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Geslain G, Cointe A, Naudin J, Dauger S, Poey N, Pages J, Le Roux E, Bonacorsi S. Diagnostic Accuracy of Blind Bronchial Sample Testing by BioFire Pneumonia plus Panel in Pediatric Intensive Care Unit Patients and Its Impact in Early Adaptation of Antimicrobial Therapy: A Prospective Observational Study. Pediatr Infect Dis J 2024; 43:725-730. [PMID: 38621162 DOI: 10.1097/inf.0000000000004349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
BACKGROUND Community-acquired and nosocomial lower-respiratory-tract infections in critically ill pediatric patients require early appropriate antibiotic therapy to optimize outcomes. Using blind bronchial samples, we assessed the diagnostic performance of the rapid-multiplex polymerase chain reaction (PCR) assay BioFire Pneumonia plus Panel vs. reference standard culturing with antimicrobial susceptibility testing. METHODS For this prospective observational study in a single pediatric intensive care unit, we included consecutive patients younger than 18 years admitted for suspected community-, hospital- or ventilator-associated pneumonia in 2021-2022. Sensitivity, specificity, positive predictive value and negative predictive value of the multiplex PCR assay were determined. The kappa coefficient was computed to assess agreement, and univariate analyses were done to identify factors associated with discrepancies between the 2 diagnostic methods. RESULTS Of the 36 included patients (median age, 1.4 years; interquartile range, 0.2-9.2), 41.7%, 27.8%, and 30.5% had community-, hospital- and ventilator-associated pneumonia, respectively. The overall κ was 0.74, indicating good agreement. Overall, the sensitivity of the multiplex PCR assay was 92% (95% CI: 77%-98%) and specificity 95% (95% CI: 92%-97%), with variations across microorganisms. The median time from sample collection to antimicrobial susceptibility test results was 3.9 (2.5-15) hours with the multiplex PCR assay and 60.5 (47.6-72.2) hours with the reference technique. CONCLUSION The BioFire Pneumonia plus Panel used to test blind bronchial samples had satisfactory diagnostic performance in critically ill pediatric patients. The rapid results provided by this test may improve the appropriateness of antimicrobial therapy and help minimize the use of antibiotics.
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Affiliation(s)
- Guillaume Geslain
- From the Paediatric Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
- Paris Cité University, IAME, INSERM UMR 1137, Paris, France
| | - Aurélie Cointe
- Paris Cité University, IAME, INSERM UMR 1137, Paris, France
- Department of Microbiology, Escherichia coli National Reference Center, Robert-Debré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Jérôme Naudin
- From the Paediatric Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Stéphane Dauger
- From the Paediatric Intensive Care Unit, Robert-Debré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
- Paris Cité University, NeuroDiderot, INSERM UMR 1141, Paris, France
| | - Nora Poey
- Department of General Paediatrics, Paediatric Infectious Diseases and Internal Medicine, Robert-Debré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Justine Pages
- Clinical Epidemiology Unit, INSERM CIC 1426, Robert-Debré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Enora Le Roux
- Clinical Epidemiology Unit, INSERM CIC 1426, Robert-Debré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
| | - Stéphane Bonacorsi
- Paris Cité University, IAME, INSERM UMR 1137, Paris, France
- Department of Microbiology, Escherichia coli National Reference Center, Robert-Debré University Hospital, Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France
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López-Cortés LE, Delgado-Valverde M, Moreno-Mellado E, Goikoetxea Aguirre J, Guio Carrión L, Blanco Vidal MJ, López Soria LM, Pérez-Rodríguez MT, Martínez Lamas L, Arnaiz de Las Revillas F, Armiñanzas C, Ruiz de Alegría-Puig C, Jiménez Aguilar P, Del Carmen Martínez-Rubio M, Sáez-Bejar C, de Las Cuevas C, Martín-Aspas A, Galán F, Yuste JR, Leiva-León J, Bou G, Capón González P, Boix-Palop L, Xercavins-Valls M, Goenaga-Sánchez MÁ, Anza DV, Castón JJ, Rufián MR, Merino E, Rodríguez JC, Loeches B, Cuervo G, Guerra Laso JM, Plata A, Pérez Cortés S, López Mato P, Sierra Monzón JL, Rosso-Fernández C, Bravo-Ferrer JM, Retamar-Gentil P, Rodríguez-Baño J. Efficacy and safety of a structured de-escalation from antipseudomonal β-lactams in bloodstream infections due to Enterobacterales (SIMPLIFY): an open-label, multicentre, randomised trial. THE LANCET. INFECTIOUS DISEASES 2024; 24:375-385. [PMID: 38215770 DOI: 10.1016/s1473-3099(23)00686-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND De-escalation from broad-spectrum to narrow-spectrum antibiotics is considered an important measure to reduce the selective pressure of antibiotics, but a scarcity of adequate evidence is a barrier to its implementation. We aimed to determine whether de-escalation from an antipseudomonal β-lactam to a narrower-spectrum drug was non-inferior to continuing the antipseudomonal drug in patients with Enterobacterales bacteraemia. METHODS An open-label, pragmatic, randomised trial was performed in 21 Spanish hospitals. Patients with bacteraemia caused by Enterobacterales susceptible to one of the de-escalation options and treated empirically with an antipseudomonal β-lactam were eligible. Patients were randomly assigned (1:1; stratified by urinary source) to de-escalate to ampicillin, trimethoprim-sulfamethoxazole (urinary tract infections only), cefuroxime, cefotaxime or ceftriaxone, amoxicillin-clavulanic acid, ciprofloxacin, or ertapenem in that order according to susceptibility (de-escalation group), or to continue with the empiric antipseudomonal β-lactam (control group). Oral switching was allowed in both groups. The primary outcome was clinical cure 3-5 days after end of treatment in the modified intention-to-treat (mITT) population, formed of patients who received at least one dose of study drug. Safety was assessed in all participants. Non-inferiority was declared when the lower bound of the 95% CI of the absolute difference in cure rate was above the -10% non-inferiority margin. This trial is registered with EudraCT (2015-004219-19) and ClinicalTrials.gov (NCT02795949) and is complete. FINDINGS 2030 patients were screened between Oct 5, 2016, and Jan 23, 2020, of whom 171 were randomly assigned to the de-escalation group and 173 to the control group. 164 (50%) patients in the de-escalation group and 167 (50%) in the control group were included in the mITT population. 148 (90%) patients in the de-escalation group and 148 (89%) in the control group had clinical cure (risk difference 1·6 percentage points, 95% CI -5·0 to 8·2). The number of adverse events reported was 219 in the de-escalation group and 175 in the control group, of these, 53 (24%) in the de-escalation group and 56 (32%) in the control group were considered severe. Seven (5%) of 164 patients in the de-escalation group and nine (6%) of 167 patients in the control group died during the 60-day follow-up. There were no treatment-related deaths. INTERPRETATION De-escalation from an antipseudomonal β-lactam in Enterobacterales bacteraemia following a predefined rule was non-inferior to continuing the empiric antipseudomonal drug. These results support de-escalation in this setting. FUNDING Plan Nacional de I+D+i 2013-2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades, Spanish Network for Research in Infectious Diseases; Spanish Clinical Research and Clinical Trials Platform, co-financed by the EU; European Development Regional Fund "A way to achieve Europe", Operative Program Intelligence Growth 2014-2020.
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Affiliation(s)
- Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain.
| | - Mercedes Delgado-Valverde
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Elisa Moreno-Mellado
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | | | - Laura Guio Carrión
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Cruces, Barakaldo, Spain
| | | | | | - María Teresa Pérez-Rodríguez
- Servicio de Medicina Interna, Complexo Hospitalario Universitario de Vigo (CHUVI), Xerencia de Xestión Integrada de Vigo, Spain
| | - Lucía Martínez Lamas
- Grupo de Investigación de Microbiología y Enfermedades Infecciosas, Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), CHUVI, Vigo, Spain
| | - Francisco Arnaiz de Las Revillas
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Carlos Armiñanzas
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Carlos Ruiz de Alegría-Puig
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | | | - Carmen Sáez-Bejar
- Servicio de Medicina Interna, Hospital Universitario de la Princesa, Madrid, Spain
| | | | - Andrés Martín-Aspas
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Facultad de Medicina, Hospital Universitario Puerta del Mar, Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Universidad de Cádiz, Cádiz, Spain
| | - Fátima Galán
- Servicio de Microbiología, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - José Ramón Yuste
- Servicio de Enfermedades Infecciosas, Clínica Universitaria de Navarra, Pamplona, Spain
| | - José Leiva-León
- Servicio de Microbiología, Clínica Universitaria de Navarra, Pamplona, Spain
| | - Germán Bou
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Servicio de Microbiología-Instituto de Investigación Biomédica, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | | | - Lucía Boix-Palop
- Servicio de Enfermedades Infecciosas, Hospital Universitario Mútua de Terrassa, Barcelona, Spain
| | | | | | - Diego Vicente Anza
- Servicio de Microbiología, Hospital Universitario de Donostia, Donostia, Spain
| | - Juan José Castón
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Manuel Recio Rufián
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Esperanza Merino
- Unidad de Enfermedades Infecciosas, Hospital General Universitario Dr Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Juan Carlos Rodríguez
- Servicio de Microbiología, Hospital General Universitario Dr Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Belén Loeches
- Unidad de Enfermedades Infecciosas, Hospital Universitario La Paz, Madrid, Spain
| | - Guillermo Cuervo
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | - Antonio Plata
- Unidad de Enfermedades Infecciosas, Hospital Universitario Regional de Málaga, Málaga, Spain
| | | | - Pablo López Mato
- Unidad de Enfermedades Infecciosas, Hospital de Ourense, Ourense, Spain
| | - José Luis Sierra Monzón
- Servicio de Enfermedades Infecciosas and Servicio de Urgencias, Hospital Clínico Universitario Lozano Blesa, IIS Aragón, Zaragoza, Spain
| | - Clara Rosso-Fernández
- Unidad de Investigación Clínica y Ensayos Clínicos (UICEC-HUVR), Hospitales Universitarios Virgen del Rocío y Virgen Macarena, Sevilla, Spain
| | - José María Bravo-Ferrer
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Pilar Retamar-Gentil
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
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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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Essmann L, Wirz Y, Gregoriano C, Schuetz P. One biomarker does not fit all: tailoring anti-infective therapy through utilization of procalcitonin and other specific biomarkers. Expert Rev Mol Diagn 2023; 23:739-752. [PMID: 37505928 DOI: 10.1080/14737159.2023.2242782] [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: 05/05/2023] [Revised: 07/05/2023] [Accepted: 07/27/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Considering the ongoing increase in antibiotic resistance, the importance of judicious use of antibiotics through reduction of exposure is crucial. Adding procalcitonin (PCT) and other biomarkers to pathogen-specific tests may help to further improve antibiotic therapy algorithms and advance antibiotic stewardship programs to achieve these goals. AREAS COVERED In recent years, several trials have investigated the inclusion of biomarkers such as PCT into clinical decision-making algorithms. For adult patients, findings demonstrated improvements in the individualization of antibiotic treatment, particularly for patients with respiratory tract infections and sepsis. While most trials were performed in hospitals with central laboratories, point-of-care testing might further advance the field by providing a cost-effective and rapid diagnostic tool in upcoming years. Furthermore, novel biomarkers including CD-64, presepsin, Pancreatic stone and sTREM-1, have all shown promising results for increased accuracy of sepsis diagnosis. Availability of these markers however is currently still limited and there is insufficient evidence for their routine use in clinical care. EXPERT OPINION In addition to new host-response markers, combining such biomarkers with pathogen-directed diagnostics present a promising strategy to increase algorithm accuracy in differentiating between bacterial and viral infections. Recent advances in microbiologic testing using PCR or nucleic amplification tests may further improve the diagnostic yield and promote more targeted pathogen-specific antibiotic therapy.
