1
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Hammond A, Porter R, Lynch KE, Cason TH, Passaretti P. Impact of emergency medicine clinical pharmacist practitioner-driven sepsis antibiotic interventions. Am J Emerg Med 2024; 76:24-28. [PMID: 37979228 DOI: 10.1016/j.ajem.2023.11.012] [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: 06/30/2023] [Revised: 11/04/2023] [Accepted: 11/07/2023] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND The 2021 Surviving Sepsis Campaign Guidelines recommend administration of antimicrobials within the first hour of recognition of sepsis. Over the last decade, several studies have demonstrated improved time-to-antibiotic administration and antibiotic appropriateness when a pharmacist was involved in the care of patients with sepsis. To our knowledge, no studies evaluating the appropriate use of antibiotics in sepsis driven entirely by an Emergency Medicine (EM) Clinical Pharmacist Practitioner (CPP) have been published. The purpose of this study is to evaluate the impact of an EM CPP-driven protocol on antimicrobial interventions in patients with sepsis in the emergency department (ED). METHODS This was a retrospective comparison of patients with sepsis for whom antimicrobials were ordered in the ED without pharmacist intervention to patients whose antimicrobials were ordered by an EM CPP via a sepsis consult to pharmacy. An EM CPP reviewed individual patient profiles for pertinent historical admissions, culture data, and allergy profiles to guide antimicrobial selection for the suspected source of infection and entered orders under their scope of practice with formal documentation in the electronic medical record (EMR). The primary objective of this study was to compare the rates of appropriate empiric antibiotic utilization in septic patients admitted from the ED pre- and post-protocol implementation. Secondary endpoints included the following, broadening of ED-initiated empiric antibiotics on hospital admission, time-to-antibiotic administration, in-hospital mortality, Rapid Emergency Medicine Score (REMS) association with in-hospital mortality, and hospital length of stay. RESULTS A total of 144 patients were included: 80 patients prescribed antibiotics without pharmacist intervention and 64 prescribed antibiotics by an EM CPP. Appropriate empiric antibiotic selection in the ED improved from 57.5% (46/80) to 86% (55/64) with EM CPP intervention (difference 28.5%; p < 0.01). Time-to-first antibiotic administration decreased by 64 min (p < 0.01). Administration of antibiotics within 60 min, broadening of antibiotics on admission, hospital length of stay, and in-hospital mortality did not significantly differ across groups. CONCLUSIONS In this small, single-center study, an EM Clinical Pharmacist Practitioner-driven protocol for patients with sepsis in the emergency department improved the rate of appropriate empiric antimicrobial selection and time-to-antibiotic administration.
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Affiliation(s)
- Aubrie Hammond
- CaroMont Regional Medical Center, 2525 Court Dr, Gastonia, NC 28054, United States of America.
| | - Regan Porter
- CaroMont Regional Medical Center, 2525 Court Dr, Gastonia, NC 28054, United States of America
| | - Kevin E Lynch
- CaroMont Regional Medical Center, 2525 Court Dr, Gastonia, NC 28054, United States of America
| | - Taylor H Cason
- CaroMont Regional Medical Center, 2525 Court Dr, Gastonia, NC 28054, United States of America
| | - Patrick Passaretti
- CaroMont Regional Medical Center, 2525 Court Dr, Gastonia, NC 28054, United States of America
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2
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Souganidis ES, Patel B, Sampayo EM. Physician-Specific Utilization of an Electronic Best Practice Alert for Pediatric Sepsis in the Emergency Department. Pediatr Emerg Care 2022; 38:e1417-e1422. [PMID: 35696307 DOI: 10.1097/pec.0000000000002778] [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: 11/25/2022]
Abstract
BACKGROUND Early recognition of sepsis remains a critical goal in the pediatric emergency department (ED). Although this has led to the development of best practice alerts (BPAs) to facilitate screening and bundled care, research on how individual physicians interact with sepsis alerts and protocols is limited. This study aims to identify common reasons for acceptance and rejection of a sepsis BPA by pediatric emergency medicine (PEM) physicians and understand how the BPA affects physician management of patients with suspected sepsis. METHODS This is a qualitative study of PEM physicians in a quaternary-care children's hospital. Data were collected through semistructured interviews and analyzed through an iterative coding process until thematic saturation was achieved. Member checking was completed to ensure trustworthiness. Thematic analysis of PEM physicians' rejection reasons in the electronic health record was used to categorize their responses and calculate each theme's frequency. RESULTS Twenty-two physicians participated in this study. Seven physicians (32%) relied solely on patient characteristics when deciding to accept the BPA, whereas the remaining physicians considered nonpatient factors specific to the ED environment, individualized practice patterns, and BPA design. Eleven principal reasons for BPA rejection were derived from 1406 electronic health record responses, with clinical appearance not consistent with shock being the most common. Physicians identified the BPA's configuration and incomplete understanding of the BPA as the biggest barriers to utilization and provided strategies to improve the BPA screening process and streamline sepsis care. Physicians emphasized the need for further BPA education for physicians and triage staff and improved transparency of the alert. CONCLUSIONS Physicians consider patient and nonpatient factors when responding to the BPA. Improved BPA functionality combined with measures to enhance screening, optimize sepsis management, and educate ED providers on the BPA may increase satisfaction with the alert and promote more effective utilization when it fires.
