Evaluation of an Opt-Out Protocol for Antibiotic De-Escalation in Patients With Suspected Sepsis: A Multicenter, Randomized, Controlled Trial

Assessment of De-Escalation of Empirical Antimicrobial Therapy in Medical Wards with Recognized Prevalence of Multi-Drug-Resistant Pathogens: A Multicenter Prospective Cohort Study in Non-ICU Patients with Microbiologically Documented Infection

Antimicrobial resistance poses a major threat to human health worldwide and the implementation of antimicrobial stewardship programs (ASPs), including antimicrobial de-escalation (ADE), is a multifaceted tool for minimizing unnecessary or inappropriate antibiotic exposure. This was a prospective observational study of 142 non-Intensive Care Unit (ICU) patients with microbiologically documented infection who were initially administered empirical antimicrobial therapy and admitted to the medical wards of 6 tertiary-care hospitals in Greece from January 2017 to December 2018. Patients were divided into two groups, the ADE and non-ADE group, based on whether ADE was applied or not, respectively. Exploratory end-points were ADE feasibility, safety and efficacy. ADE was applied in 76 patients at a median time of 4 days (IQR: 3, 5). An increased likelihood of ADE was observed in patients with urinary tract (OR: 10.04, 95% CI: 2.91, 34.57; p < 0.001), skin and soft tissue (OR: 16.28, 95% CI: 1.68, 158.08; p = 0.016) and bloodstream infections (OR: 2.52, 95% CI: 1, 6.36; p = 0.05). Factors significantly associated with higher rates of ADE were clarithromycin administration, diagnosis of urinary tract infection (UTI), isolation of E. coli, age and symptoms type on admission. Mortality was lower in the ADE group (18.4% vs. 30.3% p < 0.1) and ADE was not significantly associated with the probability of death (p = 0.432). ADE was associated with favorable clinical outcomes and can be performed even in settings with high prevalence of multi-drug resistant (MDR) pathogens without compromising safety.

Significant Publications on Infectious Diseases Pharmacotherapy in 2022

Purpose: To provide summarization of the most significant infectious diseases (ID) pharmacotherapy articles published in peer-reviewed literature in 2022. Summary: Members of the Houston Infectious Diseases Network (HIDN) nominated notable articles providing significant contributions to ID pharmacotherapy in 2022. Article nominations included those pertaining to general ID, as well as those including coronavirus disease 2019 (COVID-19), and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pharmacotherapy. A total of 71 articles were nominated by HIDN. Members: 68 articles pertaining to general ID pharmacotherapy and 3 articles focusing on HIV/AIDS. To aid selection of the most these most notable articles of 2022, a survey was created and distributed to members of the Society of Infectious Diseases Pharmacists (SIDP). Of the 153 SIDP members who participated in the survey, there were 128 recorded votes for the top 10 general ID pharmacotherapy articles and 30 votes recorded for the top HIV/AIDS article. The most notable publications are summarized. Conclusion: Post pandemic significant advances in antimicrobial stewardship and infectious disease states continues to occur in a world recently focused on the coronavirus disease 2019 (COVID-19) global pandemic. Continuous growth in publication of ID-related articles over the past year lends towards the aims of this review to aid clinicians in remaining current on key practice-changing ID pharmacotherapy publications from 2022.

Efficacy and safety of a structured de-escalation from antipseudomonal β-lactams in bloodstream infections due to Enterobacterales (SIMPLIFY): an open-label, multicentre, randomised trial

BACKGROUND

De-escalation from broad-spectrum to narrow-spectrum antibiotics is considered an important measure to reduce the selective pressure of antibiotics, but a scarcity of adequate evidence is a barrier to its implementation. We aimed to determine whether de-escalation from an antipseudomonal β-lactam to a narrower-spectrum drug was non-inferior to continuing the antipseudomonal drug in patients with Enterobacterales bacteraemia.