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Affiliation(s)
- Lennart Essmann
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - Yannick Wirz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Philipp Schuetz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
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Kim JH, Yoo SH, Keam B, Heo DS. Antibiotic prescription patterns during last days of hospitalized patients with advanced cancer: the role of palliative care consultation. J Antimicrob Chemother 2023:7176305. [PMID: 37220755 DOI: 10.1093/jac/dkad156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 05/08/2023] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVES Issues regarding antibiotic use in end-of-life patients with advanced cancer present a challenging ethical dilemma in academic referral centres. This study aimed to investigate the role of palliative care consultation on antibiotic prescription patterns among hospitalized patients with advanced cancer during their last days of life. METHODS This retrospective cohort study included adult patients with metastatic solid cancer admitted to a tertiary referral hospital for at least 4 days and subsequently died and who were given antibiotics 4 days before death between January 2018 and December 2021. Patients were divided into palliative care consultation (PC) and non-consultation (non-PC) groups. The outcomes were the proportion of patients who received antibiotic combination treatment, antibiotic escalation and antibiotic de-escalation within 3 days of death. Propensity score analysis with the inverse probability of the treatment weighting method was used to compare the outcomes. RESULTS Among the 1177 patients enrolled, 476 (40.4%) received palliative care consultation and 701 (59.6%) did not. The PC group received considerably less antibiotic combination treatment (49.0% versus 61.1%, adjusted OR: 0.69, 95% CI: 0.53-0.90, P = 0.006) and antibiotic escalation (15.8% versus 34.8%, adjusted OR: 0.41, 95% CI: 0.30-0.57, P < 0.001) than the non-PC group. Additionally, the PC group reported significantly higher antibiotic de-escalation (30.7% versus 17.4%, adjusted OR: 1.74, 95% CI: 1.28-2.36, P < 0.001). CONCLUSION Receiving palliative care consultation may minimize aggressive antibiotic prescription patterns in the last days of patients with advanced cancer in an academic referral centre setting.
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Affiliation(s)
- Jeong-Han Kim
- Division of Infectious Diseases, Department of Internal Medicine, Ewha Woman University College of Medicine, Mokdong Hospital, Seoul, Republic of Korea
| | - Shin Hye Yoo
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea
| | - Bhumsuk Keam
- Center for Palliative Care and Clinical Ethics, Seoul National University Hospital, Seoul, Republic of Korea
- Division of Medical Oncology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dae Seog Heo
- Patient-Centered Clinical Research Coordinating Center, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
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Days of Antibiotic Spectrum Coverage Trends and Assessment in Patients with Bloodstream Infections: A Japanese University Hospital Pilot Study. Antibiotics (Basel) 2022; 11:antibiotics11121745. [PMID: 36551402 PMCID: PMC9774691 DOI: 10.3390/antibiotics11121745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 12/11/2022] Open
Abstract
The antibiotic spectrum is not reflected in conventional antimicrobial metrics. Days of antibiotic spectrum coverage (DASC) is a novel quantitative metric for antimicrobial consumption developed with consideration of the antibiotic spectrum. However, there were no data regarding disease and pathogen-specific DASC. Thus, this study aimed to evaluate the DASC trend in patients with bloodstream infections (BSIs). DASC and days of therapy (DOT) of in-patients with positive blood culture results during a 2-year interval were evaluated. Data were aggregated to calculate the DASC, DOT, and DASC/DOT per patient stratified by pathogens. During the 2-year study period, 1443 positive blood culture cases were identified, including 265 suspected cases of contamination. The overall DASC, DASC/patient, DOT, DOT/patient, and DASC/DOT metrics were 226,626; 157.1; 28,778; 19.9; and 7.9, respectively. A strong correlation was observed between DASC and DOT, as well as DASC/patient and DOT/patient. Conversely, DASC/DOT had no correlation with other metrics. The combination of DASC and DOT would be a useful benchmark for the overuse and misuse evaluation of antimicrobial therapy in BSIs. Notably, DASC/DOT would be a robust metric to evaluate the antibiotic spectrum that was selected for patients with BSIs.
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Okada N, Azuma M, Tsujinaka K, Abe A, Takahashi M, Yano Y, Sato M, Shibata T, Goda M, Ishizawa K. Clinical Impact of a Pharmacist-Driven Prospective Audit with Intervention and Feedback on the Treatment of Patients with Bloodstream Infection. Antibiotics (Basel) 2022; 11:antibiotics11091144. [PMID: 36139925 PMCID: PMC9495130 DOI: 10.3390/antibiotics11091144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/18/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022] Open
Abstract
Evidence for the utility of pharmacist-driven antimicrobial stewardship programs remains limited. This study aimed to evaluate the usefulness of our institutional pharmacist-driven prospective audit with intervention and feedback (PAF) on the treatment of patients with bloodstream infections (BSIs). The effect of pharmacist-driven PAF was estimated using an interrupted time series analysis with a quasi-experimental design. The proportion of de-escalation during BSI treatment increased by 44% after the implementation of pharmacist-driven PAF (95% CI: 30−58, p < 0.01). The number of days of therapy decreased by 16 per 100 patient days for carbapenem (95% CI: −28 to −3.5, p = 0.012) and by 15 per 100 patient days for tazobactam/piperacillin (95% CI: −26 to −4.9, p < 0.01). Moreover, the proportion of inappropriate treatment in empirical and definitive therapy was significantly reduced after the implementation of pharmacist-driven PAF. Although 30-day mortality did not change, compliance with evidenced-based bundles in the BSI of Staphylococcus aureus significantly increased (p < 0.01). In conclusion, our pharmacist-driven PAF increased the proportion of de-escalation and decreased the use of broad-spectrum antibiotics, as well as the proportion of inappropriate treatment in patients with BSI. This indicates that pharmacist-driven PAF is useful in improving the quality of antimicrobial treatment and reducing broad-spectrum antimicrobial use in the management of patients with BSI.
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Affiliation(s)
- Naoto Okada
- Department of Pharmacy, Tokushima University Hospital, Tokushima 770-8503, Japan
- Department of Infection Control and Prevention, Tokushima University Hospital, Tokushima 770-8503, Japan
- Correspondence: ; Tel.: +81-88-633-9385
| | - Momoyo Azuma
- Department of Infection Control and Prevention, Tokushima University Hospital, Tokushima 770-8503, Japan
| | - Kaito Tsujinaka
- Department of Pharmacy, Tokushima University Hospital, Tokushima 770-8503, Japan
| | - Akane Abe
- Department of Infection Control and Prevention, Tokushima University Hospital, Tokushima 770-8503, Japan
| | - Mari Takahashi
- Department of Infection Control and Prevention, Tokushima University Hospital, Tokushima 770-8503, Japan
| | - Yumiko Yano
- Department of Infection Control and Prevention, Tokushima University Hospital, Tokushima 770-8503, Japan
| | - Masami Sato
- Department of Infection Control and Prevention, Tokushima University Hospital, Tokushima 770-8503, Japan
| | - Takahiro Shibata
- Department of Pharmacy, Tokushima University Hospital, Tokushima 770-8503, Japan
| | - Mitsuhiro Goda
- Department of Pharmacy, Tokushima University Hospital, Tokushima 770-8503, Japan
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima 770-8503, Japan
| | - Keisuke Ishizawa
- Department of Pharmacy, Tokushima University Hospital, Tokushima 770-8503, Japan
- Department of Clinical Pharmacology and Therapeutics, Tokushima University Graduate School of Biomedical Sciences, Tokushima 770-8503, Japan
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima 770-8503, Japan
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8
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Meagher KM, Watson S, Suh GA, Virk A. The New Precision Stewards? J Pers Med 2022; 12:jpm12081308. [PMID: 36013256 PMCID: PMC9409858 DOI: 10.3390/jpm12081308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/26/2022] [Accepted: 08/04/2022] [Indexed: 11/20/2022] Open
Abstract
The precision health era is likely to reduce and respond to antimicrobial resistance (AMR). Our stewardship and precision efforts share terminology, seeking to deliver the “right drug, at the right dose, at the right time.” Already, rapid diagnostic testing, phylogenetic surveillance, and real-time outbreak response provide just a few examples of molecular advances we dub “precision stewardship.” However, the AMR causal factors range from the molecular to that of global health policy. Mirroring the cross-sectoral nature of AMR science, the research addressing the ethical, legal and social implications (ELSI) of AMR ranges across academic scholarship. As the rise of AMR is accompanied by an escalating sense of its moral and social significance, what is needed is a parallel field of study. In this paper, we offer a gap analysis of this terrain, or an agenda for “the ELSI of precision stewardship.” In the first section, we discuss the accomplishments of a multi-decade U.S. national investment in ELSI research attending to the advances in human genetics. In the next section, we provide an overview of distinct ELSI topics pertinent to AMR. The distinctiveness of an ELSI agenda for precision stewardship suggests new opportunities for collaboration to build the stewardship teams of the future.
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Affiliation(s)
- Karen M. Meagher
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN 55905, USA
- Correspondence: ; Tel.: +1-507-293-9528
| | - Sara Watson
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN 55905, USA
| | - Gina A. Suh
- Division of Public Health, Infectious Disease, and Occupational Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Abinash Virk
- Division of Public Health, Infectious Disease, and Occupational Medicine, Mayo Clinic, Rochester, MN 55905, USA
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9
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The 2021 Dutch Working Party on Antibiotic Policy (SWAB) guidelines for empirical antibacterial therapy of sepsis in adults. BMC Infect Dis 2022; 22:687. [PMID: 35953772 PMCID: PMC9373543 DOI: 10.1186/s12879-022-07653-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The Dutch Working Party on Antibiotic Policy (SWAB) in collaboration with relevant professional societies, has updated their evidence-based guidelines on empiric antibacterial therapy of sepsis in adults. METHODS Our multidisciplinary guideline committee generated ten population, intervention, comparison, and outcome (PICO) questions relevant for adult patients with sepsis. For each question, a literature search was performed to obtain the best available evidence and assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The quality of evidence for clinically relevant outcomes was graded from high to very low. In structured consensus meetings, the committee formulated recommendations as strong or weak. When evidence could not be obtained, recommendations were provided based on expert opinion and experience (good practice statements). RESULTS Fifty-five recommendations on the antibacterial therapy of sepsis were generated. Recommendations on empiric antibacterial therapy choices were differentiated for sepsis according to the source of infection, the potential causative pathogen and its resistance pattern. One important revision was the distinction between low, increased and high risk of infection with Enterobacterales resistant to third generation cephalosporins (3GRC-E) to guide the choice of empirical therapy. Other new topics included empirical antibacterial therapy in patients with a reported penicillin allergy and the role of pharmacokinetics and pharmacodynamics to guide dosing in sepsis. We also established recommendations on timing and duration of antibacterial treatment. CONCLUSIONS Our multidisciplinary committee formulated evidence-based recommendations for the empiric antibacterial therapy of adults with sepsis in The Netherlands.
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10
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Abelenda-Alonso G, Rombauts A, Gudiol C, García-Lerma E, Pallarés N, Ardanuy C, Calatayud L, Niubó J, Tebé C, Carratalà J. Effect of positive microbiological testing on antibiotic de-escalation and outcomes in community-acquired pneumonia: A propensity score analysis. Clin Microbiol Infect 2022; 28:1602-1608. [PMID: 35809784 DOI: 10.1016/j.cmi.2022.06.021] [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: 02/25/2022] [Revised: 06/03/2022] [Accepted: 06/18/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The usefulness of routine microbiological testing for rationalizing antibiotic use in hospitalized patients with community-acquired pneumonia (CAP) continues to be a subject of debate. We aim to determine the effect of positive microbiological testing on antimicrobial de-escalation and clinical outcomes in CAP. METHODS A retrospective analysis of a prospectively collected cohort of non-immunosuppressed adults hospitalized with CAP was performed. The primary study outcome was antimicrobial de-escalation. Secondary outcomes included 30-day case-fatality rate, adverse events, and CAP recurrence. Adjustment for confounders, was performed by inverse probability weighting propensity score (IPW-PS), logistic regression and cause-specific Cox model. RESULTS Of 3677 patients with CAP, 1924 (52.3%) had any positive microbiological test. Antimicrobial de-escalation was performed in 648/1924 (33.7%) of patients with positive microbiological testing and in 179/1753 (10.2%) of those with non positive results. When propensity score was entered into the multivariate analysis, positive microbiological testing (Adjusted Odds Ratio [AOR] 2.59 (1.96 - 3.41) and clinical stability at day 3 (AOR 1.87; 1.45 - 2.10) were two of the main factors independently associated with antimicrobial de-escalation. After applying an adjusted cause-specific Cox model, antimicrobial de-escalation was not associated with a higher 30-day case-fatality rate (Adjusted Hazard Ratio [AHR] 0.44; 0.14 - 1.43), higher frequency of adverse events (AHR 0.77; 0.53 - 1.12) or CAP recurrence (AHR 0.77; 0.45 - 1.28). CONCLUSIONS Antimicrobial de-escalation was more often performed in hospitalized patients with CAP who had positive microbiological tests than in those with non positive results, and it did not adversely affect relevant clinical outcomes.