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Affiliation(s)
- Ellie S Souganidis
- From the Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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3
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August BA, Griebe KM, Stine JJ, Hauser CD, Hunsaker T, Jones MC, Martz C, Peters MA, To L, Belanger R, Schlacht S, Swiderek J, Davis SL, Mlynarek ME, Smith ZR. Evaluating the impact of severe sepsis
3‐hour
bundle compliance on
28‐day in‐hospital
mortality: A propensity adjusted, nested case–control study. Pharmacotherapy 2022; 42:651-658. [DOI: 10.1002/phar.2715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 05/20/2022] [Accepted: 05/21/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Benjamin A. August
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - Kristin M. Griebe
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - John J. Stine
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | | | - Todd Hunsaker
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - Mathew C. Jones
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - Carolyn Martz
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - Michael A. Peters
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - Long To
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | | | | | - Jennifer Swiderek
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine Henry Ford Hospital Detroit Michigan USA
| | - Susan L. Davis
- Wayne State University Eugene Applebaum College of Pharmacy and Health Sciences Detroit Michigan USA
| | - Mark E. Mlynarek
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
| | - Zachary R. Smith
- Department of Pharmacy Services Henry Ford Hospital Detroit Michigan USA
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4
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Taneja I, Damhorst GL, Lopez-Espina C, Zhao SD, Zhu R, Khan S, White K, Kumar J, Vincent A, Yeh L, Majdizadeh S, Weir W, Isbell S, Skinner J, Devanand M, Azharuddin S, Meenakshisundaram R, Upadhyay R, Syed A, Bauman T, Devito J, Heinzmann C, Podolej G, Shen L, Timilsina SS, Quinlan L, Manafirasi S, Valera E, Reddy B, Bashir R. Diagnostic and prognostic capabilities of a biomarker and EMR-based machine learning algorithm for sepsis. Clin Transl Sci 2021; 14:1578-1589. [PMID: 33786999 PMCID: PMC8301583 DOI: 10.1111/cts.13030] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 01/08/2023] Open
Abstract
Sepsis is a major cause of mortality among hospitalized patients worldwide. Shorter time to administration of broad‐spectrum antibiotics is associated with improved outcomes, but early recognition of sepsis remains a major challenge. In a two‐center cohort study with prospective sample collection from 1400 adult patients in emergency departments suspected of sepsis, we sought to determine the diagnostic and prognostic capabilities of a machine‐learning algorithm based on clinical data and a set of uncommonly measured biomarkers. Specifically, we demonstrate that a machine‐learning model developed using this dataset outputs a score with not only diagnostic capability but also prognostic power with respect to hospital length of stay (LOS), 30‐day mortality, and 3‐day inpatient re‐admission both in our entire testing cohort and various subpopulations. The area under the receiver operating curve (AUROC) for diagnosis of sepsis was 0.83. Predicted risk scores for patients with septic shock were higher compared with patients with sepsis but without shock (p < 0.0001). Scores for patients with infection and organ dysfunction were higher compared with those without either condition (p < 0.0001). Stratification based on predicted scores of the patients into low, medium, and high‐risk groups showed significant differences in LOS (p < 0.0001), 30‐day mortality (p < 0.0001), and 30‐day inpatient readmission (p < 0.0001). In conclusion, a machine‐learning algorithm based on electronic medical record (EMR) data and three nonroutinely measured biomarkers demonstrated good diagnostic and prognostic capability at the time of initial blood culture.
