Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients

Getting rapid diagnostic test data into the appropriate hands by leveraging pharmacy staff and a clinical surveillance platform: a case study from a US community hospital

OBJECTIVES

To outline the procedural implementation and optimization of rapid diagnostic test (RDT) results for bloodstream infections (BSIs) and to evaluate the combination of RDTs with real-time antimicrobial stewardship team (AST) support plus clinical surveillance platform (CSP) software on time to appropriate therapy in BSIs at a single health system.

METHODS

Blood culture reporting and communication were reported for four time periods: (i) a pre-BCID [BioFire® FilmArray® Blood Culture Identification (BCID) Panel] implementation period that consisted of literature review and blood culture notification procedure revision; (ii) a BCID implementation period that consisted of BCID implementation, real-time results notification via CSP, and creation of a treatment algorithm; (iii) a post-BCID implementation period; and (iv) a BCID2 implementation period. Time to appropriate therapy metrics was reported for the BCID2 time period.

RESULTS

The mean time from BCID2 result to administration of effective antibiotics was 1.2 h (range 0-7.9 h) and time to optimal therapy was 7.6 h (range 0-113.8 h) during the BCID2 Panel implementation period. When comparing time to optimal antibiotic administration among patients growing ceftriaxone-resistant Enterobacterales, the BCID2 Panel group (mean 2.8 h) was significantly faster than the post-BCID Panel group (17.7 h; P = 0.0041).

CONCLUSIONS

Challenges exist in communicating results to the appropriate personnel on the healthcare team who have the knowledge to act on these data and prescribe targeted therapy against the pathogen(s) identified. In this report, we outline the procedures for telephonic communication and CSP support that were implemented at our health system to distribute RDT data to individuals capable of assessing results, enabling timely optimization of antimicrobial therapy.

Bloodstream infections due to multi-drug resistant bacteria in the emergency department: prevalence, risk factors and outcomes-a retrospective observational study

Multidrug-resistant organisms (MDROs) are prevalent in patients admitted to the Emergency Department (ED) and increase the risk of inappropriate empirical antibiotic therapy. Risk stratification for MDRO infection is essential to early identify patients requiring empirical broad-spectrum antibiotic therapy, but it remains challenging for emergency physicians. This study aimed to evaluate prevalence, risk factors, and outcomes of patients admitted to the ED with a bloodstream infection (BSI) caused by MDROs. A retrospective observational study enrolling all consecutive adult patients admitted with a BSI to the ED of Niguarda Hospital, Italy, from January 2019 to December 2021 was performed. 757 patients were enrolled, 14.1% with septic shock. 156 (20%) patients had a BSI caused by MDRO: extended-spectrum beta-lactamase (ESBL) producing Enterobacterales were the most prevalent followed by methicillin-resistant Staphylococcus aureus (MRSA). Risk factors for BSI due to MDRO and specifically for ESBL were chronic renal failure (OR 2.2; 95%CI 1.4-3.6), nursing home residency (OR 4.4; 95%CI 1.9-10.2) and antibiotic therapy in the last 90-days (OR 2.6; 95%CI 1.7-4), whereas for MRSA were dialysis (OR 12.3; 95%CI 1.8-83), antibiotic therapy and/or hospital admission in the past 90-days (OR 3.6; 95%CI 1.2-10.6) and ureteral stent or nephrostomy (OR 7.8; 95%CI 1.5-40.9). Patients with BSI due to MDRO had a higher rate of inappropriate empirical antibiotic therapy (50%) and longer length of stay, but no higher in-hospital mortality. Among patients admitted to the ED with a BSI, MDROs are frequent and often associated with inappropriate empirical antibiotic therapy. Specific updated risk factors for MDRO may help clinicians to better identify patients requiring a broader antibiotic therapy in the ED, while awaiting microbiological results.

Early identification of suspected serious infection among patients afebrile at initial presentation using neural network models and natural language processing: A development and external validation study in the emergency department

OBJECTIVE

To develop and externally validate models based on neural networks and natural language processing (NLP) to identify suspected serious infections in emergency department (ED) patients afebrile at initial presentation.

METHODS

This retrospective study included adults who visited the ED afebrile at initial presentation. We developed four models based on artificial neural networks to identify suspected serious infection. Patient demographics, vital signs, laboratory test results and information extracted from initial ED physician notes using term frequency-inverse document frequency were used as model variables. Models were trained and internally validated with data from one hospital and externally validated using data from a different hospital. Model discrimination was evaluated using area under the receiver operating characteristic curve (AUC) and 95% confidence intervals (CIs).

RESULTS

The training, internal validation, and external validation datasets comprised 150,699, 37,675, and 85,098 patients, respectively. The AUCs (95% CIs) for Models 1 (demographics + vital signs), 2 (demographics + vital signs + initial ED physician note), 3 (demographics + vital signs + laboratory tests), and 4 (demographics + vital signs + laboratory tests + initial ED physician note) in the internal validation dataset were 0.789 (0.782-0.796), 0.867 (0.862-0.872), 0.881 (0.876-0.887), and 0.911 (0.906-0.915), respectively. In the external validation dataset, the AUCs (95% CIs) of Models 1, 2, 3, and 4 were 0.824 (0.817-0.830), 0.895 (0.890-0.899), 0.879 (0.873-0.884), and 0.913 (0.909-0.917), respectively. Model 1 can be utilized immediately after ED triage, Model 2 can be utilized after the initial physician notes are recorded (median time from ED triage: 28 min), and Models 3 and 4 can be utilized after the initial laboratory tests are reported (median time from ED triage: 68 min).

CONCLUSIONS

We developed and validated models to identify suspected serious infection in the ED. Extracted information from initial ED physician notes using NLP contributed to increased model performance, permitting identification of suspected serious infection at early stages of ED visits.

Implementation of a quality improvement strategy to optimise the management of community acquired pneumonia in a rural health setting

PROBLEM

In Australia, inappropriate prescribing of antimicrobials is higher in rural and regional areas than in major city hospitals. Inappropriate prescribing is defined as the prescription of antimicrobial agents that do not adhere to guidelines in terms of type of antimicrobial chosen, dose and/or duration or are deemed unnecessary. A review of antimicrobial prescribing in a Queensland rural Hospital and Health Service (HHS) identified that respiratory infections were an area for potential improvement.

SETTING

The study was performed in a rural HHS in Queensland.

KEY MEASURES FOR IMPROVEMENT

Appropriateness of antimicrobial prescribing for baseline and post-implementation phases of the study was evaluated according to Therapeutic Guidelines: antibiotic recommendations for community acquired pneumonia (CAP).

STRATEGIES FOR CHANGE

Quality improvement strategy to implement a multifaceted package of interventions for CAP.

EFFECTS OF CHANGE

Post-implementation, overall appropriateness of antimicrobial prescribing improved and there was a decrease in duration of antimicrobial therapy.

LESSONS LEARNT

A quality improvement strategy to implement a multifaceted package of interventions for CAP has shown to be acceptable and effective in improving the antimicrobial prescribing in a rural setting. Our findings highlight the importance of utilising a multifaceted package of interventions which can be tailored to the prescribers and the patients at hand. It is also valuable to engage with local clinicians to promote the optimal management of common infections in the rural setting.

Impact of inadequate empirical antibiotic treatment on outcome of non-critically ill children with bacterial infections

BACKGROUND

The impact of inadequate empirical antibiotic treatment on patient outcomes and hospitalization duration for non-life-threatening infections in children remains poorly understood. We aimed to assess the effects of inadequate empirical antibiotic treatment on these factors in pediatric patients.

METHODS

The medical records of children admitted for infectious diseases with bacteria isolated from sterile sites between 2018 and 2020 were retrospectively reviewed. Patients who received adequate empirical treatment were compared with those who received inadequate treatment in terms of demographic, clinical, and laboratory variables.

RESULTS

Forty-eight patients who received inadequate empirical antimicrobial treatment were compared to 143 patients who received adequate empirical treatment. Inadequate empirical antimicrobial treatment did not significantly affect the length of hospital stay or the incidence of complications in non-critically ill children with bacterial infections. Younger age and underlying renal abnormalities were identified as risk factors for inadequate antimicrobial treatment, while associated bacteremia was more common in the adequate antimicrobial treatment group.

CONCLUSIONS

inadequate antibiotic treatment did not affect the outcomes of non-critically ill children with bacterial infectious diseases. Therefore, routine empirical broad-spectrum treatment may not be necessary for these cases, as it can lead to additional costs and contribute to antibiotic resistance. Larger prospective studies are needed to confirm these findings.