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Affiliation(s)
- Gabriela Abelenda-Alonso
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Alexander Rombauts
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Carlota Gudiol
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; University of Barcelona; Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
| | | | | | - Carmen Ardanuy
- University of Barcelona; Department of Clinical Microbiology, Bellvitge University Hospital, Barcelona, Spain; Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Laura Calatayud
- Department of Clinical Microbiology, Bellvitge University Hospital, Barcelona, Spain; Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Jordi Niubó
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Department of Clinical Microbiology, Bellvitge University Hospital, Barcelona, Spain
| | | | - Jordi Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; University of Barcelona; Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
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11
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Venugopalan V, Hamza M, Santevecchi B, DeSear K, Cherabuddi K, Peloquin CA, Al-Shaer MH. Implementation of a β-lactam therapeutic drug monitoring program: Experience from a large academic medical center. Am J Health Syst Pharm 2022; 79:1586-1591. [PMID: 35704702 DOI: 10.1093/ajhp/zxac171] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To describe the implementation and operationalization of a β-lactam (BL) therapeutic drug monitoring(TDM) program at a large academic center. SUMMARY BLs are the most used class of antibiotics. Suboptimal antibiotic exposure is a significant concern in hospitalized patients, particularly in those with altered pharmacokinetics. BL-TDM provides clinicians the opportunity to optimize drug concentrations to ensure maximal therapeutic efficacy while minimizing toxicity. However, BL-TDM has not been widely adopted due to the lack of access to assays. The University of Florida Shands Hospital developed a BL-TDM program in 2015. This is a consultative service primarily run by pharmacists and is conducted in all patient care areas. An analysis was performed on the first BL-TDM encounter for 1,438 patients. BL-TDM was most frequently performed for cefepime (61%, n = 882), piperacillin (15%, n = 218), and meropenem (11%, n = 151). BL-TDM was performed a median of 3 days (interquartile range, 1-5 days) from BL initiation. Among patients with available minimum inhibitory concentration (MIC) values and trough concentrations, the pharmacokinetic/pharmacodynamic (PK/PD) target of 100% fT>MIC was attained in 308 patients (88%). BL-TDM resulted in a dosage adjustment in 25% (n = 361) of patients. CONCLUSION Implementation of a BL-TDM program requires the concerted efforts of physicians, pharmacists, nursing staff, phlebotomists, and personnel in the analytical laboratory. Standard antibiotic dosing failed to achieve optimal PK/PD targets in all patients; utilizing BL-TDM, dose adjustments were made in 1 of every 4 patients.
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Affiliation(s)
- Veena Venugopalan
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Malva Hamza
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Barbara Santevecchi
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Kathryn DeSear
- University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Kartikeya Cherabuddi
- Division of Infectious Diseases, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Mohammad H Al-Shaer
- Infectious Disease Pharmacokinetics Laboratory, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
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12
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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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13
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Deshpande A, Rothberg MB. Reply to Blot and Dinh. Clin Infect Dis 2022; 74:750-751. [PMID: 34245247 PMCID: PMC8743298 DOI: 10.1093/cid/ciab545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Abhishek Deshpande
- Center for Value-Based Care Research, Cleveland Clinic
Community Care, Cleveland Clinic, Cleveland, Ohio, USA,Department of Infectious Diseases, Respiratory Institute,
Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael B. Rothberg
- Center for Value-Based Care Research, Cleveland Clinic
Community Care, Cleveland Clinic, Cleveland, Ohio, USA
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14
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Onorato L, Monari C, Capuano S, Grimaldi P, Coppola N. Prevalence and Therapeutic Management of Infections by Multi-Drug-Resistant Organisms (MDROs) in Patients with Liver Cirrhosis: A Narrative Review. Antibiotics (Basel) 2022; 11:232. [PMID: 35203834 PMCID: PMC8868525 DOI: 10.3390/antibiotics11020232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 12/11/2022] Open
Abstract
Bacterial infections are common events that significantly impact the clinical course of patients with cirrhosis. As in the general population, infections caused by multi-drug-resistant organisms (MDROs) are progressively increasing in cirrhotic patients, accounting for up to 30-35% of all infections. Nosocomial acquisition and prior exposure to antimicrobial treatment or invasive procedures are well-known risk factors for MDRO infections. Several studies have demonstrated that infections due to MDROs have a poorer prognosis and higher rates of treatment failure, septic shock, and hospital mortality. Due to the increasing rate of antimicrobial resistance, the approach to empirical treatment in cirrhotic patients with life-threatening infections has become significantly more challenging. In order to ensure a prompt administration of effective antibiotic therapy while avoiding unnecessary antibiotic exposure at the same time, it is of utmost importance to choose the correct antimicrobial therapy and administration schedule based on individual clinical characteristics and risk factors and rapidly adopt de-escalation strategies as soon as microbiological data are available. In the present paper, we aimed to provide an overview of the most frequent infections diagnosed in cirrhotic patients, the prevalence and impact of antimicrobial resistance, and potential therapeutic options in this population.
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Affiliation(s)
| | | | | | | | - Nicola Coppola
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (L.O.); (C.M.); (S.C.); (P.G.)
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15
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Schumann J, Johanns U, Ahmad-Nejad P, Ghebremedhin B, Woebker G. The Impact of the FilmArray-Based Detection of Microbial Pathogens from Positive Blood Culture Vials on the Time to Optimal Antimicrobial Regimen in Intensive Care Units of the Helios University Clinic Wuppertal, Germany. J Clin Med 2021; 10:jcm10245880. [PMID: 34945183 PMCID: PMC8704407 DOI: 10.3390/jcm10245880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 11/16/2022] Open
Abstract
The role of empirical therapy and time to first effective treatment, including the antimicrobial stewardship program, are decisive in patients presenting with bloodstream infections (BSI). The FilmArray® Blood Culture Identification Panel (FA BCID 1.0) detects 24 bacterial and fungal pathogens as well as 3 resistance genes from positive blood cultures in approximately 70 min. In this paper, we evaluate the impact of the additional FA BCID analysis on the time to an optimal antimicrobial therapy and on the length of stay in the ICU, ICU mortality, and PCT level reduction. This retro-/prospective trial was conducted in BSI patients in the ICU at a German tertiary care hospital. A total of 179 individual patients with 200 episodes of BSI were included in the prospective intervention group, and 150 patients with 170 episodes of BSI in the retrospective control group. In the intervention group, BSI data were analyzed including the MALDI-TOF MS (matrix assisted laser desorption ionization time-of-flight mass spectrometry) and FA BCID results from January 2019 to August 2020; the data from the control group, including the MALDI-TOF results, were collected retrospectively from the year 2018. The effective and appropriate antimicrobial regimen occurred in a median of 17 hours earlier in the intervention versus control group (p = 0.071). Furthermore, changes in the antimicrobial regimens of the intervention group that did not immediately lead to an optimal therapy occurred significantly earlier by a median of 24 hours (p = 0.029). Surrogate markers, indicating an earlier recovery of the patients from the intervention group, such as length of stay at the ICU, duration of mechanical ventilation, or an earlier reduction in PCT level, were not significantly affected. However, mortality did not differ between the patient groups. A postulated reduction of the antimicrobial therapy, in those cases in which coagulase-negative Staphylococcus species were identified, did occur in the control group, but not in the intervention group (p = 0.041). The implementation of FA BCID into the laboratory workflow can improve patient care by optimizing antimicrobial regimen earlier in BSI patients as it provides rapid and accurate results for key pathogens associated with BSI, as well as important antimicrobial resistance markers, e.g., mecA or vanA.
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Affiliation(s)
- Jannik Schumann
- Center for Clinical and Translational Research (CCTR), Institute for Medical Laboratory Diagnostics, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany; (J.S.); (P.A.-N.); (B.G.)
| | - Ulrike Johanns
- Clinic for Intensive Care Medicine, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany;
| | - Parviz Ahmad-Nejad
- Center for Clinical and Translational Research (CCTR), Institute for Medical Laboratory Diagnostics, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany; (J.S.); (P.A.-N.); (B.G.)
| | - Beniam Ghebremedhin
- Center for Clinical and Translational Research (CCTR), Institute for Medical Laboratory Diagnostics, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany; (J.S.); (P.A.-N.); (B.G.)
| | - Gabriele Woebker
- Clinic for Intensive Care Medicine, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany;
- Correspondence: ; Tel.: +49-(0)-202-896-2720; Fax: +49-(0)-202-896-2718
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16
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Wang HC, Tsai MH, Chu SM, Liao CC, Lai MY, Huang HR, Chiang MC, Fu RH, Hsu JF. Clinical characteristics and outcomes of neonates with polymicrobial ventilator-associated pneumonia in the intensive care unit. BMC Infect Dis 2021; 21:965. [PMID: 34535089 PMCID: PMC8446475 DOI: 10.1186/s12879-021-06673-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/08/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Ventilator associated pneumonia (VAP) caused by more than one microorganisms is not uncommon and may be potentially challenging, but the relevant data is scarce in ventilated neonates. We aimed to investigate the clinical characteristics and outcomes of polymicrobial VAP in the neonatal intensive care unit (NICU). METHODS All neonates with definite diagnosis of VAP from a tertiary level neonatal intensive care unit (NICU) in Taiwan between October 2017 and September 2020 were prospectively observed and enrolled for analyses. All clinical features, therapeutic interventions and outcomes were compared between the polymicrobial VAP and monomicrobial VAP episodes. Multivariate regression analyses were used to find the independent risk factors for treatment failure. RESULTS Among 236 episodes of neonatal VAP, 60 (25.4%) were caused by more than one microorganisms. Polymicrobial VAP episodes were more likely to be associated with multidrug-resistant pathogens (53.3% versus 34.7%, P = 0.014), more often occurred in later days of life and in neonates with prolonged intubation and underlying bronchopulmonary dysplasia. Otherwise most clinical characteristics of polymicrobial VAP were similar to those of monomicrobial VAP. The therapeutic responses and treatment outcomes were also comparable between these two groups, although modification of therapeutic antibiotics were significantly more common in polymicrobial VAP episodes than monomicrobial VAP episodes (63.3% versus 46.2%; P < 0.001). None of any specific pathogens was significantly associated with worse outcomes. Instead, it is the severity of illness, including presence of concurrent bacteremia, septic shock, and requirement of high-frequency oscillatory ventilator and underlying neurological sequelae that are independently associated with treatment failure. CONCLUSIONS Polymicrobial VAP accounted for 25.4% of all neonatal VAP in the NICU, and frequently occurred in neonates with prolonged intubation and underlying bronchopulmonary dysplasia. In our cohort, most clinical features, therapeutic responses and final outcomes of neonates with monomicrobial and polymicrobial VAP did not differ significantly.
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Affiliation(s)
- Hsiao-Chin Wang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Horng Tsai
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ming Chu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Chu Liao
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Mei-Yin Lai
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsuan-Rong Huang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Chou Chiang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ren-Huei Fu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Hsu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, No. 5, Fu-Shin Rd., Kwei Shan, Taoyuan County, 333, Linkou, Taiwan, ROC.
