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Zimmet AN, Ha D, Mui E, Smith M, Hawkins M, Alegria W, Holubar M. "Electronic Phenotyping" Antimicrobials to Facilitate Outpatient Stewardship for Asymptomatic Bacteriuria and Urinary Tract Infection in Renal Transplant. Open Forum Infect Dis 2024; 11:ofae119. [PMID: 38533270 PMCID: PMC10964979 DOI: 10.1093/ofid/ofae119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/13/2024] [Indexed: 03/28/2024] Open
Abstract
Asymptomatic bacteriuria and urinary tract infection in renal transplant are important antimicrobial stewardship targets but are difficult to identify within electronic medical records. We validated an "electronic phenotype" of antibacterials prescribed for these indications. This may be more useful than billing data in assessing antibiotic indication in this outpatient setting.
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Affiliation(s)
- Alex N Zimmet
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, CA, USA
| | - David Ha
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, CA, USA
| | - Emily Mui
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, CA, USA
| | - Mary Smith
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, CA, USA
| | - Marten Hawkins
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, CA, USA
| | - William Alegria
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, CA, USA
| | - Marisa Holubar
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Antimicrobial Safety and Sustainability Program, Stanford Health Care, Stanford, CA, USA
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Tsai H, Bartash R, Burack D, Swaminathan N, So M. Bring it on again: antimicrobial stewardship in transplant infectious diseases: updates and new challenges. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e3. [PMID: 38234416 PMCID: PMC10789986 DOI: 10.1017/ash.2023.517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/12/2023] [Accepted: 11/13/2023] [Indexed: 01/19/2024]
Abstract
Advancement in solid organ transplantation and hematopoietic stem cell transplant continues to improve the health outcomes of patients and widens the number of eligible patients who can benefit from the medical progress. Preserving the effectiveness of antimicrobials remains crucial, as otherwise transplant surgeries would be unsafe due to surgical site infections, and the risk of sepsis with neutropenia would preclude stem cell transplant. In this review, we provide updates on three previously discussed stewardship challenges: febrile neutropenia, Clostridioides difficile infection, and asymptomatic bacteriuria. We also offer insight into four new stewardship challenges: the applicability of the "shorter is better" paradigm shift to antimicrobial duration; antibiotic allergy delabeling and desensitization; colonization with multidrug-resistant gram-negative organisms; and management of cytomegalovirus infections. Specifically, data are accumulating for "shorter is better" and antibiotic allergy delabeling in transplant patients, following successes in the general population. Unique to transplant patients are the impact of multidrug-resistant organism colonization on clinical decision-making of antibiotic prophylaxis in transplant procedure and the need for antiviral stewardship in cytomegalovirus. We highlighted the expansion of antimicrobial stewardship interventions as potential solutions for these challenges, as well as gaps in knowledge and opportunities for further research.
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Affiliation(s)
- Helen Tsai
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rachel Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Daniel Burack
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Neeraja Swaminathan
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Miranda So
- Sinai Health-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, ON, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
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Bork JT, Heil EL. What Is Left to Tackle in Inpatient Antimicrobial Stewardship Practice and Research. Infect Dis Clin North Am 2023; 37:901-915. [PMID: 37586930 DOI: 10.1016/j.idc.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Despite widespread uptake of antimicrobial stewardship in acute care hospitals, there is ongoing need for innovation and optimization of ASPs. This article discusses current antimicrobial stewardship practice challenges and ways to improve current antimicrobial stewardship workflows. Additionally, we propose new workflows that further engage front line clinicians in optimizing their own antibiotic decision making.
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Affiliation(s)
- Jacqueline T Bork
- Division of Infectious Diseases, Institute of Human Virology in the Department of Medicine, University of Maryland, School of Medicine, 22 S Greene Street, Baltimore, MD 21201, USA
| | - Emily L Heil
- Department of Practice, Sciences, and Health-Outcomes Research, University of Maryland, School of Pharmacy, 20 N Pine Street, Baltimore, MD 21201, USA.
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Silva JT, Montoro J, Pérez-Jacoiste Asín MA, Fernández-Ruiz M, Polanco N, González E, Caro-Teller JM, Andrés A, Aguado JM, López-Medrano F. A joint program of antimicrobial stewardship and hospital-acquired infection control to reduce healthcare-associated infections after kidney transplantation: The Hipomenes study. Am J Transplant 2023; 23:1949-1960. [PMID: 37479034 DOI: 10.1016/j.ajt.2023.07.009] [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: 02/13/2023] [Revised: 06/28/2023] [Accepted: 07/13/2023] [Indexed: 07/23/2023]
Abstract
Infection is a common complication in kidney transplant recipients (KTRs). The usefulness of antimicrobial stewardship programs (ASP) and hospital-acquired infection control (HAIC) initiatives in the general inpatient population is well established. We performed a quasi-experimental study to evaluate a joint ASP/HAIC initiative focused on KTRs. A dedicated ASP team optimized antimicrobial prescriptions in consecutive KTRs during the intervention period (June 2015-March 2016). A multifaceted, evidence-based HAIC program was concurrently implemented. Results were compared with the preceding period (June 2014-March 2015). We included 96 and 100 KTRs in the intervention and preintervention periods, respectively. There was a reduction in the consumption of meropenem (rate ratio [RR]: 0.63; 95% confidence interval [CI]: 0.53-0.75; P <.0001), ceftazidime (RR: 0.31; 95% CI: 0.21-0.45; P <.0001), vancomycin (RR: 0.65; 95% CI: 0.53-0.8; P <.0001), and ciprofloxacin (RR: 0.66; 95% CI: 0.55-0.81; P <.0001) and an increase of fosfomycin (RR: 1.80; 95% CI: 1.17-2.76; P =.008) during the intervention period. The incidence of cystitis (RR: 0.30; 95% CI: 0.28-0.33; P <.001) and upper urinary tract infection (RR: 0.56; 95% CI: 0.33-0.95; P =.04) decreased. A specific ASP/HAIC initiative was effective in optimizing antimicrobial use and reducing the incidence of common bacterial infections among KTRs.
