7, with hospital length of stay being the main driver of cost, and the incremental difference in effectiveness was 0.10. Overall, cefazolin results in savings of $97 156.8 per death averted (ICER, $–97 156.8/death averted). In the probabilistic analysis, at a willingness-to-pay of $50 000, cefazolin had a 68% chance of being cost-effective compared with ASPs. In cost-effectiveness acceptability curves, the cefazolin strategy was cost-effective in 73.5%–81.8% of simulations compared with ASP for a willingness-to-pay ranging up to $50 000. Conclusions The use of cefazolin is a cost-effective strategy for the treatment of MSSA bacteremia and, when clinically appropriate, this strategy results in considerable health care cost-savings.
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Affiliation(s)
- Elina Eleftheria Pliakos
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Panayiotis D Ziakas
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA
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15
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Paediatric Antimicrobial Stewardship for Respiratory Infections in the Emergency Setting: A Systematic Review. Antibiotics (Basel) 2021; 10:antibiotics10111366. [PMID: 34827304 PMCID: PMC8615165 DOI: 10.3390/antibiotics10111366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/02/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022] Open
Abstract
Antimicrobial resistance occurs due to the propensity of microbial pathogens to develop resistance to antibiotics over time. Antimicrobial stewardship programs (ASPs) have been developed in response to this growing crisis, to limit unnecessary antibiotic prescription through initiatives such as education-based seminars, prescribing guidelines, and rapid respiratory pathogen (RRP) testing. Paediatric patients who present to the emergency setting with respiratory symptoms are a particularly high-risk population susceptible to inappropriate antibiotic prescribing behaviours and are therefore an ideal cohort for focused ASPs. The purpose of this systematic review was to assess the efficacy and safety of ASPs in this clinical context. A systematic search of PubMed, Medline, EMBASE and the Cochrane Database of Systematic Reviews was conducted to review the current evidence. Thirteen studies were included in the review and these studies assessed a range of stewardship interventions and outcome measures. Overall, ASPs reduced the rates of antibiotic prescription, increased the prescription of narrow-spectrum antibiotics, and shortened the duration of antibiotic therapy. Multimodal interventions that were education-based and those that used RRP testing were found to be the most effective. Whilst we found strong evidence that ASPs are effective in reducing antibiotic prescribing, further studies are required to assess whether they translate to equivalent clinical outcomes.
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16
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Ilges D, Ritchie DJ, Krekel T, Neuner EA, Hampton N, Kollef MH, Micek S. Assessment of Antibiotic De-escalation by Spectrum Score in Patients With Nosocomial Pneumonia: A Single-Center, Retrospective Cohort Study. Open Forum Infect Dis 2021; 8:ofab508. [PMID: 34805436 PMCID: PMC8600177 DOI: 10.1093/ofid/ofab508] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/11/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Hospital-acquired and ventilator-associated pneumonia (HAP/VAP) cause significant mortality. Guidelines recommend empiric broad-spectrum antibiotics followed by de-escalation (DE). This study sought to assess the impact of DE on treatment failure. METHODS This single-center retrospective cohort study screened all adult patients with a discharge diagnosis code for pneumonia from 2016 to 2019. Patients were enrolled if they met predefined criteria for HAP/VAP ≥48 hours after admission. Date of pneumonia diagnosis was defined as day 0. Spectrum scores were calculated, and DE was defined as a score reduction on day 3 versus day 1. Patients with DE were compared to patients with no de-escalation (NDE). The primary outcome was composite treatment failure, defined as all-cause mortality or readmission for pneumonia within 30 days of diagnosis. RESULTS Of 11860 admissions screened, 1812 unique patient-admissions were included (1102 HAP, 710 VAP). Fewer patients received DE (876 DE vs 1026 NDE). Groups were well matched at baseline, although more patients receiving DE had respiratory cultures ordered (56.6% vs 50.6%, P = .011). There was no difference in composite treatment failure (35.0% DE vs 33.8% NDE, P = .604). De-escalation was not associated with treatment failure on multivariable Cox regression analysis (hazard ratio, 1.13; 95% confidence interval, 0.96-1.33). Patients receiving DE had fewer antibiotic days (median 9 vs 11, P < .0001), episodes of Clostridioides difficile infection (2.2% vs 3.8%, P = .046), and hospital days (median 20 vs 22 days, P = .006). CONCLUSIONS De-escalation and NDE resulted in similar rates of 30-day treatment failure; however, DE was associated with fewer antibiotic days, episodes of C difficile infection, and days of hospitalization.
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Affiliation(s)
- Dan Ilges
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - David J Ritchie
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
| | - Tamara Krekel
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Elizabeth A Neuner
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Nicholas Hampton
- Center for Clinical Excellence, BJC HealthCare, St. Louis, Missouri, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Scott Micek
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
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17
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Yoon YK, Kwon KT, Jeong SJ, Moon C, Kim B, Kiem S, Kim HS, Heo E, Kim SW. Guidelines on Implementing Antimicrobial Stewardship Programs in Korea. Infect Chemother 2021; 53:617-659. [PMID: 34623784 PMCID: PMC8511380 DOI: 10.3947/ic.2021.0098] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022] Open
Abstract
These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Korean Society for Antimicrobial Therapy, Seoul, Korea
| | - Ki Tae Kwon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Korean Society of Infectious Diseases, Seoul, Korea
| | - Chisook Moon
- Korean Society of Infectious Diseases, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Bongyoung Kim
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungmin Kiem
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyung-Sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Eunjeong Heo
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Shin-Woo Kim
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
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18
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Branstetter JW, Barker L, Yarbrough A, Ross S, Stultz JS. Challenges of Antibiotic Stewardship in the Pediatric and Neonatal Intensive Care Units. J Pediatr Pharmacol Ther 2021; 26:659-668. [PMID: 34588929 DOI: 10.5863/1551-6776-26.7.659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 07/01/2021] [Indexed: 12/14/2022]
Abstract
The goals of antimicrobial stewardship programs (ASPs) are to optimize antimicrobial prescribing habits in order to improve patient outcomes, reduce antimicrobial resistance, and reduce hospital costs. Multiple society-endorsed guidelines and government policies reinforce the importance of ASP implementation. Effective antimicrobial stewardship can impact unique patients, hospitals, and societal antibiotic-resistance burden. The role and subsequent success of these programs has largely been reported in the adult population. Pediatric and neonatal intensive care units present unique challenges for traditional antimicrobial stewardship approaches. The purpose of this review article is to explore the challenges of appropriate antibiotic use in the pediatric and neonatal intensive care units and to summarize strategies ASPs can use to overcome these challenges. These problems include non-specific disease presentations, limited evidence for definitive treatment durations in many pediatric infections, fewer pediatric-trained infectious disease physicians, and applicability of intensive laboratory obtainment, collection, and interpretation. Additionally, many ASP implementation studies evaluating the efficacy of ASPs exclude the PICU and NICU. Areas of focus for pediatric ASPs should likely include appropriate antibiotic initiation, appropriate antibiotic duration, and appropriate antibiotic de-escalation.
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19
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Rashidzada Z, Cairns KA, Peel TN, Jenney AW, Doyle JS, Dooley MJ, Cheng AC. Early antimicrobial stewardship team intervention on appropriateness of antimicrobial therapy in suspected sepsis: a randomized controlled trial. JAC Antimicrob Resist 2021; 3:dlab097. [PMID: 34458731 PMCID: PMC8390781 DOI: 10.1093/jacamr/dlab097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/17/2021] [Indexed: 01/01/2023] Open
Abstract
Objectives There has been concern that the imperative to administer rapid antimicrobials in septic patients may result in inappropriate antimicrobial use. We aimed to determine the impact of early antimicrobial stewardship (AMS) team intervention in patients with Medical Emergency Team (MET) calls for suspected sepsis. Methods We performed a randomized controlled trial of non-ICU inpatients who had a MET call for suspected sepsis. Patients were randomized to standard care (management of antimicrobial therapy by the treating team) or early targeted intervention (AMS review 48 h post-MET call). The primary outcome was appropriateness of antimicrobial therapy 72 h post-MET call, as determined by a panel of blinded infectious diseases physicians. Results In total, 90 patients were enrolled; 45 were randomly allocated to the intervention group, and 45 to the control group. More patients in the AMS intervention group were receiving appropriate antimicrobials 72 h following the MET call (67% versus 44%, P = 0.03). In the intervention group, 27 recommendations were made by the AMS team; 74% of recommendations were accepted, including 30% of cases where antimicrobials were discontinued or de-escalated. There were non-significant differences in total duration of antimicrobial therapy (8.7 versus 10.7 days, P = 0.39), sepsis-related ICU-admission rates (13% versus 18%, P = 0.56) and sepsis-related in-hospital mortality (7% versus 9%, P = 0.71) between intervention and control groups, respectively. Conclusions AMS team intervention resulted in significant improvement in appropriateness of antimicrobial therapy following MET calls due to suspected sepsis. Targeted AMS review should be implemented to support early antimicrobial de-escalation and optimization in patients with suspected sepsis.
