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Escrihuela-Vidal F, Palacios-Baena ZR, Agirre JG, Pérez-Rodríguez MT, Reguera Iglesias JM, Cuquet Pedragosa J, Sánchez Gómez L, Boix-Palop L, Bahamonde Carrasco A, Natera-Kindelán C, Fernández-Suárez J, Jover-Sáenz A, Smithson Amat A, Del Arco Jiménez A, Sánchez Calvo JM, Martín-Aspas A, Martínez Pérez-Crespo PM, López-Hernández I, Rodríguez-Baño J, López-Cortés LE. Early Antibiotic De-escalation in Patients With Severe Infections Due to Bloodstream Infection by Enterobacterales: A Post Hoc Analysis of a Prospective Multicentre Cohort. Int J Antimicrob Agents 2024; 64:107317. [PMID: 39233214 DOI: 10.1016/j.ijantimicag.2024.107317] [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: 04/25/2024] [Revised: 08/16/2024] [Accepted: 08/26/2024] [Indexed: 09/06/2024]
Abstract
BACKGROUND Data about antibiotic de-escalation in sepsis associated with the bloodstream and caused by Enterobacterales are scarce. The objectives of this study are to identify factors associated with early de-escalation and to analyse the impact of de-escalation on mortality in patients with Enterobacterales bloodstream infection (BSI) with a Sequential Organ Failure Assessment (SOFA) score ≥ 2. METHODS A prospective, multicentre cohort study was performed including episodes of BSI due to Enterobacterales and a SOFA score ≥ 2 who were receiving an active antipseudomonal β-lactam; the isolate should be susceptible to at least 1 narrower-spectrum antibiotic. Variables associated with de-escalation were identified using logistic binary regression. The association of de-escalation with 30-day mortality was investigated. Confounding was controlled by calculating a propensity score used as covariate, as matching variable, and for inverse probability treatment weighting. RESULTS Of the 582 patients included, de-escalation was performed in 311 (53.4%). Neutropenia (adjusted odds ratio [aOR] = 0.37; 95% confidence interval [95% CI] = 0.18-0.75), central venous catheter (aOR = 0.52; 95% CI = 0.32-0.83), and extended-spectrum β-lactamase (ESBL)-producing isolate (aOR = 0.28; 95% CI = 0.17-0.48) were negatively associated with de-escalation, and urinary tract source was positively associated (aOR = 2.27; 95% CI = 1.56-3.33). The 30-day mortality was 6.8% (21 patients) in de-escalated patients and 14.4% (39) in not de-escalated patients (relative risk, 0.63; 95% CI = 0.44-0.89). In multivariate analysis including the propensity score, de-escalation was not associated with mortality (AOR = 0.98; 95% CI = 0.39-2.47) and was protective in the case of urinary or biliary tract source (AOR = 0.31, 95% CI = 0.09-1.06). Matched and inverse probability treatment weighting analysis showed similar results. CONCLUSIONS These results suggest that early de-escalation from antipseudomonal β-lactams is safe in patients with Enterobacterales bacteremia and SOFA ≥ 2.
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Affiliation(s)
- Francesc Escrihuela-Vidal
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, IDIBELL (Institut d´Investigació Biomèdica de Bellvitge), University of Barcelona, Barcelona, Spain
| | - Zaira R Palacios-Baena
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; Hospital Universitario Virgen Macarena, and Departamento de Medicina, Universidad de Sevilla, Seville, Spain; CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | | | | | | | - Jordi Cuquet Pedragosa
- Departamento de Medicina Interna, Hospital Universitario de Granollers, Granollers, Spain
| | - Leticia Sánchez Gómez
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Hospital Universitario de Burgos, Burgos, Spain
| | - Lucía Boix-Palop
- Servicio de Enfermedades Infecciosas, Hospital Universitari Mútua de Terrassa, Barcelona, Spain
| | | | - Clara Natera-Kindelán
- Unidad Clínica de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Jonathan Fernández-Suárez
- Unidad de Microbiología, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Hospital Universitario Central de Asturias, Oviedo
| | - Alfredo Jover-Sáenz
- Unidad Funcional de Infecciones Nosocomiales, Hospital Arnau de Vilanova, Lérida, Spain
| | - Alejandro Smithson Amat
- Unidad de Medicina Interna, Fundació Hospital de l'Esperit Sant, Santa Coloma de Gramenet, Spain
| | - Alfonso Del Arco Jiménez
- Grupo Enfermedades Infecciosas, Servicio de Medicina Interna, Hospital Universitario Costa del Sol, Marbella, Málaga, Spain
| | - Juan Manuel Sánchez Calvo
- Hospital Universitario de Jerez, Jerez de la Frontera, Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Universidad de Cádiz, Cadiz, Spain
| | - Andrés Martín-Aspas
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Facultad de Medicina, Hospital Universitario Puerta del Mar, Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Universidad de Cádiz, Cadiz, Spain
| | | | - Inmaculada López-Hernández
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; Hospital Universitario Virgen Macarena, and Departamento de Medicina, Universidad de Sevilla, Seville, Spain; CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; Hospital Universitario Virgen Macarena, and Departamento de Medicina, Universidad de Sevilla, Seville, Spain; CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS)/CSIC; Hospital Universitario Virgen Macarena, and Departamento de Medicina, Universidad de Sevilla, Seville, Spain; CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain.
