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Seo D, Heo I, Moon J, Kwon J, Huh Y, Kang B, Song S, Kim S, Jung K. Impact of a Rounding Checklist Implementation in the Trauma Intensive Care Unit on Clinical Outcomes. Healthcare (Basel) 2024; 12:871. [PMID: 38727427 PMCID: PMC11083085 DOI: 10.3390/healthcare12090871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
We aimed to evaluate the effectiveness of an intensive care unit (ICU) round checklist, FAST HUGS BID (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, Ulcer prophylaxis, Glycemic control, Spontaneous breathing trial, Bowel regimen, Indwelling catheter removal, and De-escalation of antibiotics-abbreviated as FD hereafter), in improving clinical outcomes in patients with severe trauma. We included patients admitted to our trauma ICU from 2016 to 2020 and divided them into two groups: before (before-FD, 2016-2017) and after (after-FD, 2019-2020) implementation of the checklist. We compared patient characteristics and clinical outcomes, including ICU and hospital length of stay (LOS) and in-hospital mortality. Survival analysis was performed using Kaplan-Meier curves and multivariable logistic regression models; furthermore, multiple linear regression analysis was used to identify independent factors associated with ICU and hospital LOS. Compared with the before-FD group, the after-FD group had significantly lower in-hospital mortality and complication rates, shorter ICU and hospital LOS, and reduced duration of mechanical ventilation. Moreover, implementation of the checklist was a significant independent factor in reducing ICU and hospital LOS and in-hospital mortality. Implementation of the FD checklist is associated with decreased ICU and hospital LOS and in-hospital mortality.
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Affiliation(s)
- Dongmin Seo
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Inhae Heo
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
| | - Jonghwan Moon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Junsik Kwon
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Yo Huh
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Byunghee Kang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Seoyoung Song
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Sora Kim
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon 16499, Republic of Korea; (D.S.); (J.M.)
- Ajou University Hospital Gyeonggi South Regional Trauma Center, Suwon 16499, Republic of Korea
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Huo X, Liu P. An agent-based model on antimicrobial de-escalation in intensive care units: Implications on clinical trial design. PLoS One 2024; 19:e0301944. [PMID: 38626111 PMCID: PMC11020418 DOI: 10.1371/journal.pone.0301944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/21/2024] [Indexed: 04/18/2024] Open
Abstract
Antimicrobial de-escalation refers to reducing the spectrum of antibiotics used in treating bacterial infections. This strategy is widely recommended in many antimicrobial stewardship programs and is believed to reduce patients' exposure to broad-spectrum antibiotics and prevent resistance. However, the ecological benefits of de-escalation have not been universally observed in clinical studies. This paper conducts computer simulations to assess the ecological effects of de-escalation on the resistance prevalence of Pseudomonas aeruginosa-a frequent pathogen causing nosocomial infections. Synthetic data produced by the models are then used to estimate the sample size and study period needed to observe the predicted effects in clinical trials. Our results show that de-escalation can reduce colonization and infections caused by bacterial strains resistant to the empiric antibiotic, limit the use of broad-spectrum antibiotics, and avoid inappropriate empiric therapies. Further, we show that de-escalation could reduce the overall super-infection incidence, and this benefit becomes more evident under good compliance with hand hygiene protocols among health care workers. Finally, we find that any clinical study aiming to observe the essential effects of de-escalation should involve at least ten arms and last for four years-a size never attained in prior studies. This study explains the controversial findings of de-escalation in previous clinical studies and illustrates how mathematical models can inform outcome expectations and guide the design of clinical studies.
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Affiliation(s)
- Xi Huo
- Department of Mathematics, University of Miami, Coral Gables, FL, United States of Ameica
| | - Ping Liu
- LinkedIn Corporation, Mountain View, CA, United States of Ameica
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Anyanwu MU, Jaja IF, Okpala COR, Njoga EO, Okafor NA, Oguttu JW. Mobile Colistin Resistance ( mcr) Gene-Containing Organisms in Poultry Sector in Low- and Middle-Income Countries: Epidemiology, Characteristics, and One Health Control Strategies. Antibiotics (Basel) 2023; 12:1117. [PMID: 37508213 PMCID: PMC10376608 DOI: 10.3390/antibiotics12071117] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 07/30/2023] Open
Abstract
Mobile colistin resistance (mcr) genes (mcr-1 to mcr-10) are plasmid-encoded genes that threaten the clinical utility of colistin (COL), one of the highest-priority critically important antibiotics (HP-CIAs) used to treat infections caused by multidrug-resistant and extensively drug-resistant bacteria in humans and animals. For more than six decades, COL has been used largely unregulated in the poultry sector in low- and middle-income countries (LMICs), and this has led to the development/spread of mcr gene-containing bacteria (MGCB). The prevalence rates of mcr-positive organisms from the poultry sector in LMICs between January 1970 and May 2023 range between 0.51% and 58.8%. Through horizontal gene transfer, conjugative plasmids possessing insertion sequences (ISs) (especially ISApl1), transposons (predominantly Tn6330), and integrons have enhanced the spread of mcr-1, mcr-2, mcr-3, mcr-4, mcr-5, mcr-7, mcr-8, mcr-9, and mcr-10 in the poultry sector in LMICs. These genes are harboured by Escherichia, Klebsiella, Proteus, Salmonella, Cronobacter, Citrobacter, Enterobacter, Shigella, Providencia, Aeromonas, Raoultella, Pseudomonas, and Acinetobacter species, belonging to diverse clones. The mcr-1, mcr-3, and mcr-10 genes have also been integrated into the chromosomes of these bacteria and are mobilizable by ISs and integrative conjugative elements. These bacteria often coexpress mcr with virulence genes and other genes conferring resistance to HP-CIAs, such as extended-spectrum cephalosporins, carbapenems, fosfomycin, fluoroquinolone, and tigecycline. The transmission routes and dynamics of MGCB from the poultry sector in LMICs within the One Health triad include contact with poultry birds, feed/drinking water, manure, poultry farmers and their farm workwear, farming equipment, the consumption and sale of contaminated poultry meat/egg and associated products, etc. The use of pre/probiotics and other non-antimicrobial alternatives in the raising of birds, the judicious use of non-critically important antibiotics for therapy, the banning of nontherapeutic COL use, improved vaccination, biosecurity, hand hygiene and sanitization, the development of rapid diagnostic test kits, and the intensified surveillance of mcr genes, among others, could effectively control the spread of MGCB from the poultry sector in LMICs.