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Affiliation(s)
- Zohal Rashidzada
- Pharmacy Department, Alfred Health, Melbourne, Australia.,Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Kelly A Cairns
- Pharmacy Department, Alfred Health, Melbourne, Australia
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia.,Department of Infectious Diseases, Monash University, Melbourne, Australia
| | - Adam W Jenney
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia.,Department of Infectious Diseases, Monash University, Melbourne, Australia
| | - Joseph S Doyle
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia.,Department of Infectious Diseases, Monash University, Melbourne, Australia.,Burnet Institute, Melbourne, Australia
| | - Michael J Dooley
- Pharmacy Department, Alfred Health, Melbourne, Australia.,Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Allen C Cheng
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia.,Department of Infectious Diseases, Monash University, Melbourne, Australia.,Department of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
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20
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Johnson SH, Waisbren SJ. Physician Responsiveness to Positive Blood Culture Results at the Minneapolis Veterans Affairs Hospital-Is Anyone Paying Attention? Fed Pract 2021; 38:128-135. [PMID: 33859464 DOI: 10.12788/fp.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Patients presenting with suspected infections are typically placed on empiric broad-spectrum antibiotics. With mounting evidence supporting the efficacy of using the narrowest spectrum of antimicrobial therapy to cover the suspected pathogen, current guidelines recommend decreasing the breadth of coverage in response to culture results both in relation to microbe identification and antibiotic sensitivity. Methods A retrospective chart review of electronic health records at the Minneapolis Veterans Affairs Medical Center (VAMC) in Minnesota was performed for 208 positive blood cultures with antibiotic spectrum analysis from July 1, 2015 to June 30, 2016. The time of reporting for pathogen identification and subsequent pathogen susceptibilities were compared to the time at which any alterations to antibiotic coverage were made. The breadth of antibiotic coverage was recorded using a nonlinear spectrum score. The use of this score allowed for the reliable classification of antibiotic adjustments as either deescalation, escalation, or no change. Results The percentage of cases deescalated was higher in response to physician (house staff or attending physician) notification of pathogen susceptibility information when compared with a response to pathogen identification alone (33.2% vs 22.6%). Empiric antibiotics were not altered within 24 hours in response to pathogen identification in 70.7% of cases and were not altered within 24 hours in response to pathogen sensitivity determination in 58.6% of cases. However, when considering the time frame from when empiric antibiotics were started to 24 hours after notification of susceptibility information, 49.5% of cases were deescalated and 41.5% of cases had no net change in the antibiotic spectrum score. The magnitude of deescalations were notably larger than escalations. The mean (SD) time to deescalation of antibiotic coverage was shorter (P =.049) in response to pathogen identification at 8 (7.4) hours compared with sensitivity information at 10.4 (7) hours, but may not be clinically relevant. Conclusion Health care providers at the Minneapolis VAMC appear to be using positive blood culture results in a timely fashion consistent with best practices. Because empirically initiated antibiotics typically are broad in spectrum, the magnitude of deescalations were notably larger than escalations. Adherence to these standards may be a reflection of the infectious disease staff oversight of antibiotic administration. Furthermore, the systems outlined in this quality improvement study may be replicated at other VAMCs across the country by either in-house infectious disease staff or through remote monitoring of the electronic health record by other infectious disease experts at a more centralized VAMC. Widespread adoption throughout the Veterans Health Administration may result in improved antibiotic resistance profiles and better clinical outcomes for our nation's veterans.
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Affiliation(s)
- Shaun Heimbichner Johnson
- is a Medical Student at Case Western Reserve University School of Medicine in Cleveland, Ohio. is a Surgeon and Assistant Service Chief at the Minneapolis Veterans Affairs Health Care System in Minnesota and an Assistant Professor of Surgery at the University of Minnesota
| | - Steven James Waisbren
- is a Medical Student at Case Western Reserve University School of Medicine in Cleveland, Ohio. is a Surgeon and Assistant Service Chief at the Minneapolis Veterans Affairs Health Care System in Minnesota and an Assistant Professor of Surgery at the University of Minnesota
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21
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Giacomini E, Perrone V, Alessandrini D, Paoli D, Nappi C, Degli Esposti L. Evidence of Antibiotic Resistance from Population-Based Studies: A Narrative Review. Infect Drug Resist 2021; 14:849-858. [PMID: 33688220 PMCID: PMC7937387 DOI: 10.2147/idr.s289741] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/11/2021] [Indexed: 12/23/2022] Open
Abstract
The 20th century witnessed the dawn of the antibiotic revolution and is now facing the rising phenomenon of antibiotic resistance. In this narrative review, we aim to describe antibiotic resistance in clinical practice settings through population-based studies from different countries reporting the role of misuse of antibiotics in the development of resistance and the clinical and economic burden associated. The misuse of antibiotics was documented in the wide population as well as in hospitals and care facilities. It was mainly reported as over-use and inappropriate prescribing. Improper dosage regimens and longer treatment duration were regarded as pivotal factors related to antibiotic resistance; the emerging strategy of "antibiotic-de-escalation" could be the key to overcome these issues. The investigation of the self-medication attitude revealed widespread antibiotic use without following medical instructions or medical consultation. Moreover, several studies established the association of antibiotic resistance with increased risk of longer hospitalizations and mortality, highlighting the heavy clinical and economic burden of this phenomenon. In this narrative review, the widespread inappropriate use of antibiotics emerged as one of the main causes of antibiotic resistance, which negative outcomes call for the development of antibiotic stewardship programs and global surveillance networks.
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Affiliation(s)
- Elisa Giacomini
- CliCon S.r.l. Health, Economics & Outcomes Research, Ravenna, Italy
| | | | | | - Daniela Paoli
- CliCon S.r.l. Health, Economics & Outcomes Research, Ravenna, Italy
| | - Carmela Nappi
- CliCon S.r.l. Health, Economics & Outcomes Research, Ravenna, Italy
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Why Vancomycin Is Overly Prescribed Despite the Lack of Supporting Microbiological Data. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2021. [DOI: 10.1097/ipc.0000000000000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Princess I, Vadala R. Clinical Microbiology in the Intensive Care Unit: Time for Intensivists to Rejuvenate this Lost Art. Indian J Crit Care Med 2021; 25:566-574. [PMID: 34177177 PMCID: PMC8196372 DOI: 10.5005/jp-journals-10071-23810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We live in an era of evolving microbial infections and equally evolving drug resistance among microorganisms. In any healthcare facility, intensivists play the most pivotal role with critically ill patients under their direct care. Majority of the critically ill patients already harbor a microorganism at admission or acquire one in the form of healthcare-associated infections during their course of intensive care unit stay. It is therefore rather imperative for intensivists to possess sound knowledge in clinical microbiology. On a negative note, most clinicians have very meager and remote knowledge acquired during their undergraduate years. This knowledge is rather theoretical than applied and wanes over the years becoming nonbeneficial in intensive patient care. We, therefore, intend to explore important concepts in applied microbiology and infection control that intensivists should know and implement in their clinical practice on a day-to-day basis. How to cite this article: Princess I, Vadala R. Clinical Microbiology in the Intensive Care Unit: Time for Intensivists to Rejuvenate this Lost Art. Indian J Crit Care Med 2021;25(5):566–574.
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Affiliation(s)
- Isabella Princess
- Department of Microbiology, Apollo Speciality Hospitals, Vanagaram Branch, Chennai, Tamil Nadu, India
| | - Rohit Vadala
- Metro Centre for Respiratory Diseases, Metro Multispeciality Hospital, Noida, Uttar Pradesh, India
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Battula V, Krupanandan RK, Nambi PS, Ramachandran B. Safety and Feasibility of Antibiotic De-escalation in Critically Ill Children With Sepsis - A Prospective Analytical Study From a Pediatric ICU. Front Pediatr 2021; 9:640857. [PMID: 33763396 PMCID: PMC7982649 DOI: 10.3389/fped.2021.640857] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 02/12/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction: De-escalation is the key to balance judicious antibiotic usage for life-threatening infections and reducing the emergence of antibiotic resistance caused by antibiotic overuse. Robust evidence is lacking regarding the safety of antibiotic de-escalation in culture negative sepsis. Materials and Methods: Children admitted to the PICU during the first 6 months of 2019 with suspected infection were included. Based on the clinical condition, cultures and septic markers, antibiotics were de-escalated or continued at 48-72 h. Outcome data like worsening of primary infection, acquisition of hospital acquired infection, level of ICU support and mortality were captured. Results: Among the 360 admissions, 247 (68.6%) children received antibiotics. After excluding 92 children, 155 children with 162 episodes of sepsis were included in the study. Thirty four episodes were not eligible for de-escalation. Among the eligible group of 128 episodes, antibiotics were de-escalated in 95 (74.2%) and continued in 33 (25.8%). The primary infection worsened in 5 (5.2%) children in the de-escalation group and in 1 (3%) in non de-escalation group [Hazard ratio: 2.12 (95%CI: 0.39-11.46)]. There were no significant differences in rates of hospital acquired infection, mortality or length of ICU stay amongst the groups. Blood cultures and assessment of clinical recovery played a major role in de-escalation of antibiotics and the clinician's hesitation to de-escalate in critically ill culture negative children was the main reason for not de-escalating among eligible children. Conclusion: Antibiotic de-escalation appears to be a safe strategy to apply in criticallly ill children, even in those with negative cultures.
