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Almajid A, Bazroon A, Albarbari H, Al-Awami HM, AlAhmed A, Bakhurji OM, Alharbi G, Aldawood F, AlKhamis Z, Alqarni M, Alabdullah M, Almutairi R. Evaluation of the Appropriateness of Piperacillin-Tazobactam Prescription in Community-Acquired Pneumonia: A Tertiary-Center Experience. Cureus 2023; 15:e51385. [PMID: 38292950 PMCID: PMC10825886 DOI: 10.7759/cureus.51385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 02/01/2024] Open
Abstract
Background Antimicrobial resistance (AMR) has been designated a public health crisis by the World Health Organization. AMR can lead to escalated healthcare costs, higher mortality rates, increased morbidity, and more frequent hospitalizations. This study aimed to retrospectively evaluate the appropriateness of Tazocin prescription for community-acquired pneumonia (CAP). Methodology We conducted a retrospective analysis of patients aged ≥18 years who were admitted with a diagnosis of CAP and administered intravenous Tazocin between November 2021 and October 2022. The primary objective was to assess the appropriateness of Tazocin prescriptions in patients with CAP. Results A total of 39 patients with CAP were included, with a mean age of 61 ± 17.36 years. Overall, 24 (61%) patients were male. The rate of inappropriate prescriptions of Tazocin was 66.6%. The incidence of inappropriate Tazocin prescription varied significantly among different medical specialties, with the highest rate observed in the oncology-palliative specialty (90%; p = 0.033). Conclusions Our study affirms the inclination of physicians to prescribe Tazocin for CAP without justifiable indications and highlights the unwarranted use of Tazocin for CAP across various medical specialties. This is evidenced by the notably high rate of inappropriate empirical prescriptions.
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Affiliation(s)
- Ali Almajid
- Department of Internal Medicine, King Fahad Specialist Hospital, Dammam, SAU
| | - Ali Bazroon
- Department of Internal Medicine, King Fahad Specialist Hospital, Dammam, SAU
| | - Hassan Albarbari
- Department of Internal Medicine, King Fahad Specialist Hospital, Dammam, SAU
| | - Hashim M Al-Awami
- Department of Internal Medicine, King Fahad Specialist Hospital, Dammam, SAU
| | - Alzahraa AlAhmed
- Faculty of Medicine, King Abdulaziz University Hospital, Jeddah, SAU
| | - Omar M Bakhurji
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | - Fatemah Aldawood
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Zainab AlKhamis
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Mohammed Alqarni
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | - Raghad Almutairi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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2
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Ovchinnikova OG, Treat LP, Teelucksingh T, Clarke BR, Miner TA, Whitfield C, Walker KA, Miller VL. Hypermucoviscosity Regulator RmpD Interacts with Wzc and Controls Capsular Polysaccharide Chain Length. mBio 2023; 14:e0080023. [PMID: 37140436 PMCID: PMC10294653 DOI: 10.1128/mbio.00800-23] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 05/05/2023] Open
Abstract
Klebsiella pneumoniae is a leading cause of nosocomial infections, including pneumonia, bacteremia, and urinary tract infections. Treatment options are increasingly restricted by the high prevalence of resistance to frontline antibiotics, including carbapenems, and the recently identified plasmid-conferred colistin resistance. The classical pathotype (cKp) is responsible for most of the nosocomial infections observed globally, and these isolates are often multidrug resistant. The hypervirulent pathotype (hvKp) is a primary pathogen capable of causing community-acquired infections in immunocompetent hosts. The hypermucoviscosity (HMV) phenotype is strongly associated with the increased virulence of hvKp isolates. Recent studies demonstrated that HMV requires capsule (CPS) synthesis and the small protein RmpD but is not dependent on the increased amount of capsule associated with hvKp. Here, we identified the structure of the capsular and extracellular polysaccharide isolated from hvKp strain KPPR1S (serotype K2) with and without RmpD. We found that the polymer repeat unit structure is the same in both strains and that it is identical to the K2 capsule. However, the chain length of CPS produced by strains expressing rmpD demonstrates more uniform length. This property was reconstituted in CPS from Escherichia coli isolates that possess the same CPS biosynthesis pathway as K. pneumoniae but naturally lack rmpD. Furthermore, we demonstrate that RmpD binds Wzc, a conserved capsule biosynthesis protein required for CPS polymerization and export. Based on these observations, we present a model for how the interaction of RmpD with Wzc could impact CPS chain length and HMV. IMPORTANCE Infections caused by Klebsiella pneumoniae continue to be a global public health threat; the treatment of these infections is complicated by the high frequency of multidrug resistance. K. pneumoniae produces a polysaccharide capsule required for virulence. Hypervirulent isolates also have a hypermucoviscous (HMV) phenotype that increases virulence, and we recently demonstrated that a horizontally acquired gene, rmpD, is required for HMV and hypervirulence but that the identity of the polymeric product(s) in HMV isolates is uncertain. Here, we demonstrate that RmpD regulates capsule chain length and interacts with Wzc, a part of the capsule polymerization and export machinery shared by many pathogens. We further show that RmpD confers HMV and regulates capsule chain length in a heterologous host (E. coli). As Wzc is a conserved protein found in many pathogens, it is possible that RmpD-mediated HMV and increased virulence may not be restricted to K. pneumoniae.
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Affiliation(s)
- Olga G. Ovchinnikova
- Department of Molecular and Cellular Biology, University of Guelph, Guelph, Ontario, Canada
| | - Logan P. Treat
- Department of Microbiology and Immunology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Tanisha Teelucksingh
- Department of Molecular and Cellular Biology, University of Guelph, Guelph, Ontario, Canada
| | - Bradley R. Clarke
- Department of Molecular and Cellular Biology, University of Guelph, Guelph, Ontario, Canada
| | - Taryn A. Miner
- Department of Microbiology and Immunology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Chris Whitfield
- Department of Molecular and Cellular Biology, University of Guelph, Guelph, Ontario, Canada
| | - Kimberly A. Walker
- Department of Microbiology and Immunology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Virginia L. Miller
- Department of Microbiology and Immunology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Department of Genetics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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3
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Vieceli T, Rello J. Optimization of antimicrobial prescription in the hospital. Eur J Intern Med 2022; 106:39-44. [PMID: 36100471 DOI: 10.1016/j.ejim.2022.08.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/17/2022] [Accepted: 08/29/2022] [Indexed: 11/03/2022]
Abstract
Internal Medicine wards are an appropriate focus of antibiotic stewardship, along with emergency departments and intensive care units, because a large proportion of patients are with parenteral broad-spectrum antibiotics. Given the unmet clinical need of antibiotic optimization in the hospital and the importance of front-line practitioners for antibiotic stewardship, the barriers and tactics to overcome them were discussed in a round table at the European Congress of Internal Medicine. Better rapid diagnostic tests should help to increase appropriate early antibiotic rates, favoring diversity in antibiotic choices adapted to the awareness of local resistance patterns. Providing such is a greater challenge in low-resource settings. Prescriptions should be personalized, adjusting dosage and source control to specific patients' conditions. Shorter antibiotic duration and de-escalation are major drivers to reduce adverse events, with mortality and recurrence rates being independent of antimicrobial duration. Appropriate diagnostic tests with quick turnaround times decrease excessive antibiotic use. Antimicrobial optimization requires a multidisciplinary approach and it should be a core competence of training specialists, improving opportunities to provide safer patient care.
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Affiliation(s)
- T Vieceli
- Infectious Diseases Department, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, 90035-007, Porto Alegre, RS, Brazil.
| | - J Rello
- Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Research Institute, Barcelona, Spain; Clinical Research, CHU Nîmes, Nîmes, France; Medicine Department, Universitat Internacional de Catalunya, Sant Cugat del Valles, Barcelona, Spain.
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4
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Al-Sunaidar KA, Aziz NA, Hassan Y, Jamshed S, Sekar M. Association of Multidrug Resistance Bacteria and Clinical Outcomes of Adult Patients with Sepsis in the Intensive Care Unit. Trop Med Infect Dis 2022; 7:tropicalmed7110365. [PMID: 36355907 PMCID: PMC9692934 DOI: 10.3390/tropicalmed7110365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 10/01/2022] [Accepted: 10/07/2022] [Indexed: 11/12/2022] Open
Abstract
Background: Multi-drug resistance organisms (MDRO) often cause increased morbidity, mortality, and length of stays (LOS). However, there is uncertainty whether the infection of MDRO increase the morbidity, mortality, and ICU-LOS. Objective: This study was performed to determine the prevalence of MDRO in the ICU, the site of infection, and the association of MDRO or site of infection with mortality. The secondary outcome was determined by ascertaining the association of MDRO or site of infection with ICU-LOS. Methods: A retrospective cohort study was performed with adult sepsis patients in the ICU. Univariate and multivariate (MVA) logistic regression with cox regression modeling were performed to compute the association of MDRO with ICU mortality. MVA modelling was performed for ICU-LOS predictors. Results: Out of 228 patients, the isolated MDRO was 97 (42.5%), of which 78% were Gram-negative bacteria. The mortality rate among those with MDRO was 85 (37.3%). The hospital acquired infection (HAI) was a significant predictor for ICU-LOS in univariate linear regression (R2 = 0.034, p = 0.005). In MVA linear regression, both Enterococcus faecalis infection and Acinetobacter baumannii (AC)-MDRO were predictors for ICU-LOS with (R2 = 0.478, p < 0.05). In the univariate cox regression, only the infection with AC-MDRO was a risk factor for ICU-mortality with [HR = 1.802 (95% CI: 1.2−2.706; p = 0.005)]. Conclusions: Identifying risk factors for MDRO addresses the appropriate administration of empirical antibiotics and allows to effectively control the source of infection, which would reduce mortality and ICU-LOS. The usage of broad-spectrum antibiotics should be limited to those with substantial risk factors for acquiring MDRO.