Surveillance and Resistance of Community-Onset Extended-Spectrum β-Lactamase-Producing Escherichia coli and Klebsiella pneumonia in Oral and Maxillofacial Surgery Site Infections

Background: The prevalence of community-onset infections of extended spectrum β-lactamase (ESBL)-producing strains has increased globally, yet surveillance and resistance in patients with oral and maxillofacial surgery site infections is less investigated. Patients and Methods: A retrospective cohort study was performed to investigate risk factors and resistance of ESBL-producing Escherichia coli (ESBL-EC) and ESBL-producing Klebsiella pneumonia (ESBL-KP) among community-onset patients with oral and maxillofacial surgery during January 2010 to December 2016. Demographic features, predisposing factors, clinical outcomes, and antibiotic agent costs were analyzed. Antimicrobial susceptibility testing of nine antimicrobial agents against ESBL-KP and ESBL-EC were measured. Results: Among 2,183 cultures from infection sites in patients with oral and maxillofacial surgery site (45 cases [2.06%]) were confirmed with community-onset ESBL-KP (24; 1.10%) or ESBL-EC (21; 0.96%) infection. Multivariable analysis showed the independent risk factors for ESBL-producing bacterial infection were prior history of hospitalization (adjusted odds ratio [aOR], 10.984; 95% confidence interval [CI], 5.965-59.879; p = 0.025) and malignant condition (aOR, 3.373; 95% CI 2.947-7.634; p = 0.024). Based on antimicrobial susceptibility testing, 57.8% ESBL-KP and ESBL-EC were found receiving inappropriate antimicrobial therapy, and antibiotic agent costs were higher than non-ESBL-producing bacterial infections ($493.8 ± $367.3 vs. $304.1 ± $334.7; p = 0.031). Conclusions: Infections caused by ESBL-KP and ESBL-EC among patients in sites with oral and maxillofacial surgery are associated with prior history of hospitalization and malignant conditions. Prompt detection and appropriate antibiotic administration for community-onset infections of ESBLs are necessary for such populations.

Risk factors for prolonged length of stay after first single-level lumbar microdiscectomy

OBJECTIVE

The objective is to identify risk factors that potentially prolong the hospital stay in patients after undergoing first single-level open lumbar microdiscectomy.

METHODS

A retrospective single-centre study was conducted. Demographic data, medical records, intraoperative course, and imaging studies were analysed. The outcome measure was defined by the number of days stayed after the operation. A prolonged length of stay (LOS) stay was defined as a minimum of one additional day beyond the median hospital stay in our patient collective. Bivariate analysis and multiple stepwise regression were used to identify independent factors related to the prolonged hospital stay.

RESULTS

Two hundred consecutive patients who underwent first lumbar microdiscectomy between 2018 and 2022 at our clinic were included in this study. Statistical analysis of factors potentially prolonging postoperative hospital stay was done for a total of 24 factors, seven of them were significantly related to prolonged LOS in bivariate analysis. Sex (p = 0.002, median 5 vs. 4 days for females vs. males) and age (rs = 0.35, p ≤ 0.001, N = 200) were identified among the examined demographic factors. Regarding preoperative physical status, preoperative immobility reached statistical significance (p ≤ 0.001, median 5 vs. 4 days). Diabetes mellitus (p = 0.043, median 5 vs. 4 days), anticoagulation and/or antiplatelet agents (p = 0.045, median 5 vs. 4 days), and postoperative narcotic consumption (p ≤ 0.001, median 5 vs. 4 days) as comorbidities were associated with a prolonged hospital stay. Performance of nucleotomy (p = 0.023, median 5 vs. 4 days) was a significant intraoperative factor. After linear stepwise multivariable regression, only preoperative immobility (p ≤ 0.001) was identified as independent risk factors for prolonged length of postoperative hospital stay.

CONCLUSION

Our study identified preoperative immobility as a significant predictor of prolonged hospital stay, highlighting its value in preoperative assessments and as a tool to pinpoint at-risk patients. Prospective clinical trials with detailed assessment of mobility, including grading, need to be done to verify our results.

Is administration of anti-MRSA drugs recommended for patients with pneumonia when MRSA is isolated from respiratory specimens? A systematic review and meta-analysis

It is unclear whether anti-methicillin-resistant Staphylococcus aureus (MRSA) drugs should be uniformly administered to patients with pneumonia when MRSA is isolated from respiratory specimens. A systematic review was conducted to evaluate the efficacy of the uniform administration of anti-MRSA drugs. Two researchers independently searched the literature as of December 2022, extracted relevant papers, and performed a meta-analysis. The outcomes were mortality and adverse events. No applicable randomized controlled trials were found during the study period, but four observational studies were extracted. The relative risk of mortality in the anti-MRSA group was 1.67 [95% confidence interval 0.65-4.30], which did not differ significantly from the non-administered group. Further investigation into the background of patients demonstrated that anti-MRSA drugs were administered to groups in which only MRSA was cultured. However, the pneumonia severity index did not differ from that in the non-treated group. No studies of adverse events were found. Our review did not find a beneficial contribution to mortality from uniform anti-MRSA medication to patients with pneumonia when MRSA was isolated from respiratory specimens. Factors determining risk-based individualized treatment should be validated as the future question.

Predictive models for sepsis in children with Staphylococcus aureus bloodstream infections: a retrospective cohort study

BACKGROUND

The presence of Staphylococcus aureus in the bloodstream can lead to the development of sepsis; however, the severity and risk factors of the systemic inflammatory response to Staphylococcus aureus bloodstream infections were unclear. This study is aimed to build a model to predict the risk of sepsis in children with Staphylococcus aureus bloodstream infections.

METHODS

A retrospective analysis of hospitalized pediatric patients diagnosed with Staphylococcus aureus bloodstream infections was performed between January 2013 and December 2019. Each patient was assessed using the pediatric version of the Sequential Organ Failure Assessment score (pSOFA) within 24 h of blood culture collection. A nomogram based on logistic regression models was constructed to predict the risk factors for sepsis in children with Staphylococcus aureus bloodstream infections. It was validated using the area under the receiver-operating characteristic curve (AUC).

RESULTS

Of the 94 patients included in the study, 35 cases (37.2%) developed sepsis. The pSOFA scores ranged from 0 to 8, with 35 patients having a pSOFA score of ≥ 2. Six children (6.4%) died within 30 days, who were all from the sepsis group and had different pSOFA scores. The most common organs involved in sepsis in children with staphylococcal bloodstream infections were the neurologic system (68.6%), respiratory system (48.6%), and coagulation system (45.7%). Hospital-acquired infections (adjusted odds ratio [aOR], 3.0; 95% confidence interval [CI], 1.3-7.2), implanted catheters (aOR, 10.4; 95% CI, 3.8-28.4), procalcitonin level ≥ 1.7 ng/mL (aOR, 15.4; 95% CI, 2.7-87.1), and underlying diseases, especially gastrointestinal malformations (aOR, 14.0; 95% CI, 2.9-66.7) were associated with Staphylococcus aureus sepsis. However, methicillin-resistant Staphylococcus aureus infection was not a risk factor for sepsis. The nomogram had high predictive accuracy for the estimation of sepsis risk, with an AUC of 0.85.

CONCLUSIONS

We developed a predictive model for sepsis in children with Staphylococcus aureus infection.

Impact of empiric antibiotic therapy on the clinical outcome of acute calculous cholecystitis

PURPOSE

Although mortality and morbidity of severe acute calculous cholecystitis (ACC) are still a matter of concern, the impact of inadequate empirical antibiotic therapy has been poorly studied as a risk factor. The objective was to assess the impact of the adequacy of empirical antibiotic therapy on complication and mortality rates in ACC.

METHODS

This observational retrospective cohort chart-based single-center study was conducted between 2012 and 2016. A total of 963 consecutive patients were included, and pure ACC was selected. General, clinical, postoperative, and microbiological variables were collected, and risk factors and consequences of inadequate treatment were analyzed.

RESULTS

Bile, blood, and/or exudate cultures were obtained in 76.3% of patients, more often in old, male, and severely ill patients (P < 0.001). Patients who were cultured had a higher overall rate of postoperative complications (47.4% vs. 29.7%; P < 0.001), as well as of severe complications (11.6% vs. 4.7%; P = 0.008). Patients with positive cultures had more overall complications (54.8% vs. 39.6%; P = 0.001), more severe complications (16.3% vs. 6.7%; P = 0.001), and higher mortality rates (6% vs. 1.9%; P = 0.012). Patients who received inadequate empirical antibiotic therapy had a fourfold higher mortality rate than those receiving adequate therapy (n = 283; 12.8% vs. 3.4%; P = 0.003). This association was especially marked in severe ACC TG-III patients (n = 132; 18.2 vs. 5.1%; P = 0.018) and remained a predictor of mortality in a binary logistic regression (OR 4.4; 95% CI 1.3-15.3).

CONCLUSION

Patients with positive cultures developed more complications and faced higher mortality. Adequate empirical antibiotic therapy appears to be of paramount importance in ACC, particularly in severely ill patients.

Antimicrobial action of four herbal plants over mixed-species biofilms of Candida albicans with four different microorganisms

This study aimed to evaluate the antimicrobial effect of four herbal plants glycolic extracts over mixed-species biofilm composed of Candida albicans (C. albicans) and another pathogenic bacterium as alternative therapy to be investigated. Four plants extract of Pfaffia paniculata roots; Hamamelis virginiana leaf, Stryphnodendron barbatiman tree bark and Gymnema sylvestre stem and leaves were tested over multi-species biofilm of C. albicans (ATCC 18804) and Streptococcus mutans (ATCC 35688), Staphylococcus aureus (ATCC 6538), Enterococcus faecalis (ATCC 4083) or Pseudomonas aeruginosa (ATCC 15442) for 5 min and 24 h and colony forming units per millilitre was calculated. The data were analysed using Kruskal-Wallis with Dunn's test (p ≤ 0.05). All tested extracts showed antimicrobial action over the mixed-species biofilms after 24 h. Some extracts eliminated totally the biofilms. The glycolic extract of P. paniculata, H. virginiana, S. barbatiman and G. sylvestre are effective over mixed-species biofilms and may be indicated as endodontic irrigant or intracanal medication.