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Huo X, Liu P. An agent-based model on antimicrobial de-escalation in intensive care units: Implications on clinical trial design. PLoS One 2024; 19:e0301944. [PMID: 38626111 PMCID: PMC11020418 DOI: 10.1371/journal.pone.0301944] [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: 11/20/2022] [Accepted: 03/21/2024] [Indexed: 04/18/2024] Open
Abstract
Antimicrobial de-escalation refers to reducing the spectrum of antibiotics used in treating bacterial infections. This strategy is widely recommended in many antimicrobial stewardship programs and is believed to reduce patients' exposure to broad-spectrum antibiotics and prevent resistance. However, the ecological benefits of de-escalation have not been universally observed in clinical studies. This paper conducts computer simulations to assess the ecological effects of de-escalation on the resistance prevalence of Pseudomonas aeruginosa-a frequent pathogen causing nosocomial infections. Synthetic data produced by the models are then used to estimate the sample size and study period needed to observe the predicted effects in clinical trials. Our results show that de-escalation can reduce colonization and infections caused by bacterial strains resistant to the empiric antibiotic, limit the use of broad-spectrum antibiotics, and avoid inappropriate empiric therapies. Further, we show that de-escalation could reduce the overall super-infection incidence, and this benefit becomes more evident under good compliance with hand hygiene protocols among health care workers. Finally, we find that any clinical study aiming to observe the essential effects of de-escalation should involve at least ten arms and last for four years-a size never attained in prior studies. This study explains the controversial findings of de-escalation in previous clinical studies and illustrates how mathematical models can inform outcome expectations and guide the design of clinical studies.
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Affiliation(s)
- Xi Huo
- Department of Mathematics, University of Miami, Coral Gables, FL, United States of Ameica
| | - Ping Liu
- LinkedIn Corporation, Mountain View, CA, United States of Ameica
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López-Cortés LE, Delgado-Valverde M, Moreno-Mellado E, Goikoetxea Aguirre J, Guio Carrión L, Blanco Vidal MJ, López Soria LM, Pérez-Rodríguez MT, Martínez Lamas L, Arnaiz de Las Revillas F, Armiñanzas C, Ruiz de Alegría-Puig C, Jiménez Aguilar P, Del Carmen Martínez-Rubio M, Sáez-Bejar C, de Las Cuevas C, Martín-Aspas A, Galán F, Yuste JR, Leiva-León J, Bou G, Capón González P, Boix-Palop L, Xercavins-Valls M, Goenaga-Sánchez MÁ, Anza DV, Castón JJ, Rufián MR, Merino E, Rodríguez JC, Loeches B, Cuervo G, Guerra Laso JM, Plata A, Pérez Cortés S, López Mato P, Sierra Monzón JL, Rosso-Fernández C, Bravo-Ferrer JM, Retamar-Gentil P, Rodríguez-Baño J. Efficacy and safety of a structured de-escalation from antipseudomonal β-lactams in bloodstream infections due to Enterobacterales (SIMPLIFY): an open-label, multicentre, randomised trial. THE LANCET. INFECTIOUS DISEASES 2024; 24:375-385. [PMID: 38215770 DOI: 10.1016/s1473-3099(23)00686-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND De-escalation from broad-spectrum to narrow-spectrum antibiotics is considered an important measure to reduce the selective pressure of antibiotics, but a scarcity of adequate evidence is a barrier to its implementation. We aimed to determine whether de-escalation from an antipseudomonal β-lactam to a narrower-spectrum drug was non-inferior to continuing the antipseudomonal drug in patients with Enterobacterales bacteraemia. METHODS An open-label, pragmatic, randomised trial was performed in 21 Spanish hospitals. Patients with bacteraemia caused by Enterobacterales susceptible to one of the de-escalation options and treated empirically with an antipseudomonal β-lactam were eligible. Patients were randomly assigned (1:1; stratified by urinary source) to de-escalate to ampicillin, trimethoprim-sulfamethoxazole (urinary tract infections only), cefuroxime, cefotaxime or ceftriaxone, amoxicillin-clavulanic