1
|
Walker MK, Diao G, Warner S, Babiker A, Neupane M, Strich JR, Yek C, Kadri SS. Carbapenem use in extended-spectrum cephalosporin-resistant Enterobacterales infections in US hospitals and influence of IDSA guidance: a retrospective cohort study. THE LANCET. INFECTIOUS DISEASES 2024; 24:856-867. [PMID: 38679036 PMCID: PMC11283355 DOI: 10.1016/s1473-3099(24)00149-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Disparate and rapidly changing practice recommendations from major professional infectious diseases societies for managing non-severe infections caused by extended-spectrum β-lactamase-producing Enterobacterales might hamper carbapenem stewardship. We aimed to understand the real-world management of extended-spectrum cephalosporin-resistant (ECR) Enterobacterales infections in US hospitals and factors influencing preference for carbapenems over alternative treatments. METHODS This retrospective cohort study included adults (aged ≥18 years) admitted to hospital with ECR Enterobacterales infections in the PINC AI database. Antibiotic regimens were assessed during empirical and targeted treatment periods and by infection severity and site. Likelihood of receiving targeted carbapenems over time and before or after initial release of the Infectious Diseases Society of America (IDSA) guidance on Sept 8, 2020, was established with generalised estimating equations controlling for patient, hospital, and temporal confounders. FINDINGS Between Jan 1, 2018, and Dec 31, 2021, 30 041 inpatient encounters with ECR Enterobacterales infections were identified at 168 US hospitals, of which 16 006 (53·3%) encounters were in women and 14 035 (46·7%) were in men, with a mean age of 67·3 years (SD 15·1). Although few patients received carbapenems empirically (5324 [17·7%] of 30 041), many did so as targeted treatment (17 518 [58·3%] of 30 041), including subgroups of patients without septic shock (3031 [45·6%] of 6651) and patients with urinary tract infections without septic shock (1845 [46·8%] of 3943) in whom specific narrower-spectrum alternatives were active. Transitions from non-carbapenem to carbapenem antibiotics occurred most often on the day that the ECR phenotype was reported, regardless of illness severity. Carbapenems were the predominant choice to treat ECR Enterobacterales infections over time (adjusted odds ratio 1·00 [95% CI 1·00-1·00]), with no additional immediate change (1·07 [0·95-1·20]) or sustained change (0·99 [0·98-1·00]) after IDSA guidance release. INTERPRETATION High carbapenem use in targeting non-severe ECR Enterobacterales infections in US hospitals predates 2020 IDSA guidance and has persisted thereafter. Efforts to increase awareness and implementation of recommendations among clinicians to use carbapenem-sparing alternatives in ECR Enterobacterales infections might decrease global carbapenem selective pressure. FUNDING US National Institutes of Health Intramural Research Program, National Institute of Allergy and Infectious Diseases, and US Food and Drug Administration.
Collapse
Affiliation(s)
- Morgan K Walker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - Guoqing Diao
- Department of Biostatistics, George Washington University, Washington, DC, USA
| | - Sarah Warner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - Ahmed Babiker
- Emory University School of Medicine, Atlanta, GA, USA
| | - Maniraj Neupane
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - Christina Yek
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Branch, National Heart Lung and Blood Institute, Bethesda, MD, USA.