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Affiliation(s)
| | - Ishmael Festus Jaja
- Department of Livestock and Pasture Science, University of Fort Hare, Alice 5700, South Africa
| | - Charles Odilichukwu R Okpala
- Department of Functional Food Products Development, Faculty of Biotechnology and Food Science, Wrocław University of Environmental and Life Sciences, 50-375 Wrocław, Poland
- UGA Cooperative Extension, College of Agricultural and Environmental Sciences, University of Georgia, Athens, GA 30602, USA
| | - Emmanuel Okechukwu Njoga
- Department of Veterinary Public Health and Preventive Medicine, University of Nigeria, Nsukka 400001, Nigeria
| | | | - James Wabwire Oguttu
- Department of Agriculture and Animal Health, Florida Campus, University of South Africa, Johannesburg 1709, South Africa
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Baghdadi JD, Goodman KE, Magder LS, Heil EL, Claeys K, Bork J, Harris AD. Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients. JAC Antimicrob Resist 2023; 5:dlad054. [PMID: 37193004 PMCID: PMC10182731 DOI: 10.1093/jacamr/dlad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/19/2023] [Indexed: 05/18/2023] Open
Abstract
Background Empiric Gram-negative antibiotics are frequently changed in response to new information. To inform antibiotic stewardship, we sought to identify predictors of antibiotic changes using information knowable before microbiological test results. Methods We performed a retrospective cohort study. Survival-time models were used to evaluate clinical factors associated with antibiotic escalation and de-escalation (defined as an increase or decrease, respectively, in the spectrum or number of Gram-negative antibiotics within 5 days of initiation). Spectrum was categorized as narrow, broad, extended or protected. Tjur's D statistic was used to estimate the discriminatory power of groups of variables. Results In 2019, 2 751 969 patients received empiric Gram-negative antibiotics at 920 study hospitals. Antibiotic escalation occurred in 6.5%, and 49.2% underwent de-escalation; 8.8% were changed to an equivalent regimen. Escalation was more likely when empiric antibiotics were narrow-spectrum (HR 19.0 relative to protected; 95% CI: 17.9-20.1), broad-spectrum (HR 10.3; 95% CI: 9.78-10.9) or extended-spectrum (HR 3.49; 95% CI: 3.30-3.69). Patients with sepsis present on admission (HR 1.94; 95% CI: 1.91-1.96) and urinary tract infection present on admission (HR 1.36; 95% CI: 1.35-1.38) were more likely to undergo antibiotic escalation than patients without these syndromes. De-escalation was more likely with combination therapy (HR 2.62 per additional agent; 95% CI: 2.61-2.63) or narrow-spectrum empiric antibiotics (HR 1.67 relative to protected; 95% CI: 1.65-1.69). Choice of empiric regimen accounted for 51% and 74% of the explained variation in antibiotic escalation and de-escalation, respectively. Conclusions Empiric Gram-negative antibiotics are frequently de-escalated early in hospitalization, whereas escalation is infrequent. Changes are primarily driven by choice of empiric therapy and presence of infectious syndromes.
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Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherine E Goodman
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Kimberly Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Jacqueline Bork
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
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Haseeb A, Saleem Z, Altaf U, Batool N, Godman B, Ahsan U, Ashiq M, Razzaq M, Hanif R, E-Huma Z, Amir A, Hossain MA, Raafat M, Radwan RM, Iqbal MS, Kamran SH. Impact of Positive Culture Reports of E. coli or MSSA on De-Escalation of Antibiotic Use in a Teaching Hospital in Pakistan and the Implications. Infect Drug Resist 2023; 16:77-86. [PMID: 36636371 PMCID: PMC9831081 DOI: 10.2147/idr.s391295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/23/2022] [Indexed: 01/06/2023] Open
Abstract
Background Antibiotic de-escalation is a key element of antimicrobial stewardship programs that restrict the spread and emergence of resistance. This study was performed to evaluate the impact of positive culture sensitivity reports of E. coli or Methicillin sensitive Staphylococcus aureus (MSSA) on de-escalation of antibiotic therapy. Methods This prospective observational study was performed on 256 infected patients. The samples were obtained principally from the pus of infected sites for the identification of pathogens and culture-sensitivity testing. The data were collected from patient medical files, which included their demographic data, sample type, causative microbe and antimicrobial treatment as empiric or definitive treatment based on cultures. Data were analyzed using SPSS. Results Of 256 isolated microbes, 138 (53.9%) were MSSA and 118 were E. coli (46.1%). MSSA showed 100% sensitivity to cefoxitin, oxacillin, vancomycin, fosfomycin, colistin and more than 90% to linezolid (95.3%), tigecycline (93.1%), chloramphenicol (92.2%) and amikacin (90.2%). E. coli showed 100% sensitivity to only fosfomycin and more than 90% to colistin (96.7%), polymyxin-B (95.1%) and tigecycline (92.9%). The high use of cefoperazone+sulbactam (151), amikacin (149), ceftriaxone (33), metronidazole (30) and piperacillin + tazobactam (22) was seen with empiric prescribing. Following susceptibility testing, the most common antibiotics prescribed for E. coli were meropenem IV (34), amikacin (34), ciprofloxacin (29) and cefoperazone+sulbactam (25). For MSSA cases, linezolid (48), clindamycin (30), cefoperazone+ sulbactam IV (16) and amikacin (15) was used commonly. Overall, there was 23% reduction in antibiotic use in case of E. coli and 43% reduction in MSSA cases. Conclusion Culture sensitivity reports helped in the de-escalation of antimicrobial therapy, reducing the prescribing of especially broad-spectrum antibiotics. Consequently, it is recommended that local hospital guidelines be developed based on local antimicrobial susceptibility patterns while preventing the unnecessary use of broad-spectrum antibiotics for empiric treatment.
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Affiliation(s)
- Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan,Correspondence: Zikria Saleem, Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan, Email
| | - Ummara Altaf
- Department of Pharmacy, Ghurki Trust Teaching Hospital, Lahore, Pakistan
| | - Narjis Batool
- Australian Institute of Health Innovation, Center of Health Systems and Safety Research, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK,School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa,Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
| | - Umar Ahsan
- Department of Infection Prevention and Control, Al Noor Specialist Hospital, Ministry of health, Makkah, Kingdom of Saudi Arabia
| | - Mehreen Ashiq
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Mutiba Razzaq
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Rabia Hanif
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Zill E-Huma
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Afreenish Amir
- Department of Microbiology, National University of Medical Sciences, Rawalpindi, Pakistan
| | - Mohammad Akbar Hossain
- Department of Pharmacology and Toxicology, Faculty of Medicine in Al-Qunfudah, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia
| | - Mohamed Raafat
- Department of Pharmacology and Toxicology, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Rozan Mohammad Radwan
- Pharmaceutical Care Department, Al Noor Specialist Hospital, Ministry of Health, Makkah, Saudi Arabia
| | - Muhammad Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
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Yousuf S, Rzewuska M, Duncan E, Ramsay C. Identification of outcomes reported for hospital antimicrobial stewardship interventions using a systematic review of reviews. JAC Antimicrob Resist 2023; 5:dlac127. [PMID: 36601549 PMCID: PMC9806591 DOI: 10.1093/jacamr/dlac127] [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: 09/07/2022] [Accepted: 11/25/2022] [Indexed: 01/03/2023] Open
Abstract
Background Randomized trials of hospital antimicrobial stewardship (AMS) interventions aimed to optimize antimicrobial use contribute less to the evidence base due to heterogeneity in outcome selection and reporting. Developing a core outcome set (COS) for these interventions can be a way to address this problem. The first step in developing a COS is to identify and map all outcomes. Objectives To identify outcomes reported in systematic reviews of hospital AMS interventions. Methods Cochrane Database of Systematic Reviews, MEDLINE and Embase were searched for systematic reviews published up until August 2019 of interventions relevant to reducing unnecessary antimicrobial use for inpatient populations in secondary care hospitals. The methodological quality of included reviews was assessed using AMSTAR-2, A (revised) MeaSurement Tool to Assess systematic Reviews. Extracted outcomes were analysed using deductive and inductive thematic analysis. A list of overarching (unique) outcomes reflects the outcomes identified within the systematic reviews. Results Forty-one systematic reviews were included. Thirty-three (81%) systematic reviews were of critically low or low quality. A long list of 1739 verbatim outcomes was identified and categorized under five core areas of COMET (Core Outcome Measures in Effectiveness Trials) taxonomy: 'resources use' (45%), 'physiological/clinical' (27%), 'life impact' (16%), 'death' (8%) and 'adverse events' (4%). A total of 421 conceptually different outcomes were identified and grouped into 196 overarching outcomes. Conclusions There is significant heterogeneity in outcomes reported for hospital AMS interventions. Reported outcomes do not cover all domains of the COMET framework and may miss outcomes relevant to patients (e.g. emotional, social functioning, etc.). The included systematic reviews lacked methodological rigour, which warrants further improvements.
