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Choi DH, Choi SW, Kim KH, Choi Y, Kim Y. Early identification of suspected serious infection among patients afebrile at initial presentation using neural network models and natural language processing: A development and external validation study in the emergency department. Am J Emerg Med 2024; 80:67-76. [PMID: 38507849 DOI: 10.1016/j.ajem.2024.03.006] [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: 04/10/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE To develop and externally validate models based on neural networks and natural language processing (NLP) to identify suspected serious infections in emergency department (ED) patients afebrile at initial presentation. METHODS This retrospective study included adults who visited the ED afebrile at initial presentation. We developed four models based on artificial neural networks to identify suspected serious infection. Patient demographics, vital signs, laboratory test results and information extracted from initial ED physician notes using term frequency-inverse document frequency were used as model variables. Models were trained and internally validated with data from one hospital and externally validated using data from a different hospital. Model discrimination was evaluated using area under the receiver operating characteristic curve (AUC) and 95% confidence intervals (CIs). RESULTS The training, internal validation, and external validation datasets comprised 150,699, 37,675, and 85,098 patients, respectively. The AUCs (95% CIs) for Models 1 (demographics + vital signs), 2 (demographics + vital signs + initial ED physician note), 3 (demographics + vital signs + laboratory tests), and 4 (demographics + vital signs + laboratory tests + initial ED physician note) in the internal validation dataset were 0.789 (0.782-0.796), 0.867 (0.862-0.872), 0.881 (0.876-0.887), and 0.911 (0.906-0.915), respectively. In the external validation dataset, the AUCs (95% CIs) of Models 1, 2, 3, and 4 were 0.824 (0.817-0.830), 0.895 (0.890-0.899), 0.879 (0.873-0.884), and 0.913 (0.909-0.917), respectively. Model 1 can be utilized immediately after ED triage, Model 2 can be utilized after the initial physician notes are recorded (median time from ED triage: 28 min), and Models 3 and 4 can be utilized after the initial laboratory tests are reported (median time from ED triage: 68 min). CONCLUSIONS We developed and validated models to identify suspected serious infection in the ED. Extracted information from initial ED physician notes using NLP contributed to increased model performance, permitting identification of suspected serious infection at early stages of ED visits.
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Affiliation(s)
- Dong Hyun Choi
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea; Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sae Won Choi
- Office of Hospital Information, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Ki Hong Kim
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yeongho Choi
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Disaster Medicine Research Center, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Yoonjic Kim
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Dai Y, Zhu X, Chang W, Lu H, Nie Z, Wu Y, Yao H, Chen Y, Xiao Y, Chu X. Clinical and economic evaluation of blood culture whole process optimisation in critically ill adult patients with positive blood cultures. Int J Antimicrob Agents 2024; 63:107176. [PMID: 38642811 DOI: 10.1016/j.ijantimicag.2024.107176] [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: 10/02/2023] [Revised: 03/22/2024] [Accepted: 04/12/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVES Optimising blood culture processing is important to ensure that bloodstream infections are accurately diagnosed while minimising adverse events caused by antibiotic abuse. This study aimed to evaluate the impact of optimised blood culture processes on antibiotic use, clinical outcomes and economics in intensive care unit (ICU) patients with positive blood cultures. METHODS From March 2020 to October 2021, this microbiology laboratory implemented a series of improvement measures, including the clinical utility of Fastidious Antimicrobial Neutralization (FAN® PLUS) bottles for the BacT/Alert Virtuo blood culture system, optimisation of bottle reception, graded reports and an upgraded laboratory information system. A total of 122 ICU patients were included in the pre-optimisation group from March 2019 to February 2020, while 179 ICU patients were included in the post-optimisation group from November 2021 to October 2022. RESULTS Compared with the pre-optimisation group, the average reporting time of identification and antimicrobial sensitivity was reduced by 16.72 hours in the optimised group. The time from admission to targeted antibiotic therapy within 24 hours after receiving both the Gram stain report and the final report were both significantly less in the post-optimisation group compared with the pre-optimisation group. The average hospitalisation time was reduced by 6.49 days, the average antimicrobial drug cost lowered by $1720.85 and the average hospitalisation cost by $9514.17 in the post-optimisation group. CONCLUSIONS Optimising blood culture processing was associated with a significantly increased positive detection rate, a remarkable reduction in the length of hospital stay and in hospital costs for ICU patients with bloodstream infections.
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Affiliation(s)
- Yuanyuan Dai
- Department of Clinical Laboratory, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People's Republic of China
| | - Xiongfeng Zhu
- Department of Critical Care Medicine, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People's Republic of China
| | - Wenjiao Chang
- Department of Clinical Laboratory, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People's Republic of China
| | - Huaiwei Lu
- Department of Clinical Laboratory, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People's Republic of China
| | - Zhengchao Nie
- Department of Clinical Laboratory, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People's Republic of China
| | - Yongqin Wu
- Department of Clinical Laboratory, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People's Republic of China
| | - Haifeng Yao
- Department of Information Center, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People's Republic of China
| | - Yunbo Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, People's Republic of China
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, People's Republic of China
| | - Xinmin Chu
- Department of Clinical Laboratory, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, People's Republic of China.
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Dar A, Abram TB, Megged O. Impact of inadequate empirical antibiotic treatment on outcome of non-critically ill children with bacterial infections. BMC Pediatr 2024; 24:324. [PMID: 38734642 PMCID: PMC11088006 DOI: 10.1186/s12887-024-04793-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND The impact of inadequate empirical antibiotic treatment on patient outcomes and hospitalization duration for non-life-threatening infections in children remains poorly understood. We aimed to assess the effects of inadequate empirical antibiotic treatment on these factors in pediatric patients. METHODS The medical records of children admitted for infectious diseases with bacteria isolated from sterile sites between 2018 and 2020 were retrospectively reviewed. Patients who received adequate empirical treatment were compared with those who received inadequate treatment in terms of demographic, clinical, and laboratory variables. RESULTS Forty-eight patients who received inadequate empirical antimicrobial treatment were compared to 143 patients who received adequate empirical treatment. Inadequate empirical antimicrobial treatment did not significantly affect the length of hospital stay or the incidence of complications in non-critically ill children with bacterial infections. Younger age and underlying renal abnormalities were identified as risk factors for inadequate antimicrobial treatment, while associated bacteremia was more common in the adequate antimicrobial treatment group. CONCLUSIONS inadequate antibiotic treatment did not affect the outcomes of non-critically ill children with bacterial infectious diseases. Therefore, routine empirical broad-spectrum treatment may not be necessary for these cases, as it can lead to additional costs and contribute to antibiotic resistance. Larger prospective studies are needed to confirm these findings.
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Affiliation(s)
- Amit Dar
- Department of Internal Medicine, Hadassah-Hebrew University Medical Center, Ein Kerem, Jerusalem, Israel
| | - Tali Bdolah Abram
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Orli Megged
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
- The Pediatric department and pediatric infectious diseases unit, Shaare Zedek Medical Center, P.O.B. 3235, Jerusalem, Israel.
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Sahoo R, Jadhav S, Nema V. Journey of technological advancements in the detection of antimicrobial resistance. J Formos Med Assoc 2024; 123:430-441. [PMID: 37598038 DOI: 10.1016/j.jfma.2023.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/19/2023] [Accepted: 08/07/2023] [Indexed: 08/21/2023] Open
Abstract
Increased uses rather an extensive misuse of antibiotics due to easy availability and easy access have resulted in antibiotic resistance as a global crisis. The speed of discovery of new antibiotics has slowed down recently. Therefore, there is a need to reduce the rate of increase in resistance against the presently available antibiotics, or else many infections may be left untreatable or difficult to be treated due to the high prevalence of resistance. The judicious use of broad-spectrum antibiotics can control the increase in resistance profile. Various techniques are presently being used for the detection of antibiotic resistance. Conventional phenotypic methods are preferred that are highly reliable but are much more time-consuming. The patients cannot spare more time as the infection keeps increasing. The results with genotypic methods are obtained within 24 h as compared to phenotypic methods. Hence, recent molecular methods like qPCR can be used for detection. In this review, we present an overview of various methods useful for the detection of antibiotic resistance, with emphasis on their advantages and limitations. The review also emphasizes qPCR to be the most preferred method out of all because of various advantageous factors.
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Affiliation(s)
- Rituparna Sahoo
- ICMR-National AIDS Research Institute, 73 G MIDC Bhosari, Pune, 411 026, India
| | - Sushama Jadhav
- ICMR-National AIDS Research Institute, 73 G MIDC Bhosari, Pune, 411 026, India
| | - Vijay Nema
- ICMR-National AIDS Research Institute, 73 G MIDC Bhosari, Pune, 411 026, India.
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Tran-The T, Heo E, Lim S, Suh Y, Heo KN, Lee EE, Lee HY, Kim ES, Lee JY, Jung SY. Development of machine learning algorithms for scaling-up antibiotic stewardship. Int J Med Inform 2024; 181:105300. [PMID: 37995386 DOI: 10.1016/j.ijmedinf.2023.105300] [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: 01/09/2023] [Revised: 10/03/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Antibiotic stewardship programs (ASP) aim to reduce inappropriate use of antibiotics, but their labor-intensive nature impedes their wide adoption. The present study introduces explainable machine learning (ML) models designed to prioritize inpatients who would benefit most from stewardship interventions. METHODS A cohort of inpatients who received systemic antibiotics and were monitored by a multidisciplinary ASP team at a tertiary hospital in the Republic of Korea was assembled. Data encompassing over 130,000 patient-days and comprising more than 160 features from multiple domains, including prescription records, laboratory, microbiology results, and patient conditions was collected.Outcome labels were generated using medication administration history: discontinuation, switching from intravenous to oral medication (IV to PO), and early or late de-escalation. The models were trained using Extreme Gradient Boosting (XGB) and light Gradient Boosting Machine (LGBM), with SHapley Additive exPlanations (SHAP) analysis used to explain the model's predictions. RESULTS The models demonstrated strong discrimination when evaluated on a hold-out test set(AUROC - IV to PO: 0.81, Early de-escalation: 0.78, Late de-escalation: 0.72, Discontinue: 0.80). The models identified 41%, 16%, 22%, and 17% more cases requiring discontinuation, IV to PO, early and late de-escalation, respectively, compared to the conventional length of therapy strategy, given that the same number of patients were reviewed by the ASP team. The SHAP results explain how each model makes their predictions, highlighting a unique set of important features that are well-aligned with the clinical intuitions of the ASP team. CONCLUSIONS The models are expected to improve the efficiency of ASP activities by prioritizing cases that would benefit from different types of ASP interventions along with detailed explanations.
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Affiliation(s)
| | - Eunjeong Heo
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | | | - Yewon Suh
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Kyu-Nam Heo
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Eunkyung Euni Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Ho-Young Lee
- Department of Digital Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ju-Yeun Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea.
| | - Se Young Jung
- Department of Digital Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea; Department of Family Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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Giamarellou H, Galani L, Karavasilis T, Ioannidis K, Karaiskos I. Antimicrobial Stewardship in the Hospital Setting: A Narrative Review. Antibiotics (Basel) 2023; 12:1557. [PMID: 37887258 PMCID: PMC10604258 DOI: 10.3390/antibiotics12101557] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
The increasing global threat of antibiotic resistance, which has resulted in countless fatalities due to untreatable infections, underscores the urgent need for a strategic action plan. The acknowledgment that humanity is perilously approaching the "End of the Miracle Drugs" due to the unjustifiable overuse and misuse of antibiotics has prompted a critical reassessment of their usage. In response, numerous relevant medical societies have initiated a concerted effort to combat resistance by implementing antibiotic stewardship programs within healthcare institutions, grounded in evidence-based guidelines and designed to guide antibiotic utilization. Crucial to this initiative is the establishment of multidisciplinary teams within each hospital, led by a dedicated Infectious Diseases physician. This team includes clinical pharmacists, clinical microbiologists, hospital epidemiologists, infection control experts, and specialized nurses who receive intensive training in the field. These teams have evidence-supported strategies aiming to mitigate resistance, such as conducting prospective audits and providing feedback, including the innovative 'Handshake Stewardship' approach, implementing formulary restrictions and preauthorization protocols, disseminating educational materials, promoting antibiotic de-escalation practices, employing rapid diagnostic techniques, and enhancing infection prevention and control measures. While initial outcomes have demonstrated success in reducing resistance rates, ongoing research is imperative to explore novel stewardship interventions.