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Affiliation(s)
- Khalid Ahmad Al-Sunaidar
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy and Health Sciences, Royal College of Medicine Perak, Universiti Kuala Lumpur, Ipoh 30450, Perak, Malaysia
- Correspondence: ; Tel.: +60-11-2387-8780
| | - Noorizan Abd Aziz
- Department of Clinical Pharmacy, Faculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam 42300, Selangor, Malaysia
| | - Yahaya Hassan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam 42300, Selangor, Malaysia
| | - Shazia Jamshed
- Department of Clinical Pharmacy and Practice, Faculty of Pharmacy, Universiti Sultan Zainal Abidin, Besut 22200, Terengganu, Malaysia
| | - Mahendran Sekar
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy and Health Sciences, Royal College of Medicine Perak, Universiti Kuala Lumpur, Ipoh 30450, Perak, Malaysia
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Chabert P, Provoost J, Cohen S, Dupieux-Chabert C, Bitker L, Ferry T, Goutelle S, Richard JC. Pharmacokinetics, efficacy and tolerance of cefoxitin in the treatment of cefoxitin-susceptible extended-spectrum beta-lactamase producing Enterobacterales infections in critically ill patients: a retrospective single-center study. Ann Intensive Care 2022; 12:90. [PMID: 36175707 PMCID: PMC9522958 DOI: 10.1186/s13613-022-01059-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 09/01/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cefoxitin is active against some extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-PE), but has not been evaluated so far in the intensive care unit (ICU) settings. Data upon its pharmacokinetics (PK), tolerance and efficacy in critical conditions are scanty. We performed a retrospective single-center study in a university hospital medical ICU, in subjects presenting with cefoxitin-susceptible ESBL-PE infection and treated with cefoxitin. The primary aim was to determine cefoxitin PK. Secondary endpoints were efficacy, tolerance, and emergence of cephamycin-resistance. RESULTS Forty-one patients were included in this study, mainly with ESBL-PE pneumonia (35 patients, 85%). Cefoxitin was administered during a median [interquartile range (IQR)] duration of 5 [4-7] days. Cefoxitin serum concentrations strongly depended on renal function. Target serum concentration (> 5 × minimum inhibitory concentration (MIC) 24 h after cefoxitin onset was obtained in 34 patients (83%), using a median [IQR] daily dose of 6 [6-6] g with continuous administration. The standard dosage of 6 g/24 h was not sufficient to achieve the PK/PD target serum concentration for MIC up to 4-8 mg/L, except in patients with severe renal impairment and those treated with renal replacement therapy. Treatment failure occurred in 26 cases (63%), among whom 12 patients (29%) died, 13 patients (32%) were switched to alternative antibiotic therapy and 11 patients (27%) presented with relapse of infection with the same ESBL-PE. Serious adverse events attributed to cefoxitin occurred in 7 patients (17%). Acquisition of cephamycin-resistance with the same Enterobacterales was identified in 13 patients (32%), and was associated with underdosage. CONCLUSION Continuous administration of large doses of cefoxitin appears necessary to achieve the PK/PD target in patients with normal renal function. Renal status, MIC determination and therapeutic drug monitoring may be useful for treatment individualization in this setting. The treatment failure rate was 63%. The cefoxitin safety profile was favorable, but we observed a high rate of cephamycin-resistance emergence.
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Affiliation(s)
- Paul Chabert
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France. .,Hospices Civils de Lyon, Maladies Infectieuses et Tropicales, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France.
| | - Judith Provoost
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France
| | - Sabine Cohen
- Unité Fonctionnelle de Pharmacologie Spécialisée, Hospices Civils de Lyon, UM de Pharmaco-Toxicologie, Centre Hospitalier Lyon Sud, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite Cedex, France
| | - Céline Dupieux-Chabert
- Hospices Civils de Lyon, Institut Des Agents Infectieux, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France
| | - Laurent Bitker
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, 92 rue Pasteur, CS 30122, 69361, Lyon Cedex 07, France.,Université Claude Bernard Lyon 1, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France.,CREATIS UMR 5220, INSA-Lyon, CNRS, INSERM, U1294, Université de Lyon, Université Claude Bernard Lyon 1, 69621, Lyon, France
| | - Tristan Ferry
- Hospices Civils de Lyon, Maladies Infectieuses et Tropicales, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, 92 rue Pasteur, CS 30122, 69361, Lyon Cedex 07, France.,Université Claude Bernard Lyon 1, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France
| | - Sylvain Goutelle
- Université de Lyon, 92 rue Pasteur, CS 30122, 69361, Lyon Cedex 07, France.,Université Claude Bernard Lyon 1, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France.,Service de Pharmacie, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France.,UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Université de Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Jean-Christophe Richard
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, 92 rue Pasteur, CS 30122, 69361, Lyon Cedex 07, France.,Université Claude Bernard Lyon 1, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France.,CREATIS UMR 5220, INSA-Lyon, CNRS, INSERM, U1294, Université de Lyon, Université Claude Bernard Lyon 1, 69621, Lyon, France
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6
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Tan WW, Watt KM, Boakye-Agyeman F, Cohen-Wolkowiez M, Mok YH, Yung CF, Chan YH. Optimal Dosing of Meropenem in a Small Cohort of Critically Ill Children Receiving Continuous Renal Replacement Therapy. J Clin Pharmacol 2021; 61:744-754. [PMID: 33314163 PMCID: PMC8089047 DOI: 10.1002/jcph.1798] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/07/2020] [Indexed: 11/10/2022]
Abstract
Severe sepsis is an important cause of mortality and morbidity in critically ill children. Meropenem is a broad-spectrum antibiotic commonly used to treat sepsis. Current meropenem dosage recommendations for children on continuous renal replacement therapy are extrapolated from pharmacokinetic (PK) studies done in adults. Our study aims to determine the optimal dosing in critically ill septic children receiving continuous renal replacement therapy. A prospective single-center PK study was performed in 9 children in the intensive care unit on continuous renal replacement therapy. Meropenem concentrations were measured from blood and effluent fluid samples. A population PK model was developed using nonlinear mixed-effects modeling software (NONMEM, AstraZeneca UK Ltd, Cheshire, UK). Monte Carlo simulations were performed. The PK/pharmacodynamic target aimed for plasma concentrations above minimum inhibitory concentration of 4 mg/L for 100% of dosing interval (100%ƒT>MIC ). A 2-compartment model best characterized meropenem PK. Mean (range) clearance and elimination half-life was 0.091 L/h/kg (0.04-0.157) and 3.9 hours (2.1-7.5), respectively. Dosing of 40 mg/kg/dose every 12 hours over 30 minutes achieved PK/PD target in only 32% while 20 mg/kg every 8 hours over 4 hours or 40 mg/kg every 8 hours over 2 hours achieved 100% ƒT>MIC target for at least 90% of simulated patients.
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Affiliation(s)
- Wei Wei Tan
- Department of Pharmacy, KK Women's and Children's Hospital, Singapore, Singapore
| | - Kevin M Watt
- Pharmacometrics Center, Duke Clinical Research Institute (DCRI), Durham, North Carolina, USA
| | - Felix Boakye-Agyeman
- Integrated Drug Development, Certara Strategic Consulting, Certara USA, Inc. 100 Overlook Center, Princeton, New Jersey, USA
| | - Michael Cohen-Wolkowiez
- Pharmacometrics Center, Duke Clinical Research Institute (DCRI), Durham, North Carolina, USA
| | - Yee Hui Mok
- Department of Paediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Chee Fu Yung
- Department of Paediatric Medicine, Infectious Disease Service, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- Department of Paediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
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7
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Mbadugha UJ, Surani S, Akuffo N, Udeani G. Antimicrobial Therapy for Pneumonia or Fluid Overload? Cureus 2021; 13:e12719. [PMID: 33614323 PMCID: PMC7883562 DOI: 10.7759/cureus.12719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 11/23/2022] Open
Abstract
Patients with evidence of fluid overload or heart failure (HF) without clinical symptoms of pneumonia are often treated with antimicrobial therapy for pneumonia. We conducted a retrospective study to evaluate the use of antimicrobial therapy in critically ill patients with fluid overload or heart failure diagnosed as pneumonia. A retrospective chart review of patients on antimicrobial therapy treated for pneumonia in the intensive care unit was conducted. The study's primary outcome was the number of cases with no evidence of pneumonia, including fluid overload or heart failure, managed with antimicrobial therapy for pneumonia. Patients on antimicrobial therapy for other infections were excluded. Appropriateness of antimicrobial therapy was based on radiographic evidence, clinical data, and presentation. Patient group categories were A (pneumonia) and B (no evidence of pneumonia, fluid overload, and heart failure). Based on the subdivision of patients in Group B, where there was no evidence of pneumonia, we further classified it into two subgroups: heart failure (HF)/fluid overload (Group B1) and no evidence of HF or fluid overload (Group B2). Patients with evidence of pneumonia (Group A) were compared to the group with fluid overload and heart failure (Group B1). A p-value of < 0.05% was considered significant for detecting statistical difference. Post-screening, data on 56 patients were collected for the study and analyzed. Mean body temperature and white blood cell count were 37.6 + 0.6 oC, and 17.4 + 6.88 x103 µL, respectively. Based on radiographic evidence, clinical data, and presentation, 29 (52%) were classified under Group A, while 27 (48%) were classified under Group B. Median brain natriuretic peptide (BNP) for Group A vs. Group B was 514 (IQR: 1077) vs. 758 (2212) pg/mL p=0.14. The median duration of inpatient antimicrobial therapy was 7 (interquartile range [IQR]: 6) vs. 6 (IQR: 4) days, p=0.52, while the median duration of the total (inpatient and discharge prescription) antimicrobial therapy was 11 (IQR: 6) vs. 11 (IQR: 5), p=0.21. Patients with evidence of pneumonia (Group A) were compared to the group with fluid overload and heart failure (Group B1). The median BNP for the two groups was 514 (IQR: 1077) vs. 1040 (2094) pg/mL, p=0.04. Patients with documented echocardiographic evidence of ejection fraction < 55% were 4 vs. 14 for Groups A and B1, respectively. Additionally, the median BNP for Group A vs. Group B2 was 514 (IQR: 1077) vs. 189 (418) pg/mL, p=0.02. These findings demonstrate a 48% inappropriate use of antimicrobial therapy in patients with congestive heart failure (CHF), or fluid congestion misdiagnosed as pneumonia. There was a significant difference in the median BNP observed in patients with pneumonia compared to those with fluid overload and heart failure treated as pneumonia. More cases of patients with elevated BNP and reduced left ventricular ejection fraction (LVEF) were observed in patients with fluid overload or CHF treated as pneumonia than those diagnosed with pneumonia alone. Appropriate interpretation of radiographic evidence, laboratory data, and critical clinical assessment for the use of empiric antimicrobial therapy in this population is warranted.