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Affiliation(s)
| | - Gregory L Damhorst
- Prenosis Inc., Chicago, Illinois, USA.,Department of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Sihai Dave Zhao
- Department of Statistics, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Ruoqing Zhu
- Department of Statistics, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Shah Khan
- Prenosis Inc., Chicago, Illinois, USA
| | - Karen White
- Biomedical Research Center, Carle Foundation Hospital, Urbana, Illinois, USA
| | - James Kumar
- Biomedical Research Center, Carle Foundation Hospital, Urbana, Illinois, USA
| | | | - Leon Yeh
- OSF Saint Francis Medical Center, Peoria, Illinois, USA
| | - Shirin Majdizadeh
- Biomedical Research Center, Carle Foundation Hospital, Urbana, Illinois, USA
| | - William Weir
- Biomedical Research Center, Carle Foundation Hospital, Urbana, Illinois, USA
| | - Scott Isbell
- Department of Pathology, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - James Skinner
- Biomedical Research Center, Carle Foundation Hospital, Urbana, Illinois, USA
| | - Manubolo Devanand
- Biomedical Research Center, Carle Foundation Hospital, Urbana, Illinois, USA
| | - Syed Azharuddin
- Biomedical Research Center, Carle Foundation Hospital, Urbana, Illinois, USA
| | | | - Riddhi Upadhyay
- Biomedical Research Center, Carle Foundation Hospital, Urbana, Illinois, USA
| | | | - Thomas Bauman
- OSF Saint Francis Medical Center, Peoria, Illinois, USA
| | - Joseph Devito
- OSF Saint Francis Medical Center, Peoria, Illinois, USA
| | | | | | | | | | | | | | - Enrique Valera
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Bobby Reddy
- Prenosis Inc., Chicago, Illinois, USA.,Department of Bioengineering, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
| | - Rashid Bashir
- Department of Bioengineering, University of Illinois at Urbana-Champaign, Champaign, Illinois, USA
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5
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Pakyz AL, Orndahl CM, Johns A, Harless DW, Morgan DJ, Bearman G, Hohmann SF, Stevens MP. Impact of the Centers for Medicare and Medicaid Services Sepsis Core Measure on Antibiotic Use. Clin Infect Dis 2021; 72:556-565. [PMID: 32827032 DOI: 10.1093/cid/ciaa456] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 07/28/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) implemented a core measure sepsis (SEP-1) bundle in 2015. One element was initiation of broad-spectrum antibiotics within 3 hours of diagnosis. The policy has the potential to increase antibiotic use and Clostridioides difficile infection (CDI). We evaluated the impact of SEP-1 implementation on broad-spectrum antibiotic use and CDI occurrence rates. METHODS Monthly adult antibiotic data for 4 antibiotic categories (surgical prophylaxis, broad-spectrum for community-acquired infections, broad-spectrum for hospital-onset/multidrug-resistant [MDR] organisms, and anti-methicillin-resistant Staphylococcus aureus [MRSA]) from 111 hospitals participating in the Clinical Data Base Resource Manager were evaluated in periods before (October 2014-September 2015) and after (October 2015-June 2017) policy implementation. Interrupted time series analyses, using negative binomial regression, evaluated changes in antibiotic category use and CDI rates. RESULTS At the hospital level, there was an immediate increase in the level of broad-spectrum agents for hospital-onset/MDR organisms (+2.3%, P = .0375) as well as a long-term increase in trend (+0.4% per month, P = .0273). There was also an immediate increase in level of overall antibiotic use (+1.4%, P = .0293). CDI rates unexpectedly decreased at the time of SEP-1 implementation. When analyses were limited to patients with sepsis, there was a significant level increase in use of all antibiotic categories at the time of SEP-1 implementation. CONCLUSIONS SEP-1 implementation was associated with immediate and long-term increases in broad-spectrum hospital-onset/MDR organism antibiotics. Antimicrobial stewardship programs should evaluate sepsis treatment for opportunities to de-escalate broad therapy as indicated.
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Affiliation(s)
- Amy L Pakyz
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA
| | - Christine M Orndahl
- Department of Biostatistics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Alicia Johns
- Department of Biostatistics, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - David W Harless
- Department of Economics, Virginia Commonwealth University School of Business, Richmond, Virginia, USA
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland, USA
| | - Gonzalo Bearman
- Department of Hospital Epidemiology and Infection Control, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Samuel F Hohmann
- Vizient, Inc, Chicago, Illinois, USA.,Department of Health Systems Management, Rush University, Chicago, Illinois, USA
| | - Michael P Stevens
- Department of Hospital Epidemiology and Infection Control, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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6
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Shokoohi H, Duggan NM, Adhikari S, Selame LA, Amini R, Blaivas M. Point-of-care ultrasound stewardship. J Am Coll Emerg Physicians Open 2020; 1:1326-1331. [PMID: 33392540 PMCID: PMC7771754 DOI: 10.1002/emp2.12279] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 12/23/2022] Open
Abstract
Rapid adoption and widespread use of point-of-care ultrasound (POCUS) has impacted diagnostic testing and clinical care across medical disciplines. The benefits of POCUS must be weighed against certain pitfalls, such as the risk of misdiagnosis and false assurance. Beyond technical error in image acquisition and interpretation, an important pitfall is reliance on POCUS results without considering pre-test patient characteristics or the diagnostic accuracy of POCUS in varying clinical contexts. In this article, we introduce the concept of POCUS stewardship that emphasizes critical evaluation of clinical indications prior to performing POCUS as well as the individual patient and test characteristics of POCUS when integrating results into clinical decisionmaking. Adherence to these principles can lead to optimized POCUS application and improved patient care.