| |
Collapse
|
2
|
Engel-Dettmers EM, Al Naiemi N, Dijkema HE, Braakman-Jansen AL, van Gemert-Pijnen LJ, Sinha B. Positive effects of audit and feedback on antimicrobial use in hospitalized patients limited to audited patients. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e46. [PMID: 38628373 PMCID: PMC11019582 DOI: 10.1017/ash.2024.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/23/2024] [Accepted: 02/29/2024] [Indexed: 04/19/2024]
Abstract
Objective Audit and feedback is an antimicrobial stewardship (AMS) strategy, with the potential to also optimize antimicrobial use in non-audited patients. This study aimed to determine whether audit and feedback reduce antimicrobial use in both audited and non-audited patients. Design Before-after trial with a 1-year intervention period and 2.5-year historical cohort. Setting 750-bed community hospital in the Netherlands. Patients All patients admitted to the urology wards during the 3.5-year study period were observed. Patients were classified as using antimicrobials if any antimicrobial was used for therapeutic reasons. Patients using antimicrobials prophylactically were excluded from measurements. Intervention The AMS team provided audit and feedback on antimicrobial use for patients using antimicrobials for 2 days. Retrospectively, antimicrobial use and length of stay (LOS) were compared with the historical cohort. Results Audits modified antimicrobial treatment in 52.8% of the cases. De-escalating, stopping, and switching from intravenous to oral treatment accounted for 72% of these modifications. Compared to patients from the cohort, who also used antimicrobials for 2 days, antimicrobial use decreased from 14.21 DDD/patient (95% CI, 13.08-15.34) to 11.45 DDD/patient (95% CI, 8.26-14.64; P = .047) for audited patients. Furthermore, mean LOS decreased from 7.42 days (95% CI, 6.79-8.06) to 6.13 days (95% CI, 5.38-6.89; P = .031). However, looking at all patients admitted to the urology wards, the percentage of patients using antimicrobials and total antimicrobial use remained unchanged. Conclusions Audit and feedback reduce antimicrobial use and LOS, but only for audited patients. Positive effects are not automatically transferred to patients for whom no audits have been performed.
Collapse
Affiliation(s)
- Elske M. Engel-Dettmers
- Faculty of Behavioral, Management and Social Sciences, Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
- Department of Clinical Pharmacy, ZGT, Almelo and Hengelo, The Netherlands
| | - Nashwan Al Naiemi
- Department of Medical Microbiology, Labmicta, Hengelo, The Netherlands
| | - Hero E. Dijkema
- Department of Urology, ZGT, Almelo and Hengelo, The Netherlands
| | - Annemarie L.M.A. Braakman-Jansen
- Faculty of Behavioral, Management and Social Sciences, Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Lisette J.E.W.C. van Gemert-Pijnen
- Faculty of Behavioral, Management and Social Sciences, Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Bhanu Sinha
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
3
|
Ronda M, Gumucio-Sanguino VD, Shaw E, Granada R, Tubau F, Santafosta E, Sabater J, Esteve F, Tebé C, Mañez R, Carratalà J, Puig-Asensio M, Cobo-Sacristán S, Padullés A. Long-Term Effects of a Stepwise, Multimodal, Non-Restrictive Antimicrobial Stewardship Programme for Reducing Broad-Spectrum Antibiotic Use in the ICU. Antibiotics (Basel) 2024; 13:132. [PMID: 38391518 PMCID: PMC10886276 DOI: 10.3390/antibiotics13020132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 02/24/2024] Open
Abstract
Information on the long-term effects of non-restrictive antimicrobial stewardship (AMS) strategies is scarce. We assessed the effect of a stepwise, multimodal, non-restrictive AMS programme on broad-spectrum antibiotic use in the intensive care unit (ICU) over an 8-year period. Components of the AMS were progressively implemented. Appropriateness of antibiotic prescribing was also assessed by monthly point-prevalence surveys from 2013 onwards. A Poisson regression model was fitted to evaluate trends in the reduction of antibiotic use and in the appropriateness of their prescription. From 2011 to 2019, a total of 12,466 patients were admitted to the ICU. Antibiotic use fell from 185.4 to 141.9 DDD per 100 PD [absolute difference, -43.5 (23%), 95% CI -100.73 to 13.73; p = 0.13] and broad-spectrum antibiotic fell from 41.2 to 36.5 [absolute difference, -4.7 (11%), 95% CI -19.58 to 10.18; p = 0.5]. Appropriateness of antibiotic prescribing rose by 11% per year [IRR: 0.89, 95% CI 0.80 to 1.00; p = 0.048], while broad-spectrum antibiotic use showed a dual trend, rising by 22% until 2015 and then falling by 10% per year since 2016 [IRR: 0.90, 95% CI 0.81 to 0.99; p = 0.03]. This stepwise, multimodal, non-restrictive AMS achieved a sustained reduction in broad-spectrum antibiotic use in the ICU and significantly improved appropriateness of antibiotic prescribing.
