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Assaad C, Chaibi K, Jaureguy F, Plésiat P, Carbonnelle E, Cohen Y, Zahar JR, Pilmis B. Risk factors for Pseudomonas aeruginosa VIM colonization or infection in the ICU: Case-control study. Am J Infect Control 2024; 52:1160-1165. [PMID: 38925502 DOI: 10.1016/j.ajic.2024.06.013] [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: 03/25/2024] [Revised: 06/19/2024] [Accepted: 06/19/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Carbapenem-resistant strains of Pseudomonas aeruginosa (CRPA) have become a major health care concern in many countries, against which anti-infective strategies are limited and which require adequate infection control interventions. Knowing the different modes of transmission of CRPA in intensive care units (ICUs) would be helpful to adapt the means of prevention. METHODS The aim of this retrospective case-control study was conducted between January 1, 2017 and February 28, 2022 to identify the risk factors for the acquisition of CRPA in ICUs. RESULTS During the study period, 147 patients were included (49 cases and 98 controls). Among the 49 patients, 31 (63%) acquired CRPA in clusters and 18 (37%) sporadically. A univariate analysis showed that 4 variables were associated with CRPA acquisition, including (1) prior antibiotic prescriptions, (2) admission to rooms 203 and 207, (3) severity of illness at admission, and (4) use of mechanical ventilation. Multivariate analysis identified 3 factors of CRPA acquisition, including admission to room 203 (odds ratio [OR] = 29.5 [3.52-247.09]), previous antibiotic therapy (OR = 3.44 [1.02-11.76]), and severity of condition at admission (OR = 1.02 [1-1.04]). CONCLUSIONS Our study suggests the role of a contaminated environment in the acquisition of CRPA in the ICU, along with antibiotic use.
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Affiliation(s)
- Charbel Assaad
- Unité de Prévention du Risque Infectieux, Département de Microbiologie Clinique, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, Bobigny, France
| | - Khalil Chaibi
- Service de Réanimation Médico Chirurgicale, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, Bobigny, France
| | - Françoise Jaureguy
- Unité de Prévention du Risque Infectieux, Département de Microbiologie Clinique, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, Bobigny, France
| | - Patrick Plésiat
- Université de Franche-Comté, UMR CNRS 6249 Chrono-Environnement, Besançon, France; Laboratoire Associé du Centre National de Référence de la Résistance aux Antibiotiques, Centre Hospitalier Universitaire de Besançon, Besançon, France
| | - Etienne Carbonnelle
- Unité de Prévention du Risque Infectieux, Département de Microbiologie Clinique, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, Bobigny, France
| | - Yves Cohen
- Service de Réanimation Médico Chirurgicale, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, Bobigny, France
| | - Jean-Ralph Zahar
- Service de Réanimation Médico Chirurgicale, Groupe Hospitalier Paris Seine Saint-Denis, Université Paris 13, Bobigny, France.
| | - Benoit Pilmis
- Service de Microbiologie et Plateforme de Dosage des Anti-infection, Équipe Mobile de Microbiologie Clinique, Hôpitaux Saint-Joseph & Marie Lannelongue, Paris, France; Université Paris-Saclay, INRAE, AgroParisTech, UMR 1319, Micalis Institute, Jouy-en-Josas, France
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Yang AF, Huang V, Samaroo-Campbell J, Augenbraun M. Multi-drug resistant Pseudomonas aeruginosa: a 2019-2020 single center retrospective case control study. Infect Prev Pract 2023; 5:100296. [PMID: 37520840 PMCID: PMC10372386 DOI: 10.1016/j.infpip.2023.100296] [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: 01/05/2023] [Accepted: 06/14/2023] [Indexed: 08/01/2023] Open
Abstract
Multi-drug resistance in the post COVID-19 world is a growing concern. The objective of this study was to describe temporal trends and explore independent risk factors for the isolation of multi-drug resistant (MDR) P. aeruginosa. Methods This was a retrospective case-control study of patients with P. aeruginosa isolates recovered from January 2019 to December 2020. MDR P. aeruginosa was defined as non-susceptibility to at least one agent in three or more anti-pseudomonal antimicrobial categories. Results In total, 258 unique isolates were identified. Prolonged hospitalization (P<0.001), prior antibiotic use (P<0.001), and respiratory sources (P<0.001) were strongly associated with the presence of MDR P. aeruginosa. From 2019 to 2020, there was a decrease in the total number of P. aeruginosa isolates but a significant increase in the proportion of MDR P. aeruginosa isolates (P=0.015). Conclusions Over a period that coincided with the COVID-19 pandemic, there was an increased proportion of MDR P. aeruginosa isolates from hospitalized patients. Improved identification of patients at risk for MDR P. aeruginosa could facilitate appropriate empiric antibiotic decisions like dual anti-pseudomonal therapy. The features of the COVID-19 outbreak that had a severe impact on patient care and that may have affected drug resistance in other respiratory pathogens should be explored.
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Affiliation(s)
- Ann Fan Yang
- Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Vivian Huang
- Medical School, State University of New York Health Sciences University, New York, NY, USA
| | - Jevon Samaroo-Campbell
- Department of Internal Medicine, State University of New York Health Sciences University, New York, NY, USA
| | - Michael Augenbraun
- Department of Infectious Disease, State University of New York Health Sciences University, New York, NY, USA
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Zequinão T, Telles JP, Gasparetto J, Tuon FF. Carbapenem stewardship with ertapenem and antimicrobial resistance-a scoping review. Rev Soc Bras Med Trop 2020; 53:e20200413. [PMID: 33174959 PMCID: PMC7670755 DOI: 10.1590/0037-8682-0413-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 08/24/2020] [Indexed: 11/25/2022] Open
Abstract
Consumption of carbapenem has increased due to extended-spectrum
beta-lactamase-producing bacteria spreading. Ertapenem has been suggested as a
not carbapenem-resistance inducer. We performed a scoping review of
carbapenem-sparing stewardship with ertapenem and its impact on the antibiotic
resistance of Gram-negative bacilli. We searched PubMed for studies that used
ertapenem as a strategy to reduce resistance to carbapenems and included
epidemiologic studies with this strategy to evaluate susceptibility patterns to
cephalosporins, quinolones, and carbapenems in Gram-negative-bacilli. The search
period included only studies in English, up to February 2018. From 1294
articles, 12 studies were included, mostly from the Americas.