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Affiliation(s)
- Uche J Mbadugha
- Pharmacy, Corpus Christi Medical Center, Corpus Christi, USA
| | - Salim Surani
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA
- Internal Medicine, University of North Texas, Dallas, USA
| | - Nana Akuffo
- Pharmacy, Hospital Corporation of America, Houston, USA
| | - George Udeani
- Pharmacy, College of Pharmacy, Texas A&M University, Kingsville, USA
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8
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Jovanovic B, Djuric O, Hadzibegovic A, Jovanovic S, Stanisavljevic J, Milenkovic M, Rajkovic M, Ratkovic S, Markovic-Denic L. Trauma and Antimicrobial Resistance Are Independent Predictors of Inadequate Empirical Antimicrobial Treatment of Ventilator-Associated Pneumonia in Critically Ill Patients. Surg Infect (Larchmt) 2021; 22:730-737. [PMID: 33439780 DOI: 10.1089/sur.2020.306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Bojan Jovanovic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Center for Anesthesia and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | - Olivera Djuric
- Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Center for Environmental, Nutritional and Genetic Epidemiology (CREAGEN), Section of Public Health, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Adi Hadzibegovic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Center for Anesthesia and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | - Snezana Jovanovic
- Department of Microbiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Jovana Stanisavljevic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Center for Anesthesia and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | - Marija Milenkovic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Center for Anesthesia and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | - Marija Rajkovic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Center for Anesthesia and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | - Sanja Ratkovic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Center for Anesthesia and Resuscitation, Clinical Center of Serbia, Belgrade, Serbia
| | - Ljiljana Markovic-Denic
- Faculty of Medicine, School of Medicine, University of Belgrade, Belgrade, Serbia.,Institute of Epidemiology, School of Medicine, University of Belgrade, Belgrade, Serbia
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9
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Shu H, Li L, Wang Y, Guo Y, Wang C, Yang C, Gu L, Cao B. Prediction of the Risk of Hospital Deaths in Patients with Hospital-Acquired Pneumonia Caused by Multidrug-Resistant Acinetobacter baumannii Infection: A Multi-Center Study. Infect Drug Resist 2020; 13:4147-4154. [PMID: 33244244 PMCID: PMC7683351 DOI: 10.2147/idr.s265195] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 10/15/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To predict the risk of hospital deaths in patients with hospital-acquired pneumonia (HAP) caused by multidrug-resistant Acinetobacter baumannii (MDR-AB) infection. Patients and Methods A total of 366 patients who were diagnosed with HAP caused by MDR-AB infection were enrolled between January 2013 and December 2016. The sociological characteristics and clinical data of these cases were collected. Univariate and multivariate logistic analyses were used to explore the risk factors of hospital deaths before medication and after drug withdrawal. The receiver operating characteristic (ROC) curve and the area under the curve (AUC) were utilized to assess the predictive effectiveness of the models with or without the adjustment. Results Hospital deaths occurred in 142 cases (38.80%). The results showed that acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure assessment (SOFA) scores before medication and after drug withdrawal were associated with the risk of hospital deaths. Adjusting the covariants including the age, autoimmune disease, venous cannula, transfer of patients from other hospitals, and APACHE II score at admission, then no differences were discovered in predicting the hospital deaths between adjusted APACHE II and adjusted SOFA scores before medication (AUC: 0.808 vs 0.803, P =0.614) and after drug withdrawal (AUC: 0.876 vs 0.878, P =0.789). Conclusion Before medication or after drug withdrawal, the adjusted APACHE II and adjusted SOFA scores all performed well in determining the predictive effectiveness of the hospital deaths in patients with HAP caused by MDR-AB infection, indicating that the appropriate infection control may reduce the occurrence of nosocomial deaths and improve the prognosis.
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Affiliation(s)
- Hongmei Shu
- Department of Pulmonary and Critical Care Medicine, Xuanwu Hospital Capital Medical University, Beijing, People's Republic of China.,Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Department of Respiration, Anqing Municipal Hospital, Anqing Hospital of Anhui Medical University, Anhui 246000, People's Republic of China
| | - Lijuan Li
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Yimin Wang
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Yiqun Guo
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, People's Republic of China
| | - Chunlei Wang
- Laboratory of Clinical Microbiology and Infectious Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Chunxia Yang
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, People's Republic of China
| | - Li Gu
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, People's Republic of China
| | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Laboratory of Clinical Microbiology and Infectious Diseases, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; National Clinical Research Center of Respiratory Disease, Clinical Center for Pulmonary Infection, Capital Medical University, Tsinghua University-Peking University Joint Center for Life Sciences, Beijing 100029, People's Republic of China
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10
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Kurniawan FD, Alia D, Priyanto H, Mahdani W, Hagiwara K. HIRA-TAN detects pathogens of pneumonia with a progressive course despite antibiotic treatment. Respir Investig 2019; 57:337-344. [PMID: 31031122 DOI: 10.1016/j.resinv.2019.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/09/2019] [Accepted: 03/05/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Empiric antibiotics are administered for pneumonia when the causative pathogens are unidentified. Pathogen-directed therapy is impeded by negative culture results and/or culture time lag. This circumstance necessitates a salvage method for pathogen identification, especially when antibiotic therapy has failed. Here, we aimed to preliminarily investigate the HIRA-TAN method in pneumonia with a progressive course despite prior empiric antibiotic therapy. METHODS This prospective study was conducted for patients who were referred to Dr. Zainoel Abidin Hospital, Aceh, Indonesia, from December 2016 to January 2017, owing to pneumonia with a progressive course. Sputum or pleural effusion was subjected to culture and the HIRA-TAN assay. The HIRA-TAN identified the candidate causative pathogens based on the difference in the cycle threshold (Ct) between the targeted pathogen and the single-copy human gene. RESULTS Patients (n=27) were predominantly males (22 patients, 81.5%), with a median age of 62 years. All patients had comorbid disease and were classified as hospital-acquired pneumonia (25 patients, 92.6%) with multilobar infiltrates (22 patients, 81.5%). Bacterial culture identified causative pathogen(s) in some (14 patients, 51.8%), whereas the HIRA-TAN identified pathogen(s) in most (23 patients, 85.2%). The rapid pathogen identification by the HIRA-TAN will provide valuable information in guiding pathogen-directed therapy. CONCLUSIONS The result warrants a larger clinical trial to confirm the clinical efficacy of the HIRA-TAN in patients with progressive pneumonia despite previous antibiotic treatment.
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Affiliation(s)
- Ferry Dwi Kurniawan
- Pulmonology Department, Faculty of Medicine, Syiah Kuala University, Dr. Zainoel Abidin Hospital, Aceh, Indonesia; Comprehensive Medicine 1, Saitama Medical Centre, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503, Japan
| | - Dina Alia
- Comprehensive Medicine 1, Saitama Medical Centre, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503, Japan
| | - Herry Priyanto
- Pulmonology Department, Faculty of Medicine, Syiah Kuala University, Dr. Zainoel Abidin Hospital, Aceh, Indonesia
| | - Wilda Mahdani
- Microbiology Department, Faculty of Medicine, Syiah Kuala University, Dr. Zainoel Abidin Hospital, Aceh, Indonesia
| | - Koichi Hagiwara
- Comprehensive Medicine 1, Saitama Medical Centre, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503, Japan; Division of Pulmonary Medicine, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan.
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11
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Ha DR, Haste NM, Gluckstein DP. The Role of Antibiotic Stewardship in Promoting Appropriate Antibiotic Use. Am J Lifestyle Med 2019; 13:376-383. [PMID: 31285722 PMCID: PMC6600622 DOI: 10.1177/1559827617700824] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/28/2017] [Accepted: 03/02/2017] [Indexed: 12/20/2022] Open
Abstract
Antibiotics are one of the most significant medical discoveries in human history. The widespread use of antibiotics has resulted in the emergence of antibiotic-resistant pathogens. This fact, coupled with the paucity of new antibiotic developments, has spurred efforts to combat antibiotic resistance. One of the most critical components of these efforts is antibiotic stewardship, a multidisciplinary endeavor, employing a collection of interventions in a variety of health care settings with the aim of promoting appropriate utilization of antibiotics. This article describes antibiotic stewardship programs and key practices used to minimize the development and spread of antibiotic-resistant pathogens including the optimization of antibiotic pharmacokinetics and pharmacodynamics, the application of rapid diagnostic tools, and the use of computerized provider order entry tools.
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Affiliation(s)
- David R. Ha
- David R. Ha, PharmD, Keck Graduate Institute
School of Pharmacy, 535 Watson Drive, Claremont, CA 91711; e-mail:
| | - Nina M. Haste
- Keck Graduate Institute School of Pharmacy, Pomona
Valley Hospital Medical Center, Claremont, California (DRH)
- University of California San Diego Health and
University of California San Diego Skaggs School of Pharmacy and Pharmaceutical
Sciences, La Jolla, California (NMH)
- Infectious Diseases, Pomona Valley Hospital Medical
Center, Pomona, California (DPG)
| | - Daniel P. Gluckstein
- Keck Graduate Institute School of Pharmacy, Pomona
Valley Hospital Medical Center, Claremont, California (DRH)
- University of California San Diego Health and
University of California San Diego Skaggs School of Pharmacy and Pharmaceutical
Sciences, La Jolla, California (NMH)
- Infectious Diseases, Pomona Valley Hospital Medical
Center, Pomona, California (DPG)
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12
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Song KH, Jung SI, Lee S, Park S, Kim ES, Park KH, Park WB, Choe PG, Kim YK, Kwak YG, Kim YS, Jang HC, Kiem S, Kim HI, Kim HB. Inoculum effect of methicillin-susceptible Staphylococcus aureus against broad-spectrum beta-lactam antibiotics. Eur J Clin Microbiol Infect Dis 2018; 38:67-74. [PMID: 30269181 DOI: 10.1007/s10096-018-3392-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 09/21/2018] [Indexed: 11/29/2022]
Abstract
Scarce information concerning the inoculum effect (InE) of methicillin-susceptible Staphylococcus aureus (MSSA) against broad-spectrum β-lactam antibiotics is available. We investigated the InE of MSSA against ceftriaxone, cefepime, meropenem, ampicillin/sulbactam and piperacillin/tazobactam. The bacteraemic MSSA isolates were collected at ten Korean general hospitals from Sep 2013 to Mar 2015. The InE was defined if MICs of antibiotics at high inoculum (HI, ~5 × 107 CFU/ml) increased beyond the susceptible range compared to those at standard inoculum (SI, ~5 × 105 CFU/ml). All isolates were sequenced for blaZ gene typing. Among 302 MSSA isolates, 254 (84.1%) were positive for blaZ; types A, B, C and D were 13.6%, 26.8%, 43.4% and 0.3%, respectively. Mean HI MICs of all tested antibiotics were significantly increased and increases in HI MIC of piperacillin/tazobactam (HI, 48.14 ± 4.08 vs. SI, 2.04 ± 0.08 mg/L, p < 0.001) and ampicillin/sulbactam (HI, 24.15 ± 1.27 vs. SI, 2.79 ± 0.11 mg/L, p < 0.001) were most prominent. No MSSA isolates exhibited meropenem InE, and few isolates exhibited cefepime (0.3%) and ceftriaxone (2.3%) InE, whereas 43.0% and 65.9% of MSSA isolates exhibited piperacillin/tazobactam and ampicillin/sulbactam InE, respectively. About 93% of type C blaZ versus 45% of non-type C exhibited ampicillin/sulbactam InE (p < 0.001) and 88% of type C blaZ versus 9% of non-type C exhibited piperacillin/tazobactam InE (p < 0.001). A large proportion of MSSA clinical isolates, especially those positive for type C blaZ, showed marked ampicillin/sulbactam InE and piperacillin/tazobactam.