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Affiliation(s)
- Vasudha Battula
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Ravi Kumar Krupanandan
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - P Senthur Nambi
- Department of Pediatric Infectious Diseases, Kanchi Kamakoti CHILDS Trust Hospital and The CHILDS Trust Medical Research Foundation, Chennai, India
| | - Bala Ramachandran
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
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25
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Wagner CE, Prentice JA, Saad-Roy CM, Yang L, Grenfell BT, Levin SA, Laxminarayan R. Economic and Behavioral Influencers of Vaccination and Antimicrobial Use. Front Public Health 2020; 8:614113. [PMID: 33409264 PMCID: PMC7779682 DOI: 10.3389/fpubh.2020.614113] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/01/2020] [Indexed: 01/07/2023] Open
Abstract
Despite vast improvements in global vaccination coverage during the last decade, there is a growing trend in vaccine hesitancy and/or refusal globally. This has implications for the acceptance and coverage of a potential vaccine against COVID-19. In the United States, the number of children exempt from vaccination for “philosophical belief-based” non-medical reasons increased in 12 of the 18 states that allowed this policy from 2009 to 2017 (1). Meanwhile, the overuse and misuse of antibiotics, especially in young children, have led to increasing rates of drug resistance that threaten our ability to treat infectious diseases. Vaccine hesitancy and antibiotic overuse exist side-by-side in the same population of young children, and it is unclear why one modality (antibiotics) is universally seen as safe and effective, while the other (vaccines) is seen as potentially hazardous by some. In this review, we consider the drivers shaping the use of vaccines and antibiotics in the context of three factors: individual incentives, risk perceptions, and social norms and group dynamics. We illustrate how these factors contribute to the societal and individual costs of vaccine underuse and antimicrobial overuse. Ultimately, we seek to understand these factors that are at the nexus of infectious disease epidemiology and social science to inform policy-making.
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Affiliation(s)
- Caroline E Wagner
- Department of Bioengineering, McGill University, Montreal, QC, Canada
| | - Joseph A Prentice
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, United States
| | - Chadi M Saad-Roy
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, United States.,Lewis-Sigler Institute for Integrative Genomics, Princeton University, Princeton, NJ, United States
| | - Luojun Yang
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, United States
| | - Bryan T Grenfell
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, United States.,Princeton School of Public and International Affairs, Princeton University, Princeton, NJ, United States.,Fogarty International Center, National Institutes of Health, Bethesda, MD, United States
| | - Simon A Levin
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, United States.,Princeton Environmental Institute, Princeton University, Princeton, NJ, United States
| | - Ramanan Laxminarayan
- Princeton Environmental Institute, Princeton University, Princeton, NJ, United States.,Center for Disease Dynamics, Economics & Policy, Washington, DC, United States
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Mponponsuo K, Chew D, Lu S, Somayaji R, Rennert-May E. Differences in outcomes for hospitalizations of systemic and non-systemic infections associated with vascular and cardiac grafts and devices: a population-based study. J Hosp Infect 2020; 106:828-834. [PMID: 32896585 DOI: 10.1016/j.jhin.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/01/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Use of vascular and cardiac devices has expanded and is associated with a relative, though disproportionate, increase in device-associated infections. AIM To describe the association between cardiac/vascular device infections and outcomes in those with, and without systemic infections. METHODS We used the 2016 National Inpatient Sample and the International Classification of Diseases - 10th revision codes to identify hospitalized individuals with vascular and cardiac device infections. Linear and logistic regression models were utilized to compare outcomes of death, length of stay (LOS) and hospitalization costs between individuals with and without systemic infection. FINDINGS There were a total of 65,110 hospitalizations associated with device infections with a mean age of 61.3 ± 15.9 years (standard deviation); 28,650 (44%) had systemic infections. Elixhauser comorbidity scores of three or greater were observed in 91.2% of individuals with systemic infections along with a higher prevalence of diabetes, renal disease and heart failure. The primary outcome of mortality was observed in 3965 individuals with an odds ratio of 3.97 (95% confidence interval (CI), 2.92-3.95) in those with systemic infections compared with those without. Mean LOS was 3.44 days longer (95% CI, 2.92-3.95) and mean cost was US$11,776 greater (95% CI, US$9826-12,727) in the systemic infection cohort. CONCLUSION Systemic cardiac and vascular device infections were associated with increased mortality, LOS and costs. Considering the increasing use of these life-saving devices, further work is needed to identify those at risk for infectious complications, particularly systemic infection, in order to enhance preventative strategies and improve health outcomes.
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Affiliation(s)
- K Mponponsuo
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - D Chew
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - S Lu
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - R Somayaji
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada; Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - E Rennert-May
- Duke Clinical Research Institute, Duke University, Durham, NC, USA; Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada; Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
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27
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Al-Hadithi D, Al-Zakwani I, Balkhair A, Al Suleimani YM. Evaluation of the appropriateness of meropenem prescribing at a tertiary care hospital: A retrospective study in Oman. Int J Infect Dis 2020; 96:180-186. [PMID: 32339716 DOI: 10.1016/j.ijid.2020.04.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the use of meropenem in terms of indication and continuation of treatment at Sultan Qaboos University Hospital (SQUH), Muscat, Oman. METHODS A retrospective observational study, conducted by reviewing the medical records of 400 adults, admitted patients who received at least one dose of meropenem during the study period (January 2017 to September 2017). The analysis was performed using univariate statistics. RESULTS Meropenem was prescribed empirically in 382/400 (96%) of the cases. The majority (315/361 (87%)) of the patients received the proper meropenem dose. The indication for meropenem was considered appropriate in only 196/400 (49%) of the cases. The continuation of treatment was evaluated according to culture and sensitivity results in 202 cases, out of which 112 (55%) were justified. Most of the inappropriate uses were seen in oncology and hematology cases (31/42 (74%) and 61/101 (60%), respectively) and among respiratory and urinary tract infections (126/155 (81%) and 40/46 (87%), respectively). CONCLUSIONS Approximately half of the meropenem orders at SQUH in Oman were inappropriate and unjustified by culture-test results. New strategies are needed to optimize the rational use of meropenem and to ensure appropriate de-escalation and discontinuation of meropenem whenever indicated.
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Affiliation(s)
- Dunia Al-Hadithi
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Sciences, Muscat, Sultanate of Oman
| | - Ibrahim Al-Zakwani
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Sciences, Muscat, Sultanate of Oman
| | - Abdullah Balkhair
- Infectious Diseases Unit, Department of Medicine, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Yousuf M Al Suleimani
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Sciences, Muscat, Sultanate of Oman.
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Alshareef H, Alfahad W, Albaadani A, Alyazid H, Talib RB. Impact of antibiotic de-escalation on hospitalized patients with urinary tract infections: A retrospective cohort single center study. J Infect Public Health 2020; 13:985-990. [PMID: 32276874 DOI: 10.1016/j.jiph.2020.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/27/2020] [Accepted: 03/08/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) can be caused by multiple drug-resistant bacteria. Empirical broad-spectrum antibiotics help minimize the risk of disease progression. Although antibiotic de-escalation is important to reduce resistance, adverse drug effects, and costs, few studies have evaluated the impact of antibiotic de-escalation on complicated UTIs in hospitalized patients. METHODS In this retrospective cohort single center observational study conducted over a period of 1 year at Prince Sultan Military Medical City (PSMMC), the rate of antibiotic de-escalation following reporting culture and sensitivity results, hospital length of stay (LOS), and factors associated with antibiotic de-escalation failure were determined. RESULTS Ninety-one patients were enrolled in this study. Baseline characteristics were comparable between groups. The rate of successful de-escalation was 29.7% (27 patients) while 70.3% (64 patients) failed to experience de-escalation. The median hospital LOS was significantly lower in successfully de-escalated patients, at 3 days interquartile range (IQR) (2-6), while in the failed group it was 10 days IQR (6-21) (p<0.001). However, the identified factor associated with failure was a multidrug-resistant (MDR) pathogen that was significantly higher in the failed group than in the successful group: 38 patients (59.4%) versus 6 patients (22.2%; p<0.001), respectively. CONCLUSION Antibiotic de-escalation is an essential antimicrobial stewardship strategy. The findings of this study showed that de-escalation was associated with better patient outcomes (i.e., reduced hospital LOS) in patients admitted due to UTIs. In this study's site hospital, there is a potential for improving the current de-escalation rate. MDR pathogens were the only significant reason identified for de-escalation failure. Further data are needed on the large scale to evaluate reasons for de-escalation failure.