Enterobacteriaceae resistance to quinolones and
cephalosporins was evaluated in 6 studies and carbapenem resistance in 4
studies. Group 2 carbapenem (imipenem/meropenem/doripenem) resistance on
A. baumannii was evaluated in 6
studies. All studies evaluated P.
aeruginosa resistance to Group 2 carbapenem. Resistance profiles of
Enterobacteriaceae and P. aeruginosa to
Group 2 carbapenems were not associated with ertapenem consumption. The
resistance rate of A. baumannii to Group 2 carbapenems after
ertapenem introduction was not clear due to a lack of studies without bias. In
summary, ertapenem as a strategy to spare use of Group 2 carbapenems may be an
option to stewardship programs without increasing resistance of
Enterobacteriaceae and P. aeruginosa. More
studies are needed to evaluate the influence of ertapenem on A.
baumannii.
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Affiliation(s)
- Tiago Zequinão
- Pontifícia Universidade Católica do Paraná, Faculdade de Medicina, Laboratório de Doenças Infecciosas Emergentes, Curitiba, PR, Brasil
| | - João Paulo Telles
- Pontifícia Universidade Católica do Paraná, Faculdade de Medicina, Laboratório de Doenças Infecciosas Emergentes, Curitiba, PR, Brasil.,A.C.Camargo Cancer Center, São Paulo, SP, Brasil
| | - Juliano Gasparetto
- Pontifícia Universidade Católica do Paraná, Faculdade de Medicina, Laboratório de Doenças Infecciosas Emergentes, Curitiba, PR, Brasil
| | - Felipe Francisco Tuon
- Pontifícia Universidade Católica do Paraná, Faculdade de Medicina, Laboratório de Doenças Infecciosas Emergentes, Curitiba, PR, Brasil
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Weber KL, LeSassier DS, Kappell AD, Schulte KQ, Westfall N, Albright NC, Godbold GD, Palsikar V, Acevedo CA, Ternus KL, Hewitt FC. Simulating transmission of ESKAPE pathogens plus C. difficile in relevant clinical scenarios. BMC Infect Dis 2020; 20:411. [PMID: 32532220 PMCID: PMC7477864 DOI: 10.1186/s12879-020-05121-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/27/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The prevalence of healthcare-acquired infections (HAI) and rising levels of antimicrobial resistance places significant economic and public health burdens on modern healthcare systems. A group of highly drug resistant pathogens known as the ESKAPE pathogens, along with C. difficile, are the leading causes of HAIs. Interactions between patients, healthcare workers, and environmental conditions impact disease transmission. Studying pathogen transfer under varying contact scenarios in a controlled manner is critical for understanding transmission and disinfectant strategies. In lieu of human subject research, this method has the potential to contribute to modeling the routes of pathogen transmission in healthcare settings. METHODS To overcome these challenges, we have developed a method that utilizes a synthetic skin surrogate to model both direct (skin-to-skin) and indirect (skin-to fomite-to skin) pathogen transfer between infected patients and healthy healthcare workers. This surrogate material includes a background microbiome community simulating typical human skin flora to more accurately mimic the effects of natural flora during transmission events. RESULTS We demonstrate the ability to modulate individual bacterial concentrations within this microbial community to mimic bacterial concentrations previously reported on the hands of human subjects. We also explore the effect of various decontamination approaches on pathogen transfer between human subjects, such as the use of handwashing or surface disinfectants. Using this method, we identify a potential outlier, S. aureus, that may persist and retain viability in specific transfer conditions better than the overall microbial community during decontamination events. CONCLUSIONS Our work describes the development of an in vitro method that uses a synthetic skin surrogate with a defined background microbiota to simulate skin-to-skin and skin-to fomite-to skin contact scenarios. These results illustrate the value of simulating a holistic microbial community for transfer studies by elucidating differences in different pathogen transmission rates and resistance to common decontamination practices. We believe this method will contribute to improvements in pathogen transmission modeling in healthcare settings and increase our ability to assess the risk associated with HAIs, although additional research is required to establish the degree of correlation of pathogen transmission by skin or synthetic alternatives.
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Mitsuboshi S, Tsugita M. Impact of alcohol-based hand sanitizers, antibiotic consumption, and other measures on detection rates of antibiotic-resistant bacteria in rural Japanese hospitals. J Infect Chemother 2019; 25:225-228. [DOI: 10.1016/j.jiac.2018.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 07/23/2018] [Accepted: 08/22/2018] [Indexed: 11/28/2022]
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Karampatakis T, Tsergouli K, Iosifidis E, Antachopoulos C, Karapanagiotou A, Karyoti A, Gritsi-Gerogianni N, Tsakris A, Roilides E. Impact of active surveillance and infection control measures on carbapenem-resistant Gram-negative bacterial colonization and infections in intensive care. J Hosp Infect 2018; 99:396-404. [PMID: 29792971 DOI: 10.1016/j.jhin.2018.05.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/15/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND Carbapenem-resistant Gram-negative bacteria (CRGNB) infections constitute a global threat for critically ill patients and the outcome of their hospitalization. Early identification of CRGNB through rectal surveillance cultures and routine infection control measures including contact precautions, use of appropriate disinfectants, staff education on cleaning, and hand hygiene may reduce the dissemination of CRGNB. AIM To assess the impact of enhanced infection control measures on CRGNB infections in a nine-bed polyvalent intensive care unit in a tertiary level hospital in an endemic area. METHODS A quasi-experimental study, which included patients with CRGNB infection retrospectively for six months and those participating in an active surveillance programme prospectively for the subsequent 22 months. Active surveillance programme (weekly rectal swabs) was implemented including two sub-periods with infection control measures and enhanced infection control measures. CRGNB incidence, prevalence, colonization pressure, infections and compliance with infection control measures and enhanced infection control measures were recorded. Analysis was performed through time-series and interrupted time-series. FINDINGS During the active surveillance programme, enhanced infection control measures led to a steeper downwards trend in incidence, prevalence, and colonization pressure for CRGNB compared to the infection control measures sub-period. The linear trend was for carbapenem-resistant Klebsiella pneumoniae (CRKP) and Pseudomonas aeruginosa (CRPA) infections to decrease from 19.6 to 8.1 infections per 1000 bed-days (IBD) (P = 0.001) and from 5.1 to 1.79 IBD (P = 0.043), respectively. By contrast, carbapenem-resistant Acinetobacter baumannii infections increased from 5.2 to 15.3 IBD (P = 0.001). CONCLUSION Enhanced infection control measures including enhanced hand hygiene, active surveillance combined with contact precautions, education, audits and feedback policies and interventions could reduce CRKP and CRPA in endemic areas.
