Antimicrobial stewardship in patients with acute bacterial skin and skin-structure infections: An international Delphi consensus

Development of quality indicators for antimicrobial stewardship in Belgian hospitals: a RAND - modified Delphi procedure

INTRODUCTION

Inappropriate antibiotic use is a major cause of antibiotic resistance. Therefore, optimizing antibiotic usage is essential. In Belgium, optimization of antimicrobials for the fight against multidrug resistant organisms (MDROs) is followed up by national surveillance by public health authorities. To improve appropriate antimicrobial use in hospitals, an effective national Antimicrobial Stewardship (AMS) program should include indicators for measuring both the quantity and quality of antibiotic use.

OBJECTIVES

The aim of this study was to develop a set of process quality indicators (QIs) to evaluate and improve AMS in hospitals.

METHODS

A RAND-modified Delphi procedure was used. The procedure consisted of a structured narrative literature review to select the QIs, followed by two online questionnaires and an intermediate multidisciplinary panel discussion with experts in infectious diseases from general and teaching hospitals in Belgium.

RESULTS

A total of 38 QIs were selected after the RAND-modified Delphi procedure, from which 11 QIs were selected unanimously. These QIs address compliancy of antibiotic therapy and prophylaxis with local guidelines, documentation of the rationale for antibiotic treatment in the medical record, the availability of AMS Programs and Outpatient Parenteral Antibiotic Therapy, resistance patterns and antimicrobial prescribing during focused ward rounds.

CONCLUSION

Our study selected 38 relevant process QIs, from which 11 were unanimously selected. The QIs can contribute to the improvement of quality of antibiotic use by stimulating hospitals to present better outcomes and by providing a focus on how to intervene and to improve prescribing of antimicrobials.

Dalbavancin Boosts the Ability of Neutrophils to Fight Methicillin-Resistant Staphylococcus aureus

Polymorphonuclear leukocytes (PMNs) are the most important cell type involved in the early nonspecific host response to bacterial pathogens. Staphylococcus aureus has evolved mechanisms to evade immune responses that contribute to its persistence in PMNs, and acquired resistance to several antimicrobials. Additionally, methicillin-resistant S. aureus (MRSA) is one of the most common causes of acute bacterial skin and skin-structure infections (ABSSSIs). Dalbavancin (DBV), a lipoglycopeptide, is indicated for the treatment of ABSSSIs, and has a broad spectrum of action against most microorganisms. Here, we sought to determine the effect of DBV on the neutrophil killing of MRSA and its potential immunomodulating activity. Our results revealed that DBV boosts MRSA killing by acting on both bacteria and PMNs. DBV pre-treatment of PMNs did not change the respiratory burst or degranulation, while an increased trend in neutrophil extracellular traps-associated elastase and in the production of TNFα and CXCL8 was revealed. In parallel, DBV caused a delay in the apoptosis of MRSA-infected neutrophils. In conclusion, we demonstrated a cooperative effect between the antimicrobial properties of PMNs and DBV, thus owing to their immunomodulatory activity. In the choice of the treatment management of serious S. aureus infections, DBV should be considered as an outstanding option since it reinforces PMNs pathogen clearance capability by exerting its effect directly, not only on MRSA but also on neutrophils.

Cost-minimisation analysis of oritavancin for the treatment of acute bacterial skin and skin structure infections from a United Kingdom perspective

BACKGROUND

Early discharge (ED) from hospital and outpatient parenteral antibiotic therapy (OPAT) are effective approaches for the management of a range of infections, including acute bacterial skin and skin structure infections (ABSSSI). Strategies that facilitate ED, thereby reducing complications such as healthcare-acquired infection whilst enhancing patient quality of life, are being increasingly adopted in line with good antimicrobial stewardship practice. This study presents a cost-minimisation analysis for the use of oritavancin at ED versus relevant comparators from a National Health Service (NHS) and personal and social services United Kingdom perspective.

METHODS

A cost-minimisation model considering adult patients with ABSSSI with suspected or confirmed methicillin-resistant Staphylococcus aureus (MRSA) infection, was developed based on publicly available NHS costs, practice guidelines for ABSSSI and clinical expert's opinion. Cost of treatment and treatment days were compared for oritavancin at ED to dalbavancin, teicoplanin, daptomycin and linezolid.