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17
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Routsi C, Gkoufa A, Arvaniti K, Kokkoris S, Tourtoglou A, Theodorou V, Vemvetsou A, Kassianidis G, Amerikanou A, Paramythiotou E, Potamianou E, Ntorlis K, Kanavou A, Nakos G, Hassou E, Antoniadou H, Karaiskos I, Prekates A, Armaganidis A, Pnevmatikos I, Kyprianou M, Zakynthinos S, Poulakou G, Giamarellou H. De-escalation of antimicrobial therapy in ICU settings with high prevalence of multidrug-resistant bacteria: a multicentre prospective observational cohort study in patients with sepsis or septic shock. J Antimicrob Chemother 2021; 75:3665-3674. [PMID: 32865203 DOI: 10.1093/jac/dkaa375] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 08/03/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND De-escalation of empirical antimicrobial therapy, a key component of antibiotic stewardship, is considered difficult in ICUs with high rates of antimicrobial resistance. OBJECTIVES To assess the feasibility and the impact of antimicrobial de-escalation in ICUs with high rates of antimicrobial resistance. METHODS Multicentre, prospective, observational study in septic patients with documented infections. Patients in whom de-escalation was applied were compared with patients without de-escalation by the use of a propensity score matching by SOFA score on the day of de-escalation initiation. RESULTS A total of 262 patients (mean age 62.2 ± 15.1 years) were included. Antibiotic-resistant pathogens comprised 62.9%, classified as MDR (12.5%), extensively drug-resistant (49%) and pandrug-resistant (1.2%). In 97 (37%) patients de-escalation was judged not feasible in view of the antibiotic susceptibility results. Of the remaining 165 patients, judged as patients with de-escalation possibility, de-escalation was applied in 60 (22.9%). These were matched to an equal number of patients without de-escalation. In this subset of 120 patients, de-escalation compared with no de-escalation was associated with lower all-cause 28 day mortality (13.3% versus 36.7%, OR 0.27, 95% CI 0.11-0.66, P = 0.006); ICU and hospital mortality were also lower. De-escalation was associated with a subsequent collateral decrease in the SOFA score. Cox multivariate regression analysis revealed de-escalation as a significant factor for 28 day survival (HR 0.31, 95% CI 0.14-0.70, P = 0.005). CONCLUSIONS In ICUs with high levels of antimicrobial resistance, feasibility of antimicrobial de-escalation was limited because of the multi-resistant pathogens isolated. However, when de-escalation was feasible and applied, it was associated with lower mortality.
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Affiliation(s)
- Christina Routsi
- 1st Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Evangelismos' Hospital, Athens, Greece.,Hellenic Society of Antimicrobial Chemotherapy, Greece
| | | | - Kostoula Arvaniti
- Department of Intensive Care, 'Papageorgiou' Hospital, Thessaloniki, Greece
| | - Stelios Kokkoris
- 1st Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Evangelismos' Hospital, Athens, Greece
| | | | - Vassiliki Theodorou
- Department of Intensive Care, Democritus University of Thrace, Alexandroupolis University Hospital, Alexandroupolis, Greece
| | - Anna Vemvetsou
- Department of Intensive Care, 'Papageorgiou' Hospital, Thessaloniki, Greece
| | | | | | - Elisabeth Paramythiotou
- 2nd Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' Hospital, Athens, Greece
| | - Efstathia Potamianou
- 1st Department of Respiratory Medicine, Intensive Care Unit, School of Medicine, National and Kapodistrian University of Athens, 'Sotiria' Hospital, Athens, Greece
| | - Kyriakos Ntorlis
- Department of Intensive Care, 'Konstantopouleio' Hospital, Athens, Greece
| | - Angeliki Kanavou
- Department of Intensive Care, 'Thriassio' Hospital, Elefsina, Greece
| | - Georgios Nakos
- Department of Intensive Care, 'Henry Dunant' Hospital Center, Athens, Greece
| | - Eleftheria Hassou
- Department of Intensive Care, 'Gennimatas' Hospital, Thessaloniki, Greece
| | - Helen Antoniadou
- Department of Intensive Care, 'Gennimatas' Hospital, Thessaloniki, Greece
| | - Ilias Karaiskos
- Hellenic Society of Antimicrobial Chemotherapy, Greece.,Hygeia General Hospital, Athens, Greece
| | | | - Apostolos Armaganidis
- 2nd Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Attikon' Hospital, Athens, Greece
| | - Ioannis Pnevmatikos
- Department of Intensive Care, Democritus University of Thrace, Alexandroupolis University Hospital, Alexandroupolis, Greece
| | | | - Spyros Zakynthinos
- 1st Department of Intensive Care, School of Medicine, National and Kapodistrian University of Athens, 'Evangelismos' Hospital, Athens, Greece
| | - Garyfallia Poulakou
- Hellenic Society of Antimicrobial Chemotherapy, Greece.,School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Helen Giamarellou
- Hellenic Society of Antimicrobial Chemotherapy, Greece.,Hygeia General Hospital, Athens, Greece
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Blot M, Dinh A. Empiric Antibiotics in Hospitalized Pneumonia: discontinuation is better than de-escalation! Clin Infect Dis 2021; 74:749-750. [PMID: 34117874 DOI: 10.1093/cid/ciab544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Mathieu Blot
- Infectious Diseases Department, Dijon Bourgogne University Hospital, Dijon, France.,Lipness team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
| | - Aurélien Dinh
- Infectious Disease Unit, Raymond-Poincaré University Hospital, AP-HP, Paris Saclay University, Garches, France
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19
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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20
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Suzuki A, Maeda M, Yokoe T, Hashiguchi M, Togashi M, Ishino K. Impact of the multidisciplinary antimicrobial stewardship team intervention focusing on carbapenem de-escalation: A single-centre and interrupted time series analysis. Int J Clin Pract 2021; 75:e13693. [PMID: 32893441 PMCID: PMC7988539 DOI: 10.1111/ijcp.13693] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 07/29/2020] [Accepted: 08/28/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND As a result of the constant increase in carbapenem resistance amongst gram-negative bacteria in several countries, the inappropriate use of carbapenems must be reduced. Antimicrobial stewardship programmes (ASPs) aim to improve carbapenem usage by implementing interventions, including the promotion of the de-escalation (DE) strategy. Thus, this study aimed to evaluate the impact of this strategy on carbapenem use based on a clear definition of DE. METHODS The post-prescription review and feedback (PPRF) strategy, which is used to optimise carbapenem use, was implemented by the antimicrobial stewardship team (AST). We compared the DE rate during the pre-AST intervention period (from April 2017 to March 2018) and post-AST intervention period (from April 2018 to March 2019). RESULT A total of 1500 patients (n = 771 in the pre-AST intervention period and n = 729 in the intervention post-AST period) were admitted to the hospital. The average duration of antibiotic therapy decreased from 9.9 to 7.7 days. The DE rate significantly increased in the post-AST intervention period compared with the pre-AST intervention period (51.4% vs 40.3%; P < .001). CONCLUSION The PPRF strategy implemented by the AST could improve the carbapenem usage by increasing the DE rate of carbapenem.
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Affiliation(s)
- Ayako Suzuki
- Department of PharmacyShowa University Fujigaoka HospitalKanagawaJapan
- Division of Infection Control SciencesDepartment of Clinical PharmacyShowa University School of PharmacyTokyoJapan
- Department of Infection Control and PreventionShowa University Fujigaoka HospitalKanagawaJapan
| | - Masayuki Maeda
- Division of Infection Control SciencesDepartment of Clinical PharmacyShowa University School of PharmacyTokyoJapan
| | - Takuya Yokoe
- Department of Infection Control and PreventionShowa University Fujigaoka HospitalKanagawaJapan
| | - Miyuki Hashiguchi
- Department of Infection Control and PreventionShowa University Fujigaoka HospitalKanagawaJapan
| | - Mayumi Togashi
- Department of Infection Control and PreventionShowa University Fujigaoka HospitalKanagawaJapan
| | - Keiko Ishino
- Division of Infection Control SciencesDepartment of Clinical PharmacyShowa University School of PharmacyTokyoJapan
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21
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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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22
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Wu S, Huang G, de St Maurice A, Lehman D, Graber CJ, Goetz MB, Haake DA. The Impact of Rapid Species Identification on Management of Bloodstream Infections: What's in a Name? Mayo Clin Proc 2020; 95:2509-2524. [PMID: 32829901 DOI: 10.1016/j.mayocp.2020.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 02/05/2020] [Accepted: 02/12/2020] [Indexed: 10/23/2022]
Abstract
Bloodstream infections are a leading cause of morbidity and mortality. Molecular rapid diagnostic tests (mRDTs) are transforming care for patients with bloodstream infection by providing the opportunity to dramatically shorten times to effective therapy and speeding de-escalation of overly broad empiric therapy. However, because of the novelty of these tests which provide information regarding microbial identification and whether specific antibiotic-resistance mutations were detected, many front-line providers still delay final decisions until complete phenotypic susceptibility results are available several days later. Thus the benefits of mRDTs have been largely limited to circumstances where antimicrobial stewardship programs closely monitor these tests and intervene as soon as the results are available. We searched PubMed and Google Scholar for articles published from 1980 to 2019 using the terms antibiotic, antifungal, bacteremia, bloodstream infection, candidemia, candidiasis, children, coagulase negative staphylococcus, consultation, contamination, costs, echocardiogram, endocarditis, enterobacteriaceae, enterococcus, Gram-negative, guidelines, IDSA, immunocompromised, infectious disease or ID, lumbar puncture, meningitis, mortality, MRSA, MSSA, neonatal, outcomes, pediatric, pneumococcal, polymicrobial, Pseudomonas, rapid diagnostic testing, resistance, risk factors, sepsis, Staphylococcus aureus, stewardship, streptococcus, and treatment. With the data from this search, we aim to provide guidance to front-line providers regarding the interpretation and immediate actions to be taken in response to the identification of common bloodstream pathogens by mRDTs. In addition to antimicrobial therapy, additional diagnostic or therapeutic interventions are recommended for particular organisms and clinical settings to either determine the extent of infection or control its source. Pediatric perspectives are offered for those bloodstream pathogens for which management differs from that in adults.
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Affiliation(s)
- Simon Wu
- VA Greater Los Angeles Healthcare System, California; David Geffen School of Medicine at the University of California, Los Angeles
| | - Glen Huang
- David Geffen School of Medicine at the University of California, Los Angeles
| | | | - Deborah Lehman
- David Geffen School of Medicine at the University of California, Los Angeles
| | - Christopher J Graber
- VA Greater Los Angeles Healthcare System, California; David Geffen School of Medicine at the University of California, Los Angeles
| | - Matthew B Goetz
- VA Greater Los Angeles Healthcare System, California; David Geffen School of Medicine at the University of California, Los Angeles
| | - David A Haake
- VA Greater Los Angeles Healthcare System, California; David Geffen School of Medicine at the University of California, Los Angeles.
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23
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Impacts of Multidrug-Resistant Pathogens and Inappropriate Initial Antibiotic Therapy on the Outcomes of Neonates with Ventilator-Associated Pneumonia. Antibiotics (Basel) 2020; 9:antibiotics9110760. [PMID: 33143219 PMCID: PMC7693013 DOI: 10.3390/antibiotics9110760] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/26/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022] Open
Abstract
It is unknown whether neonatal ventilator-associated pneumonia (VAP) caused by multidrug-resistant (MDR) pathogens and inappropriate initial antibiotic treatment is associated with poor outcomes after adjusting for confounders. Methods: We prospectively observed all neonates with a definite diagnosis of VAP from a tertiary level neonatal intensive care unit (NICU) in Taiwan between October 2017 and March 2020. All clinical features, therapeutic interventions, and outcomes were compared between the MDR–VAP and non-MDR–VAP groups. Multivariate regression analyses were used to investigate independent risk factors for treatment failure. Results: Of 720 neonates who were intubated for more than 2 days, 184 had a total of 245 VAP episodes. The incidence rate of neonatal VAP was 10.1 episodes/per 1000 ventilator days. Ninety-six cases (39.2%) were caused by MDR pathogens. Neonates with MDR–VAP were more likely to receive inadequate initial antibiotic therapy (51.0% versus 4.7%; p < 0.001) and had delayed resolution of clinical symptoms (38.5% versus 25.5%; p = 0.034), although final treatment outcomes were comparable with the non-MDR–VAP group. Inappropriate initial antibiotic treatment was not significantly associated with worse outcomes. The VAP-attributable mortality rate and overall mortality rate of this cohort were 3.7% and 12.0%, respectively. Independent risk factors for treatment failure included presence of concurrent bacteremia (OR 4.83; 95% CI 2.03–11.51; p < 0.001), septic shock (OR 3.06; 95% CI 1.07–8.72; p = 0.037), neonates on high-frequency oscillatory ventilator (OR 4.10; 95% CI 1.70–9.88; p = 0.002), and underlying neurological sequelae (OR 3.35; 95% CI 1.47–7.67; p = 0.004). Conclusions: MDR–VAP accounted for 39.2% of all neonatal VAP in the neonatal intensive care unit (NICU), but neither inappropriate initial antibiotics nor MDR pathogens were associated with treatment failure. Neonatal VAP with concurrent bacteremia, septic shock, and underlying neurological sequelae were independently associated with final worse outcomes.