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Affiliation(s)
- T Karampatakis
- Infectious Disease Unit, 3(rd) Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece; Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - K Tsergouli
- Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - E Iosifidis
- Infectious Disease Unit, 3(rd) Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece; Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece
| | - C Antachopoulos
- Infectious Disease Unit, 3(rd) Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece; Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece
| | - A Karapanagiotou
- Intensive Care Unit, Hippokration General Hospital, Thessaloniki, Greece
| | - A Karyoti
- Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece; Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece
| | | | - A Tsakris
- Microbiology Department, National and Kapodistrian University School of Medicine, Athens, Greece
| | - E Roilides
- Infectious Disease Unit, 3(rd) Department of Pediatrics, Medical Faculty, Aristotle University School of Health Sciences, Hippokration General Hospital, Thessaloniki, Greece; Infection Control Committee, Hippokration General Hospital, Thessaloniki, Greece.
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Gould DJ, Moralejo D, Drey N, Chudleigh JH, Taljaard M. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev 2017; 9:CD005186. [PMID: 28862335 PMCID: PMC6483670 DOI: 10.1002/14651858.cd005186.pub4] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure. This is an update of a previously published review. OBJECTIVES To assess the short- and long-term success of strategies to improve compliance to recommendations for hand hygiene, and to determine whether an increase in hand hygiene compliance can reduce rates of health care-associated infection. SEARCH METHODS We conducted electronic searches of the Cochrane Register of Controlled Trials, PubMed, Embase, and CINAHL. We conducted the searches from November 2009 to October 2016. SELECTION CRITERIA We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series analyses (ITS) that evaluated any intervention to improve compliance with hand hygiene using soap and water or alcohol-based hand rub (ABHR), or both. DATA COLLECTION AND ANALYSIS Two review authors independently screened citations for inclusion, extracted data, and assessed risks of bias for each included study. Meta-analysis was not possible, as there was substantial heterogeneity across studies. We assessed the certainty of evidence using the GRADE approach and present the results narratively in a 'Summary of findings' table. MAIN RESULTS This review includes 26 studies: 14 randomised trials, two non-randomised trials and 10 ITS studies. Most studies were conducted in hospitals or long-term care facilities in different countries, and collected data from a variety of healthcare workers. Fourteen studies assessed the success of different combinations of strategies recommended by the World Health Organization (WHO) to improve hand hygiene compliance. Strategies consisted of the following: increasing the availability of ABHR, different types of education for staff, reminders (written and verbal), different types of performance feedback, administrative support, and staff involvement. Six studies assessed different types of performance feedback, two studies evaluated education, three studies evaluated cues such as signs or scent, and one study assessed placement of ABHR. Observed hand hygiene compliance was measured in all but three studies which reported product usage. Eight studies also reported either infection or colonisation rates. All studies had two or more sources of high or unclear risks of bias, most often associated with blinding or independence of the intervention.Multimodal interventions that include some but not all strategies recommended in the WHO guidelines may slightly improve hand hygiene compliance (five studies; 56 centres) and may slightly reduce infection rates (three studies; 34 centres), low certainty of evidence for both outcomes.Multimodal interventions that include all strategies recommended in the WHO guidelines may slightly reduce colonisation rates (one study; 167 centres; low certainty of evidence). It is unclear whether the intervention improves hand hygiene compliance (five studies; 184 centres) or reduces infection (two studies; 16 centres) because the certainty of this evidence is very low.Multimodal interventions that contain all strategies recommended in the WHO guidelines plus additional strategies may slightly improve hand hygiene compliance (six studies; 15 centres; low certainty of evidence). It is unclear whether this intervention reduces infection rates (one study; one centre; very low certainty of evidence).Performance feedback may improve hand hygiene compliance (six studies; 21 centres; low certainty of evidence). This intervention probably slightly reduces infection (one study; one centre) and colonisation rates (one study; one centre) based on moderate certainty of evidence.Education may improve hand hygiene compliance (two studies; two centres), low certainty of evidence.Cues such as signs or scent may slightly improve hand hygiene compliance (three studies; three centres), low certainty of evidence.Placement of ABHR close to point of use probably slightly improves hand hygiene compliance (one study; one centre), moderate certainty of evidence. AUTHORS' CONCLUSIONS With the identified variability in certainty of evidence, interventions, and methods, there remains an urgent need to undertake methodologically robust research to explore the effectiveness of multimodal versus simpler interventions to increase hand hygiene compliance, and to identify which components of multimodal interventions or combinations of strategies are most effective in a particular context.