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Affiliation(s)
- Hamid Shokoohi
- Harvard Medical SchoolEmergency Ultrasound FellowshipMassachusetts General HospitalBostonMassachusettsUSA
| | - Nicole M. Duggan
- Harvard Affiliated Emergency Medicine Residency ProgramDepartment of Emergency Medicine, Massachusetts General HospitalBrigham and Women's HospitalBostonMassachusettsUSA
| | - Srikar Adhikari
- Emergency Medicine, Emergency UltrasoundUniversity of ArizonaTucsonArizonaUSA
| | - Lauren Ann Selame
- Emergency Ultrasound, Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Richard Amini
- Department of Emergency MedicineUniversity of ArizonaTucsonArizonaUSA
| | - Michael Blaivas
- Department of MedicineUniversity of South CarolinaColumbiaSouth CarolinaUSA
- Society of Ultrasound in Medical EducationColumbiaSouth CarolinaUSA
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7
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Persistently elevated early warning scores and lactate identifies patients at high risk of mortality in suspected sepsis. Eur J Emerg Med 2020; 27:125-131. [PMID: 31464702 DOI: 10.1097/mej.0000000000000630] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE In the UK, the National Early Warning Score (NEWS) is recommended as part of screening for suspicion of sepsis. Is a change in NEWS a better predictor of mortality than an isolated score when screening for suspicion of sepsis?. METHODS A prospectively gathered cohort of 1233 adults brought in by ambulance to two UK nonspecialist hospitals, with suspicion of sepsis at emergency department (ED) triage (2015-2017) was analysed. Associations with 30-day mortality and ICU admission rate were compared between groups with an isolated NEWS ≥5 points prehospital and those with persistently elevated NEWS prehospital, in ED and at ward admission. The effect of adding the ED (venous or arterial) lactate was also assessed. RESULTS Mortality increased if the NEWS persisted ≥5 at ED arrival 22.1% vs. 10.2% [odds ratio (OR) 2.5 (1.6-4.0); P < 0.001]. Adding an ED lactate ≥2 mmol/L was associated with an increase in mortality greater than for NEWS alone [32.2% vs. 13.3%, OR 3.1 (2.2-4.1); P < 0.001], and increased ICU admission [13.9% vs. 3.7%, OR 3.1 (2.2-4.3); P < 0.001]. If NEWS remained ≥5 at ward admission (predominantly within 4 h of ED arrival), mortality was 32.1% vs. 14.3%, [OR 2.8 (2.1-3.9); P < 0.001] and still higher if accompanied by an elevated ED lactate [42.1% vs. 16.4%, OR 3.7 (2.6-5.3); P < 0.001]. CONCLUSION Persistently elevated NEWS, from prehospital through the ED to the time of ward admission, combined with an elevated ED lactate identifies patients with suspicion of sepsis at highest risk of in-hospital mortality.
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8
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Pulia M, Redwood R. Empiric Antibiotic Prescribing for Suspected Sepsis: A Stewardship Balancing Act. Am J Med Sci 2020; 360:613-614. [PMID: 32980122 PMCID: PMC7482602 DOI: 10.1016/j.amjms.2020.08.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/26/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Michael Pulia
- Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA.
| | - Robert Redwood
- Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
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9
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Pulia MS, Wolf I, Schulz LT, Pop-Vicas A, Schwei RJ, Lindenauer PK. COVID-19: An Emerging Threat to Antibiotic Stewardship in the Emergency Department. West J Emerg Med 2020; 21:1283-1286. [PMID: 32970587 PMCID: PMC7514390 DOI: 10.5811/westjem.2020.7.48848] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023] Open
Abstract
While current research efforts focus primarily on identifying patient level interventions that mitigate the direct impact of COVID-19, it is important to consider the collateral effects of COVID-19 on antimicrobial resistance. Early reports suggest high rates of antibiotic utilization in COVID-19 patients despite their lack of direct activity against viral pathogens. The ongoing pandemic is exacerbating known barriers to optimal antibiotic stewardship in the ED, representing an additional direct threat to patient safety and public health. There is an urgent need for research analyzing overall and COVID-19 specific antibiotic prescribing trends in the ED. Optimizing ED stewardship during COVID-19 will likely require a combination of traditional stewardship approaches (e.g. academic detailing, provider education, care pathways) and effective implementation of host response biomarkers and rapid COVID-19 diagnostics. Antibiotic stewardship interventions with demonstrated efficacy in mitigating the impact of COVID-19 on ED prescribing should be widely disseminated and inform the ongoing pandemic response.
