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Vazquez-Colon Z, Marcus JE, Levy E, Shah A, MacLaren G, Peek G. Infectious diseases and infection control prevention strategies in adult and pediatric population on ECMO. Perfusion 2024:2676591241249612. [PMID: 38860785 DOI: 10.1177/02676591241249612] [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: 06/12/2024]
Abstract
As survival after ECMO improves and use of ECMO support increases in both pediatric and adult population, there is a need to focus on both the morbidities and complications associated with ECMO and how to manage and prevent them. Infectious complications during ECMO often have a significant clinical impact, resulting in increased morbidity or mortality irrespective of the underlying etiology necessitating cardiorespiratory support. In this review article, we discuss the prevention, management, challenges, and differences of infectious complications in adult and pediatric patients receiving ECMO support.
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Affiliation(s)
- Zasha Vazquez-Colon
- Congenital Heart Center, Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Joseph E Marcus
- Infectious Diseases Services, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, TX, USA
- Department of Medicine, Uniformed Services University, Bethesda, MD
| | - Emily Levy
- Divisions of Pediatric Infectious Diseases and Pediatric Critical Care Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aditya Shah
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Hospital, Singapore
- Antimicrobial Stewardship Program, Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore
| | - Giles Peek
- Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, FL, USA
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Seidelman JL, Moehring R, Gettler E, Krishnan J, McGugan L, Jordan R, Murphy M, Pena H, Polage CR, Alame D, Lewis S, Smith B, Anderson D, Mehdiratta N. Implementation of a diagnostic stewardship intervention to improve blood-culture utilization in 2 surgical ICUs: Time for a blood-culture change. Infect Control Hosp Epidemiol 2024; 45:452-458. [PMID: 38073558 PMCID: PMC11007355 DOI: 10.1017/ice.2023.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/25/2023] [Accepted: 10/11/2023] [Indexed: 04/10/2024]
Abstract
OBJECTIVE We compared the number of blood-culture events before and after the introduction of a blood-culture algorithm and provider feedback. Secondary objectives were the comparison of blood-culture positivity and negative safety signals before and after the intervention. DESIGN Prospective cohort design. SETTING Two surgical intensive care units (ICUs): general and trauma surgery and cardiothoracic surgery. PATIENTS Patients aged ≥18 years and admitted to the ICU at the time of the blood-culture event. METHODS We used an interrupted time series to compare rates of blood-culture events (ie, blood-culture events per 1,000 patient days) before and after the algorithm implementation with weekly provider feedback. RESULTS The blood-culture event rate decreased from 100 to 55 blood-culture events per 1,000 patient days in the general surgery and trauma ICU (72% reduction; incidence rate ratio [IRR], 0.38; 95% confidence interval [CI], 0.32-0.46; P < .01) and from 102 to 77 blood-culture events per 1,000 patient days in the cardiothoracic surgery ICU (55% reduction; IRR, 0.45; 95% CI, 0.39-0.52; P < .01). We did not observe any differences in average monthly antibiotic days of therapy, mortality, or readmissions between the pre- and postintervention periods. CONCLUSIONS We implemented a blood-culture algorithm with data feedback in 2 surgical ICUs, and we observed significant decreases in the rates of blood-culture events without an increase in negative safety signals, including ICU length of stay, mortality, antibiotic use, or readmissions.
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Affiliation(s)
- Jessica L. Seidelman
- Duke Center for Antimicrobial Stewardship and Infection Prevention Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
| | - Rebekah Moehring
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
| | - Erin Gettler
- Duke Center for Antimicrobial Stewardship and Infection Prevention Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
| | - Jay Krishnan
- Duke Center for Antimicrobial Stewardship and Infection Prevention Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
| | - Lynn McGugan
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Rachel Jordan
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Margaret Murphy
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Heather Pena
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Diana Alame
- Department of Pathology, Duke University School of Medicine, Durham, North Carolina
| | - Sarah Lewis
- Duke Center for Antimicrobial Stewardship and Infection Prevention Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
| | - Becky Smith
- Duke Center for Antimicrobial Stewardship and Infection Prevention Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
| | - Deverick Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina
| | - Nitin Mehdiratta
- Department of Anesthesiology, Division of Anesthesia Critical Care and GVT, Duke University School of Medicine, Durham, North Carolina
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Reddy P. Clinical Approach to Nosocomial Bacterial Sepsis. Cureus 2022; 14:e28601. [PMID: 36185840 PMCID: PMC9521889 DOI: 10.7759/cureus.28601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 08/21/2022] [Indexed: 11/22/2022] Open
Abstract
Bacterial sepsis and septic shock are associated with a high mortality, and when clinically suspected, clinicians must initiate broad-spectrum antimicrobials within the first hour of diagnosis. Thorough review of prior cultures involving multidrug-resistant (MDR) pathogens along with other likely pathogens should be performed to provide an appropriate broad-spectrum empiric antibiotic coverage. The appropriate antibiotic loading dose followed by individualized modification of maintenance dose should be implemented based on the presence of hepatic or renal dysfunction. Use of procalcitonin is no longer recommended to determine need for initial antibacterial therapy and for de-escalation. Daily reevaluation of appropriateness of treatment is necessary based on the culture results and clinical response. All positive cultures should be carefully screened for possible contamination or colonization, which may not represent the true organism causing the sepsis. Culture negative sepsis accounts for one-half of all cases, and de-escalation of initial antibiotic regimen should be done gradually in these patients with close monitoring.