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Affiliation(s)
- Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sook-In Jung
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Shinwon Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, 49241, Republic of Korea.
| | - Sohee Park
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan, 49241, Republic of Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kyung-Hwa Park
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Keun Kim
- Department of Internal Medicine, Yonsei University Medical School, Wonju, Republic of Korea
| | - Yee Gyung Kwak
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Yeon-Sook Kim
- Division of Infectious Diseases, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Hee-Chang Jang
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Hwasun, Jeollanam-do, Republic of Korea
| | - Sungmin Kiem
- Department of Internal Medicine, Inje University College of Medicine, Busan, Republic of Korea
| | - Hye-In Kim
- Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Republic of Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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13
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A Nonparametric Pharmacokinetic Approach to Determine the Optimal Dosing Regimen for 30-Minute and 3-Hour Meropenem Infusions in Critically Ill Patients. Ther Drug Monit 2017; 38:593-9. [PMID: 27454665 DOI: 10.1097/ftd.0000000000000323] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pharmacokinetics of meropenem differ widely in the critically ill population. It is imperative to maintain meropenem concentrations above the inhibitory concentrations for most of the interdose interval. A population pharmacokinetic/pharmacodynamic model was developed to determine the probability of target attainment for 3-hour and 30-minute infusion regimens in this population. METHODS This study was performed in an intensive care setting among adult patients who were initiated on meropenem at a dose of 1000 mg. Multiple blood specimens were collected at predetermined time points during the interdose period, and meropenem concentrations were measured using high performance liquid chromatography. Using Pmetrics, a pharmacokinetic/pharmacodynamic model was developed and validated. Monte Carlo simulation was performed, and probability of target attainment (100% T > minimum inhibitory concentration (MIC), with a probability >0.9) for doubling MICs was determined for different regimens of meropenem. RESULTS A 2-compartment multiplicative gamma error model best described the population parameters from 34 patients. The pharmacokinetic parameters used in the final model were Ke (elimination rate constant from the central compartment), Vc (volume of distribution of central compartment), KCP and KPC (intercompartmental rate constants), and IC2 (the fitted amount of meropenem in the peripheral compartment). Inclusion of creatinine clearance (CLcreat) and body weight as covariates improved the model prediction (Ke = Ke0 × (Equation is included in full-text article.), Vc = Vc0 × Weight). The Ke and Vc [geometric mean (range)] of the individuals were 0.54 (0.01-2.61)/h and 9.36 (4.35-21.62) L, respectively. The probability of attaining the target, T > MIC of 100%, was higher for 3-hour infusion regimens compared with 30-minute infusion regimens for all ranges of CLcreat. CONCLUSIONS This study emphasizes that extended regimens of meropenem are preferable for treating infections caused by bacteria with higher MICs. The nonparametric analysis using body weight and CLcreat as covariate adequately predicted the pharmacokinetics of meropenem in critically ill patients with a wide range of renal function.
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14
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Ting SW, Lee CH, Liu JW. Risk factors and outcomes for the acquisition of carbapenem-resistant Gram-negative bacillus bacteremia: A retrospective propensity-matched case control study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2017; 51:621-628. [PMID: 28732563 DOI: 10.1016/j.jmii.2016.08.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/31/2016] [Accepted: 08/31/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND/PURPOSE A substantial number of carbapenem-resistant Gram-negative bacilli (CR GNB) have been identified among the etiologic multidrug-resistant GNB in healthcare-associated infections. For achieving a better therapeutic outcome by minimizing inappropriate empirical antibiotic treatment before blood culture and susceptibility testing results are available, it is very important to identify patients who are at risk for the development of CR GNB bacteremia. METHODS Retrospective analysis of propensity-score matched (PSM) adult patients with CR GNB bacteremia (PSM-group 1 [n = 95]) and those with non-CR GNB bacteremia (PSM-group 2 [n = 190]). RESULTS PSM-group 1 was found to a significantly longer length of hospital stay (27 vs. 18 days; p < 0.001) after emerging GNB bacteremia and a higher 30-day all-cause mortality rate (27.4% vs. 5.8%; p < 0.001), when compared with PSM-2 group. Independent risk factors for the acquisition of CR GNB bacteremia were previous exposure to an antipseudomonal penicillin (odds ratio [OR] = 3.58; 95% confidence interval [CI] = 1.30-9.90), an antipseudomonal cephalosporin (OR = 3.49; 95% CI = 1.09-11.24), and a carbapenem (OR = 3.60; 95% CI = 1.37-9.47), and longer length of hospital stay before the development of GNB bacteremia (OR = 1.03; 95% CI = 1.01-1.05). CONCLUSION Risk factors for acquisition of CR GNB bacteremia identified in this study each may serve as a reminder alerting clinicians to hospitalized patients at risk for CR GNB bacteremia requiring appropriate antibiotic coverage, and in these circumstances, combined antibiotics may be used until antimicrobial de-escalation/adjustment is clearly indicated by the subsequently identified pathogenic GNB and its susceptibility profile.
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Affiliation(s)
- Shih-Wen Ting
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chen-Hsiang Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jien-Wei Liu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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15
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Personne Y, Ozongwu C, Platt G, Basurto-Lozada P, Shamin M, Gant V, Zumla A, Enne V. ‘Sample-in, answer-out’? Evaluation and comprehensive analysis of the Unyvero P50 pneumonia assay. Diagn Microbiol Infect Dis 2016; 86:5-10. [DOI: 10.1016/j.diagmicrobio.2016.06.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/01/2016] [Accepted: 06/09/2016] [Indexed: 01/10/2023]
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16
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Falcó V, Burgos J, Papiol E, Ferrer R, Almirante B. Investigational drugs in phase I and phase II clincial trials for the treatment of hospital-acquired pneumonia. Expert Opin Investig Drugs 2016; 25:653-65. [PMID: 26998623 DOI: 10.1517/13543784.2016.1168803] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Hospital acquired pneumonia (HAP) is one of the main infections acquired by patients during a stay in hospital. The main issue when dealing with patients with HAP and ventilator associated pneumonia (VAP) is the increasing role of multi-drug resistant organisms (MDROs). AREAS COVERED In this review the authors summarize the actual situation of MDROs as a cause of HAP and VAP. They also review the current treatment options stated in the most important international guidelines. Finally, they focus on the investigational drugs that have reached the phase III stage of development and the novel compounds that are being studied in phase I and II clinical trials. EXPERT OPINION Thanks to their excellent activity against MDROs, drugs in development for the treatment of HAP and VAP can significantly improve the therapeutic options available. In selected patients, the possibility to administer directed therapy with monoclonal antibodies to specific pathogens is an exciting strategy in the fight against widespread resistance.
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Affiliation(s)
- Vicenç Falcó
- a Infectious Diseases Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Joaquin Burgos
- a Infectious Diseases Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Elisabeth Papiol
- b Intensive Care Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Ricard Ferrer
- b Intensive Care Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
| | - Benito Almirante
- a Infectious Diseases Department, University Hospital Vall d'Hebron , Universitat Autònoma de Barcelona , Barcelona , Spain
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17
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Bassetti M, Welte T, Wunderink RG. Treatment of Gram-negative pneumonia in the critical care setting: is the beta-lactam antibiotic backbone broken beyond repair? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:19. [PMID: 26821535 PMCID: PMC4731981 DOI: 10.1186/s13054-016-1197-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Beta-lactam antibiotics form the backbone of treatment for Gram-negative pneumonia in mechanically ventilated patients in the intensive care unit. However, this beta-lactam antibiotic backbone is increasingly under pressure from emerging resistance across all geographical regions, and health-care professionals in many countries are rapidly running out of effective treatment options. Even in regions that currently have only low levels of resistance, the effects of globalization are likely to increase local pressures on the beta-lactam antibiotic backbone in the near future. Therefore, clinicians are increasingly faced with a difficult balancing act: the need to prescribe adequate and appropriate antibiotic therapy while reducing the emergence of resistance and the overuse of antibiotics. In this review, we explore the burden of Gram-negative pneumonia in the critical care setting and the pressure that antibiotic resistance places on current empiric therapy regimens (and the beta-lactam antibiotic backbone) in this patient population. New treatment approaches, such as systemic and inhaled antibiotic alternatives, are on the horizon and are likely to help tackle the rising levels of beta-lactam antibiotic resistance. In the meantime, it is imperative that the beta-lactam antibiotic backbone of currently available antibiotics be supported through stringent antibiotic stewardship programs.
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Affiliation(s)
- Matteo Bassetti
- Santa Maria Misericordia University Hospital, Piazzale S. Maria Misericordia 15, 33100, Udine, Italy.