RESULTS

Following the empiric use of either flucloxacillin or vancomycin in the inpatient setting, oritavancin was compared to OPAT with dalbavancin, teicoplanin and daptomycin, and oral linezolid from day 4 of treatment. Oritavancin at ED reduced treatment duration by 0.8 days and led to cost savings of £281 in comparison to dalbavancin. In comparison to teicoplanin, daptomycin and linezolid, oritavancin reduced treatment duration by 5 days, with marginally higher costs (£446, £137, and £1,434, respectively).

CONCLUSION

Oritavancin, used to support ED, is associated with lower costs compared with dalbavancin and reduced treatment duration relative to all comparators. Its use would support an ED approach in MRSA ABSSSI management.

Antioxidant, Antimicrobial, and Insecticidal Properties of a Chemically Characterized Essential Oil from the Leaves of Dittrichia viscosa L

Since some synthetic insecticides cause damage to human health, compounds in plants can be viable alternatives to conventional synthetic pesticides. Dittrichia viscosa L. is a perennial Mediterranean plant known to possess biological activities, including insecticidal properties. The chemical composition of an essential oil (EOD) from D. viscosa, as well as its antioxidant, antimicrobial, and insecticidal effects on the cowpea weevil (Callosobruchus maculatus) were determined. Forty-one volatile compounds were identified in EOD, which accounted for 97.5% of its constituents. Bornyl acetate (41%) was a major compound, followed by borneol (9.3%), α-amorphene (6.6%), and caryophyllene oxide (5.7%). EOD exhibited significant antioxidant activity in all tests performed, with an IC₅₀ of 1.30 ± 0.05 mg/mL in the DPPH test and an EC₅₀ equal to 36.0 ± 2.5 mg/mL in the FRAP assay. In the phosphor-molybdenum test, EOD results ranged from 39.81 ± 0.7 to 192.1 ± 0.8 mg AAE/g E. EOD was active on E. coli (9.5 ± 0.5 mm), S. aureus (31.0 ± 1.5 mm), C. albicans (20.4 ± 0.5 mm), and S. cerevisiae (28.0 ± 1.0 mm), with MICs ranging from 0.1 mg/mL to 3.3 mg/mL. We found that 1 µL of EOD caused 97.5 ± 5.0% insect mortality after 96 h in the inhalation test and 60.0 ± 8.3% in the ingestion assay. The median lethal concentration (LC₅₀) was 7.8 ± 0.3 μL EO/L, while the effective concentration in the ingestion test (LC₅₀) was 15.0 ± 2.1 μL EO/L. We found that 20 µL of EOD caused a reduction of more than 91% of C. maculatus laid eggs.

Estrategias de protección antimicrobiana en el cuidado de heridas: evidencia para el uso de apósitos recubiertos con DACC

BACKGROUND

Antimicrobial resistance (AMR) is one of the most serious health threats globally. The development of new antimicrobials is not keeping pace with the evolution of resistant microorganisms, and novel ways of tackling this problem are required. One of such initiatives has been the development of antimicrobial stewardship programmes (AMS). The use of wound dressings that employ a physical sequestration and retention approach to reduce bacterial burden offers a novel approach to support AMS. Bacterial-binding by dressings and their physical removal can minimise their damage and prevent the release of harmful endotoxins.

OBJECTIVE

To highlight AMS to promote the correct use of antimicrobials and to investigate how dialkylcarbamyl chloride (DACC)-coated dressings can support AMS.

METHOD

MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar were searched to identify articles relating to AMS, and the use of wound dressings in the prevention and treatment of wound infections. The evidence supporting alternative wound dressings that can reduce bioburden and prevent wound infection in a way that does not kill or damage the microorganisms were reviewed.

RESULTS

The evidence demonstrated that using bacterial-binding wound dressings that act in a physical manner (eg, DACC-coated dressings) to preventing infection in both acute and hard-to-heal wounds does not exacerbate AMR and supports AMS.