Collapse
Affiliation(s)
- Mar Ronda
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Victor Daniel Gumucio-Sanguino
- Department of Intensive Care, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Evelyn Shaw
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Rosa Granada
- Department of Intensive Care, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Fe Tubau
- Department of Microbiology, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Eva Santafosta
- Department of Intensive Care, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Joan Sabater
- Department of Intensive Care, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Francisco Esteve
- Department of Intensive Care, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Cristian Tebé
- Biostatistics Support and Research Unit, Germans Trias i Pujol Research Institute and Hospital (IGTP), Carretera de Can Ruti, Camí de les Escoles s/n, 08916 Badalona, Barcelona, Spain
- Department of Clinical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, Campus Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Rafael Mañez
- Department of Intensive Care, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
- Department of Clinical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, Campus Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Mireia Puig-Asensio
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Sara Cobo-Sacristán
- Department of Pharmacy, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Pharmacotherapy, Pharmacogenetics and Pharmaceutical Technology, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ariadna Padullés
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
- Department of Pharmacy, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Pharmacotherapy, Pharmacogenetics and Pharmaceutical Technology, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| |
Collapse
|
4
|
Ausman SE, Mara KC, Brown CS, Epps KL, Kooda K, Mendez J, Rivera CG. CLinician and patient characteristics effect on Antimicrobial Stewardship Interventions (CLASI) study. Infect Control Hosp Epidemiol 2023; 44:2002-2008. [PMID: 37222155 DOI: 10.1017/ice.2023.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To determine whether the gender of clinicians making antimicrobial stewardship recommendations has an impact on intervention acceptance rate. DESIGN A retrospective, multivariable analysis of antimicrobial stewardship prospective audit and feedback outcomes. SETTING A multisite healthcare system including Mayo Clinic Rochester (MN), Mayo Clinic Arizona, Mayo Clinic Florida and 17 health-system hospital sites, where prospective audit and feedback is performed and documented within an electronic tool embedded in the medical record. PARTICIPANTS The study included 143 Mayo Clinic clinicians (84 cisfemales and 59 cismales). METHODS Outcomes were analyzed from July 1, 2017, to June 30, 2022, for intervention rates, communication methods, and intervention acceptance by clinician gender, profession, patient age, and intensive care unit (ICU) status of patient. RESULTS Of 81,927 rules, 71,729 rules met study inclusion. There were 18,175 (25%) rules associated with an intervention. Most of the rules were reviewed by pharmacists (86.2%) and stewardship staff (85.5%). Of 10,363 interventions with an outcome documented, 8,829 (85.2%) were accepted and 1,534 (14.8%) were rejected. Female clinicians had 6,782 (86.5%) of 7,843 interventions accepted, and male clinicians had 2,047 (81.2%) of 2,520 interventions accepted (P = .19). Female patients had more interventions than male patients (female vs male: 25.9% vs 24.9%; OR, 1.04; 95% CI, 1.02-1.08; P = .001). Patients in the ICU had a significantly lower intervention acceptance rate (ICU vs non-ICU: 78.2% vs 86.7%; OR, 0.56; 95% CI, 0.45-0.7; P < .001). CONCLUSIONS Female and male clinicians were equally effective at prospective audit and feedback in a multisite antimicrobial stewardship program. Patients in the ICU were less likely to have stewardship interventions accepted.