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany
| | - Richard G Wunderink
- Northwestern University Feinberg School of Medicine, 676 North St. Clair Street, Arkes 14-015, Chicago, IL, 60611, USA
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O’Dowd H, Shannon DE, Chandupatla KR, Dixit V, Engtrakul JJ, Ye Z, Jones SM, O’Brien CF, Nicolau DP, Tessier PR, Crandon JL, Song B, Macikenas D, Hanzelka BL, Le Tiran A, Bennani YL, Charifson PS, Grillot AL. Discovery and Characterization of a Water-Soluble Prodrug of a Dual Inhibitor of Bacterial DNA Gyrase and Topoisomerase IV. ACS Med Chem Lett 2015; 6:822-6. [PMID: 26191374 DOI: 10.1021/acsmedchemlett.5b00196] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 06/22/2015] [Indexed: 11/29/2022] Open
Abstract
Benzimidazole 1 is the lead compound resulting from an antibacterial program targeting dual inhibitors of bacterial DNA gyrase and topoisomerase IV. With the goal of improving key drug-like properties, namely, the solubility and the formulability of 1, an effort to identify prodrugs was undertaken. This has led to the discovery of a phosphate ester prodrug 2. This prodrug is rapidly cleaved to the parent drug molecule upon both oral and intravenous administration. The prodrug achieved equivalent exposure of 1 compared to dosing the parent in multiple species. The prodrug 2 has improved aqueous solubility, simplifying both intravenous and oral formulation.
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Affiliation(s)
- Hardwin O’Dowd
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
| | - Dean E. Shannon
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
| | - Kishan R. Chandupatla
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
| | - Vaishali Dixit
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
| | - Juntyma J. Engtrakul
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
| | - Zhengqi Ye
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
| | - Steven M. Jones
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
| | - Colleen F. O’Brien
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
| | - David P. Nicolau
- Center
for Anti-Infective Research and Development, Hartford Hospital, 80
Seymour Street, Hartford, Connecticut 06102, United States
| | - Pamela R. Tessier
- Center
for Anti-Infective Research and Development, Hartford Hospital, 80
Seymour Street, Hartford, Connecticut 06102, United States
| | - Jared L. Crandon
- Center
for Anti-Infective Research and Development, Hartford Hospital, 80
Seymour Street, Hartford, Connecticut 06102, United States
| | - Bin Song
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
| | - Dainius Macikenas
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
| | - Brian L. Hanzelka
- Vertex Pharmaceuticals Incorporated, 2500 Crosspark Road, Bioventures Center, Coralville, Iowa 52241, United States
| | - Arnaud Le Tiran
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
| | - Youssef L. Bennani
- Vertex Pharmaceuticals Incorporated, 275 Boulevard Armand Frappier, Laval, QC H7V 4A7, Canada
| | - Paul S. Charifson
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
| | - Anne-Laure Grillot
- Vertex Pharmaceuticals Incorporated, 50 Northern Avenue, Boston, Massachusetts 02210, United States
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19
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Douglas IS, Price CS, Overdier KH, Wolken RF, Metzger SW, Hance KR, Howson DC. Rapid automated microscopy for microbiological surveillance of ventilator-associated pneumonia. Am J Respir Crit Care Med 2015; 191:566-73. [PMID: 25585163 DOI: 10.1164/rccm.201408-1468oc] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Diagnosis of ventilator-associated pneumonia (VAP) is imprecise. OBJECTIVES To (1) determine whether alternate-day surveillance mini-bronchoalveolar lavage (mini-BAL) in ventilated adults could reduce time to initiation of targeted treatment and (2) evaluate the potential for automated microscopy to reduce analysis time. METHODS Adult intensive care unit patients who were anticipated to require ventilation for at least a further 48 hours were included. Mini-BALs were processed for identification, quantitation, and antibiotic susceptibility, using (1) clinical culture (50 ± 7 h) and (2) automated microscopy (∼5 h plus offline analysis). MEASUREMENTS AND MAIN RESULTS Seventy-seven mini-BALs were performed in 33 patients. One patient (3%) was clinically diagnosed with VAP. Of 73 paired samples, culture identified 7 containing pneumonia panel bacteria (>10(4) colony-forming units/ml) from five patients (15%) (4 Staphylococcus aureus [3 methicillin-resistant S. aureus], 2 Stenotrophomonas maltophilia, 1 Klebsiella pneumoniae) and resulted in antimicrobial changes/additions to two of five (40%) of those patients. Microscopy identified 7 of 7 microbiologically positive organisms and 64 of 66 negative samples compared with culture. Antimicrobial responses were concordant in four of five comparisons. Antimicrobial changes/additions would have occurred in three of seven microscopy-positive patients (43%) had those results been clinically available in 5 hours, including one patient diagnosed later with VAP despite negative mini-BAL cultures. CONCLUSIONS Microbiological surveillance detected infection in patients at risk for VAP independent of clinical signs, resulting in changes to antimicrobial therapy. Automated microscopy was 100% sensitive and 97% specific for high-risk pneumonia organisms compared with clinical culturing. Rapid microscopy-based surveillance may be informative for treatment and antimicrobial stewardship in patients at risk for VAP.
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Affiliation(s)
- Ivor S Douglas
- 1 Division of Pulmonary Sciences and Critical Care Medicine
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Population pharmacokinetics and Monte Carlo dosing simulations of meropenem during the early phase of severe sepsis and septic shock in critically ill patients in intensive care units. Antimicrob Agents Chemother 2015; 59:2995-3001. [PMID: 25753628 DOI: 10.1128/aac.04166-14] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 03/01/2015] [Indexed: 11/20/2022] Open
Abstract
Pathophysiological changes during the early phase of severe sepsis and septic shock in critically ill patients, resulting in altered pharmacokinetic (PK) patterns for antibiotics, are important factors influencing therapeutic success. The aims of this study were (i) to reveal the population PK parameters and (ii) to assess the probability of target attainment (PTA) for meropenem. The PK studies were carried out following administration of 1 g of meropenem every 8 h during the first 24 h of severe sepsis and septic shock in nine patients, and a Monte Carlo simulation was performed to determine the PTA of achieving 40% exposure time during which the free plasma drug concentration remains above the MIC (fT>MIC) and 80% fT>MIC. The volume of distribution (V) and total clearance (CL) of meropenem in these patients were 23.7 liters and 7.82 liters/h, respectively. For pathogens with MICs of 4 μg/ml, the PTAs of 40% fT>MIC following administration of meropenem as a 1-h infusion of 1 g every 8 h and a 4-h infusion of 0.5 g every 8 h were 92.52% and 90.29%, respectively. For pathogens with MICs of 2 μg/ml in immunocompromised hosts, the PTAs of 80% fT>MIC following administration of 1-h and 4-h infusions of 2 g of meropenem every 8 h were 84.32% and 94.72%, respectively. These findings indicated that the V of meropenem was greater and the CL of meropenem was lower than the values obtained in a previous study with healthy subjects. The maximum recommended dose, i.e., 2 g of meropenem every 8 h, may be required for treatment of life-threatening infections in this patient population.
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Population pharmacokinetics and dosing simulations of imipenem in serious bacteraemia in immunocompromised patients with febrile neutropenia. J Pharmacol Sci 2015; 127:164-9. [DOI: 10.1016/j.jphs.2014.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 12/01/2014] [Accepted: 12/02/2014] [Indexed: 11/23/2022] Open
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Khasawneh FA, Karim A, Mahmood T, Ahmed S, Jaffri SF, Mehmood M. Safety and feasibility of antibiotic de-escalation in bacteremic pneumonia. Infect Drug Resist 2014; 7:177-82. [PMID: 25061323 PMCID: PMC4085320 DOI: 10.2147/idr.s65928] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Antibiotic de-escalation is a potential strategy advocated to conserve the effectiveness of broad-spectrum antibiotics. The aim of this study was to examine the safety and feasibility of antibiotic de-escalation in patients admitted with bacteremic pneumonia. Methods A retrospective chart review was done for patients with bacteremic pneumonia admitted to Northwest Texas Hospital in Amarillo, TX, USA, during 2008. Antibiotic de-escalation was defined as changing the empiric antibiotic regimen to a culture-directed single agent with a narrower spectrum than the original regimen. Results Sixty-eight patients were admitted with bacteremic pneumonia. Eight patients were not eligible for de-escalation. Among the 60 patients who were eligible for de-escalation, the treating physicians failed to de-escalate antibiotics in 27 cases (45.0%). Discharge to a long-term care facility predicted failure to de-escalate antibiotics, while an infectious diseases consultation was significantly associated with antibiotic de-escalation. The average daily cost of antibacterial therapy in the de-escalation group was $25.7 compared with $61.6 in the group where de-escalation was not implemented. The difference in mean length of hospital stay and mortality between the two groups was not statistically significant. Conclusion Antibiotic de-escalation is a safe management strategy but unfortunately is not widely adopted. Although bacterial resistance poses a significant threat and is rising, antimicrobial de-escalation has emerged as a potential intervention that can conserve the effectiveness of broad-spectrum antibiotics without compromising the patient’s outcome. This practice is becoming important in the face of slow development of new anti-infective agents.