Cefto Real-Life Study: Real-World Data on the Use of Ceftobiprole in a Multicenter Spanish Cohort

BACKGROUND

Ceftobiprole is a fifth-generation cephalosporin that has been approved in Europe solely for the treatment of community-acquired and nosocomial pneumonia. The objective was to analyze the use of ceftobiprole medocaril (Cefto-M) in Spanish clinical practice in patients with infections in hospital or outpatient parenteral antimicrobial therapy (OPAT).

METHODS

This retrospective, observational, multicenter study included patients treated from 1 September 2021 to 31 December 2022.

RESULTS

A total of 249 individuals were enrolled, aged 66.6 ± 15.4 years, of whom 59.4% were male with a Charlson index of four (IQR 2-6), 13.7% had COVID-19, and 4.8% were in an intensive care unit (ICU). The most frequent type of infection was respiratory (55.8%), followed by skin and soft tissue infection (21.7%). Cefto-M was administered to 67.9% of the patients as an empirical treatment, in which was administered as monotherapy for 7 days (5-10) in 53.8% of cases. The infection-related mortality was 11.2%. The highest mortality rates were identified for ventilator-associated pneumonia (40%) and infections due to methicillin-resistant Staphylococus aureus (20.8%) and Pseudomonas aeruginosa (16.1%). The mortality-related factors were age (OR: 1.1, 95%CI (1.04-1.16)), ICU admission (OR: 42.02, 95%CI (4.49-393.4)), and sepsis/septic shock (OR: 2.94, 95%CI (1.01-8.54)).

CONCLUSIONS

In real life, Cefto-M is a safe antibiotic, comprising only half of prescriptions for respiratory infections, that is mainly administered as rescue therapy in pluripathological patients with severe infectious diseases.

Shortening identification times: comparative observational study of three early blood culture testing protocols

Background

While early appropriate antibiotic therapy is a proven means of limiting the progression of infections, especially bacteremia, empirical antibiotic therapy in sepsis is ineffective up to 30%. The aim of this study was to compare early blood culture testing protocols in terms of their ability to shorten the delay between blood sampling and appropriate antibiotic therapy.

Methods

In this french observational study, we compared three blood culture testing protocols. Positive blood cultures were tested using either GenMark ePlex panels (multiplex PCR period), a combination of MRSA/SA PCR, β-Lacta and oxidase tests (multitest period), or conventional identification and susceptibility tests only (reference period). Conventional identification and susceptibility tests were performed in parallel for all samples, as the gold standard.

Results

Among the 270 patients with positive blood cultures included, early and conventional results were in good agreement, especially for the multitest period. The delay between a blood culture positivity and initial results was 3.8 (2.9-6.9) h in the multiplex PCR period, 2.6 (1.3-4.5) h in the multitest period and 3.7 (1.8-8.2) h in the reference period (p<0.01). Antibiotic therapy was initiated or adjusted in 68 patients based on early analysis results. The proportion of patients receiving appropriate antibiotic therapy within 48 h of blood sampling was higher in the multiplex PCR and multitest periods, (respectively 90% and 88%) than in the reference period (71%).

Conclusion

These results suggest rapid bacterial identification and antibiotic resistance tests are feasible, efficient and can expedite appropriate antibiotic therapy.

Prevalence and determinants of antimicrobial resistance of pathogens isolated from cancer patients in an intensive care unit in Alexandria, Egypt

BACKGROUND

Infections caused by multidrug-resistant organisms (MDROs) are a globally increasing threat among critically ill patients, especially those with underlying malignancies. We aimed to assess the prevalence and susceptibility patterns of MDROs among cancer patients in intensive care units (ICU), and their predictors.

METHODS

Over 4 years, we retrospectively reviewed medical records of 497 malignancy patients in the ICU of a tertiary hospital in Alexandria, Egypt. The data for various factors, such as demographic characteristics, comorbidities, causative pathogen, and antimicrobial resistance (AMR), were collected and analyzed using univariate analysis. Logistic multivariate regression analysis was used to estimate the probability of developing MDROs among this population.

RESULTS

A total of 748 isolates were obtained from 1249 specimens. Gram-negative bacteria detected (459) comprised 61.4% of all isolates, while only 75 (10%) were gram-positive, and 214 (28.6%) were fungal pathogens. The most frequently encountered isolate was Klebsiella pneumoniae (n = 183), of which 107 were carbapenem-resistant (CR) and 62 were extended-spectrum beta-lactamase (ESBL)-producing. This was followed by Escherichia coli (n = 136), of which 17 were CR and 100 were ESBL-producing strains, while 3 were resistant to quinolones. Acinetobacter baumannii came in third (n = 67), with 63 being CR. The overall susceptibility of gram-negative bacteria was recorded as highest to colistin (97.3%). The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and Enterococcal species among gram-positive bacteria were 54.6% and 33.3%, respectively, with no resistance reported to vancomycin or linezolid. Among the MDRO infection predictors were neutropenia, recent antibiotics use, and receiving chemotherapy. Neutropenia had the highest odds ratio (OR: 2.3, CI: 1.28-4.09), followed by recent antibiotics use (OR: 1.8, CI: 1.22-2.59).

CONCLUSION

Gram-negative bacilli were the most frequently reported MDROs, with resistance to higher generation cephalosporins and even carbapenems limiting antibiotic treatment options to older class antibiotics, such as colistin, with potential side effects, including nephrotoxicity. Estimating AMR probability using the prediction model of risk factors, such as neutropenia and previous antibiotics use, may be functional in the rapid identification of higher-risk patients.

Evaluation of the meropenem dosage and administration schedule in patients with bacteremia initial therapy

BACKGROUND

The standard meropenem (MEPM) regimen allowed by insurance in Japan is 0.5 g two or three times a day. Differences in dosages and administration schedules in Japan were evaluated.

METHODS

Patients with bacteremia for whom MEPM was used as the initial treatment at our institution between 2016 and 2021 were included. We retrospectively investigated patients classified into two groups: those treated according to severe infections (high-dose groupand others (low-dose group). After propensity score matching, we compared the probability of achieving free drug blood levels above the minimum inhibitory concentration (MIC) in 24 h (%fT > MIC) and outcomes.

RESULTS

The probability of 100% fT > MIC was significantly higher in the high-dose group (96.4% vs 74.5%, odds ratio [OR] = 0.3, 95% confidence interval [CI] = 0.2-0.4, P = < 0.001). Regarding outcomes, the 30-day mortality rate was significantly lower in the high-dose group (1.4% vs. 11.4%, OR = 8.0, 95% CI = 1.5-43.7, P = 0.019).

CONCLUSIONS

To improve outcomes in patients with bacteremia treated with MEPM, support for appropriate antimicrobial use is necessary for compliance with the dosage and administration schedule according to severe infections in initial treatment.

Polymyxin combination therapy for multidrug-resistant, extensively-drug resistant, and difficult-to-treat drug-resistant gram-negative infections: is it superior to polymyxin monotherapy?

INTRODUCTION

The increasing prevalence of infections with multidrug-resistant (MDR), extensively-drug resistant (XDR) or difficult-to-treat drug resistant (DTR) Gram-negative bacilli (GNB), including Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, Enterobacter species, and Escherichia coli poses a severe challenge.

AREAS COVERED

The rapid growing of multi-resistant GNB as well as the considerable deceleration in development of new anti-infective agents have made polymyxins (e.g. polymyxin B and colistin) a mainstay in clinical practices as either monotherapy or combination therapy. However, whether the polymyxin-based combinations lead to better outcomes remains unknown. This review mainly focuses on the effect of polymyxin combination therapy versus monotherapy on treating GNB-related infections. We also provide several factors in designing studies and their impact on optimizing polymyxin combinations.

EXPERT OPINION

An abundance of recent in vitro and preclinical in vivo data suggest clinical benefit for polymyxin-drug combination therapies, especially colistin plus meropenem and colistin plus rifampicin, with synergistic killing against MDR, XDR, and DTR P. aeruginosa, K. pneumoniae and A. baumannii. The beneficial effects of polymyxin-drug combinations (e.g. colistin or polymyxin B + carbapenem against carbapenem-resistant K. pneumoniae and carbapenem-resistant A. baumannii, polymyxin B + carbapenem + rifampin against carbapenem-resistant K. pneumoniae, and colistin + ceftolozan/tazobactam + rifampin against PDR-P. aeruginosa) have often been shown in clinical setting by retrospective studies. However, high-certainty evidence from large randomized controlled trials is necessary. These clinical trials should incorporate careful attention to patient's sample size, characteristics of patient's groups, PK/PD relationships and dosing, rapid detection of resistance, MIC determinations, and therapeutic drug monitoring.