METHODS

An open-label, pragmatic, randomised trial was performed in 21 Spanish hospitals. Patients with bacteraemia caused by Enterobacterales susceptible to one of the de-escalation options and treated empirically with an antipseudomonal β-lactam were eligible. Patients were randomly assigned (1:1; stratified by urinary source) to de-escalate to ampicillin, trimethoprim-sulfamethoxazole (urinary tract infections only), cefuroxime, cefotaxime or ceftriaxone, amoxicillin-clavulanic acid, ciprofloxacin, or ertapenem in that order according to susceptibility (de-escalation group), or to continue with the empiric antipseudomonal β-lactam (control group). Oral switching was allowed in both groups. The primary outcome was clinical cure 3-5 days after end of treatment in the modified intention-to-treat (mITT) population, formed of patients who received at least one dose of study drug. Safety was assessed in all participants. Non-inferiority was declared when the lower bound of the 95% CI of the absolute difference in cure rate was above the -10% non-inferiority margin. This trial is registered with EudraCT (2015-004219-19) and ClinicalTrials.gov (NCT02795949) and is complete.

FINDINGS

2030 patients were screened between Oct 5, 2016, and Jan 23, 2020, of whom 171 were randomly assigned to the de-escalation group and 173 to the control group. 164 (50%) patients in the de-escalation group and 167 (50%) in the control group were included in the mITT population. 148 (90%) patients in the de-escalation group and 148 (89%) in the control group had clinical cure (risk difference 1·6 percentage points, 95% CI -5·0 to 8·2). The number of adverse events reported was 219 in the de-escalation group and 175 in the control group, of these, 53 (24%) in the de-escalation group and 56 (32%) in the control group were considered severe. Seven (5%) of 164 patients in the de-escalation group and nine (6%) of 167 patients in the control group died during the 60-day follow-up. There were no treatment-related deaths.

INTERPRETATION

De-escalation from an antipseudomonal β-lactam in Enterobacterales bacteraemia following a predefined rule was non-inferior to continuing the empiric antipseudomonal drug. These results support de-escalation in this setting.

FUNDING

Plan Nacional de I+D+i 2013-2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades, Spanish Network for Research in Infectious Diseases; Spanish Clinical Research and Clinical Trials Platform, co-financed by the EU; European Development Regional Fund "A way to achieve Europe", Operative Program Intelligence Growth 2014-2020.

A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2022

Keeping abreast of the antimicrobial stewardship-related articles published each year is challenging. The Southeastern Research Group Endeavor identified antimicrobial stewardship-related, peer-reviewed literature that detailed an actionable intervention during 2022. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight actionable interventions used by antimicrobial stewardship programs to capture potentially effective strategies for local implementation.

Are behavioral economics interventions effective in increasing colorectal cancer screening uptake: A systematic review of evidence and meta-analysis?

Various interventions have been investigated to improve the uptake of colorectal cancer screening. In this paper, the authors have attempted to provide a pooled estimate of the effect size of the BE interventions running a systematic review based meta-analysis. In this study, all the published literatures between 2000 and 2022 have been reviewed. Searches were performed in PubMed, Scopus and Cochrane databases. The main outcome was the demanding the one of the colorectal cancer screening tests. The quality assessment was done by two people so that each person evaluated the studies separately and independently based on the individual participant data the modified Jadad scale. Pooled effect size (odds ratio) was estimated using random effects model at 95% confidence interval. Galbraith, Forrest and Funnel plots were used in data analysis. Publication bias was also investigated through Egger's test. All the analysis was done in STATA 15. From the initial 1966 records, 38 were included in the final analysis in which 72612 cases and 71493 controls have been studied. About 72% have been conducted in the USA. The heterogeneity of the studies was high based on the variation in OR (I2 = 94.6%, heterogeneity X2 = 670.01 (d.f. = 36), p < 0.01). The random effect pooled odds ratio (POR) of behavioral economics (BE) interventions was calculated as 1.26 (95% CI: 1.26 to 1.43). The bias coefficient is noteworthy (3.15) and statistically significant (p< 0.01). According to the results of this meta-analysis, health policy and decision makers can improve the efficiency and cost effectiveness of policies to control this type of cancer by using various behavioral economics interventions. It's noteworthy that due to the impossibility of categorizing behavioral economics interventions; we could not perform by group analysis.