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Affiliation(s)
- José Tiago Silva
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Antimicrobial Stewardship Team in Hospitalized Patients, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | - Juan Montoro
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | | | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; School of Medicine, Universidad Complutense, Madrid, Spain
| | - Natalia Polanco
- Department of Nephrology, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | - Esther González
- Department of Nephrology, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | - José Manuel Caro-Teller
- Antimicrobial Stewardship Team in Hospitalized Patients, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Department of Pharmacy, University Hospital "12 de Octubre", Madrid, Spain
| | - Amado Andrés
- School of Medicine, Universidad Complutense, Madrid, Spain; Department of Nephrology, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; School of Medicine, Universidad Complutense, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; School of Medicine, Universidad Complutense, Madrid, Spain.
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Stangl FP, Godly J, Kranz J, Neumann T, Schneidewind L. [Do we need to treat asymptomatic bacteriuria in immunocompromised patients? : A rapid review]. UROLOGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00120-023-02059-8. [PMID: 36941381 DOI: 10.1007/s00120-023-02059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Antimicrobial resistance (AMR), especially multidrug resistant Escherichia coli strains, is a problem even in Europe. That is why inadequate usage of antibiotic therapy should be avoided, especially in the treatment of asymptomatic bacteriuria (ASB). OBJECTIVES Should ASB be treated with antibiotics in immunocompromized patients, namely solid organ transplant, especially kidney transplant or stem cell transplant recipients? MATERIALS AND METHODS A rapid review based on a systematic literature search in MEDLINE between 1980 and 2022 was performed. For evidence synthesis, only randomized controlled trials (RCTs) or quasi-RCTs were considered. RESULTS No studies were identified for the search term solid organ and stem cell transplantation. Three RCTs (antibiotic therapy versus no therapy) were included for adult kidney transplantation. None of the studies showed a benefit for antibiotic therapy of ASB in reduction of symptomatic urinary tract infections, especially in the late transplantation phase two months after kidney transplantation; furthermore, this therapy may promote AMR development. In addition, there are numerous gaps of evidence, e.g., in pediatric transplantation or regarding the influence of special immunosuppressants. CONCLUSION There is no evidence for antibiotic therapy of ASB in adult kidney transplantation two months after the surgery. Further studies addressing the identified evidence gaps are essential for the prevention of further AMR development.
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Affiliation(s)
- Fabian P Stangl
- Universitätsklinik für Urologie, Inselspital Bern, Bern, Schweiz
| | - Julia Godly
- Universitätsklinik für Urologie, Inselspital Bern, Bern, Schweiz
| | - Jennifer Kranz
- Klinik für Urologie und Kinderurologie, Uniklinik RWTH Aachen, Aachen, Deutschland
- Universitätsklinik und Poliklinik für Urologie, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - Thomas Neumann
- Klinik für Innere Medizin C, Universitätsmedizin Greifswald, Greifswald, Deutschland
| | - Laila Schneidewind
- Urologische Klinik und Poliklinik, Universitätsmedizin Rostock, Schillingallee 35, 18055, Rostock, Deutschland.
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So M, Nakamachi Y, Thursky K. Auditing tools for antimicrobial prescribing in solid organ transplant recipients: The why, the how, and an assessment of current options. Transpl Infect Dis 2022; 24:e13905. [DOI: 10.1111/tid.13905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/17/2022] [Accepted: 06/29/2022] [Indexed: 01/15/2023]
Affiliation(s)
- Miranda So
- Sinai Health‐University Health Network Antimicrobial Stewardship Program, University Health Network Toronto Ontario Canada
- Leslie Dan Faculty of Pharmacy University of Toronto Toronto Ontario Canada
| | - Yoshiko Nakamachi
- Sinai Health‐University Health Network Antimicrobial Stewardship Program, University Health Network Toronto Ontario Canada
| | - Karin Thursky
- National Centre for Antimicrobial Stewardship, Peter Doherty Institute for Infection and Immunity University of Melbourne Melbourne Victoria Australia
- Royal Melbourne Hospital Melbourne Victoria Australia
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