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Affiliation(s)
- Dinah J Gould
- Cardiff UniversitySchool of Healthcare SciencesEastgate HouseCardiffWalesUK
| | - Donna Moralejo
- Memorial UniversitySchool of NursingH2916, Health Sciences Centre300 Prince Philip DriveSt. John'sNLCanadaA1B 3V6
| | - Nicholas Drey
- City, University of LondonCentre for Health Services ResearchNorthampton SquareLondonUKEC1V 0HB
| | - Jane H Chudleigh
- City, University of LondonSchool of Health SciencesNorthampton SquareLondonUKEC1V 0HB
| | - Monica Taljaard
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ Civic Campus1053 Carling Ave, Box 693OttawaONCanadaK1Y 4E9
- University of OttawaSchool of Epidemiology, Public Health and Preventive MedicineOttawaONCanada
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Antimicrobial resistance in human populations: challenges and opportunities. GLOBAL HEALTH EPIDEMIOLOGY AND GENOMICS 2017; 2:e4. [PMID: 29276617 PMCID: PMC5732576 DOI: 10.1017/gheg.2017.4] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 01/05/2017] [Accepted: 03/30/2017] [Indexed: 12/24/2022]
Abstract
Antimicrobial resistance (AMR) is a global public health threat. Emergence of AMR occurs naturally, but can also be selected for by antimicrobial exposure in clinical and veterinary medicine. Despite growing worldwide attention to AMR, there are substantial limitations in our understanding of the burden, distribution and determinants of AMR at the population level. We highlight the importance of population-based approaches to assess the association between antimicrobial use and AMR in humans and animals. Such approaches are needed to improve our understanding of the development and spread of AMR in order to inform strategies for the prevention, detection and management of AMR, and to support the sustainable use of antimicrobials in healthcare.
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Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, Gould IM, Ramsay CR, Michie S. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2:CD003543. [PMID: 28178770 PMCID: PMC6464541 DOI: 10.1002/14651858.cd003543.pub4] [Citation(s) in RCA: 397] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotic resistance is a major public health problem. Infections caused by multidrug-resistant bacteria are associated with prolonged hospital stay and death compared with infections caused by susceptible bacteria. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. We updated this systematic review to evaluate the impact of interventions to improve antibiotic prescribing to hospital inpatients. OBJECTIVES To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and to investigate the effect of two intervention functions: restriction and enablement. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, and Embase. We searched for additional studies using the bibliographies of included articles and personal files. The last search from which records were evaluated and any studies identified incorporated into the review was January 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies (NRS). We included three non-randomised study designs to measure behavioural and clinical outcomes and analyse variation in the effects: non- randomised trials (NRT), controlled before-after (CBA) studies and interrupted time series (ITS) studies. For this update we also included three additional NRS designs (case control, cohort, and qualitative studies) to identify unintended consequences. Interventions included any professional or structural interventions as defined by the Cochrane Effective Practice and Organisation of Care Group. We defined restriction as 'using rules to reduce the opportunity to engage in the target behaviour (or increase the target behaviour by reducing the opportunity to engage in competing behaviours)'. We defined enablement as 'increasing means/reducing barriers to increase capability or opportunity'. The main comparison was between intervention and no intervention. DATA COLLECTION AND ANALYSIS Two review authors extracted data and assessed study risk of bias. We performed meta-analysis and meta-regression of RCTs and meta-regression of ITS studies. We classified behaviour change functions for all interventions in the review, including those studies in the previously published versions. We analysed dichotomous data with a risk difference (RD). We assessed certainty of evidence with GRADE criteria. MAIN RESULTS This review includes 221 studies (58 RCTs, and 163 NRS). Most studies were from North America (96) or Europe (87). The remaining studies were from Asia (19), South America (8), Australia (8), and the East Asia (3). Although 62% of RCTs were at a high risk of bias, the results for the main review outcomes were similar when we restricted the analysis to studies at low risk of bias.More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% confidence interval (CI) 14% to 16%; 23,394 participants; high-certainty evidence). This represents an increase from 43% to 58% .There were high levels of heterogeneity of effect size but the direction consistently favoured intervention.The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67; 14 RCTs; 3318 participants; high-certainty evidence) from 11.0 days. Information from non-randomised studies showed interventions to be associated with improvement in prescribing according to antibiotic policy in routine clinical practice, with 70% of interventions being hospital-wide compared with 31% for RCTs. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs; 15,827 participants; moderate-certainty evidence). Antibiotic stewardship interventions probably reduce length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs; 3834 participants; moderate-certainty evidence). One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence).Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions (high-certainty evidence). Enabling interventions that included feedback were probably more effective than those that did not (moderate-certainty evidence).There was very low-certainty evidence about the effect of the interventions on reducing Clostridium difficile infections (median -48.6%, interquartile range -80.7% to -19.2%; 7 studies). This was also the case for resistant gram-negative bacteria (median -12.9%, interquartile range -35.3% to 25.2%; 11 studies) and resistant gram-positive bacteria (median -19.3%, interquartile range -50.1% to +23.1%; 9 studies). There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use. Heterogeneity of intervention effect on prescribing outcomesWe analysed effect modifiers in 29 RCTs and 91 ITS studies. Enablement and restriction were independently associated with a larger effect size (high-certainty evidence). Feedback was included in 4 (17%) of 23 RCTs and 20 (47%) of 43 ITS studies of enabling interventions and was associated with greater intervention effect. Enablement was included in 13 (45%) of 29 ITS studies with restrictive interventions and enhanced intervention effect. AUTHORS' CONCLUSIONS We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment. Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Additional trials comparing antibiotic stewardship with no intervention are unlikely to change our conclusions. Enablement consistently increased the effect of interventions, including those with a restrictive component. Although feedback further increased intervention effect, it was used in only a minority of enabling interventions. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Consequently, effective dissemination of our findings could have considerable health service and policy impact. Future research should instead focus on targeting treatment and assessing other measures of patient safety, assess different stewardship interventions, and explore the barriers and facilitators to implementation. More research is required on unintended consequences of restrictive interventions.