Collapse
Affiliation(s)
- Sara E Ausman
- Department of Pharmacy, Mayo Clinic Health System, Eau Claire, Wisconsin
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin L Epps
- Department of Pharmacy, Mayo Clinic, Jacksonville, Florida
| | - Kirstin Kooda
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Julio Mendez
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Florida
| | | |
Collapse
|
5
|
Neuner EA, Atkinson A, Ilges D, Krekel T, Ritchie DJ, Bewley AF, Durkin MJ, Hsueh K, Sayood S. Mixed methods evaluation of handshake antimicrobial stewardship on adult inpatient medicine floors. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e210. [PMID: 38156212 PMCID: PMC10753471 DOI: 10.1017/ash.2023.465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 12/30/2023]
Abstract
Objective To evaluate the effects of handshake antimicrobial stewardship on medicine floors at a large tertiary care hospital. Design Retrospective observational study. Setting 1,278-bed academic hospital. Patients Adults admitted to non-ICU medicine services. Interventions A handshake stewardship team consisting of an infectious diseases (ID) physician and pharmacist reviewed charts of patients receiving antimicrobials on medicine floors without a formal ID consult. Recommendations were communicated in-person to providers and acceptance rates were examined with descriptive statistics. Additional data regarding program perception among providers were obtained via surveys. Antibiotic usage trends were extracted from National Healthcare Safety Network Antimicrobial Use option data and evaluated using an interrupted time-series analysis pre- and post-intervention. Results The overall acceptance rate of interventions was 80%, the majority being recommendations either to discontinue (37%) or de-escalate therapy (28%). Medical residents and hospitalists rated the intervention favorably with 90% reporting recommendations were helpful all or most of the time. There was a statistically significant decrease in vancomycin (78 vs 70 DOT/1,000 d present (DP), p = 0.002) and meropenem (24 vs 17 DOT/1,000 DP, p = 0.007) usage and a statistically significant increase in amoxicillin-clavulanate usage (11 vs 15 DOT/1,000 DP, p < 0.001). Overall antibiotic usage remained unchanged by the intervention, though pre-intervention there was a nonsignificant overall increasing trend while post-intervention there was a nonsignificant decreasing trend in overall usage. There was no change in in-hospital mortality. Conclusion The addition of handshake stewardship with adult medicine services was favorably viewed by participants and led to shifts in antibiotic usage.
Collapse
Affiliation(s)
| | - Andrew Atkinson
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Dan Ilges
- Department of Pharmacy, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Tamara Krekel
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - David J. Ritchie
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Alice F. Bewley
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Michael J. Durkin
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kevin Hsueh
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Sena Sayood
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| |
Collapse
|
6
|
Schinas G, Polyzou E, Spernovasilis N, Gogos C, Dimopoulos G, Akinosoglou K. Preventing Multidrug-Resistant Bacterial Transmission in the Intensive Care Unit with a Comprehensive Approach: A Policymaking Manual. Antibiotics (Basel) 2023; 12:1255. [PMID: 37627675 PMCID: PMC10451180 DOI: 10.3390/antibiotics12081255] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/27/2023] Open
Abstract
Patients referred to intensive care units (ICU) commonly contract infections caused by multidrug-resistant (MDR) bacteria, which are typically linked to complications and high mortality. There are numerous independent factors that are associated with the transmission of these pathogens in the ICU. Preventive multilevel measures that target these factors are of great importance in order to break the chain of transmission. In this review, we aim to provide essential guidance for the development of robust prevention strategies, ultimately ensuring the safety and well-being of patients and healthcare workers in the ICU. We discuss the role of ICU personnel in cross-contamination, existing preventative measures, novel technologies, and strategies employed, along with antimicrobial surveillance and stewardship (AMSS) programs, to construct effective and thoroughly described policy recommendations. By adopting a multifaceted approach that combines targeted interventions with broader preventive strategies, healthcare facilities can create a more coherent line of defense against the spread of MDR pathogens. These recommendations are evidence-based, practical, and aligned with the needs and realities of the ICU setting. In conclusion, this comprehensive review offers a blueprint for mitigating the risk of MDR bacterial transmission in the ICU, advocating for an evidence-based, multifaceted approach.
Collapse
Affiliation(s)
- Georgios Schinas
- Department of Medicine, University of Patras, 26504 Patras, Greece; (G.S.); (E.P.); (C.G.); (K.A.)
| | - Elena Polyzou
- Department of Medicine, University of Patras, 26504 Patras, Greece; (G.S.); (E.P.); (C.G.); (K.A.)
