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Huttner A, Tamma PD, Yahav D. Re: 'ESR and CRP: It's Time to Stop the Zombie Tests' by Spellberg et al. Clin Microbiol Infect 2024:S1198-743X(24)00448-8. [PMID: 39332597 DOI: 10.1016/j.cmi.2024.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2024] [Accepted: 09/19/2024] [Indexed: 09/29/2024]
Affiliation(s)
- Angela Huttner
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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2
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Chen W, Zhang K, Huang F, Zhao L, Waldren GC, Jiang Q, Chen SX, Wang B, Guo W, Zhang DY, Zhang JX. Advancing quantitative PCR with color cycle multiplex amplification. Nucleic Acids Res 2024; 52:e81. [PMID: 39119904 PMCID: PMC11417387 DOI: 10.1093/nar/gkae683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/01/2024] [Accepted: 08/02/2024] [Indexed: 08/10/2024] Open
Abstract
Quantitative PCR (qPCR) is the gold standard for detection and quantitation of known DNA targets, but the scarcity of spectrally distinct fluorophores and filter sets limits the number of detectable targets. Here, we introduce color cycle multiplex amplification (CCMA) to significantly increase the number of detectable DNA targets in a single qPCR reaction using standard instrumentation. In CCMA, presence of one DNA target species results in a pre-programmed pattern of fluorescence increases. This pattern is distinguished by cycle thresholds (Cts) through rationally designed delays in amplification. For example, we design an assay wherein Staphylococcus aureus sequentially induces FAM, then Cy5.5, then ROX fluorescence increases with more than 3 cycles between each signal. CCMA offers notably higher potential for multiplexing because it uses fluorescence permutation rather than combination. With 4 distinct fluorescence colors, CCMA theoretically allows the detection of up to 136 distinct DNA target sequences using fluorescence permutation. Experimentally, we demonstrated a single-tube qPCR assay screening 21 sepsis-related bacterial DNA targets in samples of blood, sputum, pleural effusion and bronchoalveolar lavage fluid, with 89% clinical sensitivity and 100% clinical specificity, showing its potential as a powerful tool for advanced quantitative screening in molecular diagnostics.
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Affiliation(s)
- Wei Chen
- Department of Innovation, NuProbe USA, Houston, TX 77054, USA
| | - Kerou Zhang
- Department of Innovation, NuProbe USA, Houston, TX 77054, USA
| | - Fei Huang
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, Shanghai 200032, China
| | - Lan Zhao
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai 200433, China
| | | | - Qi Jiang
- Department of Innovation, NuProbe USA, Houston, TX 77054, USA
| | - Sherry X Chen
- Department of Innovation, NuProbe USA, Houston, TX 77054, USA
| | - Bonnie Wang
- Department of Innovation, NuProbe USA, Houston, TX 77054, USA
| | - Wei Guo
- Department of Laboratory Medicine, Zhongshan Hospital, Fudan University, Shanghai, Shanghai 200032, China
| | - David Y Zhang
- Department of Innovation, NuProbe USA, Houston, TX 77054, USA
| | - Jinny X Zhang
- Department of Innovation, NuProbe USA, Houston, TX 77054, USA
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3
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Crotty M, Devall H, Cook N, Fischer F, Alexander J, Hunter L, Dominguez E. Short Versus Long Antibiotic Duration in Streptococcus pneumoniae Bacteremia. Open Forum Infect Dis 2024; 11:ofae478. [PMID: 39257675 PMCID: PMC11385198 DOI: 10.1093/ofid/ofae478] [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: 06/16/2024] [Accepted: 08/29/2024] [Indexed: 09/12/2024] Open
Abstract
Background Streptococcus pneumoniae is a common pathogen associated with bloodstream infections, respiratory infections, peritonitis, infective endocarditis, and meningitis. Literature assessing duration of antibiotic therapy for a S pneumoniae bacteremia secondary to common infection is scarce, leading to variability in practice. Therefore, this study evaluated the effectiveness of short (5-10 days) versus long (11-16 days) antibiotic durations for S pneumoniae bacteremia. Methods This retrospective, single-center cohort study assessed hospitalized patients with S pneumoniae-positive blood cultures, who received active antibiotics within 48 hours of first positive blood culture collection and achieved clinical stability by day 10 of the first positive blood culture collection. Exclusion criteria included treatment duration <5 or >16 days, death before completion of 10 days of therapy, polymicrobial bloodstream infection, and invasive infection. Rates of clinical failure (composite of 30-day hospital readmission, bacteremia recurrence, and mortality) were compared between the groups. Results A total of 162 patients were included, with 51 patients in the short- and 111 patients in the long-duration group. Pneumonia was the suspected source of bacteremia in 90.1% of patients. Rates of clinical failure were not significantly different between the 2 groups. Patients received a median antibiotic course of 7 days in the short group compared to 14 days in the long group; however, there was no significant difference observed in the median hospital length of stay, median intensive care unit length of stay, or rate of Clostridioides difficile infection. Conclusions Shorter antibiotic courses may be appropriate in patients with S pneumoniae bacteremia secondary to community-acquired pneumonia.
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Affiliation(s)
- Matthew Crotty
- Department of Pharmacy, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Hadley Devall
- Department of Pharmacy, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Natalie Cook
- Department of Pharmacy, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Francis Fischer
- Department of Internal Medicine, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Julie Alexander
- Department of Internal Medicine, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Leigh Hunter
- Department of Internal Medicine, Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Edward Dominguez
- Organ Transplant Infectious Diseases, Methodist Transplant Specialists, Methodist Dallas Medical Center, Dallas, Texas, USA
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4
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Clutter DS, Samiezade-Yazd Z, Champsi JH, Schapiro J, Silverberg MJ. Antibiotic duration and route for treatment of adults with uncomplicated streptococcal bloodstream infections: a retrospective study in a large healthcare system. Antimicrob Agents Chemother 2024; 68:e0022024. [PMID: 38975753 PMCID: PMC11304718 DOI: 10.1128/aac.00220-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 06/11/2024] [Indexed: 07/09/2024] Open
Abstract
Data guiding the duration and route of streptococcal bloodstream infection (BSI) treatment are lacking. We conducted a retrospective cohort study of adults hospitalized with uncomplicated streptococcal BSI in a large integrated healthcare system from 2013 to 2020. The exposures of interest were antibiotic duration (5-10 days vs. 11-15 days) and antibiotic route (oral switch vs. entirely intravenous). The primary outcome was a composite 90-day outcome comprised of all-cause mortality, recurrent streptococcal BSI, or readmission. We performed non-inferiority analyses for each exposure. Separate multivariable Cox proportional hazards regression models were constructed for each exposure. The antibiotic duration analysis included 1,407 patients (5-10 days, n = 246; 11-15 days, n = 1,161). We found that 5-10-day courses were non-inferior to 11-15-day courses (P = 0.047). The antibiotic route analysis included 1,461 patients (oral switch, n = 1,112; entirely intravenous, n = 349). Oral step-down therapy did not meet the criteria for non-inferiority (P = 0.06). In the adjusted models, no significant difference was found in the primary outcome rate by antibiotic duration or antibiotic route at discharge. We found that 5-10-day courses were non-inferior to longer courses, and thus may be a safe and effective treatment option in the treatment of uncomplicated streptococcal bacteremia. Randomized controlled trials are needed to confirm the equivalent outcomes with shorter regimens and to definitively determine the optimal antibiotic route on discharge.
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Affiliation(s)
- Dana S. Clutter
- Division of Infectious Diseases, Kaiser Permanente South San Francisco Medical Center, South San Francisco, California, USA
| | - Zahra Samiezade-Yazd
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Jamila H. Champsi
- Division of Infectious Diseases, Kaiser Permanente South San Francisco Medical Center, South San Francisco, California, USA
| | - Jeffrey Schapiro
- Kaiser Permanente Northern California Regional Laboratory, Berkeley, California, USA
| | - Michael J. Silverberg
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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5
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You TY, Lo CL, Tsai WC, Jan HE, Ko WC, Lee NY. Efficacy of short- versus prolonged-courses of antimicrobial therapy for carbapenem-resistant Klebsiella pneumoniae bloodstream infections: A propensity score-matched cohort study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024; 57:594-600. [PMID: 38849216 DOI: 10.1016/j.jmii.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 05/09/2024] [Accepted: 05/25/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND As limited antibiotic options are available for the treatment of carbapenem-resistant Klebsiella pneumoniae (CRKP) bloodstream infections (BSIs), the optimal treatment duration for CRKP BSIs is unclear. Our objective was to investigate whether short courses (6-10 days) are as effective as prolonged courses (≥11 days) of active antibiotic therapy for CRKP BSIs. METHODS A retrospective cohort study comprising adults with monomicrobial CRKP BSI receiving a short or prolonged course of in vitro active therapy at a medical center was conducted between 2010 and 2021. Comparisons of two therapeutic strategies were assessed by the logistic regression model and propensity score analysis. The primary endpoint was 30-day crude mortality. Secondary outcomes included recurrent BSIs, the emergence of multidrug-resistant organisms and candidemia during hospitalization after completing antibiotic therapy for CRKP BSIs. RESULTS Of 263 eligible adults, 160 (60.8%) were male, and the median (interquartile range) age was 69.0 (53.0-76.0) years. Common comorbidities included diabetes (143 patients, 54.4%), malignancy (75, 28.5%), cerebrovascular accident (58, 22.1%), and hemodialysis (49, 18.6%). The 30-day mortality rate was 8.4% (22 patients). Of 84 propensity score well-balanced matched pairs, the 30-day mortality was similar in the short-course and prolonged-course group (6.0% and 7.1%, respectively; P = 1.00). However, there were less episodes candidemia in the short-course group (1.2% versus 13.1%; odds ratio, 0.08; 95% confidence interval, 0.01-0.63; P = 0.005). CONCLUSION Short courses of active therapy for CRKP BSIs demonstrate comparable clinical outcomes to prolonged courses and are associated with a lower risk of subsequent candidemia.
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Affiliation(s)
- Tian-Yu You
- Department of Internal Medicine and Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Lung Lo
- Department of Internal Medicine and Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Chia Tsai
- Department of Internal Medicine and Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hao-En Jan
- Department of Internal Medicine and Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine and Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Nan-Yao Lee
- Department of Internal Medicine and Center for Infection Control, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Ranganath N, Hassett LC, Saleh OMA, Yetmar ZA. Short versus prolonged duration of therapy for Pseudomonas aeruginosa bacteraemia: a systematic review and meta-analysis. J Hosp Infect 2024; 148:155-166. [PMID: 38685414 DOI: 10.1016/j.jhin.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 02/28/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024]
Abstract
The optimal duration of therapy for Pseudomonas aeruginosa bloodstream infection (PSA-BSI) is unknown, with prolonged therapy frequently favored due to severity of infection, patient complexity, risk of multi-drug resistance, and high mortality. We therefore conducted a systematic review and meta-analysis of studies with head-to-head comparison of short versus prolonged therapy for PSA-BSI. A comprehensive search including Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus was performed. We pooled risk ratios using DerSimonian-Laird random effects model and performed subgroup analysis of outcomes including all-cause mortality, recurrent infection, and composite of these outcomes among patients receiving short versus prolonged therapy for PSA-BSI. Heterogeneity was assessed by the I2-index. Risk of bias for cohort studies was assessed using ROBINS-I tool. Of the 908 identified studies, six were included in the systematic review and five studies with head-to-head comparison of treatment duration were assessed in the meta-analysis, totalling 1746 patients. No significant difference in propensity score-weighted composite outcome (30-day all-cause mortality or recurrent infection) was noted between patients receiving short or prolonged therapy, with a pooled RR risk ratio of 0.80 (95% CI confidence interval 0.51-1.25, P=0.32; I2 = 0%). Additionally, duration of therapy did not impact individual outcomes of 30-day all-cause mortality or recurrent/persistent infection. Our meta-analysis demonstrated that short duration of antimicrobial therapy may have similar efficacy to prolonged treatment for PSA-BSI. Future randomized trials will be necessary to definitively determine optimal management of PSA bacteraemia.
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Affiliation(s)
- N Ranganath
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA.
| | - L C Hassett
- Mayo Clinic Libraries, Mayo Clinic, Rochester, MN, USA
| | - O M A Saleh
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Z A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA; Department of Infectious Disease, Cleveland Clinic, Cleveland, OH, USA
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Lee CC, Chen PL, Ho CY, Hong MY, Hung YP, Ko WC. Prompt antimicrobial therapy and source control on survival and defervescence of adults with bacteraemia in the emergency department: the faster, the better. Crit Care 2024; 28:176. [PMID: 38790061 PMCID: PMC11127347 DOI: 10.1186/s13054-024-04963-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/20/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Bacteraemia is a critical condition that generally leads to substantial morbidity and mortality. It is unclear whether delayed antimicrobial therapy (and/or source control) has a prognostic or defervescence effect on patients with source-control-required (ScR) or unrequired (ScU) bacteraemia. METHODS The multicenter cohort included treatment-naïve adults with bacteraemia in the emergency department. Clinical information was retrospectively obtained and etiologic pathogens were prospectively restored to accurately determine the time-to-appropriate antibiotic (TtAa). The association between TtAa or time-to-source control (TtSc, for ScR bacteraemia) and 30-day crude mortality or delayed defervescence were respectively studied by adjusting independent determinants of mortality or delayed defervescence, recognised by a logistic regression model. RESULTS Of the total 5477 patients, each hour of TtAa delay was associated with an average increase of 0.2% (adjusted odds ratio [AOR], 1.002; P < 0.001) and 0.3% (AOR 1.003; P < 0.001) in mortality rates for patients having ScU (3953 patients) and ScR (1524) bacteraemia, respectively. Notably, these AORs were augmented to 0.4% and 0.5% for critically ill individuals. For patients experiencing ScR bacteraemia, each hour of TtSc delay was significantly associated with an average increase of 0.31% and 0.33% in mortality rates for overall and critically ill individuals, respectively. For febrile patients, each additional hour of TtAa was significantly associated with an average 0.2% and 0.3% increase in the proportion of delayed defervescence for ScU (3085 patients) and ScR (1266) bacteraemia, respectively, and 0.5% and 0.9% for critically ill individuals. For 1266 febrile patients with ScR bacteraemia, each hour of TtSc delay respectively was significantly associated with an average increase of 0.3% and 0.4% in mortality rates for the overall population and those with critical illness. CONCLUSIONS Regardless of the need for source control in cases of bacteraemia, there seems to be a significant association between the prompt administration of appropriate antimicrobials and both a favourable prognosis and rapid defervescence, particularly among critically ill patients. For ScR bacteraemia, delayed source control has been identified as a determinant of unfavourable prognosis and delayed defervescence. Moreover, this association with patient survival and the speed of defervescence appears to be augmented among critically ill patients.