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Affiliation(s)
- Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Lamprini Galani
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Theodoros Karavasilis
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Konstantinos Ioannidis
- Clinical Pharmacists, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece;
| | - Ilias Karaiskos
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
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Chikeka K, Gbadamosi K, Tran H, Chughtai I, Muhammad S, Senay M, Lam B, Ngouajio-Teguiafa L, Nonyel N, DeLaine L, McSwain C, Price D, Michaels K. Pilot Study: Impact of a Pharmacist-Led 48-Hour Antibiotic Time-Out on Antibiotic Utilization and Outcome Measures in a Community Teaching Hospital. Hosp Pharm 2023; 58:277-281. [PMID: 37216074 PMCID: PMC10192984 DOI: 10.1177/00185787221139429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Purpose: The objective of this study is to determine the impact of a 48-hour time-out on the utilization of targeted empiric intravenous (IV) antibiotics through a systematic approach. Methods: This is a single-center, prospective, interventional study approved by the Institutional Review Board. Study groups were stratified into a control and intervention arm. Inclusion criteria consisted of patients 18 years of age or greater, on targeted broad-spectrum IV antibiotics for more than 24 hours: daptomycin, ertapenem, meropenem, piperacillin-tazobactam, vancomycin. Exclusion criteria included febrile neutropenic, pregnant, critically ill, and surgical prophylactic patients. Targeted interventions made by pharmacists included: IV to oral conversions, dose optimizations/adjustments, and de-escalations. Primary endpoints were days of therapy per 1000 patient days (DOT/1000), days of therapy at risk per 1000 patient days (DOT/1000 DAR), and de-escalation rates. Results: Table 1 depicts a total 88.69% mean reduction of DOT/1000 of the intervention arm for vancomycin, piperacillin/tazobactam, and meropenem (P-value <.0001) when compared to the control arm. Table 2 depicts a total 88.86% mean reduction of DOT/1000 DAR of the intervention arm for vancomycin, piperacillin/tazobactam, and meropenem (P-value <.0001) when compared to control. Table 3 shows a 77.11% increase in total de-escalation rates (P-value = .0107) in the intervention group when compared to control group (63.52%). Conclusion: This study displays the essential role that pharmacists play in antibiotic stewardship. This study further reveals that the stewarding tool utilized contributed to significant reductions in the usage of targeted empiric intravenous antibiotics.
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Potvin M, Larranaga Lapique E, Hites M, Martiny D. Implementing Alfred60 AST in a clinical lab: Clinical impact on the management of septic patients and financial analysis. ANNALES PHARMACEUTIQUES FRANÇAISES 2023; 81:466-474. [PMID: 36402206 DOI: 10.1016/j.pharma.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/22/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Sepsis is an important cause of morbidity and mortality. An accelerated microbiology diagnosis is crucial in order to reduce the time to initiate targeted antibiotic therapy. The Alfred60AST system is able to provide phenotypic Antimicrobial Susceptibility Testing (AST) results within hours. This study has two objectives: assess the clinical impact of this technology and determine its cost-effectiveness. METHODS During a ten-week period, all new enterobacterial or enterococcal bloodstream infection was analyzed with the Alfred60AST system, in parallel with routine methods. Its impact on the clinician's therapeutic strategy was studied. In order to assess the financial and practical aspects of the method, an analysis of the extracosts and a survey of the technical staff were conducted. RESULTS Fifty-three cases of bacteriemia were included. For the Enterobacteriaceae bacteriemias, a clinical impact was shown in 18.9% of the cases (e.g, treatment modification). The financial analysis highlighted an increase in costs (+38% for Enterobacteriaceae, +50% for Enterococci), compared to the theoretical costs reported by the firm, due to the workflow and the volumes of samples used. Finally, results of the technical staff survey were favorable in terms of ease of use of the system. CONCLUSION In addition to its ease of use, the Alfred60AST system is able to provide an AST in a record time. This study shows a real interest of the technique in the therapeutic management of patients with enterobacterial sepsis. However, its routine implementation requires an increase of the analyzed volumes as well as a 24/7 organization of the laboratory in order to be profitable.
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Affiliation(s)
- M Potvin
- Microbiology Department, LHUB-ULB, rue haute, 322, 1000 Brussels, Belgium.
| | - E Larranaga Lapique
- Department of Infectious Disease, Erasme Hospital, route de Lennik, 808, 1070 Brussels, Belgium
| | - M Hites
- Department of Infectious Disease, Erasme Hospital, route de Lennik, 808, 1070 Brussels, Belgium
| | - D Martiny
- Microbiology Department, LHUB-ULB, rue haute, 322, 1000 Brussels, Belgium
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Yarahuan JKW, Flett K, Nakamura MM, Jones SB, Fine A, Hunter RB. Digital Antimicrobial Stewardship Decision Support to Improve Antimicrobial Management. Appl Clin Inform 2023; 14:418-427. [PMID: 36918166 PMCID: PMC10232213 DOI: 10.1055/a-2054-0270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/12/2023] [Indexed: 03/16/2023] Open
Abstract
OBJECTIVES We sought to create a digital application to support clinicians in empiric and pathogen-directed antibiotic ordering based on local susceptibility patterns and evidence-based treatment durations, thereby promoting antimicrobial stewardship. METHODS We formed a multidisciplinary team that met bimonthly from 2017 to 2018 to design and construct a web-based antimicrobial stewardship platform called Antibiogram + . We used an iterative and agile technical development process with frequent feedback from clinicians. RESULTS Antibiogram+ is an online tool, accessible via the electronic health record and hospital intranet, which offers institutional antibiotic susceptibilities for major pathogens, recommendations for empiric antibiotic selection and treatment durations for common pediatric conditions, antimicrobial dosing and monitoring guidance, and links to other internal clinical decision support resources. The tool was accessed 11,823 times with 492 average monthly views during the first 2 years after release. Compared with use of a preexisting print antibiogram and dosing card, pediatric residents more frequently reported "often" being sure of antibiotic dosing with Antibiogram+ (58 vs. 15%, p < 0.01). Respondents also reported improved confidence in choice of antibiotic, but this finding did not reach statistical significance (55 vs. 35%, p = 0.26). CONCLUSION We report the successful development of a digital antimicrobial stewardship platform with consistent rates of access during the first 2 years following release and improved provider comfort with antibiotic management.
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Affiliation(s)
- Julia K. W. Yarahuan
- Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Kelly Flett
- Novant Health Eastover Pediatrics, Charlotte, North Carolina, United States
| | - Mari M. Nakamura
- Antimicrobial Stewardship Program, Boston Children's Hospital, Boston, Massachusetts, United States
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Sarah B. Jones
- Antimicrobial Stewardship Program, Boston Children's Hospital, Boston, Massachusetts, United States
- Department of Pharmacy, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Andrew Fine
- Department of Pediatrics, Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, United States
| | - R. Brandon Hunter
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital, Houston, Texas, United States
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Kong ZX, N. Karunakaran R, Abdul Jabar K, Ponnampalavanar S, Chong CW, Teh CSJ. A retrospective study on molecular epidemiology trends of carbapenem resistant Enterobacteriaceae in a teaching hospital in Malaysia. PeerJ 2022; 10:e12830. [PMID: 35223201 PMCID: PMC8877335 DOI: 10.7717/peerj.12830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 01/04/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Carbapenem resistant Enterobacteriaceae (CRE) has rapidly disseminated worldwide and has become a global threat to the healthcare system due to its resistance towards "last line" antibiotics. This study aimed to investigate the prevalence of CRE and the resistance mechanism as well as the risk factors associated with in-hospital mortality. METHODS A total of 168 CRE strains isolated from a tertiary teaching hospital from 2014-2015 were included in this study. The presence of carbapenemase genes and minimum inhibitory concentration of imipenem, meropenem and colistin were investigated. All carbapenem-resistant Klebsiella pneumoniae (K. pneumoniae) strains were characterised by PFGE. The risk factors of patients infected by CRE associated with in-hospital mortality were determined statistically. RESULTS The predominant CRE species isolated was K. pneumoniae. The carbapenemases detected were blaOXA-48, blaOXA-232, blaVIM and blaNDM of which blaOXA-48 was the predominant carbapenemase detected among 168 CRE strains. A total of 40 CRE strains harboured two different carbapenemase genes. A total of seven clusters and 48 pulsotypes were identified among 140 CRKp strains. A predominant pulsotype responsible for the transmission from 2014 to 2015 was identified. Univariate statistical analysis identified that the period between CRE isolation and start of appropriate therapy of more than 3 days was statistically associated with in-hospital mortality.
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Affiliation(s)
- Zhi Xian Kong
- Department of Medical Microbiology, University of Malaya, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Rina N. Karunakaran
- Department of Medical Microbiology, University of Malaya, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Kartini Abdul Jabar
- Department of Medical Microbiology, University of Malaya, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Sasheela Ponnampalavanar
- Department of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Chun Wie Chong
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia
| | - Cindy Shuan Ju Teh
- Department of Medical Microbiology, University of Malaya, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
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Antimicrobial Stewardship Program: Reducing Antibiotic's Spectrum of Activity Is not the Solution to Limit the Emergence of Multidrug-Resistant Bacteria. Antibiotics (Basel) 2022; 11:antibiotics11010070. [PMID: 35052947 PMCID: PMC8772858 DOI: 10.3390/antibiotics11010070] [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: 11/07/2021] [Revised: 12/20/2021] [Accepted: 12/30/2021] [Indexed: 12/10/2022] Open
Abstract
Overconsumption of antibiotics in hospitals has led to policy implementation, including the control of antibiotic prescriptions. The impact of these policies on the evolution of antimicrobial resistance remains uncertain. In this work, we review the possible limits of such policies and focus on the need for a more efficient approach. Establishing a causal relationship between the introduction of new antibiotics and the emergence of new resistance mechanisms is difficult. Several studies have demonstrated that many resistance mechanisms existed before the discovery of antibiotics. Overconsumption of antibiotics has worsened the phenomenon of resistance. Antibiotics are responsible for intestinal dysbiosis, which is suspected of being the source of bacterial resistance. The complexity of the intestinal microbiota composition, the impact of the pharmacokinetic properties of antibiotics, and the multiplicity of other factors involved in the acquisition and emergence of multidrug-resistant organisms, lead us to think that de-escalation, in the absence of studies proving its effectiveness, is not the solution to limiting the spread of multidrug-resistant organisms. More studies are needed to clarify the ecological risk caused by different antibiotic classes. In the meantime, we need to concentrate our efforts on limiting antibiotic prescriptions to patients who really need it, and work on reducing the duration of these treatments.
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Christensen JJ, Junker H, Madsen CB, Christiansen CF, Kristensen T, Lund TK, Fallesen M, Kjølsen R, Hansen B, Hansen PK, Jensen US. Performance of QMAC-dRASTTM (Direct Rapid Antimicrobial Susceptibility Testing) - a Newcomer in Phenotypic Automatic AST. Open Microbiol J 2021. [DOI: 10.2174/1874285802115010043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective:
QMAC-dRASTTM is a phenotypic automatized Antibiotic Susceptibility Testing (AST) system based on microfluidic chip technology enabling observation of changes in a single bacterial cell under antibiotic treatment conditions. The 96 wells plate with dried antibiotics comprises 19 and 17 antibiotics for the Gram-Negatives (GNs) and Gram-Positives (GPs), respectively. Categorical (Sensitive, Intermediate or Resistant) results were compared to results obtained by our laboratory standard susceptibility testing procedure and given as Categorical Agreement (CA).