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Patras, Greece
| | | | - Charalambos Gogos
- Department of Medicine, University of Patras, 26504 Patras, Greece; (G.S.); (E.P.); (C.G.); (K.A.)
| | - George Dimopoulos
- 3rd Department of Critical Care, Evgenidio Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Karolina Akinosoglou
- Department of Medicine, University of Patras, 26504 Patras, Greece; (G.S.); (E.P.); (C.G.); (K.A.)
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Patras, Greece
| |
Collapse
|
7
|
Mokrani D, Chommeloux J, Pineton de Chambrun M, Hékimian G, Luyt CE. Antibiotic stewardship in the ICU: time to shift into overdrive. Ann Intensive Care 2023; 13:39. [PMID: 37148398 PMCID: PMC10163585 DOI: 10.1186/s13613-023-01134-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/20/2023] [Indexed: 05/08/2023] Open
Abstract
Antibiotic resistance is a major health problem and will be probably one of the leading causes of deaths in the coming years. One of the most effective ways to fight against resistance is to decrease antibiotic consumption. Intensive care units (ICUs) are places where antibiotics are widely prescribed, and where multidrug-resistant pathogens are frequently encountered. However, ICU physicians may have opportunities to decrease antibiotics consumption and to apply antimicrobial stewardship programs. The main measures that may be implemented include refraining from immediate prescription of antibiotics when infection is suspected (except in patients with shock, where immediate administration of antibiotics is essential); limiting empiric broad-spectrum antibiotics (including anti-MRSA antibiotics) in patients without risk factors for multidrug-resistant pathogens; switching to monotherapy instead of combination therapy and narrowing spectrum when culture and susceptibility tests results are available; limiting the use of carbapenems to extended-spectrum beta-lactamase-producing Enterobacteriaceae, and new beta-lactams to difficult-to-treat pathogen (when these news beta-lactams are the only available option); and shortening the duration of antimicrobial treatment, the use of procalcitonin being one tool to attain this goal. Antimicrobial stewardship programs should combine these measures rather than applying a single one. ICUs and ICU physicians should be at the frontline for developing antimicrobial stewardship programs.
Collapse
Affiliation(s)
- David Mokrani
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Juliette Chommeloux
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Hékimian
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
- Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
| |
Collapse
|
8
|
Alves J, Abreu B, Palma P, Alp E, Vieceli T, Rello J. Antimicrobial Stewardship on Patients with Neutropenia: A Narrative Review Commissioned by Microorganisms. Microorganisms 2023; 11:1127. [PMID: 37317101 DOI: 10.3390/microorganisms11051127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 06/16/2023] Open
Abstract
The emergence of antibiotic resistance poses a global health threat. High-risk patients such as those with neutropenia are particularly vulnerable to opportunistic infections, sepsis, and multidrug-resistant infections, and clinical outcomes remain the primary concern. Antimicrobial stewardship (AMS) programs should mainly focus on optimizing antibiotic use, decreasing adverse effects, and improving patient outcomes. There is a limited number of published studies assessing the impact of AMS programs on patients with neutropenia, where early appropriate antibiotic choice can be the difference between life and death. This narrative review updates the current advances in strategies of AMS for bacterial infections among high-risk patients with neutropenia. Diagnosis, drug, dose, duration, and de-escalation (5D) are the core variables among AMS strategies. Altered volumes of distribution can make standard dose regimens inadequate, and developing skills towards a personalized approach represents a major advance in therapy. Intensivists should partner antibiotic stewardship programs to improve patient care. Assembling multidisciplinary teams with trained and dedicated professionals for AMS is a priority.