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Affiliation(s)
- Ching-Chi Lee
- Clinical Medical Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
- Division of Infectious Disease, Departments of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
| | - Po-Lin Chen
- Division of Infectious Disease, Departments of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Ching-Yu Ho
- Department of Adult Critical Care Medicine, Tainan Sin-Lau Hospital, No.57, Sec. 1, Dongmen Road, East Dist., Tainan, 70142, Taiwan
- Department of Nursing, National Tainan Junior College of Nursing, Tainan, Taiwan
| | - Ming-Yuan Hong
- Departments of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
| | - Yuan-Pin Hung
- Division of Infectious Disease, Departments of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
- Department of Medicine, Medical College, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan
- Department of Internal Medicine, Tainan Hospital, Ministry of Health and Welfare, No. 125, Jhongshan Rd., West Central Dist., Tainan City, Taiwan
| | - Wen-Chien Ko
- Division of Infectious Disease, Departments of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
- Department of Medicine, Medical College, National Cheng Kung University, No. 138, Sheng Li Road, 70403, Tainan, Taiwan.
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Gill EL, Gill CM, McEvoy C. Validation of a Stenotrophomonas maltophilia bloodstream infection prediction score in the hematologic malignancy population. Ann Hematol 2024; 103:1745-1752. [PMID: 38453704 PMCID: PMC11009769 DOI: 10.1007/s00277-024-05686-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/28/2024] [Indexed: 03/09/2024]
Abstract
Stenotrophomonas maltophilia (SM) bloodstream infections (BSIs) contribute to significant mortality in hematologic malignancy (HM) and hematopoietic stem cell transplantation (HSCT) patients. A risk score to predict SM BSI could reduce time to appropriate antimicrobial therapy (TTAT) and improve patient outcomes. A single center cohort study of hospitalized adults with HM/HSCT was conducted. Patients had ≥ 1 blood culture with a Gram-negative (GN) organism. A StenoSCORE was calculated for each patient. The StenoSCORE2 was developed using risk factors for SM BSI identified via logistic regression. Receiver operating characteristic (ROC) curves were plotted. Sensitivity and specificity for the StenoSCORE and StenoSCORE2 were calculated. Thirty-six SM patients and 534 non-SM patients were assessed. A StenoSCORE ≥ 33 points was 80% sensitive, 68% specific, and accurately classified 69% of GN BSIs. StenoSCORE2 variables included acute leukemia, prolonged neutropenia, mucositis, ICU admission, recent meropenem and/or cefepime exposure. The StenoSCORE2 performed better than the StenoSCORE (ROC AUC 0.84 vs. 0.77). A StenoSCORE2 ≥ 4 points was 86% sensitive, 76% specific, and accurately classified 77% of GN BSIs. TTAT was significantly longer for patients with SM BSI compared with non-SM BSI (45.16 h vs. 0.57 h; p < 0.0001). In-hospital and 28-day mortality were significantly higher for patients with SM BSI compared to non-SM BSI (58.3% vs. 18.5% and 66.7% vs. 26.4%; p-value < 0.0001). The StenoSCORE and StenoSCORE2 performed well in predicting SM BSIs in patients with HM/HSCT and GN BSI. Clinical studies evaluating whether StenoSCORE and/or StenoSCORE2 implementation improves TTAT and clinical outcomes are warranted.
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Affiliation(s)
- Emily L Gill
- Department of Pharmacy, Barnes Jewish Hospital, 216 S. Kingshighway Blvd, Mailstop 90-52-41, Saint Louis, MO, 63110, USA.
| | - Christian M Gill
- Department of Pharmacy, SSM-Health St. Louis University Hospital, Saint Louis, MO, USA
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Colleen McEvoy
- Division of Pulmonary and Critical Care, Washington University School of Medicine, Saint Louis, MO, USA
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Engers DW, Tamma PD, Fiawoo S, Fong K, Jariwala R, Jenkins TC, Kendall RE, Lee JH, McCreary EK, Patel PK, Shihadeh KC, Slish J, Van Schooneveld TC, Malani AN. Transition to Oral Antibiotic Therapy for Hospitalized Adults With Gram-Negative Bloodstream Infections. JAMA Netw Open 2024; 7:e2349864. [PMID: 38165674 PMCID: PMC10762571 DOI: 10.1001/jamanetworkopen.2023.49864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/14/2023] [Indexed: 01/04/2024] Open
Abstract
Importance Management of gram-negative bloodstream infections (GN-BSIs) with oral antibiotics is highly variable. Objective To examine the transition from intravenous (IV) to oral antibiotics, including selection, timing, and associated clinical and microbial characteristics, among hospitalized patients with GN-BSIs. Design, Setting, and Participants A retrospective cohort study was conducted of 4581 hospitalized adults with GN-BSIs at 24 US hospitals between January 1 and December 31, 2019. Patients were excluded if they died within 72 hours. Patients were excluded from the oral therapy group if transition occurred after day 7. Statistical analysis was conducted from July 2022 to October 2023. Exposures Administration of antibiotics for GN-BSIs. Main Outcomes and Measures Baseline characteristics and clinical parameters reflecting severity of illness were evaluated in groups receiving oral and IV therapy. The prevalence of transition from IV to oral antibiotics by day 7, median day of transition, sources of infection, and oral antibiotic selection were assessed. Results Of a total of 4581 episodes with GN-BSIs (median age, 67 years [IQR, 55-77 years]; 2389 men [52.2%]), 1969 patients (43.0%) receiving IV antibiotics were transitioned to oral antibiotics by day 7. Patients maintained on IV therapy were more likely than those transitioned to oral therapy to be immunosuppressed (833 of 2612 [31.9%] vs 485 of 1969 [24.6%]; P < .001), require intensive care unit admission (1033 of 2612 [39.5%] vs 334 of 1969 [17.0%]; P < .001), have fever or hypotension as of day 5 (423 of 2612 [16.2%] vs 49 of 1969 [2.5%]; P < .001), require kidney replacement therapy (280 of 2612 [10.7%] vs 63 of 1969 [3.2%]; P < .001), and less likely to have source control within 7 days (1852 of 2612 [70.9%] vs 1577 of 1969 [80.1%]; P < .001). Transitioning patients from IV to oral therapy by day 7 was highly variable across hospitals, ranging from 25.8% (66 of 256) to 65.9% (27 of 41). A total of 4109 patients (89.7%) achieved clinical stability within 5 days. For the 3429 episodes (74.9%) with successful source control by day 7, the median day of source control was day 2 (IQR, 1-3 days) for the oral group and day 2 (IQR, 1-4 days) for the IV group (P < .001). Common infection sources among patients administered oral therapy were the urinary tract (1277 of 1969 [64.9%]), hepatobiliary (239 of 1969 [12.1%]), and intra-abdominal (194 of 1969 [9.9%]). The median day of oral transition was 5 (IQR, 4-6 days). Total duration of antibiotic treatment was significantly shorter among the oral group than the IV group (median, 11 days [IQR, 9-14 days] vs median, 13 days [IQR, 8-16 days]; P < .001]. Fluoroquinolones (62.2% [1224 of 1969]), followed by β-lactams (28.3% [558 of 1969]) and trimethoprim-sulfamethoxazole (11.5% [227 of 1969]), were the most commonly prescribed oral antibiotics. Conclusions and Relevance In this cohort study of 4581 episodes of GN-BSIs, transition to oral antibiotic therapy by day 7 occurred in fewer than half of episodes, principally with fluoroquinolones, although this practice varied significantly between hospitals. There may have been additional opportunities for earlier and more frequent oral antibiotic transitions because most patients demonstrated clinical stability by day 5.
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Affiliation(s)
- Drew W. Engers
- Department of Internal Medicine, Infectious Diseases, Trinity Health, Ann Arbor, Michigan
| | - Pranita D. Tamma
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Suiyini Fiawoo
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Karen Fong
- Department of Pharmacy, University of Utah Health, Salt Lake City
| | - Ripal Jariwala
- Department of Pharmaceutical Services, University of California, San Francisco
| | - Timothy C. Jenkins
- Department of Medicine, Division of Infectious Diseases, Denver Health, Denver, Colorado
| | - Ronald E. Kendall
- Department of Pharmacy, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Jae Hyoung Lee
- Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Erin K. McCreary
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Payal K. Patel
- Department of Infectious Diseases, Intermountain Health, Salt Lake City, Utah
| | | | - Judianne Slish
- Department of Pharmacy, University of Rochester Medicine–Highland Hospital, Rochester, New York
| | - Trevor C. Van Schooneveld
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Anurag N. Malani
- Department of Internal Medicine, Infectious Diseases, Trinity Health, Ann Arbor, Michigan
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Chotiprasitsakul D, Trirattanapikul A, Namsiripongpun W, Chaihongsa N, Santanirand P. From Epidemiology of Community-Onset Bloodstream Infections to the Development of Empirical Antimicrobial Treatment-Decision Algorithm in a Region with High Burden of Antimicrobial Resistance. Antibiotics (Basel) 2023; 12:1699. [PMID: 38136733 PMCID: PMC10740575 DOI: 10.3390/antibiotics12121699] [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: 10/21/2023] [Revised: 11/14/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
Antimicrobial-resistant (AMR) infections have increased in community settings. Our objectives were to study the epidemiology of community-onset bloodstream infections (BSIs), identify risk factors for AMR-BSI and mortality-related factors, and develop the empirical antimicrobial treatment-decision algorithm. All adult, positive blood cultures at the emergency room and outpatient clinics were evaluated from 08/2021 to 04/2022. AMR was defined as the resistance of organisms to an antimicrobial to which they were previously sensitive. A total of 1151 positive blood cultures were identified. There were 450 initial episodes of bacterial BSI, and 114 BSIs (25%) were AMR-BSI. Non-susceptibility to ceftriaxone was detected in 40.9% of 195 E. coli isolates and 16.4% among 67 K. pneumoniae isolates. A treatment-decision algorithm was developed using the independent risk factors for AMR-BSI: presence of multidrug-resistant organisms (MDROs) within 90 days (aOR 3.63), prior antimicrobial exposure within 90 days (aOR 1.94), and urinary source (aOR 1.79). The positive and negative predictive values were 53.3% and 83.2%, respectively. The C-statistic was 0.73. Factors significantly associated with 30-day all-cause mortality were Pitt bacteremia score (aHR 1.39), solid malignancy (aHR 2.61), and urinary source (aHR 0.30). In conclusion, one-fourth of community-onset BSI were antimicrobial-resistant, and one-third of Enterobacteriaceae were non-susceptible to ceftriaxone. Treatment-decision algorithms may reduce overly broad antimicrobial treatment.
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Affiliation(s)
- Darunee Chotiprasitsakul
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (W.N.)
| | - Akeatit Trirattanapikul
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (W.N.)
| | - Warunyu Namsiripongpun
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (A.T.); (W.N.)
| | - Narong Chaihongsa
- Microbiology Laboratory, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (N.C.); (P.S.)
| | - Pitak Santanirand
- Microbiology Laboratory, Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (N.C.); (P.S.)
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11
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Gandhi K, Wrzesinski M, Bunnell K, Gibble A. Oral antibiotic step-down therapy for nonstaphylococcal gram-positive bloodstream infections. Diagn Microbiol Infect Dis 2023; 107:116068. [PMID: 37774630 DOI: 10.1016/j.diagmicrobio.2023.116068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 08/03/2023] [Accepted: 08/18/2023] [Indexed: 10/01/2023]
Abstract
Bloodstream infections traditionally are treated with intravenous (IV) therapy. This study's purpose is to evaluate if oral step-down therapy is noninferior to IV therapy for gram-positive bloodstream infections (GP-BSIs). This retrospective cohort study included patients who received IV therapy and those who received oral step-down therapy for a nonstaphylococcal GP-BSI from 2017 to 2019. The primary endpoint was a composite outcome of 90-day all-cause mortality and clinical failure. A total of 308 patients were included (n = 94, oral; n = 214, IV). The oral step-down group had a lower incidence of 90-day clinical failure (9% vs 14%; P < 0.001). The IV group had a longer hospital stay (4 vs 6 days, P < 0.001); however, there were no significant differences in secondary outcomes. Bivariate analysis found no predictors of 90-day clinical failure. Oral step-down therapy was found to be noninferior to IV therapy.
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Affiliation(s)
- Kelvin Gandhi
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI, USA.
| | | | - Kristen Bunnell
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI, USA; Department of Clinical Sciences, Medical College of Wisconsin School of Pharmacy, Milwaukee, WI USA
| | - Allison Gibble
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI, USA
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12
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Hand J, Imlay H. Antimicrobial Stewardship in Immunocompromised Patients: Current State and Future Opportunities. Infect Dis Clin North Am 2023; 37:823-851. [PMID: 37741735 DOI: 10.1016/j.idc.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
Abstract
Immunocompromised (IC) patients are high risk for complications due to a high rate of antibiotic exposure. Antimicrobial stewardship interventions targeted to IC patients can be challenging due to limited data in this population and a high risk of severe infection-related outcomes. Here, the authors review immunocompromised antimicrobial stewardship barriers, metrics, and opportunities for antimicrobial use and testing optimization. Last, the authors highlight future steps in the field.
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Affiliation(s)
- Jonathan Hand
- Ochsner Health, New Orleans, LA, USA; University of Queensland School of Medicine, Ochsner Clinical School
| | - Hannah Imlay
- University of Utah Department of Internal Medicine, Salt Lake City, UT, USA.
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13
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Patel HH, Benny B, Nahar P, Landis A. The Impact of Antimicrobial Stewardship in Treating Patients with Escherichia coli Bacteremia in a Small Single Center Community Hospital. Innov Pharm 2023; 14:10.24926/iip.v14i4.5526. [PMID: 38495353 PMCID: PMC10939489 DOI: 10.24926/iip.v14i4.5526] [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] [Indexed: 03/19/2024] Open
Abstract
Purpose: There are many challenges that pharmacist led antimicrobial stewardship programs can encounter including lack of resources, costs, and inaccurate antimicrobial susceptibility testing (AST) results. The COVID-19 pandemic has led to increased resistance especially with gram negative infections. At a small single center community hospital, gram negative infections, particularly Escherichia coli infections, predominately occur. Therefore, this study aims to address gram negative bacteremia burden and its impact on antimicrobial stewardship efforts for combatting Escherichia coli and ESBL organisms with such barriers during the pandemic. Methods: In a retrospective cohort study, patients ≥ 18 years of age from a small community hospital were reviewed. Patients were excluded if their blood cultures were not positive for Escherichia coli and if antibiotics were not initiated during hospital stay. The primary endpoint was to determine the length of hospital stay. Critical secondary endpoints include antibiotic de-escalations, duration of antibiotics, time to definitive antibiotic therapy, serum procalcitonin levels, blood culture availabilities, MIC breakpoints, co-infection of COVID-19, and Clostridioides difficile occurrences. Results: Out of 74 patients with gram negative bacteremia, 41 patients specifically had Escherichia coli bacteremia. The primary endpoint results showed that patients with Escherichia coli bacteremia that stayed in the ICU had a length of stay of 13.6 days. Patients with Escherichia coli bacteremia in the Non-ICU setting has a length of stay of 7.3 days, and patients with ESBL bacteremia in the Non-ICU setting had a length of stay of 6.8 days. Conclusions: Despite the various challenges that antimicrobial stewardship programs (ASP) face in a single center small community hospital, the ASP at this small community hospital utilizes various policies and tools to increase appropriate antibiotic use and decrease hospital length of stay in patients with Escherichia coli bacteremia.