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24
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de Melo RC, de Araújo BC, de Bortoli MC, Toma TS. [Prevention and control of antimicrobial stewardship: a review of evidenceGestión de las intervenciones en materia de prevención y control de la resistencia a los antimicrobianos en los hospitales: revisión de la evidencia]. Rev Panam Salud Publica 2020; 44:e35. [PMID: 32973894 PMCID: PMC7498289 DOI: 10.26633/rpsp.2020.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/04/2020] [Indexed: 11/24/2022] Open
Abstract
Objective To identify effective interventions to manage antimicrobial resistance in hospital settings and potential barriers to their implementation. Method A synthesis of evidence for health policy was performed using SUPPORT tools. Literature searches were performed in November and December 2018 in 14 databases. A face-to-face deliberative dialogue workshop to identify implementation barriers was performed with 23 participants (manager, researchers, and health care professionals) and 14 listeners divided into three groups. Researchers with experience in deliberative dialogue acted as facilitators. Results Twenty-seven systematic reviews focusing on antimicrobial stewardship using combined or individual strategies were identified. The interventions included education, electronic systems, use of biomarkers, and several strategies of antimicrobial management. The main barriers to the implementation of interventions, identified in the literature and deliberative dialogue workshop, were poor infrastructure and insufficient human resources, patient complaints regarding the treatment received, cultural differences within the multidisciplinary team, work overload, and lack of financing/planning. Conclusion Most of the strategies identified were effective for antimicrobial stewardship in hospital settings. The reliability of results may be strengthened with the performance of additional research of higher methodological quality.
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Affiliation(s)
- Roberta Crevelário de Melo
- Secretaria de Estado de Saúde, Instituto de Saúde, Centro de Tecnologias de Saúde para o SUS São Paulo (SP) Brasil Secretaria de Estado de Saúde, Instituto de Saúde, Centro de Tecnologias de Saúde para o SUS, São Paulo (SP), Brasil
| | - Bruna Carolina de Araújo
- Secretaria de Estado de Saúde, Instituto de Saúde, Centro de Tecnologias de Saúde para o SUS São Paulo (SP) Brasil Secretaria de Estado de Saúde, Instituto de Saúde, Centro de Tecnologias de Saúde para o SUS, São Paulo (SP), Brasil
| | - Maritsa Carla de Bortoli
- Secretaria de Estado de Saúde, Instituto de Saúde, Centro de Tecnologias de Saúde para o SUS São Paulo (SP) Brasil Secretaria de Estado de Saúde, Instituto de Saúde, Centro de Tecnologias de Saúde para o SUS, São Paulo (SP), Brasil
| | - Tereza Setsuko Toma
- Secretaria de Estado de Saúde, Instituto de Saúde, Centro de Tecnologias de Saúde para o SUS São Paulo (SP) Brasil Secretaria de Estado de Saúde, Instituto de Saúde, Centro de Tecnologias de Saúde para o SUS, São Paulo (SP), Brasil
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25
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Hanses F. [Anti-infective treatment : Treatment strategies for sepsis and septic shock]. Internist (Berl) 2020; 61:1002-1009. [PMID: 32865593 DOI: 10.1007/s00108-020-00855-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Sepsis and septic shock are still associated with a high mortality and morbidity. A decisive factor for improvement of the outcome is the prompt initiation of an effective antibiotic treatment. The early recognition of sepsis within the first hour is here one of the biggest challenges. Effective empirical treatment comprises purposefully selected broad-spectrum antibiotics and also combination treatment or antimycotics in special situations. De-escalation strategies to narrow down or shorten the treatment are safe and can limit the side effects.
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Affiliation(s)
- Frank Hanses
- Interdisziplinäre Notaufnahme und Abteilung für Krankenhaushygiene und Infektiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
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26
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Monard C, Pehlivan J, Auger G, Alviset S, Tran Dinh A, Duquaire P, Gastli N, d'Humières C, Maamar A, Boibieux A, Baldeyrou M, Loubinoux J, Dauwalder O, Cattoir V, Armand-Lefèvre L, Kernéis S. Multicenter evaluation of a syndromic rapid multiplex PCR test for early adaptation of antimicrobial therapy in adult patients with pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:434. [PMID: 32665030 PMCID: PMC7359443 DOI: 10.1186/s13054-020-03114-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/29/2020] [Indexed: 01/13/2023]
Abstract
Background Improving timeliness of pathogen identification is crucial to allow early adaptation of antibiotic therapy and improve prognosis in patients with pneumonia. We evaluated the relevance of a new syndromic rapid multiplex PCR test (rm-PCR) on respiratory samples to guide empirical antimicrobial therapy in adult patients with community-acquired pneumonia (CAP), hospital-acquired pneumonia (HAP), and ventilator-acquired pneumonia (VAP). Methods This retrospective multicenter study was conducted in four French university hospitals. Respiratory samples were obtained from patients with clinical and radiological signs of pneumonia and simultaneously tested using conventional microbiological methods and the rm-PCR. A committee composed of an intensivist, a microbiologist, and an infectious diseases specialist retrospectively assessed all medical files and agreed on the most appropriate antimicrobial therapy for each pneumonia episode, according to the results of rm-PCR and blinded to the culture results. The rm-PCR-guided antimicrobial regimen was compared to the empirical treatment routinely administered to the patient in standard care. Results We included 159 pneumonia episodes. Most patients were hospitalized in intensive care units (n = 129, 81%), and episodes were HAP (n = 68, 43%), CAP (n = 54, 34%), and VAP (n = 37, 23%). Conventional culture isolated ≥ 1 microorganism(s) at significant level in 95 (60%) patients. The syndromic rm-PCR detected at least one bacteria in 132 (83%) episodes. Based on the results of the rm-PCR, the multidisciplinary committee proposed a modification of the empirical therapy in 123 (77%) pneumonia episodes. The modification was a de-escalation in 63 (40%), an escalation in 35 (22%), and undetermined in 25 (16%) patients. In microbiologically documented episodes (n = 95), the rm-PCR increased appropriateness of the empirical therapy to 83 (87%), as compared to 73 (77%) in routine care. Conclusions Use of a syndromic rm-PCR test has the potential to reduce unnecessary antimicrobial exposure and increase the appropriateness of empirical antibiotic therapy in adult patients with pneumonia.
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Affiliation(s)
- Céline Monard
- Département d'Anesthésie et Réanimation, Hospices Civils de Lyon, Hôpital E. Herriot, Lyon, France
| | - Jonathan Pehlivan
- Service de Réanimation Médicale Infectieuse, APHP, Hôpital Bichat Claude Bernard, Paris, France
| | - Gabriel Auger
- Service de Bactériologie-Hygiène Hospitalière, CHU de Rennes, Rennes, France.,CNR de la Résistance aux Antibiotiques (Laboratoire Associé Entérocoques), Rennes, France
| | - Sophie Alviset
- Equipe Mobile d'Infectiologie, APHP, Hôpital Cochin, Centre Université de Paris, Paris, France
| | - Alexy Tran Dinh
- Département d'anesthésie-réanimation, APHP, Hôpital Bichat-Claude Bernard, Université de Paris, Paris, France.,Inserm U 1148 LVTS, Université de Paris, Paris, France
| | - Paul Duquaire
- Département d'Anesthésie et Réanimation, Hospices Civils de Lyon, Hôpital E. Herriot, Lyon, France
| | - Nabil Gastli
- Service de Bactériologie, APHP, Hôpital Cochin, Centre Université de Paris, Paris, France
| | - Camille d'Humières
- Service de Bactériologie, APHP Nord, Université de Paris, Hôpital Bichat, Paris, France.,IAME, INSERM, Université de Paris, Paris, France
| | - Adel Maamar
- Service de Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Université de Rennes, Rennes, France.,Faculté de Médecine, Université de Rennes 1, Unité INSERM CIC 1414, IFR 140, Rennes, France
| | - André Boibieux
- Equipe mobile d'infectiologie, Hospices Civils de Lyon, Hôpital E. Herriot, Lyon, France
| | - Marion Baldeyrou
- Service de Maladies Infectieuses et Réanimation Médicale, CHU Rennes, Rennes, France
| | - Julien Loubinoux
- Service de Bactériologie, AP-HP Centre, Hôpital Cochin, Université de Paris, Paris, France
| | - Olivier Dauwalder
- Plateau de Microbiologie 24/24, Institut des Agents Infectieux, Hospices Civils de Lyon, Centre de Biologie et Pathologie Nord, Lyon, France.,INSERM CIRI LYON, Equipe "Pathogénie des Staphylocoques", Lyon, France
| | - Vincent Cattoir
- Service de Bactériologie-Hygiène Hospitalière, CHU de Rennes, Rennes, France.,CNR de la Résistance aux Antibiotiques (laboratoire associé 'Entérocoques), Rennes, France.,Unité Inserm U1230, Université de Rennes 1, Rennes, France
| | - Laurence Armand-Lefèvre
- Service de Bactériologie, APHP Nord, Université de Paris, Hôpital Bichat, Paris, France.,IAME, INSERM, Université de Paris, Paris, France
| | - Solen Kernéis
- Equipe Mobile d'Infectiologie, APHP, Hôpital Cochin, Centre Université de Paris, Paris, France. .,IAME, INSERM, Université de Paris, Paris, France.