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Affiliation(s)
- Hanan Alshareef
- Department of Pharmacy Practice, College of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia; Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
| | - Wafa Alfahad
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abeer Albaadani
- Department of Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Huda Alyazid
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ruba Bin Talib
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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Yao J, Guan S, Liu Z, Li X, Zhou Q. Changes in immune indicators and bacteriologic profile were associated with patients with ventilator-associated pneumonia. Medicine (Baltimore) 2020; 99:e19716. [PMID: 32311958 PMCID: PMC7440178 DOI: 10.1097/md.0000000000019716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The aim of this study is to explore and identify ventilator-associated pneumonia (VAP)-related prognostic immune factors and further detect the drug-resistant pathogens to establish the theoretical guidance for clinical prevention and treatment strategies of VAP. A total of 478 patients using ventilator who were hospitalized in July 2014 to November 2016 in our hospital were enrolled in this study. About 103 patients with VAP (21.5%, 103/478) among 478 cases of patients using ventilator. Among the 103 patients with VAP, the distribution of pathogenic bacteria and drug resistance in patients with VAP were detected and analyzed. In the VAP group, 35 patients died and 43 patients had simultaneous sepsis. Compared with those of non-VAP group, the proportion of CD3 (P = .012), CD3CD4 (P = .024) and CD8CD28 ( P = .017) T cells in VAP group increased significantly, which indicated more severe immune response. Multivariate regression model analysis revealed that tracheotomy of mechanical ventilation (P = .013), mechanical ventilation time ≥7 days (P = .02) and aspiration and reflux (P = .011) were independent risk factors associated with VAP. According to the results of bacterial culture and drug sensitivity test, rational selection of antibiotics and monitoring of patients within intensive care unit can effectively control the incidence of VAP and improve the prognosis of patients.
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30
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Balamuth F, Alpern ER, Kan M, Shumyatcher M, Hayes K, Lautenbach E, Himes BE. Gene Expression Profiles in Children With Suspected Sepsis. Ann Emerg Med 2020; 75:744-754. [PMID: 31983492 DOI: 10.1016/j.annemergmed.2019.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 09/09/2019] [Accepted: 09/24/2019] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE Sepsis recognition is a clinical challenge in children. We aim to determine whether peripheral blood gene expression profiles are associated with pathogen type and sepsis severity in children with suspected sepsis. METHODS This was a prospective pilot observational study in a tertiary pediatric emergency department with a convenience sample of children enrolled. Participants were older than 56 days and younger than 18 years, had suspected sepsis, and had not received broad-spectrum antibiotics in the previous 4 hours. Primary outcome was source pathogen, defined as confirmed bacterial source from sterile body fluid or confirmed viral source. Secondary outcome was sepsis severity, defined as maximum therapy required for shock reversal in the first 3 hospital days. We drew peripheral blood for ribonucleic acid isolation at the sepsis protocol activation, obtained gene expression measures with the GeneChip Human Gene 2.0 ST Array, and conducted differential expression analysis. RESULTS We collected ribonucleic acid samples from a convenience sample of 122 children with suspected sepsis and 12 healthy controls. We compared the 66 children (54%) with confirmed bacterial or viral infection and found 558 differentially expressed genes, many related to interferon signaling or viral immunity. We did not find statistically significant gene expression differences in patients according to sepsis severity. CONCLUSION The study demonstrates feasibility of evaluating gene expression profiling data in children evaluated for sepsis in the pediatric emergency department setting. Our results suggest that gene expression profiling may facilitate identification of source pathogen in children with suspected sepsis, which could ultimately lead to improved tailoring of sepsis treatment and antimicrobial stewardship.
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Affiliation(s)
- Fran Balamuth
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Elizabeth R Alpern
- Department of Pediatrics, Northwestern School of Medicine, Division of Emergency Medicine, and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mengyuan Kan
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Maya Shumyatcher
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Katie Hayes
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ebbing Lautenbach
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Blanca E Himes
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
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A Prospective Cohort Study of Factors Associated with Empiric Antibiotic De-escalation in Neonates Suspected with Early Onset Sepsis (EOS). Paediatr Drugs 2020; 22:321-330. [PMID: 32185682 PMCID: PMC7222079 DOI: 10.1007/s40272-020-00388-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Prolonged empiric antibiotic use, resulting from diagnostic uncertainties, in suspected early onset sepsis (EOS) cases constitutes a significant problem. Unnecessary antibiotic use increases the risk of antibiotic resistance. Furthermore, prolonged antibiotic use increases the risk of mortality and morbidity in neonates. Proactive measures including empiric antibiotic de-escalation are crucial to overcome these problems. METHODS This was a prospective cohort study conducted in the neonatal intensive care units of two public hospitals in Malaysia. Neonates with a gestational age greater than 34 weeks who were started on empiric antibiotics within 72 h of life were screened. The data were then stratified according to de-escalation and non-de-escalation practices, where de-escalation practice was defined as narrowing down or discontinuation of empiric antibiotic within 72 h of treatment. RESULTS A total of 1045 neonates were screened, and 429 were included. The neonates were then divided based on de-escalation (n = 207) and non-de-escalation (n = 222) practices. Neonates under non-de-escalation practices showed significantly longer durations of antibiotic use compared to those under de-escalation practices (p < 0.05), with no difference in treatment outcomes. Five factors were found to be associated with de-escalation of antibiotics. They are cesarean section delivery, exposure to antenatal steroids, nil history of maternal pyrexia, absence of meconium-stained amniotic fluid, and normal C-reactive protein ≤ 0.5 mg/dL (p < 0.05). CONCLUSIONS Empiric antibiotic de-escalation appears feasible as a routine form of treatment for EOS in late preterm and term neonates.
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Sadatsharifi A, Davarpanah MA, Namazi S, Mottaghi S, Mahmoudi L. Economic Burden Of Inappropriate Empiric Antibiotic Therapy: A Report From Southern Iran. Risk Manag Healthc Policy 2019; 12:339-348. [PMID: 31849550 PMCID: PMC6913765 DOI: 10.2147/rmhp.s222200] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 11/08/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction Widespread inappropriate antibiotic prescribing by healthcare professionals in the hospital setting is a great concern that may cause many undesirable consequences. Adherences to antibiotic guidelines have proven to be a simple and effective intervention to guide the choice of appropriate empiric antibiotic regimens and reduce the unnecessary variations in the practice among practitioners. The objective of this study was to evaluate the prescription patterns of empiric antibiotic therapy in relation to treatment guidelines and the economic burden of discordance with guidelines in a major referral Iranian university hospital. Method Hospital records of hospitalized patients with empiric antibiotic prescription, from September 2016 to February 2017 were reviewed. The process consisted of comparing empiric antimicrobial administration with institutional guidelines for each patient by a clinical pharmacist and an infectious disease specialist to evaluate the appropriate utilization of antibiotics. Adherence to guideline, the cost of antibiotics usage for each patient and the excess cost consequent from discordance with guideline was calculated. Results The most inappropriate prescribed antibiotics were carbapenems and aminoglycosides. Overall guideline adherence was 27.8%. Frequency of antibiotic usage incompatibility with the guidelines on the basis of dosing interval, duration of therapy and drug indication were 31.46%, 29.44% and 19.36%, respectively. General surgery and internal medicine wards had the least and the most inappropriate antibiotic administration, respectively. Totally antibiotic usage cost was 578,959.39 USD (24,316,294,800 Iranian Rials, IRR) for 6 months, which the excess costs of inappropriate antibiotic prescribing, was 471,319.69 USD (19,795,427,225 IRR). The estimated annual excess cost is 942,639.38 USD (39,590,854,450 IRR). Conclusion In this research, physicians’ adherence with guidelines for empiric antibiotic therapy was low which was led to 471,319.69 USD excess costs. These results urge institution policy makers to develop guidelines to ensure active dissemination and implementation of them to decrease inappropriate antibiotic usage.
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Affiliation(s)
- Arman Sadatsharifi
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Soha Namazi
- Department of Clinical Pharmacy, School of pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Shaghayegh Mottaghi
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Laleh Mahmoudi
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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Chandrasekhar D, Manaparambil H, Parambil JC. Outcome assessment of intervention on appropriateness of antibiotic use among geriatric patients: A prospective interventional study from a tertiary care referral hospital. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2019. [DOI: 10.1016/j.cegh.2018.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Bultas AC, Bery AI, Deal EN, Hartmann AP, Richter SK, Call WB. Predictors of Treatment Failure Following De-escalation to a Fluoroquinolone in Culture-Negative Nosocomial Pneumonia. Ann Pharmacother 2019; 53:1207-1213. [DOI: 10.1177/1060028019867114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: Little evidence exists for de-escalation of nosocomial pneumonia therapy without positive cultures. Objective: The purpose of this study was to identify potential predictors of treatment failure following de-escalation to a fluoroquinolone in culture-negative nosocomial pneumonia. Methods: The study involved a single-center, retrospective cohort of patients admitted with diagnosis of nosocomial pneumonia and positive chest radiography who received at least 24 hours of fluoroquinolone monotherapy following at least 24 hours of appropriate empirical antibiotics. Treatment failure was defined using a composite of all-cause death within 30 days of discharge, treatment re-escalation, or readmission for pneumonia within 30 days of discharge. The Cox proportional hazards model was used to analyze predictors of treatment failure. Duration of empirical antibiotics and significant univariable exploratory predictors were included in multivariable analysis. Results: Of 164 patients, 23 (14%) failed de-escalation. Duration of empirical antibiotics (68.5 ± 32.1 vs 65.8 ± 35 hours) was not associated with treatment failure in univariable (Hazard Ratio [HR] = 1.002 [95% CI = 0.991-1.013]) or multivariable analyses (HR = 1.003 [95% CI = 0.991-1.015]). Significant exploratory predictors on univariable analysis included active cancer, intensive care unit (ICU) admission at empirical initiation, APACHE II score, and steroid use ≥20-mg prednisone equivalent. ICU admission at empirical initiation (HR = 2.439 [95% CI = 1.048-5.676]) and steroid use ≥20-mg prednisone equivalent (HR = 2.946 [95% CI = 1.281-6.772]) were associated with treatment failure on multivariable analysis. Conclusion and Relevance: Duration of empirical antibiotics does not appear to influence failure of de-escalation to fluoroquinolone monotherapy in culture-negative nosocomial pneumonia.