Collapse
Affiliation(s)
- Joana Alves
- Infectious Diseases Department, Hospital de Braga, 4710-243 Braga, Portugal
| | - Betânia Abreu
- Pharmaceuticals Department, Hospital de Braga, 4710-243 Braga, Portugal
| | - Pedro Palma
- Infectious Diseases Department, Centro Hospitalar do Tâmega e Sousa, 4564-007 Penafiel, Portugal
| | - Emine Alp
- Infectious Diseases and Clinical Microbiology Department, Ankara Yıldırım Beyazıt University, 06760 Ankara, Turkey
| | - Tarsila Vieceli
- Infectious Diseases Department, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Brazil
| | - Jordi Rello
- Clinical Research in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), 08035 Barcelona, Spain
- FOREVA Research Pôle, Centre Hôpitalaire Universitaire de Nîmes, 30900 Nîmes, France
| |
Collapse
|
9
|
Moehring RW, Yarrington ME, Warren BG, Lokhnygina Y, Atkinson E, Bankston A, Collucio J, David MZ, Davis AE, Davis J, Dionne B, Dyer AP, Jones TM, Klompas M, Kubiak DW, Marsalis J, Omorogbe J, Orajaka P, Parish A, Parker T, Pearson JC, Pearson T, Sarubbi C, Shaw C, Spivey J, Wolf R, Wrenn RH, Dodds Ashley ES, Anderson DJ. Evaluation of an Opt-Out Protocol for Antibiotic De-Escalation in Patients With Suspected Sepsis: A Multicenter, Randomized, Controlled Trial. Clin Infect Dis 2023; 76:433-442. [PMID: 36167851 DOI: 10.1093/cid/ciac787] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/09/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Sepsis guidelines recommend daily review to de-escalate or stop antibiotics in appropriate patients. This randomized, controlled trial evaluated an opt-out protocol to decrease unnecessary antibiotics in patients with suspected sepsis. METHODS We evaluated non-intensive care adults on broad-spectrum antibiotics despite negative blood cultures at 10 US hospitals from September 2018 through May 2020. A 23-item safety check excluded patients with ongoing signs of systemic infection, concerning or inadequate microbiologic data, or high-risk conditions. Eligible patients were randomized to the opt-out protocol vs usual care. Primary outcome was post-enrollment antibacterial days of therapy (DOT). Clinicians caring for intervention patients were contacted to encourage antibiotic discontinuation using opt-out language. If continued, clinicians discussed the rationale for continuing antibiotics and de-escalation plans. To evaluate those with zero post-enrollment DOT, hurdle models provided 2 measures: odds ratio of antibiotic continuation and ratio of mean DOT among those who continued antibiotics. RESULTS Among 9606 patients screened, 767 (8%) were enrolled. Intervention patients had 32% lower odds of antibiotic continuation (79% vs 84%; odds ratio, 0.68; 95% confidence interval [CI], .47-.98). DOT among those who continued antibiotics were similar (ratio of means, 1.06; 95% CI, .88-1.26). Fewer intervention patients were exposed to extended-spectrum antibiotics (36% vs 44%). Common reasons for continuing antibiotics were treatment of localized infection (76%) and belief that stopping antibiotics was unsafe (31%). Thirty-day safety events were similar. CONCLUSIONS An antibiotic opt-out protocol that targeted patients with suspected sepsis resulted in more antibiotic discontinuations, similar DOT when antibiotics were continued, and no evidence of harm. CLINICAL TRIALS REGISTRATION NCT03517007.