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Affiliation(s)
- Michael S. Pulia
- University of Wisconsin Madison, School of Medicine and Public Health, Department of Emergency Medicine, Madison, Wisconsin
| | - Ian Wolf
- University of Wisconsin Madison, School of Medicine and Public Health, Madison, Wisconsin
| | - Lucas T. Schulz
- University of Wisconsin Madison, School of Medicine and Public Health, Department of Pharmacy, Madison, Wisconsin
| | - Aurora Pop-Vicas
- University of Wisconsin Madison, School of Medicine and Public Health, Department of Medicine, Madison, Wisconsin
| | - Rebecca J. Schwei
- University of Wisconsin Madison, School of Medicine and Public Health, Department of Emergency Medicine, Madison, Wisconsin
| | - Peter K. Lindenauer
- University of Massachusetts Medical School - Baystate, Department of Medicine, Springfield, Massachusetts
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10
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Oxman D, Lohr K, Gupta E, Madara J, Len E, Hseih J. Incidence of Multidrug Resistant Infections in Emergency Department Patients with Suspected Sepsis. Am J Med Sci 2020; 360:650-655. [PMID: 32868035 DOI: 10.1016/j.amjms.2020.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/17/2020] [Accepted: 07/14/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Inappropriate antibiotic therapy in sepsis is associated with poor outcomes, clinicians often provide routine coverage for multidrug resistant (MDR) bacteria. However, these regimens may contribute to problems related to antibiotic overuse. To understand the incidence and related factors of multidrug resistant bacterial infections in ED patients with sepsis, we examined how often patients with sepsis in our emergency department had MDR infections. We also explored risk factors for, and outcomes from, MDR bacterial infections. METHODS We reviewed records of patients presenting to our emergency department (ED) meeting criteria for severe sepsis or septic shock from March 2012 to July 2013. Patient demographics, comorbidities, preadmission location, and APACHE II scores were analyzed, as were clinical outcomes. RESULTS A total of 191 episodes were examined. 108 (57%) cases were culture-positive, and of these, 23 (12.0%) had an MDR pathogen recovered. Among patients with positive cultures, MDR patients used mechanical ventilation more often 29% vs. 52% (P = 0.03) and had longer mean ICU and hospital length of stays: 4.0 vs 9.3 (P < 0.08) and 10.6 vs 20.8 (P = 0.01), respectively. We did not identify statistically significant predictors of MDR infection. CONCLUSIONS The overall number of infections due to MDR bacteria was low, and MDR gram-negative infections were uncommon. The use of multiple empiric antibiotics for resistant gram-negative infections in the ED may be beneficial in only a small number of cases. Additionally, empiric coverage for vancomycin-resistant enterococci may need to be considered more often. Larger studies may help further elucidate the rates of MDR infections in ED patients, and identify specific risk factors to rationally guide empiric antibiotic treatment.
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Affiliation(s)
- David Oxman
- Division of Pulmonary and Critical Care Medicine, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
| | - Kristin Lohr
- Department of Medicine, Lankenau Hospital, Philadelphia, Pennsylvania
| | - Ena Gupta
- Division of Pulmonary and Critical Care Medicine, Albert Einstein Medical Center, Philadelphia, Pennsylvania
| | - John Madara
- Division of Pulmonary and Critical Care Medicine, Sidney Kimmel Medical College at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Edward Len
- Division of Pulmonary and Critical Care Medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jerry Hseih
- Pacific Pulmonary Medical Group, Riverside, California
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11
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Manuel-Vázquez A, Palacios-Ortega F, García-Septiem J, Thuissard IJ, Sanz-Rosa D, Arias-Díaz J, Maríajover-Navalón J, Ramia JM. Antimicrobial Stewardship Programs Are Required in a Department of Surgery: "How" Is the Question A Quasi-Experimental Study: Results after Three Years. Surg Infect (Larchmt) 2020; 21:35-42. [PMID: 31347989 DOI: 10.1089/sur.2018.311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective: Our aim was to describe our antimicrobial stewardship program and the methodology based on the results in a surgical department. Methods: Our study was a quasi-experimental study conducted from January 1, 2009, through September 30, 2017. The site was the General and Digestive Surgery Department in a public primary referral center, the University Hospital of Getafe (Madrid, Spain). We implemented the antimicrobial stewardship program following a prospective audit and feedback model, with a surgeon incorporated into the manaagement group. We studied the deaths and 30-day re-admission rates, length of stay, prevalence of gram-negative bacilli, meropenem resistance, and days of treatment with meropenem. Results: After three years of the program, we recorded a significant decrease in Pseudomonas aeruginosa prevalence, a significant increase in Klebsiella pneumoniae prevalence, a decrease in meropenem resistance, and a reduction in meropenem days of treatment. Conclusions: Antimicrobial stewardship programs have a desirable effect on patients. In our experience, the program team should be led by a staff from the particular department. When human resources are limited, the sustainability, efficiency, and effectiveness of interventions are feasible only with adequate computer support. Finally, but no less important, the necessary feedback between the prescribers and the team must be based on an ad hoc method such as that provided by statistical control charts, a median chart in our study.