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Affiliation(s)
- Peter Davey
- University of DundeePopulation Health SciencesMackenzie BuildingKirsty Semple WayDundeeScotlandUKDD2 4BF
| | - Charis A Marwick
- University of DundeePopulation Health Sciences Division, Medical Research InstituteDundeeUK
| | - Claire L Scott
- NHS Education for ScotlandScottish Dental Clinical Effectiveness ProgrammeDundee Dental Education CentreSmall's WyndDundeeUKDD1 4HN
| | - Esmita Charani
- Imperial College LondonNIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial ResistanceDu Cane RoadLondonUKW12 OHS
| | - Kirsty McNeil
- University of DundeeSchool of Medicine147 Forth CrescentDundeeScotlandUKDD2 4JA
| | - Erwin Brown
- No affiliation31 Park CrescentFrenchayBristolUKBS16 1NZ
| | - Ian M Gould
- Aberdeen Royal InfirmaryDepartment of Medical MicrobiologyForesterhillAberdeenUKAB25 2ZN
| | - Craig R Ramsay
- University of AberdeenHealth Services Research Unit, Division of Applied Health SciencesPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
| | - Susan Michie
- University College LondonResearch Department of Primary Care and Population HealthUpper Floor 3, Royal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Huh K, Chung DR, Park HJ, Kim MJ, Lee NY, Ha YE, Kang CI, Peck KR, Song JH. Impact of monitoring surgical prophylactic antibiotics and a computerized decision support system on antimicrobial use and antimicrobial resistance. Am J Infect Control 2016; 44:e145-52. [PMID: 26975714 DOI: 10.1016/j.ajic.2016.01.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 01/07/2016] [Accepted: 01/13/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Monitoring of performance indicators and implementation of a computerized decision support system (CDSS) have been suggested as effective measures to improve quality of care. We conducted this study to evaluate the effect of monitoring of surgical prophylactic antibiotics (SPAs) and the CDSS on the antimicrobial use and resistance rate of major nosocomial pathogens. METHODS An interrupted time series with segmented regression analysis in 3 periods (preintervention, SPAs monitoring, and CDSS) was conducted in a tertiary care hospital. Immediate change and change in trends of antimicrobial use density, resistance rate of nosocomial pathogens, and cost of antibiotics in each intervention period were compared with those of the preintervention period. RESULTS Compared with the preintervention period, the change in the slope of the total use of antibiotics was -8.71 defined daily dose (DDD) per 1,000 patient days per month (95% confidence interval [CI], -11.43 to -5.98; P < .01) in the SPAs monitoring period and -1.95 DDD per 1,000 patient days per month (95% CI, -2.93 to -0.96; P < .01) in the CDSS period. Use of third-generation cephalosporins and aminoglycosides showed change comparable with that of total antibiotics use, but use of vancomycin and carbapenem was unchanged in the CDSS period. Trends of the proportions of extended-spectrum β-lactamase-producing Escherichia coli, meropenem-resistant Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus have been reversed or decreased in slope in the CDSS period. Length of hospital stay also showed a negative change in slope in the CDSS period. CONCLUSIONS Monitoring of SPAs and implementation of the CDSS can be effective measures for antimicrobial stewardship.
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Affiliation(s)
- Kyungmin Huh
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Hyo Jung Park
- Department of Pharmacy, Samsung Medical Center, Seoul, Republic of Korea
| | - Min-Ji Kim
- Department of Biostatistics, Samsung Biomedical Research Institute, Seoul, Republic of Korea
| | - Nam Yong Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Eun Ha
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Hoon Song
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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De Silva M, Ning C, Ghanbar S, Zhanel G, Logsetty S, Liu S, Kumar A. Evidence that a novel quaternary compound and its organic N-chloramine derivative do not select for resistant mutants of Pseudomonas aeruginosa. J Hosp Infect 2015; 91:53-8. [PMID: 26122622 DOI: 10.1016/j.jhin.2015.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 05/12/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND Pseudomonas aeruginosa is well known for causing hospital-acquired infections that are often difficult to treat because of its high intrinsic and acquired resistance to antibiotics. Resistance-nodulation-division (RND) efflux pumps are the major contributors to the intrinsic multidrug resistance (MDR) in this organism. Various biocides used in hospital settings have been shown to select for RND-pump-overexpressing mutants of P. aeruginosa that show cross-resistance to clinically relevant antibiotics. Therefore, finding biocides that do not select for multidrug-resistant mutants is important in controlling the spread of bacteria such as P. aeruginosa. AIM To evaluate the potential of a novel quaternary ammonium compound and its N-chloramine derivative in selecting for MDR mutants of P. aeruginosa. METHODS P. aeruginosa PA01 was cultured in the presence of increasing concentrations of the quaternary ammonium compound and its N-chloramine derivative respectively, and one mutant each selected. Susceptibility of the mutants to both compounds as well as antibiotics was tested. Susceptibility of P. aeruginosa strains with deletions in RND pumps was also tested for both compounds to determine whether they are a substrate of these pumps. Expression of mexB, mexD, and mexY genes in the mutants was analysed using quantitative reverse transcriptase-polymerase chain reaction to determine whether the compounds can select for pump-overexpressing mutants. FINDINGS We show that whereas both compounds can be pumped by the MexCD-OprJ pump, they neither select for mutants that overexpress RND pumps nor for mutants that display cross-resistance to antibiotics. CONCLUSION These compounds are promising candidates to be used as disinfectants in hospital settings.
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Affiliation(s)
- M De Silva
- Department of Microbiology, University of Manitoba, Winnipeg, MB, Canada
| | - C Ning
- Department of Textile Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - S Ghanbar
- Department of Chemistry, University of Manitoba, Winnipeg, MB, Canada
| | - G Zhanel
- Department of Medical Microbiology, University of Manitoba, Winnipeg, MB, Canada
| | - S Logsetty
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - S Liu
- Department of Textile Sciences, University of Manitoba, Winnipeg, MB, Canada; Department of Chemistry, University of Manitoba, Winnipeg, MB, Canada; Department of Medical Microbiology, University of Manitoba, Winnipeg, MB, Canada
| | - A Kumar
- Department of Microbiology, University of Manitoba, Winnipeg, MB, Canada; Department of Medical Microbiology, University of Manitoba, Winnipeg, MB, Canada.