Antimicrobial materials for endotracheal tubes: A review on the last two decades of technological progress

Ventilator-associated pneumonia (VAP) is an unresolved problem in nosocomial settings, remaining consistently associated with a lack of treatment, high mortality, and prolonged hospital stay. The endotracheal tube (ETT) is the major culprit for VAP development owing to its early surface microbial colonization and biofilm formation by multiple pathogens, both critical events for VAP pathogenesis and relapses. To combat this matter, gradual research on antimicrobial ETT surface coating/modification approaches has been made. This review provides an overview of the relevance and implications of the ETT bioburden for VAP pathogenesis and how technological research on antimicrobial materials for ETTs has evolved. Firstly, certain main VAP attributes (definition/categorization; outcomes; economic impact) were outlined, highlighting the issues in defining/diagnosing VAP that often difficult VAP early- and late-onset differentiation, and that generate misinterpretations in VAP surveillance and discrepant outcomes. The central role of the ETT microbial colonization and subsequent biofilm formation as fundamental contributors to VAP pathogenesis was then underscored, in parallel with the uncovering of the polymicrobial ecosystem of VAP-related infections. Secondly, the latest technological developments (reported since 2002) on materials able to endow the ETT surface with active antimicrobial and/or passive antifouling properties were annotated, being further subject to critical scrutiny concerning their potentialities and/or constraints in reducing ETT bioburden and the risk of VAP while retaining/improving the safety of use. Taking those gaps/challenges into consideration, we discussed potential avenues that may assist upcoming advances in the field to tackle VAP rampant rates and improve patient care. STATEMENT OF SIGNIFICANCE: The use of the endotracheal tube (ETT) in patients requiring mechanical ventilation is associated with the development of ventilator-associated pneumonia (VAP). Its rapid surface colonization and biofilm formation are critical events for VAP pathogenesis and relapses. This review provides a comprehensive overview on the relevance/implications of the ETT biofilm in VAP, and on how research on antimicrobial ETT surface coating/modification technology has evolved over the last two decades. Despite significant technological advances, the limited number of gathered reports (46), highlights difficulty in overcoming certain hurdles associated with VAP (e.g., persistent colonization/biofilm formation; mechanical ventilation duration; hospital length of stay; VAP occurrence), which makes this an evolving, complex, and challenging matter. Challenges and opportunities in the field are discussed.

Instant detection of extended-spectrum β-lactamase-producing bacteria from the urine of patients using infrared spectroscopy combined with machine learning

Antibiotics are considered the most effective treatment against bacterial infections. However, most bacteria have already developed resistance to a broad spectrum of commonly used antibiotics, mainly due to their uncontrolled use. Extended-spectrum beta-lactamase (ESBL)-producing bacteria are an essential class of multidrug-resistant (MDR) bacteria. It is of extreme urgency to develop a method that can detect ESBL-producing bacteria rapidly for the effective treatment of patients with bacterial infectious diseases. Fourier transform infrared (FTIR) microscopy is a sensitive method that can rapidly detect cellular molecular changes. In this study, we examined the potential of FTIR spectroscopy-based machine learning algorithms for the rapid detection of ESBL-producing bacteria obtained directly from a patient's urine. Using 591 ESBL-producing and 1658 non-ESBL-producing samples of Escherichia coli (E. coli) and Klebsiella pneumoniae, our results show that the FTIR spectroscopy-based machine learning approach can identify ESBL-producing bacteria within 40 minutes from receiving a patient's urine sample, with a success rate of 80%.

Fast identification and susceptibility determination of E. coli isolated directly from patients' urine using infrared-spectroscopy and machine learning

For effective treatment, it is crucial to identify the infecting bacterium at the species level and to determine its antimicrobial susceptibility. This is especially true now, when numerous bacteria have developed multidrug resistance to most commonly used antibiotics. Currently used methods need ∼ 48 h to identify a bacterium and determine its susceptibility to specific antibiotics. This study reports the potential of using infrared spectroscopy with machine learning algorithms to identify E. coli isolated directly from patients' urine while simultaneously determining its susceptibility to antibiotics within ∼ 40 min after receiving the patient's urine sample. For this goal, 1,765 E. coli isolates purified directly from urine samples were collected from patients with urinary tract infections (UTIs). After collection, the samples were tested by infrared microscopy and analyzed by machine learning. We achieved success rates of ∼ 96% in isolate level identification and ∼ 84% in susceptibility determination.

Sequestration of Antimicrobial Agents in Xcoating and Heparin-Coated Extracorporeal Membrane Oxygenation Circuits: An In Vitro Study

Limited data exist to guide antimicrobial therapy commonly prescribed to patients undergoing extracorporeal membrane oxygenation (ECMO). This study aimed to describe the kinetics of the cefazolin, doripenem, daptomycin, and levofloxacin in heparin-coated and Xcoating ECMO circuits. Circuits were primed with bovine whole blood and maintained at a physiological pH and temperature for 24 h. Each antimicrobial agent was added to the whole blood before priming. Equivalent doses of these drugs were added to glass jars containing fresh bovine whole blood as a control. Serial blood samples were collected from the ECMO circuits and controls over 24 h, and drug concentrations were quantified using validated assays. The concentrations of cefazolin, doripenem, daptomycin, and levofloxacin did not decrease significantly over 24 h. Collectively, these antimicrobial agents can be administered without the need to consider sequestration when using either heparin-coated or Xcoating circuits.

Contemporary Tools for the Cure against Pernicious Microorganisms: Micro-/Nanorobots

One of the most pressing concerns to global public health is the emergence of drug-resistant pathogenic microorganisms due to increased unconscious antibiotic usage. With the rising antibiotic resistance, existing antimicrobial agents lose their effectiveness over time. This indicates that newer and more effective antimicrobial agents and methods should be investigated. Many studies have shown that micro-/nanorobots exhibit promise in the treatment of microbial infections with their great properties, such as the intrinsic antimicrobial activities owing to their oxidative stress induction and metal ion release capabilities, and effective and autonomous delivery of antibiotics to the target area. In addition, they have multiple simultaneous mechanisms of action against microbes, which makes them remarkable in antimicrobial activity. This review focuses on the antimicrobial micro-/nanorobots and their strategies to impede biofilm formation, following a brief introduction of the latest advancements in micro-/nanorobots, and their implementations against various bacteria, and other microorganisms.

Helicobacter Pylori-Induced Gastric Infections: From Pathogenesis to Novel Therapeutic Approaches Using Silver Nanoparticles

Helicobacter pylori is the first formally recognized bacterial carcinogen and the most important single digestive pathogen responsible for the induction of gastroduodenal diseases such as gastritis, peptic ulcer, and, finally, gastric neoplasia. The recently reported high rates of antimicrobial drug resistance hamper the current therapies of H. pylori, with therapeutic failure reaching up to 40% of patients. In this context, new treatment options and strategies are urgently needed, but the successful development of these new therapeutic tools is conditioned by the understanding of the high adaptability of H. pylori to the gastric acidic environment and the complex pathogenic mechanism. Due to several advantages, including good antibacterial efficiency, possible targeted delivery, and long tissular persistence, silver nanoparticles (AgNPs) offer the opportunity of exploring new strategies to improve the H. pylori therapy. A new paradigm in the therapy of H. pylori gastric infections using AgNPs has the potential to overcome the current medical limitations imposed by the H. pylori drug resistance, which is reported for most of the current organic antibiotics employed in the classical therapies. This manuscript provides an extensive overview of the pathology of H. pylori-induced gastritis, gastric cancer, and extradigestive diseases and highlights the possible benefits and limitations of employing AgNPs in the therapeutic strategies against H. pylori infections.

Analysis of Rates, Causes, and Risk Factors for 90-Day Readmission After Surgery for Large Hiatal Hernia: A Two-Center Study

Background: Hospital readmissions have become a more examined indicator of surgical care delivery and quality. There is scarcity of data in the literature on the rate, risk factors, and most common reasons of readmission following major hiatal hernia surgery. The primary endpoint was 90-day readmission after surgery for large hiatal hernia. Secondary endpoint was to examine which characteristics related with a higher risk of readmission. Methods: A retrospective review of two distinct institutional databases was performed for patients who had surgery for a large hiatal hernia between January 2012 and December 2019. Demographic, perioperative, and outpatient data were collected from the medical record. Results: A total of 71 patients met the inclusion criteria, most of them suffering from a type III hernia (66.2%). Mean operative time was 146 (±56.5) minutes and median length of stay (LOS) was 6 days (interquartile range = 3). The overall morbidity was 21.1% and the in-hospital mortality was 1.4%. The 30- and 90-day readmission rates were 7% and 8.5%, respectively. The mean time to readmission was 14.3 (±15.6) days. The reasons for 90-day hospital readmission were dysphagia (50%), pneumonia (16.7%), congestive heart failure (16.7%), and bowel obstruction (16.7%). Grade of esophagitis ≥2, presence of Barrett's esophagus, and LOS longer than 8 days were significant risk factors for unplanned readmission within 90 days. Conclusion: We observed that about 6 out of 71 patients who had surgery readmitted within 90 days (8.5%). Readmissions were most often linked to esophagitis ≥2, presence of Barrett's esophagus, and LOS longer than 8 days. These findings point to the necessity for focused treatments before, during, and after hospitalization to decrease morbidity and extra costs in this high-risk population.