Methods:
In a 3-month period (2019/2020), blood cultures detected positive were included. Excluded were known off-panel strains of QMAC-dRASTTM, such as Gram-positive bacilli, Streptococcus and Candida species. Percentages of CA (CA, %) between QMAC-dRASTTM and routine testing methods used in the laboratory (EUCAST disc diffusion and/or etest/Broth Micro Dilution MIC), were calculated.
Results:
255 positive blood cultures from as many patients were examined. Of the positive blood culture strains, 144 were GNs, and 111 were GPs. An overall combined CA,% of 96.3 (2410 of 2502 determinations) was obtained, and discrepancies were noted in 92 of 2502 test results (3.7%). The percentage of very major errors (VMEs) was 0.7% for GNs and 2.2% for GPs. For 87% of blood culture specimens examined, susceptibility reports were available within 6-7 hours.
Conclusion:
The high CA,% for as well GNs as GPs are promising. The presented time to report data obtained by QMAC-dRASTTM in this study being of 3-8 hours for blood culture specimens examined strongly support a further possible improvement in the workflow for handling blood stream infections.
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Faugno AK, Laidman AY, Perez Martinez JD, Campbell AJ, Blyth CC. Do rapid diagnostic methods improve antibiotic prescribing in paediatric bacteraemia? J Paediatr Child Health 2021; 57:574-580. [PMID: 33197961 DOI: 10.1111/jpc.15272] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/09/2020] [Accepted: 10/27/2020] [Indexed: 01/09/2023]
Abstract
AIM Rapid blood culture pathogen identification facilitated by matrix-assisted laser desorption ionisation time-of-flight and GeneXpert has the potential to improve antibiotic prescribing. This study investigates the impact of these rapid diagnostics on the timeliness of effective and optimal antibiotic prescribing in paediatric patients with bacteraemia. METHODS A single centre retrospective cohort study was performed comparing paediatric bacteraemia cases pre- and post-rapid diagnostic implementation. Primary outcomes were the proportion of cases receiving, and median time to administration of effective and optimal antibiotics from blood culture collection. Secondary outcomes included hospital length of stay, intensive care unit admissions, and all-cause mortality. RESULTS A total of 255 bacteraemia cases were subject to final data analysis, 129 in the control cohort (pre-implementation of rapid diagnostics) and 126 in the rapid diagnostics cohort. The median time to effective (2.3 vs. 1.8 h, P = 0.20) and optimal therapy (44.4 vs. 39.1 h, P = 0.66) did not differ significantly between the cohorts. There was also no significant difference found in the number of cases reaching effective (120 vs. 116, P = 0.77) and optimal therapy (66 vs. 62, P = 0.76), length of stay (7 vs. 9 days), all-cause mortality (1.6 vs. 1.6%) and number of intensive care unit admissions (20 vs. 15). CONCLUSION The implementation of rapid diagnostics, when used in isolation, resulted in no improvement in antibiotic prescribing or patient clinical outcomes. To be effective, rapid diagnostics must be coupled with active real-time antimicrobial stewardship promotion, de-escalation or modification based on early laboratory results.
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Affiliation(s)
- Amy K Faugno
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Medical Services, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Alexandra Y Laidman
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Department of Haematology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Jonathan D Perez Martinez
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Medical Services, Joondalup Health Campus, Perth, Western Australia, Australia
| | - Anita J Campbell
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Christopher C Blyth
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia.,Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia.,Department of Microbiology, PathWest Laboratory Medicine WA, QEII Medical Centre, Perth, Western Australia, Australia
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Anteneh DA, Kifle ZD, Mersha GB, Ayele TT. Appropriateness of Antibiotics Use and Associated Factors in Hospitalized Patients at University of Gondar Specialized Hospital, Amhara, Ethiopia: Prospective Follow-up Study. INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2021; 58:469580211060744. [PMID: 34873941 PMCID: PMC8661117 DOI: 10.1177/00469580211060744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Appropriate antibiotic use means that the patient receives the appropriate drug at adequate doses and duration for a susceptible pathogen. This improves the effectiveness of antibiotic therapy and prevents the emergence of resistant pathogens. Thus, this study aimed to assess the appropriateness of antibiotics use and associated factors among hospitalized patients. Methods: A hospital-based prospective follow-up study was conducted in internal medicine. Data were collected by chart review and interview of prescribers and patients using a pre-tested questionnaire derived from RAND modified Delphi method. Appropriate antibiotic use means that the patient receives the drug based on culture result at the right time in adequate doses and duration. Frequencies and percentage distribution of dependent variables were analyzed. Moreover, bivariate and multivariate analyses were used to assess the factors influencing factors. Result: Of the 303 study participants, the mean age was44.36 ± 1.07 years and the majority 173 (57.1%) of the participants were females. The appropriateness of antibiotics use among hospitalized patients was 26 (8.6%). Males have used antibiotics more appropriately than females [5.99 (Adjusted odd ration (AOR) 95% CI 2.00-7.98)], while employed study participants were used antibiotics more appropriately than nonemployees [7.29 (AOR 95% CI 1.34-9.58)]. Moreover, patients who received antibiotics after blood culture [2.74 (AOR 95% CI 1.09-8.37)] and cerebrospinal fluid culture [5.82 (AOR 95% CI 1.84-5.63)] were used antibiotics more appropriately than patients who received antibiotics without culture. In addition, patients who believe that the prescribed antibiotics prevent complication of the disease [4.21 (AOR 95% CI 1.33-7.35)] were used antibiotics more appropriately than those who didn’t understand the use of antibiotics. Conclusion: The appropriateness of antibiotics use was very low in the study area. Patient gender, ethnicity, source of income, patient’s belief in antibiotics, and specimen cultures were significantly associated with the appropriateness of antibiotics use.
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Affiliation(s)
- Demssie Ayalew Anteneh
- Department of Hospital clinical Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Zemene Demelash Kifle
- Department of Pharmacology, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Gizeaddis Belay Mersha
- Department of hospital microbiology, university of Gondar comprehensive specialized hospital, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Bassetti M, Vena A, Battaglini D, Pelosi P, Giacobbe DR. The role of new antimicrobials for Gram-negative infections in daily clinical practice. Curr Opin Infect Dis 2020; 33:495-500. [PMID: 33009142 DOI: 10.1097/qco.0000000000000686] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW To discuss a possible clinical reasoning for treating resistant Gram-negative bacteria (GNB) infections in daily clinical practice, as well as developing a research agenda for the field. RECENT FINDINGS Novel agents, both belonging to β-lactams and to other classes of antimicrobials, have recently become available, likely replacing polymyxins or polymyxin-based combination regimens as the preferred choices for the first-line treatment of severe resistant GNB infections in the near future. SUMMARY The peculiar characteristics of novel agents for severe resistant GNB infections have abruptly made the structure of previous therapeutic algorithms somewhat obsolete, in view of the differential activity of most of them against different classes of carbapenemases. Furthermore, other agents showing activity against resistant GNB are in late phase of clinical development. Optimizing the use of novel agents in order both to guarantee the best available treatment to patients and to delay the emergence and spread of resistance is an important task that cannot be postponed, especially considering the unavailability of well tolerated and fully efficacious options for treating resistant GNB infections that we faced in the last 15 years.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences
- Department of Health Sciences, Universiy of Genoa
| | - Antonio Vena
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences
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Andrade FF, Gomes R, Martins-Oliveira I, Dias A, Rodrigues AG, Pina-Vaz C. A Rapid Flow Cytometric Antimicrobial Susceptibility Assay (FASTvet) for Veterinary Use - Preliminary Data. Front Microbiol 2020; 11:1944. [PMID: 32849485 PMCID: PMC7427462 DOI: 10.3389/fmicb.2020.01944] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/23/2020] [Indexed: 01/04/2023] Open
Abstract
A rapid flow cytometric antimicrobial susceptibility test for bacteria isolated from companion animals – the FASTvet assay, developed by FASTinov®, was evaluated. Bacterial strains isolated from different biological samples of companion animals with infectious diseases in progress were obtained from several veterinary clinical laboratories across the country. A total of 115 strains, comprising 65 Gram-negative and 50 Gram positive isolates, were incubated with 13 antimicrobial drugs (ampicillin, amoxicillin-clavulanic acid, piperacillin-tazobactam, cefpodoxime, imipenem, enrofloxacin, gentamicin, amikacin for Gram-negative; penicillin, cefoxitin, enrofloxacin, vancomycin and ampicillin for Gram-positive) at breakpoint concentrations following CLSI protocol (CLSI Vet 01, 2018) for 1 h and analyzed by flow cytometry. The overall categorical agreement was 95.6% in case of Gram-negative and of 96.7% in Gram-positive isolates when compared to microdilution. FASTvet kits contribute to reduce the turnaround time (2 vs. 24 h) with early determination of the antimicrobial susceptibility profile. The correct and rapid choice of the target antibiotic therapy, will have a positive impact on animal care, contributing for preventing antimicrobial resistance. In conclusion, FASTinov® vet kits showed an excellent performance, both for Gram-negative and Gram-positive isolates encouraging us to enlarge the sample size and planning multicentric studies.
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Affiliation(s)
- Ferdinando F Andrade
- Department of Microbiology, Faculty of Medicine, CINTESIS, University of Porto, Porto, Portugal.,Farmanimal Veterinary Centre, Caldas da Rainha, Portugal
| | | | | | - Ana Dias
- FASTinov, Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Acácio G Rodrigues
- Department of Microbiology, Faculty of Medicine, CINTESIS, University of Porto, Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Cidália Pina-Vaz
- Department of Microbiology, Faculty of Medicine, CINTESIS, University of Porto, Porto, Portugal.,FASTinov, Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
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Liao S, Tang Y, Chu C, Lu W, Baligen B, Man Y, Qu Y. Application of green tea extracts epigallocatechin‐3‐gallate in dental materials: Recent progress and perspectives. J Biomed Mater Res A 2020; 108:2395-2408. [PMID: 32379385 DOI: 10.1002/jbm.a.36991] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 03/26/2020] [Accepted: 04/04/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Shengnan Liao
- Department of Oral Implantology, West China Hospital of Stomatology; State Key Laboratory of Oral Diseases Sichuan University Chengdu Sichuan China
| | - Yu Tang
- Stomatology College & the Affiliated Stomatology Hospital of Southwest Medical University Luzhou Sichuan China
| | - Chenyu Chu
- Department of Oral Implantology, West China Hospital of Stomatology; State Key Laboratory of Oral Diseases Sichuan University Chengdu Sichuan China
| | - Weitong Lu
- Department of Oral Implantology, West China Hospital of Stomatology; State Key Laboratory of Oral Diseases Sichuan University Chengdu Sichuan China
| | - Bolatihan Baligen
- Department of Oral Implantology, West China Hospital of Stomatology; State Key Laboratory of Oral Diseases Sichuan University Chengdu Sichuan China
| | - Yi Man
- Department of Oral Implantology, West China Hospital of Stomatology; State Key Laboratory of Oral Diseases Sichuan University Chengdu Sichuan China
| | - Yili Qu
- Department of Oral Implantology, West China Hospital of Stomatology; State Key Laboratory of Oral Diseases Sichuan University Chengdu Sichuan China
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Calarasu C, Chichirelo-Konstantynovych KD, Frent S. ERS International Congress, Madrid, 2019: highlights from the Respiratory Infections Assembly. ERJ Open Res 2020; 6:00316-2019. [PMID: 32420314 PMCID: PMC7211950 DOI: 10.1183/23120541.00316-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 04/15/2020] [Indexed: 01/21/2023] Open
Abstract
The European Respiratory Society (ERS) International Congress organised in Madrid, Spain, in 2019 welcomed >22 000 participants from 134 countries. For each ERS assembly, an impressive number of abstracts were submitted. The topics covered by Assembly 10 (Respiratory Infections and Tuberculosis) were included this year in the top five research areas with the most submitted abstracts, with a total of 424 abstracts accepted for presentation. As it would be difficult for any delegate to stay up to date with all the scientific advances in the field, we wanted to highlight three of the Congress sessions that included presentations on respiratory infections and tuberculosis that we deemed as important and we hope the readers will consider this material of great interest.