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McGowan JE. Antimicrobial Stewardship—the State of the Art in 2011 Focus on Outcome and Methods. Infect Control Hosp Epidemiol 2015; 33:331-7. [DOI: 10.1086/664755] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Antimicrobial stewardship programs attempt to optimize prescribing of these drugs to benefit both current and future patients. Recent regulatory and other incentives have led to widespread adoption of such programs. Measurements of the success of these programs have focused primarily on process measures. However, evaluation of outcome measures will be needed to ensure sustainability of these efforts. Outcome efforts to date provide some evidence for improved care of individual patients, some evidence for minimizing emergence of resistance, and ample evidence for cost reduction. Attention to evaluation methods must be increased to provide convincing evidence for the continuation of such programs.
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Trends and correlation of antibacterial usage and bacterial resistance: time series analysis for antibacterial stewardship in a Chinese teaching hospital (2009-2013). Eur J Clin Microbiol Infect Dis 2014; 34:795-803. [PMID: 25487131 DOI: 10.1007/s10096-014-2293-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 11/26/2014] [Indexed: 10/24/2022]
Abstract
The purpose of this investigation was to describe the effect of antibacterial stewardship and evaluate the trends and correlation of antibacterial resistance and usage from 2009 to 2013 in a tertiary-care teaching hospital in northwest China. Antibacterial usage was expressed as defined daily doses per 100 patients per day (DDDs/100 PDs). Hospital-wide population-level data and time series analysis were used to evaluate the trends and determine associations between antibacterial exposure and acquisition of resistance. Yearly consumption of overall antibacterials significantly decreased from 66.54 to 28.08 DDDs/100 PDs (β = -10.504, p < 0.01). The resistant rates of the five most frequently isolated species (including Escherichia coli, Acinetobacter baumannii, Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae) significantly decreased or remained stable, and none of them showed a statistically significant upward trend. The medical quality indicators got better or remained stable. Autoregressive integrated moving average (ARIMA) models demonstrated that the monthly resistance rate of P. aeruginosa to imipenem was strongly correlated with antipseudomonal carbapenems usage (β = 34.94, p < 0.001), as did the correlation of P. aeruginosa to meropenem with antipseudomonal third-generation cephalosporins usage (β = 32.76, p < 0.01) and K. pneumoniae to amikacin with aminoglycosides usage (β = 22.01, p < 0.001). The decreased antibacterial use paralleled the improved bacterial resistance without deteriorating medical quality indicators during antimicrobial stewardship. It also suggests that optimum antibiotic use is necessary to alleviate the threat posed by resistant microorganisms at the hospital level.
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Rodriguez-Osorio CA, Sanchez-Martinez CO, Araujo-Melendez J, Criollo E, Macias-Hernandez AE, Ponce-de-Leon A, Ponce-de-Leon S, Sifuentes-Osornio J. Impact of ertapenem on antimicrobial resistance in a sentinel group of Gram-negative bacilli: a 6 year antimicrobial resistance surveillance study. J Antimicrob Chemother 2014; 70:914-21. [PMID: 25480492 DOI: 10.1093/jac/dku471] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To determine the association between ertapenem and resistance of Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter baumannii-calcoaceticus complex to different antimicrobials while adjusting for relevant hospital factors. METHODS This was a retrospective time-series study conducted at a tertiary care centre from September 2002 to August 2008. The specific impact of ertapenem on the resistance of these Gram-negative bacilli (GNB) was assessed by multiple linear regression analysis, adjusting for the average length of stay, rate of hospital-acquired infections and use of 10 other antimicrobials, including type 2 carbapenems. RESULTS Unadjusted analyses revealed significant increases over the duration of the study in the number of GNB resistant to meropenem/imipenem among 1000 isolates each of E. coli (0.46 ± 0.22, P < 0.05), P. aeruginosa (6.26 ± 2.26, P < 0.05), K. pneumoniae (8.06 ± 1.50, P < 0.0005) and A. baumannii-calcoaceticus complex (25.39 ± 6.81, P < 0.0005). Increased resistance to cefepime (and other extended-spectrum cephalosporins) was observed in E. coli (9.55 ± 1.45, P < 0.0005) and K. pneumoniae (15.21 ± 2.42, P < 0.0005). A. baumannii-calcoaceticus complex showed increased resistance to all antimicrobials except amikacin. After controlling for confounders, ertapenem was not significantly associated (P > 0.05) with changes in resistance for any pathogen/antimicrobial combination. CONCLUSIONS After controlling for confounders, ertapenem was not associated with changes in resistance in a group of sentinel GNB, although significant variations in resistance to different antimicrobials were observed in the unadjusted analyses. These results emphasize the importance of implementation of local resistance surveillance platforms and stewardship programmes to combat the global emergence and spread of antimicrobial resistance.
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Affiliation(s)
- Carlos A Rodriguez-Osorio
- Department of Critical Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - Cesar O Sanchez-Martinez
- Laboratory of Clinical Microbiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - Javier Araujo-Melendez
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - Elia Criollo
- Department of Pharmacy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - Alejandro E Macias-Hernandez
- Department of Hospital Epidemiology and Infection Control, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - Alfredo Ponce-de-Leon
- Laboratory of Clinical Microbiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - Sergio Ponce-de-Leon
- Clinical Epidemiology Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
| | - Jose Sifuentes-Osornio
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México City, México
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Bebell LM, Muiru AN. Antibiotic use and emerging resistance: how can resource-limited countries turn the tide? Glob Heart 2014; 9:347-58. [PMID: 25667187 PMCID: PMC4369554 DOI: 10.1016/j.gheart.2014.08.009] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 08/14/2014] [Accepted: 08/22/2014] [Indexed: 12/20/2022] Open
Abstract
Antibiotic resistance is a global crisis driven by appropriate and inappropriate antibiotic use to treat human illness and promote animal growth. The antimicrobial resistance epidemic continues to spread due to the triple threat of unfettered access, minimal product regulation and oversight of antibiotic prescription, and lack of clinical diagnostic tools to support antibiotic de-escalation in low-resource settings. In high-resource settings, evidence-based strategies have improved the appropriateness of antibiotic use, limiting the spread of drug-resistant organisms and reducing hospital-associated infections, strategies which may also be effective to stop the spread of resistance in resource-poor countries. Current research and surveillance efforts on antimicrobial resistance and hospital-associated infections in low-resource settings are extremely limited and largely focused on intensive care units. Many challenges exist to improving antibiotic use and infection control in resource-limited settings, and turning the tide requires intensifying research and surveillance, antimicrobial stewardship, and developing new bedside diagnostic tools for bacterial infections and antimicrobial susceptibility.