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Affiliation(s)
- Alba Manuel-Vázquez
- General and Digestive Surgery Department, University Hospital of Guadalajara, Guadalajara, Spain
| | | | - Javier García-Septiem
- General and Digestive Surgery Department, University Hospital of Getafe, Getafe, Madrid, Spain
| | - Israel John Thuissard
- School of Doctoral Studies and Research.Universidad Europea de Madrid, Madrid, Spain
| | - David Sanz-Rosa
- School of Doctoral Studies and Research.Universidad Europea de Madrid, Madrid, Spain
| | - Javier Arias-Díaz
- San Carlos Clinical Hospital, General and Digestive Surgery Department, Faculty of Medicine, Universidad Complutense, Madrid, Spain
| | - José Maríajover-Navalón
- General and Digestive Surgery Department, University Hospital of Getafe, Getafe, Madrid, Spain
| | - José Manuel Ramia
- General and Digestive Surgery Department, University Hospital of Guadalajara, Guadalajara, Spain
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12
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Balamuth F, Alpern ER, Kan M, Shumyatcher M, Hayes K, Lautenbach E, Himes BE. Gene Expression Profiles in Children With Suspected Sepsis. Ann Emerg Med 2020; 75:744-754. [PMID: 31983492 DOI: 10.1016/j.annemergmed.2019.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 09/09/2019] [Accepted: 09/24/2019] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE Sepsis recognition is a clinical challenge in children. We aim to determine whether peripheral blood gene expression profiles are associated with pathogen type and sepsis severity in children with suspected sepsis. METHODS This was a prospective pilot observational study in a tertiary pediatric emergency department with a convenience sample of children enrolled. Participants were older than 56 days and younger than 18 years, had suspected sepsis, and had not received broad-spectrum antibiotics in the previous 4 hours. Primary outcome was source pathogen, defined as confirmed bacterial source from sterile body fluid or confirmed viral source. Secondary outcome was sepsis severity, defined as maximum therapy required for shock reversal in the first 3 hospital days. We drew peripheral blood for ribonucleic acid isolation at the sepsis protocol activation, obtained gene expression measures with the GeneChip Human Gene 2.0 ST Array, and conducted differential expression analysis. RESULTS We collected ribonucleic acid samples from a convenience sample of 122 children with suspected sepsis and 12 healthy controls. We compared the 66 children (54%) with confirmed bacterial or viral infection and found 558 differentially expressed genes, many related to interferon signaling or viral immunity. We did not find statistically significant gene expression differences in patients according to sepsis severity. CONCLUSION The study demonstrates feasibility of evaluating gene expression profiling data in children evaluated for sepsis in the pediatric emergency department setting. Our results suggest that gene expression profiling may facilitate identification of source pathogen in children with suspected sepsis, which could ultimately lead to improved tailoring of sepsis treatment and antimicrobial stewardship.
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Affiliation(s)
- Fran Balamuth
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Elizabeth R Alpern
- Department of Pediatrics, Northwestern School of Medicine, Division of Emergency Medicine, and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mengyuan Kan
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Maya Shumyatcher
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Katie Hayes
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ebbing Lautenbach
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Blanca E Himes
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA
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13
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Rothe K, Wantia N, Spinner CD, Schneider J, Lahmer T, Waschulzik B, Schmid RM, Busch DH, Katchanov J. Antimicrobial resistance of bacteraemia in the emergency department of a German university hospital (2013-2018): potential carbapenem-sparing empiric treatment options in light of the new EUCAST recommendations. BMC Infect Dis 2019; 19:1091. [PMID: 31888581 PMCID: PMC6937826 DOI: 10.1186/s12879-019-4721-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/22/2019] [Indexed: 12/21/2022] Open
Abstract
Background This study investigated predominant microorganisms causing community-onset bacteraemia at the medical emergency department (ED) of a tertiary-care university hospital in Germany from 2013 to 2018 and their antimicrobial susceptibility patterns. Methods Antimicrobial resistance patterns in patients with positive blood cultures presenting to an internal medicine ED were retrospectively analysed. Results Blood cultures were obtained at 5191 of 66,879 ED encounters, with 1013 (19.5%) positive results, and true positive results at 740 encounters (diagnostic yield, 14.3%). The most frequently isolated relevant microorganisms were Enterobacterales (n = 439, 59.3%), Staphylococcus aureus (n = 92, 12.4%), Streptococcus pneumoniae (n = 34, 4.6%), Pseudomonas aeruginosa (n = 32, 4.3%), Streptococcus pyogenes (n = 16, 2.2%), Enterococcus faecalis (n = 18, 2.4%), and Enterococcus faecium (n = 12, 1.6%). Antimicrobial susceptibility testing revealed a high proportion of resistance against ampicillin-sulbactam in Enterobacterales (42.2%). The rate of methicillin-resistant Staphylococcus aureus was low (0.4%). Piperacillin-tazobactam therapy provided coverage for 83.2% of all relevant pathogens using conventional breakpoints. Application of the new European Committee on Antimicrobial Susceptibility Testing (EUCAST) recommendations increased the percentage of susceptible isolates to high-dose piperacillin-tazobactam to 92.8% (p < 0.001). Broad-spectrum carbapenems would only cover an additional 4.8%. The addition of vancomycin or linezolid extended coverage by just 1.7%. Conclusions Using an ureidopenicillin-beta-lactamase inhibitor combination at the high dose suggested by the new EUCAST recommendations provided nearly 93% coverage for relevant pathogens in patients with suspected bloodstream infection in our cohort. This might offer a safe option to reduce the empiric use of carbapenems. Our data support the absence of a general need for glycopeptides or oxazolidinones in empiric treatment.