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Affiliation(s)
| | - Betcy Benny
- Saint Joseph’s University Philadelphia College of Pharmacy
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14
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Stoldick M, Vannier M, Verdalle-Cazes M, Etienne M, Alexandre K. Short-Course Versus Prolonged-Course Antimicrobial Therapy in Adults With Catheter-Related Septic Thrombosis: A Propensity-Weighted Retrospective Study. Open Forum Infect Dis 2023; 10:ofad530. [PMID: 37953819 PMCID: PMC10638491 DOI: 10.1093/ofid/ofad530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/24/2023] [Indexed: 11/14/2023] Open
Abstract
Background Optimal duration of antimicrobial therapy (AT) for catheter-related septic deep venous thrombosis (DVT) is unknown. We aimed to compare the outcomes of patients receiving short-course AT (≤21 days) versus prolonged-course AT (>21 days). Methods This was a monocentric retrospective study comparing adults with catheter-related septic DVT from 2015 to 2020 treated with short- or prolonged-course AT. A propensity score-weighted analysis was used to mitigate potential bias. The primary outcome was a composite of all-cause mortality or recurrent bloodstream infection 30 days after AT discontinuation. Results Of 172 patients with catheter-related septic DVT, 104 were treated with prolonged-course AT and 68 with short-course AT. In the propensity score analysis, we found no significant difference in 30-day all-cause mortality or relapse between the 2 groups (inverse probability of treatment weighted hazard ratio [wHR], 2.16 [95% confidence interval {CI}, .68-6.88]; P = .192). No differences in 90-day all-cause mortality and 90-day relapse were observed between the treatment groups (wHR, 1.01 [95% CI, .49-2.05], P = .987 and 1.13 [95% CI, .08-15.62], P = .928, respectively). Conclusions A 21-day AT could be an effective and safe option to treat catheter-related septic DVT. Further randomized studies are needed to establish the optimal duration of AT for patients with catheter-related septic DVT.
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Affiliation(s)
- Marine Stoldick
- Department of Infectious Diseases, Centre hospitalier universitaire Rouen, Rouen, France
| | - Margot Vannier
- Department of Biostatistics, Centre hospitalier universitaire Rouen, Rouen, France
| | | | - Manuel Etienne
- Univ Rouen Normandie, Université de Caen, INSERM, Normandie Univ, DYNAMICURE Unité mixte de recherche 1311, Centre hospitalier universitaire Rouen, Department of Infectious Diseases, Rouen, France
| | - Kévin Alexandre
- Univ Rouen Normandie, Université de Caen, INSERM, Normandie Univ, DYNAMICURE Unité mixte de recherche 1311, Centre hospitalier universitaire Rouen, Department of Infectious Diseases, Rouen, France
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15
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Sartelli M, Barie PS, Coccolini F, Abbas M, Abbo LM, Abdukhalilova GK, Abraham Y, Abubakar S, Abu-Zidan FM, Adebisi YA, Adamou H, Afandiyeva G, Agastra E, Alfouzan WA, Al-Hasan MN, Ali S, Ali SM, Allaw F, Allwell-Brown G, Amir A, Amponsah OKO, Al Omari A, Ansaloni L, Ansari S, Arauz AB, Augustin G, Awazi B, Azfar M, Bah MSB, Bala M, Banagala ASK, Baral S, Bassetti M, Bavestrello L, Beilman G, Bekele K, Benboubker M, Beović B, Bergamasco MD, Bertagnolio S, Biffl WL, Blot S, Boermeester MA, Bonomo RA, Brink A, Brusaferro S, Butemba J, Caínzos MA, Camacho-Ortiz A, Canton R, Cascio A, Cassini A, Cástro-Sanchez E, Catarci M, Catena R, Chamani-Tabriz L, Chandy SJ, Charani E, Cheadle WG, Chebet D, Chikowe I, Chiara F, Cheng VCC, Chioti A, Cocuz ME, Coimbra R, Cortese F, Cui Y, Czepiel J, Dasic M, de Francisco Serpa N, de Jonge SW, Delibegovic S, Dellinger EP, Demetrashvili Z, De Palma A, De Silva D, De Simone B, De Waele J, Dhingra S, Diaz JJ, Dima C, Dirani N, Dodoo CC, Dorj G, Duane TM, Eckmann C, Egyir B, Elmangory MM, Enani MA, Ergonul O, Escalera-Antezana JP, Escandon K, Ettu AWOO, Fadare JO, Fantoni M, Farahbakhsh M, Faro MP, Ferreres A, Flocco G, Foianini E, Fry DE, Garcia AF, Gerardi C, Ghannam W, Giamarellou H, Glushkova N, Gkiokas G, Goff DA, Gomi H, Gottfredsson M, Griffiths EA, Guerra Gronerth RI, Guirao X, Gupta YK, Halle-Ekane G, Hansen S, Haque M, Hardcastle TC, Hayman DTS, Hecker A, Hell M, Ho VP, Hodonou AM, Isik A, Islam S, Itani KMF, Jaidane N, Jammer I, Jenkins DR, Kamara IF, Kanj SS, Jumbam D, Keikha M, Khanna AK, Khanna S, Kapoor G, Kapoor G, Kariuki S, Khamis F, Khokha V, Kiggundu R, Kiguba R, Kim HB, Kim PK, Kirkpatrick AW, Kluger Y, Ko WC, Kok KYY, Kotecha V, Kouma I, Kovacevic B, Krasniqi J, Krutova M, Kryvoruchko I, Kullar R, Labi KA, Labricciosa FM, Lakoh S, Lakatos B, Lansang MAD, Laxminarayan R, Lee YR, Leone M, Leppaniemi A, Hara GL, Litvin A, Lohsiriwat V, Machain GM, Mahomoodally F, Maier RV, Majumder MAA, Malama S, Manasa J, Manchanda V, Manzano-Nunez R, Martínez-Martínez L, Martin-Loeches I, Marwah S, Maseda E, Mathewos M, Maves RC, McNamara D, Memish Z, Mertz D, Mishra SK, Montravers P, Moro ML, Mossialos E, Motta F, Mudenda S, Mugabi P, Mugisha MJM, Mylonakis E, Napolitano LM, Nathwani D, Nkamba L, Nsutebu EF, O’Connor DB, Ogunsola S, Jensen PØ, Ordoñez JM, Ordoñez CA, Ottolino P, Ouedraogo AS, Paiva JA, Palmieri M, Pan A, Pant N, Panyko A, Paolillo C, Patel J, Pea F, Petrone P, Petrosillo N, Pintar T, Plaudis H, Podda M, Ponce-de-Leon A, Powell SL, Puello-Guerrero A, Pulcini C, Rasa K, Regimbeau JM, Rello J, Retamozo-Palacios MR, Reynolds-Campbell G, Ribeiro J, Rickard J, Rocha-Pereira N, Rosenthal VD, Rossolini GM, Rwegerera GM, Rwigamba M, Sabbatucci M, Saladžinskas Ž, Salama RE, Sali T, Salile SS, Sall I, Kafil HS, Sakakushev BE, Sawyer RG, Scatizzi M, Seni J, Septimus EJ, Sganga G, Shabanzadeh DM, Shelat VG, Shibabaw A, Somville F, Souf S, Stefani S, Tacconelli E, Tan BK, Tattevin P, Rodriguez-Taveras C, Telles JP, Téllez-Almenares O, Tessier J, Thang NT, Timmermann C, Timsit JF, Tochie JN, Tolonen M, Trueba G, Tsioutis C, Tumietto F, Tuon FF, Ulrych J, Uranues S, van Dongen M, van Goor H, Velmahos GC, Vereczkei A, Viaggi B, Viale P, Vila J, Voss A, Vraneš J, Watkins RR, Wanjiru-Korir N, Waworuntu O, Wechsler-Fördös A, Yadgarova K, Yahaya M, Yahya AI, Xiao Y, Zakaria AD, Zakrison TL, Zamora Mesia V, Siquini W, Darzi A, Pagani L, Catena F. Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action. World J Emerg Surg 2023; 18:50. [PMID: 37845673 PMCID: PMC10580644 DOI: 10.1186/s13017-023-00518-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/23/2023] [Indexed: 10/18/2023] Open
Abstract
Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.
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16
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Ruiz-Camps I, Albasanz-Puig A. Short-course antibiotic treatment for Gram-negative bloodstream infection in neutropenic cancer patients: Less is more. Transpl Infect Dis 2023; 25:e14106. [PMID: 37489801 DOI: 10.1111/tid.14106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 07/26/2023]
Affiliation(s)
- Isabel Ruiz-Camps
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Adaia Albasanz-Puig
- Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Campus Hospitalari, Barcelona, Spain
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17
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Ranganath N, Yetmar ZA, McCandless AR, Rivera CG, Lahr BD, Tande AJ, Shah AS. Evaluating antimicrobial duration for Gram-negative bacteremia in patients with neutropenia due to hematologic malignancy or hematopoietic stem cell transplantation. Transpl Infect Dis 2023; 25:e14085. [PMID: 37279240 DOI: 10.1111/tid.14085] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND In the management of Gram-negative bloodstream infection (GN-BSI), short antimicrobial courses have been increasingly demonstrated to be non-inferior to prolonged therapy, with lower risk of Clostridioides difficile infection (CDI) and emergence of multi-drug resistant (MDR) organisms. However, immunocompromised hosts were excluded from these studies. We investigated outcomes of short (≤10 days), intermediate (11-14 days), and prolonged (≥15 days) antimicrobial durations for GN-BSI in neutropenic patients. METHODS A retrospective cohort study was conducted on neutropenic patients with monomicrobial GN-BSI between 2018 and 2022. The primary outcome was a composite of all-cause mortality and microbiologic relapse within 90 days after therapy completion. The secondary outcome was a composite of 90-day CDI and development of MDR-GN bacteria. Cox regression analysis with propensity score (PS) adjustment was used to compare outcomes between the three groups. RESULTS A total of 206 patients were classified into short (n = 67), intermediate (n = 81), or prolonged (n = 58) duration. Neutropenia was predominantly secondary to hematopoietic stem cell transplantation (48%) or hematologic malignancy (35%). The primary sources of infection included intra-abdominal (51%), vascular catheter (27%), and urinary (8%). Most patients received definitive therapy with cefepime or carbapenem. No significant difference in the primary composite endpoint was observed for intermediate versus short (PS-adjusted hazard ratio [aHR] 0.89; 95% confidence interval [95% CI] 0.39-2.03) or prolonged versus short therapy (PS-aHR 1.20; 95% CI 0.52-2.74). There was no significant difference in the secondary composite endpoint of CDI or MDR-GN emergence. CONCLUSION Our data suggest that short antimicrobial courses had comparable 90-day outcomes as intermediate and prolonged regimens for GN-BSI among immunocompromised patients with neutropenia.
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Affiliation(s)
- Nischal Ranganath
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Zachary A Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Brian D Lahr
- Division of Clinical Trials & Biostatistics, Department of Quantitative Health Sciences, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Tande
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aditya S Shah
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
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18
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Mittal N, Goel P, Goel K, Sharma R, Nath B, Singh S, Thangaraju P, Mittal R, Kahkasha K, Mithra P, Sahu R, Priyadarshini RP, Sharma N, Pala S, Rohilla SK, Kaushal J, Sah S, Rustagi S, Sah R, Barboza JJ. Awareness Regarding Antimicrobial Resistance and Antibiotic Prescribing Behavior among Physicians: Results from a Nationwide Cross-Sectional Survey in India. Antibiotics (Basel) 2023; 12:1496. [PMID: 37887197 DOI: 10.3390/antibiotics12101496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/15/2023] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
(1) Background: Understanding the physicians' knowledge, attitudes, and antimicrobial prescribing behavior is a crucial step towards designing strategies for the optimal use of these agents. (2) Methods: A cross-sectional online survey was conducted among clinicians across India between May and July 2022 using a self-administered questionnaire in English comprising 35 questions pertaining to demographic characteristics, knowledge, attitude, and practices domains. (3) Results: A total of 544 responses were received from 710 physicians contacted. Sixty percent of participants were males, with mean age of 34.7 years. Mean ± Standard Deviation scores for knowledge, attitude, and practices domains were 8 ± 1.6, 20.2 ± 3.5, and 15.3 ± 2.1, respectively. Higher scores were associated with basic [odds ratio (95% Confidence Interval), p value: 2.95 (1.21, 7.2), 0.02], medical and allied sciences [2.71 (1.09, 6.67), 0.03], and central zone [3.75 (1.39, 10.12), 0.009]. A substantial proportion of dissatisfactory responses were found regarding hospital antibiograms, antibiotics effective against anaerobes, WHO AWaRe (access, watch, and reserve) classification of antibiotics, and the role of infection prevention and control (IPC) measures in the containment of antimicrobial resistance (AMR). (4) Conclusions: There is a need to sensitize and educate clinicians on various issues related to antimicrobial use, such as antibiograms, double anaerobic cover, IPC practices, and guideline-based recommendations, to curb the AMR pandemic.