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Affiliation(s)
- Faisal A Khasawneh
- Section of Infectious Diseases, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - Adnanul Karim
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - Tashfeen Mahmood
- Department of Internal Medicine, Deaconess Hospital, Evansville, IN, USA
| | - Subhan Ahmed
- Section of Nephrology, Department of Internal Medicine, University of Oklahoma, Tulsa, OK, USA
| | - Sayyed F Jaffri
- Department of Internal Medicine, Deaconess Hospital, Evansville, IN, USA
| | - Mansoor Mehmood
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, USA
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Nseir S, Martin-Loeches I, Makris D, Jaillette E, Karvouniaris M, Valles J, Zakynthinos E, Artigas A. Impact of appropriate antimicrobial treatment on transition from ventilator-associated tracheobronchitis to ventilator-associated pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R129. [PMID: 24958136 PMCID: PMC4095698 DOI: 10.1186/cc13940] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 06/09/2014] [Indexed: 08/30/2023]
Abstract
Introduction Two small randomized controlled trials have suggested beneficial effects of antibiotic treatment in patients with ventilator-associated tracheobronchitis (VAT). The primary aim of this study is to determine the impact of appropriate antibiotic treatment on transition from VAT to ventilator-associated pneumonia (VAP) in critically ill patients. The secondary objective was to determine the incidence of VAP in patients with VAT. Methods This was a prospective observational multicenter study. All patients with a first episode of VAT were eligible. Patients with tracheostomy at intensive care unit (ICU) admission, and those with VAP prior to VAT were excluded. VAT was defined using all the following criteria: fever > 38°C with no other cause, purulent tracheal secretions, positive tracheal aspirate (≥105 cfu/mL), and absence of new infiltrate on chest X ray. Only VAP episodes diagnosed during the 96 h following VAT, and caused by the same bacteria, were taken into account. Antibiotic treatment was at the discretion of attending physicians. Risk factors for transition from VAT to VAP were determined using univariate and multivariate analysis. All variables from univariate analysis with P values <0.1 were incorporated in the multivariate logistic regression analysis. Results One thousand seven hundred and ten patients were screened for this study. Eighty-six, and 123 patients were excluded for tracheostomy at ICU admission, and VAP prior to VAT; respectively. One hundred and twenty two (7.1%) patients were included. 17 (13.9%) patients developed a subsequent VAP. The most common microorganisms in VAT patients were Pseudomonas aeruginosa (30%), Staphylococcus aureus (18%), and Acinetobacter baumannii (10%). Seventy-four (60%) patients received antimicrobial treatment, including 58 (47.5%) patients who received appropriate antimicrobial treatment. Appropriate antibiotic treatment was the only factor independently associated with reduced risk for transition from VAT to VAP (OR [95% CI] 0.12[0.02-0.59], P = 0.009). The number of patients with VAT needed to treat to prevent one episode of VAP, or one episode of VAP related to P. aeruginosa was 5, and 34; respectively. Conclusions Appropriate antibiotic treatment is independently associated with reduced risk for transition from VAT to VAP.
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Khasawneh FA, Karim A, Mahmood T, Ahmed S, Jaffri SF, Tate ME, Mehmood M. Antibiotic de-escalation in bacteremic urinary tract infections: potential opportunities and effect on outcome. Infection 2014; 42:829-34. [DOI: 10.1007/s15010-014-0639-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 05/19/2014] [Indexed: 12/13/2022]
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Impact of serum biomarkers and clinical factors on intensive care unit mortality and 6-month outcome in relatively healthy patients with severe pneumonia and acute respiratory distress syndrome. DISEASE MARKERS 2014; 2014:804654. [PMID: 24723739 PMCID: PMC3958786 DOI: 10.1155/2014/804654] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 01/29/2014] [Indexed: 12/25/2022]
Abstract
Objectives. This study aimed to identify the independent biomarkers and clinical factors that could predict ICU mortality and 6-month outcomes in relatively healthy patients with severe pneumonia and acute respiratory distress syndrome (ARDS). Patients and Methods. We prospectively enrolled patients with severe pneumonia-related ARDS that required mechanical ventilation. Patients were excluded if they were unable to take care of themselves. Several biomarkers and clinical factors were evaluated prospectively on day 1 and day 3 after ICU admission. All biomarkers and clinical factors were collected for analysis. Results. 56 patients were enrolled in this study. We determined that the initial appropriate antibiotics use was an independent clinical factor and day 1 high-mobility group protein B1 (HMGB1) concentration was an independent biomarker for ICU mortality. Interestingly, we also found that a low day 1 albumin level was an independent biomarker for predicting patient life dependence 6 months after a pneumonia event. Conclusion. Patients with severe pneumonia and ARDS requiring mechanical ventilation experience high rates of ICU mortality or disability, even if they were quite healthy before. Initial appropriate antibiotics use and day 1 level of HMGB1 were independent factors for predicting ICU mortality. Day 1 albumin level was predictive of 6-month patient life dependence.
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Edgeworth JD, Chis Ster I, Wyncoll D, Shankar-Hari M, McKenzie CA. Long-term adherence to a 5 day antibiotic course guideline for treatment of intensive care unit (ICU)-associated Gram-negative infections. J Antimicrob Chemother 2014; 69:1688-94. [PMID: 24573413 DOI: 10.1093/jac/dku038] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To determine long-term adherence to a 5 day antibiotic course guideline for treating intensive care unit (ICU)-acquired Gram-negative bacteria (GNB) infections. METHODS Descriptive analysis of patient-level data on all GNB-active antibiotics prescribed from day 3 and all GNB identified in clinical samples in 5350 patients admitted to a 30 bed general ICU between 2002 and 2009. RESULTS Four thousand five hundred and eleven of 5350 (84%) patients were treated with one or more antibiotics active against GNB commenced from day 3. Gentamicin was the most frequently prescribed antibiotic (92.2 days of therapy/1000 patient-days). Only 6% of courses spanned >6 days of therapy and 89% of antibiotic therapy days were with a single antibiotic active against GNB. There was no significant difference between gentamicin and meropenem in the number of first courses in which a resistant GNB was identified in blood cultures [11/1177 (0.9%) versus 5/351 (1.4%); P = 0.43] or respiratory tract specimens [59/951 (6.2%) versus 17/246 (6.9%); P = 0.68] at the time of starting therapy. CONCLUSIONS This study demonstrates long-term adherence to a 5 day course antibiotic guideline for treatment of ICU-associated GNB infections. This guideline is a potential antibiotic-sparing alternative to currently recommended dual empirical courses extending to ≥7 days.
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Affiliation(s)
- Jonathan D Edgeworth
- Centre for Clinical Infection and Diagnostic Research (CIDR), Department of Infectious Diseases, Kings College London and Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Irina Chis Ster
- Centre for Clinical Infection and Diagnostic Research (CIDR), Department of Infectious Diseases, Kings College London and Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Duncan Wyncoll
- School of Medicine, Kings College London and Critical Care, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Manu Shankar-Hari
- School of Medicine, Kings College London and Critical Care, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Catherine A McKenzie
- Institute of Pharmaceutical Sciences, Franklin Wilkins Building, Kings College, London SE1 7RT, UK Department of Pharmacy, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK
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Orsi GB, Falcone M, Venditti M. Surveillance and management of multidrug-resistant microorganisms. Expert Rev Anti Infect Ther 2013; 9:653-79. [PMID: 21819331 DOI: 10.1586/eri.11.77] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Multidrug-resistant organisms are an established and growing worldwide public health problem and few therapeutic options remain available. The traditional antimicrobials (glycopeptides) for multidrug-resistant Gram-positive infections are declining in efficacy. New drugs that are presently available are linezolid, daptomicin and tigecycline, which have well-defined indications for severe infections, and talavancin, which is under Phase III trial for hospital-acquired pneumonia. Unfortunately the therapies available for multidrug-resistant Gram-negatives, including carbapenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae, are limited to only colistin and tigecycline. Both of these drugs are still not registered for severe infections, such as hospital acquired pneumonia. Consequently, as confirmed by scientific evidence, a multidisciplinary approach is needed. Surveillance, infection control procedures, isolation and antimicrobial stewardship should be implemented to reduce multidrug-resistant organism diffusion.
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Affiliation(s)
- Giovanni Battista Orsi
- Dipartimento di Sanità Pubblica e Malattie Infettive, Sapienza Università di Roma, P.le Aldo Moro 5, 00185 Roma, Italy
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Outcomes of appropriate empiric combination versus monotherapy for Pseudomonas aeruginosa bacteremia. Antimicrob Agents Chemother 2012; 57:1270-4. [PMID: 23263001 DOI: 10.1128/aac.02235-12] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Pseudomonas aeruginosa bacteremia is associated with high hospital mortality. Empirical combination therapy is commonly used to increase the likelihood of appropriate therapy, but the benefits of employing >1 active agent have yet to be established. The purpose of this study was to compare outcomes of patients receiving appropriate empirical combination versus monotherapy for P. aeruginosa bacteremia. This was a retrospective, multicenter, cohort study of hospitalized adult patients with P. aeruginosa bacteremia from 2002 to 2011. The primary endpoint (30-day mortality) was assessed using multivariate logistic regression, adjusting for underlying confounding variables. Secondary endpoints of hospital mortality and time to mortality were assessed by Fisher's exact test and the Cox proportional hazards model, respectively. A total of 384 patients were analyzed. Thirty-day mortality was higher for patients receiving inappropriate therapy than for those receiving appropriate empirical therapy (43.8% versus 21.5%; P = 0.03). However, there were no statistical differences in 30-day mortality following appropriate empirical combination versus monotherapy after adjusting for baseline APACHE II scores and lengths of hospital stay prior to the onset of bacteremia (P = 0.55). Observed hospital mortality was 36.6% for patients administered combination therapy, compared with 28.7% for monotherapy patients (P = 0.17). After adjusting for baseline APACHE II scores, the relationship between time to mortality and combination therapy was not statistically significant (P = 0.59). Overall, no significant differences were observed for 30-day mortality, hospital mortality, and time to mortality between combination and monotherapy for P. aeruginosa bacteremia. Empirical combination therapy did not appear to offer an additional benefit, as long as the isolate was susceptible to at least one antimicrobial agent.
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Combination therapy for treatment of infections with gram-negative bacteria. Clin Microbiol Rev 2012; 25:450-70. [PMID: 22763634 DOI: 10.1128/cmr.05041-11] [Citation(s) in RCA: 538] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Combination antibiotic therapy for invasive infections with Gram-negative bacteria is employed in many health care facilities, especially for certain subgroups of patients, including those with neutropenia, those with infections caused by Pseudomonas aeruginosa, those with ventilator-associated pneumonia, and the severely ill. An argument can be made for empiric combination therapy, as we are witnessing a rise in infections caused by multidrug-resistant Gram-negative organisms. The wisdom of continued combination therapy after an organism is isolated and antimicrobial susceptibility data are known, however, is more controversial. The available evidence suggests that the greatest benefit of combination antibiotic therapy stems from the increased likelihood of choosing an effective agent during empiric therapy, rather than exploitation of in vitro synergy or the prevention of resistance during definitive treatment. In this review, we summarize the available data comparing monotherapy versus combination antimicrobial therapy for the treatment of infections with Gram-negative bacteria.