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27
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Real-world management of infection during chemotherapy for acute leukemia in Japan: from the results of a nationwide questionnaire-based survey by the Japan Adult Leukemia Study Group. Int J Hematol 2020; 112:409-417. [DOI: 10.1007/s12185-020-02921-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/05/2020] [Accepted: 06/11/2020] [Indexed: 12/15/2022]
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28
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De Bus L, Depuydt P, Steen J, Dhaese S, De Smet K, Tabah A, Akova M, Cotta MO, De Pascale G, Dimopoulos G, Fujitani S, Garnacho-Montero J, Leone M, Lipman J, Ostermann M, Paiva JA, Schouten J, Sjövall F, Timsit JF, Roberts JA, Zahar JR, Zand F, Zirpe K, De Waele JJ. Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure: the DIANA study. Intensive Care Med 2020; 46:1404-1417. [PMID: 32519003 PMCID: PMC7334278 DOI: 10.1007/s00134-020-06111-5] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 05/11/2020] [Indexed: 01/10/2023]
Abstract
Purpose The DIANA study aimed to evaluate how often antimicrobial de-escalation (ADE) of empirical treatment is performed in the intensive care unit (ICU) and to estimate the effect of ADE on clinical cure on day 7 following treatment initiation. Methods Adult ICU patients receiving empirical antimicrobial therapy for bacterial infection were studied in a prospective observational study from October 2016 until May 2018. ADE was defined as (1) discontinuation of an antimicrobial in case of empirical combination therapy or (2) replacement of an antimicrobial with the intention to narrow the antimicrobial spectrum, within the first 3 days of therapy. Inverse probability (IP) weighting was used to account for time-varying confounding when estimating the effect of ADE on clinical cure. Results Overall, 1495 patients from 152 ICUs in 28 countries were studied. Combination therapy was prescribed in 50%, and carbapenems were prescribed in 26% of patients. Empirical therapy underwent ADE, no change and change other than ADE within the first 3 days in 16%, 63% and 22%, respectively. Unadjusted mortality at day 28 was 15.8% in the ADE cohort and 19.4% in patients with no change [p = 0.27; RR 0.83 (95% CI 0.60–1.14)]. The IP-weighted relative risk estimate for clinical cure comparing ADE with no-ADE patients (no change or change other than ADE) was 1.37 (95% CI 1.14–1.64). Conclusion ADE was infrequently applied in critically ill-infected patients. The observational effect estimate on clinical cure suggested no deleterious impact of ADE compared to no-ADE. However, residual confounding is likely. Electronic supplementary material The online version of this article (10.1007/s00134-020-06111-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liesbet De Bus
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
| | - Pieter Depuydt
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - Johan Steen
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, C. Heymanslaan 10, Ghent, Belgium
- Renal Division, Ghent University Hospital, C. Heymanslaan 10, Ghent, Belgium
| | - Sofie Dhaese
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Ken De Smet
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Alexis Tabah
- Intensive Care Unit, Redcliffe and Caboolture Hospitals, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Murat Akova
- Departmant of Infectious Diseases and Clinical Microbiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Menino Osbert Cotta
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Gennaro De Pascale
- Dipartimento Di Scienza Dell'Emergenza, Anestesiologiche e della Rianimazione - UOC Di Anestesia, Rianimazione, Terapia Intensiva e Tossicologia Clinica - Istituto di Anestesia e Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, Athens, Greece
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Shigeki Fujitani
- Emergency Medicine and Critical Care Medicine, St. Marianna University Hospital, Kawasaki-City, Kanagawa, Japan
| | - Jose Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
- Instituto de Biomedicina de Sevilla (IBIS), Seville, Spain
| | - Marc Leone
- Service d'Anesthésie et de Réanimation, Hôpital NordAssistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Jeffrey Lipman
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - José-Artur Paiva
- Emergency and Intensive Care Department, Centro Hospitalar Universitário São João EPE, Porto, Portugal
- Faculdade de Medicina da Universidade Do Porto, Grupo de Infecção E Sépsis, Porto, Portugal
| | - Jeroen Schouten
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare, IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fredrik Sjövall
- Department of Intensive Care and Perioperative Medicine, Skane University Hospital, Malmö, Sweden
- Mitochondrial Medicine, Lund University, Lund, Sweden
| | - Jean-François Timsit
- Sorbonne Paris Cité, IAME, UMR 1137, Université de Paris, Paris, France
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard Hospital, 75018, Paris, France
| | - Jason A Roberts
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jean-Ralph Zahar
- INSERM, IAME UMR 1137, University of Paris, Paris, France
- Microbiology, Infection Control Unit, GH Paris Seine Saint-Denis, APHP, Bobigny, France
| | - Farid Zand
- Shiraz Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kapil Zirpe
- Grant Medical Foundation, Ruby Hall Clinic, Pune, Maharashtra, India
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
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29
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Van Heijl I, Schweitzer VA, Van Der Linden PD, Bonten MJM, Van Werkhoven CH. Impact of antimicrobial de-escalation on mortality: a literature review of study methodology and recommendations for observational studies. Expert Rev Anti Infect Ther 2020; 18:405-413. [PMID: 32178545 DOI: 10.1080/14787210.2020.1743683] [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] [Indexed: 10/24/2022]
Abstract
Introduction: The safety of de-escalation of empirical antimicrobial therapy is largely based on observational data, with many reporting protective effects on mortality. As there is no plausible biological explanation for this phenomenon, it is most probably caused by confounding by indication.Areas covered: We evaluate the methodology used in observational studies on the effects of de-escalation of antimicrobial therapy on mortality. We extended the search for a recent systematic review and identified 52 observational studies. The heterogeneity in study populations was large. Only 19 (36.5%) studies adjusted for confounders and four (8%) adjusted for clinical stability during admission, all as a fixed variable. All studies had methodological limitations, most importantly the lack of adjustment for clinical stability, causing bias toward a protective effect.Expert opinion: The methodology used in studies evaluating the effects of de-escalation on mortality requires improvement. We depicted all potential confounders in a directed acyclic graph to illustrate all associations between exposure (de-escalation) and outcome (mortality). Clinical stability is an important confounder in this association and should be modeled as a time-varying variable. We recommend to include de-escalation as time-varying exposure and use inverse-probability-of-treatment weighted marginal structural models to properly adjust for time-varying confounders.
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Affiliation(s)
- Inger Van Heijl
- Department of Clinical Pharmacy, Tergooi Hospital, Hilversum/Blaricum, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Valentijn A Schweitzer
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Paul D Van Der Linden
- Department of Clinical Pharmacy, Tergooi Hospital, Hilversum/Blaricum, The Netherlands
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.,Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Cornelis H Van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
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30
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Poole S, Clark TW. Rapid syndromic molecular testing in pneumonia: The current landscape and future potential. J Infect 2020; 80:1-7. [PMID: 31809764 PMCID: PMC7132381 DOI: 10.1016/j.jinf.2019.11.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/27/2019] [Accepted: 11/29/2019] [Indexed: 12/18/2022]
Abstract
Community acquired pneumonia (CAP), hospital-acquired pneumonia (HAP) and ventilator associated pneumonia (VAP) are all associated with significant mortality and cause huge expense to health care services around the world. Early, appropriate antimicrobial therapy is crucial for effective treatment. Syndromic diagnostic testing using novel, rapid multiplexed molecular platforms represents a new opportunity for rapidly targeted antimicrobial therapy to improve patient outcomes and facilitate antibiotic stewardship. In this article we review the currently available testing platforms and discuss the potential benefits and pitfalls of rapid testing in pneumonia.
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Affiliation(s)
- Stephen Poole
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust Southampton, United Kingdom.
| | - Tristan W Clark
- School of Clinical and Experimental Sciences, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
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31
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Seok H, Jeon JH, Park DW. Antimicrobial Therapy and Antimicrobial Stewardship in Sepsis. Infect Chemother 2020; 52:19-30. [PMID: 32239809 PMCID: PMC7113444 DOI: 10.3947/ic.2020.52.1.19] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Indexed: 12/27/2022] Open
Abstract
Since sepsis was first defined, sepsis management has remained challenging. To improve mortality rates for sepsis and septic shock, an accurate diagnosis and prompt administration of appropriate antibiotics are essential. The goals of antimicrobial stewardship are to achieve optimal clinical outcomes and to ensure cost-effectiveness and minimal unintended consequences, such as toxic effects and development of resistant pathogens. A combination of inadequate diagnostic criteria for sepsis and time pressure to provide broad-spectrum antimicrobial therapy remains an obstacle for antimicrobial stewardship. Efforts such as selection of appropriate empirical antibiotics and de-escalation or determination of whether or not to stop antibiotics may help to improve a patient's clinical prognosis as well as the successful implementation of antimicrobial stewardship.
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Affiliation(s)
- Hyeri Seok
- Division of Infectious Diseases, Korea University Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ji Hoon Jeon
- Division of Infectious Diseases, Korea University Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Dae Won Park
- Division of Infectious Diseases, Korea University Medicine, Korea University Ansan Hospital, Ansan, Korea.
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32
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Tabah A, Bassetti M, Kollef MH, Zahar JR, Paiva JA, Timsit JF, Roberts JA, Schouten J, Giamarellou H, Rello J, De Waele J, Shorr AF, Leone M, Poulakou G, Depuydt P, Garnacho-Montero J. Antimicrobial de-escalation in critically ill patients: a position statement from a task force of the European Society of Intensive Care Medicine (ESICM) and European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Critically Ill Patients Study Group (ESGCIP). Intensive Care Med 2019; 46:245-265. [PMID: 31781835 DOI: 10.1007/s00134-019-05866-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/12/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antimicrobial de-escalation (ADE) is a strategy of antimicrobial stewardship, aiming at preventing the emergence of antimicrobial resistance (AMR) by decreasing the exposure to broad-spectrum antimicrobials. There is no high-quality research on ADE and its effects on AMR. Its definition varies and there is little evidence-based guidance for clinicians to use ADE in the intensive care unit (ICU). METHODS A task force of 16 international experts was formed in November 2016 to provide with guidelines for clinical practice to develop questions targeted at defining ADE, its effects on the ICU population and to provide clinical guidance. Groups of 2 experts were assigned 1-2 questions each within their field of expertise to provide draft statements and rationale. A Delphi method, with 3 rounds and an agreement threshold of 70% was required to reach consensus. RESULTS We present a comprehensive document with 13 statements, reviewing the evidence on the definition of ADE, its effects in the ICU population and providing guidance for clinicians in subsets of clinical scenarios where ADE may be considered. CONCLUSION ADE remains a topic of controversy due to the complexity of clinical scenarios where it may be applied and the absence of evidence to the effects it may have on antimicrobial resistance.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe and Caboolture Hospitals, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Santa Maria Misericordia University Hospital, Udine, Italy
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Jean-Ralph Zahar
- Hygiène Hospitalière Et Prévention du Risque Infectieux, CHU Avicenne, AP-HP, 125 rue de Stalingrad, 93000, Bobigny, France
| | - José-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar Universitário São João, Faculty of Medicine and University of Porto, Grupo de Infecçao e Sépsis, Porto, Portugal
| | - Jean-Francois Timsit
- Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard University Hospital, Paris, France
- University of Paris, INSERM IAME, U1137, Team DesCID, Paris, France
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, and Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Jeroen Schouten
- Department of Intensive Care, Radboudumc, Nijmegen, The Netherlands
| | - Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Jordi Rello
- CIBERES and Vall d'Hebron Institute of Research, Barcelona, Spain
- Clinical Research in ICU, CHU Nîmes, University Montpellier, Montpellier, France
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Marc Leone
- Department of Anesthesiology and Intensive Care Medicine, Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | - Garyphallia Poulakou
- 3rd Department of Medicine, National and Kapodistrian University of Athens, Medical School, Sotiria General Hospital, Athens, Greece
| | - Pieter Depuydt
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jose Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
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33
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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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34
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Morley VJ, Woods RJ, Read AF. Bystander Selection for Antimicrobial Resistance: Implications for Patient Health. Trends Microbiol 2019; 27:864-877. [PMID: 31288975 PMCID: PMC7079199 DOI: 10.1016/j.tim.2019.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/29/2019] [Accepted: 06/13/2019] [Indexed: 12/15/2022]
Abstract
Antimicrobial therapy promotes resistance emergence in target infections and in off-target microbiota. Off-target resistance emergence threatens patient health when off-target populations are a source of future infections, as they are for many important drug-resistant pathogens. However, the health risks of antimicrobial exposure in off-target populations remain largely unquantified, making rational antibiotic stewardship challenging. Here, we discuss the contribution of bystander antimicrobial exposure to the resistance crisis, the implications for antimicrobial stewardship, and some novel opportunities to limit resistance evolution while treating target pathogens.
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Affiliation(s)
- Valerie J Morley
- Center for Infectious Disease Dynamics, Departments of Biology and Entomology, The Pennsylvania State University, University Park, PA, USA.
| | - Robert J Woods
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Andrew F Read
- Center for Infectious Disease Dynamics, Departments of Biology and Entomology, The Pennsylvania State University, University Park, PA, USA; Huck Institutes for the Life Sciences, The Pennsylvania State University, University Park, PA, USA
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35
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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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36
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Pickens CI, Wunderink RG. Principles and Practice of Antibiotic Stewardship in the ICU. Chest 2019; 156:163-171. [PMID: 30689983 DOI: 10.1016/j.chest.2019.01.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/29/2018] [Accepted: 01/11/2019] [Indexed: 12/29/2022] Open
Abstract
In the face of emerging drug-resistant pathogens and a decrease in the development of new antimicrobial agents, antibiotic stewardship should be practiced in all critical care units. Antibiotic stewardship should be a core competency of all critical care practitioners in conjunction with a formal antibiotic stewardship program (ASP). Prospective audit and feedback, and antibiotic time-outs, are effective components of an ASP in the ICU. As rapid diagnostics are introduced in the ICU, assessment of performance and effect on outcomes will clearly be needed. Disease-specific stewardship for community-acquired pneumonia that relies on clinical pathways may be particularly high-yield. Computerized decision support has the potential to individualize stewardship for specific patients. Finally, infection control and prevention is the cornerstone of every ASP.
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Affiliation(s)
- Chiagozie I Pickens
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL.
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37
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Timsit JF, Bassetti M, Cremer O, Daikos G, de Waele J, Kallil A, Kipnis E, Kollef M, Laupland K, Paiva JA, Rodríguez-Baño J, Ruppé É, Salluh J, Taccone FS, Weiss E, Barbier F. Rationalizing antimicrobial therapy in the ICU: a narrative review. Intensive Care Med 2019; 45:172-189. [PMID: 30659311 DOI: 10.1007/s00134-019-05520-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/04/2019] [Indexed: 12/13/2022]
Abstract
The massive consumption of antibiotics in the ICU is responsible for substantial ecological side effects that promote the dissemination of multidrug-resistant bacteria (MDRB) in this environment. Strikingly, up to half of ICU patients receiving empirical antibiotic therapy have no definitively confirmed infection, while de-escalation and shortened treatment duration are insufficiently considered in those with documented sepsis, highlighting the potential benefit of implementing antibiotic stewardship programs (ASP) and other quality improvement initiatives. The objective of this narrative review is to summarize the available evidence, emerging options, and unsolved controversies for the optimization of antibiotic therapy in the ICU. Published data notably support the need for better identification of patients at risk of MDRB infection, more accurate diagnostic tools enabling a rule-in/rule-out approach for bacterial sepsis, an individualized reasoning for the selection of single-drug or combination empirical regimen, the use of adequate dosing and administration schemes to ensure the attainment of pharmacokinetics/pharmacodynamics targets, concomitant source control when appropriate, and a systematic reappraisal of initial therapy in an attempt to minimize collateral damage on commensal ecosystems through de-escalation and treatment-shortening whenever conceivable. This narrative review also aims at compiling arguments for the elaboration of actionable ASP in the ICU, including improved patient outcomes and a reduction in antibiotic-related selection pressure that may help to control the dissemination of MDRB in this healthcare setting.