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Affiliation(s)
- Niti Mittal
- Department of Pharmacology, Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak 124001, India
| | - Parul Goel
- Department of Biochemistry, Shri Atal Bihari Vajpayee Government Medical College, Chhainsa, Faridabad 121004, India
| | - Kapil Goel
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Rashmi Sharma
- Department of Community Medicine, GMERS Medical College Sola, Ahmedabad 380060, India
| | - Bhola Nath
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Raebareli 229405, India
| | - Surjit Singh
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur 342001, India
| | | | - Rakesh Mittal
- Department of Pharmacology, Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak 124001, India
| | - Kahkasha Kahkasha
- Department of Biochemistry, All India Institute of Medical Sciences, Deoghar 814152, India
| | - Prasanna Mithra
- Department of Community Medicine, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal 575001, India
| | - Rajesh Sahu
- Department of Community Medicine, Armed Forces Medical College, Pune 411040, India
| | - Raman P Priyadarshini
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Karaikal 609602, India
| | - Nikita Sharma
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Bilaspur 174037, India
| | - Star Pala
- Department of Community Medicine, NEIGRIHMS, Shillong 793018, India
| | - Suneel Kumar Rohilla
- Department of Pharmacology, Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak 124001, India
| | - Jyoti Kaushal
- Department of Pharmacology, Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak 124001, India
| | - Sanjit Sah
- Global Consortium for Public Health and Research, Datta Meghe Institute of Higher Education and Research, Jawaharlal Nehru Medical College, Wardha 442001, India
| | - Sarvesh Rustagi
- School of Applied and Life Sciences, Uttaranchal University, Dehradun 248007, India
| | - Ranjit Sah
- Tribhuvan University Teaching Hospital, Kathmandu 46000, Nepal
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19
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Corona A, De Santis V, Agarossi A, Prete A, Cattaneo D, Tomasini G, Bonetti G, Patroni A, Latronico N. Antibiotic Therapy Strategies for Treating Gram-Negative Severe Infections in the Critically Ill: A Narrative Review. Antibiotics (Basel) 2023; 12:1262. [PMID: 37627683 PMCID: PMC10451333 DOI: 10.3390/antibiotics12081262] [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: 12/23/2022] [Revised: 07/04/2023] [Accepted: 07/26/2023] [Indexed: 08/27/2023] Open
Abstract
INTRODUCTION Not enough data exist to inform the optimal duration and type of antimicrobial therapy against GN infections in critically ill patients. METHODS Narrative review based on a literature search through PubMed and Cochrane using the following keywords: "multi-drug resistant (MDR)", "extensively drug resistant (XDR)", "pan-drug-resistant (PDR)", "difficult-to-treat (DTR) Gram-negative infection," "antibiotic duration therapy", "antibiotic combination therapy" "antibiotic monotherapy" "Gram-negative bacteremia", "Gram-negative pneumonia", and "Gram-negative intra-abdominal infection". RESULTS Current literature data suggest adopting longer (≥10-14 days) courses of synergistic combination therapy due to the high global prevalence of ESBL-producing (45-50%), MDR (35%), XDR (15-20%), PDR (5.9-6.2%), and carbapenemases (CP)/metallo-β-lactamases (MBL)-producing (12.5-20%) Gram-negative (GN) microorganisms (i.e., Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumanii). On the other hand, shorter courses (≤5-7 days) of monotherapy should be limited to treating infections caused by GN with higher (≥3 antibiotic classes) antibiotic susceptibility. A general approach should be based on (i) third or further generation cephalosporins ± quinolones/aminoglycosides in the case of MDR-GN; (ii) carbapenems ± fosfomycin/aminoglycosides for extended-spectrum β-lactamases (ESBLs); and (iii) the association of old drugs with new expanded-spectrum β-lactamase inhibitors for XDR, PDR, and CP microorganisms. Therapeutic drug monitoring (TDM) in combination with minimum inhibitory concentration (MIC), bactericidal vs. bacteriostatic antibiotics, and the presence of resistance risk predictors (linked to patient, antibiotic, and microorganism) should represent variables affecting the antimicrobial strategies for treating GN infections. CONCLUSIONS Despite the strategies of therapy described in the results, clinicians must remember that all treatment decisions are dynamic, requiring frequent reassessments depending on both the clinical and microbiological responses of the patient.
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Affiliation(s)
- Alberto Corona
- Accident, Emergency and ICU Department and Surgical Theatre, ASST Valcamonica, University of Brescia, 25043 Breno, Italy
| | | | - Andrea Agarossi
- Accident, Emergency and ICU Department, ASST Santi Paolo Carlo, 20142 Milan, Italy
| | - Anna Prete
- AUSL Romagna, Umberto I Hospital, 48022 Lugo, Italy
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Via GB Grassi 74, 20157 Milan, Italy
| | - Giacomina Tomasini
- Urgency and Emergency Surgery and Medicine Division ASST Valcamonica, 25123 Brescia, Italy
| | - Graziella Bonetti
- Clinical Pathology and Microbiology Laboratory, ASST Valcamonica, 25123 Brescia, Italy
| | - Andrea Patroni
- Medical Directorate, Infection Control Unit, ASST Valcamonica, 25123 Brescia, Italy
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy
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20
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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.
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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.
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21
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Mack T, Hiles JJ, Wrin J, Desai A. Use of Fluoroquinolones or Sulfamethoxazole-Trimethoprim Compared to Β-Lactams for Oral Step-Down Therapy in Hospitalized Patients With Uncomplicated Enterobacterales Bacteremia. Ann Pharmacother 2023; 57:251-258. [PMID: 35758168 DOI: 10.1177/10600280221106789] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Antibiotic therapy for uncomplicated Enterobacterales bacteremia from a urinary source has traditionally consisted of fluoroquinolones (FQs) and sulfamethoxazole-trimethoprim (SXT). However, adverse events associated with FQs and emerging antimicrobial resistance have led to alternative agents, specifically oral Β-lactams (OBLs), being utilized despite concern of subtherapeutic serum concentrations related to their low relative bioavailability. OBJECTIVE To compare efficacy of antibiotic therapies with bioavailability differences in patients with uncomplicated bacteremia from a urinary source. METHODS This was a retrospective study comparing clinical efficacy in hospitalized adult patients receiving OBL or FQ/SXT. Patients were required to receive at least 48 hours of appropriate intravenous antibiotic therapy and at least one dose of oral therapy. The primary outcome was all-cause hospital readmission within 30 days of discharge. Secondary outcomes included readmission with recurrent infectious etiology and readmission due to Clostridioides difficile infection. RESULTS Of 210 eligible patients, 91 received FQ/SXT and 119 received OBL. There was no difference between the groups in all-cause hospital readmission (FQ/SXT: 16.5%; OBL: 14.3%) (P = 0.660 [95% confidence interval, CI = -0.076, 0.120]) or readmission with recurrent bacteremia (FQ/SXT: 0%; OBL: 3.4%) (P = 0.135). There was a significant difference in repeat hospital admission with recurrent urinary tract infection (UTI) (FQ/SXT: 0%, OBL: 5.0%) (P = 0.037). CONCLUSION AND RELEVANCE OBLs appear to be non-inferior to FQ/SXT in the rate of all-cause hospital readmission within 30 days. However, OBLs may be associated with increased readmissions with recurrent UTI.
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Affiliation(s)
- Tyler Mack
- Indiana University Health Hospitals and Clinics, Indianapolis, IN, USA.,Department of Pharmacy, Cleveland Clinic Lutheran Hospital, Cleveland, OH, USA
| | - Jon J Hiles
- Indiana University Health Hospitals and Clinics, Indianapolis, IN, USA
| | - Justin Wrin
- Indiana University Health Hospitals and Clinics, Indianapolis, IN, USA
| | - Armisha Desai
- Indiana University Health Hospitals and Clinics, Indianapolis, IN, USA
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22
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Follow-up Blood Cultures in Gram-negative Bacteremia: How Do They Impact Outcomes? J Community Hosp Intern Med Perspect 2023; 12:35-42. [PMID: 36816157 PMCID: PMC9924646 DOI: 10.55729/2000-9666.1131] [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: 07/11/2022] [Revised: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction Several studies have questioned the utility of obtaining follow-up blood cultures in Gram-negative bacteremia, but the impact of this practice on clinical outcomes is not fully understood. Methods A retrospective cohort study of adult patients admitted with Gram-negative bacteremia over a two year period, to compare outcomes in those with and without follow-up blood cultures obtained. Data collected included demographics, comorbidities and presumed source of bacteremia. White blood cell count and presence of fever or hemodynamic compromise on the day of follow-up blood culture were recorded. The primary objective was to compare 30-day mortality between the two groups. Secondary objectives included comparing 30-day readmission rate, hospital length of stay and antibiotics duration. Results Of 482 included patients, 321 (66.6%) had follow-up blood cultures. 96% of follow-up blood cultures were negative. Persistent bacteremia occurred in 9 patients. There was no significant difference in 30-day mortality between those with and without follow-up blood cultures (2.9% and 2.7% respectively, P > 0.999), and no difference in 30-day readmission rate (21.4% and 23.4% respectively, P = 0.704). Patients with follow-up blood cultures had longer hospital length of stay (7 days vs 5 days, P < 0.001), and longer mean antibiotic duration (14 days vs 11 days, P < 0.001). Conclusion Obtaining follow-up blood cultures in Gram-negative bacteremia had no impact on 30-day mortality or 30-day readmission rates. It was associated with longer length of stay and antibiotic duration. We found this practice to be low yield and its routine use may be of questionable value.
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23
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Shajiei A, Berends MS, Luz CF, van Oers JA, Harmsen HJM, Vos P, Klont R, Loef BG, Reidinga AC, Bormans-Russell L, Linsen K, Dormans T, Otten M, van der Bij A, Beishuizen A, de Lange DW, de Jong E, Nijsten MW. Impact of reduced antibiotic treatment duration on antimicrobial resistance in critically ill patients in the randomized controlled SAPS-trial. Front Med (Lausanne) 2023; 10:1080007. [PMID: 36817782 PMCID: PMC9932263 DOI: 10.3389/fmed.2023.1080007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/09/2023] [Indexed: 02/05/2023] Open
Abstract
Background In the previously reported SAPS trial (https://clinicaltrials.gov/ct2/show/NCT01139489), procalcitonin-guidance safely reduced the duration of antibiotic treatment in critically ill patients. We assessed the impact of shorter antibiotic treatment on antimicrobial resistance development in SAPS patients. Materials and methods Cultures were assessed for the presence of multi-drug resistant (MDR) or highly resistant organisms (HRMO) and compared between PCT-guided and control patients. Baseline isolates from 30 days before to 5 days after randomization were compared with those from 5 to 30 days post-randomization. The primary endpoint was the incidence of new MDR/HRMO positive patients. Results In total, 8,113 cultures with 96,515 antibiotic test results were evaluated for 439 and 482 patients randomized to the PCT and control groups, respectively. Disease severity at admission was similar for both groups. Median (IQR) durations of the first course of antibiotics were 6 days (4-10) and 7 days (5-11), respectively (p = 0.0001). Antibiotic-free days were 7 days (IQR 0-14) and 6 days (0-13; p = 0.05). Of all isolates assessed, 13% were MDR/HRMO positive and at baseline 186 (20%) patients were MDR/HMRO-positive. The incidence of new MDR/HRMO was 39 (8.9%) and 45 (9.3%) in PCT and control patients, respectively (p = 0.82). The time courses for MDR/HRMO development were also similar for both groups (p = 0.33). Conclusions In the 921 randomized patients studied, the small but statistically significant reduction in antibiotic treatment in the PCT-group did not translate into a detectable change in antimicrobial resistance. Studies with larger differences in antibiotic treatment duration, larger study populations or populations with higher MDR/HRMO incidences might detect such differences.
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Affiliation(s)
- Arezoo Shajiei
- Department of Critical Care, University Medical Center Groningen, Groningen, Netherlands,Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands
| | - Matthijs S. Berends
- Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands,Department of Medical Epidemiology, Certe Foundation, Groningen, Netherlands
| | - Christian F. Luz
- Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands
| | - Jos A. van Oers
- Department of Intensive Care, Elisabeth-Tweesteden Ziekenhuis, Tilburg, Netherlands
| | - Hermie J. M. Harmsen
- Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands
| | - Piet Vos
- Department of Intensive Care, Elisabeth-Tweesteden Ziekenhuis, Tilburg, Netherlands
| | - Rob Klont
- Laboratorium Microbiologie Twente Achterhoek, Hengelo, Netherlands
| | - Bert G. Loef
- Department of Intensive Care, Martini Hospital Groningen, Groningen, Netherlands
| | - Auke C. Reidinga
- Department of Intensive Care, Martini Hospital Groningen, Groningen, Netherlands
| | | | - Kitty Linsen
- Department of Intensive Care, Zuyderland Medical Center, Heerlen, Netherlands
| | - Tom Dormans
- Department of Intensive Care, Zuyderland Medical Center, Heerlen, Netherlands
| | - Martine Otten
- Department of Intensive Care, Diakonessenhuis Utrecht, Utrecht, Netherlands
| | - Akke van der Bij
- Department of Microbiology and Immunology, Diakonessenhuis Utrecht, Utrecht, Netherlands
| | | | - Dylan W. de Lange
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Evelien de Jong
- Department of Intensive Care, Beverwijk Hospital, Beverwijk, Netherlands,Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Maarten W. Nijsten
- Department of Critical Care, University Medical Center Groningen, Groningen, Netherlands,*Correspondence: Maarten W. Nijsten ✉
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24
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McDonald EG, Prosty C, Hanula R, Bortolussi-Courval É, Albuquerque AM, Tong SYC, Hamilton F, Lee TC. Observational versus randomized controlled trials to inform antibiotic treatment durations: a narrative review. Clin Microbiol Infect 2023; 29:165-170. [PMID: 36108947 DOI: 10.1016/j.cmi.2022.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies comparing shorter and longer antibiotic treatment durations are increasingly common. Randomized controlled trials (RCTs) are an ideal methodological approach to study antibiotic treatment durations; however, these trials can be logistically and financially challenging to conduct. OBJECTIVES In this narrative review, we sought to compare the strengths and limitations of observational study data with those of RCT data in evaluating antibiotic treatment durations. We used uncomplicated Gram-negative bacteraemia as an illustrative case example because several published RCTs and observational studies have been conducted in similar patient populations. SOURCES We searched MEDLINE for articles comparing treatment durations for gram-negative bacteremia from inception to June 9th, 2022. We included studies reporting on all-cause mortality and/or relapse at day 28-30. Data comparing short- versus long-course therapy were pooled by Bayesian random effects meta-analyses to assess the odds ratios (OR) of all-cause mortality and relapse at 30 days, stratified by study design. Parameters were summarized with median and 95% highest-density credible intervals (CrI). Posterior probabilities of OR > 1.0 were estimated. Observational studies were further examined to determine if and how they addressed potential sources of bias. CONTENT We identified 1671 unique records and included 10 studies (seven observational and three RCTs). With respect to 30-day mortality, the Bayesian posterior probability that a longer course of therapy was better (i.e. OR >1.0) was 42% in RCTs (OR, 0.94; 95% CrI, 0.51-1.68) and 91% in observational studies (OR, 1.25; 95% CrI, 0.88-1.73). No observational study fully addressed all potential sources of bias. IMPLICATIONS On the basis of our findings, we discuss future directions for antibiotic treatment duration trials, including approaches to limit sources of bias in observation data and novel trial designs.