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Affiliation(s)
- Shazia Yousuf
- Corresponding author. E-mail: ; @shaziaYousuf11, @RzewuskaM, @EilidhMDuncan, @ProfRamsay
| | - Magdalena Rzewuska
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK
| | - Eilidh Duncan
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK
| | - Craig Ramsay
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, AB25 2ZD, Scotland, UK
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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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Yamaguchi R, Yamamoto T, Okamoto K, Tatsuno K, Ikeda M, Tanaka T, Wakabayashi Y, Sato T, Okugawa S, Moriya K, Suzuki H. Prospective audit and feedback implementation by a multidisciplinary antimicrobial stewardship team shortens the time to de-escalation of anti-MRSA agents. PLoS One 2022; 17:e0271812. [PMID: 35905080 PMCID: PMC9337637 DOI: 10.1371/journal.pone.0271812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/07/2022] [Indexed: 11/18/2022] Open
Abstract
Prospective audit and feedback (PAF) is considered an effective procedure for appropriate antibiotic use. However, its effect on the time to de-escalation is unclear. We aimed to evaluate the effect of daily PAF implementation, focusing on the time to de-escalation of anti-methicillin‐resistant Staphylococcus aureus (MRSA) agents as an outcome measure. To this end, a single-center, retrospective, quasi-experimental study including patients treated with intravenous anti-MRSA agents during pre-PAF (April 1, 2014 to March 31, 2015) and post-PAF (April 1, 2015 to March 31, 2016) periods was conducted. The time to de-escalation was estimated using the Kaplan–Meier method, and Cox proportional hazard analysis was performed to assess the effect of daily PAF implementation on the time to de-escalation. Interrupted time series analysis was used to evaluate the relationship between daily PAF implementation and anti-MRSA agent utilization data converted to defined daily dose (DDD) and days of therapy (DOT) per 1,000 patient days. The median time to de-escalation was significantly shorter in the post-PAF period than in the pre-PAF period (6 days vs. 7 days, P < 0.001). According to multivariate analysis, PAF implementation was independently associated with a shorter time to de-escalation (hazard ratio [HR], 1.18; 95% confidence interval [CI], 1.02 to 1.35). There were no significant differences in hospital mortality, 30-day mortality, and length of stay between the two periods. Interrupted time series analysis showed significant reductions in the trends of DDD (trend change, –0.65; 95% CI, –1.20 to –0.11) and DOT (trend change, –0.74; 95% CI, –1.33 to –0.15) between the pre-PAF and post-PAF periods. Daily PAF implementation for patients treated with intravenous anti-MRSA agents led to a shorter time to de-escalation and lower consumption of anti-MRSA agents without worsening the clinically important outcomes.
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Affiliation(s)
- Ryo Yamaguchi
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
- * E-mail:
| | - Takehito Yamamoto
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
- The Education Center for Clinical Pharmacy, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Koh Okamoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Keita Tatsuno
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Mahoko Ikeda
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Takehiro Tanaka
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Tomoaki Sato
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
| | - Shu Okugawa
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Kyoji Moriya
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Suzuki
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
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Miyamori D, Kamitani T, Kashiyama S, Ito M, Ohge H, Yamamoto Y. Bacterial susceptibility change post national shortage of first cephalosporin in Japan; a longitudinal retrospective database study using interrupted time series analysis. J Glob Antimicrob Resist 2022; 30:348-353. [PMID: 35732262 DOI: 10.1016/j.jgar.2022.06.010] [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: 04/04/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The clinical evidence for the impact of narrow-spectrum antimicrobial shortages on bacterial susceptibility is limited. Our purposes were to determine the impacts of the disruption of most of the Cefazolin (CEZ) supply in Japan on the susceptibility of pathogens and to analyze how long these changes persisted after the shortage of CEZ. METHODS We performed an interrupted time series analysis using the Japanese Infectious Disease Nationwide database. We analyzed each pathogen before and after CEZ shortage in 52 university hospitals from 2018 to 2020. May to November 2019 was designated as the implementation term for CEZ shortage. The primary outcome was the susceptibility to CEZ and other antimicrobial agents. Among all pathogens isolated from facilities, we identified pathogens that were tested for susceptibility to CEZ. RESULTS Of the 26 pathogens identified, analysis was performed on a total of 36346 isolates of five pathogens (E.coli, K.pneumoniae, K.oxytoca, P.mirabillis, S.aureus). Among four gram negative pathogens with low susceptibility, there were no significant immediate changes after the CEZ shortage, however, the slope change significantly increased by 1.29-2.69% per month and continued to improve 1 year after the shortage. Regarding S. aureus, which was highly susceptible at the baseline, neither immediate change nor slope was significant. CONCLUSIONS This quasi-experimental analysis using nationwide large database revealed that restriction of use due to narrow antimicrobial shortages may lead to improved susceptibility over the subsequent year. The results suggest that temporary switching of antimicrobial agents on a national scale could be effective.
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Affiliation(s)
- Daisuke Miyamori
- Department of General Internal Medicine, Hiroshima University Hospital
| | - Tsukasa Kamitani
- Section of education for clinical research, Kyoto University Hospital
| | - Seiya Kashiyama
- Section of Clinical Laboratory, Department of Clinical Support, Hiroshima University Hospital
| | - Masanori Ito
- Department of General Internal Medicine, Hiroshima University Hospital
| | - Hiroki Ohge
- Department of Infectious disease, Hiroshima University Hospital
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University.