acid, ciprofloxacin, or ertapenem in that order according to susceptibility (de-escalation group), or to continue with the empiric antipseudomonal β-lactam (control group). Oral switching was allowed in both groups. The primary outcome was clinical cure 3-5 days after end of treatment in the modified intention-to-treat (mITT) population, formed of patients who received at least one dose of study drug. Safety was assessed in all participants. Non-inferiority was declared when the lower bound of the 95% CI of the absolute difference in cure rate was above the -10% non-inferiority margin. This trial is registered with EudraCT (2015-004219-19) and ClinicalTrials.gov (NCT02795949) and is complete. FINDINGS 2030 patients were screened between Oct 5, 2016, and Jan 23, 2020, of whom 171 were randomly assigned to the de-escalation group and 173 to the control group. 164 (50%) patients in the de-escalation group and 167 (50%) in the control group were included in the mITT population. 148 (90%) patients in the de-escalation group and 148 (89%) in the control group had clinical cure (risk difference 1·6 percentage points, 95% CI -5·0 to 8·2). The number of adverse events reported was 219 in the de-escalation group and 175 in the control group, of these, 53 (24%) in the de-escalation group and 56 (32%) in the control group were considered severe. Seven (5%) of 164 patients in the de-escalation group and nine (6%) of 167 patients in the control group died during the 60-day follow-up. There were no treatment-related deaths. INTERPRETATION De-escalation from an antipseudomonal β-lactam in Enterobacterales bacteraemia following a predefined rule was non-inferior to continuing the empiric antipseudomonal drug. These results support de-escalation in this setting. FUNDING Plan Nacional de I+D+i 2013-2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades, Spanish Network for Research in Infectious Diseases; Spanish Clinical Research and Clinical Trials Platform, co-financed by the EU; European Development Regional Fund "A way to achieve Europe", Operative Program Intelligence Growth 2014-2020.
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Affiliation(s)
- Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain.
| | - Mercedes Delgado-Valverde
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Elisa Moreno-Mellado
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | | | - Laura Guio Carrión
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Cruces, Barakaldo, Spain
| | | | | | - María Teresa Pérez-Rodríguez
- Servicio de Medicina Interna, Complexo Hospitalario Universitario de Vigo (CHUVI), Xerencia de Xestión Integrada de Vigo, Spain
| | - Lucía Martínez Lamas
- Grupo de Investigación de Microbiología y Enfermedades Infecciosas, Instituto de Investigación Sanitaria Galicia Sur (IIS Galicia Sur), CHUVI, Vigo, Spain
| | - Francisco Arnaiz de Las Revillas
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Carlos Armiñanzas
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain
| | - Carlos Ruiz de Alegría-Puig
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Servicio de Microbiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | | | - Carmen Sáez-Bejar
- Servicio de Medicina Interna, Hospital Universitario de la Princesa, Madrid, Spain
| | | | - Andrés Martín-Aspas
- Unidad de Enfermedades Infecciosas, Servicio de Medicina Interna, Facultad de Medicina, Hospital Universitario Puerta del Mar, Instituto de Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Universidad de Cádiz, Cádiz, Spain
| | - Fátima Galán
- Servicio de Microbiología, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - José Ramón Yuste
- Servicio de Enfermedades Infecciosas, Clínica Universitaria de Navarra, Pamplona, Spain
| | - José Leiva-León
- Servicio de Microbiología, Clínica Universitaria de Navarra, Pamplona, Spain
| | - Germán Bou
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Servicio de Microbiología-Instituto de Investigación Biomédica, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | | | - Lucía Boix-Palop
- Servicio de Enfermedades Infecciosas, Hospital Universitario Mútua de Terrassa, Barcelona, Spain
| | | | | | - Diego Vicente Anza