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Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, McGill University Health Centre, Montréal, Québec, Canada; Clinical Practice Assessment Unit, Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada; Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada.
| | - Connor Prosty
- Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Ryan Hanula
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Émilie Bortolussi-Courval
- Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada
| | - Arthur M Albuquerque
- School of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Fergus Hamilton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, United Kingdom; Infection Science, North Bristol NHS Trust, Bristol, United Kingdom
| | - Todd C Lee
- Clinical Practice Assessment Unit, Royal Victoria Hospital, McGill University Health Centre, Montréal, Québec, Canada; Division of Experimental Medicine, Faculty of Medicine and Health Sciences, McGill University, Montréal, Québec, Canada; Division of Infectious Diseases, McGill University Health Centre, Montréal, Québec, Canada
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25
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Turjeman A, von Dach E, Molina J, Franceschini E, Koppel F, Yelin D, Dishon-Benattar Y, Mussini C, Rodríguez-Baño J, Cisneros JM, Huttner A, Paul M, Leibovici L, Yahav D. Duration of antibiotic treatment for Gram-negative bacteremia - Systematic review and individual participant data (IPD) meta-analysis. EClinicalMedicine 2023; 55:101750. [PMID: 36483269 PMCID: PMC9722443 DOI: 10.1016/j.eclinm.2022.101750] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 10/29/2022] [Accepted: 11/01/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND We aim to compare the effect of short versus long treatment duration in Gram-negative bacteremia on all-cause mortality in pre-specified sub-groups. METHODS Individual participant data meta-analysis of randomized controlled trials (RCTs) comparing short (≤7) versus longer (>7 days) antibiotic treatment for Gram-negative bacteremia. Participants were adults (≥18 years), with Gram-negative bacteremia during hospital stay. We searched PubMed, Cochrane Central Register of Controlled Trials, and Web of Science to identify trials conducted up to May 2022. Primary outcome was 90-day all-cause mortality. Secondary outcomes were 30-day mortality, relapse of bacteremia, length of hospital stay, readmission, local or distant infection complications, adverse events, and resistance emergence.Outcomes were assessed in pre-specified subgroups: women vs men; non-urinary vs urinary source; presence vs absence of hypotension on initial presentation; immunocompromised patients versus non-immunocompromised patients, and age (above/below 65). Fixed-effect meta-analysis model was used to estimate pooled odds ratio (OR) and 95% confidence interval (CI). All three trials had low risk of bias for allocation generation and concealment. FINDINGS Three RCTs (1186 patients) were included; 1121 with enterobacterales bacteremia. No significant difference in mortality was demonstrated between 7- and 14-days treatment (90-day mortality: OR 1.08, 95% CI 0.73-1.58; 30-day mortality: 1.08, 0.62-1.91). Relapse (1.00, 0.50-1.97); length of hospital stay (P = 0.78); readmission (0.96, 0.80-1.22); and infection complications (local: 1.62 0.76-3.47; distant: 2.00, 0.18-22.08), were without significant difference, and so were adverse events or resistance emergence.No significant difference in clinical outcomes between 7 and 14 days of antibiotics was demonstrated in the subgroups of gender, age, hemodynamic status, immune status, and source of infection. INTERPRETATION For patients hemodynamically stable and afebrile at 48 h prior to discontinuation, seven days of antibiotic therapy for enterobacterales bacteremia result in similar outcomes as 14 days, in terms of mortality, relapse, length of hospital stay, complications of infection, resistance emergence, and adverse events. These results apply for any adult age group, gender, source of infection, immune status, and hemodynamic status on presentation. FUNDING There was no funding source for this study.
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Affiliation(s)
- Adi Turjeman
- Research Authority, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elodie von Dach
- Faculty of Medicine, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, Clinical Research Center, Geneva University Hospitals, Geneva, Switzerland
| | - José Molina
- Clinical Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
- Center for Biomedical Research Network (CIBER) on Infectious Diseases, Madrid, Spain
| | - Erica Franceschini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Fidi Koppel
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
| | - Dana Yelin
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
| | - Yael Dishon-Benattar
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Cristina Mussini
- Clinic of Infectious Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Jesús Rodríguez-Baño
- Center for Biomedical Research Network (CIBER) on Infectious Diseases, Madrid, Spain
- Clinical Unit of Infectious Diseases and Microbiology, Virgen Macarena University Hospital; Department of Medicine, School of Medicine, University of Seville; and Biomedicine Institute of Seville/CSIC, Seville, Spain
| | - José Miguel Cisneros
- Clinical Unit of Infectious Diseases, Microbiology and Parasitology, Virgen del Rocío University Hospital, Seville, Spain
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
- Center for Biomedical Research Network (CIBER) on Infectious Diseases, Madrid, Spain
| | - Angela Huttner
- Faculty of Medicine, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Leonard Leibovici
- Research Authority, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
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26
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Impact of specialty on the self-reported practice of using oral antibiotic therapy for definitive treatment of bloodstream infections. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2023; 3:e48. [PMID: 36970426 PMCID: PMC10031584 DOI: 10.1017/ash.2023.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 03/11/2023]
Abstract
Abstract
Background:
No established guidelines exist regarding the role of oral antibiotic therapy (OAT) to treat bloodstream infections (BSIs), and practices may vary depending on clinician specialty and experience.
Objective:
To assess practice patterns regarding oral antibiotic use for treatment of bacteremia in infectious diseases clinicians (IDCs, including physicians and pharmacists and trainees in these groups) and non–infectious diseases clinicians (NIDCs).
Design:
Open-access survey.
Participants:
Clinicians caring for hospitalized patients receiving antibiotics.
Methods:
An open-access, web-based survey was distributed to clinicians at a Midwestern academic medical center using e-mail and to clinicians outside the medical center using social media. Respondents answered questions regarding confidence prescribing OAT for BSI in different scenarios. We used χ2 analysis for categorical data evaluated association between responses and demographic groups.
Results:
Of 282 survey responses, 82.6% of respondents were physicians, 17.4% pharmacists, and IDCs represented 69.2% of all respondents. IDCs were more likely to select routine use of OAT for BSI due to gram-negative anaerobes (84.6% vs 59.8%; P < .0001), Klebsiella spp (84.5% vs 69.0%; P < .009), Proteus spp (83.6% vs 71.3%; P < .027), and other Enterobacterales (79.5% vs 60.9%; P < .004). Our survey results revealed significant differences in selected treatment of Staphylococcus aureus syndromes. Fewer IDCs than NIDCs selected OAT to complete treatment for methicillin-resistant S. aureus (MRSA) BSI due to gluteal abscess (11.9% vs 25.6%; P = .012) and methicillin-susceptible S. aureus (MSSA) BSI due to septic arthritis (13.9% vs 20.9%; P = .219).
Conclusions:
Practice variation and discordance with evidence for the use of OAT for BSIs exists among IDCs versus NIDCs, highlighting opportunities for education in both clinician groups.
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27
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Cheong HS, Park KH, Kim HB, Kim SW, Kim B, Moon C, Lee MS, Yoon YK, Jeong SJ, Kim YC, Eun BW, Lee H, Shin JY, Kim HS, Hwang IS, Park CS, Kwon KT. Core Elements for Implementing Antimicrobial Stewardship Programs in Korean General Hospitals. Infect Chemother 2022; 54:637-673. [PMID: 36596679 PMCID: PMC9840955 DOI: 10.3947/ic.2022.0171] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
Currently, antimicrobial resistance (AMR) is a major threat to global public health. The antimicrobial stewardship program (ASP) has been proposed as an important approach to overcome this crisis. ASP supports the optimal use of antimicrobials, including appropriate dosing decisions, administration duration, and administration routes. In Korea, efforts are being made to overcome AMR using ASPs as a national policy. The current study aimed to develop core elements of ASP that could be introduced in domestic medical facilities. A Delphi survey was conducted twice to select the core elements through expert consensus. The core elements for implementing the ASP included (1) leadership commitment, (2) operating system, (3) action, (4) tracking, (5) reporting, and (6) education. To ensure these core elements are present at medical facilities, multiple departments must collaborate as teams for ASP operations. Establishing a reimbursement system and a workforce for ASPs are prerequisites for implementing ASPs. To ensure that ASP core elements are actively implemented in medical facilities, it is necessary to provide financial support for ASPs in medical facilities, nurture the healthcare workforce in performing ASPs, apply the core elements to healthcare accreditation, and provide incentives to medical facilities by quality evaluation criteria.
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Affiliation(s)
- Hae Suk Cheong
- Division of Infectious Diseases, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung-Hwa Park
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Shin-Woo Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Chisook Moon
- Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Mi Suk Lee
- Department of Internal Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Kim
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Wook Eun
- Department of Pediatrics, Nowon Eulji University Hospital, Seoul, Korea
| | - Hyukmin Lee
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji-Yeon Shin
- Department of Preventive Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyung-sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In Sun Hwang
- Korea Institute for Healthcare Accreditation, Seoul, Korea
| | - Choon-Seon Park
- Health Insurance Review and Assessment Research Institute, Health Insurance Review and Assessment Service, Wonju, Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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How to manage central venous catheter-related bloodstream infections due to Gram-negative bacilli? Curr Opin Infect Dis 2022; 35:583-588. [PMID: 35852791 DOI: 10.1097/qco.0000000000000855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to review recent data evaluating the management of central venous catheter-related bloodstream infection due to Gram-negative bacilli (GNB). RECENT FINDINGS The incidence of GNB catheter-related bloodstream infection (CRBSI) has been increasing considerably in the last years, and this has raised a concern due to the high reported rate of multidrug-resistant in these infections what poses a considerable challenge for effective treatment. However, there are no specific guidelines for the management of GNB-CRBSI and optimal treatment duration has not been clearly defined. Recent studies have shown that the risk for complications is clearly different to what is stablished for Staphylococcus aureus . Therefore, a short course of antibiotic therapy might be effective once the central venous catheter (CVC) has been removed and the monitoring complications through control blood cultures or echocardiography seem to be less helpful in GNB CRBSI. SUMMARY The incidence of GNB CRBSI has been increasing considerably in the last years; this has raised a concern due to the high reported rate of MDR in these infections what poses a considerable challenge for effective treatment. However, there are no specific guidelines for the management of GNB-CRBSI and optimal treatment duration has not been clearly defined. Recent studies have shown that the risk for complications is clearly different to what is stablished for S. aureus . Therefore, a short course of antibiotic therapy might be effective once the CVC has been removed and the monitoring complications through control blood cultures or echocardiography seem to be less helpful in GNB-CRBSI.
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Comparison between Short Therapy and Standard Therapy in Pediatric Patients Hospitalized with Urinary Tract Infection: A Single Center Retrospective Analysis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9111647. [PMID: 36360375 PMCID: PMC9688884 DOI: 10.3390/children9111647] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 01/25/2023]
Abstract
Introduction: There is marked heterogeneity in clinicians’ choice of antibiotic duration for pediatric urinary tract infections (UTIs). Most patients with bacterial UTIs still receive between 7 and 10 days of antibiotics. Prolonged antibiotic exposure drives the emergence of resistance and increases the occurrence of adverse effects. There is increasing evidence that shorter antibiotic regimens may be equally effective compared with longer ones. However, studies evaluating shorter therapies in children hospitalized with urinary tract infections have not yet been performed. Methods: We performed a retrospective study comparing children hospitalized with UTIs treated with a short antibiotic (<7 days) or standard antibiotic treatment. The primary aim of our study was to assess the efficacy of a shorter antibiotic therapy for children with UTIs, compared with an historical group of children treated with a standard 7−14 days course. Results: 112 patients, 46 of which were females (41.1%) with a median age 6 months were enrolled. A total of 33 patients (29.5%) underwent a short therapy. All patients were successfully discharged from the acute episode, independently from antibiotic duration. Short therapy was associated with a lower risk of urinary tract relapse (22 relapses (95.6%) in the standard group, 1 (4.4%) in the short group; OR 0.081; 95%CI 0.01−0.63). Conclusions: Short antibiotic therapy was equivalent to standard duration therapy for the cure of UTIs in hospitalized children and was also associated with a lower rate of recurrences. This study provides the basis for a larger prospective randomized study to address the role of short antibiotic therapies in children with UTIs requiring hospitalization
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Imlay H, Spellberg B. Shorter is better: The case for short antibiotic courses for common infections in solid organ transplant recipients. Transpl Infect Dis 2022; 24:e13896. [DOI: 10.1111/tid.13896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/09/2022] [Accepted: 06/17/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Hannah Imlay
- Department of Medicine University of Utah Salt Lake City Utah USA
| | - Brad Spellberg
- Los Angeles County and University of Southern California Medical Center Los Angeles California USA
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The 2021 Dutch Working Party on Antibiotic Policy (SWAB) guidelines for empirical antibacterial therapy of sepsis in adults. BMC Infect Dis 2022; 22:687. [PMID: 35953772 PMCID: PMC9373543 DOI: 10.1186/s12879-022-07653-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The Dutch Working Party on Antibiotic Policy (SWAB) in collaboration with relevant professional societies, has updated their evidence-based guidelines on empiric antibacterial therapy of sepsis in adults. METHODS Our multidisciplinary guideline committee generated ten population, intervention, comparison, and outcome (PICO) questions relevant for adult patients with sepsis. For each question, a literature search was performed to obtain the best available evidence and assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The quality of evidence for clinically relevant outcomes was graded from high to very low. In structured consensus meetings, the committee formulated recommendations as strong or weak. When evidence could not be obtained, recommendations were provided based on expert opinion and experience (good practice statements). RESULTS Fifty-five recommendations on the antibacterial therapy of sepsis were generated. Recommendations on empiric antibacterial therapy choices were differentiated for sepsis according to the source of infection, the potential causative pathogen and its resistance pattern. One important revision was the distinction between low, increased and high risk of infection with Enterobacterales resistant to third generation cephalosporins (3GRC-E) to guide the choice of empirical therapy. Other new topics included empirical antibacterial therapy in patients with a reported penicillin allergy and the role of pharmacokinetics and pharmacodynamics to guide dosing in sepsis. We also established recommendations on timing and duration of antibacterial treatment. CONCLUSIONS Our multidisciplinary committee formulated evidence-based recommendations for the empiric antibacterial therapy of adults with sepsis in The Netherlands.
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Lee IR, Tong SYC, Davis JS, Paterson DL, Syed-Omar SF, Peck KR, Chung DR, Cooke GS, Libau EA, Rahman SNBA, Gandhi MP, Shi L, Zheng S, Chaung J, Tan SY, Kalimuddin S, Archuleta S, Lye DC. Early oral stepdown antibiotic therapy versus continuing intravenous therapy for uncomplicated Gram-negative bacteraemia (the INVEST trial): study protocol for a multicentre, randomised controlled, open-label, phase III, non-inferiority trial. Trials 2022; 23:572. [PMID: 35854360 PMCID: PMC9295110 DOI: 10.1186/s13063-022-06495-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background The incidence of Gram-negative bacteraemia is rising globally and remains a major cause of morbidity and mortality. The majority of patients with Gram-negative bacteraemia initially receive intravenous (IV) antibiotic therapy. However, it remains unclear whether patients can step down to oral antibiotics after appropriate clinical response has been observed without compromising outcomes. Compared with IV therapy, oral therapy eliminates the risk of catheter-associated adverse events, enhances patient quality of life and reduces healthcare costs. As current management of Gram-negative bacteraemia entails a duration of IV therapy with limited evidence to guide oral conversion, we aim to evaluate the clinical efficacy and economic impact of early stepdown to oral antibiotics. Methods This is an international, multicentre, randomised controlled, open-label, phase III, non-inferiority trial. To be eligible, adult participants must be clinically stable / non-critically ill inpatients with uncomplicated Gram-negative bacteraemia. Randomisation to the intervention or standard arms will be performed with 1:1 allocation ratio. Participants randomised to the intervention arm (within 72 h from index blood culture collection) will be immediately switched to an oral fluoroquinolone or trimethoprim-sulfamethoxazole. Participants randomised to the standard arm will continue to receive IV therapy for at least 24 h post-randomisation before clinical re-assessment and decision-making by the treating doctor. The recommended treatment duration is 7 days of active antibiotics (including empiric therapy), although treatment regimen may be longer than 7 days if clinically indicated. Primary outcome is 30-day all-cause mortality, and the key secondary outcome is health economic evaluation, including estimation of total healthcare cost as well as assessment of patient quality of life and number of quality-adjusted life years saved. Assuming a 30-day mortality of 8% in the standard and intervention arms, with 6% non-inferiority margin, the target sample size is 720 participants which provides 80% power with a one-sided 0.025 α-level after adjustment for 5% drop-out. Discussion A finding of non-inferiority in efficacy of oral fluoroquinolones or trimethoprim-sulfamethoxazole versus IV standard of care antibiotics may hypothetically translate to wider adoption of a more cost-effective treatment strategy with better quality of life outcomes. Trial registration ClinicalTrials.govNCT05199324. Registered 20 January 2022. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06495-3.