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Naito Y, Maeda M, Nagatomo Y, Ugajin K, Akima E, Tanaka M, Tokimatsu I, Sasaki T. Impact of the Antimicrobial Stewardship Team Intervention Focusing on Changes in Prescribing Trends and the Rate of Carbapenem-resistant <i>P. aeruginosa</i>. YAKUGAKU ZASSHI 2022; 142:527-534. [DOI: 10.1248/yakushi.21-00202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Yuika Naito
- Department of Hospital Pharmaceutics, Showa University School of Pharmacy
| | - Masayuki Maeda
- Division of Infection Control Sciences, Department of Clinical Pharmacy, Showa University School of Pharmacy
| | - Yasuhiro Nagatomo
- Department of Infection Prevention and Control, Showa University Hospital
| | - Kazuhisa Ugajin
- Department of Infection Prevention and Control, Showa University Hospital
| | - Etsuko Akima
- Department of Infection Prevention and Control, Showa University Hospital
| | - Michiko Tanaka
- Department of Hospital Pharmaceutics, Showa University School of Pharmacy
| | - Issei Tokimatsu
- Division of Infection Diseases, Department of Medicine, Showa University School of Medicine
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11
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Sellers LA, Fitton KM, Segovia MF, Forehand CC, Dobbin KK, Newsome AS. Time to blood, respiratory and urine culture positivity in the intensive care unit: Implications for de-escalation. SAGE Open Med 2021; 9:20503121211040702. [PMID: 34434557 PMCID: PMC8381457 DOI: 10.1177/20503121211040702] [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: 04/22/2021] [Accepted: 08/02/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives Concern for late detection of bacterial pathogens is a barrier to early de-escalation efforts. The purpose of this study was to assess blood, respiratory and urine culture results at 72 h to test the hypothesis that early negative culture results have a clinically meaningful negative predictive value. Methods We retrospectively reviewed all patients admitted to the medical intensive care unit between March 2012 and July 2018 with blood cultures obtained. Blood, respiratory and urine culture results were assessed for time to positivity, defined as the time between culture collection and preliminary species identification. The primary outcome was the negative predictive value of negative blood culture results at 72 h. Secondary outcomes included sensitivity, specificity, positive predictive value and negative predictive value of blood, respiratory and urine culture results. Results The analysis included 1567 blood, 514 respiratory and 1059 urine cultures. Of the blood, respiratory and urine cultures ultimately positive, 90.3%, 76.2% and 90.4% were positive at 72 h. The negative predictive value of negative 72-h blood, respiratory and urine cultures were 0.99, 0.82 and 0.97, respectively. Antibiotic de-escalation had good specificity, positive predictive value and negative predictive value for finalized negative cultures. Conclusion Negative blood and urine culture results at 72 h had a high negative predictive value. These findings have important ramifications for antimicrobial stewardship efforts and support protocolized re-evaluation of empiric antibiotic therapy at 72 h. Caution should be used in patients with clinically suspected pneumonia, since negative respiratory culture results at 72 h were weakly predictive of finalized negative cultures.
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Affiliation(s)
- Lindsey A Sellers
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | | | | | - Christy C Forehand
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA.,Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Athens, GA, USA
| | - Kevin K Dobbin
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Andrea Sikora Newsome
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA.,Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Athens, GA, USA
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Diagnosis, Treatment, and Prevention of Urinary Tract Infections in Post-Acute and Long-Term Care Settings: A Consensus Statement From AMDA's Infection Advisory Subcommittee. J Am Med Dir Assoc 2021; 21:12-24.e2. [PMID: 31888862 DOI: 10.1016/j.jamda.2019.11.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/06/2019] [Accepted: 11/10/2019] [Indexed: 02/04/2023]
Abstract
The diagnosis and management of urinary tract infections (UTIs) among residents of post-acute and long-term care (PALTC) settings remains challenging. Nonspecific symptoms, complex medical conditions, insufficient awareness of diagnostic criteria, and unnecessary urine studies all contribute to the inappropriate diagnosis and treatment of UTIs in PALTC residents. In 2017, the Infection Advisory Subcommittee at AMDA-The Society for Post-Acute and Long-Term Care Medicine convened a workgroup comprised of experts in geriatrics and infectious diseases to review recent literature regarding UTIs in the PALTC population. The workgroup used evidence as well as their collective clinical expertise to develop this consensus statement with the goal of providing comprehensive guidance on the diagnosis, treatment, and prevention of UTIs in PALTC residents. The recommendations acknowledge limitations inherent to providing medical care for frail older adults, practicing within a resource limited setting, and prevention strategies tailored to PALTC populations. In addition, the consensus statement encourages integrating antibiotic stewardship principles into the policies and procedures used by PALTC nursing staff and by prescribing clinicians as they care for residents with a suspected UTI.
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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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Princess I, Vadala R. Clinical Microbiology in the Intensive Care Unit: Time for Intensivists to Rejuvenate this Lost Art. Indian J Crit Care Med 2021; 25:566-574. [PMID: 34177177 PMCID: PMC8196372 DOI: 10.5005/jp-journals-10071-23810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We live in an era of evolving microbial infections and equally evolving drug resistance among microorganisms. In any healthcare facility, intensivists play the most pivotal role with critically ill patients under their direct care. Majority of the critically ill patients already harbor a microorganism at admission or acquire one in the form of healthcare-associated infections during their course of intensive care unit stay. It is therefore rather imperative for intensivists to possess sound knowledge in clinical microbiology. On a negative note, most clinicians have very meager and remote knowledge acquired during their undergraduate years. This knowledge is rather theoretical than applied and wanes over the years becoming nonbeneficial in intensive patient care. We, therefore, intend to explore important concepts in applied microbiology and infection control that intensivists should know and implement in their clinical practice on a day-to-day basis. How to cite this article: Princess I, Vadala R. Clinical Microbiology in the Intensive Care Unit: Time for Intensivists to Rejuvenate this Lost Art. Indian J Crit Care Med 2021;25(5):566–574.
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Affiliation(s)
- Isabella Princess
- Department of Microbiology, Apollo Speciality Hospitals, Vanagaram Branch, Chennai, Tamil Nadu, India
| | - Rohit Vadala
- Metro Centre for Respiratory Diseases, Metro Multispeciality Hospital, Noida, Uttar Pradesh, India
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Battula V, Krupanandan RK, Nambi PS, Ramachandran B. Safety and Feasibility of Antibiotic De-escalation in Critically Ill Children With Sepsis - A Prospective Analytical Study From a Pediatric ICU. Front Pediatr 2021; 9:640857. [PMID: 33763396 PMCID: PMC7982649 DOI: 10.3389/fped.2021.640857] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 02/12/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction: De-escalation is the key to balance judicious antibiotic usage for life-threatening infections and reducing the emergence of antibiotic resistance caused by antibiotic overuse. Robust evidence is lacking regarding the safety of antibiotic de-escalation in culture negative sepsis. Materials and Methods: Children admitted to the PICU during the first 6 months of 2019 with suspected infection were included. Based on the clinical condition, cultures and septic markers, antibiotics were de-escalated or continued at 48-72 h. Outcome data like worsening of primary infection, acquisition of hospital acquired infection, level of ICU support and mortality were captured. Results: Among the 360 admissions, 247 (68.6%) children received antibiotics. After excluding 92 children, 155 children with 162 episodes of sepsis were included in the study. Thirty four episodes were not eligible for de-escalation. Among the eligible group of 128 episodes, antibiotics were de-escalated in 95 (74.2%) and continued in 33 (25.8%). The primary infection worsened in 5 (5.2%) children in the de-escalation group and in 1 (3%) in non de-escalation group [Hazard ratio: 2.12 (95%CI: 0.39-11.46)]. There were no significant differences in rates of hospital acquired infection, mortality or length of ICU stay amongst the groups. Blood cultures and assessment of clinical recovery played a major role in de-escalation of antibiotics and the clinician's hesitation to de-escalate in critically ill culture negative children was the main reason for not de-escalating among eligible children. Conclusion: Antibiotic de-escalation appears to be a safe strategy to apply in criticallly ill children, even in those with negative cultures.