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Piskin N, Aydemir H, Oztoprak N, Akduman D, Comert F, Kokturk F, Celebi G. Inadequate treatment of ventilator-associated and hospital-acquired pneumonia: risk factors and impact on outcomes. BMC Infect Dis 2012; 12:268. [PMID: 23095664 PMCID: PMC3511218 DOI: 10.1186/1471-2334-12-268] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2011] [Accepted: 08/24/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Initial antimicrobial therapy (AB) is an important determinant of clinical outcome in patients with severe infections as pneumonia, however well-conducted studies regarding prognostic impact of inadequate initial AB in patients who are not undergoing mechanical ventilation (MV) are lacking. In this study we aimed to identify the risk factors for inadequate initial AB and to determine its subsequent impact on outcomes in both ventilator associated pneumonia (VAP) and hospital acquired pneumonia (HAP). METHODS We retrospectively studied the accuracy of initial AB in patients with pneumonia in a university hospital in Turkey. A total of 218 patients with HAP and 130 patients with VAP were included. For each patient clinical, radiological and microbiological data were collected. Stepwise multivariate logistic regression analysis was used for risk factor analysis. Survival analysis was performed by using Kaplan-Meier method with Log-rank test. RESULTS Sixty six percent of patients in VAP group and 41.3% of patients in HAP group received inadequate initial AB. Multiple logistic regression analysis revealed that the risk factors for inadequate initial AB in HAP patients were; late-onset HAP (OR = 2.35 (95% CI, 1.05-5.22; p = 0.037) and APACHE II score at onset of HAP (OR = 1.06 (95% CI, 1.01-1.12); p = 0.018). In VAP patients; antibiotic usage in the previous three months (OR = 3.16 (95% CI, 1.27-7.81); p = 0.013) and admission to a surgical unit (OR = 2.9 (95% CI, 1.17-7.19); p = 0.022) were found to be independent risk factors for inadequate initial AB. No statistically significant difference in crude hospital mortality and 28-day mortality was observed between the treatment groups in both VAP and HAP. However we showed a significant increase in length of hospital stay, duration of mechanical ventilation and a prolonged clinical resolution in the inadequate AB group in both VAP and HAP. CONCLUSION Our data suggests that the risk factors for inadequate initial AB are indirectly associated with the acquisition of resistant bacteria for both VAP and HAP. Although we could not find a positive correlation between adequate initial AB and survival; empirical AB with a broad spectrum should be initiated promptly to improve secondary outcomes.
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Affiliation(s)
- Nihal Piskin
- Departments of Infectious Diseases and Clinical Microbiology, School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey.
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Wilson BZ, Anzueto A, Restrepo MI, Pugh MJV, Mortensen EM. Comparison of two guideline-concordant antimicrobial combinations in elderly patients hospitalized with severe community-acquired pneumonia. Crit Care Med 2012; 40:2310-4. [PMID: 22622401 PMCID: PMC4066649 DOI: 10.1097/ccm.0b013e31825151a8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Two of the guideline-concordant therapies for severe community-acquired pneumonia are either a beta-lactam and fluoroquinolone or beta-lactam and macrolide. However it is unclear if there is a benefit for one vs. the other for elderly patients with severe community-acquired pneumonia. DESIGN A retrospective population-based cohort study of patients with community-acquired pneumonia. SETTING Patients admitted to an intensive care unit of any Department of Veterans Affairs hospital during 5-yr period. PATIENTS We included only those patients>65 yrs of age admitted to the intensive care unit with community-acquired pneumonia who received either beta-lactam+fluoroquinolone or beta-lactam+macrolide antibiotic therapy for pneumonia. INTERVENTION Not applicable. MEASUREMENTS We used multilevel regression models to examine the effect of beta-lactam+fluoroquinolone vs. beta-lactam+macrolide on each of the outcomes after adjusting for potential confounders using propensity scores. MAIN RESULTS The cohort consisted of 1,989 patients: 98.5% male and a mean age of 74 yrs. For treatment, 44% of subjects received beta-lactam+fluoroquinolone and 56% received beta-lactam+macrolide. Unadjusted 30-day mortality was 27% for beta-lactam+fluoroquinolone and 24% for beta-lactam+macrolide (p=.11). In the multilevel models, the use of beta-lactam+fluoroquinolone was not significantly associated with 30-day mortality (odds ratio 1.05, 95% confidence interval 0.85-1.30). However, the use of beta-lactam+fluoroquinolone was significantly associated with increased mean length of stay (incidence rate ratio 1.30, 95% confidence interval 1.27-1.33). CONCLUSIONS We found no significant difference for 30-day mortality but did demonstrate an association with increase in length of stay associated with the use of beta-lactam + fluoroquinolone. Randomized controlled trials are needed to determine the most effective antibiotics regimes for patients with severe pneumonia.
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Affiliation(s)
- Bryan Z Wilson
- VERDICT/South Texas Veterans Health Care System, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Niederman MS, Soulountsi V. De-escalation therapy: is it valuable for the management of ventilator-associated pneumonia? Clin Chest Med 2012; 32:517-34. [PMID: 21867820 DOI: 10.1016/j.ccm.2011.05.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In therapy for ventilator-associated pneumonia, it is essential to get initial empiric therapy correct; this is challenging because many patients are infected with multidrug-resistant pathogens. The need for achieving appropriate therapy can lead to broad-spectrum empiric therapy, which can represent antibiotic overuse and promote even more resistance. In an effort to combat this problem, de-escalation therapy has been proposed, with the goals of reducing the number of drugs, the spectrum of therapy, and the duration of therapy. This review examines the factors associated with an effective de-escalation strategy and ways to increase the rates of de-escalation in the future.
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Affiliation(s)
- Michael S Niederman
- Department of Medicine, Winthrop-University Hospital, Mineola, NY 11501, USA.
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Snydman DR. Empiric antibiotic selection strategies for healthcare-associated pneumonia, intra-abdominal infections, and catheter-associated bacteremia. J Hosp Med 2012; 7 Suppl 1:S2-S12. [PMID: 23677631 DOI: 10.1002/jhm.980] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 08/22/2011] [Accepted: 08/28/2011] [Indexed: 11/10/2022]
Abstract
Initial selection and early deployment of appropriate/adequate empiric antimicrobial therapy is critical to minimize the significant morbidity and mortality associated with hospital- or healthcare-associated infections (HAIs). Initial empiric therapy that inadequately covers the pathogen(s) causing a serious HAI has been associated with increased mortality, longer hospital stay, and elevated healthcare costs. Moreover, subsequent modification of initial inadequate therapy, later in the disease process when culture results become available, may not remedy the impact of the initial choice. Because of this, it is important that initial empiric therapy covers the most likely pathogens associated with infection in a particular patient, even if this initial regimen turns out to be unnecessarily broad, based on subsequent culture results. The current paradigm for management of serious HAIs is to initiate empiric therapy with a broad-spectrum regimen covering likely pathogens, based on local surveillance and susceptibility data, and presence of risk factors for involvement of a resistant microorganism. Subsequent modification (de-escalation) of the initial regimen becomes possible later, when culture results are available and clinical status can be better assessed, 2 to 4 days after initiation of empiric therapy. When possible, de-escalation and other steps to modify antimicrobial exposure are important for minimizing risk of antimicrobial resistance development. This article examines the general process for selection of initial empiric antibiotic therapy for patients with HAIs, illustrated through 3 case studies dealing with healthcare-associated pneumonia, complicated intra-abdominal infection, and catheter-associated bacteremia, respectively.
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Affiliation(s)
- David R Snydman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St,Boston, MA 02111, USA.
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Johnson SJ, Ernst EJ, Moores KG. Is double coverage of gram-negative organisms necessary? Am J Health Syst Pharm 2011; 68:119-24. [PMID: 21200057 DOI: 10.2146/ajhp090360] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The appropriateness of combination therapy for infections caused by gram-negative organisms is examined. SUMMARY Mortality from Pseudomonas aeruginosa infection is particularly high; therefore, empirical regimens are often selected to ensure coverage for this organism. The initial use of combination antimicrobial therapy for gram-negative infections is usually justified by one of three reasons: the potential for synergistic activity between two classes of antimicrobial agents, the broad empirical coverage provided by two antimicrobial agents with differing spectra of activity and resistance patterns, or the prevention of resistance development during antimicrobial therapy. Disadvantages of using combination therapy are increased drug toxicity, increased costs, and increased risk of superinfection with more-resistant bacteria or fungi. There are no clinical data that suggest that the combination of a β-lactam plus a fluoroquinolone results in improved patient outcomes compared with a β-lactam alone or a β-lactam plus an aminoglycoside. Results from studies that evaluate combination therapy versus monotherapy for gram-negative bacilli conflict with the common practice of use of double coverage. Strong evidence to support the administration of antimicrobials for double coverage of gram-negative organisms is lacking. Antimicrobial overuse may lead to antibiotic resistance, unnecessary adverse effects, and increased costs. CONCLUSION The available clinical evidence does not support the routine use of combination antimicrobial therapy for treatment of gram-negative infections. Patients with shock or neutropenia may benefit from combination therapy that includes an aminoglycoside.
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Affiliation(s)
- Sarah J Johnson
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, USA
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Fraimow HS, Tsigrelis C. Antimicrobial resistance in the intensive care unit: mechanisms, epidemiology, and management of specific resistant pathogens. Crit Care Clin 2011; 27:163-205. [PMID: 21144992 DOI: 10.1016/j.ccc.2010.11.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Infections caused by drug-resistant and multidrug-resistant microbial pathogens pose tremendous challenges to health care systems, including challenges related to the diagnosis, treatment, and containment of these infections. These challenges are amplified in the intensive care unit (ICU), where pressures for selection and emergence of resistance and risks of transmission of resistant pathogens are highest, and where the threat of resistance drives selection of empiric antimicrobial regimens. This article reviews basic concepts of resistance to antibacterial agents including mechanisms and modes of transmission, and discusses management issues for the important drug-resistant pathogens found in the ICU.
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Affiliation(s)
- Henry S Fraimow
- Division of Infectious Diseases, UMDNJ-Robert Wood Johnson Medical School, Cooper University Hospital, 401 Haddon Avenue, Room 274, Camden, NJ 08103, USA.