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Sadyrbaeva-Dolgova S, Aznarte-Padial P, Jimenez-Morales A, Expósito-Ruiz M, Calleja-Hernández MÁ, Hidalgo-Tenorio C. Pharmacist recommendations for carbapenem de-escalation in urinary tract infection within an antimicrobial stewardship program. J Infect Public Health 2019; 13:558-563. [PMID: 31685404 DOI: 10.1016/j.jiph.2019.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/31/2019] [Accepted: 09/18/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Carbapenem antibiotics are considered the treatment of choice for serious extended-spectrum beta-lactamase-producing Gram-negative bacteria infections. Our objectives were to analyze the results of carbapenem de-escalation therapy in complicated urinary tract infections (UTIs) attended in a third-level Spanish hospital and to evaluate the impact of pharmacist recommendation in this practice, the outcomes obtained, and associated factors. METHODS This prospective observational study of carbapenem prescriptions and de-escalation performance was conducted in a third-level hospital between August 1 2013 and July 31, 2014. Data were gathered on carbapenem treatment duration, de-escalation, length of hospital stay, mortality rate, and associated re-admissions. RESULTS De-escalation, which was only ordered for patients with positive cultures, was conducted in 49.7% of the 163 patients with complicated UTI. More than half (69.1%) of pharmacist interventions were accepted. De-escalation reduced the median hospital stay by five days (p=0.030). Crude hospital mortality was lower in the de-escalation group (7.4% vs. 29.3%, p<0.001), although their exposure to carbapenems was lower (4 vs 6 days, p<0.001). Factors associated with de-escalation were ICU stay for at least 48h, pharmacist recommendation and ESBL or AmpC producing Enterobacteriaceae. Factors associated with in-hospital mortality were age, previous admission and duration of hospital stay, but not pharmacist recommendation. Otherwise, carbapenem de-escalation was associated as a protective factor against in-hospital mortality. CONCLUSIONS Carbapenem de-escalation in accordance with pharmacist recommendation proved to be a safe approach in complicated UTI, reducing the hospital stay of patients without affecting the re-admission rate.
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Affiliation(s)
| | - Pilar Aznarte-Padial
- Department of Pharmacy, University Hospital Virgen de las Nieves, Granada, Spain
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Charani E, de Barra E, Rawson TM, Gill D, Gilchrist M, Naylor NR, Holmes AH. Antibiotic prescribing in general medical and surgical specialties: a prospective cohort study. Antimicrob Resist Infect Control 2019; 8:151. [PMID: 31528337 PMCID: PMC6743118 DOI: 10.1186/s13756-019-0603-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background Qualitative work has described the differences in prescribing practice across medical and surgical specialties. This study aimed to understand if specialty impacts quantitative measures of prescribing practice. Methods We prospectively analysed the antibiotic prescribing across general medical and surgical teams for acutely admitted patients. Over a 12-month period (June 2016 – May 2017) 659 patients (362 medical, 297 surgical) were followed for the duration of their hospital stay. Antibiotic prescribing across these cohorts was assessed using Chi-squared or Wilcoxon rank-sum, depending on normality of data. The t-test was used to compare age and length of stay. A logistic regression model was used to predict escalation of antibiotic therapy. Results Surgical patients were younger (p < 0.001) with lower Charlson Comorbidity Index scores (p < 0.001). Antibiotics were prescribed for 45% (162/362) medical and 55% (164/297) surgical patients. Microbiological results were available for 26% (42/164) medical and 29% (48/162) surgical patients, of which 55% (23/42) and 48% (23/48) were positive respectively. There was no difference in the spectrum of antibiotics prescribed between surgery and medicine (p = 0.507). In surgery antibiotics were 1) prescribed more frequently (p = 0.001); 2) for longer (p = 0.016); 3) more likely to be escalated (p = 0.004); 4) less likely to be compliant with local policy (p < 0.001) than medicine. Conclusions Across both specialties, microbiology investigation results are not adequately used to diagnose infections and optimise their management. There is significant variation in antibiotic decision-making (including escalation patterns) between general surgical and medical teams. Antibiotic stewardship interventions targeting surgical specialties need to go beyond surgical prophylaxis. It is critical to focus on of review the patients initiated on therapeutic antibiotics in surgical specialties to ensure that escalation and continuation of therapy is justified.
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Affiliation(s)
- E Charani
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
| | - E de Barra
- 2Royal College of Surgeons in Ireland, RCSI Education & Research Centre, Beaumont Hospital, Beaumont, Dublin 9, Ireland
| | - T M Rawson
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
| | - D Gill
- 3Department of Biostatistics and Epidemiology, School of Public Health, Imperial College London, London, W2 1PG UK
| | - M Gilchrist
- Department of Pharmacy, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London, W12 1NY UK
| | - N R Naylor
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
| | - A H Holmes
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
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Impact of an automated antibiotic time-out alert on the de-escalation of broad-spectrum antibiotics at a large community teaching hospital. Infect Control Hosp Epidemiol 2019; 40:1287-1289. [PMID: 31436144 DOI: 10.1017/ice.2019.197] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Broad-spectrum antibiotic de-escalation before and after implementation of a 72-hour antibiotic time-out alert within the electronic medical record was analyzed. De-escalation occurred significantly more often after the implementation of the alert (55.0% vs 35.1%; 95% confidence interval, -0.3491 to -0.0488; P < .01).
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Hijazi K, Joshi C, Gould IM. Challenges and opportunities for antimicrobial stewardship in resource-rich and resource-limited countries. Expert Rev Anti Infect Ther 2019; 17:621-634. [PMID: 31282277 DOI: 10.1080/14787210.2019.1640602] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Inappropriate prescription practices, patient and provider knowledge and attitudes, variable availability of diagnostic and surveillance systems, and the unrestricted use of antimicrobials in animals and plants are contributory factors to the global crisis of antimicrobial resistance (AMR). Areas covered: Notwithstanding that interventions to revert AMR should be tailored to the socio-politico-economic landscape, there is a global consensus for the implementation and enhancement of antimicrobial stewardship strategies. Yet the implementation of Antimicrobial Stewardship Programs (ASPs) remains relatively limited within healthcare settings and faces complex challenges in resource-limited countries. The current review summarizes the limitations of current ASPs, translation challenges in resource-limited countries, and potential solutions. Expert opinion: Suboptimal ASP implementation in hospitals is multifactorial. Restriction of antimicrobial use should be informed by risk-benefit analyses, including the potential for substitute prescribing, and displacement of selection pressures. Thresholds in population use of antibiotics above which AMR increases may provide quantitative targets for ASPs. Horizontal and vertical collaborations involving policymakers and the general public are of paramount importance. While impactful prescribing changes require sustained engagement of the public and health-care professionals, we warn against over-estimating the benefits of behavioral interventions. We advocate for population-level stewardship interventions in addition to investment in structural factors that will aid ASP implementation.
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Affiliation(s)
- Karolin Hijazi
- a Institute of Dentistry, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen , Aberdeen , UK
| | - Chaitanya Joshi
- b Department of Medical Microbiology, Aberdeen Royal Infirmary , Aberdeen , UK
| | - Ian M Gould
- b Department of Medical Microbiology, Aberdeen Royal Infirmary , Aberdeen , UK
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Mitchell KF, Safdar N, Abad CL. Evaluating carbapenem restriction practices at a private hospital in Manila, Philippines as a strategy for antimicrobial stewardship. ACTA ACUST UNITED AC 2019; 77:31. [PMID: 31312447 PMCID: PMC6610803 DOI: 10.1186/s13690-019-0358-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/13/2019] [Indexed: 11/10/2022]
Abstract
Background Hospital antimicrobial stewardship programs are especially critical in countries such as the Philippines, where antibiotic resistant infections are highly prevalent. At the study institution in Manila, Philippines, a Prior Approval for Restricted Antimicrobials (PARA) is required for non-infectious disease specialists to prescribe certain antimicrobials, including carbapenems. PARA request forms include specification of empiric or definitive therapy based on diagnostic tests. Recommended duration of therapy is typically 3 days for empiric use and 7 days for definitive, with possible extension upon specialist approval. Methods The study took place at an 800-bed tertiary hospital. We performed a retrospective review of patient medical records and laboratory reports dating from January 1 to December 31, 2016. Information related to patient demographics, carbapenem prescription, laboratory diagnosis, and therapy were compiled. Carbapenem prescriptions were classified as 'adherent' or 'non-adherent' according to clinical guidelines related to infection diagnosis, treatment duration, and de-escalation. Results Of the 185 patients on carbapenem therapy, Prescriptions of carbapenems were either definitive (n = 56), empiric (n = 127), or prophylactic (n = 2) as defined by the ordering provider. 69 out of 185 (37%) prescriptions were deemed non-adherent to guidelines, despite receiving approvals for their respective requests. Of these, 72% were non-adherent due to failure to de-escalate the carbapenem and 28% were non-adherent due to an incomplete course of therapy. Conclusion Despite initial PARA approval for carbapenem therapy, 37% of prescriptions were non-guideline-adherent, highlighting the ongoing challenges in implementing this type of stewardship strategy. In order to increase the effectiveness of PARA, additional approaches may be warranted, including the application of strict policies which reinforce follow-up of available culture results, justification of therapy extension, or referral to an infectious disease specialist.