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Affiliation(s)
- Vasudha Battula
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Ravi Kumar Krupanandan
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - P Senthur Nambi
- Department of Pediatric Infectious Diseases, Kanchi Kamakoti CHILDS Trust Hospital and The CHILDS Trust Medical Research Foundation, Chennai, India
| | - Bala Ramachandran
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
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Yamada K, Kuwabara G, Imoto W, Yamairi K, Shibata W, Oshima K, Yoshii N, Nakaie K, Niki M, Okada Y, Fujita A, Sakurai N, Kaneko Y, Kakeya H. Blood culture reports by infectious disease physicians can improve prognosis of bacteremia, including weekend-onset cases. Int J Infect Dis 2020; 100:174-179. [PMID: 32777587 DOI: 10.1016/j.ijid.2020.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Cases of positive blood cultures were previously reported by a microbiological technologist (MT) to an attending physician (AP), and the Antimicrobial Stewardship team provided medical assistance by grasping the situation at the morning meeting the next day. Since April 2018, MTs have reported positive blood cultures to an infectious disease physician (IDP), who proposes the management approach to the AP and provides weekend support. This study assessed the effectiveness of blood culture reports provided by IDPs to APs on outcomes of bacteremia, including weekend-onset cases. METHODS Patient characteristics and prognoses before (October 2017 to March 2018) and after intervention (April to September 2018) were compared. RESULTS The pre-intervention and post-intervention groups comprised 134 and 161 patients, respectively. Patients were more likely to be older (>65 years) in the post-intervention group (p < 0.05). There were no significant between-group differences in infection severity. The rate of de-escalation significantly increased from 38.1%-57.8% (p = 0.001). The rates of 28-day and in-hospital mortality reduced following the intervention (21.3% vs. 8.2% and 32.8% vs. 10.6%; p = 0.004 and p < 0.001, respectively). In-hospital mortality for weekend-onset cases also reduced following the intervention (33.3% vs. 12.9%, p = 0.01). Sepsis was a poor prognostic factor (OR 8.070, 95% CI 3.320-19.600, p < 0.001) and intervention was a good prognostic factor (OR 0.311, 95% CI 0.142-0.680, p = 0.003) affecting 28-day mortality in multivariate analysis. CONCLUSIONS Changes to blood culture result reporting protocols can improve outcomes of bacteremia, including weekend-onset cases.
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Affiliation(s)
- Koichi Yamada
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan; Research Center for Infectious Diseases, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Gaku Kuwabara
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Waki Imoto
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Kazushi Yamairi
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Wataru Shibata
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Kazuhiro Oshima
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Naoko Yoshii
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Kiyotaka Nakaie
- Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Makoto Niki
- Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Yasuyo Okada
- Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Akiko Fujita
- Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Norihiro Sakurai
- Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan
| | - Yukihiro Kaneko
- Research Center for Infectious Diseases, Graduate School of Medicine, Osaka City University, Osaka, Japan; Bacteriology, Osaka City University Hospital, Osaka, Japan
| | - Hiroshi Kakeya
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, Osaka, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, Osaka, Japan; Research Center for Infectious Diseases, Graduate School of Medicine, Osaka City University, Osaka, Japan.
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17
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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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Kuwabara G, Yukawa S, Yamada K, Imoto W, Yamairi K, Shibata W, Yoshii N, Watanabe T, Asai K, Niki M, Nakaie K, Okada Y, Fujita A, Kaneko Y, Kawaguchi T, Kakeya H. The effect of intervention by an antimicrobial stewardship team on anaerobic bacteremia. Anaerobe 2020; 64:102214. [PMID: 32446953 DOI: 10.1016/j.anaerobe.2020.102214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 11/30/2022]
Abstract
The effect of antimicrobial stewardship (AS) on anaerobic bacteremia is uncertain. This study aimed to assess the effect of interventions by the AS team (AST) on clinical and microbiological outcomes and antimicrobial use. An AS program was introduced at Osaka City University Hospital in January 2014; an interdisciplinary AST was established. We enrolled patients with anaerobic bacteremia between January 2009 and December 2018. Patients were classified into the pre-intervention group (from January 2009 to December 2013) and the post-intervention group (from January 2014 to December 2018). A significant decrease in definitive carbapenem use (P = 0.0242) and an increase in empiric tazobactam/piperacillin use (P = 0.0262) were observed in the post-intervention group. The de-escalation rate increased significantly from 9.38% to 32.7% (P = 0.0316) in the post-intervention group. The susceptibility of Bacteroides species and 30-day mortality did not worsen in the post-intervention group. These results showed that interventions by an AST can reduce carbapenem use and increase the de-escalation rate without worsening patient outcomes.
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Affiliation(s)
- Gaku Kuwabara
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Satomi Yukawa
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Koichi Yamada
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Research Center for Infectious Diseases, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Waki Imoto
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Kazushi Yamairi
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Wataru Shibata
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Naoko Yoshii
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Tetsuya Watanabe
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Kazuhisa Asai
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Makoto Niki
- Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Kiyotaka Nakaie
- Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Yasuyo Okada
- Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Akiko Fujita
- Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Yukihiro Kaneko
- Research Center for Infectious Diseases, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Bacteriology, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Tomoya Kawaguchi
- Department of Respiratory Medicine, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Hiroshi Kakeya
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Research Center for Infectious Diseases, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan.
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Voigt C, Silbert S, Widen RH, Marturano JE, Lowery TJ, Ashcraft D, Pankey G. The T2Bacteria Assay Is a Sensitive and Rapid Detector of Bacteremia That Can Be Initiated in the Emergency Department and Has Potential to Favorably Influence Subsequent Therapy. J Emerg Med 2020; 58:785-796. [DOI: 10.1016/j.jemermed.2019.11.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 10/01/2019] [Accepted: 11/23/2019] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW In the last 2 years, two major guidelines for the management of nosocomial pneumonia have been published: The International European Respiratory Society/European Society of Intensive Care Medicine/European Society of Clinical Microbiology and Infectious Diseases/Asociación Latinoamericana de Toráx guidelines for the management of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) and the American guidelines for management of adults with HAP and VAP; both the guidelines made important clinical recommendations for the management of patients. RECENT FINDINGS With the increasing emergence of multidrug resistant (MDR) organisms, paired with a relative reduction in new antibiotic development, nosocomial infections have become one of the most significant issues affecting global healthcare today. Despite several stark differences between the European and American guidelines, they are in agreement about many aspects of nosocomial pneumonia management. SUMMARY American and European guidelines promote prompt and appropriate empiric treatment which is immediately guided by local microbiological data, followed by an adequate de-escalation protocol based on culture results with a 1-week course of treatment. Both also questioned the use of biomarkers in HAP/VAP, whether as part of the diagnosis or daily assessment of patients. On the contrary, they have conflicting views in regards to the optimum method of diagnosis, the risk factors used to stratify patients, the use of clinical scoring systems and the various antibiotic classes used. All were presented with varying levels of evidence to support these differences in opinion, indicating that further research into these areas is required before a consensus can be agreed upon.