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Affiliation(s)
- Cristina Calarasu
- University of Medicine and Pharmacy of Craiova, Dept of Medical Specialities, Craiova, Romania
| | | | - Stefan Frent
- Pulmonology Dept, University of Medicine and Pharmacy Timisoara, Timisoara, Romania
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Sadatsharifi A, Davarpanah MA, Namazi S, Mottaghi S, Mahmoudi L. Economic Burden Of Inappropriate Empiric Antibiotic Therapy: A Report From Southern Iran. Risk Manag Healthc Policy 2019; 12:339-348. [PMID: 31849550 PMCID: PMC6913765 DOI: 10.2147/rmhp.s222200] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 11/08/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction Widespread inappropriate antibiotic prescribing by healthcare professionals in the hospital setting is a great concern that may cause many undesirable consequences. Adherences to antibiotic guidelines have proven to be a simple and effective intervention to guide the choice of appropriate empiric antibiotic regimens and reduce the unnecessary variations in the practice among practitioners. The objective of this study was to evaluate the prescription patterns of empiric antibiotic therapy in relation to treatment guidelines and the economic burden of discordance with guidelines in a major referral Iranian university hospital. Method Hospital records of hospitalized patients with empiric antibiotic prescription, from September 2016 to February 2017 were reviewed. The process consisted of comparing empiric antimicrobial administration with institutional guidelines for each patient by a clinical pharmacist and an infectious disease specialist to evaluate the appropriate utilization of antibiotics. Adherence to guideline, the cost of antibiotics usage for each patient and the excess cost consequent from discordance with guideline was calculated. Results The most inappropriate prescribed antibiotics were carbapenems and aminoglycosides. Overall guideline adherence was 27.8%. Frequency of antibiotic usage incompatibility with the guidelines on the basis of dosing interval, duration of therapy and drug indication were 31.46%, 29.44% and 19.36%, respectively. General surgery and internal medicine wards had the least and the most inappropriate antibiotic administration, respectively. Totally antibiotic usage cost was 578,959.39 USD (24,316,294,800 Iranian Rials, IRR) for 6 months, which the excess costs of inappropriate antibiotic prescribing, was 471,319.69 USD (19,795,427,225 IRR). The estimated annual excess cost is 942,639.38 USD (39,590,854,450 IRR). Conclusion In this research, physicians’ adherence with guidelines for empiric antibiotic therapy was low which was led to 471,319.69 USD excess costs. These results urge institution policy makers to develop guidelines to ensure active dissemination and implementation of them to decrease inappropriate antibiotic usage.
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Affiliation(s)
- Arman Sadatsharifi
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Soha Namazi
- Department of Clinical Pharmacy, School of pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Shaghayegh Mottaghi
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Laleh Mahmoudi
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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Vekaria-Hirani V, Kumar R, Musoke R. Antibiotic prescribing practices in paediatric septic shock in a tertiary care hospital in a resource limited setting: an audit. Pan Afr Med J 2019; 34:133. [PMID: 33708302 PMCID: PMC7906553 DOI: 10.11604/pamj.2019.34.133.15820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/02/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction Early empiric broad spectrum antibiotic administration in children with septic shock improves outcome. Knowledge on possible bacterial aetiology, drug resistance pattern and rational choice of antibiotics is crucial in management of septic shock. Methods This was an audit carried out among 50 (0- 5 years age) children admitted with septic shock at the Kenyatta National Hospital between October to December 2016. A standard questionnaire was used for data collection as per the Surviving Sepsis Guideline. Data were stored in Excel and analyzed in Strata 12. Results Of the 50 admitted children with septic shock 86% were less than one-year age. Samples for blood cultures were removed from 12(24%) prior to administration of antibiotics. Blood culture bottles were unavailable in 80%. All children received antibiotics. Antibiotics were initiated in 44(88%) in the golden hour of diagnosis of septic shock. Monotherapy with cephalosporins 30 (60%) was the commonest choice of initial antibiotic. Antibiotics were changed in 7(22.6%) and 1(5.3%) at 24 and 48 hours respectively due to clinical deterioration. Over mortality at 72 hours was 35 (70%). All the 9 children initiated on meropenem monotherapy on admission died. Conclusion The majority of patients with septic shock were under one-year age. All patients were initiated on antibiotics. Blood cultures were done in a quarter of the patients. Monotherapy with cephalosporin was the commonest choice of antibiotic. De-escalation was not well accomplished due to microbiological culture limitation. There was no standard antibiotic choice hence antibiotic use in septic shock needs to be included in the paediatric local guidelines.
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Affiliation(s)
| | - Rashmi Kumar
- Paediatric Department, University of Nairobi, Nairobi, Kenya
| | - Rachel Musoke
- Paediatric Department, University of Nairobi, Nairobi, Kenya
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Performance and potential clinical impact of Alfred60AST (Alifax®) for direct antimicrobial susceptibility testing on positive blood culture bottles. Eur J Clin Microbiol Infect Dis 2019; 39:53-63. [DOI: 10.1007/s10096-019-03690-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/26/2019] [Indexed: 01/31/2023]
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Giacobbe DR, Corcione S, Salsano A, Del Puente F, Mornese Pinna S, De Rosa FG, Mikulska M, Santini F, Viscoli C. Current and emerging pharmacotherapy for the treatment of infections following open-heart surgery. Expert Opin Pharmacother 2019; 20:751-772. [PMID: 30785333 DOI: 10.1080/14656566.2019.1574753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Patients undergoing open-heart surgery may suffer from postoperative complications, including severe infections. Antimicrobials to treat infectious complications in this population should be selected thoughtfully, taking into account three different and fundamental issues: (i) the site of infection; (ii) the suspected or proven causative agent and its susceptibility pattern; and (iii) the risk of suboptimal pharmacokinetic characteristics and potential toxicity of the chosen drug/s. AREAS COVERED The present narrative review summarizes the current and future antimicrobial options for the treatment of infections developing after open-heart surgery. EXPERT OPINION The pharmacological treatment of infections developing in cardiac surgery patients poses peculiar challenges, including the need for an active empirical therapy for severe events such as bloodstream infections, deep sternal wound infections, or early-onset postoperative prosthetic endocarditis. In addition, the risk for multidrug-resistant pathogens should also be taken into account in endemic areas. A multidisciplinary evaluation on a patient-by-patient basis, deeply involving infectious diseases specialists and cardiothoracic surgeons, remains essential for appropriately balancing both short-term and long-term risks and benefits of any possible surgical reintervention in combination with adequate pharmacotherapy.
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Affiliation(s)
| | - Silvia Corcione
- b Department of Medical Sciences, Infectious Diseases , University of Turin , Turin , Italy
| | - Antonio Salsano
- c Division of Cardiac Surgery, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate (DISC) , University of Genoa , Genoa , Italy.,d Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino , Genoa , Italy
| | - Filippo Del Puente
- a Dipartimento di Scienze della Salute (DISSAL) , University of Genoa , Genoa , Italy
| | - Simone Mornese Pinna
- b Department of Medical Sciences, Infectious Diseases , University of Turin , Turin , Italy
| | | | - Malgorzata Mikulska
- a Dipartimento di Scienze della Salute (DISSAL) , University of Genoa , Genoa , Italy.,d Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino , Genoa , Italy
| | - Francesco Santini
- c Division of Cardiac Surgery, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate (DISC) , University of Genoa , Genoa , Italy.,d Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino , Genoa , Italy
| | - Claudio Viscoli
- a Dipartimento di Scienze della Salute (DISSAL) , University of Genoa , Genoa , Italy.,d Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Policlinico San Martino , Genoa , Italy
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How small modifications in laboratory workflow of blood cultures can have a significant impact on time to results. Eur J Clin Microbiol Infect Dis 2018; 37:1753-1760. [DOI: 10.1007/s10096-018-3309-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
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Vandenberg O, Kozlakidis Z, Schrenzel J, Struelens MJ, Breuer J. Control of Infectious Diseases in the Era of European Clinical Microbiology Laboratory Consolidation: New Challenges and Opportunities for the Patient and for Public Health Surveillance. Front Med (Lausanne) 2018; 5:15. [PMID: 29457001 PMCID: PMC5801420 DOI: 10.3389/fmed.2018.00015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/18/2018] [Indexed: 01/03/2023] Open
Abstract
Many new innovative diagnostic approaches have been made available during the last 10 years with major impact on patient care and public health surveillance. In parallel, to enhance the cost-effectiveness of the clinical microbiology laboratories (CMLs), European laboratory professionals have streamlined their organization leading to amalgamation of activities and restructuring of their professional relationships with clinicians and public health specialists. Through this consolidation process, an operational model has emerged that combines large centralized clinical laboratories performing most tests on one high-throughput analytical platform connected to several distal laboratories dealing locally with urgent analyses at near point of care. The centralization of diagnostic services over a large geographical region has given rise to the concept of regional-scale "microbiology laboratories network." Although the volume-driven cost savings associated with such laboratory networks seem self-evident, the consequence(s) for the quality of patient care and infectious disease surveillance and control remain less obvious. In this article, we describe the range of opportunities that the changing landscape of CMLs in Europe can contribute toward improving the quality of patient care but also the early detection and enhanced surveillance of public health threats caused by infectious diseases. The success of this transformation of health services is reliant on the appropriate preparation in terms of staff, skills, and processes that would be inclusive of stakeholders. In addition, rigorous metrics are needed to set out more concrete laboratory service performance objectives and assess the expected benefits to society in terms of saving lives and preventing diseases.
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Affiliation(s)
- Olivier Vandenberg
- Innovation and Business Development Unit, LHUB-ULB, Pôle Hospitalier Universitaire de Bruxelles, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Centre for Environmental Health and Occupational Health, School of Public Health, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Zisis Kozlakidis
- Division of Infection and Immunity, University College London, London, United Kingdom
- The Farr Institute of Health Informatics Research, University College London, London, United Kingdom
| | - Jacques Schrenzel
- Genomic Research Laboratory, Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
- Bacteriology Laboratory, Service of Laboratory Medicine, Department of Genetics and Laboratory Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Marc Jean Struelens
- Microbiology Coordination Section, Office of the Chief Scientist, European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
| | - Judith Breuer
- Division of Infection and Immunity, University College London, London, United Kingdom
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Yu JC, Hsieh PH, Tsai HW, Chang WH, Liu TH, Lee MS, Peng KT, Huang KC, Lee GB. Rapid identification of pathogens responsible for necrotizing fasciitis on an integrated microfluidic system. BIOMICROFLUIDICS 2017; 11:064108. [PMID: 29282420 PMCID: PMC5726975 DOI: 10.1063/1.5007081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 11/20/2017] [Indexed: 05/07/2023]
Abstract
Necrotic fasciitis (NF) is a particularly aggressive and serious infection of the fascia that can penetrate into the musculature and internal organs, resulting in death if not treated promptly. In this work, an integrated microfluidic system composed of micropumps, microvalves, and micromixers was used to automate the detection of pathogens associated with NF. The entire molecular diagnostic process, including bacteria isolation, lysis, nucleic acid amplification and optical detection steps, was enacted on this developed system. Mannose binding lectin coated magnetic beads were first used as probes to isolate all bacteria in a sample. In this work, polymerase chain reaction assays featuring primers specific to genes from each of four NF-causing bacteria (Vibrio vulnificus, Aeromonas hydrophila, and methicillin-sensitive and resistant Staphylococcus aureus) were used to rapidly and exclusively verify the presence of the respective bacterial strains, and the limits of detection were experimentally found to be 11, 1960, 14, and 11 400 colony forming units/reaction, respectively; all values reflect improvement over ones reported in literature. This integrated microfluidic chip may then be valuable in expediting diagnosis and optimizing treatment options for those with NF; such diagnostic improvements could ideally diminish the need for amputation and even reduce the morality rate associated with this life-threatening illness.