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Affiliation(s)
- Kaitlin F Mitchell
- 1Division of Infectious Diseases, Department of Medicine, University of Wisconsin-Madison, Madison, WI USA.,5Present Address: Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO USA
| | - Nasia Safdar
- 1Division of Infectious Diseases, Department of Medicine, University of Wisconsin-Madison, Madison, WI USA.,2William S. Middleton Memorial Veterans Hospital, Madison, WI USA.,3Infection Control Department, University of Wisconsin-Madison, Madison, WI USA
| | - Cybele L Abad
- Department of Medicine, Section of Infectious Diseases, The Medical City Hospital, Ortigas Ave, Pasig City, Philippines
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Sadyrbaeva-Dolgova S, Aznarte-Padial P, Pasquau-Liaño J, Expósito-Ruiz M, Calleja Hernández MÁ, Hidalgo-Tenorio C. Clinical outcomes of carbapenem de-escalation regardless of microbiological results: A propensity score analysis. Int J Infect Dis 2019; 85:80-87. [PMID: 31075508 DOI: 10.1016/j.ijid.2019.04.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/27/2019] [Accepted: 04/30/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the safety and efficacy of de-escalation in patients under treatment with carbapenems and its impact on clinical outcomes. METHODS A prospective observational study was conducted for 1year. Patients administered active carbapenems for at least 24h were included. Primary outcomes were in-hospital mortality, mortality at 30 days after carbapenem prescription, and infection-related readmission within 30 days. De-escalation was defined as the substitution of carbapenem with narrower spectrum antimicrobial agents or its discontinuation during the first 96h of treatment. RESULTS The study included 1161 patients, and de-escalation was performed in 667 (57.5%) of these. In the de-escalation group, 54.9% of cultures were positive. After propensity score matching, 30-day mortality was lower (17.4% vs. 25.7%, p=0.036), carbapenem treatment was 4 days shorter (4 vs. 8 days, p<0.001), total antibiotic therapy duration was 2 days longer (12 vs. 10 days, p=0.003), and length of hospital stay was 5 days shorter (8 vs. 13 days, p=0.008) in the de-escalated versus non-de-escalated patients. In-hospital mortality and 30-day readmission rates did not differ significantly between these groups. CONCLUSION Carbapenem de-escalation is a safe strategy that does not compromise the clinical status of patients.
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Affiliation(s)
- Svetlana Sadyrbaeva-Dolgova
- Department of Pharmacy, University Hospital Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria de Granada, Granada, Spain.
| | - Pilar Aznarte-Padial
- Department of Pharmacy, University Hospital Virgen de las Nieves, Granada, Spain
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Epidemiology of invasive and non-invasive pneumococcal infections in hospitalised adult patients in a Lebanese medical centre, 2006-2015. J Infect Public Health 2019; 13:2092-2100. [PMID: 30948221 DOI: 10.1016/j.jiph.2019.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/01/2019] [Accepted: 03/03/2019] [Indexed: 11/22/2022] Open
Abstract
This is a retrospective medical file review of adult inpatients with Streptococcus pneumoniae infections admitted to a Lebanese hospital between 2006 and 2015. We revisited the clinical scenarios of these infections in view of increasing antibiotic resistance in Lebanon. One hundred and three patients were included; 92% were eligible for pneumococcal vaccination, yet none were vaccinated. Non-invasive pneumococcal disease (non-IPD) represented 64% of these infections. Superinfections caused by antibiotic-resistant bacteria were documented in 17.5% of the patients, with the predominance of ventilator-associated pneumonia (12.6%). Kidney disease and septic shock were positive predictors for mortality [adjusted odds ratio (OR) = 14.96, 95% confidence interval (CI) 2.34-95.45, P = 0.004; OR = 5.09, 95% CI 1.33-19.51, P = 0.02, respectively]. Herein, the differences in clinical success, S. pneumoniae infection-related death, and total mortality were not statistically significant between invasive pneumococcal disease (IPD) and non-IPD subgroups (59.5% vs. 77.3%, P = 0.056; 21.6% vs. 9.1%, P = 0.08; and 35.1% vs. 22.7%, P = 0.174; respectively). Upon comparing antibiotic susceptibility of S. pneumoniae during the first two years of the study (2006-2007) (n = 32 isolates) and the last two (2014-2015) (n = 14 isolates), there was an increasing non-susceptibility to penicillin (34.4%-50.0%, P = 0.25), and a decreasing susceptibility to erythromycin and clindamycin (81.3%-78.6%, P = 0.67 and 90.6%-85.7%, P = 0.65; respectively).
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Lee BJ, Wang SK, Constantino-Corpuz JK, Apolinario K, Nadler B, McDanel JS, Scheetz MH, Rhodes NJ. Cefazolin vs. anti-staphylococcal penicillins for treatment of methicillin-susceptible Staphylococcus aureus bloodstream infections in acutely ill adult patients: Results of a systematic review and meta-analysis. Int J Antimicrob Agents 2019; 53:225-233. [DOI: 10.1016/j.ijantimicag.2018.11.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 11/06/2018] [Accepted: 11/17/2018] [Indexed: 12/21/2022]
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Ali M, Naureen H, Tariq MH, Farrukh MJ, Usman A, Khattak S, Ahsan H. Rational use of antibiotics in an intensive care unit: a retrospective study of the impact on clinical outcomes and mortality rate. Infect Drug Resist 2019; 12:493-499. [PMID: 30881054 PMCID: PMC6396654 DOI: 10.2147/idr.s187836] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Intensive care units (ICUs) are specialized units where patients with critical conditions are admitted for getting specialized and individualized medical treatment. High mortality rates have been observed in ICUs, but the exact reason and factors affecting the mortality rates have not yet been studied in the local population in Pakistan. Aim This study was aimed to determine rational use of antibiotic therapy in ICU patients and its impact on clinical outcomes and mortality rate. Methods This was a retrospective, longitudinal (cohort) study including 100 patients in the ICU of the largest tertiary care hospital of the capital city of Pakistan. Results It was observed that empiric antibiotic therapy was initiated in 68% of patients, while culture sensitivity test was conducted for only 19% of patients. Thirty-percent of patients developed nosocomial infections and empiric antibiotic therapy was not initiated for those patients (P<0.05). Irrational antibiotic prescribing was observed in 86% of patients, and among them, 96.5% mortality was observed (P<0.05). The overall mortality rate was 83%; even higher mortality rates were observed in patients on a ventilator, patients with serious drug-drug interactions, and patients prescribed with irrational antibiotics or nephrotoxic drugs. Adverse clinical outcomes leading to death were observed to be significantly associated (P<0.05) with irrational antibiotic prescribing, nonadjustment of doses of nephrotoxic drugs, use of steroids, and major drug-drug interactions. Conclusion It was concluded that empiric antibiotic therapy is beneficial in patients and leads to a reduction in the mortality rate. Factors including irrational antibiotic selection, prescribing contraindicated drug combinations, and use of nephrotoxic drugs were associated with high mortality rate and poor clinical outcomes.