- Servicio de Microbiología, Hospital Universitario de Donostia, Donostia, Spain
| | - Juan José Castón
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Manuel Recio Rufián
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain; Unidad de Enfermedades Infecciosas, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Esperanza Merino
- Unidad de Enfermedades Infecciosas, Hospital General Universitario Dr Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Juan Carlos Rodríguez
- Servicio de Microbiología, Hospital General Universitario Dr Balmis, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Belén Loeches
- Unidad de Enfermedades Infecciosas, Hospital Universitario La Paz, Madrid, Spain
| | - Guillermo Cuervo
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Bellvitge, Barcelona, Spain
| | | | - Antonio Plata
- Unidad de Enfermedades Infecciosas, Hospital Universitario Regional de Málaga, Málaga, Spain
| | | | - Pablo López Mato
- Unidad de Enfermedades Infecciosas, Hospital de Ourense, Ourense, Spain
| | - José Luis Sierra Monzón
- Servicio de Enfermedades Infecciosas and Servicio de Urgencias, Hospital Clínico Universitario Lozano Blesa, IIS Aragón, Zaragoza, Spain
| | - Clara Rosso-Fernández
- Unidad de Investigación Clínica y Ensayos Clínicos (UICEC-HUVR), Hospitales Universitarios Virgen del Rocío y Virgen Macarena, Sevilla, Spain
| | - José María Bravo-Ferrer
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Pilar Retamar-Gentil
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, CSIC, Seville, Spain; Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
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Sinto R, Lie KC, Setiati S, Suwarto S, Nelwan EJ, Karyanti MR, Karuniawati A, Djumaryo DH, Prayitno A, Sumariyono S, Sharland M, Moore CE, Hamers RL, Day NPJ, Limmathurotsakul D. Diagnostic and antibiotic use practices among COVID-19 and non-COVID-19 patients in the Indonesian National Referral Hospital. PLoS One 2024; 19:e0297405. [PMID: 38452030 PMCID: PMC10919621 DOI: 10.1371/journal.pone.0297405] [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: 11/01/2023] [Accepted: 12/26/2023] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Little is known about diagnostic and antibiotic use practices in low and middle-income countries (LMICs) before and during COVID-19 pandemic. This information is crucial for monitoring and evaluation of diagnostic and antimicrobial stewardships in healthcare facilities. METHODS We linked and analyzed routine databases of hospital admission, microbiology laboratory and drug dispensing of Indonesian National Referral Hospital from 2019 to 2020. Patients were classified as COVID-19 cases if their SARS-CoV-2 RT-PCR result were positive. Blood culture (BC) practices and time to discontinuation of parenteral antibiotics among inpatients who received a parenteral antibiotic for at least four consecutive days were used to assess diagnostic and antibiotic use practices, respectively. Fine and Grey subdistribution hazard model was used. RESULTS Of 1,311 COVID-19 and 58,917 non-COVID-19 inpatients, 333 (25.4%) and 18,837 (32.0%) received a parenteral antibiotic for at least four consecutive days. Proportion of patients having BC taken within ±1 calendar day of parenteral antibiotics being started was higher in COVID-19 than in non-COVID-19 patients (21.0% [70/333] vs. 18.7% [3,529/18,837]; p<0.001). Cumulative incidence of having a BC taken within 28 days was higher in COVID-19 than in non-COVID-19 patients (44.7% [149/333] vs. 33.2% [6,254/18,837]; adjusted subdistribution-hazard ratio [aSHR] 1.71, 95% confidence interval [CI] 1.47-1.99, p<0.001). The median time to discontinuation of parenteral antibiotics was longer in COVID-19 than in non-COVID-19 patients (13 days vs. 8 days; aSHR 0.73, 95%Cl 0.65-0.83, p<0.001). CONCLUSIONS Routine electronic data could be used to inform diagnostic and antibiotic use practices in LMICs. In Indonesia, the proportion of timely blood culture is low in both COVID-19 and non-COVID-19 patients, and duration of parenteral antibiotics is longer in COVID-19 patients. Improving diagnostic and antimicrobial stewardship is critically needed.