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Affiliation(s)
- Ju-Ching Yu
- Department of Power Mechanical Engineering, National Tsing Hua University, Hsinchu 30013, Taiwan
| | - Pang-Hsin Hsieh
- Department of Orthopaedic Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Hsing-Wen Tsai
- Department of Orthopaedic Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi 61363, Taiwan
| | - Wen-Hsin Chang
- Department of Power Mechanical Engineering, National Tsing Hua University, Hsinchu 30013, Taiwan
| | - Ting-Hang Liu
- Department of Power Mechanical Engineering, National Tsing Hua University, Hsinchu 30013, Taiwan
| | - Mel S Lee
- Department of Orthopaedic Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
| | - Kuo-Ti Peng
- Department of Orthopaedic Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi 61363, Taiwan
| | - Kuo-Chin Huang
- Department of Orthopaedic Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi 61363, Taiwan
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Berendsen EM, Levin E, Braakman R, der Riet-van Oeveren DV, Sedee NJA, Paauw A. Identification of microorganisms grown in blood culture flasks using liquid chromatography–tandem mass spectrometry. Future Microbiol 2017; 12:1135-1145. [DOI: 10.2217/fmb-2017-0050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Aim: Bloodstream infections are a common cause of disease and a fast and accurate identification of the causative agent or agents of bloodstream infections would aid the start of adequate treatment. Materials & methods: A liquid chromatography–tandem mass spectrometry (LC–MS/MS) shotgun proteomics method was developed for the identification of bacterial species directly from blood cultures that were simulated by inoculating blood culture bottles with single or multiple clinically relevant microorganisms. Results: Using LC–MS/MS, the single species were correctly identified in 100% of the blood cultures, whereas for polymicrobial infections, 78% of both species were correctly identified in blood cultures. Conclusion: The LC–MS/MS method allows for the identification of the causative agent of positive blood cultures.
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Affiliation(s)
- Erwin M Berendsen
- Department of CBRN Protection, Netherlands Organization for Applied Scientific Research TNO, Lange Kleiweg 137, 2288 GJ Rijswijk, The Netherlands
| | - Evgeni Levin
- Department of Microbiology & Systems Biology, Netherlands Organization for Applied Scientific Research TNO, Utrechtseweg 48, 3704HE Zeist, The Netherlands
| | - René Braakman
- Department of CBRN Protection, Netherlands Organization for Applied Scientific Research TNO, Lange Kleiweg 137, 2288 GJ Rijswijk, The Netherlands
| | - Debora van der Riet-van Oeveren
- Department of CBRN Protection, Netherlands Organization for Applied Scientific Research TNO, Lange Kleiweg 137, 2288 GJ Rijswijk, The Netherlands
| | - Norbert JA Sedee
- Department of CBRN Protection, Netherlands Organization for Applied Scientific Research TNO, Lange Kleiweg 137, 2288 GJ Rijswijk, The Netherlands
| | - Armand Paauw
- Department of CBRN Protection, Netherlands Organization for Applied Scientific Research TNO, Lange Kleiweg 137, 2288 GJ Rijswijk, The Netherlands
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Liu Q, Ren J, Wu X, Wang G, Wang Z, Wu J, Huang J, Lu T, Li J. Shifting trends in bacteriology and antimicrobial resistance among gastrointestinal fistula patients in China: an eight-year review in a tertiary-care hospital. BMC Infect Dis 2017; 17:637. [PMID: 28934938 PMCID: PMC5609055 DOI: 10.1186/s12879-017-2744-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 09/18/2017] [Indexed: 01/07/2023] Open
Abstract
Background The purpose of this study was to determine the shifting trends in bacteriology and antimicrobial resistance of infectious specimens isolated from gastrointestinal (GI) fistula patients over eight years in China. Methods We retrospectively reviewed the microbial records of intra-abdominal specimens at a teaching hospital from 2008 to 2015. Study period was divided into the first half (2008–2011) and the second half (2012–2015). All isolates underwent antibiotic susceptibility testing by the micro dilution method. Results A total of 874 intra-abdominal isolates were consecutively collected from 502 GI fistula patients (mean age, 46.5 years, 71.1% male) during the study period. Patients in the second study period (2012–2015) were older (>65 years) and more likely to have experienced cancer. Over the entire study period, most infections were caused by E. coli (24.2%) and K. pneumonia (14.1%). There was a significant decrease in the proportion E. coli isolates that were extended- spectrum beta-lactamase (ESBL)-positive (P = 0.026). The proportion of E. coli resistant to imipenem increased from 14.3% in 2008–2011 to 25.9% in 2012–2015 (P = 0.037). Imipenem resistance prevalence was higher in ESBL-negative bacteria than ESBL-positive bacteria for both E. coli and K. pneumonia (P < 0.001). In Enterococcus, significant increase in resistance to ampicillin (P = 0.01) and moxifloxacin (P = 0.02) over time were observed. In Staphylococcus and fungi, rates of antibiotic resistance did not significantly change over the study period. Conclusions Gram-negative bacteria predominated as causative agents of intra-abdominal infections in GI fistula patients, and there was an increase in levels of resistance to certain antibiotics, particularly carbapenems. Infection control and source control are important tools available to surgeons to prevent the emergence of antibiotic-resistant pathogens. Electronic supplementary material The online version of this article (10.1186/s12879-017-2744-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Qinjie Liu
- Department of Surgery, Jinling Hospital, Nanjing Medical University, 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Jianan Ren
- Department of Surgery, Jinling Hospital, Nanjing Medical University, 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China. .,Department of Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, People's Republic of China. .,Department of Surgery, Jinling Hospital, Medical School of Southeast University, 305 East Zhongshan Road, Nanjing, People's Republic of China.
| | - Xiuwen Wu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Gefei Wang
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Zhiwei Wang
- Department of Surgery, Jinling Hospital, Nanjing Medical University, 305 East Zhongshan Road, Nanjing, 210002, People's Republic of China
| | - Jie Wu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Jinjian Huang
- Department of Surgery, Jinling Hospital, Medical School of Southeast University, 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Tianyu Lu
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, People's Republic of China
| | - Jieshou Li
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, People's Republic of China
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Modeling antibiotic treatment in hospitals: A systematic approach shows benefits of combination therapy over cycling, mixing, and mono-drug therapies. PLoS Comput Biol 2017; 13:e1005745. [PMID: 28915236 PMCID: PMC5600366 DOI: 10.1371/journal.pcbi.1005745] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 08/28/2017] [Indexed: 12/30/2022] Open
Abstract
Multiple treatment strategies are available for empiric antibiotic therapy in hospitals, but neither clinical studies nor theoretical investigations have yielded a clear picture when which strategy is optimal and why. Extending earlier work of others and us, we present a mathematical model capturing treatment strategies using two drugs, i.e the multi-drug therapies referred to as cycling, mixing, and combination therapy, as well as monotherapy with either drug. We randomly sample a large parameter space to determine the conditions determining success or failure of these strategies. We find that combination therapy tends to outperform the other treatment strategies. By using linear discriminant analysis and particle swarm optimization, we find that the most important parameters determining success or failure of combination therapy relative to the other treatment strategies are the de novo rate of emergence of double resistance in patients infected with sensitive bacteria and the fitness costs associated with double resistance. The rate at which double resistance is imported into the hospital via patients admitted from the outside community has little influence, as all treatment strategies are affected equally. The parameter sets for which combination therapy fails tend to fall into areas with low biological plausibility as they are characterised by very high rates of de novo emergence of resistance to both drugs compared to a single drug, and the cost of double resistance is considerably smaller than the sum of the costs of single resistance.
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Antibacterial glass-ionomer cement restorative materials: A critical review on the current status of extended release formulations. J Control Release 2017; 262:317-328. [DOI: 10.1016/j.jconrel.2017.07.041] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 07/28/2017] [Accepted: 07/29/2017] [Indexed: 02/02/2023]
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Direct identification from positive blood broth culture by matrix-assisted laser desorption-ionization time-of-flight mass spectrometry (MALDI-TOF MS). Braz J Infect Dis 2017; 21:339-342. [PMID: 28399425 PMCID: PMC9427800 DOI: 10.1016/j.bjid.2017.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 11/20/2022] Open
Abstract
Bloodstream infections (BSIs) are among the most concerning bacterial infections. They are one of the leading causes of morbidity and mortality, and occur in 30–70% of critical care patients. The prompt identification of the causative microorganism can help choosing the appropriate antimicrobial therapy that will lead to better clinical outcomes. Blood culture is one of the most relevant tests for microbiological diagnosis of bacterial infections. The introduction of the MALDI-TOF microbiological diagnosis significantly decreased the time of identifying microorganisms. However, it depends on the growth on solid culture medium. In this study, 538 bottles of positive blood cultures were evaluated to test the accuracy of an in house modified protocol. The study sample consisted of 198 Gram-negative and 350 Gram-positive bacteria. In all, 460 (83.94%) species were identified based on the direct plate findings. The protocol allowed the identification of 185/198 (93.43%) of the Gram-negative bacteria, including aerobes, anaerobes, and non-fermenters, and 275/350 (78.85%) of the Gram-positive bacteria. The proposed method has the potential to provide accurate results in comparison to the traditional method with the potential to reduce the turnaround time for the results and optimize antimicrobial therapy in BSI.
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Stefanetti V, Beccati F, Passamonti F, Sgariglia E, Coletti M, Vuerich M, Marenzoni ML. Detection and DNA quantification of Enterococcus casseliflavus in a foal with septic meningitis. J Am Vet Med Assoc 2017; 249:96-100. [PMID: 27308888 DOI: 10.2460/javma.249.1.96] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CASE DESCRIPTION A 3-month-old 180-kg (396-lb) Hanoverian colt was examined because of fever, lethargy, inappetence, drooping of the left ear, and stiff neck posture. Initial treatment included empirical antimicrobial treatment and NSAIDs. CLINICAL FINDINGS Initial findings were consistent with CNS anomalies. Endoscopy revealed hyperemia, ecchymosis, and some mucopurulent exudate in the right guttural pouch. Hematologic findings were consistent with neutrophilic inflammation. On the third day of hospitalization, severe neurologic signs were observed. Computed tomography of the skull revealed a comminuted fracture of the axial aspect of the right mandibular condyle. Examination of CSF revealed turbidity, xanthochromia, and intracellular and extracellular cocci, consistent with septic meningitis. After DNA extraction from blood and CSF, sequenced products from a PCR assay for the bacterial 16S rRNA gene were 99% identical to Enterococcus casseliflavus. Microbial culture of CSF and blood samples yielded bacteria with Enterococcus spp morphology; antimicrobials were selected on the basis of susceptibility testing that identified the isolate as vancomycin resistant. A quantitative PCR assay was used to estimate Enterococcus DNA concentrations in CSF and blood. TREATMENT AND OUTCOME Treatment for E casseliflavus meningitis, including trimethoprim-sulfadiazine and ampicillin sodium administration, resulted in resolution of clinical signs. Culture of CSF and blood samples after 12 days of the targeted treatment yielded no growth. CLINICAL RELEVANCE To the authors' knowledge, this was the first report of E casseliflavus meningitis in a horse. Treatment was successful; vancomycin-resistant enterococci can be a clinical problem and may potentially be zoonotic.