Effects of ex vivo Extracorporeal Membrane Oxygenation Circuits on Sequestration of Antimicrobial Agents

Objectives: Our ex vivo study was designed to determine the sequestration of teicoplanin, tigecycline, micafungin, meropenem, polymyxin B, caspofungin, cefoperazone sulbactam, and voriconazole in extracorporeal membrane oxygenation (ECMO) circuits.

Methods: Simulated closed-loop ECMO circuits were prepared using 2 types of blood-primed ECMO. After the circulation was stabilized, the study drugs were injected into the circuit. Blood samples were collected at 2, 5, 15, 30 min, 1, 3, 6, 12, and 24 h after injection. Drug concentrations were measured by high-performance liquid chromatography-tandem mass spectrometry. Control groups were stored at 4°C after 3, 6, 12, and 24 h immersing in a water bath at 37°C to observe spontaneous drug degradation.

Results: Twenty-six samples were analyzed. The average drug recoveries from the ECMO circuits and control groups at 24 h relative to baseline were 67 and 89% for teicoplanin, 100 and 145% for tigecycline, 67 and 99% for micafungin, 45 and 75% for meropenem, 62 and 60% for polymyxin B, 83 and 85% for caspofungin, 79 and 98% for cefoperazone, 75 and 87% for sulbactam, and 60 and 101% for voriconazole, respectively. Simple linear regression showed no significant correlation between lipophilicity (r² = 0.008, P = 0.225) or the protein binding rate (r² = 0.168, P = 0.479) of drugs and the extent of drug loss in the ECMO circuits.

Conclusions: In the two ECMO circuits, meropenem and voriconazole were significantly lost, cefoperazone was slightly lost, while tigecycline and caspofungin were not lost. Drugs with high lipophilicity were lost more in the Maquet circuit than in the Sorin circuit. This study needs more in vivo studies with larger samples for further confirmation, and it suggests that therapeutic drug concentration monitoring should be strongly considered during ECMO.

Duplex dPCR System for Rapid Identification of Gram-Negative Pathogens in the Blood of Patients with Bloodstream Infection: A Culture-Independent Approach

Early and accurate detection of pathogens is important to improve clinical outcomes of bloodstream infections (BSI), especially in the case of drug-resistant pathogens. In this study, we aimed to develop a culture-independent digital PCR (dPCR) system for multiplex detection of major sepsiscausing gram-negative pathogens and antimicrobial resistance genes using plasma DNA from BSI patients. Our duplex dPCR system successfully detected nine targets (five bacteria-specific targets and four antimicrobial resistance genes) through five reactions within 3 hours. The minimum detection limit was 50 ag of bacterial DNA, suggesting that 1 CFU/ml of bacteria in the blood can be detected. To validate the clinical applicability, cell-free DNA samples from febrile patients were tested with our system and confirmed high consistency with conventional blood culture. This system can support early identification of some drug-resistant gram-negative pathogens, which can help improving treatment outcomes of BSI.

Friends or Foes? Rapid Determination of Dissimilar Colistin and Ciprofloxacin Antagonism of Pseudomonas aeruginosa Phages

Phage therapy is a century-old technique employing viruses (phages) to treat bacterial infections, and in the clinic it is often used in combination with antibiotics. Antibiotics, however, interfere with critical bacterial metabolic activities that can be required by phages. Explicit testing of antibiotic antagonism of phage infection activities, though, is not a common feature of phage therapy studies. Here we use optical density-based 'lysis-profile' assays to assess the impact of two antibiotics, colistin and ciprofloxacin, on the bactericidal, bacteriolytic, and new-virion-production activities of three Pseudomonas aeruginosa phages. Though phages and antibiotics in combination are more potent in killing P. aeruginosa than either acting alone, colistin nevertheless substantially interferes with phage bacteriolytic and virion-production activities even at its minimum inhibitory concentration (1× MIC). Ciprofloxacin, by contrast, has little anti-phage impact at 1× or 3× MIC. We corroborate these results with more traditional measures, particularly colony-forming units, plaque-forming units, and one-step growth experiments. Our results suggest that ciprofloxacin could be useful as a concurrent phage therapy co-treatment especially when phage replication is required for treatment success. Lysis-profile assays also appear to be useful, fast, and high-throughput means of assessing antibiotic antagonism of phage infection activities.

Detection of nosocomial pneumonia pathogens using a fluorescence-based device

BACKGROUND

Early detection of nosocomial pneumonia pathogens is a significant factor in hospital-acquired pneumonia care. This study aimed to determine the autofluorescence properties of five nosocomial pneumonia pathogens using a fluorescence-based device and to establish evidence for clinical guidelines.

METHODS

The following bacterial strains were assessed: Acinetobacter baumannii (AB), Escherichia coli (EC), Enterococcus faecalis (EF), Klebsiella pneumoniae (KP), and Staphylococcus aureus (SA). The bacteria were cultured separately on tryptic soy agar at 37°C under aerobic conditions for 168 h. Fluorescence photographs of each species were captured every 24 h using a fluorescence-based device with fixed camera settings. The images were analyzed by measuring the red and green values (R/G ratio) at a central point in each colony, and the R/G ratios were analyzed using the Kruskal-Wallis non-parametric test.

RESULTS

KP and SA showed red fluorescence with their R/G values, which were significantly higher than those of the other strains (p < 0.001). In particular, the R/G ratio of KP increased steadily until 72 h of incubation, peaking at 3.65. In addition, AB and EC showed orange fluorescence with higher red ratios than green ratios. EF and SA showed green fluorescence all through 168 h of incubation, with R/G values less than 1.0.

CONCLUSIONS

Nosocomial pneumonia pathogens can be identified and classified via bacterial autofluorescence emission. It is possible to develop a rapid and easy-to-use identification technology based on bacterial autofluorescence for clinical applications.

The Potential Role of Clinical Metagenomics in Infectious Diseases: Therapeutic Perspectives

Clinical metagenomics (CMg) is the process of sequencing nucleic acid of clinical samples to obtain clinically relevant information such as the identification of microorganisms and their susceptibility to antimicrobials. Over the last decades, sequencing and bioinformatic solutions supporting CMg have much evolved and an increasing number of case reports and series covering various infectious diseases have been published. Metagenomics is a new approach to infectious disease diagnosis that is currently being developed and is certainly one of the most promising for the coming years. However, most CMg studies are retrospective, and few address the potential impact CMg could have on patient management, including initiation, adaptation, or cessation of antimicrobials. In this narrative review, we have discussed the potential role of CMg in bacteriology, virology, mycology, and parasitology. Several reports and case-series confirm that CMg is an innovative tool with which one can (i) identify more microorganisms than with conventional methods in a single test, (ii) obtain results within hours, and (iii) tailor the antimicrobial regimen of patients. However, the cost-efficiency of CMg and its real impact on patient management are still to be determined.

Audit of empirical antibiotic therapy for sepsis and the impact of early multidisciplinary consultation on patient outcomes

OBJECTIVES

To perform an audit of empirical antibiotic therapy (EAT) of sepsis at the emergency department and to analyse the impact of an antimicrobial stewardship (AMS) programme on process and patient outcomes.

PATIENTS AND METHODS

A prospective, single-centre cohort study including patients with sequential organ failure assessment (SOFA) score ≥2 from whom blood cultures were taken was conducted between February 2019 and April 2020. EAT was assessed using eight applicable inpatient quality indicators (IQIs) for responsible antibiotic use. Patient outcomes were hospital length-of-stay (LOS), ICU admission, ICU LOS, and in-hospital mortality.

RESULTS

The audit included 900 sepsis episodes in 803 patients. Full guideline adherence regarding choice and dosing was 45.9%; adherence regarding choice alone was 68.1%. EAT was active against all likely pathogens in 665/787 (84.5%) episodes. In the guideline non-adherent group, choice of EAT was inappropriate in 122/251 (48.6%) episodes. Changes within 3 days occurred in 335/900 (37.2%) episodes. Treating physicians changed administration route more often, whereas microbiological/infectious disease (ID)/AMS consultant advice resulted in de-escalation and discontinuation (P = 0.000). Guideline-adherent choice was associated with significantly shorter LOS (6 (4-11) vs. 8 (5-15) days). Full adherence was associated with significantly lower mortality (23 (6.4%) vs. 48 (11.3%)) and shorter LOS (6 (4-10) vs. 8 (5-14) days).

CONCLUSION

Five global quality indicators of EAT were measurable in routine clinical practice. Full adherence to guidelines was only moderate. Adherence to guidelines was associated with better patient outcomes.

Comparing Hospital and Primary Care Physicians' Attitudes and Knowledge Regarding Antibiotic Prescribing: A Survey within the Centre Region of Portugal

BACKGROUND

Antibiotic resistance is a worldwide public health problem, leading to longer hospital stays, raising medical costs and mortality levels. As physicians' attitudes are key factors to antibiotic prescribing, this study sought to explore their differences between primary care and hospital settings.