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Affiliation(s)
- Robert Sinto
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia, Jakarta Pusat, Jakarta, Indonesia
- Infection and Antimicrobial Resistance Control Committee, Cipto Mangunkusumo National Hospital, Jakarta Pusat, Jakarta, Indonesia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Internal Medicine, Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia, Jakarta Pusat, Jakarta, Indonesia
| | - Khie Chen Lie
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia, Jakarta Pusat, Jakarta, Indonesia
- Infection and Antimicrobial Resistance Control Committee, Cipto Mangunkusumo National Hospital, Jakarta Pusat, Jakarta, Indonesia
| | - Siti Setiati
- Department of Internal Medicine, Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia, Jakarta Pusat, Jakarta, Indonesia
- Center for Clinical Epidemiology and Evidence Based Medicine, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National Hospital, Jakarta Pusat, Jakarta, Indonesia
| | - Suhendro Suwarto
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia, Jakarta Pusat, Jakarta, Indonesia
| | - Erni J. Nelwan
- Division of Tropical and Infectious Diseases, Department of Internal Medicine, Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia, Jakarta Pusat, Jakarta, Indonesia
- Infection and Antimicrobial Resistance Control Committee, Cipto Mangunkusumo National Hospital, Jakarta Pusat, Jakarta, Indonesia
| | - Mulya Rahma Karyanti
- Infection and Antimicrobial Resistance Control Committee, Cipto Mangunkusumo National Hospital, Jakarta Pusat, Jakarta, Indonesia
- Department of Child Health, Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia, Jakarta Pusat, Jakarta, Indonesia
| | - Anis Karuniawati
- Infection and Antimicrobial Resistance Control Committee, Cipto Mangunkusumo National Hospital, Jakarta Pusat, Jakarta, Indonesia
- Department of Clinical Microbiology, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National Hospital, Jakarta Pusat, Jakarta, Indonesia
| | - Dean Handimulya Djumaryo
- Infection and Antimicrobial Resistance Control Committee, Cipto Mangunkusumo National Hospital, Jakarta Pusat, Jakarta, Indonesia
- Department of Clinical Pathology, Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia, Jakarta Pusat, Jakarta, Indonesia
| | - Ari Prayitno
- Infection and Antimicrobial Resistance Control Committee, Cipto Mangunkusumo National Hospital, Jakarta Pusat, Jakarta, Indonesia
- Department of Child Health, Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia, Jakarta Pusat, Jakarta, Indonesia
| | - Sumariyono Sumariyono
- Department of Internal Medicine, Cipto Mangunkusumo National Hospital, Faculty of Medicine Universitas Indonesia, Jakarta Pusat, Jakarta, Indonesia
- Board of Directors, Cipto Mangunkusumo National Hospital, Jakarta Pusat, Jakarta, Indonesia
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infection, St George’s University of London, Cranmer Terrace, London, United Kingdom
| | - Catrin E. Moore
- Centre for Neonatal and Paediatric Infection, St George’s University of London, Cranmer Terrace, London, United Kingdom
| | - Raph L. Hamers
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit Indonesia, Faculty of Medicine Universitas Indonesia, Jakarta Pusat, Jakarta, Indonesia
| | - Nicholas P. J. Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Direk Limmathurotsakul
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Ramadas A, Ambaras Khan R, Khalid KE, Leong CL, Makmor-Bakry M. Clinical impact of multidisciplinary carbapenem stewardship interventions: a retrospective cohort study. J Pharm Policy Pract 2023; 16:94. [PMID: 37488614 PMCID: PMC10364350 DOI: 10.1186/s40545-023-00599-0] [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: 01/13/2023] [Accepted: 07/14/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Antimicrobial stewardship (AMS) program aims to optimise antimicrobial utilisation and curb antimicrobial resistance. We investigated the clinical impact of AMS among patients with carbapenem in medical wards of a tertiary hospital. METHODS A retrospective cohort study was conducted on hospitalised adult patients treated with carbapenem and reviewed by a multidisciplinary AMS team. We compared the clinical outcomes of accepted (n = 103) and not-accepted AMS intervention cases (n = 37). The outcomes evaluated include trends of total white blood cells (TWBC), C-reactive protein (CRP), body temperature at day-7, and clinical status at day-30 post-AMS intervention. RESULTS The interventions included discontinuation (50%), de-escalation (47.9%) and escalation (2.1%) of antibiotics, where the acceptance rate was 67.1%, 80.6% and 66.7%, respectively. Overall, we found no significant difference in clinical outcomes between accepted and not-accepted AMS interventions at day-7 and day-30 post-interventions. On day-7, 62.0% of patients in the accepted group showed decreased or normalised TWBC and CRP levels compared to 47.4% of the not-accepted group (p = 0.271). The mortality at day-30 (32% versus 35%, p = 0.73), discharge rate (53.4% versus 45.9%, p = 0.437), and median length of hospital stay (36.0 versus 30.0 days, p = 0.526) between the groups were comparable. The predictors of 30-day mortality in the study subjects were Charlson Comorbidity Index > 3 (OR: 2.84, 95% CI 1.28-6.29, p = 0.010) and being febrile at day-7 (OR: 4.58, 95% CI 1.83-11.5, p = 0.001). CONCLUSION AMS interventions do not result in significant adverse clinical impact and mortality risk.