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van den Bijllaardt W, Buiting AG, Mouton JW, Muller AE. Shortening the incubation time for antimicrobial susceptibility testing by disk diffusion for Enterobacteriaceae: how short can it be and are the results accurate? Int J Antimicrob Agents 2017; 49:631-637. [PMID: 28263895 DOI: 10.1016/j.ijantimicag.2016.12.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 12/07/2016] [Accepted: 12/17/2016] [Indexed: 11/18/2022]
Abstract
The standard incubation time for antimicrobial susceptibility testing (AST) by disk diffusion is primarily based on laboratory working hours rather than growth and kill characteristics of bacteria. Faster AST results could result in better patient outcomes and reduced costs by initiating earlier appropriate therapy. The earliest possible reading moment for disk diffusion using established disk zone diameter breakpoints for Enterobacteriaceae was determined with a special focus on the accuracy of the results. A total of 88 Enterobacteriaceae challenge isolates, including isolates with specific resistance mechanisms such as extended-spectrum β-lactamase (ESBL), were subjected to disk diffusion with 15 antibiotics. Hourly images were automatically produced by an incubator/camera combination from 1 h to 20 h. Disk zones were plotted over time for all combinations. Essential and categorical agreement rates using the final reading after 20 h of incubation as a reference were calculated for every hour. In total, 1320 antibiotic-micro-organism combinations were tested. Clear growth with readable inhibition zones was visible after 6 h of incubation for the majority (95.8%) of plates and after 7 h for all incubated plates. However, zone sizes changed significantly after those time points for a number of strains. After 10 h of incubation, minor, major and very major error rates were 1.6% (n = 21), 0.2% (n = 1) and 0.7% (n = 4), respectively. The results of this study clearly indicate that early reading of inhibition zones to 10 h after incubation is feasible and accurate and thus may save significantly on turnaround time.
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Affiliation(s)
- Wouter van den Bijllaardt
- Laboratory for Medical Microbiology and Immunology, Elisabeth-TweeSteden Hospital, Hilvarenbeekse weg 60, 5022GC Tilburg, The Netherlands; Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands.
| | - Anton G Buiting
- Laboratory for Medical Microbiology and Immunology, Elisabeth-TweeSteden Hospital, Hilvarenbeekse weg 60, 5022GC Tilburg, The Netherlands
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology, Haaglanden Medical Centre, The Hague, The Netherlands
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Ge MC, Kuo AJ, Liu KL, Wen YH, Chia JH, Chang PY, Lee MH, Wu TL, Chang SC, Lu JJ. Routine identification of microorganisms by matrix-assisted laser desorption ionization time-of-flight mass spectrometry: Success rate, economic analysis, and clinical outcome. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 50:662-668. [PMID: 27426930 DOI: 10.1016/j.jmii.2016.06.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/26/2016] [Accepted: 06/13/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) has been widely used in microbial identification. This study evaluated the performance of MALDI-TOF MS and investigated the economic and medical impact of MALDI-TOF MS implementation. METHODS A total of 12,202 clinical isolates collected from April to September 2013 were identified using MALDI-TOF MS, and the success rates in identifying isolates were analyzed. The differences in the processing time, cost of consumables, weight of waste, and clinical impact between MALDI-TOF MS and biochemical reaction were compared. RESULTS MALDI-TOF MS successfully identified 96% of 12,202 isolates, including 96.8% of 10,502 aerobes, 90.5% of 1481 anaerobes, 93.8% of 81 yeasts, and 90.6% of 138 nontuberculous mycobacteria at the genus level. By using MALDI-TOF MS, the processing time for aerobes decreased from 32.5 hours to 4.1 hours, and that for anaerobes decreased from 71.5 hours to 46 hours. For detection of aerobes and anaerobes, the cost of consumables was estimated to decrease by US$0.9 per isolate, thus saving US$94,500 in total annual isolation. Furthermore, the weight of waste decreased six-fold, resulting in a reduction of 350 kg/month or 4.2 tons/year. MALDI-TOF MS also increased the percentage of correct antibiotics treatment for Escherichia coli and Klebsiella pneumonia from 56.1% to 75% and shortened the initiation time of the correct antibiotic action from 3.3 hours to 2.5 hours. CONCLUSIONS MALDI-TOF MS is a rapid, reliable, economical, and environmentally friendly method for routine microbial identification and may contribute to early appropriate antibiotic treatment in clinical settings.
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Affiliation(s)
- Mao-Cheng Ge
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - An-Jing Kuo
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kuei-Lan Liu
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Ying-Hao Wen
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ju-Hsin Chia
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pi-Yueh Chang
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Hsun Lee
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tsu-Lan Wu
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Cheng Chang
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Jang-Jih Lu
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Verroken A, Defourny L, le Polain de Waroux O, Belkhir L, Laterre PF, Delmée M, Glupczynski Y. Clinical Impact of MALDI-TOF MS Identification and Rapid Susceptibility Testing on Adequate Antimicrobial Treatment in Sepsis with Positive Blood Cultures. PLoS One 2016; 11:e0156299. [PMID: 27228001 PMCID: PMC4881997 DOI: 10.1371/journal.pone.0156299] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 05/12/2016] [Indexed: 11/18/2022] Open
Abstract
Shortening the turn-around time (TAT) of positive blood culture (BC) identification (ID) and susceptibility results is essential to optimize antimicrobial treatment in patients with sepsis. We aimed to evaluate the impact on antimicrobial prescription of a modified workflow of positive BCs providing ID and partial susceptibility results for Enterobacteriaceae (EB), Pseudomonas aeruginosa and Staphylococcus aureus on the day of BC positivity detection. This study was divided into a pre-intervention period (P0) with a standard BC workflow followed by 2 intervention periods (P1, P2) with an identical modified workflow. ID was performed with MALDI-TOF MS from blood, on early or on overnight subcultures. According to ID results, rapid phenotypic assays were realized to detect third generation cephalosporin resistant EB/P. aeruginosa or methicillin resistant S. aureus. Results were transmitted to the antimicrobial stewardship team for patient's treatment revision. Times to ID, to susceptibility results and to optimal antimicrobial treatment (OAT) were compared across the three study periods. Overall, 134, 112 and 154 positive BC episodes in P0, P1 and P2 respectively were included in the analysis. Mean time to ID (28.3 hours in P0) was reduced by 65.3% in P1 (10.2 hours) and 61.8% in P2 (10.8 hours). Mean time to complete susceptibility results was reduced by 27.5% in P1 and 27% in P2, with results obtained after 32.4 and 32.6 hours compared to 44.7 hours in P0. Rapid tests allowed partial susceptibility results to be obtained after a mean time of 11.8 hours in P1 and 11.7 hours in P2. Mean time to OAT was decreased to 21.6 hours in P1 and to 17.9 hours in P2 compared to 36.1 hours in P0. Reducing TAT of positive BC with MALDI-TOF MS ID and rapid susceptibility testing accelerated prescription of targeted antimicrobial treatment thereby potentially improving the patients' clinical outcome.
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Affiliation(s)
- Alexia Verroken
- Institut de recherche expérimentale et clinique (IREC), pôle de microbiologie (MBLG), Université catholique de Louvain, Brussels, Belgium
- Laboratoire de microbiologie, Cliniques universitaires Saint-Luc – Université catholique de Louvain, Brussels, Belgium
- * E-mail:
| | - Lydwine Defourny
- Laboratoire de microbiologie, Cliniques universitaires Saint-Luc – Université catholique de Louvain, Brussels, Belgium
| | - Olivier le Polain de Waroux
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Leïla Belkhir
- Département de médecine interne et pathologies infectieuses, Cliniques universitaires Saint-Luc – Université catholique de Louvain, Brussels, Belgium
| | - Pierre-François Laterre
- Département des soins intensifs, Cliniques universitaires Saint-Luc – Université catholique de Louvain, Brussels, Belgium
| | - Michel Delmée
- Institut de recherche expérimentale et clinique (IREC), pôle de microbiologie (MBLG), Université catholique de Louvain, Brussels, Belgium
- Laboratoire de microbiologie, Cliniques universitaires Saint-Luc – Université catholique de Louvain, Brussels, Belgium
| | - Youri Glupczynski
- National Reference Centre for Monitoring Antimicrobial Resistance in Gram-negative bacteria, CHU UCL Namur, Yvoir, Belgium
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Pathogen Prevalence and Antimicrobial Susceptibility Among Enterobacteriaceae Causing Hospital-associated Intra-abdominal Infections in Adults in the United States (2012-2013). Clin Ther 2016; 38:1510-1521. [PMID: 27234360 DOI: 10.1016/j.clinthera.2016.04.035] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 04/07/2016] [Accepted: 04/18/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE Selection and prompt initiation of the appropriate empiric antimicrobial therapy are critical to decrease morbidity and mortality and shorten the length of hospitalization among patients with hospital-associated intra-abdominal infections (HA-IAIs). Therapeutic choices for the treatment of patients with HA-IAI require careful consideration. This study was conducted to evaluate the antimicrobial susceptibility of common pathogens collected from adult patients with HA-IAI in the United States. METHODS Gram-negative bacilli (N = 1285) were collected during 2012-2013 from SMART (Study for Monitoring Antimicrobial Resistance Trends). Isolates were tested at a central laboratory by using Clinical and Laboratory Standards Institute methods and interpretation of susceptibility to 12 antimicrobial agents. FINDINGS Most of the isolates (80.8%) were Enterobacteriaceae, and Escherichia coli was the most common species. Susceptibility to frequently used antimicrobial agents for treating IAI showed that ertapenem, imipenem, and amikacin were more active than other agents against Enterobacteriaceae, including multidrug-resistant isolates. More than 92% of E coli, including extended-spectrum β-lactamase (ESBL) producers, and Klebsiella pneumoniae isolates were susceptible to ertapenem, imipenem, and amikacin. Cefepime was the most active (>90% susceptibility) cephalosporin against all species except K pneumoniae (86.6%) but with much reduced activity against isolates with ESBLs. Piperacillin/tazobactam had reduced activity against Enterobacter species (70.4%-76.4% susceptible) and ESBL-producing K pneumoniae (22.5% susceptible). Fluoroquinolones exhibited poor activity against E coli (overall susceptibility <70%). IMPLICATIONS Proper empiric antimicrobial treatment, including combining appropriate agents, of HA-IAI requires detailed understanding of the epidemiology of common pathogens and antimicrobial resistance patterns. In light of rising rates of antimicrobial resistance, ongoing surveillance is critical for clinical decision-making.
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Namazi S, Sagheb MM, Hashempour MM, Sadatsharifi A. Usage Pattern and Serum Level Measurement of Amikacin in the Internal Medicine Ward of the Largest Referral Hospital in the South of Iran: A Pharmacoepidemiological Study. IRANIAN JOURNAL OF MEDICAL SCIENCES 2016; 41:191-9. [PMID: 27217603 PMCID: PMC4876297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The inappropriate use of aminoglycosides has harmful effects such as the development of resistant pathogens and the incidence of nephrotoxicity and ototoxicity. Therefore, drug utilization evaluation of these drugs may improve their usage remarkably. The aim of this study was to assess the usage pattern of amikacin in an internal medicine ward. METHODS This cross-sectional study was conducted in the Internal Medicine Ward of Nemazee Teaching Hospital, Shiraz, Iran, in 2011. The guideline for amikacin use was approved by the institutional Pharmacy and Therapeutics Committee, and the study criteria were developed to assess several parameters involved in amikacin therapy such as appropriateness of drug use, dosage, duration of therapy, toxicity monitoring, and serum concentration assay. Serum concentration was assayed using a Cobas Mira AutoAnalyzer. Clinical and paraclinical parameters such as glomerular filtration rate, culture, microbial sensitivity, white blood cell count, and fever were collected. RESULTS Sixty-three patients were evaluated. Fifty-seven percent of the patients needed dose readjustment; however, it was not performed for 89% of them. Culture between 48 and 72 hours after amikacin administration was not controlled for 79% of the patients. In 19% of the patients, optimum therapeutic effect was not achieved. The mean±SD of the trough and peak concentrations was 7.63±5.4 μg/mL and 15.67±7.79 μg/mL, respectively. Forty-five percent of the trough and 38% of the peak levels were within the therapeutic range. The overall adherence of amikacin usage to the guideline was only 48%. CONCLUSION To achieve appropriate treatment and prevent toxic effects, we recommend that pharmacokinetic dosing methods, amikacin guideline, and serum monitoring be considered.