METHODS

A survey was conducted between September 2011 and February 2012 in the center region of Portugal in the form of a questionnaire to compare hospital (n = 154) and primary care (n = 421) physicians' attitudes and knowledge regarding antibiotic prescribing.

RESULTS

More than 70% of the attitudes were statistically different (p < 0.05) between hospital physicians (HPs) and primary care physicians (PCPs). When compared to PCPs, HPs showed higher agreement with antibiotic resistances being a public health problem and ascribed more importance to microbiological tests and to the influence of prescription on the development of resistances. On the other hand, PCPs tended to agree more regarding the negative impact of self-medication with antibiotics dispensed without medical prescription and the need for rapid diagnostic tests. Seven out of nine sources of knowledge's usefulness were statistically different between both settings, with HPs considering most of the knowledge sources to be more useful than PCPs.

CONCLUSIONS

Besides the efforts made to improve both antibiotic prescribing and use, there are differences in the opinions between physicians working in different settings that might impact the quality of antibiotic prescribing. In the future, these differences must be considered to develop more appropriate interventions.

Implementation of a novel antimicrobial stewardship strategy for rural facilities utilising telehealth

A significant portion of healthcare takes place in small hospitals, and many are located in rural and regional areas. Facilities in these regions frequently do not have adequate resources to implement an onsite antimicrobial stewardship programme and there are limited data relating to their implementation and effectiveness. We present an innovative model of providing a specialist telehealth antimicrobial stewardship service utilising a centralised service (Queensland Statewide Antimicrobial Stewardship Program) to a rural Hospital and Health Service. Results of a 2-year post-implementation follow-up showed an improvement in adherence to guidelines [33.7% (95% CI 27.0-40.4%) vs. 54.1% (95% CI 48.7-59.5%)] and appropriateness of antimicrobial prescribing [49.0% (95% CI 42.2-55.9%) vs. 67.5% (95% CI 62.7-72.4%) (P < 0.001). This finding was sustained after adjustment for hospitals, with improvement occurring sequentially across the years for adherence to guidelines [adjusted odds ratio (aOR) = 2.44, 95% CI 1.70-3.51] and appropriateness of prescribing (aOR = 2.48, 95% CI 1.70-3.61). There was a decrease in mean total antibiotic use (DDDs/1000 patient-days) between the years 2016 (52.82, 95% CI 44.09-61.54) and 2018 (39.74, 95% CI 32.76-46.73), however this did not reach statistical significance. Additionally, there was a decrease in mean hospital length of stay (days) from 2016 (3.74, 95% CI 3.08-4.41) to 2018 (2.55, 95% CI 1.98-3.12), although this was not statistically significant. New telehealth-based models of antimicrobial stewardship can be effective in improving prescribing in rural areas. Programmes similar to ours should be considered for rural facilities.

Pharmacist-Driven Antibiotic Stewardship Program in Febrile Neutropenic Patients: A Single Site Prospective Study in Thailand

The antibiotic stewardship program (ASP) is a necessary part of febrile neutropenia (FN) treatment. Pharmacist-driven ASP is one of the meaningful approaches to improve the appropriateness of antibiotic usage. Our study aimed to determine role of the pharmacist in ASPs for FN patients. We prospectively studied at Thammasat University Hospital between August 2019 and April 2020. Our primary outcome was to compare the appropriate use of target antibiotics between the pharmacist-driven ASP group and the control group. The results showed 90 FN events in 66 patients. The choice of an appropriate antibiotic was significantly higher in the pharmacist-driven ASP group than the control group (88.9% vs. 51.1%, p < 0.001). Furthermore, there was greater appropriateness of the dosage regimen chosen as empirical therapy in the pharmacist-driven ASP group than in the control group (97.8% vs. 88.7%, p = 0.049) and proper duration of target antibiotics in documentation therapy (91.1% vs. 75.6%, p = 0.039). The multivariate analysis showed a pharmacist-driven ASP and infectious diseases consultation had a favorable impact on 30-day infectious diseases-related mortality in chemotherapy-induced FN patients (OR 0.058, 95%CI:0.005–0.655, p = 0.021). Our study demonstrated that pharmacist-driven ASPs could be a great opportunity to improve antibiotic appropriateness in FN patients.

Hospitalization Costs and Length of Stay in Chinese Naval Hospitals Between 2008 and 2016 Based on Influencing Factors: A Longitudinal Comparison

INTRODUCTION

A retrospective review conducted in three hospitals of Guangdong and Hainan, China. To analyze the variation tendency of mean hospitalization costs and length of stay (LOS) in naval hospitals over nine years, paying special attention to the factors affecting hospitalization costs and LOS to provide a reference base for health resource allocation in naval hospitals.

MATERIALS AND METHODS

A total of 21,375 cases of military patients who were hospitalized and treated in three naval hospitals between January 2008 to December 2016 were extracted from the military health system. There were 16,278 complete and effective cases during those nine years. The situation, trends, and factors influencing hospitalization costs and LOS were analyzed using descriptive statistics, Mann-Whitney U test, Kruskal-Wallis H test, and multiple linear regressions.

RESULTS

The following factors showed statistically significant differences in hospitalization costs: special care, primary care, year, military rank, critical illness, allergies, and condition (p < 0.0001); and number of hospitalizations, gender, and age (p < 0.01). The following factors showed statistically significant differences in hospital LOS: year, number of hospitalizations, outcomes, military rank, special care, severity of illness, and condition (p < 0.0001); allergy (p < 0.01); and service and gender (p < 0.05). LOS between 2008-2016 showed a decreasing tendency, while hospitalization costs showed an increasing trend. There were 6 factors that affected Abstract (or Structured Summary) both the cost of hospitalization and LOS: special care, year, military rank, condition, allergy, and gender.

CONCLUSIONS

The results suggest that improving efficiency of military hospital require strengthening hierarchical referrals and controlling hospital LOS. Shortening LOS, optimizing clinical pathways, and reasonably controlling the costs associated with medicines and surgery can help reduce hospitalization costs for military patients. Controlling the growth of hospitalization costs can help avoid the physical and psychological burden of medical over-treatment on patients and may also optimize the allocation of military health resources.

In Situ Nucleic Acid Amplification and Ultrasensitive Colorimetric Readout in a Paper-Based Analytical Device Using Silver Nanoplates

A rapid, highly sensitive, and quantitative colorimetric paper-based analytical device (PAD) based on silver nanoplates (AgNPls) and loop-mediated isothermal amplification (LAMP) is presented. It is shown that cauliflower-like concatemer LAMP products can mediate crystal etching of AgNPls, with a threefold signal enhancement versus linear dsDNA. Methicillin-resistant Staphylococcus aureus (MRSA), an antimicrobial resistant bacterium that poses a formidable risk with persistently high mortality, is used as a model pathogen. Due to the excellent color contrast provided by AgNPls, the PAD allows qualitative analysis by the naked eye and quantitative analysis using a smartphone camera, with detection limits down to a single copy in just 30 min, and a linear response from 1 to 10⁴ copies (R² = 0.994). The entire assay runs in situ on the paper surface, which drastically simplifies operation of the device. This is the first demonstration of single copy detection using a colorimetric readout, and the developed PAD shows great promise for translation into an ultrasensitive gene-based point-of-care test for any infectious disease target, via modification of the LAMP primer set.

Surgical Infection Society 2020 Updated Guidelines on the Management of Complicated Skin and Soft Tissue Infections

Background: The Surgical Infection Society (SIS) Guidelines for the treatment of complicated skin and soft tissue infections (SSTIs) were published in October 2009 in Surgical Infections. The purpose of this project was to provide a succinct update on the earlier guidelines based on an additional decade of data. Methods: We reviewed the previous guidelines eliminating bite wounds and diabetic foot infections including their associated references. Relevant articles on the topic of complicated SSTIs from 2008-2020 were reviewed and graded individually. Comparisons were then made between the old and the new graded recommendations with review of the older references by two authors when there was disparity between the grades. Results: The majority of new studies addressed antimicrobial options and duration of therapy particularly in complicated abscesses. There were fewer updated studies on diagnosis and specific operative interventions. Many of the topics addressed in the original guidelines had no new literature to evaluate. Conclusions: Most recommendations remain unchanged from the original guidelines with the exception of increased support for adjuvant antimicrobial therapy after drainage of complex abscess and increased data for the use of alternative antimicrobial agents.