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Affiliation(s)
- I Russel Lee
- National Centre for Infectious Diseases, Singapore, Singapore.
| | - Steven Y C Tong
- Department of Infectious Diseases, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Joshua S Davis
- School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
| | | | | | | | - Graham S Cooke
- Department of Infectious Diseases, Imperial College London, London, UK
| | | | - Siti-Nabilah B A Rahman
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation, Singapore, Singapore
| | - Mihir P Gandhi
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation, Singapore, Singapore
| | - Luming Shi
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation, Singapore, Singapore
| | - Shuwei Zheng
- Department of Infectious Disease, Sengkang General Hospital, Singapore, Singapore
| | - Jenna Chaung
- Division of Infectious Diseases, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Seow Yen Tan
- Department of Infectious Diseases, Changi General Hospital, Singapore, Singapore
| | - Shirin Kalimuddin
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore.,Programme in Emerging Infectious Diseases, Duke-NUS Medical School, Singapore, Singapore
| | - Sophia Archuleta
- Division of Infectious Diseases, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - David C Lye
- National Centre for Infectious Diseases, Singapore, Singapore. .,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore. .,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore.
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Olson J, Franz-O'Neal E, Cipriano FA, Ou Z, Presson AP, Thorell EA. Impact of Early Oral Antibiotic Therapy in Infants With Bacteremic Urinary Tract Infections. Hosp Pediatr 2022; 12:632-638. [PMID: 35726551 DOI: 10.1542/hpeds.2021-006479] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine the effect of early conversion to oral antibiotics in infants ≤90 days with gram-negative bacteremia and concomitant urinary tract infection on hospital length of stay (LOS) and 30-day revisits for urinary tract infection. DESIGN This retrospective cohort study included infants ≤ 90 days who had concomitant positive blood and urine cultures with gram-negative bacteremia at 22 hospitals from January 1, 2002 through January 31, 2020. Early oral conversion was defined as a maximum intravenous (IV) duration of 4 days. We conducted a noninferiority test to compare early oral conversion to long IV therapy. A propensity score framework was used to assess comparisons in survey-weighted regression models using matched weights. RESULTS Among 174 infants, 73 infants received early oral conversion. The LOS was shorter in infants receiving early oral conversion compared to long IV therapy (median 2 days [interquartile range 2, 3] vs 4 days [3, 5]), descriptively (P < .001) and in noninferiority analysis (ratio = 0.43; 90% CI 0.35, 0.53, P < .001). Thirty-day revisits occurred in 5 of 174 (2.8%) of total patients. Early oral conversion did not meet our noninferiority criteria for the 30-day revisits (odds ratio: 4.22, 90%; confidence interval: 0.83, 21.34, P = .91). CONCLUSIONS Early oral conversion was associated with shorter LOS. The rate of 30-day revisit rates overall was low.
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Affiliation(s)
- Jared Olson
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Utah, Salt Lake City.,Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah, Salt Lake City
| | - Erika Franz-O'Neal
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Utah, Salt Lake City.,Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah, Salt Lake City
| | - Frank A Cipriano
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Utah, Salt Lake City.,Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah, Salt Lake City
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Emily A Thorell
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Utah, Salt Lake City.,Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah, Salt Lake City
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Babich T, Naucler P, Valik JK, Giske CG, Benito N, Cardona R, Rivera A, Pulcini C, Fattah MA, Haquin J, Macgowan A, Grier S, Chazan B, Yanovskay A, Ami RB, Landes M, Nesher L, Zaidman-Shimshovitz A, McCarthy K, Paterson DL, Tacconelli E, Buhl M, Mauer S, Rodríguez-Baño J, de Cueto M, Oliver A, de Gopegui ER, Cano A, Machuca I, Gozalo-Marguello M, Martinez-Martinez L, Gonzalez-Barbera EM, Alfaro IG, Salavert M, Beovic B, Saje A, Mueller-Premru M, Pagani L, Vitrat V, Kofteridis D, Zacharioudaki M, Maraki S, Weissman Y, Paul M, Dickstein Y, Leibovici L, Yahav D. Duration of Treatment for Pseudomonas aeruginosa Bacteremia: a Retrospective Study. Infect Dis Ther 2022; 11:1505-1519. [PMID: 35612693 PMCID: PMC9334465 DOI: 10.1007/s40121-022-00657-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/09/2022] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION There is no consensus regarding optimal duration of antibiotic therapy for Pseudomonas aeruginosa bacteremia. We aimed to evaluate the impact of short antibiotic course. METHODS We present a retrospective multicenter study including patients with P. aeruginosa bacteremia during 2009-2015. We evaluated outcomes of patients treated with short (6-10 days) versus long (11-15 days) antibiotic courses. The primary outcome was a composite of 30-day mortality or bacteremia recurrence and/or persistence. Univariate and inverse probability treatment-weighted (IPTW) adjusted multivariate analysis for the primary outcome was performed. To avoid immortal time bias, the landmark method was used. RESULTS We included 657 patients; 273 received a short antibiotic course and 384 a long course. There was no significant difference in baseline characteristics of patients. The composite primary outcome occurred in 61/384 patients in the long-treatment group (16%) versus 32/273 in the short-treatment group (12%) (p = 0.131). Mortality accounted for 41/384 (11%) versus 25/273 (9%) of cases, respectively. Length of hospital stay was significantly shorter in the short group [median 13 days, interquartile range (IQR) 9-21 days, versus median 15 days, IQR 11-26 days, p = 0.002]. Ten patients in the long group discontinued antibiotic therapy owing to adverse events, compared with none in the short group. On univariate and multivariate analyses, duration of therapy was not associated with the primary outcome. CONCLUSIONS In this retrospective study, 6-10 days of antibiotic course for P. aeruginosa bacteremia were as effective as longer courses in terms of survival and recurrence. Shorter therapy was associated with reduced length of stay and less drug discontinuation.
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Affiliation(s)
- Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Rabin Medical Center, Research Authority, Beilinson Hospital, Petah-Tikva, Israel
| | - Pontus Naucler
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - John Karlsson Valik
- Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Christian G Giske
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Natividad Benito
- Infectious Diseases Unit, Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau - Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ruben Cardona
- Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alba Rivera
- Department of Microbiology, Hospital de la Santa Creu i Sant Pau - Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain
| | - Celine Pulcini
- Université de Lorraine, APEMAC, 54000, Nancy, France.,Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, 54000, Nancy, France
| | - Manal Abdel Fattah
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, 54000, Nancy, France
| | - Justine Haquin
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, 54000, Nancy, France
| | - Alasdair Macgowan
- Department of Infection Sciences, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Sally Grier
- Department of Infection Sciences, Pathology Sciences Building, Southmead Hospital, Bristol, UK
| | - Bibiana Chazan
- Infectious Diseases Unit, Rappaport Faculty of Medicine, Technion, Emek Medical Center, Afula, Haifa, Israel
| | - Anna Yanovskay
- Infectious Diseases Unit, Rappaport Faculty of Medicine, Technion, Emek Medical Center, Afula, Haifa, Israel
| | - Ronen Ben Ami
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Infectious Diseases Unit, Sourasky Medical Center, Tel-Aviv, Israel
| | - Michal Landes
- Infectious Diseases Unit, Sourasky Medical Center, Tel-Aviv, Israel
| | - Lior Nesher
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Adi Zaidman-Shimshovitz
- Infectious Disease Institute, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheba, Israel
| | - Kate McCarthy
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - David L Paterson
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Evelina Tacconelli
- Division of Infectious Diseases, Tuebingen University Hospital, Tuebingen, Germany
| | - Michael Buhl
- Division of Infectious Diseases, Tuebingen University Hospital, Tuebingen, Germany
| | - Susanna Mauer
- Division of Infectious Diseases, Tuebingen University Hospital, Tuebingen, Germany
| | - Jesús Rodríguez-Baño
- Departamentos de Medicina y Microbiología, Unidad Clínica de Enfermedades Infecciosas and Microbiología, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Seville, Spain
| | - Marina de Cueto
- Departamentos de Medicina y Microbiología, Unidad Clínica de Enfermedades Infecciosas and Microbiología, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Seville, Spain
| | - Antonio Oliver
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma, Spain
| | - Enrique Ruiz de Gopegui
- Servicio de Microbiología and Unidad de Investigación, Hospital Universitario Son Espases, Instituto de Investigación Illes Balears (IdISBa), Palma, Spain
| | - Angela Cano
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | - Isabel Machuca
- Infectious Diseases Unit, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Cordoba, Spain
| | | | - Luis Martinez-Martinez
- Microbiology Service, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
| | | | | | - Miguel Salavert
- Infectious Diseases Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Bojana Beovic
- Department of Infectious Diseases, University Medical Centre, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Andreja Saje
- Department of Infectious Diseases, University Medical Centre, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Manica Mueller-Premru
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Leonardo Pagani
- Infectious Diseases Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Virginie Vitrat
- Infectious Diseases Unit, Annecy-Genevois Hospital Center (CHANGE), Annecy, France
| | - Diamantis Kofteridis
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Maria Zacharioudaki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Sofia Maraki
- Infectious Disease Unit, Department of Internal Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Yulia Weissman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mical Paul
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Yaakov Dickstein
- Infectious Diseases Unit, Rambam Health Care Campus, Haifa, Israel
| | - Leonard Leibovici
- Rabin Medical Center, Research Authority, Beilinson Hospital, Petah-Tikva, Israel
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Center, 2 Sheba Road, 52621, Ramat-Gan, Israel.
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Yahav D, Paul M, Van Nieuwkoop C, Huttner A. Is shorter always better? The pros and cons of treating Gram-negative bloodstream infections with 7 days of antibiotics. JAC Antimicrob Resist 2022; 4:dlac058. [PMID: 35719202 PMCID: PMC9201237 DOI: 10.1093/jacamr/dlac058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Accumulating evidence from randomized controlled trials (RCTs) supports 7 days treatment for uncomplicated Gram-negative bacteraemia. However, some patient populations were not well represented in these RCTs, including critically ill patients, immunocompromised patients and those with MDR bacteria. In this debate document, we discuss the pros and cons for treating patients with Gram-negative bacteraemia with a 7 day antibiotic course. We surmise that the patients who were not well represented in the RCTs are probably those who have most to lose from the drawbacks of prolonged antibiotic courses, including adverse events, superinfections and resistance development. Treatment durations among these patients can be managed individually, with C-reactive protein or procalcitonin guidance or by clinical measures, and with care to discontinue antibiotics as soon as the patient recovers clinically from the infection.
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Affiliation(s)
- Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Center , Ramat-Gan , Israel
- Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus , Haifa , Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology , Haifa , Israel
| | - Cees Van Nieuwkoop
- Department of Internal Medicine, Haga Teaching Hospital , The Hague , The Netherlands
| | - Angela Huttner
- Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland
- Centre for Clinical Research, Geneva University , Geneva , Switzerland
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Antimicrobial Treatment Options for Difficult-to-Treat Resistant Gram-Negative Bacteria Causing Cystitis, Pyelonephritis, and Prostatitis: A Narrative Review. Drugs 2022; 82:407-438. [PMID: 35286622 PMCID: PMC9057390 DOI: 10.1007/s40265-022-01676-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 02/06/2023]
Abstract
Urinary tract infections, including cystitis, acute pyelonephritis, and prostatitis, are among the most common diagnoses prompting antibiotic prescribing. The rise in antimicrobial resistance over the past decades has led to the increasing challenge of urinary tract infections because of multidrug-resistant and "difficult-to-treat resistance" among Gram-negative bacteria. Recent advances in pharmacotherapy and medical microbiology are modernizing how these urinary tract infections are treated. Advances in pharmacotherapy have included not only the development and approval of novel antibiotics, such as ceftazidime/avibactam, meropenem/vaborbactam, imipenem/relebactam, ceftolozane/tazobactam, cefiderocol, plazomicin, and glycylcyclines, but also the re-examination of the potential role of legacy antibiotics, including older aminoglycosides and tetracyclines. Recent advances in medical microbiology allow phenotypic and molecular mechanism of resistance testing, and thus antibiotic prescribing can be tailored to the mechanism of resistance in the infecting pathogen. Here, we provide a narrative review on the clinical and pre-clinical studies of drugs that can be used for difficult-to-treat resistant Gram-negative bacteria, with a particular focus on data relevant to the urinary tract. We also offer a pragmatic framework for antibiotic selection when encountering urinary tract infections due to difficult-to-treat resistant Gram-negative bacteria based on the organism and its mechanism of resistance.
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Thaden JT, Tamma PD, Pan Q, Doi Y, Daneman N. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlac005. [PMID: 35156030 PMCID: PMC8827556 DOI: 10.1093/jacamr/dlac005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Trials supporting shorter durations of antibiotic therapy for Gram-negative bloodstream infections (GN-BSI) have recently been published. However, adoption of these findings into practice is unclear given limited eligibility criteria and relatively large non-inferiority margins of these studies. To better understand contemporary management of GN-BSI, we conducted an international survey of infectious diseases (ID) specialists. Methods We developed and disseminated an online survey to assess practice patterns involving treatment duration of GN-BSI, including providers from 28 countries. χ2 tests, t-tests and multivariable linear regression with generalized estimating equations were used to identify factors associated with treatment duration. Results In total, 277 ID specialists completed the survey (64% physicians, 31% pharmacists). The median reported duration of antibiotics was 7 days (IQR, 7–10 days) for all GN-BSI sources. Thirty percent of providers typically recommend durations that differ by ≥7 days depending on the source of GN-BSI, and 71% treat ≥10 days for at least one source. In an adjusted model, factors associated with increased duration included intra-abdominal (+1.01 days, 95% CI 0.57–1.45 days; P < 0.0001), vascular catheter (+0.74 days; 0.33–1.15 days; P = 0.0004), and respiratory (+0.76 days; 0.38–1.14 days; P < 0.0001) sources of GN-BSI relative to urinary sources. Providers that transition patients to oral therapy report shorter durations than those who treat with full IV therapy (−0.60 days; −1.12 to −0.09 days; P = 0.02). Conclusions There is extensive heterogeneity in duration of therapy for treating GN-BSI, particularly with respect to source of GN-BSI. Investigations into appropriate treatment durations for different GN-BSI sources are needed.