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Alshareef H, Alfahad W, Albaadani A, Alyazid H, Talib RB. Impact of antibiotic de-escalation on hospitalized patients with urinary tract infections: A retrospective cohort single center study. J Infect Public Health 2020; 13:985-990. [PMID: 32276874 DOI: 10.1016/j.jiph.2020.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/27/2020] [Accepted: 03/08/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) can be caused by multiple drug-resistant bacteria. Empirical broad-spectrum antibiotics help minimize the risk of disease progression. Although antibiotic de-escalation is important to reduce resistance, adverse drug effects, and costs, few studies have evaluated the impact of antibiotic de-escalation on complicated UTIs in hospitalized patients. METHODS In this retrospective cohort single center observational study conducted over a period of 1 year at Prince Sultan Military Medical City (PSMMC), the rate of antibiotic de-escalation following reporting culture and sensitivity results, hospital length of stay (LOS), and factors associated with antibiotic de-escalation failure were determined. RESULTS Ninety-one patients were enrolled in this study. Baseline characteristics were comparable between groups. The rate of successful de-escalation was 29.7% (27 patients) while 70.3% (64 patients) failed to experience de-escalation. The median hospital LOS was significantly lower in successfully de-escalated patients, at 3 days interquartile range (IQR) (2-6), while in the failed group it was 10 days IQR (6-21) (p<0.001). However, the identified factor associated with failure was a multidrug-resistant (MDR) pathogen that was significantly higher in the failed group than in the successful group: 38 patients (59.4%) versus 6 patients (22.2%; p<0.001), respectively. CONCLUSION Antibiotic de-escalation is an essential antimicrobial stewardship strategy. The findings of this study showed that de-escalation was associated with better patient outcomes (i.e., reduced hospital LOS) in patients admitted due to UTIs. In this study's site hospital, there is a potential for improving the current de-escalation rate. MDR pathogens were the only significant reason identified for de-escalation failure. Further data are needed on the large scale to evaluate reasons for de-escalation failure.
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Affiliation(s)
- Hanan Alshareef
- Department of Pharmacy Practice, College of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia; Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
| | - Wafa Alfahad
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Abeer Albaadani
- Department of Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Huda Alyazid
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ruba Bin Talib
- Department of Pharmacy, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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22
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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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23
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Hamilton LA, Behal ML. Altering Routine Intensive Care Unit Practices to Support Commensalism. Nutr Clin Pract 2020; 35:433-441. [PMID: 32189422 DOI: 10.1002/ncp.10484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The gastrointestinal (GI) tract consists of trillions of organisms that support multiple functions in the body, from immunity, digestion, and absorption to drug metabolism. These microbes form an overall collection of microorganisms that form the body's microbiome. In critical illness, many of these functions are aberrant, and the microbiome is altered, leading to untoward effects. Some of the most common medications received by patients include antibiotics and proton pump inhibitors, which affect particular changes in the microbiome. In addition, patients receiving prolonged enteral and parenteral nutrition experience changes in the microbiological composition and diversity of their GI tracts. Research is ongoing to characterize the crosstalk between the microbiome and immune function as targets for drug and nutrition therapy.
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Affiliation(s)
- Leslie A Hamilton
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, Tennessee, USA
| | - Michael L Behal
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Knoxville, Tennessee, USA
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Hopkins TM, Juang P, Weaver K, Kollef MH, Betthauser KD. Outcomes of Macrolide Deescalation in Severe Community-acquired Pneumonia. Clin Ther 2019; 41:2540-2548. [PMID: 31676040 DOI: 10.1016/j.clinthera.2019.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/08/2019] [Accepted: 10/08/2019] [Indexed: 01/28/2023]
Abstract
PURPOSE Current data suggest potential benefits with β-lactam plus macrolide combination therapy for empiric treatment of intensive care unit (ICU) patients with severe community-acquired pneumonia (CAP). However, it is unclear whether deescalation to β-lactam monotherapy in the absence of positive results on diagnostic tests, such as the BioFire FilmArray Respiratory Panel 2 (BioFire polymerase chain reaction [PCR]), affects clinical outcomes. The purpose of this study was to compare outcomes between patients with negative BioFire PCR results deescalated to β-lactam monotherapy with those not deescalated. METHODS This single-center, retrospective cohort study assessed the in-hospital mortality rates of critically ill adults with CAP treated for ≥48 h with combination β-lactam and azithromycin therapy. Additional end points included hospital length of stay (LOS), ICU LOS, duration of mechanical ventilatory support, 30-day readmission, and incidence of azithromycin-related adverse effects. FINDINGS A total of 94 patients were included: 53 in the deescalation group and 41 in the nondeescalation group. No difference was observed with respect to in-hospital mortality (2.4% vs 11.3%, P = 0.312), although patients in the deescalated group experienced shorter ICU (1.9 vs 3.4 days, P = 0.029) and hospital LOS (6 vs 7 days, P = 0.025). No differences were found between groups with respect to additional secondary end points. Simple logistic regression confirmed that deescalation was not associated with hospital mortality (odds ratio = 0.17, 95% CI, 0.02-1.70). IMPLICATIONS In this study of ICU patients with severe CAP and a negative BioFire PCR result, deescalation from combination β-lactam and macrolide therapy to β-lactam monotherapy was not associated with increased in-hospital mortality but was associated with decreased hospital and ICU LOS. Larger prospective studies are warranted to verify these findings.
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Affiliation(s)
- Tiffany M Hopkins
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Paul Juang
- Division of Specialty Care Pharmacy, St. Louis College of Pharmacy, St. Louis, Missouri, USA
| | - Katherine Weaver
- Department of Pharmacy Medicine, University of Louisville Hospital, Louisville, Kentucky, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kevin D Betthauser
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA.