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Affiliation(s)
- Muhammad Ali
- Faculty of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan
| | - Humaira Naureen
- Faculty of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan
| | - Muhammad Haseeb Tariq
- Pharmaceutical Evaluation and Registration Division, Drug Regulatory Authority of Pakistan, Islamabad, Pakistan, .,Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia,
| | - Muhammad Junaid Farrukh
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, Malaysia.,Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Abubakar Usman
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia,
| | - Shahana Khattak
- Faculty of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan
| | - Hina Ahsan
- Faculty of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan
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Seok H, Park DW. Optimal antimicrobial therapy and antimicrobial stewardship in sepsis and septic shock. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2019. [DOI: 10.5124/jkma.2019.62.12.638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Hyeri Seok
- Division of Infectious Diseases, Department of Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Dae Won Park
- Division of Infectious Diseases, Department of Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
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Singh R, Azim A, Gurjar M, Poddar B, Baronia AK. Audit of Antibiotic Practices: An Experience from a Tertiary Referral Center. Indian J Crit Care Med 2019; 23:7-10. [PMID: 31065201 PMCID: PMC6481268 DOI: 10.5005/jp-journals-10071-23104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims To estimate the prevalence of antibiotic de-escalation at admission in patients referred to a tertiary hospital in India. The secondary outcomes were the adequacy of empirical antibiotic therapy and culture positivity rates in the de-escalated group. Materials and methods A prospective observational study, in a 20-bedded intensive care unit (ICU) of tertiary care hospital. Patients >18 years, surviving > 48 hours, were included (June– December 2017). Demographic data, previous cultures, and antibiotics from other hospitals, laboratory parameters in the first 24 hours, and severity of illness were noted. Changes made in antibiotic therapy within 48 hours were recorded. Patients were analyzed into three groups: “No change”–empiric therapy was maintained, “Escalation”–switch to or addition of an antibiotic with a broader spectrum, and “De-escalation”–switch to or interruption of a drug class. Results The total number of patients eligible was 75. The mean age of the population is 43.38 (SD + 3.4) and groups were comparable in terms of mean sequential organ failure assessment score (SOFA) and acute physiology, age, chronic health evaluation (APACHE) 2. The prevalence of de-escalation was 60% at admission. The escalation group consisted of 24%. Sixteen percent patients belonged to no change group. Results showed that 38% of patients were on carbapenems, dual gram negative was given to 26%, and empirical methicillin-resistant staphylococcus aureus (MRSA) coverage was 28% on admission. Conclusion Our study aims to provide data about actual practices in the Indian scenario. It highlights the generous use of high-end antibiotics in the community. Indian practices are far cry from theoretical teaching and western data. The need for antibiotic stewardship program in our country for both public and private health sectors is the need of the hour. How to cite this article Singh R, Azim A, Gurjar M, Poddar B, Baronia AK. Audit of Antibiotic Practices: An Experience from a Tertiary Referral Center. Indian Journal of Critical Care Medicine, January 2019;23(1):7-10.
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Affiliation(s)
- Ritu Singh
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Afzal Azim
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Banani Poddar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arvind K Baronia
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Palacios-Baena ZR, Delgado-Valverde M, Valiente Méndez A, Almirante B, Gómez-Zorrilla S, Borrell N, Corzo JE, Gurguí M, De la Calle C, García-Álvarez L, Ramos L, Gozalo M, Morosini MI, Molina J, Causse M, Pascual Á, Rodríguez-Baño J, de Cueto M, Planes Reig AM, Tubau Quintano F, Peña C, Galán Otalora ME, Ruíz de Alegría C, Cantón R, Lepe JA, Cisneros JM, Torre-Cisneros J, Lara R. Impact of De-escalation on Prognosis of Patients With Bacteremia due to Enterobacteriaceae: A Post Hoc Analysis From a Multicenter Prospective Cohort. Clin Infect Dis 2018; 69:956-962. [DOI: 10.1093/cid/ciy1032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 12/04/2018] [Indexed: 12/31/2022] Open
Abstract
Abstract
Background
More data are needed about the safety of antibiotic de-escalation in specific clinical situations as a strategy to reduce exposure to broad-spectrum antibiotics. The aims of this study were to investigate predictors of de-escalation and its impact on the outcome of patients with bloodstream infection due to Enterobacteriaceae (BSI-E).
Methods
A post hoc analysis was performed on a prospective, multicenter cohort of patients with BSI-E initially treated with ertapenem or antipseudomonal β-lactams. Logistic regression was used to analyze factors associated with early de-escalation (EDE) and Cox regression for the impact of EDE and late de-escalation (LDE) on 30-day all-cause mortality. A propensity score (PS) for EDE vs no de-escalation (NDE) was calculated. Failure at end of treatment and length of hospital stay were also analyzed.
Results
Overall, 516 patients were included. EDE was performed in 241 patients (46%), LDE in 95 (18%), and NDE in 180 (35%). Variables independently associated with a lower probability of EDE were multidrug-resistant isolates (odds ratio [OR], 0.50 [95% confidence interval {CI}, .30–.83]) and nosocomial infection empirically treated with imipenem or meropenem (OR, 0.35 [95% CI, .14–.87]). After controlling for confounders, EDE was not associated with increased risk of mortality; hazard ratios (HR) (95% CIs) were as follows: general model, 0.58 (.25–1.31); model with PS, 0.69 (.29–1.65); and PS-based matched pairs, 0.98 (.76–1.26). LDE was not associated with mortality. De-escalation was not associated with clinical failure or length of hospital stay.
Conclusions
De-escalation in patients with monomicrobial bacteremia due to Enterobacteriaceae was not associated with a detrimental impact on clinical outcome.
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Affiliation(s)
- Zaira R Palacios-Baena
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena, Departamentos de Medicina y Microbiología, Universidad de Sevilla and Instituto de Biomedicina de Sevilla
| | - Mercedes Delgado-Valverde
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena, Departamentos de Medicina y Microbiología, Universidad de Sevilla and Instituto de Biomedicina de Sevilla
| | - Adoración Valiente Méndez
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena, Departamentos de Medicina y Microbiología, Universidad de Sevilla and Instituto de Biomedicina de Sevilla
| | - Benito Almirante
- Servei de Malalties Infeccioses, Hospital Universitari Vall d’Hebron, Barcelona
| | | | - Núria Borrell
- Servicio de Microbiología, Hospital Universitario Son Espases, Palma de Mallorca, Islas Baleares
| | - Juan E Corzo
- Unidad Clínica Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen de Valme, Sevilla
| | - Mercedes Gurguí
- Unitat de Malaties Infeccioses, Hospital de la Santa Creu i Sant Pau
| | | | - Lara García-Álvarez
- Departamento de Enfermedades Infecciosas, Hospital San Pedro-Centro de Investigación Biomédica de La Rioja, Logroño
| | - Lucía Ramos
- Servicio de Microbiología, Hospital Universitario A Coruña, Santander
| | - Mónica Gozalo
- Servicio de Microbiología, Hospital Marqués de Valdecilla-Instituto de Investigación Sanitaria Valdecilla, Santander
| | | | - José Molina
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Universidad de Sevilla and Instituto de Biomedicina de Sevilla
| | - Manuel Causse
- Unidad de Gestión Clínica de Microbiología, Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Clínica, Universidad de Córdoba, Spain
| | - Álvaro Pascual
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena, Departamentos de Medicina y Microbiología, Universidad de Sevilla and Instituto de Biomedicina de Sevilla
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena, Departamentos de Medicina y Microbiología, Universidad de Sevilla and Instituto de Biomedicina de Sevilla
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Leong HN, Kurup A, Tan MY, Kwa ALH, Liau KH, Wilcox MH. Management of complicated skin and soft tissue infections with a special focus on the role of newer antibiotics. Infect Drug Resist 2018; 11:1959-1974. [PMID: 30464538 PMCID: PMC6208867 DOI: 10.2147/idr.s172366] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Complicated skin and soft tissue infections (cSSTIs) represent the severe form of infectious disease that involves deeper soft tissues. Involvement of methicillin-resistant Staphylococcus aureus (MRSA) further complicates cSSTI with increased hospitalization, health care costs, and overall mortality. Various international guidelines provide recommendations on the management of cSSTIs, with the inclusion of newer antibiotics. This literature-based review discusses the overall management of cSSTI, including appropriate use of antibiotics in clinical practice. Successful treatment of cSSTIs starts with early and precise diagnosis, including identification of causative pathogen and its load, determination of infection severity, associated complications, and risk factors. The current standard-of-care for cSSTIs involves incision, drainage, surgical debridement, broad-spectrum antibiotic therapy, and supportive care. In recent years, the emergence of newer antibiotics (eg, ceftaroline, tigecycline, daptomycin, linezolid, etc) has provided clinicians wider options of antimicrobial therapy. Selection of antibiotics should be based on the drug characteristics, effectiveness, safety, and treatment costs, alongside other aspects such as host factors and local multidrug resistance rates. However, larger studies on newer antibiotics are warranted to refine the decision making on the appropriate antimicrobial therapy. Local Antimicrobial Stewardship Program strategies in health care settings could guide clinicians for early initiation of specific treatments to combat region-specific antimicrobial resistance, minimize adverse effects, and to improve outcomes such as reduction in Clostridium difficile infections. These strategies involving iv-to-oral switch, de-escalation to narrow-spectrum antibiotics, and dose optimization have an impact on the overall improvement of cSSTI therapy outcomes, especially in countries like Singapore that has a high disease burden.