CONCLUSION

Some wound dressings work via a mechanism that promotes the binding and physical sequestration and removal of intact microorganisms from the wound bed (eg, a wound dressing that uses DACC technology to prevent/reduce infection). They provide a valuable tool that aligns with the requirements of AMS by effectively reducing wound bioburden without inducing/selecting for resistant bacteria.

Antimicrobial stewardship strategies in wound care: evidence to support the use of dialkylcarbamoyl chloride (DACC)- coated wound dressings

BACKGROUND

Traditionally, infections are treated with antimicrobials (for example, antibiotics, antiseptics, etc), but antimicrobial resistance (AMR) has become one of the most serious health threats of the 21st century (before the emergence of COVID-19). Wounds can be a source of infection by allowing unconstrained entry of microorganisms into the body, including antimicrobial-resistant bacteria. The development of new antimicrobials (particularly antibiotics) is not keeping pace with the evolution of resistant microorganisms and novel ways of addressing this problem are urgently required. One such initiative has been the development of antimicrobial stewardship (AMS) programmes, which educate healthcare workers, and control the prescribing and targeting of antimicrobials to reduce the likelihood of AMR. Of great importance has been the European Wound Management Association (EWMA) in supporting AMS by providing practical recommendations for optimising antimicrobial therapy for the treatment of wound infection. The use of wound dressings that use a physical sequestration and retention approach rather than antimicrobial agents to reduce bacterial burden offers a novel approach that supports AMS. Bacterial-binding by dressings and their physical removal, rather than active killing, minimises their damage and hence prevents the release of damaging endotoxins.

AIM

Our objective is to highlight AMS for the promotion of the judicious use of antimicrobials and to investigate how dialkylcarbamoyl chloride (DACC)-coated dressings can support AMS goals.

METHOD

MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar were searched to identify published articles describing data relating to AMS, and the use of a variety of wound dressings in the prevention and/or treatment of wound infections. The evidence supporting alternative wound dressings that can reduce bioburden and prevent and/or treat wound infection in a manner that does not kill or damage the microorganisms (for example, by actively binding and removing intact microorganisms from wounds) were then narratively reviewed.

RESULTS

The evidence reviewed here demonstrates that using bacterial-binding wound dressings that act in a physical manner (for example, DACC-coated dressings) as an alternative approach to preventing and/or treating infection in both acute and hard-to-heal wounds does not exacerbate AMR and supports AMS.

CONCLUSION

Some wound dressings work via a mechanism that promotes the binding and physical uptake, sequestration and removal of intact microorganisms from the wound bed (for example, a wound dressing that uses DACC technology to successfully prevent/reduce infection). They provide a valuable tool that aligns with the requirements of AMS (for example, reducing the use of antimicrobials in wound treatment regimens) by effectively reducing wound bioburden without inducing/selecting for resistant bacteria.

The role of dalbavancin for Gram positive infections in the COVID-19 era: state of the art and future perspectives

INTRODUCTION

The COVID-19 pandemic has dramatically challenged the national health systems worldwide in the last months. Dalbavancin is a novel antibiotic with a long plasmatic half-life and simplified weekly administration regimens, thus representing a promising option for the outpatient treatment of Gram-positive infections and the early discharge of hospitalized patients. Dalbavancin is approved for the treatment of acute bacterial skin and skin structure infections (ABSSSIs). Many preliminary data seem to support its use in other indications, such as osteomyelitis, prosthetic joint infections, and infective endocarditis.

AREAS COVERED

A search in the literature using validated keywords (dalbavancin, Gram-positive infections, Gram-positive cocci, ABSSSI, intravenous treatment, and long-acting antibiotics) was conducted on biomedical bibliographic databases (PubMed and Embase) from 2004 to 30 September 2020. Results were analyzed during two consensus conferences with the aim to review the current evidence on dalbavancin in Gram-positive infections, mainly ABSSSI, osteomyelitis, and infective endocarditis, highlight the main limitations of available studies and suggest possible advantages of the molecule.

EXPERT OPINION

The board identifies some specific subgroups of patients with ABSSSIs who could mostly benefit from a treatment with dalbavancin and agrees that the design of homogenous and robust studies would allow a broader use of dalbavancin even in other clinical settings.