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Rodrigues C, Siciliano RF, Filho HC, Charbel CE, de Carvalho Sarahyba da Silva L, Baiardo Redaelli M, de Paula Rosa Passetti AP, Franco MRG, Rossi F, Zeigler R, De Backer D, Franco RA, de Almeida JP, Rizk SI, Fukushima JT, Landoni G, Uip DE, Hajjar LA, Strabelli TMV. The effect of a rapid molecular blood test on the use of antibiotics for nosocomial sepsis: a randomized clinical trial. J Intensive Care 2019; 7:37. [PMID: 31367384 PMCID: PMC6647273 DOI: 10.1186/s40560-019-0391-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/08/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Appropriate use of antimicrobials is essential to improve outcomes in sepsis. The aim of this study was to determine whether the use of a rapid molecular blood test-SeptiFast (SF) reduces the antibiotic consumption through early de-escalation in patients with nosocomial sepsis compared with conventional blood cultures (BCs). METHODS This was a prospective, randomized, superiority, controlled trial conducted at Sao Paulo Heart Institute in the period October 2012-May 2016. Adult patients admitted to the hospital for at least 48 h with a diagnosis of nosocomial sepsis underwent microorganism identification by both SF test and BCs. Patients randomized into the intervention group received antibiotic therapy adjustment according to the results of SF. Patients randomized into the control group received standard antibiotic adjustment according to the results of BCs. The primary endpoint was antimicrobial consumption during the first 14 days after randomization. RESULTS A total of 200 patients were included (100 in each group). The intention to treat analysis found no significant differences in median antibiotic consumption. In the subgroup of patients with positive SF and blood cultures (19 and 25 respectively), we found a statistically significant reduction in the median antimicrobial consumption which was 1429 (1071-2000) days of therapy (DOT)/1000 patients-day in the intervention group and 1889 (1357-2563) DOT/1000 patients-day in the control group (p = 0.017), in the median time of antimicrobial de-escalation (8 versus 54 h-p < 0.001), in the duration of antimicrobial therapy (p = 0.039) and in anti-gram-positive antimicrobial costs (p = 0.002). Microorganism identification was possible in 24.5% of patients (45/184) by SF and 21.2% (39/184) by BC (p = 0.45). CONCLUSION This randomized clinical trial showed that the use of a rapid molecular-based pathogen identification test does not reduce the median antibiotic consumption in nosocomial sepsis. However, in patients with positive microbiological tests, the use of SeptiFast reduced antimicrobial consumption through early de-escalation compared to conventional blood cultures. These results were driven by a reduction in the consumption of antimicrobials used for Gram-positive bacteria. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (NCT01450358) on 12th October 2011.
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Affiliation(s)
- Cristhieni Rodrigues
- Infectious Diseases Control, Heart Institute, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | | | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University of Milan, Milan, Italy
| | | | | | - Flávia Rossi
- Microbiology Division, University of Sao Paulo, São Paulo, Brazil
| | - Rogerio Zeigler
- Infectious Diseases Control, Heart Institute, University of Sao Paulo, São Paulo, Brazil
| | - Daniel De Backer
- Department of Intensive Care at the Erasme University, Universite Libre de Bruxelles, Bruxelles, Belgium
| | - Rafael Alves Franco
- Intensive Care Unit, Instituto do Cancer, University of Sao Paulo, São Paulo, Brazil
| | | | - Stéphanie Itala Rizk
- Intensive Care Unit, Instituto do Cancer, University of Sao Paulo, São Paulo, Brazil
| | - Julia Tizue Fukushima
- Intensive Care Unit, Instituto do Cancer, University of Sao Paulo, São Paulo, Brazil
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University of Milan, Milan, Italy
| | - David Everson Uip
- Infectious Diseases Control, Heart Institute, University of Sao Paulo, São Paulo, Brazil
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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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27
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Leong HN, Kurup A, Tan MY, Kwa ALH, Liau KH, Wilcox MH. Management of complicated skin and soft tissue infections with a special focus on the role of newer antibiotics. Infect Drug Resist 2018; 11:1959-1974. [PMID: 30464538 PMCID: PMC6208867 DOI: 10.2147/idr.s172366] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Complicated skin and soft tissue infections (cSSTIs) represent the severe form of infectious disease that involves deeper soft tissues. Involvement of methicillin-resistant Staphylococcus aureus (MRSA) further complicates cSSTI with increased hospitalization, health care costs, and overall mortality. Various international guidelines provide recommendations on the management of cSSTIs, with the inclusion of newer antibiotics. This literature-based review discusses the overall management of cSSTI, including appropriate use of antibiotics in clinical practice. Successful treatment of cSSTIs starts with early and precise diagnosis, including identification of causative pathogen and its load, determination of infection severity, associated complications, and risk factors. The current standard-of-care for cSSTIs involves incision, drainage, surgical debridement, broad-spectrum antibiotic therapy, and supportive care. In recent years, the emergence of newer antibiotics (eg, ceftaroline, tigecycline, daptomycin, linezolid, etc) has provided clinicians wider options of antimicrobial therapy. Selection of antibiotics should be based on the drug characteristics, effectiveness, safety, and treatment costs, alongside other aspects such as host factors and local multidrug resistance rates. However, larger studies on newer antibiotics are warranted to refine the decision making on the appropriate antimicrobial therapy. Local Antimicrobial Stewardship Program strategies in health care settings could guide clinicians for early initiation of specific treatments to combat region-specific antimicrobial resistance, minimize adverse effects, and to improve outcomes such as reduction in Clostridium difficile infections. These strategies involving iv-to-oral switch, de-escalation to narrow-spectrum antibiotics, and dose optimization have an impact on the overall improvement of cSSTI therapy outcomes, especially in countries like Singapore that has a high disease burden.
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Affiliation(s)
- Hoe Nam Leong
- Rophi Clinic, Mount Elizabeth Novena Specialist Centre, Singapore, Singapore,
| | - Asok Kurup
- Infectious Diseases Care Private Ltd, Mount Elizabeth Medical Centre, Singapore, Singapore
| | - Mak Yong Tan
- My Orthopaedic Clinic, Gleneagles Medical Centre, Singapore, Singapore
| | - Andrea Lay Hoon Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore.,Emerging Infectious Diseases Program, Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Kui Hin Liau
- LIAU KH Specialist Clinic, Mount Elizabeth Novena Specialist Centre, Singapore, Singapore
| | - Mark H Wilcox
- Department of Medical Microbiology, Leeds Teaching Hospitals and University of Leeds, Leeds, UK
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Ambaras Khan R, Aziz Z. Antibiotic de-escalation in patients with pneumonia in the intensive care unit: A systematic review and meta-analysis. Int J Clin Pract 2018; 72:e13245. [PMID: 30144239 DOI: 10.1111/ijcp.13245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 07/16/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES OF THE REVIEW Antibiotic de-escalation is part of an antibiotic stewardship strategy to achieve adequate therapy for infections while avoiding the prolonged use of broad-spectrum antibiotics. However, there is a paucity of clinical evidence on the clinical impact of this strategy in pneumonia patients in the intensive care unit (ICU). This review aimed to evaluate the impact of antibiotic de-escalation therapy for adult patients diagnosed with pneumonia in the ICU. METHODS USED TO CONDUCT THE REVIEW This review was conducted in accordance with the Meta-analysis of Observational Studies in Epidemiology (MOOSE) recommendation. Electronic databases including MEDLINE, CINAHL, PubMed, Embase, Cochrane Databases and Cochrane Central Register of Controlled Trials were searched up to March 2017 for relevant trials. The methodological quality of included trials was assessed by using a modified version of the Newcastle-Ottawa Quality Assessment Scale for Case-Control and Cohort Studies. A meta-analysis was conducted using the random-effect model to combine the rate of mortality and length of stay outcomes. FINDINGS OF THE REVIEW Nine observational trials involving 2128 patients were considered eligible for inclusion. Although based on low quality evidence, there was a statistically significant difference in favour of the impact of de-escalation on hospital stay but not mortality (MD -5.96 days; 95% CI -8.39 to -3.52). INTERPRETATIONS AND IMPLICATIONS OF THE FINDINGS This review highlights the need for more rigorous studies to be carried out before a firm conclusion on the benefit of de-escalation therapy is supported.