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Affiliation(s)
- Lisa M Bebell
- Department of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA; Massachusetts General Hospital Center for Global Health, Boston, MA, USA.
| | - Anthony N Muiru
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Falagas ME, Tansarli GS, Kapaskelis A, Vardakas KZ. Ertapenem use and antimicrobial resistance to group 2 carbapenems in Gram-negative infections: a systematic review. Expert Rev Anti Infect Ther 2014; 11:69-78. [DOI: 10.1586/eri.12.149] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tacconelli E, Cataldo M, Dancer S, De Angelis G, Falcone M, Frank U, Kahlmeter G, Pan A, Petrosillo N, Rodríguez-Baño J, Singh N, Venditti M, Yokoe D, Cookson B. ESCMID guidelines for the management of the infection control measures to reduce transmission of multidrug-resistant Gram-negative bacteria in hospitalized patients. Clin Microbiol Infect 2014; 20 Suppl 1:1-55. [DOI: 10.1111/1469-0691.12427] [Citation(s) in RCA: 527] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 09/29/2013] [Accepted: 10/06/2013] [Indexed: 01/04/2023]
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Song X, Stockwell DC, Floyd T, Short BL, Singh N. Improving hand hygiene compliance in health care workers: Strategies and impact on patient outcomes. Am J Infect Control 2013; 41:e101-5. [PMID: 23643451 DOI: 10.1016/j.ajic.2013.01.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 01/18/2013] [Accepted: 01/18/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND We described a systematic process for improving hand hygiene (HH) compliance in health care providers and assessed the impact of HH on patient outcomes. METHODS This retrospective cohort study was conducted between July 2008 and September 2011 in a children's hospital. We employed failure mode effectiveness analysis to identify barriers for complying with HH requirements and instituted improvement measures. We conducted a subanalysis using methicillin-resistant Staphylococcus aureus (MRSA) acquisition data and HH compliance data collected in the neonatal intensive care unit (NICU) to demonstrate the impact of HH on patient outcomes. RESULTS The overall HH compliance rate increased from 50.3% preintervention (July 2008-September 2008) to 84.0% postintervention (January 2009-September 2011) (relative risk [RR], 1.7; 95% confidence interval [CI]: 1.6-1.9). Compliance among physicians and nurses increased from 48.6% to 87.0% (RR, 1.4; 95% CI: 1.3-1.6) and from 46.5% to 77.9% (RR, 1.3; 95% CI: 1.2-1.4), respectively. Sustaining HH at 80% or higher was associated with a 48% further reduction of MRSA acquisition (incident rate ratio, -0.52; 95% CI: -0.31 to -0.90) in a unit that had comprehensive MRSA prevention measures. This reduction represents the prevention of 1.3 MRSA acquisitions per month, resulting in a saving of 11.6 NICU-days and $66,397 hospital charges. CONCLUSION This study demonstrated the utility of failure mode effectiveness analysis to improve staff HH and suggested HH as a potential cost-effective means for preventing MRSA in hospitals.
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Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ, Wilcox M. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013:CD003543. [PMID: 23633313 DOI: 10.1002/14651858.cd003543.pub3] [Citation(s) in RCA: 358] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The first publication of this review in Issue 3, 2005 included studies up to November 2003. This update adds studies to December 2006 and focuses on application of a new method for meta-analysis of interrupted time series studies and application of new Cochrane Effective Practice and Organisation of Care (EPOC) Risk of Bias criteria to all studies in the review, including those studies in the previously published version. The aim of the review is to evaluate the impact of interventions from the perspective of antibiotic stewardship. The two objectives of antibiotic stewardship are first to ensure effective treatment for patients with bacterial infection and second support professionals and patients to reduce unnecessary use and minimize collateral damage. OBJECTIVES To estimate the effectiveness of professional interventions that, alone or in combination, are effective in antibiotic stewardship for hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial-resistant pathogens or Clostridium difficile infection and their impact on clinical outcome. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE from 1980 to December 2006 and the EPOC specialized register in July 2007 and February 2009 and bibliographies of retrieved articles. The main comparison is between interventions that had a restrictive element and those that were purely persuasive. Restrictive interventions were implemented through restriction of the freedom of prescribers to select some antibiotics. Persuasive interventions used one or more of the following methods for changing professional behaviour: dissemination of educational resources, reminders, audit and feedback, or educational outreach. Restrictive interventions could contain persuasive elements. SELECTION CRITERIA We included randomized clinical trials (RCTs), controlled clinical trials (CCT), controlled before-after (CBA) and interrupted time series studies (ITS). Interventions included any professional or structural interventions as defined by EPOC. The intervention had to include a component that aimed to improve antibiotic prescribing to hospital inpatients, either by increasing effective treatment or by reducing unnecessary treatment. The results had to include interpretable data about the effect of the intervention on antibiotic prescribing or microbial outcomes or relevant clinical outcomes. DATA COLLECTION AND ANALYSIS Two authors extracted data and assessed quality. We performed meta-regression of ITS studies to compare the results of persuasive and restrictive interventions. Persuasive interventions advised physicians about how to prescribe or gave them feedback about how they prescribed. Restrictive interventions put a limit on how they prescribed; for example, physicians had to have approval from an infection specialist in order to prescribe an antibiotic. We standardized the results of some ITS studies so that they are on the same scale (percent change in outcome), thereby facilitating comparisons of different interventions. To do this, we used the change in level and change in slope to estimate the effect size with increasing time after the intervention (one month, six months, one year, etc) as the percent change in level at each