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Affiliation(s)
- Soha Namazi
- Department of Pharmacotherapy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran,Correspondence: Soha Namazi, PharmD, PhD; Department of Pharmacotherapy, School of Pharmacy, Shiraz University of Medical Sciences, P.O. Box: 71645111, Shiraz, Iran Tel: + 98 71 32424128 Fax: +98 71 32424126
| | - Mohammad Mahdi Sagheb
- Department of Internal Medicine, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Mahdi Hashempour
- Department of Pharmacotherapy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Arman Sadatsharifi
- Department of Pharmacotherapy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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Abstract
Bloodstream infections (BSI) carry a heavy burden of morbidity and mortality in modern internal medicine wards (IMW). These wards are often filled with elderly subjects with several risk factors for BSI, such as multiple comorbidities, polypharmacy, immunosuppression, and indwelling devices. Diagnosing BSI in such a setting might require a high degree of suspicion, since the clinical presentation could be affected by underlying conditions and concomitant medications, which might delay the administration of an appropriate antimicrobial therapy, an event strongly and unfavorably influencing survival. Furthermore, selecting the appropriate antimicrobial therapy to treat these patients is becoming an increasingly complex task in which all possible benefits and costs should be carefully analyzed from patient and public health perspectives. Only a specialized, continuous, and interdisciplinary approach could really improve the management of IMW patients in an era of increasing antimicrobial resistance and complexity of care.
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Affiliation(s)
- Valerio Del Bono
- a Clinica Malattie Infettive, IRCCS AOU San Martino-IST, Università di Genova , Genova , Italy
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Does it Matter if we get it right? Impact of appropriateness of empiric antimicrobial therapy among surgical patients. Shock 2015; 42:185-91. [PMID: 24727868 DOI: 10.1097/shk.0000000000000192] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Previous studies have shown conflicting evidence regarding the impact of inappropriate, initial antibiotic therapy. The purpose of this study was to evaluate the impact of inappropriate empiric antimicrobial therapy for the treatment of infection among surgical patients. We hypothesized that inappropriate empiric antimicrobial therapy would predict increased mortality risk compared with appropriate therapy. This was a retrospective analysis of a prospectively maintained database of all surgical patients admitted to a tertiary care center from 1996 to 2007 and treated for sepsis. "Appropriate" empiric antibiotic treatment was determined by sensitivity testing. Demographics and comorbidities, infection sites, infection organisms, and outcomes were compared between inappropriately and appropriately treated groups. Multivariable log-binomial regression was performed. There were 2,855 patients (7,158 infectious episodes) identified by culture analysis as either appropriately or inappropriately treated. Three hundred seventeen (15%) inappropriately treated infectious episodes resulted in death compared with 718 (14%) of the appropriately treated infectious episodes. After adjusting for statistically significant variables, inappropriately treated episodes of infection were not found to be associated with an increased risk for mortality compared with appropriately treated episodes of infection (relative risk, 1.0; 95% confidence interval, 0.99 - 1.02; P = 0.36). Our study observed no difference in mortality between appropriately and inappropriately treated infections within a surgical population.
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Rapid antimicrobial susceptibility testing of clinical isolates by digital time-lapse microscopy. Eur J Clin Microbiol Infect Dis 2015; 34:2385-94. [PMID: 26407621 PMCID: PMC4655009 DOI: 10.1007/s10096-015-2492-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 09/14/2015] [Indexed: 01/21/2023]
Abstract
Rapid antimicrobial susceptibility testing (AST) is essential for early and appropriate therapy. Methods with short detection time enabling same-day treatment optimisation are highly favourable. In this study, we evaluated the potential of a digital time-lapse microscope system, the oCelloScope system, to perform rapid AST. The oCelloScope system demonstrated a very high accuracy (96 % overall agreement) when determining the resistance profiles of four reference strains, nine clinical isolates, including multi-drug-resistant isolates, and three positive blood cultures. AST of clinical isolates (168 antimicrobial agent–organism combinations) demonstrated 3.6 % minor, no major and 1.2 % very major errors of the oCelloScope system compared to conventional susceptibility testing, as well as a rapid and correct phenotypic detection of strains with methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum β-lactamase (ESBL) profiles. The net average time-to-result was 108 min, with 95 % of the results being available within 180 min. In conclusion, this study strongly indicates that the oCelloScope system holds considerable potential as an accurate and sensitive AST method with short time-to-result, enabling same-day targeted antimicrobial therapy, facilitating antibiotic stewardship and better patient management. A full-scale validation of the oCelloScope system including more isolates is necessary to assess the impact of using it for AST.
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Egli A, Osthoff M, Goldenberger D, Halter J, Schaub S, Steiger J, Weisser M, Frei R. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF) directly from positive blood culture flasks allows rapid identification of bloodstream infections in immunosuppressed hosts. Transpl Infect Dis 2015; 17:481-7. [PMID: 25704776 DOI: 10.1111/tid.12373] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/31/2014] [Accepted: 01/28/2015] [Indexed: 12/29/2022]
Abstract
INTRODUCTION In immunosuppressed hosts, rapid identification of microorganisms of bloodstream infections is crucial to ensuring effective antimicrobial therapy. Conventional culture requires up to 72 h from sample collection to pathogen identification. METHODS We used the SepsiTyper Kit and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF; Microflex, Bruker) directly from positive blood culture (BacT/ALERT 3D, FN/FA vials; bioMérieux) in comparison to standard culture methodology (VITEK 2; bioMérieux) for species identification. RESULTS A total of 62 consecutive positive blood cultures from immunosuppressed patients (solid organ or hematopoietic transplant recipients, or with febrile neutropenia) were analyzed. Culture yielded gram-negative bacteria (GNB) in 27/62 (43.5%) and gram-positive (GPB) in 35/62 (56.5%) vials. For GNB, the predominant species identified by MALDI-TOF and confirmed by VITEK were Escherichia coli (16/16 correctly identified) and Enterobacter cloacae (4/4), with a sensitivity and specificity of 92.6% and 100%, respectively. For GPB, predominant species were Staphylococcus aureus (3/3), coagulase-negative staphylococci (12/24), and Enterococcus faecium (6/6) with a sensitivity of 100%, 60%, and 100%, respectively. The median time from blood collection to species identification was 27.4 h with MALDI-TOF identification and 46.6 h with conventional methodology. CONCLUSION Using MALDI-TOF directly from positive blood cultures allowed a shorter time to identification with high sensitivity and specificity in immunosuppressed patients.
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Affiliation(s)
- A Egli
- Division of Clinical Microbiology, University Hospital Basel, Basel, Switzerland.,Vaccine Research Infection Biology Lab, Department Biomedicine, University of Basel, Basel, Switzerland
| | - M Osthoff
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - D Goldenberger
- Division of Clinical Microbiology, University Hospital Basel, Basel, Switzerland
| | - J Halter
- Hematology, University Hospital Basel, Basel, Switzerland
| | - S Schaub
- Division of Nephrology and Transplant Immunology, University Hospital Basel, Basel, Switzerland
| | - J Steiger
- Division of Nephrology and Transplant Immunology, University Hospital Basel, Basel, Switzerland
| | - M Weisser
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - R Frei
- Division of Clinical Microbiology, University Hospital Basel, Basel, Switzerland
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Madaras-Kelly K, Jones M, Remington R, Caplinger C, Huttner B, Samore M. Description and validation of a spectrum score method to measure antimicrobial de-escalation in healthcare associated pneumonia from electronic medical records data. BMC Infect Dis 2015; 15:197. [PMID: 25927970 PMCID: PMC4418054 DOI: 10.1186/s12879-015-0933-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 04/15/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Comparison of antimicrobial de-escalation rates between healthcare settings is problematic. To objectively and electronically measure de-escalation a method based upon the spectrum of antimicrobial regimens administered (i.e., spectrum score) was developed. METHODS A Delphi process was used to develop applicable concepts. Spectrum scores were created for 27 antimicrobials based upon susceptibility for 19 organisms. National VA susceptibility data was used to estimate microbial spectrum. Susceptibility estimates were converted to ordinal scores, and values for organisms with multi-drug resistance potential were weighted more heavily. Organism scores were summed to create antibiotic-specific spectrum scores and extended mathematically to score multi-antimicrobial regimens. Vignettes were created from antimicrobial regimens administered to 300 patients hospitalized with pneumonia. Daily spectrum scores were calculated for each case. Hospitalization day 4 scores were subtracted from day 2 scores (i.e., spectrum score ∆). A positive spectrum score ∆ defined de-escalation. Experts ranked each pneumonia case on a 7-point Likert scale (Likert >4 indicated de-escalation). Spectrum score ∆s were compared to expert review. Findings were used to identify score deficiencies. Next, 40 pairs of cases were modified to include antimicrobial administration routes. Each pair contained almost similar regimens; however, one contained oral (PO) the other only intravenous (IV) antimicrobials on day 4 of therapy. Experts reviewed cases as described. Spectrum score ∆ credits to account for PO conversion were derived from the mean paired differences in Likert Score. De-escalation status was evaluated in 100 vignettes containing antimicrobial route by different experts and compared to the modified method. RESULTS Initial sensitivity and specificity of the spectrum score ∆ to detect expert classified de-escalation events was 86.3 and 96.0%, respectively. In paired cases, the mean (± SD) Likert score was 5.0 (1.5) and 4.6 (1.5) for PO and IV (P = 0.002), respectively. To improve de-escalation event detection, two credits were added to spectrum score ∆s based upon the percentage of antimicrobials administered PO on day 4. The final method, exhibited sensitivity and specificity to detect expert classified de-escalation events of 96.2 and 93.6%, respectively. CONCLUSIONS The final spectrum score method exhibited excellent agreement with expert judgments of de-escalation events in pneumonia.
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Affiliation(s)
- Karl Madaras-Kelly
- Pharmacy Service, Boise Veterans Affairs Medical Center and College of Pharmacy, Idaho State University, T111, 500 W Fort Street, Boise, 83702, USA.
| | - Makoto Jones
- IDEAS Center, VA Salt Lake City Health Care System and Division of Epidemiology Health Care System and Division of Epidemiology, University of Utah, 500 Foothill Drive, Salt Lake City, 84148, UT, USA.
| | - Richard Remington
- Research Service, Boise Veterans Affairs Medical Center and Quantified Inc, T111, 500 W Fort Street, Boise, 83702, USA.
| | - Christina Caplinger
- Research Fellow, Pharmacy Service, Boise Veterans Affairs Medical Center, T111, 500 W Fort Street, Boise, 83702, USA.
| | - Benedikt Huttner
- Infection Control Programme & Division of Infectious Diseases, Faculty of Medicine, Geneva University Hospitals, Rue Gabrielle Perret- Gentil 4, Geneva, 1211, Switzerland.
| | - Matthew Samore
- IDEAS Center, VA Salt Lake City Health Care System and Division of Epidemiology, University of Utah, 500 Foothill Drive, Salt Lake City, UT, 84148, USA.
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Radomski M, Zettervall S, Schroeder ME, Messing J, Dunne J, Sarani B. Critical Care for the Patient With Multiple Trauma. J Intensive Care Med 2015; 31:307-18. [PMID: 25673631 DOI: 10.1177/0885066615571895] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 01/12/2015] [Indexed: 02/06/2023]
Abstract
Trauma remains the leading cause of death worldwide and the leading cause of death in those less than 44 years old in the United States. Admission to a verified trauma center has been shown to decrease mortality following a major injury. This decrease in mortality has been a direct result of improvements in the initial evaluation and resuscitation from injury as well as continued advances in critical care. As such, it is vital that intensive care practitioners be familiar with various types of injuries and their associated treatment strategies as well as their potential complications in order to minimize the morbidity and mortality frequently seen in this patient population.