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Affiliation(s)
- Jean-François Timsit
- Medical and Infectious Diseases ICU, APHP, Bichat-Claude Bernard Hospital, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France.
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Olaf Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - George Daikos
- Scool of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andre Kallil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric Kipnis
- Surgical Critical Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, CHU Lille, Lille, France
| | - Marin Kollef
- Critical Care Research, Washington University School of Medicine and Respiratory Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Kevin Laupland
- Department of Medicine, Royal Inland Hospital, Kamloops, Canada
| | - Jose-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar São João and Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jesús Rodríguez-Baño
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena, Departament of Medicine, University of Sevilla, Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Étienne Ruppé
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
- Bacteriology Laboratory, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jorge Salluh
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, IDOR, Rio De Janeiro, Brazil
| | | | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, AP-HP, Clichy, France
- INSERM, CRI, UMR 1149, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
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38
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Mathieu C, Pastene B, Cassir N, Martin-Loeches I, Leone M. Efficacy and safety of antimicrobial de-escalation as a clinical strategy. Expert Rev Anti Infect Ther 2018; 17:79-88. [PMID: 30570361 DOI: 10.1080/14787210.2019.1561275] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION De-escalation is a widely recommended strategy in regard to guidelines, with an associated adherence to guidelines being around 50%. This review discusses data supporting de-escalation and possible obstacles for its implementation. Areas covered: Although it does not have a consensual definition, de-escalation consists of reducing the spectrum of empirical antimicrobial treatment based on the microbiological findings. Many observational studies have suggested that this strategy is likely safe and efficient for treating various types of infection. However, randomized controlled trials published as of now have not shown any improvement on the outcomes. Regarding the adverse effects of de-escalation on ecological pressure and multidrug resistance emergence, the data are contradictory. The implementation of new techniques, such as rapid diagnosis, can help guide clinicians. Expert opinion: De-escalation should be included as part of a large antibiotic stewardship program to balance the risk and benefit of each administration, and each physician prescribing antibiotics should be challenged for the quality of her/his prescription on a daily basis. In the future, one of our duties will involve determining whether a delay of antimicrobial treatment - making it possible to improve diagnostic performance and obtain the first laboratory results - is either safe or unsafe for our patients.
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Affiliation(s)
- Calypso Mathieu
- a Assistance Publique Hôpitaux de Marseille, Service d'anesthésie et de réanimation , Aix-Marseille Université , Marseille , France
| | - Bruno Pastene
- a Assistance Publique Hôpitaux de Marseille, Service d'anesthésie et de réanimation , Aix-Marseille Université , Marseille , France
| | - Nadim Cassir
- b IRD, APHM, MEPHI, IHU-Méditerranée Infection , Aix-Marseille Université , Marseille , France
| | - Ignacio Martin-Loeches
- c Multidisciplinary Intensive Care Research Organization (MICRO) , St James's Hospital , Dublin , Ireland
| | - Marc Leone
- a Assistance Publique Hôpitaux de Marseille, Service d'anesthésie et de réanimation , Aix-Marseille Université , Marseille , France.,b IRD, APHM, MEPHI, IHU-Méditerranée Infection , Aix-Marseille Université , Marseille , France
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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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Tabak YP, Vankeepuram L, Ye G, Jeffers K, Gupta V, Murray PR. Blood Culture Turnaround Time in U.S. Acute Care Hospitals and Implications for Laboratory Process Optimization. J Clin Microbiol 2018; 56:e00500-18. [PMID: 30135230 PMCID: PMC6258864 DOI: 10.1128/jcm.00500-18] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/08/2018] [Indexed: 01/03/2023] Open
Abstract
The rapid identification of blood culture isolates and antimicrobial susceptibility test (AST) results play critical roles for the optimal treatment of patients with bloodstream infections. Whereas others have looked at the time to detection in automated culture systems, we examined the overall time from specimen collection to actionable test results. We examined four points of time, namely, blood specimen collection, Gram stain, organism identification (ID), and AST reports, from electronic data from 13 U.S. hospitals for the 11 most common, clinically significant organisms in septic patients. We compared the differences in turnaround times and the times from when specimens were collected and the results were reported in the 24-h spectrum. From January 2015 to June 2016, 165,593 blood specimens were collected, of which, 9.5% gave positive cultures. No matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry was used during the study period. Across the 10 common bacterial isolates (n = 6,412), the overall median (interquartile range) turnaround times were 0.80 (0.64 to 1.08), 1.81 (1.34 to 2.46), and 2.71 (2.46 to 2.99) days for Gram stain, organism ID, and AST, respectively. For all positive cultures, approximately 25% of the specimens were collected between 6:00 a.m. and 11:59 a.m. In contrast, more of the laboratory reporting times were concentrated between 6:00 a.m. and 11:59 a.m. for Gram stain (43%), organism ID (78%), and AST (82%), respectively (P < 0.001). The overall average turnaround times from specimen collection for Gram stain, organism ID, and AST were approximately 1, 2, and 3 days, respectively. The laboratory results were reported predominantly in the morning hours. Laboratory automation and work flow optimization may play important roles in reducing the microbiology result turnaround time.
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Affiliation(s)
- Ying P Tabak
- Becton, Dickenson and Co., Medical Affairs, Franklin Lakes, New Jersey, USA
| | - Latha Vankeepuram
- Becton, Dickenson and Co., Medical Affairs, Franklin Lakes, New Jersey, USA
| | - Gang Ye
- Becton, Dickenson and Co., Medical Affairs, Franklin Lakes, New Jersey, USA
| | - Kay Jeffers
- Becton, Dickenson and Co., Technology Solution, San Diego, California, USA
| | - Vikas Gupta
- Becton, Dickenson and Co., Digital Health, Franklin Lakes, New Jersey, USA
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Community-acquired pneumonia requiring hospitalization: rational decision making and interpretation of guidelines. Curr Opin Pulm Med 2018; 23:204-210. [PMID: 28198726 DOI: 10.1097/mcp.0000000000000371] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review focuses on the evidence base for guideline recommendations on the diagnosis, the optimal choice, timing and duration of empirical antibiotic therapy, and the use of microbiological tests for patients hospitalized with community-acquired pneumonia (CAP): issues for which guidelines are frequently used as a quick reference. Furthermore, we will discuss possibilities for future research in these topics. RECENT FINDINGS Many national and international guideline recommendations, even on critical elements of CAP management, are based on low-to-moderate quality evidence. SUMMARY The diagnosis and management of CAP has hardly changed for decades. The recommendation to cover atypical pathogens in all hospitalized CAP patients is based on observational studies only and is challenged by two recent trials. The following years, improved diagnostic testing, radiologically by low-dose Computed Tomography or ultrasound and/or microbiologically by point-of-care multiplex PCR, has the potential to largely influence the choice and start of antibiotic therapy in hospitalized CAP patients. Rapid microbiological testing will hopefully improve antibiotic de-escalation or early pathogen-directed therapy, both potent ways of reducing broad-spectrum antibiotic use. Current guideline recommendations on the timing and duration of antibiotic therapy are based on limited evidence, but will be hard to improve.
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Gustinetti G, Raiola AM, Varaldo R, Galaverna F, Gualandi F, Del Bono V, Bacigalupo A, Angelucci E, Viscoli C, Mikulska M. De-Escalation and Discontinuation of Empirical Antibiotic Treatment in a Cohort of Allogeneic Hematopoietic Stem Cell Transplantation Recipients during the Pre-Engraftment Period. Biol Blood Marrow Transplant 2018; 24:1721-1726. [PMID: 29578073 DOI: 10.1016/j.bbmt.2018.03.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/18/2018] [Indexed: 01/19/2023]
Abstract
To investigate rates and outcomes of antibiotic de-escalation during pre-engraftment neutropenia in allogeneic hematopoietic stem cell transplantation (HSCT) recipients. 110 consecutive HSCTs performed between January 2013 and March 2014 were analyzed. De-escalation was defined as narrowing the spectrum of antibiotic treatment either within (early) or after 96 hours (late) from starting antibiotics. Discontinuation, considered a form of de-escalation, was defined as stopping antibiotics before engraftment. De-escalation failure was defined as restarting/escalating antibiotics within 96 hours after de-escalation. Predictors of de-escalation were analyzed. Among 102 patients who started antibiotics and were included, 68 (67%) received monotherapy (mainly piperacillin-tazobactam, n = 58), whereas 34 (33%) received combination therapy (mainly meropenem plus glycopeptide, n = 24). Median duration of neutropenia was 17 days. Bloodstream infections (BSIs) were diagnosed in 28 patients (20%). Early de-escalation rate was 25.5% (n = 26) and mostly consisted of reducing the spectrum of β-lactams (n = 11, 42%). In comparison with theoretical scenario of continuing therapy until engraftment, the median savings in terms of antibiotic days were 10 for meropenem, 8 for piperacillin-tazobactam, and 7 for vancomycin. Failure rate of early de-escalation was 15% (4/26). Late de-escalation rate was 30.4% (n = 31) and failure rate 19% (6/31). The rate of de-escalation any time before engraftment was 55.9% (n = 57), including discontinuation in 33 patients (32%). Death at day 60 after HSCT occurred in 3 patients who never underwent de-escalation. Acute myeloid disease and BSIs were independent predictors of early de-escalation. De-escalation, including discontinuation, is feasible and safe in pre-engraftment neutropenia after allogeneic HSCT.
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Affiliation(s)
- Giulia Gustinetti
- Division of Infectious Diseases, Department of Health Science (DISSAL), Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Anna Maria Raiola
- Division of Hematology and Hematopoietic Stem Cell Transplantation Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Riccardo Varaldo
- Division of Hematology and Hematopoietic Stem Cell Transplantation Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Federica Galaverna
- Division of Hematology and Hematopoietic Stem Cell Transplantation Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Francesca Gualandi
- Division of Hematology and Hematopoietic Stem Cell Transplantation Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Valerio Del Bono
- Division of Infectious Diseases, Department of Health Science (DISSAL), Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Andrea Bacigalupo
- Istituto di Ematologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Emanuele Angelucci
- Division of Hematology and Hematopoietic Stem Cell Transplantation Unit, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Claudio Viscoli
- Division of Infectious Diseases, Department of Health Science (DISSAL), Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Science (DISSAL), Ospedale Policlinico San Martino-IRCCS per l'Oncologia, University of Genoa, Genoa, Italy.