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Textoris J, Wiramus S, Martin C, Leone M. Overview of antimicrobial therapy in intensive care units. Expert Rev Anti Infect Ther 2011; 9:97-109. [PMID: 21171881 DOI: 10.1586/eri.10.147] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In the management of a patient with severe sepsis, it is important to suspect the infection early, to collect samples immediately after diagnosis and to promptly initiate a broad-spectrum antibiotic treatment. The choice of this empirical antimicrobial therapy should be based on host characteristics, site of infection, local ecology and pharmacokinetics/pharmacodynamics of antibiotics. In severe infection, guidelines recommend the use of a combination of antibiotics. After results of cultures are obtained, treatment should be re-evaluated to either de-escalate or escalate the antibiotic prescription. This is associated with optimal costs, decreased incidence of superinfection and minimal development of antimicrobial resistance. All these steps should rely on written protocols, and the compliance to these protocols should be continuously monitored in order to detect violations and implement corrective procedures.
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Affiliation(s)
- Julien Textoris
- Service d'Anesthésie et de Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Marseille, France
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Nseir S, Blazejewski C, Lubret R, Wallet F, Courcol R, Durocher A. Risk of acquiring multidrug-resistant Gram-negative bacilli from prior room occupants in the intensive care unit. Clin Microbiol Infect 2010; 17:1201-8. [PMID: 21054665 DOI: 10.1111/j.1469-0691.2010.03420.x] [Citation(s) in RCA: 182] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The objective of this prospective cohort study was to determine whether admission to an intensive care unit (ICU) room previously occupied by a patient with multidrug-resistant (MDR) Gram-negative bacilli (GNB) increases the risk of acquiring these bacteria by subsequent patients. All patients hospitalized for >48 h were eligible. Patients with MDR GNB at ICU admission were excluded. The MDR GNB were defined as MDR Pseudomonas aeruginosa, Acinetobacter baumannii and extended spectrum β-lactamase (ESBL) -producing GNB. All patients were hospitalized in single rooms. Cleaning of ICU rooms between two patients was performed using quaternary ammonium disinfectant. Risk factors for MDR P. aeruginosa, A. baumannii and ESBL-producing GNB were determined using univariate and multivariate analysis. Five hundred and eleven consecutive patients were included; ICU-acquired MDR P. aeruginosa was diagnosed in 82 (16%) patients, A. baumannii in 57 (11%) patients, and ESBL-producing GNB in 50 (9%) patients. Independent risk factors for ICU-acquired MDR P. aeruginosa were prior occupant with MDR P. aeruginosa (OR 2.3, 95% CI 1.2-4.3, p 0.012), surgery (OR 1.9, 95% CI 1.1-3.6, p 0.024), and prior piperacillin/tazobactam use (OR 1.2, 95% CI 1.1-1.3, p 0.040). Independent risk factors for ICU-acquired A. baumannii were prior occupant with A. baumannii (OR 4.2, 95% CI 2-8.8, p <0.001), and mechanical ventilation (OR 9.3, 95% CI 1.1-83, p 0.045). Independent risk factors for ICU-acquired ESBL-producing GNB were tracheostomy (OR 2.6, 95% CI 1.1-6.5, p 0.049), and sedation (OR 6.6, 95% CI 1.1-40, p 0.041). We conclude that admission to an ICU room previously occupied by a patient with MDR P. aeruginosa or A. baumannii is an independent risk factor for acquisition of these bacteria by subsequent room occupants. This relationship was not identified for ESBL-producing GNB.
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Affiliation(s)
- S Nseir
- Intensive Care Unit, Calmette Hospital, University Hospital of Lille, Lille, France.
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Recognition and prevention of multidrug-resistant Gram-negative bacteria in the intensive care unit. Crit Care Med 2010; 38:S345-51. [DOI: 10.1097/ccm.0b013e3181e6cbc5] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Nseir S, Grailles G, Soury-Lavergne A, Minacori F, Alves I, Durocher A. Accuracy of American Thoracic Society/Infectious Diseases Society of America criteria in predicting infection or colonization with multidrug-resistant bacteria at intensive-care unit admission. Clin Microbiol Infect 2010; 16:902-8. [DOI: 10.1111/j.1469-0691.2009.03027.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Corona A, Bertolini G, Lipman J, Wilson AP, Singer M. Antibiotic use and impact on outcome from bacteraemic critical illness: the BActeraemia Study in Intensive Care (BASIC). J Antimicrob Chemother 2010; 65:1276-85. [DOI: 10.1093/jac/dkq088] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Donaldson AD, Razak L, Liang LJ, Fisher DA, Tambyah PA. Carbapenems and subsequent multiresistant bloodstream infection: does treatment duration matter? Int J Antimicrob Agents 2009; 34:246-51. [PMID: 19628129 DOI: 10.1016/j.ijantimicag.2009.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 02/26/2009] [Accepted: 04/06/2009] [Indexed: 10/20/2022]
Abstract
It has been proposed that initial empirical broad-spectrum antibiotic therapy will result in better clinical outcomes and that shorter courses will reduce the 'collateral damage' of promoting antibiotic resistance. There are few data from Intensive Care Units (ICUs) that support this latter conclusion. A prospective observational study was undertaken at the National University Hospital, Singapore, to examine the relationship between duration of carbapenem therapy and subsequent nosocomial multidrug-resistant (MDR) bloodstream infection (BSI). Over a 2-year period, 415 ICU patients receiving empirical carbapenem therapy were prospectively followed. MDR BSI occurred on 35 occasions in 31 patients, comprising 21 carbapenem-resistant Acinetobacter baumannii, 3 carbapenem-resistant Pseudomonas aeruginosa and 11 meticillin-resistant Staphylococcus aureus (MRSA). There was no difference in the duration of carbapenems for those who developed MDR BSI compared with those who did not [median duration 8 days (range 3-23 days) vs. 9 days (range 3-59 days); P=0.78]. On multivariate analysis using the Cox proportional hazard model the hazard ratio was 0.935 (P=0.070). In this cohort of critically ill patients, a shorter duration of carbapenem therapy was not shown to protect against subsequent development of MDR BSI. Strategies that depend primarily on reducing broad-spectrum antibiotic duration may be inadequate in preventing the emergence of MDR organisms.
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Affiliation(s)
- Annabelle D Donaldson
- Yong Loo Lin School of Medicine, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
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Pea F, Viale P. Bench-to-bedside review: Appropriate antibiotic therapy in severe sepsis and septic shock--does the dose matter? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:214. [PMID: 19519961 PMCID: PMC2717408 DOI: 10.1186/cc7774] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Appropriate antibiotic therapy in patients with severe sepsis and septic shock should mean prompt achievement and maintenance of optimal exposure at the infection site with broad-spectrum antimicrobial agents administered in a timely manner. Once the causative pathogens have been identified and tested for in vitro susceptibility, subsequent de-escalation of antimicrobial therapy should be applied whenever feasible. The goal of appropriate antibiotic therapy must be pursued resolutely and with continuity, in view of the ongoing explosion of antibiotic-resistant infections that plague the intensive care unit setting and of the continued decrease in new antibiotics emerging. This article provides some principles for the correct handling of antimicrobial dosing regimens in patients with severe sepsis and septic shock, in whom various pathophysiological conditions may significantly alter the pharmacokinetic behaviour of drugs.
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Affiliation(s)
- Federico Pea
- Department of Experimental and Clinical Pathology, Institute of Clinical Pharmacology & Toxicology, Medical School, University of Udine, 33100 Udine, Italy.
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Maragakis LL, Perencevich EN, Cosgrove SE. Clinical and economic burden of antimicrobial resistance. Expert Rev Anti Infect Ther 2008; 6:751-63. [PMID: 18847410 DOI: 10.1586/14787210.6.5.751] [Citation(s) in RCA: 219] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Knowledge of the clinical and economic impact of antimicrobial resistance is useful to influence programs and behavior in healthcare facilities, to guide policy makers and funding agencies, to define the prognosis of individual patients and to stimulate interest in developing new antimicrobial agents and therapies. There are a variety of important issues that must be considered when designing or interpreting studies into the clinical and economic outcomes associated with antimicrobial resistance. One of the most misunderstood issues is how to measure cost appropriately. Although imperfect, existing data show that there is an association between antimicrobial resistance in Staphylococcus aureus, enterococci and Gram-negative bacilli and increases in mortality, morbidity, length of hospitalization and cost of healthcare. Patients with infections due to antimicrobial-resistant organisms have higher costs (US $6,000-30,000) than do patients with infections due to antimicrobial-susceptible organisms; the difference in cost is even greater when patients infected with antimicrobial-resistant organisms are compared with patients without infection. Given limited budgets, knowledge of the clinical and economic impact of antibiotic-resistant bacterial infections, coupled with the benefits of specific interventions targeted to reduce these infections, will allow for optimal control and improved patient safety. In this review, the authors discuss a variety of important issues that must be considered when designing or interpreting studies of the clinical and economic outcomes associated with antimicrobial resistance. Representative literature is reviewed regarding the associations between antimicrobial resistance in specific pathogens and adverse outcomes, including increased mortality, length of hospital stay and cost.
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Affiliation(s)
- Lisa L Maragakis
- The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Diagnosis of ventilator-associated pneumonia: is there a gold standard and a simple approach? Curr Opin Infect Dis 2008; 21:174-8. [PMID: 18317042 DOI: 10.1097/qco.0b013e3282f55dd1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Diagnosis of ventilator-associated pneumonia remains controversial. Different approaches are advocated, but none has yet demonstrated superiority. Diagnosis based on clinical data and aetiological diagnosis of ventilator-associated pneumonia episodes are two concepts that should be combined in an integrative evaluation for ventilator-associated pneumonia. Recent findings in diagnosis are reviewed here. RECENT FINDINGS Studies of various diagnostic strategies have been conducted to evaluate whether they influence outcome. Strategies include use of biomarkers (e.g. C-reactive protein and procalcitonin) and use of clinical scores to render the diagnostic process more objective. The appropriateness of the available aetiological diagnostic techniques and their reliability in the absence of a 'gold standard' for diagnosis were also recently addressed. It remains controversial whether type of culture (quantitative or nonquantitative) or sampling method (invasive or noninvasive) influences aetiological diagnosis or outcomes in ventilator-associated pneumonia. It is unlikely that any single approach is the optimal diagnostic assessment whenever ventilator-associated pneumonia is suspected. SUMMARY Microbiological data should always be used in association with clinical data when assessing patients with suspected ventilator-associated pneumonia. Integration of these data might be the most simple and effective strategy for diagnosing ventilator-associated pneumonia.
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