Collapse
Affiliation(s)
- Rebekah W Moehring
- Department of Medicine, Infectious Diseases, Duke University, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Michael E Yarrington
- Department of Medicine, Infectious Diseases, Duke University, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Bobby G Warren
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Yuliya Lokhnygina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Erica Atkinson
- Department of Pharmacy, Southeastern Regional Medical Center, Lumberton, North Carolina, USA
| | - Allison Bankston
- Department of Pharmacy, Piedmont Newnan Hospital, Newnan, Georgia, USA
| | - Julia Collucio
- Department of Pharmacy, Piedmont Atlanta Hospital, Atlanta, Georgia, USA
| | - Michael Z David
- Department of Medicine, Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Angelina E Davis
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Janice Davis
- Department of Pharmacy, Piedmont Fayette Hospital, Fayette, Georgia, USA
| | - Brandon Dionne
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Pharmacy and Health Systems Sciences, Northeastern University School of Pharmacy and Pharmaceutical Sciences, Boston, Massachusetts, USA
| | - April P Dyer
- Department of Medicine, Infectious Diseases, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Travis M Jones
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Michael Klompas
- Department of Medicine, Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | - David W Kubiak
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John Marsalis
- Department of Pharmacy, Piedmont Newnan Hospital, Newnan, Georgia, USA
| | | | - Patricia Orajaka
- Department of Pharmacy, Iredell Health, Statesville, North Carolina, USA
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Todd Parker
- Department of Pharmacy, Piedmont Atlanta Hospital, Atlanta, Georgia, USA
| | - Jeffrey C Pearson
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tonya Pearson
- Department of Pharmacy, Piedmont Fayette Hospital, Fayette, Georgia, USA
| | - Christina Sarubbi
- Department of Pharmacy, UNC REX Healthcare, Raleigh, North Carolina, USA
| | - Christian Shaw
- Department of Pharmacy, Wilson Medical Center, Wilson, North Carolina, USA
| | - Justin Spivey
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA.,Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Robert Wolf
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rebekah H Wrenn
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA.,Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Elizabeth S Dodds Ashley
- Department of Medicine, Infectious Diseases, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Deverick J Anderson
- Department of Medicine, Infectious Diseases, Duke University, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | | |
Collapse
|
10
|
Sadeq AA, Hasan SS, AbouKhater N, Conway BR, Abdelsalam AE, Shamseddine JM, Babiker ZOE, Nsutebu EF, Bond SE, Aldeyab MA. Exploring Antimicrobial Stewardship Influential Interventions on Improving Antibiotic Utilization in Outpatient and Inpatient Settings: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2022; 11:antibiotics11101306. [PMID: 36289964 PMCID: PMC9598859 DOI: 10.3390/antibiotics11101306] [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: 08/25/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022] Open
Abstract
Antimicrobial stewardship interventions are targeted efforts by healthcare organizations to optimize antimicrobial use in clinical practice. The study aimed to explore effective interventions in improving antimicrobial use in hospitals. Literature was systemically searched for interventional studies through PubMed, CINAHL, and Scopus databases that were published in the period between January 2010 to April 2022. A random-effects model was used to pool and evaluate data from eligible studies that reported antimicrobial stewardship (AMS) interventions in outpatient and inpatient settings. Pooled estimates presented as proportions and standardized mean differences. Forty-eight articles were included in this review: 32 in inpatient and 16 in outpatient settings. Seventeen interventions have been identified, and eight outcomes have been targeted. AMS interventions improved clinical, microbiological, and cost outcomes in most studies. When comparing non-intervention with intervention groups using meta-analysis, there was an insignificant reduction in length of stay (MD: -0.99; 95% CI: -2.38, 0.39) and a significant reduction in antibiotics' days of therapy (MD: -2.73; 95% CI: -3.92, -1.54). There were noticeable reductions in readmissions, mortality rates, and antibiotic prescriptions post antimicrobial stewardship multi-disciplinary team (AMS-MDT) interventions. Studies that involved a pharmacist as part of the AMS-MDT showed more significant improvement in measured outcomes than the studies that did not involve a pharmacist.
Collapse
Affiliation(s)
- Ahmed A. Sadeq
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Syed Shahzad Hasan
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Noha AbouKhater
- Department of Medicine, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Barbara R. Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Abeer E. Abdelsalam
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Jinan M. Shamseddine
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Zahir Osman Eltahir Babiker
- Division of Infecious Diseases, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Emmanuel Fru Nsutebu
- Division of Infecious Diseases, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Stuart E. Bond
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Pharmacy Department, Mid Yorkshire Hospitals NHS Trust, Wakefield WF1 4DG, UK
| | - Mamoon A. Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Correspondence: ; Tel.: +44-01484-472825
| |
Collapse
|
11
|
Lack of pathogen identification influencing antibiotic de-escalation in hospital-acquired pneumonia. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2022; 2:e181. [PMID: 36386010 PMCID: PMC9641501 DOI: 10.1017/ash.2022.325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/09/2022]
|