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Affiliation(s)
- Kathrin Rothe
- Technical University of Munich, School of Medicine, Institute for Medical Microbiology, Immunology and Hygiene, Trogerstr. 30, 81675, Munich, Germany. .,German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.
| | - Nina Wantia
- Technical University of Munich, School of Medicine, Institute for Medical Microbiology, Immunology and Hygiene, Trogerstr. 30, 81675, Munich, Germany.,German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Christoph D Spinner
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
| | - Jochen Schneider
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
| | - Tobias Lahmer
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
| | - Birgit Waschulzik
- Institute of Medical Informatics, Statistics, and Epidemiology, Technical University of Munich, Munich, Germany
| | - Roland M Schmid
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
| | - Dirk H Busch
- Technical University of Munich, School of Medicine, Institute for Medical Microbiology, Immunology and Hygiene, Trogerstr. 30, 81675, Munich, Germany.,German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Juri Katchanov
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
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14
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LaFave J, Levy D, Gekle R, Bramante R. Incidence of Clostridium difficile Infection After Sepsis Protocol Antibiotics. West J Emerg Med 2019; 20:977-981. [PMID: 31738730 PMCID: PMC6860382 DOI: 10.5811/westjem.2019.10.42070] [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: 12/21/2019] [Accepted: 10/07/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction The management of sepsis includes the prompt administration of intravenous antibiotics. There is concern that sepsis treatment protocols may be inaccurate in identifying true sepsis and exposing patients to potentially harmful antibiotics, sometimes unnecessarily. This study was designed to investigate those concerns by focusing on in-hospital Clostridium difficile infection (CDI), which is a known complication of exposure to antibiotics. Methods Our emergency department (ED) recently implemented a protocol to help combat sepsis and increase compliance with the 2017 Sepsis CMS Core Measures (SEP-1) guidelines. In this single-center, retrospective cohort analysis we queried the electronic health record to gather data on nosocomial CDI and antibiotics prescribed over a five-year period to analyze the effect of the introduction of a sepsis protocol order set. The primary goal of this study was to measure the hospital-wide CDI rate for three years prior to implementation of the sepsis bundle, and then compare this to the hospital-wide CDI rate two years post-implementation. As a secondary outcome, we compared the number of antibiotics prescribed in the ED 12 months prior to administration of the sepsis protocol vs 12 months post-initiation. Results Over the course of five years, the hospital averaged 9.4 nosocomial CDIs per 10,000 patient hours. Prior to implementation of the sepsis bundle, the average CDI rate was 11.6 (±1.11, 95%) and after implementation the average rate dropped to 6.2 (±1.27, 95%, p<0.01). The mean number of antibiotics ordered per patient visit was 0.33 (±0.015, 95%) prior to bundle activation, and, following sepsis bundle activation, the rate was 0.38 (±0.019, 95%, p<0.01). This accounted for 38% of all ED patient visits receiving antibiotics, a 5% increase after the sepsis bundle was introduced. Conclusion In this study, we found that CDI infections declined after implementation of a sepsis bundle. There was, however an increase in the number of patients being exposed to antibiotics after this hospital policy change. There are more risks than just CDI with antibiotic exposure, and these were not measured in this study. Subsequent studies should focus on the ongoing effects of timed, protocolized care and the associated risks.
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Affiliation(s)
- Jordan LaFave
- Good Samaritan Hospital Medical Center, Department of Emergency Medicine, West Islip, New York
| | - David Levy
- Good Samaritan Hospital Medical Center, Department of Emergency Medicine, West Islip, New York
| | - Robert Gekle
- Good Samaritan Hospital Medical Center, Department of Emergency Medicine, West Islip, New York
| | - Robert Bramante
- Good Samaritan Hospital Medical Center, Department of Emergency Medicine, West Islip, New York
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15
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Ward L, Andreassen S, Astrup JJ, Rahmani Z, Fantini M, Sambri V. Clinical- vs. model-based selection of patients suspected of sepsis for direct-from-blood rapid diagnostics in the emergency department: a retrospective study. Eur J Clin Microbiol Infect Dis 2019; 38:1515-1522. [PMID: 31079313 DOI: 10.1007/s10096-019-03581-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 05/02/2019] [Indexed: 12/11/2022]
Abstract
Selecting high-risk patients may improve the cost-effectiveness of rapid diagnostics. Our objective was to assess whether model-based selection or clinical selection is better for selecting high-risk patients with a high rate of bacteremia and/or DNAemia. This study involved a model-based, retrospective selection of patients from a cohort from which clinicians selected high-risk patients for rapid direct-from-blood diagnostic testing. Patients were included if they were suspected of sepsis and had blood cultures ordered at the emergency department. Patients were selected by the model by adding those with the highest probability of bacteremia until the number of high-risk patients selected by clinicians was reached. The primary outcome was bacteremia rate. Secondary outcomes were DNAemia rate, and 30-day mortality. Data were collected for 1395 blood cultures. Following exclusion, 1142 patients were included in the analysis. In each high-risk group, 220/1142 were selected, where 55 were selected both by clinicians and the model. For the remaining 165 in each group, the model selected for a higher bacteremia rate (74/165, 44.8% vs. 45/165, 27.3%, p = 0.001), and a higher 30-day mortality (49/165, 29.7% vs. 19/165, 11.5%, p = 0.00004) than the clinically selected group. The model outperformed clinicians in selecting patients with a high rate of bacteremia. Using such a model for risk stratification may contribute towards closing the gap in cost between rapid and culture-based diagnostics.