Trauma and Antimicrobial Resistance Are Independent Predictors of Inadequate Empirical Antimicrobial Treatment of Ventilator-Associated Pneumonia in Critically Ill Patients

Background: We aimed to assess independent risk factors for inadequate initial antimicrobial treatment (IAT) in critically ill patients with ventilator-associated pneumonia (VAP) treated in intensive care units (ICU) and to determine whether IAT is associated with adverse outcomes in patients with VAP. Patients and Methods: A prospective cohort study was performed and included 152 patients with VAP treated in an ICU for more than 48 hours. The main outcomes of interest were all-cause ICU mortality and VAP-related mortality. Other outcomes considered were: intra-hospital mortality, VAP-related sepsis, relapse, re-infection, length of stay in ICU (ICU LOS), and number of days on mechanical ventilation (MV). Results: One-third of patients (35.5%) received inadequate antimicrobial therapy. Trauma (odds ratio [OR], 3.55; 95% confidence interval [CI], 1.25-10.06) and extensively drug-resistant (XDR) causative agent (OR, 3.09; 95% CI, 1.23-7.74) were independently associated with inadequate IAT. Inadequate IAT was associated with a higher mortality rate (OR, 3.08; 95% CI, 1.30-7.26), VAP-related sepsis (OR, 2.39; 95% CI, 1.07-5.32), relapse (OR, 3.25; 95% CI, 1.34-7.89), re-infection (OR, 6.06; 95% CI, 2.48-14.77), and ICU LOS (β 4.65; 95% CI, 0.93-8.36). Acinetobacter spp., Pseudomonas aeruginosa and Klebsiella/Enterobacter spp. were the most common bacteria in patients with IAT and those with adequate antimicrobial therapy. Conclusions: This study demonstrated that inadequate IAT is associated with a higher risk of the majority of adverse outcomes in patients with VAP treated in ICUs. Trauma and XDR strains of bacteria are independent predictors of inadequate IAT of VAP in critically ill patients.

Clinical features and outcome of septic shock in dogs: 37 Cases (2008-2015)

OBJECTIVES

To describe patient characteristics of dogs with septic shock, investigate markers of disease severity, and assess treatment impact on outcome.

DESIGN

Retrospective study.

SETTING

Single center, university veterinary teaching intensive care unit.

ANIMALS

Thirty-seven dogs with septic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Mean number of organ dysfunction was 3.24 ± 1.0, and included cardiovascular (100%), respiratory (73%), hematologic (68%), renal (49%), and hepatic (32%) dysfunction. The gastrointestinal tract was the most common source of sepsis. Mean blood pressure prior to resuscitation was 50 ± 8 mm Hg. All dogs were given IV fluids before vasopressor therapy with a mean rate of 12.1 ± 11.0 mL/kg/h. All dogs were given antimicrobials, administered within a mean of 4.3 ± 5.7 hours after diagnosis. Dopamine or norepinephrine was administered IV, respectively in 51.3% and 37.8% of dogs, with a mean duration of hypotension of 2.6 ± 3.0 hours. Mortality rate was 81.1%. Survivors were more likely to have a feeding tube (P = 0.007) and to have gastrointestinal sepsis (P = 0.012), and less likely to have respiratory dysfunction (P < 0.001). APPLE_Full scores (P = 0.014) and time to antimicrobial therapy (P = 0.047) were identified as predictors of mortality. Treatment bundles consisting of 7 interventions that may improve outcomes in people with septic shock were evaluated. Survivors received 4.1 ± 1.3 interventions, whereas nonsurvivors received 2.4 ± 1.4 (P = 0.003).

CONCLUSIONS

Septic shock in dogs confers a guarded prognosis. Early antimicrobial therapy and the utilization of treatment bundles may increase survivability in dogs with septic shock. More research is warranted to investigate the impact of specific interventions on survival.

Multidrug-Resistant and Extensively Drug-Resistant Enterobacteriaceae: Prevalence, Treatments, and Outcomes - A Retrospective Cohort Study

Background

Drug-resistant gram-negative bacteria (GNB) are a global public health threat, especially in intensive care units (ICU). This study explored the prevalence of drug-resistant Enterobacteriaceae infections in an ICU in Saudi Arabia. The appropriateness of the antibiotic therapies used and their ability to improve the clinical outcomes were also assessed.

Methods

A retrospective study was conducted from 2015 to 2018 in the different ICUs of a tertiary-care hospital in Saudi Arabia. Positive cultures for multidrug-resistant (MDR), extensively drug-resistant (XDR), and pandrug-resistant (PDR) Enterobacteriaceae, including Klebsiella pneumoniae, Escherichia coli, and Enterobacter sp., were included. The primary outcomes involved microbiological cure and 30 days in-hospital mortality rate, while the secondary outcome included the length of hospital stay (LOS). Regression models were used to assess the relationship between appropriateness of the antibiotic therapy and clinical outcomes.

Results

Of the 227 Enterobacteriaceae cultures included in this study, 60% were either MDR (n= 130) or XDR (n= 8) infections; no PDR Enterobacteriaceae cultures were identified. Majority of the patients were female (54%), and the average age was 60.1 ± 17.7 years. MDR/XDR cultures primarily comprised E. coli (51.4%), followed by K. pneumoniae (33%) and Enterobacter sp. (16%). Most commonly used antibiotics were piperacillin/tazobactam (53%), carbapenems (47%), and cephalosporins (21.3%). Antibiotic therapy was considered appropriate in only 85 of 138 (61.59%) patients. Microbiological cure rate was achieved in 40% of the cases, and in-hospital death rate was 84%. The average LOS was 27 days. Appropriateness of the antibiotic therapy prescribed could not predict any of the study outcomes.

Conclusion

The study revealed a high prevalence of drug-resistant Enterobacteriaceae infections, which were associated with a high mortality rate. Therefore, it is essential to assess the effectiveness of antimicrobial stewardship program and infection prevention and control practices, particularly in critically ill patients.

High Prevalence of Antibiotic-Resistant Gram-Negative Bacteria Causing Surgical Site Infection in a Tertiary Care Hospital of Northeast India

Background and objective Surgical site infections (SSI) are the most common healthcare-associated infections in low- and middle-income countries associated with substantial morbidity and mortality and impose heavy demands on healthcare resources. We aimed to study the microbiological profile of SSI pathogens and their antibiotic-resistant patterns in a tertiary care teaching hospital serving mostly rural population Methods A prospective, hospital-based cross-sectional study on pathogen profile and drug resistance was conducted from January 2015 to December 2016. Study subjects were the patients who developed signs of SSI after undergoing surgical procedures at three surgical wards (General Surgery, Orthopedics, and Obstetrics & Gynecology). The selection of the patients was based on CDC Module. Standard bacteriological methods were applied for isolation of pathogens and antibiotic-susceptibility testing based on CLSI (Clinical Laboratory Standard Institute) guidelines. Results Out of 518 enrolled subjects, 197 showed growth after aerobic culture yielding 228 pathogen isolates; 12.2% of samples showed polymicrobial growth. Escherichia coli (22.4%) and Klebsiella species (20.6%) were the predominant isolated bacteria followed by Staphylococcus species (18.4%), Pseudomonas species (12.3%), and Enterococcus species (6.6%). Gram-negative bacteria (GNB) were highly resistant to ampicillin (90.1%) and cefazolin (85.9%). High resistance was also observed to mainstay drugs like ceftriaxone (48.4%), cefepime (61%), amoxycillin-clavulanic acid (43.4%), and ciprofloxacin/levofloxacin (37.7%). Among the Gram-positive cocci, Staphylococcus aureus showed 85-96% resistance to penicillin and 65-74% to ampicillin. But GPCs were relatively less resistant to quinolones (16-18%) and macrolides (21.5%). S. aureus was 100% sensitive to vancomycin and clindamycin but vancomycin-resistant Enterococci was encountered in 3/15 (20%) isolates. Conclusion GNBs were responsible for more than two-thirds of aerobic-culture positive SSI and showed high resistance to the commonly used antibiotics thus leaving clinicians with few choices. This necessitates periodic surveillance of causative organisms and their antibiotic-susceptibility pattern to help in formulating hospital antibiotic policy. The antibiotic stewardship program is yet to be adopted in our hospital.

Identification of Factors Affecting Mortality in Late-Onset Ventilator-Associated Pneumonia

Objective

Pneumonia that develops 48 hours after intubation has been defined as ventilator-associated pneumonia (VAP) in patients hospitalized in the intensive care unit (ICU). Late-onset VAP (LO-VAP) is described as pneumonia that occurs within or after the 5th day of mechanical ventilation. We aimed to determine the factors that affect the mortality and survival in patients with LO-VAP.

Materials and Methods

We retrospectively reviewed the hospital records of adult patients (>18 years) who developed LO-VAP in the training and research hospital between January 2014 and June 2018. We compared the demographic findings and laboratory characteristics of the survivors and deaths on the 28-day mortality.

Results

The mean age of 231 (90 female and 141 male) patients with LO-VAP was 73.43±14.06 years. As a result of multivariate logistic regression analysis, we determined that advanced age (p=0.023; 95% confidence interval [CI]: 1.003-1.047) and unconsciousness (p=0.001; 95% CI: 1.674-6.547) were the independent factors affecting mortality. However, parenteral nutrition (PN) (p=0.027; 95% CI: 0.263-0.923) and tracheostomy (p=0.001; 95% CI: 0.112-0.545) were the independent factors supporting survival. We found that acute physiology and chronic health evaluation II score, presence of bacteremia, and enteral nutrition did not have a significant effect on mortality.

Conclusion

Use of tracheostomy and PN in patients with LO-VAP has a positive effect on survival. Our study also points out that mortality can be high in patients with advanced age and unconsciousness.