time point. We did not extrapolate beyond the end of data collection after the intervention. The meta-regression was performed using standard weighted linear regression with the standard errors of the coefficients adjusted where necessary. MAIN RESULTS For this update we included 89 studies that reported 95 interventions. Of the 89 studies, 56 were ITSs (of which 4 were controlled ITSs), 25 were RCT (of which 5 were cluster-RCTs), 5 were CBAs and 3 were CCTs (of which 1 was a cluster-CCT).Most (80/95, 84%) of the interventions targeted the antibiotic prescribed (choice of antibiotic, timing of first dose and route of administration). The remaining 15 interventions aimed to change exposure of patients to antibiotics by targeting the decision to treat or the duration of treatment. Reliable data about impact on antibiotic prescribing data were available for 76 interventions (44 persuasive, 24 restrictive and 8 structural). For the persuasive interventions, the median change in antibiotic prescribing was 42.3% for the ITSs, 31.6% for the controlled ITSs, 17.7% for the CBAs, 3.5% for the cluster-RCTs and 24.7% for the RCTs. The restrictive interventions had a median effect size of 34.7% for the ITSs, 17.1% for the CBAs and 40.5% for the RCTs. The structural interventions had a median effect of 13.3% for the RCTs and 23.6% for the cluster-RCTs. Data about impact on microbial outcomes were available for 21 interventions but only 6 of these also had reliable data about impact on antibiotic prescribing.Meta-analysis of 52 ITS studies was used to compare restrictive versus purely persuasive interventions. Restrictive interventions had significantly greater impact on prescribing outcomes at one month (32%, 95% confidence interval (CI) 2% to 61%, P = 0.03) and on microbial outcomes at 6 months (53%, 95% CI 31% to 75%, P = 0.001) but there were no significant differences at 12 or 24 months. Interventions intended to decrease excessive prescribing were associated with reduction in Clostridium difficile infections and colonization or infection with aminoglycoside- or cephalosporin-resistant gram-negative bacteria, methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis. Meta-analysis of clinical outcomes showed that four interventions intended to increase effective prescribing for pneumonia were associated with significant reduction in mortality (risk ratio 0.89, 95% CI 0.82 to 0.97), whereas nine interventions intended to decrease excessive prescribing were not associated with significant increase in mortality (risk ratio 0.92, 95% CI 0.81 to 1.06). AUTHORS' CONCLUSIONS The results show that interventions to reduce excessive antibiotic prescribing to hospital inpatients can reduce antimicrobial resistance or hospital-acquired infections, and interventions to increase effective prescribing can improve clinical outcome. This update provides more evidence about unintended clinical consequences of interventions and about the effect of interventions to reduce exposure of patients to antibiotics. The meta-analysis supports the use of restrictive interventions when the need is urgent, but suggests that persuasive and restrictive interventions are equally effective after six months.
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Affiliation(s)
- Peter Davey
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK.
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Sousa D, Castelo-Corral L, Gutierrez-Urbon JM, Molina F, Lopez-Calvino B, Bou G, Llinares P. Impact of ertapenem use on Pseudomonas aeruginosa and Acinetobacter baumannii imipenem susceptibility rates: collateral damage or positive effect on hospital ecology? J Antimicrob Chemother 2013; 68:1917-25. [DOI: 10.1093/jac/dkt091] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Avner BS, Fialho AM, Chakrabarty AM. Overcoming drug resistance in multi-drug resistant cancers and microorganisms: a conceptual framework. Bioengineered 2012; 3:262-70. [PMID: 22750915 DOI: 10.4161/bioe.21130] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Resistance development against multiple drugs is a common feature among many pathogens--including bacteria such as Pseudomonas aeruginosa, viruses, and parasites--and also among cancers. The reasons are two-fold. Most commonly-used rationally-designed small molecule drugs or monoclonal antibodies, as well as antibiotics, strongly inhibit a key single step in the growth and proliferation of the pathogen or cancer cells. The disease agents quickly change or switch off this single target, or activate the efflux mechanisms to pump out the drug, thereby becoming resistant to the drug. A second problem is the way drugs are designed. The pharmaceutical industry chooses to use, by high-throughput screening, compounds that are maximally inhibitory to the key single step in the growth of the pathogen or cancer, thereby promoting selective pressure. An ideal drug would be one that inhibits multiple steps in the disease progression pathways with less stringency in these steps. Low levels of inhibition at multiple steps provide cumulative strong inhibitory effect, but little incentives or ability on the part of the pathogen/cancer to develop resistance. Such intelligent drug design involving multiple less stringent inhibitory steps is beyond the scope of the drug industry and requires evolutionary wisdom commonly possessed by bacteria. This review surveys assessments of the current clinical situation with regard to drug resistance in P. aeruginosa, and examines tools currently employed to limit this trend. We then provide a conceptual framework in which we explore the similarities between multi-drug resistance in pathogens and in cancers. We summarize promising work on anti-cancer drugs derived from the evolutionary wisdom of bacteria such as P. aeruginosa, and how such strategies can be the basis for how to look for candidate protein/peptide antibiotic drugs from bioengineered bugs. Such multi-domain proteins, unlike diffusible antibiotics, are not diffusible because of their large size and are often released only on contact with the perceived competitor. Thus, multi-domain proteins are missed during traditional methods of looking for growth zone inhibition of susceptible bacteria as demonstrated by antibiotics, but may represent the weapons of the future in the fights against both drug-resistant cancers and pathogens such as P. aeruginosa.
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Affiliation(s)
- Benjamin S Avner
- Department of Physiology and Biophysics, University of Illinois College of Medicine, Chicago, IL, USA
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