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Affiliation(s)
- Joshua T. Thaden
- Division of Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
- Corresponding author. E-mail:
| | - Pranita D. Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Qing Pan
- Department of Statistics, The George Washington University, Washington, DC, USA
| | - Yohei Doi
- Center for Innovative Antimicrobial Therapy, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Departments of Microbiology and Infectious Diseases, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Nick Daneman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Duration of antibiotic therapy for Enterobacterales and Pseudomonas aeruginosa: a review of recent evidence. Curr Opin Infect Dis 2021; 34:693-700. [PMID: 34261907 DOI: 10.1097/qco.0000000000000756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Emergence of multidrug-resistant organisms, impact on intestinal microbiome, side effects and hospital costs are some of the factors that have encouraged multiple studies over the past two decades to evaluate different duration of antibiotic therapy with the goal of shorter but effective regimens. Here, we reviewed the most recent relevant data on the duration of therapy focused on two of the most common Gram-negative organisms in clinical practice, Pseudomonas aeruginosa and Enterobacterales. RECENT FINDINGS Recent studies including meta-analysis confirm that short antibiotic courses for both Enterobacterales and P. aeruginosa infections have comparable clinical outcomes to longer courses of therapy. Despite the advocacy for short-course therapy in contemporary guidelines, recent evidence in the USA has revealed a high prevalence of inappropriate antibiotic usage due to excessive duration of therapy. SUMMARY Although the decision process regarding the optimal duration of antibiotic therapy is multifactorial, the vast majority of infections other than endocardial or bone and joint, can be treated with short-course antibiotic therapy (i.e., ≤7 days). The combination of biomarkers, clinical response to therapy, and microbiologic clearance help determine the optimal duration in patients with infections caused by P. aeruginosa and Enterobacterales.
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Lee CC, Ho CY, Chen PL, Hsieh CC, Wang WYC, Lin CH, Ko WC. Is qSOFA Suitable for Early Diagnosis of Sepsis Among Bacteremia Patients in Emergency Departments? Time for a Reappraisal of Sepsis-3 Criteria. Front Med (Lausanne) 2021; 8:743822. [PMID: 34746178 PMCID: PMC8563787 DOI: 10.3389/fmed.2021.743822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/20/2021] [Indexed: 12/20/2022] Open
Abstract
Background: For early recognition of patients with sepsis, quick Sequential Organ Failure Assessment (qSOFA) was proposed by Sepsis-3 criteria as initial sepsis identification outside of intensive care units. However, the new definition has subsequently led to controversy and prompted much discussion for delayed treatment efforts. We aimed to validate Sepsis-3 criteria on bacteremia patients by investigating prognostic impacts of inappropriate administration of empirical antimicrobial therapy (EAT) and delayed source control (SC) compared to Sepsis-2 criteria. Methods: In the multicenter cohort of adults with community-onset bacteremia in emergency departments (EDs), adverse effects of delayed treatment efforts on 30-day mortality were examined in septic and non-septic patients by fulfilling the Sepsis-2 or Sepsis-3 criteria using the Cox regression model after adjusting independent determinants of mortality. Results: Of the 3,898 total adults, septic patients accounted for 92.8% (3,619 patients) by Sepsis-2 criteria (i.e., SIRS criteria). Using Sepsis-3 criteria, 1,827 (46.9%) patients were diagnosed with early sepsis (i.e., initial qSOFA scores ≥ 2) in EDs and 2,622 (67.3%) with sepsis during hospitalization (i.e., increased SOFA scores of ≥ 2 from ED arrival). The prognostic impacts of inappropriate EAT or delayed SC (for complicated bacteremia) were both significant in septic patients with fulfilling the Sepsis-2 or Sepsis-3 (i.e., SOFA) criteria, respectively. Meanwhile, these delayed treatment efforts trivially impact prognoses of non-septic patients recognized by the Sepsis-2 or Sepsis-3 (i.e., SOFA) definitions. Notably, prognostic effects of inappropriate EAT or delayed SC were disclosed for septic patients in EDs, specifically those with qSOFA scores of ≥ 2, and prognostic impacts of delayed treatment efforts remained significant for patients initially recognized early as being non-septic (i.e., initial qSOFA scores of <2). Conclusions: For patients with community-onset bacteremia, inappropriate EAT and delayed SC might result in unfavorable outcomes of patients early identified as being non-septic on ED arrival based on the qSOFA scores (by Sepsis-3 criteria). Accordingly, a more prudent diagnosis of sepsis adopted among bacteremia patients in the ED is necessary.
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Affiliation(s)
- Ching-Chi Lee
- Clinical Medicine Research Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ching-Yu Ho
- Department of Adult Critical Care Medicine, Tainan Sin-Lau Hospital, Tainan, Taiwan
| | - Po-Lin Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Chia Hsieh
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Chih-Hao Lin
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wen-Chien Ko
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Heil EL, Bork JT, Abbo LM, Barlam TF, Cosgrove SE, Davis A, Ha DR, Jenkins TC, Kaye KS, Lewis JS, Ortwine JK, Pogue JM, Spivak ES, Stevens MP, Vaezi L, Tamma PD. Optimizing the Management of Uncomplicated Gram-Negative Bloodstream Infections: Consensus Guidance Using a Modified Delphi Process. Open Forum Infect Dis 2021; 8:ofab434. [PMID: 34738022 PMCID: PMC8561258 DOI: 10.1093/ofid/ofab434] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 08/19/2021] [Indexed: 12/24/2022] Open
Abstract
Background Guidance on the recommended durations of antibiotic therapy, the use of oral antibiotic therapy, and the need for repeat blood cultures remain incomplete for gram-negative bloodstream infections. We convened a panel of infectious diseases specialists to develop a consensus definition of uncomplicated gram-negative bloodstream infections to assist clinicians with management decisions. Methods Panelists, who were all blinded to the identity of other members of the panel, used a modified Delphi technique to develop a list of statements describing preferred management approaches for uncomplicated gram-negative bloodstream infections. Panelists provided level of agreement and feedback on consensus statements generated and refined them from the first round of open-ended questions through 3 subsequent rounds. Results Thirteen infectious diseases specialists (7 physicians and 6 pharmacists) from across the United States participated in the consensus process. A definition of uncomplicated gram-negative bloodstream infection was developed. Considerations cited by panelists in determining if a bloodstream infection was uncomplicated included host immune status, response to therapy, organism identified, source of the bacteremia, and source control measures. For patients meeting this definition, panelists largely agreed that a duration of therapy of ~7 days, transitioning to oral antibiotic therapy, and forgoing repeat blood cultures, was reasonable. Conclusions In the absence of professional guidelines for the management of uncomplicated gram-negative bloodstream infections, the consensus statements developed by a panel of infectious diseases specialists can provide guidance to practitioners for a common clinical scenario.
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Affiliation(s)
- Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Jacqueline T Bork
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Lilian M Abbo
- Department of Medicine, University of Miami Miller School of Medicine, Jackson Health System, Miami, Florida, USA
| | - Tamar F Barlam
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sara E Cosgrove
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Angelina Davis
- Division of Infectious Diseases, Duke Antimicrobial Stewardship Outreach Network, Durham, North Carolina, USA
| | - David R Ha
- Department of Quality and Patient Safety, Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | | | - Keith S Kaye
- Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James S Lewis
- Department of Pharmacy, Oregon Health and Science University, Portland, Oregon, USA
| | - Jessica K Ortwine
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA
| | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Emily S Spivak
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael P Stevens
- Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Liza Vaezi
- Department of Pharmacy, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Avni-Nachman S, Yahav D, Nesher E, Rozen-Zvi B, Rahamimov R, Mor E, Ben-Zvi H, Milo Y, Atamna A, Green H. Short versus prolonged antibiotic treatment for complicated urinary tract infection after kidney transplantation. Transpl Int 2021; 34:2686-2695. [PMID: 34668610 DOI: 10.1111/tri.14144] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/14/2021] [Accepted: 10/10/2021] [Indexed: 01/12/2023]
Abstract
There is no consensus regarding the optimal duration of antibiotic therapy for urinary tract infection (UTI) following kidney transplantation (KT). We performed a retrospective study comparing short (6-10 days) versus prolonged (11-21 days) antibiotic therapy for complicated UTI among KT recipients. Univariate and inverse probability treatment weighted (IPTW) adjusted multivariate analysis for composite primary outcome of all-cause mortality or readmissions within 30 days and relapsed UTI 180 days were performed. Overall, 214 KT recipients with complicated UTI were included; 115 short-course treatment (median 8, interquartile range [IQR] 6-9 days), 99 prolonged course (median 14, IQR 12-21 days). The composite outcome occurred in 33 (28.6%) in the short-course group and 30 (30%) in the prolonged-course group; relapsed UTI occurred in 19 (16.5%) vs. 21 (21%), respectively. Duration of antibiotic treatment was not associated with any of these outcomes. The only risk factor for mortality/readmissions in multivariate analysis was deceased donor. No differences between groups were demonstrated for length of hospital stay, rates of bacteraemia, resistance development, and serum creatinine at 30 and 90 days. In conclusion, we found no difference in clinical outcomes between KT recipients treated for complicated UTI with short-course antibiotic (6-10 days) versus longer course (11-21 days).
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Affiliation(s)
| | - Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eviatar Nesher
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Transplant Department, Rabin Medical Center, Petah-Tikva, Israel
| | - Benaya Rozen-Zvi
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel
| | - Ruth Rahamimov
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Transplant Department, Rabin Medical Center, Petah-Tikva, Israel.,Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel
| | - Eytan Mor
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Surgery and Transplantation, Transplant Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Haim Ben-Zvi
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Microbiology Laboratory, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | - Yaniv Milo
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alaa Atamna
- Infectious Diseases Unit, Rabin Medical Center, Petah-Tikva, Israel
| | - Hefziba Green
- Department of Medicine B, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel
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Bae M, Jeong Y, Bae S, Kim MJ, Chong YP, Kim SH, Lee SO, Choi SH, Kim YS, Jung J. Short versus prolonged courses of antimicrobial therapy for patients with uncomplicated Pseudomonas aeruginosa bloodstream infection: a retrospective study. J Antimicrob Chemother 2021; 77:223-228. [PMID: 34590681 DOI: 10.1093/jac/dkab358] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/30/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The optimal duration of antimicrobial therapy for uncomplicated Pseudomonas aeruginosa bloodstream infection (BSI) is unknown. We compared the outcomes of short and prolonged courses of antimicrobial therapy in adults with uncomplicated pseudomonal BSI. METHODS All patients with uncomplicated P. aeruginosa BSI admitted at a tertiary-care hospital from April 2010 to April 2020 were included. We compared the primary outcome (a composite of the rate of recurrent P. aeruginosa infection and mortality within 30 days after discontinuing antimicrobial therapy) among patients who underwent short (7‒11 days) and prolonged (12‒21 days) courses of antimicrobial therapy using propensity score analysis with the inverse probability of treatment weighting (IPTW) method. RESULTS We evaluated 1477 patients with P. aeruginosa BSI; of them, 290 met the eligibility criteria who received antimicrobial agents with in vitro activity, including 97 (33%) who underwent short-course therapy [median of 9 (IQR = 8‒11) days] and 193 (67%) who underwent prolonged-course therapy [median of 15 (IQR = 14‒18) days]. We found no significant difference in the risk of recurrence or 30 day mortality between the prolonged-course and short-course groups [n = 30 (16%) versus n = 11 (11%); IPTW-adjusted HR = 0.68, 95% CI = 0.34 - 1.36, P = 0.28]. The prolonged-course therapy did not significantly reduce the risk of the recurrence of P. aeruginosa infection within 180 days compared with short-course therapy [n = 37 (19%) versus n = 12 (12%); IPTW-adjusted HR = 0.57, 95% CI = 0.29 - 1.10, P = 0.09]. CONCLUSIONS Short-course antimicrobial therapy could be as effective as prolonged-course therapy for uncomplicated P. aeruginosa BSI.
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Affiliation(s)
- Moonsuk Bae
- Division of Infectious Disease, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yunseo Jeong
- University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seongman Bae
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Molina J, Montero-Mateos E, Praena-Segovia J, León-Jiménez E, Natera C, López-Cortés LE, Valiente L, Rosso-Fernández CM, Herrero M, Aller-García AI, Cano Á, Gutiérrez-Gutiérrez B, Márquez-Gómez I, Álvarez-Marín R, Infante C, Roca C, Valiente-Méndez A, Pachón J, Reguera JM, Corzo-Delgado JE, Torre-Cisneros J, Rodríguez-Baño J, Cisneros JM. Seven-versus 14-day course of antibiotics for the treatment of bloodstream infections by Enterobacterales: a randomized, controlled trial. Clin Microbiol Infect 2021; 28:550-557. [PMID: 34508886 DOI: 10.1016/j.cmi.2021.09.001] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To prove that 7-day courses of antibiotics for bloodstream infections caused by members of the Enterobacterales (eBSIs) allow a reduction in patients' exposure to antibiotics while achieving clinical outcomes similar to those of 14-day schemes. METHODS A randomized trial was performed. Adult patients developing eBSI with appropriate source control were assigned to 7 or 14 days of treatment, and followed 28 days after treatment cessation; treatments could be resumed whenever necessary. The primary endpoint was days of treatment at the end of follow-up. Clinical outcomes included clinical cure, relapse of eBSI and relapse of fever. A superiority margin of 3 days was set for the primary endpoint, and a non-inferiority margin of 10% was set for clinical outcomes. Efficacy and safety were assessed together with a DOOR/RADAR (desirability of outcome ranking and response adjusted for duration of antibiotic risk) analysis. RESULTS 248 patients were assigned to 7 (n = 119) or 14 (n = 129) days of treatment. In the intention-to-treat analysis, median days of treatment at the end of follow-up were 7 and 14 days (difference 7, 95%CI 7-7). The non-inferiority margin was also met for clinical outcomes, except for relapse of fever (-0.2%, 95%CI -10.4 to 10.1). The DOOR/RADAR showed that 7-day schemes had a 77.7% probability of achieving better results than 14-day treatments. CONCLUSIONS 7-day schemes allowed a reduction in antibiotic exposure of patients with eBSI while achieving outcomes similar to those of 14-day schemes. The possibility of relapsing fever in a limited number of patients, without relevance to final outcomes, may not be excluded, but was overcome by the benefits of shortening treatments.