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Patient-specific risk factors contributing to blood culture contamination. ANTIMICROBIAL STEWARDSHIP AND HEALTHCARE EPIDEMIOLOGY 2022; 2:e46. [PMID: 36310794 PMCID: PMC9614848 DOI: 10.1017/ash.2022.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/15/2022] [Accepted: 01/18/2022] [Indexed: 11/11/2022]
Abstract
Objective: Contaminated blood cultures result in extended hospital stays and unnecessary antibiotic therapy. Patient-specific factors associated with blood culture contamination remain largely unexplored. Identifying patients at higher risk of blood culture contamination could alert healthcare providers to take extra precautionary measures to limit contamination in these patients, and thereby prevent associated adverse outcomes. We sought to identify patient-related factors that contribute to blood culture contamination in hospitalized patients. Design and setting: We conducted a secondary data analysis of a retrospective cohort study at an academic medical center. Patients: Study participants included 19,255 adult patients who had blood culture(s) performed during a hospital admission between June 2014 and December 2016. Methods: Data were analyzed to evaluate risk factors for blood culture contamination using logistic regression. Results: Among adult patients, we identified 464 contaminated episodes and 11,010 negative blood-culture episodes. Chronic obstructive pulmonary disease (adjusted odds ratio [AOR], 1.67; 95% confidence interval [CI], 1.20–2.34) and stay in an intensive care unit (ICU) during an admission (AOR, 1.41; 95% CI, 1.14–1.74) were associated with blood culture contamination. Other risk factors included race, body mass index, and admission from the emergency department. Subgroup analyses of patients admitted from the emergency department showed similar results. Conclusions: We identified patient-specific factors that increase the odds of false-positive blood cultures. By introducing mitigation strategies to limit contamination in patients with these risk factors, it may be possible to reduce the adverse clinical impact of blood culture contamination.
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Angell KE, Lawler JV, Hewlett AL, Rupp ME, Bergman SJ, Van Schooneveld TC, Broadhurst MJ, Brett-Major DM. Antibacterial use in the age of SARS-CoV-2. JAC Antimicrob Resist 2021; 3:dlab073. [PMID: 34223134 PMCID: PMC8210028 DOI: 10.1093/jacamr/dlab073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/23/2021] [Indexed: 01/28/2023] Open
Abstract
Background Balancing the use of antibacterial therapy against selection for resistance in this pandemic era has introduced both questions and guidelines. In this project, we explored how prescription of empirical antibacterial therapy differs between those with and without SARS-CoV-2 infection. Methods Multivariable logistic regression was used to determine whether COVID-19 status and other factors play a role in the prescription of antibacterial therapy in an inpatient setting at a large referral academic medical centre. Further analysis was conducted to determine whether these factors differ between those testing positive and negative for SARS-CoV-2. Results Of 405 patients in the cohort, 175 received antibacterial therapy and 296 tested positive for SARS-CoV-2. A positive SARS-CoV-2 test carried an OR of 0.3 (95% CI: 0.19, 0.49) for receiving antibacterial treatment in the first 48 h after admission (P < 0.0001) adjusting for age and procalcitonin results. Patients were 1% and 3% less likely to receive antibacterials for every year increase in age in the overall group and among those testing negative for SARS-CoV-2, respectively. Younger age was found to impact use of antibacterial therapy in both the overall analysis as well as the SARS-CoV-2 negative subgroup (P = 0.03 and P = 0.01). High procalcitonin values were found to be associated with increased antibacterial therapy use in both the overall and stratified analyses. Conclusions Antibacterial therapy prescription differs by COVID-19 disease status, and procalcitonin results are most highly associated with antibacterial use across strata.
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Affiliation(s)
- Kathleen E Angell
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA
| | - James V Lawler
- Global Center for Health Security, University of Nebraska Medical Center, Omaha, NE, USA.,Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Angela L Hewlett
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mark E Rupp
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Scott J Bergman
- Antimicrobial Stewardship Program, Nebraska Medicine, Omaha, NE, USA
| | - Trevor C Van Schooneveld
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - M Jana Broadhurst
- Global Center for Health Security, University of Nebraska Medical Center, Omaha, NE, USA.,Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - David M Brett-Major
- Department of Epidemiology, College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA.,Global Center for Health Security, University of Nebraska Medical Center, Omaha, NE, USA
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