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Affiliation(s)
- Rahela Ambaras Khan
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Zoriah Aziz
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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29
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Li H, Yang CH, Huang LO, Cui YH, Xu D, Wu CR, Tang JG. Antibiotics De-Escalation in the Treatment of Ventilator-Associated Pneumonia in Trauma Patients: A Retrospective Study on Propensity Score Matching Method. Chin Med J (Engl) 2018; 131:1151-1157. [PMID: 29722334 PMCID: PMC5956765 DOI: 10.4103/0366-6999.231529] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: Antimicrobial de-escalation refers to starting the antimicrobial treatment with broad-spectrum antibiotics, followed by narrowing the drug spectrum according to culture results. The present study evaluated the effect of de-escalation on ventilator-associated pneumonia (VAP) in trauma patients. Methods: This retrospective study was conducted on trauma patients with VAP, who received de-escalation therapy (de-escalation group) or non-de-escalation therapy (non-de-escalation group). Propensity score matching method was used to balance the baseline characteristics between both groups. The 28-day mortality, length of hospitalization and Intensive Care Unit stay, and expense of antibiotics and hospitalization between both groups were compared. Multivariable analysis explored the factors that influenced the 28-day mortality and implementation of de-escalation. Results: Among the 156 patients, 62 patients received de-escalation therapy and 94 patients received non-de-escalation therapy. No significant difference was observed in 28-day mortality between both groups (28.6% vs. 23.8%, P = 0.620). The duration of antibiotics treatment in the de-escalation group was shorter than that in the non-de-escalation group (11 [8–13] vs. 14 [8–19] days, P = 0.045). The expenses of antibiotics and hospitalization in de-escalation group were significantly lower than that in the non-de-escalation group (6430 ± 2730 vs. 7618 ± 2568 RMB Yuan, P = 0.043 and 19,173 ± 16,861 vs. 24,184 ± 12,039 RMB Yuan, P = 0.024, respectively). Multivariate analysis showed that high Acute Physiology and Chronic Health Evaluation II (APACHE II) score, high injury severity score, multi-drug resistant (MDR) infection, and inappropriate initial antibiotics were associated with patients' 28-day mortality, while high APACHE II score, MDR infection and inappropriate initial antibiotics were independent factors that prevented the implementation of de-escalation. Conclusions: De-escalation strategy in the treatment of trauma patients with VAP could reduce the duration of antibiotics treatments and expense of hospitalization, without increasing the 28-day mortality and MDR infection.
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Affiliation(s)
- Hu Li
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Chun-Hui Yang
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Li-Ou Huang
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Yu-Hui Cui
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Dan Xu
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Chun-Rong Wu
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
| | - Jian-Guo Tang
- Department of Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China
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30
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Ambaras Khan R, Aziz Z. The methodological quality of guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia: A systematic review. J Clin Pharm Ther 2018; 43:450-459. [PMID: 29722052 DOI: 10.1111/jcpt.12696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 03/27/2018] [Indexed: 12/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Clinical practice guidelines serve as a framework for physicians to make decisions and to support best practice for optimizing patient care. However, if the guidelines do not address all the important components of optimal care sufficiently, the quality and validity of the guidelines can be reduced. The objectives of this study were to systematically review current guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), evaluate their methodological quality and highlight the similarities and differences in their recommendations for empirical antibiotic and antibiotic de-escalation strategies. METHODS This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Electronic databases including MEDLINE, CINAHL, PubMed and EMBASE were searched up to September 2017 for relevant guidelines. Other databases such as NICE, Scottish Intercollegiate Guidelines Network (SIGN) and the websites of professional societies were also searched for relevant guidelines. The quality and reporting of included guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument. RESULTS AND DISCUSSION Six guidelines were eligible for inclusion in our review. Among 6 domains of AGREE-II, "clarity of presentation" scored the highest (80.6%), whereas "applicability" scored the lowest (11.8%). All the guidelines supported the antibiotic de-escalation strategy, whereas the majority of the guidelines (5 of 6) recommended that empirical antibiotic therapy should be implemented in accordance with local microbiological data. All the guidelines suggested that for early-onset HAP/VAP, therapy should start with a narrow spectrum empirical antibiotic such as penicillin or cephalosporins, whereas for late-onset HAP/VAP, the guidelines recommended the use of a broader spectrum empirical antibiotic such as the penicillin extended spectrum carbapenems and glycopeptides. WHAT IS NEW AND CONCLUSIONS Expert guidelines promote the judicious use of antibiotics and prevent antibiotic overuse. The quality and validity of available HAP/VAP guidelines would be enhanced by improving their adherence to accepted best practice for the management of HAP and VAP.
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Affiliation(s)
- R Ambaras Khan
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Z Aziz
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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31
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Fu R, Chen T, Song J, Wang G, Li L, Ruan E, Liu H, Wang Y, Wang H, Xing L, Wu Y, Liu H, Qu W, Shao Z. De-escalation empirical antibiotic therapy improved survival for patients with severe aplastic anemia treated with antithymocyte globulin. Medicine (Baltimore) 2017; 96:e5905. [PMID: 28178130 PMCID: PMC5312987 DOI: 10.1097/md.0000000000005905] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 12/13/2016] [Accepted: 12/27/2016] [Indexed: 01/05/2023] Open
Abstract
We aimed to investigate the efficacy and safety of de-escalation empirical therapy for controlling infection in patients with severe aplastic anaemia (SAA) treated with antithymocyte globulin (ATG). Eighty-seven ATG-treated SAA patients who had microbiological culture-confirmed infections from 2006 to 2015 in our center were retrospectively analyzed. The efficacy of de-escalation and non-de-escalation therapy was compared. Among all 87 patients, 63 patients were treated with de-escalation therapy and 24 patients with non-de-escalation therapy. More patients showed response to anti-infection treatment in de-escalation group than in non-de-escalation group both on day 7 (60.32% vs. 25.00%, P = 0.003) and on day 30 (79.37% vs. 58.33%, P = 0.047) since the initial antimicrobial therapy. On day 30, more patients had increased absolute neutrophil count in de-escalation group compared with non-de-escalation group (76.19% vs. 45.83%, P = 0.007), and de-escalation group had lower morality rate (17.46% vs. 37.50%, P = 0.047) and better survival outcome (P = 0.023) on day 90. Twenty-three patients in de-escalation group and 5 patients in non-escalation group received granulocyte transfusions. Granulocyte transfusions helped to control infections in both de-escalation group (P = 0.027) and non-de-escalation group (P = 0.042) on day 7, but did not improve survival on day 90. We concluded that de-escalation antibiotics improved survival in SAA patients after ATG treatment. Early administration of broad-spectrum antibiotics pending microbiological cultures combined with a commitment to change to narrow-spectrum antibiotics should be recommended for controlling infections in SAA patients treated with ATG. Granulocyte transfusions might be an adjunctive therapy in controlling infections.
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