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Affiliation(s)
- Logan Ward
- Treat Systems ApS, Aalborg, Denmark. .,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
| | - Steen Andreassen
- Treat Systems ApS, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | | | - Zakia Rahmani
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Michela Fantini
- Unit of Microbiology, The Greater Romagna Area Hub Laboratory, Pievesestina, Italy
| | - Vittorio Sambri
- Unit of Microbiology, The Greater Romagna Area Hub Laboratory, Pievesestina, Italy.,DIMES, University of Bologna, Bologna, Italy
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16
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Comparing appropriateness of antibiotics for nursing home residents by setting of prescription initiation: a cross-sectional analysis. Antimicrob Resist Infect Control 2018; 7:74. [PMID: 29946449 PMCID: PMC6000953 DOI: 10.1186/s13756-018-0364-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/24/2018] [Indexed: 11/10/2022] Open
Abstract
Background The pervasive, often inappropriate, use of antibiotics in healthcare settings has been identified as a major public health threat due to the resultant widespread emergence of antibiotic resistant bacteria. In nursing homes (NH), as many as two-thirds of residents receive antibiotics each year and up to 75% of these are estimated to be inappropriate. The objective of this study was to characterize antibiotic therapy for NH residents and compare appropriateness based on setting of prescription initiation. Methods This was a retrospective, cross-sectional multi-center study that occurred in five NHs in southern Wisconsin between January 2013 and September 2014. All NH residents with an antibiotic prescribing events for suspected lower respiratory tract infections (LRTI), skin and soft tissue infections (SSTI), and urinary tract infections (UTI), initiated in-facility, from an emergency department (ED), or an outpatient clinic were included in this sample. We assessed appropriateness of antibiotic prescribing using the Loeb criteria based on documentation available in the NH medical record or transfer documents. We compared appropriateness by setting and infection type using the Chi-square test and estimated associations of demographic and clinical variables with inappropriate antibiotic prescribing using logistic regression. Results Among 735 antibiotic starts, 640 (87.1%) were initiated in the NH as opposed to 61 (8.3%) in the outpatient clinic and 34 (4.6%) in the ED. Inappropriate antibiotic prescribing for urinary tract infections differed significantly by setting: NHs (55.9%), ED (73.3%), and outpatient clinic (80.8%), P = .023. Regardless of infection type, patients who had an antibiotic initiated in an outpatient clinic had 2.98 (95% CI: 1.64–5.44, P < .001) times increased odds of inappropriate use. Conclusions Antibiotics initiated out-of-facility for NH residents constitute a small but not trivial percent of all prescriptions and inappropriate use was high in these settings. Further research is needed to characterize antibiotic prescribing patterns for patients managed in these settings as this likely represents an important, yet under recognized, area of consideration in attempts to improve antibiotic stewardship in NHs.
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17
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Affolabi D, Sogbo F, Laleye G, Orekan J, Massou F, Kehinde A, Anagonou S. Rapid detection of extended-spectrum-β-lactamase-producing Enterobacteriaceae in blood cultures using the ESBL NDP test in Cotonou, Benin. J Med Microbiol 2017. [PMID: 28639543 DOI: 10.1099/jmm.0.000509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Rapid and inexpensive tests for detecting extended-spectrum-β-lactamase (ESBL)-producing Enterobacteriaceae are needed, particularly in low-resource countries where infections with these bacteria constitute a major public health issue. The recently described ESBL NDP test performed well in developed countries. This study was designed to assess performance, cost and feasibility of this test in positive blood cultures, in Cotonou, Benin (West Africa). METHODOLOGY The test was performed on 175 positive Bactec broth blood cultures containing Enterobacteriaceae, and blindly compared with the double-disc synergy test (DDST) for the phenotypic detection of ESBL producers. RESULTS There was a complete agreement between the ESBL NDP test and the DDST. On average, the time to give results was 37 min for a sample and the cost was US$ 7.3. CONCLUSION The ESBL NDP test is rapid, relatively affordable and performed well in our setting.
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Affiliation(s)
- Dissou Affolabi
- Faculty of Health Sciences, Abomey-Calavi University, 01 BP 188 Cotonou, Benin
| | - Fredéric Sogbo
- Faculty of Health Sciences, Abomey-Calavi University, 01 BP 188 Cotonou, Benin
| | - Gracieux Laleye
- Faculty of Health Sciences, Abomey-Calavi University, 01 BP 188 Cotonou, Benin
| | - Jeanne Orekan
- Faculty of Health Sciences, Abomey-Calavi University, 01 BP 188 Cotonou, Benin
| | - Faridath Massou
- Faculty of Health Sciences, Abomey-Calavi University, 01 BP 188 Cotonou, Benin
| | - Aderemi Kehinde
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Medical Microbiology and Parasitology, University College Hospital, Ibadan, Nigeria
| | - Séverin Anagonou
- Faculty of Health Sciences, Abomey-Calavi University, 01 BP 188 Cotonou, Benin
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