Development of Inpatient Stewardship Metrics: Is It Time for Public Reporting?

Given the complexity and nuance needed to make antimicrobial prescribing decisions, metrics aiming to assess these decisions can be complex in method, require resource investment for measurement, and demand thoughtfulness in how to use data for program implementation and messaging to key partners. Antimicrobial stewardship programs today use several metrics of antimicrobial use in parallel with other clinical data for a multitude of purposes and audiences. Here, we discuss goals for inpatient stewardship metrics, current metrics used by stewardship programs locally and nationally, and future directions for antimicrobial use metric development.

Early Discontinuation of Antibiotics in Patients Admitted With Clinically Suspected Serious Infection but Negative Cultures: Retrospective Cohort Study of Practice Patterns and Outcomes at 111 US Hospitals

Background

The optimal duration for antibiotics in patients hospitalized with culture-negative serious infection (CNSI) is unknown. We compared outcomes in patients with CNSI treated with 3 or 4 vs ≥5 days of antibiotics.

Methods

CNSI was identified among adults admitted to 111 US hospitals between 2009 and 2014 via electronic health record data, defined as suspected serious infection (blood cultures drawn and ≥3 days of antibiotics) and negative culture- and nonculture-based tests for infection. Patients treated with antibiotics on their last hospital day and patients with diagnosis codes for sepsis-mimicking conditions were excluded. Among patients without fevers/hypothermia or vasopressors by day 3, we calculated odds ratios for in-hospital mortality or discharge to hospice associated with 3 or 4 vs ≥5 days of antibiotics, adjusting for confounders.

Results

Antibiotics were discontinued in 3 or 4 days in 1862 (9%) of 20 714 patients with CNSI. Early discontinuation was not associated with higher mortality odds overall (adjusted odds ratio [aOR], 1.27; 95% CI, .98-1.65), in patients presenting with (1.39; .88-2.22) and without sepsis (1.17; .81-1.69), and in those with pulmonary (1.23; .65-2.34) and nonpulmonary CNSI (1.30; .99-1.72). Early discontinuation appeared detrimental with propensity score weighting (aOR, 1.36; 95% CI, 1.03-1.80) and when retaining patients with sepsis mimics (1.38; 1.16-1.65), but it was protective (0.48; .37-.64]) when retaining patients who received antibiotics on their last hospital day.

Conclusions

Early discontinuation of antibiotics in CNSI was not associated with significant harm in our primary analysis, but different conclusions based on alternative analytic decisions, as well as risk of residual confounding, indicate that randomized controlled trials are needed.

Infectious Diseases: What You May Have Missed in 2022

In 2022, COVID-19 remained the infectious disease at the top of most internal medicine physicians' minds. However, it was not the only infectious disease that was the topic of clinically relevant research that year. This article highlights some important infectious disease evidence unrelated to COVID-19 that was published in 2022. The literature was screened for sound new evidence relevant to internal medicine specialists and subspecialists whose focus of practice is not infectious diseases. The publications highlighted relate to various organisms in different patient populations. One article provides insight into the role of Helicobacter pylori eradication in the treatment of functional dyspepsia. The descriptive epidemiology of bacterial (Staphylococcus aureus) and viral (mpox) infections are the focus of 2 other articles. Several articles address the management of resistant and difficult-to-treat infections: multidrug-resistant gram-negative infections, resistant HIV-1, rifampin-resistant tuberculosis, cryptococcal meningitis, and invasive fungal infection in the setting of neutropenia. Another article provides data on effective HIV preexposure prophylaxis in women, an understudied population. Finally, given the urgent need to reduce inappropriate use of antibiotics, an article on antibiotic stewardship for hospitalized patients with presumed sepsis in a non-intensive care unit setting is also included.