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Affiliation(s)
- Hoe Nam Leong
- Rophi Clinic, Mount Elizabeth Novena Specialist Centre, Singapore, Singapore,
| | - Asok Kurup
- Infectious Diseases Care Private Ltd, Mount Elizabeth Medical Centre, Singapore, Singapore
| | - Mak Yong Tan
- My Orthopaedic Clinic, Gleneagles Medical Centre, Singapore, Singapore
| | - Andrea Lay Hoon Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore.,Emerging Infectious Diseases Program, Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Kui Hin Liau
- LIAU KH Specialist Clinic, Mount Elizabeth Novena Specialist Centre, Singapore, Singapore
| | - Mark H Wilcox
- Department of Medical Microbiology, Leeds Teaching Hospitals and University of Leeds, Leeds, UK
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Ferrer R, Martínez ML, Gomà G, Suárez D, Álvarez-Rocha L, de la Torre MV, González G, Zaragoza R, Borges M, Blanco J, Herrejón EP, Artigas A. Improved empirical antibiotic treatment of sepsis after an educational intervention: the ABISS-Edusepsis study. CRITICAL CARE (LONDON, ENGLAND) 2018. [PMID: 29933756 DOI: 10.1186/s13054-18-2091-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early appropriate antibiotic treatment is essential in sepsis. We aimed to evaluate the impact of a multifaceted educational intervention to improve antibiotic treatment. We hypothesized that the intervention would hasten and improve the appropriateness of empirical antibiotic administration, favor de-escalation, and decrease mortality. METHODS We prospectively studied all consecutive patients with sepsis/septic shock admitted to 72 intensive care units (ICUs) throughout Spain in two 4-month periods (before and immediately after the 3-month intervention). We compared process-of-care variables (resuscitation bundle and time-to-initiation, appropriateness, and de-escalation of empirical antibiotic treatment) and outcome variables between the two cohorts. The primary outcome was hospital mortality. We analyzed the intervention's long-term impact in a subset of 50 ICUs. RESULTS We included 2628 patients (age 64.1 ± 15.2 years; men 64.0%; Acute Physiology and Chronic Health Evaluation (APACHE) II, 22.0 ± 8.1): 1352 in the preintervention cohort and 1276 in the postintervention cohort. In the postintervention cohort, the mean (SD) time from sepsis onset to empirical antibiotic therapy was lower (2.0 (2.7) vs. 2.5 (3.6) h; p = 0.002), the proportion of inappropriate empirical treatments was lower (6.5% vs. 8.9%; p = 0.024), and the proportion of patients in whom antibiotic treatment was de-escalated was higher (20.1% vs. 16.3%; p = 0.004); the expected reduction in mortality did not reach statistical significance (29.4% in the postintervention cohort vs. 30.5% in the preintervention cohort; p = 0.544). Gains observed after the intervention were maintained in the long-term follow-up period. CONCLUSIONS Despite advances in sepsis treatment, educational interventions can still improve the delivery of care; further improvements might also improve outcomes.
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Affiliation(s)
- Ricard Ferrer
- Intensive Care Department, Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain. .,CIBER Enfermedades Respiratorias, Madrid, Spain.
| | - María Luisa Martínez
- Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain
| | - Gemma Gomà
- Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - David Suárez
- Epidemiology and Assessment Unit, Fundació Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - Luis Álvarez-Rocha
- Intensive Care Department, Hospital Universitario de la Coruña, A Coruña, Spain
| | | | - Gumersindo González
- Intensive Care Department, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Rafael Zaragoza
- Intensive Care Department, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Marcio Borges
- Intensive Care Department, Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Jesús Blanco
- CIBER Enfermedades Respiratorias, Madrid, Spain.,Intensive Care Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Antonio Artigas
- CIBER Enfermedades Respiratorias, Madrid, Spain.,Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain.,Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
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49
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Ferrer R, Martínez ML, Gomà G, Suárez D, Álvarez-Rocha L, de la Torre MV, González G, Zaragoza R, Borges M, Blanco J, Herrejón EP, Artigas A. Improved empirical antibiotic treatment of sepsis after an educational intervention: the ABISS-Edusepsis study. Crit Care 2018; 22:167. [PMID: 29933756 PMCID: PMC6013897 DOI: 10.1186/s13054-018-2091-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 06/08/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Early appropriate antibiotic treatment is essential in sepsis. We aimed to evaluate the impact of a multifaceted educational intervention to improve antibiotic treatment. We hypothesized that the intervention would hasten and improve the appropriateness of empirical antibiotic administration, favor de-escalation, and decrease mortality. METHODS We prospectively studied all consecutive patients with sepsis/septic shock admitted to 72 intensive care units (ICUs) throughout Spain in two 4-month periods (before and immediately after the 3-month intervention). We compared process-of-care variables (resuscitation bundle and time-to-initiation, appropriateness, and de-escalation of empirical antibiotic treatment) and outcome variables between the two cohorts. The primary outcome was hospital mortality. We analyzed the intervention's long-term impact in a subset of 50 ICUs. RESULTS We included 2628 patients (age 64.1 ± 15.2 years; men 64.0%; Acute Physiology and Chronic Health Evaluation (APACHE) II, 22.0 ± 8.1): 1352 in the preintervention cohort and 1276 in the postintervention cohort. In the postintervention cohort, the mean (SD) time from sepsis onset to empirical antibiotic therapy was lower (2.0 (2.7) vs. 2.5 (3.6) h; p = 0.002), the proportion of inappropriate empirical treatments was lower (6.5% vs. 8.9%; p = 0.024), and the proportion of patients in whom antibiotic treatment was de-escalated was higher (20.1% vs. 16.3%; p = 0.004); the expected reduction in mortality did not reach statistical significance (29.4% in the postintervention cohort vs. 30.5% in the preintervention cohort; p = 0.544). Gains observed after the intervention were maintained in the long-term follow-up period. CONCLUSIONS Despite advances in sepsis treatment, educational interventions can still improve the delivery of care; further improvements might also improve outcomes.
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Affiliation(s)
- Ricard Ferrer
- Intensive Care Department, Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain.
- CIBER Enfermedades Respiratorias, Madrid, Spain.
| | - María Luisa Martínez
- Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain
| | - Gemma Gomà
- Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - David Suárez
- Epidemiology and Assessment Unit, Fundació Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - Luis Álvarez-Rocha
- Intensive Care Department, Hospital Universitario de la Coruña, A Coruña, Spain
| | | | - Gumersindo González
- Intensive Care Department, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Rafael Zaragoza
- Intensive Care Department, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Marcio Borges
- Intensive Care Department, Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Jesús Blanco
- CIBER Enfermedades Respiratorias, Madrid, Spain
- Intensive Care Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Antonio Artigas
- CIBER Enfermedades Respiratorias, Madrid, Spain
- Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain
- Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
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50
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Manyi-Loh C, Mamphweli S, Meyer E, Okoh A. Antibiotic Use in Agriculture and Its Consequential Resistance in Environmental Sources: Potential Public Health Implications. Molecules 2018; 23:E795. [PMID: 29601469 PMCID: PMC6017557 DOI: 10.3390/molecules23040795] [Citation(s) in RCA: 617] [Impact Index Per Article: 102.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 02/14/2018] [Accepted: 03/02/2018] [Indexed: 01/08/2023] Open
Abstract
Due to the increased demand of animal protein in developing countries, intensive farming is instigated, which results in antibiotic residues in animal-derived products, and eventually, antibiotic resistance. Antibiotic resistance is of great public health concern because the antibiotic-resistant bacteria associated with the animals may be pathogenic to humans, easily transmitted to humans via food chains, and widely disseminated in the environment via animal wastes. These may cause complicated, untreatable, and prolonged infections in humans, leading to higher healthcare cost and sometimes death. In the said countries, antibiotic resistance is so complex and difficult, due to irrational use of antibiotics both in the clinical and agriculture settings, low socioeconomic status, poor sanitation and hygienic status, as well as that zoonotic bacterial pathogens are not regularly cultured, and their resistance to commonly used antibiotics are scarcely investigated (poor surveillance systems). The challenges that follow are of local, national, regional, and international dimensions, as there are no geographic boundaries to impede the spread of antibiotic resistance. In addition, the information assembled in this study through a thorough review of published findings, emphasized the presence of antibiotics in animal-derived products and the phenomenon of multidrug resistance in environmental samples. This therefore calls for strengthening of regulations that direct antibiotic manufacture, distribution, dispensing, and prescription, hence fostering antibiotic stewardship. Joint collaboration across the world with international bodies is needed to assist the developing countries to implement good surveillance of antibiotic use and antibiotic resistance.
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Affiliation(s)
- Christy Manyi-Loh
- Fort Hare Institute of Technology, University of Fort Hare, Alice Campus, Alice 5700, Eastern Cape, South Africa.
- Applied and Environmental Microbiology Research Group (AEMREG), Department of Biochemistry and Microbiology, University of Fort Hare, Alice Campus, Alice 5700, Eastern Cape, South Africa.
- SAMRC Microbial Water Quality Monitoring Centre, University of Fort Hare, Alice Campus, Alice 5700, Eastern Cape, South Africa.
| | - Sampson Mamphweli
- Fort Hare Institute of Technology, University of Fort Hare, Alice Campus, Alice 5700, Eastern Cape, South Africa.
| | - Edson Meyer
- Fort Hare Institute of Technology, University of Fort Hare, Alice Campus, Alice 5700, Eastern Cape, South Africa.
| | - Anthony Okoh
- Applied and Environmental Microbiology Research Group (AEMREG), Department of Biochemistry and Microbiology, University of Fort Hare, Alice Campus, Alice 5700, Eastern Cape, South Africa.
- SAMRC Microbial Water Quality Monitoring Centre, University of Fort Hare, Alice Campus, Alice 5700, Eastern Cape, South Africa.
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