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Affiliation(s)
- José Molina
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Enrique Montero-Mateos
- Department of Pathology and Institute of Biomedical Research of Salamanca (IBSAL), University Hospital of Salamanca, Salamanca, Spain
| | - Julia Praena-Segovia
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Eva León-Jiménez
- Unit of Infectious Diseases and Microbiology, Virgen de Valme University Hospital, Seville, Spain
| | - Clara Natera
- Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Service of Infectious Diseases. Reina Sofia University Hospital, Córdoba, Spain
| | - Luis E López-Cortés
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Clinical Unit of Infectious Diseases and Microbiology, Virgen Macarena University Hospital, Seville, Spain
| | - Lucía Valiente
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Málaga Regional University Hospital, Málaga, Spain
| | - Clara M Rosso-Fernández
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Spanish Clinical Research Network, Virgen del Rocío University Hospital, Seville, Spain
| | - Marta Herrero
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Ana I Aller-García
- Unit of Infectious Diseases and Microbiology, Virgen de Valme University Hospital, Seville, Spain
| | - Ángela Cano
- Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Service of Infectious Diseases. Reina Sofia University Hospital, Córdoba, Spain
| | - Belén Gutiérrez-Gutiérrez
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Clinical Unit of Infectious Diseases and Microbiology, Virgen Macarena University Hospital, Seville, Spain
| | - Ignacio Márquez-Gómez
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Málaga Regional University Hospital, Málaga, Spain
| | - Rocío Álvarez-Marín
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Carmen Infante
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Cristina Roca
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain
| | - Adoración Valiente-Méndez
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Clinical Unit of Infectious Diseases and Microbiology, Virgen Macarena University Hospital, Seville, Spain
| | - Jerónimo Pachón
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Department of Medicine, University of Seville, Seville, Spain
| | - José María Reguera
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Málaga Regional University Hospital, Málaga, Spain
| | | | - Julián Torre-Cisneros
- Maimonides Institute for Research in Biomedicine of Córdoba (IMIBIC), Service of Infectious Diseases. Reina Sofia University Hospital, Córdoba, Spain; Department of Medical and Surgical Sciences, University of Córdoba (UCO), Córdoba, Spain
| | - Jesús Rodríguez-Baño
- Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Clinical Unit of Infectious Diseases and Microbiology, Virgen Macarena University Hospital, Seville, Spain; Department of Medicine, University of Seville, Seville, Spain
| | - José Miguel Cisneros
- Unit of Infectious Diseases, Microbiology and Preventive Medicine, Virgen del Rocío University Hospital, Seville, Spain; Institute of Biomedicine of Seville (IBiS), Virgen del Rocío and Virgen Macarena University Hospitals/CSIC/University of Seville, Seville, Spain; Department of Medicine, University of Seville, Seville, Spain.
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Grant J, Saux NL. Duration of antibiotic therapy for common infections. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2021; 6:181-197. [PMID: 36337760 PMCID: PMC9615468 DOI: 10.3138/jammi-2021-04-29] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 04/29/2021] [Indexed: 06/16/2023]
Affiliation(s)
- Jennifer Grant
- Division of Medical Microbiology and Infectious Diseases, Vancouver General Hospital, Vancouver Costal Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicole Le Saux
- Division of Infectious Diseases, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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StenoSCORE: Predicting Stenotrophomonas maltophilia Bloodstream Infections in the Hematologic Malignancy Population. Antimicrob Agents Chemother 2021; 65:e0079321. [PMID: 34060899 DOI: 10.1128/aac.00793-21] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Stenotrophomonas maltophilia bloodstream infections (BSI) are associated with considerable mortality in the hematologic malignancy population. Trimethoprim-sulfamethoxazole (TMP-SMX) is the treatment of choice; however, it is not routinely included in empirical treatment regimens, both because of its adverse event profile and the relative rarity of S. maltophilia infections. We developed a risk score to predict hematologic malignancy patients at increased risk for S. maltophilia BSI to guide early (TMP-SMX) therapy. Patients ≥12 years of age admitted to five hospitals between July 2016 and December 2019 were included. Two separate risk scores were developed, (i) a "knowledge-driven" risk score based upon previously identified risk factors in the literature in addition to variables identified by regression analysis using the current cohort, and (ii) a risk score based upon automatic variable selection. For both scores, discrimination (receiver operator characteristic [ROC] curves and C statistics) and calibration (Hosmer-Lemeshow goodness-of-fit test and graphical calibration plots) were assessed. Internal validation was assessed using leave-one-out cross-validation. In total, 337 unique patients were included; 21 (6.2%) had S. maltophilia BSI. The knowledge-driven risk score (acute leukemia, absolute neutrophil count category, mucositis, central line, and ≥3 days of carbapenem therapy) had superior performance (C statistic = 0.75; 0.71 after cross-validation) compared to that of the risk score utilizing automatic variable selection (C statistic = 0.63; 0.38 after cross-validation). A user-friendly risk score incorporating five variables easily accessible to clinicians performed moderately well to predict hematologic malignancy patients at increased risk for S. maltophilia BSI. External validation using a larger cohort is necessary to create a refined risk score before broad clinical application.
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Abstract
PURPOSE OF REVIEW The potential benefits on antimicrobial resistance emergence, incidence of antibiotic-related adverse effects, and health costs have pushed to shorten therapeutic courses for Gram-negative bacilli (GNB) infections. However, the safety of this approach is still under investigation. This review gathers recent contributions to the evaluation of the impact on antimicrobial resistance and clinical outcome of shorter therapeutic courses against GNB infections, and highlights data on the modern approach of adjustable antibiotic duration. RECENT FINDINGS Recent advances include data on the safety of 7-day treatment of uncomplicated Enterobacteriaceae bloodstream infections with favorable early 48-h evolution. A promising innovative approach with individualized treatment duration arises, supported by recently published results on GNB bacteremia evaluating fixed antibiotic durations and an adaptive antibiotic duration driven by blood levels of C-reactive protein. SUMMARY Recent literature illustrates a strong trend towards shortened antibiotic durations in GNB infections, illustrated by lately published data in GNB bacteremia and ongoing studies in GNB ventilator-associated pneumonia. However, short antibiotic course for specific situations, such as immunodeficiency, drug-resistance, and inadequate source control should be handled with caution because of lack of supportive data.
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Shapiro DJ, Hall M, Lipsett SC, Hersh AL, Ambroggio L, Shah SS, Brogan TV, Gerber JS, Williams DJ, Grijalva CG, Blaschke AJ, Neuman MI. Short- Versus Prolonged-Duration Antibiotics for Outpatient Pneumonia in Children. J Pediatr 2021; 234:205-211.e1. [PMID: 33745996 DOI: 10.1016/j.jpeds.2021.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/15/2021] [Accepted: 03/11/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To identify practice patterns in the duration of prescribed antibiotics for the treatment of ambulatory children with community-acquired pneumonia (CAP) and to compare the frequency of adverse clinical outcomes between children prescribed short-vs prolonged-duration antibiotics. STUDY DESIGN We performed a retrospective cohort study from 2010-2016 using the IBM Watson MarketScan Medicaid Database, a claims database of publicly insured patients from 11 states. We included children 1-18 years old with outpatient CAP who filled a prescription for oral antibiotics (n = 121 846 encounters). We used multivariable logistic regression to determine associations between the duration of prescribed antibiotics (5-9 days vs 10-14 days) and subsequent hospitalizations, new antibiotic prescriptions, and acute care visits. Outcomes were measured during the 14 days following the end of the dispensed antibiotic course. RESULTS The most commonly prescribed duration of antibiotics was 10 days (82.8% of prescriptions), and 10.5% of patients received short-duration therapy. During the follow-up period, 0.2% of patients were hospitalized, 6.2% filled a new antibiotic prescription, and 5.1% had an acute care visit. Compared with the prolonged-duration group, the aORs for hospitalization, new antibiotic prescriptions, and acute care visits in the short-duration group were 1.16 (95% CI 0.80-1.66), 0.93 (95% CI 0.85-1.01), and 1.06 (95% CI 0.98-1.15), respectively. CONCLUSIONS Most children treated for CAP as outpatients are prescribed at least 10 days of antibiotic therapy. Among pediatric outpatients with CAP, no significant differences were found in rates of adverse clinical outcomes between patients prescribed short-vs prolonged-duration antibiotics.
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Affiliation(s)
- Daniel J Shapiro
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA.
| | | | - Susan C Lipsett
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, UT
| | - Lilliam Ambroggio
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, CO
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medicine Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Thomas V Brogan
- Division of Critical Care, Seattle Children's Hospital, Seattle, WA; Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Carlos G Grijalva
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN
| | - Anne J Blaschke
- Sections of Emergency Medicine and Hospital Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Denver, CO
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
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Ruiz-Ruigómez M, Fernández-Ruiz M, San-Juan R, López-Medrano F, Orellana MÁ, Corbella L, Rodríguez-Goncer I, Hernández Jiménez P, Aguado JM. Impact of duration of antibiotic therapy in central venous catheter-related bloodstream infection due to Gram-negative bacilli. J Antimicrob Chemother 2021; 75:3049-3055. [PMID: 32591804 DOI: 10.1093/jac/dkaa244] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND A progressive increase in the incidence of catheter-related bloodstream infection (CRBSI) due to Gram-negative bacilli (GNB) has been reported. Current guidelines recommend antibiotic treatment for at least 7-14 days, although the supporting evidence is limited. METHODS We performed a retrospective single-centre study including all patients with a definite diagnosis of GNB CRBSI from January 2012 to October 2018 in which the central venous catheter (CVC) was removed. The occurrence of therapeutic failure [clinical failure (persistence of symptoms and laboratory signs of infection), microbiological failure (persistent bacteraemia or relapse) and/or all-cause 30 day mortality] was compared between episodes receiving short [≤7 days (SC)] or long courses [>7 days (LC)] of appropriate antibiotic therapy following CVC removal. RESULTS We included 54 GNB CRBSI episodes with an overall rate of therapeutic failure of 27.8% (15/54). Episodes receiving SC therapy were more frequently due to MDR GNB [60.9% (14/23) versus 34.5% (10/29); P = 0.058] and had higher Pitt scores [median (IQR) 1 (0-4) versus 0 (0-2); P = 0.086]. There were no significant differences in the rate of therapeutic failure between episodes treated with SC or LC therapy [30.4% (7/23) versus 27.6% (8/29); OR 1.15; 95% CI 0.34-3.83; P = 0.822]. The use of SCs was not associated with increased odds of therapeutic failure in any of the exploratory models performed. CONCLUSIONS The administration of appropriate antibiotic therapy for ≤7 days may be as safe and effective as longer courses in episodes of GNB CRBSI once the CVC has been removed.
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Affiliation(s)
- María Ruiz-Ruigómez
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - Rafael San-Juan
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - María Ángeles Orellana
- Department of Microbiology, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - Laura Corbella
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - Isabel Rodríguez-Goncer
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - Pilar Hernández Jiménez
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Hospital Universitario '12 de Octubre', Instituto de Investigación Hospital '12 de Octubre' (imas12), Madrid, Spain
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Walsh TL, Bremmer DN, Moffa MA, Trienski TL, Buchanan C, Stefano K, Hand C, Taylor T, Kasarda K, Shively NR, Bhanot N, Cheronis N, DiSilvio BE, Cho CY, Carr DR. Impact of an Antimicrobial Stewardship Program-bundled initiative utilizing Accelerate Pheno™ system in the management of patients with aerobic Gram-negative bacilli bacteremia. Infection 2021; 49:511-519. [PMID: 33528813 PMCID: PMC8159835 DOI: 10.1007/s15010-021-01581-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/18/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Gram-negative bacteria (GNB) are a leading cause of bloodstream infections (BSI) and management is complicated by antibiotic resistance. The Accelerate Pheno™ system (ACC) can provide rapid organism identification and antimicrobial susceptibility testing (AST). METHODS A retrospective, pre-intervention/post-intervention study was conducted to compare management of non-critically ill patients with GNB BSI before and after implementation of a bundled initiative. This bundled initiative included dissemination of a clinical decision algorithm, ACC testing on all GNB isolated from blood cultures, real-time communication of results to the Antimicrobial Stewardship Program (ASP), and prospective audit with feedback by the ASP. The pre-intervention period was January 2018 through December 2018, and the post-intervention period was May 2019 through February 2020. RESULTS Seventy-seven and 129 patients were included in the pre-intervention and post-intervention cohorts, respectively. When compared with the pre-intervention group, the time from Gram stain to AST decreased from 46.1 to 6.9 h (p < 0.001), and the time to definitive therapy (TTDT) improved from 32.6 to 10.5 h (p < 0.001). Implementation led to shorter median total duration of antibiotic therapy (14.2 vs 9.5 days; p < 0.001) and mean hospital length of stay (7.9 vs 5.3 days; p = 0.047) without an increase in 30-day readmissions (22.1% vs 14%; p = 0.13). CONCLUSION Implementation of an ASP-bundled approach incorporating the ACC aimed at optimizing antibiotic therapy in the management GNB BSI in non-critically ill patients led to reduced TTDT, shorter duration of antibiotic therapy, and shorter hospital length of stay without adversely affecting readmission rates.
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Affiliation(s)
- Thomas L Walsh
- Medicine Institute and Division of Infectious Diseases, Allegheny Health Network, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA.
| | - Derek N Bremmer
- Department of Pharmacy, Allegheny Health Network, Pittsburgh, PA, USA
| | - Matthew A Moffa
- Medicine Institute and Division of Infectious Diseases, Allegheny Health Network, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA.
| | - Tamara L Trienski
- Department of Pharmacy, Allegheny Health Network, Pittsburgh, PA, USA
| | - Carley Buchanan
- Department of Pharmacy, Allegheny Health Network, Pittsburgh, PA, USA
| | - Kelly Stefano
- Department of Microbiology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Catharine Hand
- Department of Microbiology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Tricia Taylor
- Department of Microbiology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Karen Kasarda
- Department of Microbiology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Nathan R Shively
- Medicine Institute and Division of Infectious Diseases, Allegheny Health Network, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA
| | - Nitin Bhanot
- Medicine Institute and Division of Infectious Diseases, Allegheny Health Network, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA
| | - Nicholas Cheronis
- Medicine Institute and Division of Infectious Diseases, Allegheny Health Network, Allegheny General Hospital, 320 East North Ave. East Wing Office Building, Suite 406, Pittsburgh, PA, 15212, USA
- Medicine Institute and Division of Pulmonary and Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Briana E DiSilvio
- Medicine Institute and Division of Pulmonary and Critical Care Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Christian Y Cho
- Department of Pharmacy, Allegheny Health Network, Pittsburgh, PA, USA
| | - Dustin R Carr
- Department of Pharmacy, Allegheny Health Network, Pittsburgh, PA, USA
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