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Blot M, Pivot D, Bourredjem A, Salmon-Rousseau A, de Curraize C, Croisier D, Chavanet P, Binquet C, Piroth L. Effectiveness of and obstacles to antibiotic streamlining to amoxicillin monotherapy in bacteremic pneumococcal pneumonia. Int J Antimicrob Agents 2017; 50:359-364. [DOI: 10.1016/j.ijantimicag.2017.03.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 03/08/2017] [Accepted: 03/22/2017] [Indexed: 12/15/2022]
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Leibovici L. Are we making an impact? Clin Microbiol Infect 2017; 23:783-784. [PMID: 28782650 DOI: 10.1016/j.cmi.2017.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 11/28/2022]
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Lee CC, Wang JL, Lee CH, Hung YP, Hong MY, Tang HJ, Ko WC. Clinical benefits of antimicrobial de-escalation in adults with community-onset monomicrobial Escherichia coli, Klebsiella species and Proteus mirabilis bacteremia. Int J Antimicrob Agents 2017; 50:371-376. [PMID: 28694235 DOI: 10.1016/j.ijantimicag.2017.03.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 03/20/2017] [Accepted: 03/22/2017] [Indexed: 01/22/2023]
Abstract
The clinical benefits of an antimicrobial de-escalation strategy were compared with those of a no-switch strategy in bacteremic patients. Adults with community-onset monomicrobial Escherichia coli, Klebsiella species and Proteus mirabilis bacteremia treated empirically using broad-spectrum beta-lactams, including third-generation cephalosporins (GCs), fourth-GC or carbapenems, were treated definitively with first- or second-GCs (de-escalation group), the same regimens as empirical antibiotics (no-switch group), or antibiotics with a broader-spectrum than empirical antibiotics (escalation group). The eligible 454 adults were categorized as the de-escalation (231 patients, 50.9%), no-switch (177, 39.0%), and escalation (46, 10.1%) groups. Patients with de-escalation therapy were more often female, had less critical illness and fatal comorbidity, and had a higher survival rate than patients in the other two groups. After propensity score matching in the de-escalation and no-switch groups, critical illness at onset (Pitt bacteremia score ≥ 4; 16.5% vs. 12.7%; P = 0.34) or day 3 (2.5% vs. 2.5%; P = 1.00), fatal comorbidity (16.5% vs. 21.5%; P = 0.25), time to defervescence (4.6 vs. 4.7 days; P = 0.89), hospital stays (11.5 vs. 10.3 days; P = 0.13) and 4-week crude mortality rate (4.4% vs. 4.4%; P = 1.00) were similar. However, lower antibiotic cost (mean: 212.1 vs. 395.6 US$, P <0.001) and fewer complications of bloodstream infections due to resistant pathogens (0% vs. 5.1%, P = 0.004) were observed in the de-escalation group. De-escalation to narrower-spectrum cephalosporins is safe and cost-effective for adults with community-onset EKP bacteremia stabilized by empirical broad-spectrum beta-lactams.
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Affiliation(s)
- Ching-Chi Lee
- Division of Critical Care Medicine, Department of Internal Medicine, Madou Sin-Lau Hospital, Tainan, Taiwan; Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jiun-Ling Wang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Hsun Lee
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Emergency Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yuan-Pin Hung
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Ming-Yuan Hong
- Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Emergency Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Hung-Jen Tang
- Department of Medicine, Chi-Mei Medical Center, Taiwan; Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan.
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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López-Cortés LE, Rosso-Fernández C, Núñez-Núñez M, Lavín-Alconero L, Bravo-Ferrer J, Barriga Á, Delgado M, Lupión C, Retamar P, Rodríguez-Baño J. Targeted simplification versus antipseudomonal broad-spectrum beta-lactams in patients with bloodstream infections due to Enterobacteriaceae (SIMPLIFY): a study protocol for a multicentre, open-label, phase III randomised, controlled, non-inferiority clinical trial. BMJ Open 2017; 7:e015439. [PMID: 28601833 PMCID: PMC5734512 DOI: 10.1136/bmjopen-2016-015439] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 04/04/2017] [Accepted: 04/27/2017] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Within the context of antimicrobial stewardship programmes, de-escalation of antimicrobial therapy is one of the proposed strategies for reducing the unnecessary use of broad-spectrum antibiotics (BSA). The empirical treatment of nosocomial and some healthcare-associated bloodstream infections (BSI) frequently includes a beta-lactam with antipseudomonal activity as monotherapy or in combination with other drugs, so there is a great opportunity to optimise the empirical therapy based on microbiological data. De-escalation is assumed as standard of care for experts in infectious diseases. However, it is less frequent than it would desirable. METHODS AND ANALYSIS The SIMPLIFY trial is a multicentre, open-label, non-inferiority phase III randomised controlled clinical trial, designed as a pragmatic 'real-practice' trial. The aim of this trial is to demonstrate the non-inferiority of de-escalation from an empirical beta-lactam with antipseudomonal activity to a targeted narrow-spectrum antimicrobial in patients with BSI due to Enterobacteriaceae. The primary outcome is clinical cure, which will be assessed at the test of cure visit. It will be conducted at 19 Spanish public and university hospitals. ETHICS AND DISSEMINATION Each participating centre has obtained the approval of the ethics review committee, the agreement of the directors of the institutions and authorisation from the Spanish Regulatory Agency (Agencia Española del Medicamento y Productos Sanitarios). Data will be presented at international conferences and published in peer-reviewed journals. DISCUSSION Strategies to reduce the use of BSA should be a priority. Most of the studies that support de-escalation are observational, retrospective and heterogeneous. A recent Cochrane review stated that well-designed clinical trials should be conducted to assess the safety and efficacy of de-escalation. TRIAL REGISTRATION NUMBER The European Union Clinical Trials Register: EudraCT number 2015-004219-19. Clinical trials.gov: NCT02795949. Protocol version: V.2.0, dated 16 May 2016. All items from the WHO Trial Registration Data Set are included in the registry.
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Affiliation(s)
- Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología Clínica, Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen Macarena /CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Clara Rosso-Fernández
- Unidad de Investigación Clínica y Ensayos Clínicos (UICEC-HUVR), Hospitales Universitario Virgen del Rocío y Virgen Macarena, Sevilla, Spain
- Farmacología Clínica, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - María Núñez-Núñez
- Unidad Clínica de Enfermedades Infecciosas y Microbiología Clínica, Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen Macarena /CSIC/Universidad de Sevilla, Sevilla, Spain
- Unidad Clínica de Farmacia. Hospitales Universitarios Virgen Macarena, Sevilla, Spain
| | - Lucía Lavín-Alconero
- Unidad de Investigación Clínica y Ensayos Clínicos (UICEC-HUVR), Hospitales Universitario Virgen del Rocío y Virgen Macarena, Sevilla, Spain
| | - José Bravo-Ferrer
- Unidad Clínica de Enfermedades Infecciosas y Microbiología Clínica, Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen Macarena /CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Ángel Barriga
- Unidad de Investigación Clínica y Ensayos Clínicos (UICEC-HUVR), Hospitales Universitario Virgen del Rocío y Virgen Macarena, Sevilla, Spain
| | - Mercedes Delgado
- Unidad Clínica de Enfermedades Infecciosas y Microbiología Clínica, Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen Macarena /CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Carmen Lupión
- Unidad Clínica de Enfermedades Infecciosas y Microbiología Clínica, Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen Macarena /CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Pilar Retamar
- Unidad Clínica de Enfermedades Infecciosas y Microbiología Clínica, Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen Macarena /CSIC/Universidad de Sevilla, Sevilla, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología Clínica, Instituto de Biomedicina de Sevilla (IBiS)/Hospital Universitario Virgen Macarena /CSIC/Universidad de Sevilla, Sevilla, Spain
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017; 45:486-552. [PMID: 28098591 DOI: 10.1097/ccm.0000000000002255] [Citation(s) in RCA: 1889] [Impact Index Per Article: 269.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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Lee CH, Hsieh CC, Hong MY, Hung YP, Ko WC, Lee CC. Comparing the therapeutic efficacies of third-generation cephalosporins and broader-spectrum β-lactams as appropriate empirical therapy in adults with community-onset monomicrobial Enterobacteriaceae bacteraemia: a propensity score matched analysis. Int J Antimicrob Agents 2017; 49:617-623. [PMID: 28315452 DOI: 10.1016/j.ijantimicag.2017.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/25/2016] [Accepted: 01/07/2017] [Indexed: 11/19/2022]
Abstract
In this study, the therapeutic efficacy of third-generation cephalosporins (3GCs) was compared with that of broader-spectrum β-lactams (BSBLs) [fourth-generation cephalosporins (4GCs) and carbapenems] as empirical therapy in adults with community-onset monomicrobial Enterobacteriaceae bacteraemia. Compared with those in the 3GC group (n = 477), a significantly higher proportion of patients in the BSBL group (n = 141) had initial presentation with severe sepsis or septic shock, critical illness (Pitt bacteraemia score ≥4) at bacteraemia onset and fatal co-morbidities (McCabe classification). For propensity score matching, 318 of the 477 patients in the 3GC group were matched with 106 patients in the BSBL group with the closest propensity scores on the basis of five independent predictors of 28-day mortality. After appropriate matching, no significant differences were observed in major baseline characteristics between the 3GC and BSBL groups in terms of causative micro-organism, bacteraemia severity, major source of bacteraemia, major co-morbidities and severity of co-morbidity. Consequently, the early clinical failure rate (12.9% vs. 12.3%; P = 0.87), bacteraemia severity (Pitt bacteraemia score ≥4; 4.6% vs. 8.2%; P = 0.17) at Day 3, and 3-day (3.8% vs. 7.5%; P = 0.11) and 28-day (13.2% vs. 17.0%; P = 0.33) crude mortality rates between the two groups were similar. These data suggest that the efficacy of 3GCs is similar to that of 4GCs or carbapenems when used as empirical antimicrobial therapy for community-onset Enterobacteriaceae bacteraemia.
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Affiliation(s)
- Chung-Hsun Lee
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Department of Medicine, Medical College, National Cheng Kung University, Tainan 70403, Taiwan
| | - Chih-Chia Hsieh
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan
| | - Ming-Yuan Hong
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Department of Medicine, Medical College, National Cheng Kung University, Tainan 70403, Taiwan
| | - Yuan-Pin Hung
- Department of Medicine, Medical College, National Cheng Kung University, Tainan 70403, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan 70043, Taiwan
| | - Wen-Chien Ko
- Department of Medicine, Medical College, National Cheng Kung University, Tainan 70403, Taiwan; Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan.
| | - Ching-Chi Lee
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan; Division of Critical Care Medicine, Department of Internal Medicine, Madou Sin-Lau Hospital, Tainan 72152, Taiwan; Graduate Institute of Medical Sciences, College of Health Sciences, Chang Jung Christian University, Tainan 71101, Taiwan.
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Gutiérrez-Pizarraya A, Leone M, Garnacho-Montero J, Martin C, Martin-Loeches I. Collaborative approach of individual participant data of prospective studies of de-escalation in non-immunosuppressed critically ill patients with sepsis. Expert Rev Clin Pharmacol 2017; 10:457-465. [PMID: 28266901 DOI: 10.1080/17512433.2017.1293520] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is a concern to conduct de-escalation in very sick patients. AIMS To determine if de-escalation is feasible in ICU settings. METHODS We performed a metaanalysis of published studies conducted comparing de-escalation (defined by withdrawal of at least one antimicrobial empirically prescribed, switch to a new antimicrobial with narrower spectrum and withdrawal of at least one antimicrobial plus change of another drug to a new one with narrower spectrum) in non-immunocompromised patients with sepsis admitted to ICU. RESULTS Eight hundred and seventeen patients with severe sepsis or septic shock were evaluated. De-escalation was applied in 274 patients (33.5%). We found no differences in hospital long of stay between de-escalation group compared to those who did not receive it. We also found significant lower hospital mortality in de-escalation group as compared with no modification group in front of the others (25.9 vs. 43.1%; p < 0.001). Taking into account the etiology of infection, in both gram negative and gram positives microorganisms, de-escalation strategy was assessed as a good prognosis factor for mortality in the adjusted multivariate analysis (OR 0.41; 95% CI 0.22-0.74 and OR 0.33; 95% CI 0.15-0.70 respectively) whereas SOFA score along with age were found as a factors independently associated with a worse clinical outcome (OR 1.23; 95% CI 1.12-1.35 and OR 1.02; 95% CI 1.01-1.04 respectively). CONCLUSIONS In our study there was an independent association of de-escalation and decrease mortality rate.
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Affiliation(s)
- Antonio Gutiérrez-Pizarraya
- a Department of Intensive Care Medicine , Instituto de Biomedicina de Sevilla, IBIS/Hospitales Universitarios Virgen Macarena -Virgen del Rocío /CSIC/Universidad de Sevilla , Sevilla , Spain
| | - Marc Leone
- b Service d'anesthésie et de réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille , Aix Marseille Université , Marseille , France
| | - Jose Garnacho-Montero
- c Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen Macarena, Instituto Biomedicina , Sevilla , Spain
| | - Claude Martin
- b Service d'anesthésie et de réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille , Aix Marseille Université , Marseille , France
| | - Ignacio Martin-Loeches
- d Trinity College, St James's University Hospital, Trinity Centre for Health Sciences, Multidisciplinary Intensive Care Research Organization (MICRO) , Dublin , Ireland
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43:304-377. [PMID: 28101605 DOI: 10.1007/s00134-017-4683-6] [Citation(s) in RCA: 3709] [Impact Index Per Article: 529.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/06/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
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