Impact of a pharmacist-driven antimicrobial stewardship program in a private hospital in Costa Rica

Objective.

To measure the impact generated by the implementation of the pharmacy-driven antimicrobial stewardship program of the Clínica Bíblica Hospital.

Methods.

This is a retrospective observational study that evaluates the consumption of antibiotics for the periods before and during implementation of the Clínica Bíblica Hospital antimicrobial stewardship program, calculated by means of defined daily dose per 1 000 patient-days and days of therapy per 1 000 patient-days. In addition, bacterial resistance patterns for the periods 2014–2015 and 2016–2017 were compared.

Results.

Consumption of most-used antibiotics was calculated, looking for trends that might be associated with the activities implemented by the Clínica Bíblica Hospital antimicrobial stewardship program. Comparing some of the antibiotics with the highest consumption in periods I and II, use of levofloxacin and ceftriaxone showed a decrease of 54.0% (p < 0.001) and 14.6% (p = 0.003), respectively, whereas there was an increase in the use of cefazolin of 4 539.3% (p < 0.001). Regarding percentage of bacterial resistance, in most bacterial isolates no statistically significant changes were observed between the two periods.

Conclusions.

A reduction in the overall consumption of antibiotics has been achieved over time, most likely attributable to the antimicrobial stewardship program. However, this trend was not observed for all the antibiotics studied. The pattern of resistance among the commonly isolated microorganisms did not vary greatly between the periods studied, which suggests that either the antimicrobial stewardship program may have prevented an increase in bacterial resistance since its implementation, or that it is too soon to see impact on bacterial resistance.

Clinimetric properties and suitability of selected quality indicators for assessing antibiotic use in hospitalized adults: a multicentre point prevalence study in 24 hospitals in Germany

OBJECTIVES

The capability to measure and monitor the quality of antibiotic prescribing is an important component of antibiotic stewardship (ABS) programmes. Several catalogues of consensus-based structure and process-of-care quality indicators (QIs) have been proposed, but only a few studies have tested and validated ABS QIs in practice tests. This multicentre study determined the clinimetric properties and suitability of a set of 33 process QIs for ABS that had earlier been developed and in part recommended in a German-Austrian hospital ABS practice guideline.

METHODS

Two point prevalence surveys were conducted in a convenience sample of 24 acute care hospitals throughout Germany, and data of all screened adult inpatients with prescription of a systemic antibiotic at a given day (n=4310) were included in the study. For each QI, the following clinimetric properties were assessed: applicability, feasibility, performance, case mix stability and interobserver reliability.

RESULTS

Eighteen QIs were considered sufficiently feasible, applicable and reliable, and had adequate room for improvement. The finally selected QIs primarily cover antibiotic therapy of common infections (bloodstream infection, pneumonia and urinary tract infection), while two of the QIs each address surgical prophylaxis and general aspects of antibiotic administration.

CONCLUSIONS

Practice tests may be important to test the suitability of consensus process-of-care QIs in the field of hospital ABS. The 18 selected QIs considered suitable enough for hospital ABS in this study should be regarded as priority QIs useful for internal quality control and assurance. More research and additional practice tests may be needed to confirm their suitability for external quality assessment schemes.

Effectiveness of Electronic Guidelines (GERH®) to Improve the Clinical Use of Antibiotics in An Intensive Care Unit

The objective of the study was to evaluate the capacity of GERH^®-derived local resistance maps (LRMs) to predict antibiotic susceptibility profiles and recommend the appropriate empirical treatment for ICU patients with nosocomial infection. Data gathered between 2007 and 2016 were retrospectively studied to compare susceptibility information from antibiograms of microorganisms isolated in blood cultures, lower respiratory tract samples, and urine samples from all ICU patients meeting clinical criteria for infection with the susceptibility mapped by LRMs for these bacterial species. Susceptibility described by LRMs was concordant with in vitro study results in 73.9% of cases. The LRM-predicted outcome agreed with the antibiogram result in >90% of cases infected with the bacteria for which GERH^® offers data on susceptibility to daptomycin, vancomycin, teicoplanin, linezolid, and rifampicin. Full adherence to LRM recommendations would have improved the percentage adequacy of empirical prescriptions by 2.2% for lower respiratory tract infections (p = 0.018), 3.1% for bacteremia (p = 0.07), and 5.3% for urinary tract infections (p = 0.142). LRMs may moderately improve the adequacy of empirical antibiotic therapy, especially for lower respiratory tract infections. LRMs recommend appropriate prescriptions in approximately 50% of cases but are less useful in patients with bacteremia or urinary tract infection.

Variation in antibiotic use across intensive care units (ICU): A population-based cohort study in Ontario, Canada

OBJECTIVES

Antibiotics are commonly used in intensive care units (ICUs), yet differences in antibiotic use across ICUs are unknown. Herein, we studied antibiotic use across ICUs and examined factors that contributed to variation.

METHODS

We conducted a retrospective cohort study using data from Ontario's Critical Care Information System (CCIS), which included 201 adult ICUs and 2,013,397 patient days from January 2012 to June 2016. Antibiotic use was measured in days of therapy (DOT) per 1,000 patient days. ICU factors included ability to provide ventilator support (level 3) or not (level 2), ICU type (medical-surgical or other), and academic status. Patient factors included severity of illness using multiple-organ dysfunction score (MODS), ventilatory support, and central venous catheter (CVC) use. We analyzed the effect of these factors on variation in antibiotic use.

RESULTS

Overall, 269,351 patients (56%) received antibiotics during their ICU stay. The mean antibiotic use was 624 (range 3-1460) DOT per 1,000 patient days. Antibiotic use was significantly higher in medical-surgical ICUs compared to other ICUs (697 vs 410 DOT per 1,000 patient days; P < .0001) and in level 3 ICUs compared to level 2 ICUs (751 vs 513 DOT per 1,000 patient days; P < .0001). Higher antibiotic use was associated with higher severity of illness and intensity of treatment. ICU and patient factors explained 47% of the variation in antibiotic use across ICUs.

CONCLUSIONS

Antibiotic use varies widely across ICUs, which is partially associated with ICUs and patient characteristics. These differences highlight the importance of antimicrobial stewardship to ensure appropriate use of antibiotics in ICU patients.

Calculated parenteral initial treatment of bacterial infections: Economic aspects of antibiotic treatment

This is the seventeenth chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. This chapter analyses economic aspects of antiinfective therapy. Any treatment decision is also a cost decision. In this chapter the authors particularly analyse whether or not there is evidence that certain clinically effective strategies as Antimicrobial Stewardship programs (AMS), guideline adherent initial therapy, early diagnostics, De-escalation, sequence therapy or therapeutic drug monitoring also have benficial economic effects. These can be direct savings or shortening of length of stay to free resources.

Ventilator-associated pneumonia in patients with cerebral hemorrhage: Impact on mortality and microbiological characterization

Ventilator-associated pneumonia (VAP) is a major complication among critically ill patients who depend on mechanical ventilation. Few reports have focused on intracerebral hemorrhage patients with VAP. Our main objective was to investigate the bacteria distribution characteristics and the impact of ventilator-associated pneumonia mortality in critical cerebral hemorrhage patients. This retrospective study included 89 cases of cerebral hemorrhage patients with VAP admitted to the ICU of Huashan Hospital. We used the chi-square test to compare qualitative variables and Student's t-test to compare means between groups of normally distributed quantitative variables. Multiple logistic regression analysis was used to assess mortality-independent predictors in the ICU. A total of 42% patients with cerebral hemorrhage were diagnosed with VAP in the ICU during the study period, and the mortality rate was 18%. Acinetobacter baumannii (n=58), Klebsiella pneumoniae (n=52), and Pseudomonas aeruginosa (n=21) were the most common pathogenic bacteria. Blood volume >30ml, tracheal ventilation mode and head of bed elevation were independent factors associated with increased mortality. Glasgow Coma Scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the time from bleeding to intubation were other potentially important factors. While the number of infecting bacteria may not be directly related to death, it can increase antibiotic consumption and length of intensive care unit (ICU) stays. Blood volume >30ml, tracheal ventilation mode and head of bed elevation were directly related to the death of critical cerebral hemorrhage patients with ventilator-associated pneumonia.

When are combinations of antibiotics clinically useful?

Antimicrobial resistance is a global crisis. Prescribing antibacterial combinations may be one way of reducing the development of resistance in target pathogens, as in the treatment of tuberculosis. Combinations may be useful for ascertaining synergy, broadening antimicrobial cover to reduce the risk of non-susceptibility, antimicrobial stewardship reasons, and immune modulation. The current research literature and/or prevailing global standards of clinical care suggest that combination therapy may be advantageous in: severe community-acquired pneumonia; severe hospital-acquired or ventilator-associated pneumonia or when there is a high risk of resistance in hospital-acquired or ventilator-associated pneumonia; multi-drug or extensively drug-resistant Gram-negative infections; and severe group A streptococcal infections. In other situations, combinations may be harmful. Overall, outside of tuberculosis, combination antibacterial therapy is likely to improve outcomes only in specific circumstances and there is little evidence to suggest that this prevents the development of bacterial resistance. Further high-quality research is essential.