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Affiliation(s)
- Michal Radomski
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - Sara Zettervall
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - Mary Elizabeth Schroeder
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - Jonathan Messing
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - James Dunne
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
| | - Babak Sarani
- Department of Surgery, Center for Trauma and Critical Care (CTACC), George Washington University, Washington, DC, USA
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Characteristics of surgical patients receiving inappropriate empiric antimicrobial therapy. J Trauma Acute Care Surg 2015; 77:546-54. [PMID: 25051386 DOI: 10.1097/ta.0000000000000309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Inappropriate antibiotics have been observed to result in an increased duration of antibiotic treatment and hospital length of stay, development of multidrug-resistant organisms, and mortality rate compared with appropriate antibiotic treatment. Few studies have evaluated independent risk factors associated with inappropriateness. The purpose of this study was to identify independent predictors of inappropriate, empiric antimicrobial therapy for the treatment of severe sepsis. METHODS This was a retrospective analysis of a prospectively maintained database of all surgical/trauma patients admitted to a tertiary care center from 1996 to 2007 and treated for sepsis. "Appropriate" empiric antibiotic treatment was determined by sensitivity testing. Demographics and comorbidities, infection sites, infection organisms, and outcomes between strata were compared. Differences in outcome were estimated using relative risk and 95% confidence intervals for correlated data. RESULTS A total of 2,855 patients (7,158 infections) were identified. Independent predictors of inappropriate, empiric antimicrobial therapy for the treatment of severe sepsis included site of infection and organism type. Severity of illness, age, medical conditions, and community versus health care-associated infections were not associated with inappropriate therapy. Although inappropriate empiric therapy was associated with a longer length of stay and duration of antimicrobial use, it did not result in higher mortality. CONCLUSION Our study observed that inappropriate empiric antibiotic selection is related to site of infection and pathogen. Other clinical variables do not appear to predict inappropriateness of antibiotic treatment. Efforts should be focused on early broad-spectrum therapy and more rapid microbiologic methods. LEVEL OF EVIDENCE Therapeutic/care management study, level II.
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44
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Czilwik G, Messinger T, Strohmeier O, Wadle S, von Stetten F, Paust N, Roth G, Zengerle R, Saarinen P, Niittymäki J, McAllister K, Sheils O, O'Leary J, Mark D. Rapid and fully automated bacterial pathogen detection on a centrifugal-microfluidic LabDisk using highly sensitive nested PCR with integrated sample preparation. LAB ON A CHIP 2015; 15:3749-59. [PMID: 26235430 DOI: 10.1039/c5lc00591d] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Diagnosis of infectious diseases suffers from long turnaround times for gold standard culture-based identification of bacterial pathogens, therefore impeding timely specific antimicrobial treatment based on laboratory evidence. Rapid molecular diagnostics-based technologies enable detection of microorganisms within hours however cumbersome workflows and complex equipment still prevent their widespread use in the routine clinical microbiology setting. We developed a centrifugal-microfluidic "LabDisk" system for rapid and highly-sensitive pathogen detection on a point-of-care analyser. The unit-use LabDisk with pre-stored reagents features fully automated and integrated DNA extraction, consensus multiplex PCR pre-amplification and geometrically-multiplexed species-specific real-time PCR. Processing merely requires loading of the sample and DNA extraction reagents with minimal hands-on time of approximately 5 min. We demonstrate detection of as few as 3 colony-forming-units (cfu) of Staphylococcus warneri, 200 cfu of Streptococcus agalactiae, 5 cfu of Escherichia coli and 2 cfu of Haemophilus influenzae in a 200 μL serum sample. The turnaround time of the complete analysis from "sample-to-result" was 3 h and 45 min. The LabDisk consequently provides an easy-to-use molecular diagnostic platform for rapid and highly-sensitive detection of bacterial pathogens without requiring major hands-on time and complex laboratory instrumentation.
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Affiliation(s)
- G Czilwik
- Hahn Schickard, Georges-Koehler-Allee 103, 79110 Freiburg, Germany.
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Lew KY, Ng TM, Tan M, Tan SH, Lew EL, Ling LM, Ang B, Lye D, Teng CB. Safety and clinical outcomes of carbapenem de-escalation as part of an antimicrobial stewardship programme in an ESBL-endemic setting. J Antimicrob Chemother 2014; 70:1219-25. [PMID: 25473028 DOI: 10.1093/jac/dku479] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate the safety and clinical outcomes of patients who received carbapenem de-escalation as guided by an antimicrobial stewardship programme (ASP) in a setting where ESBL-producing Enterobacteriaceae are endemic. METHODS Patients receiving meropenem or imipenem underwent a prospective ASP review for eligibility for de-escalation according to defined institutional guidelines. Patients in whom carbapenem was de-escalated or not de-escalated, representing the acceptance and rejection of the ASP recommendation, respectively, were compared. The primary outcome was the clinical success rate; secondary outcomes included the 30 day readmission and mortality rates, the duration of carbapenem therapy, the incidence of adverse drug reactions due to antimicrobials, the acquisition of carbapenem-resistant Gram-negative bacteria and the occurrence of Clostridium difficile-associated diarrhoea (CDAD). RESULTS The de-escalation recommendations for 300 patients were evaluated; 204 (68.0%) were accepted. The patient demographics and disease severity were similar. The clinical success rates were similar [de-escalated versus not de-escalated, 183/204 (89.7%) versus 85/96 (88.5%), P=0.84], as was the survival at hospital discharge [173/204 (84.8%) versus 79/96 (82.3%), P=0.58]. In the de-escalated group, the duration of carbapenem therapy was shorter (6 versus 8 days, P<0.001), the rate of adverse drug reactions was lower [11/204 (5.4%) versus 12/96 (12.5%), P=0.037], there was less diarrhoea [9/204 (4.4%) versus 12/96 (12.5%), P=0.015], there was a lower incidence of carbapenem-resistant Acinetobacter baumannii acquisition [4/204 (2.0%) versus 7/96 (7.3%), P=0.042] and there was a lower incidence of CDAD [2/204 (1.0%) versus 4/96 (4.2%), P=0.081]. CONCLUSIONS This study suggests that the ASP-guided de-escalation of carbapenems led to comparable clinical success, fewer adverse effects and a lower incidence of the development of resistance. This approach is safe and practicable, and should be a key component of an ASP.
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Affiliation(s)
- Kaung Yuan Lew
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, 117543 Singapore
| | - Tat Ming Ng
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Michelle Tan
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Sock Hoon Tan
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Ee Ling Lew
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Li Min Ling
- Communicable Disease Center, Institute of Infectious Diseases and Epidemiology, Department of Infectious Disease, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Brenda Ang
- Communicable Disease Center, Institute of Infectious Diseases and Epidemiology, Department of Infectious Disease, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - David Lye
- Communicable Disease Center, Institute of Infectious Diseases and Epidemiology, Department of Infectious Disease, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road 119228, Singapore
| | - Christine B Teng
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, 117543 Singapore Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
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Pimenta F, Abreu AC, Simões LC, Simões M. What should be considered in the treatment of bacterial infections by multi-drug therapies: a mathematical perspective? Drug Resist Updat 2014; 17:51-63. [PMID: 25156320 DOI: 10.1016/j.drup.2014.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Bacterial infections are a global health concern with high levels of mortality and morbidity associated. The resistance of pathogens to drugs is one leading cause of this problem, being common the administration of multiple drugs to improve the therapeutic effects. This review critically explores diverse aspects involved in the treatment of bacterial infections through multi-drug therapies, from a mathematical and within-host perspectives. Five recent models were selected and are reviewed. These models fall into the following question: which drugs to select, the respective dose, the administration period to effectively eradicate the infection in the shortest period of time and with reduced side effects? In this analysis, three groups of variables were considered: pharmacokinetics, pharmacodynamics and disturbance variables. To date, there is no model that fully answers to this issue for a living organism and it is questionable whether this would be possible for any case of infection.
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Affiliation(s)
- Francisco Pimenta
- Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias, s/n, 4200-465 Porto, Portugal
| | - Ana Cristina Abreu
- LEPABE, Department of Chemical Engineering, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias, s/n, 4200-465 Porto, Portugal
| | - Lúcia Chaves Simões
- LEPABE, Department of Chemical Engineering, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias, s/n, 4200-465 Porto, Portugal; CEB, Centre of Biological Engineering, University of Minho, Campus de Gualtar, 4710-057 Braga, Portugal
| | - Manuel Simões
- LEPABE, Department of Chemical Engineering, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias, s/n, 4200-465 Porto, Portugal.
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Martiny D, Debaugnies F, Gateff D, Gérard M, Aoun M, Martin C, Konopnicki D, Loizidou A, Georgala A, Hainaut M, Chantrenne M, Dediste A, Vandenberg O, Van Praet S. Impact of rapid microbial identification directly from positive blood cultures using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry on patient management. Clin Microbiol Infect 2013; 19:E568-81. [DOI: 10.1111/1469-0691.12282] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Revised: 05/16/2013] [Accepted: 05/23/2013] [Indexed: 11/30/2022]
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Harrison RF, Ouyang H. Fever and the rational use of antimicrobials in the emergency department. Emerg Med Clin North Am 2013; 31:945-68. [PMID: 24176473 PMCID: PMC7132744 DOI: 10.1016/j.emc.2013.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Any patient presenting to the emergency department (ED) with fever triggers consideration of the administration of an antimicrobial. Empiric antimicrobial therapy has become a cornerstone of treatment. Frequently, the decision to initiate empiric treatment needs to be made before the definitive diagnosis is known. In such cases, an organized approach is helpful. This article aims to provide a systems-based approach to prescribing antimicrobials to patients presenting to the ED with fever, while understanding the risk associated with overutilization. An understanding of the key considerations is needed to ensure that decisions are made well and appropriate treatment begins promptly.
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Affiliation(s)
- Raquel F Harrison
- Department of Emergency Medicine, New York-Presbyterian Hospital, The University Hospitals of Columbia and Cornell, New York, NY, USA
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McConeghy KW, Bleasdale SC, Rodvold KA. The Empirical Combination of Vancomycin and a -Lactam for Staphylococcal Bacteremia. Clin Infect Dis 2013; 57:1760-5. [DOI: 10.1093/cid/cit560] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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50
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Becher RD, Hoth JJ, Rebo JJ, Kendall JL, Miller PR. Locally derived versus guideline-based approach to treatment of hospital-acquired pneumonia in the trauma intensive care unit. Surg Infect (Larchmt) 2013; 13:352-9. [PMID: 23268613 DOI: 10.1089/sur.2011.056] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Appropriate initial antibiotic therapy for presumed pneumonia in critically ill patients decreases the mortality rate. To achieve this goal, treatment guidelines developed by groups such as the American Thoracic Society (ATS) have been stressed. However, often overlooked is the importance of incorporating local microbiologic data into an empiric algorithm. Our hypothesis was that an empiric algorithm supported by our locally-driven analysis would predict more accurate coverage than one defined strictly by an unmodified guideline-driven approach. METHODS Retrospective review of all first hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) pathogens in consecutive trauma intensive care unit (TICU) patients over 18 months. Microbiologic data were analyzed to update our TICU-specific empiric algorithm. The ATS guidelines define patients at risk for multidrug-resistant (MDR) organisms on the basis of standardized criteria and time since admission (early <5 days; late ≥5 days). RESULTS A total of 164 pathogens caused 117 pneumonias. For early coverage, ATS guidelines stress identification of MDR risks; these criteria failed to identify 8 of 13 (62%) early MDR pneumonias. For early HAP/VAP with no MDR risks, the ATS guidelines recommend monotherapy; susceptibility differed (49% to ciprofloxacin, 68% to ampicillin-sulbactam, 83% to ceftriaxone). A total of 15% of early pathogens were MDR gram-positive, so addition of vancomycin resulted in adequate predicted coverage of 100%, 79%, and 95% for ciprofloxacin, ampicillin-sulbactam, and ceftriaxone, respectively. For late HAP/VAP, ATS recommends regimens based on broad-spectrum drugs. Vancomycin with ciprofloxacin, cefepime, or piperacillin-tazobactam had predicted coverage of 95%, 94%, and 93%, respectively. CONCLUSIONS The empiric algorithm derived from analysis of local microbiologic data predicted significantly better coverage than one defined by an unmodified guideline-driven approach for early HAP/VAP. Our locally-derived TICU algorithm of ceftriaxone+vancomycin for early pneumonia and piperacillin-tazobactam+vancomycin for late pneumonia optimizes the adequacy of initial therapy. Understanding local patterns of pneumonia ensures the creation and maintenance of empiric algorithms that achieve the best clinical outcomes.
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Affiliation(s)
- Robert D Becher
- Acute Care Surgery Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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