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Affiliation(s)
- Anitha Ramadas
- Department of Pharmacy, Hospital Kuala Lumpur, Ministry of Health, Kuala Lumpur, Malaysia
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Rahela Ambaras Khan
- Department of Pharmacy, Hospital Kuala Lumpur, Ministry of Health, Kuala Lumpur, Malaysia.
| | - Khairil Erwan Khalid
- Infectious Diseases Unit, Department of Medicine, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Chee Loon Leong
- Infectious Diseases Unit, Department of Medicine, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Mohd Makmor-Bakry
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Lin J, Zhou M, Chen J, Zhang L, Lu M, Liu Z. De-escalation from Echinocandins to Azole Treatment in Critically Ill Patients with Candidemia. Int J Infect Dis 2022; 121:69-74. [PMID: 35472525 DOI: 10.1016/j.ijid.2022.04.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES This study aims to further explore the duration of echinocandins and analyze the de-escalation (DE) strategy in patients with candidemia. METHODS Multivariable logistic regression was used to evaluate the association between the duration of echinocandins (≤ 5-day group vs > 5-day group) and in-hospital mortality. RESULTS Of the 357 cases of candidemia, 200 patients (56.02%) were identified in the ≤5-day group. The ≤5-day group did not have a higher in-hospital mortality than the >5-day group in the multivariable model (odds ratio [OR] 1.536, 95% confidence interval (CI) 0.837-2.819, P-value = 0.166), and the finding was validated by the propensity score matching and inverse probability of treatment weighting models. Subgroup analyses showed that patients in the ≤5-day group without DE may have a poor prognosis (OR 4.223, 95% CI 1.773-10.055, P-value = 0.001). The patients in the ≤5-day group, with a sequential organ failure assessment (SOFA) score of ≥3 evaluated at the time of stopping echinocandins, may have a poor prognosis (OR 2.164, 95% CI 1.009-4.641, P-value = 0.047). CONCLUSION In critically ill adult patients with candidemia, the ≤5-day group with DE was feasible. However, the SOFA score was recommended when stopping echinocandins to ensure the safety of DE therapy.
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Affiliation(s)
- Jing Lin
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China; Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Menglan Zhou
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China; Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Jialong Chen
- Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China; Department of Respiratory and Critical Care Medicine, Peking Hospital, Beijing, China
| | - Li Zhang
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Minya Lu
- Department of Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China; Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Zhengyin Liu
- Department of Infectious Disease, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
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Teh HL, Abdullah S, Ghazali AK, Khan RA, Ramadas A, Leong CL. Impact of Extended and Restricted Antibiotic Deescalation on Mortality. Antibiotics (Basel) 2021; 11:antibiotics11010022. [PMID: 35052899 PMCID: PMC8772729 DOI: 10.3390/antibiotics11010022] [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: 10/21/2021] [Revised: 12/01/2021] [Accepted: 12/07/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND More data are needed about the safety of antibiotic de-escalation in specific clinical situations as a strategy to reduce exposure to broad-spectrum antibiotics. This study aims to compare the survival curve of patient de-escalated (early or late) against those not de-escalated on antibiotics, to determine the association of patient related, clinical related, and pressure sore/device related characteristics on all-cause 30-day mortality and determine the impact of early and late antibiotic de-escalation on 30-day all-cause mortality. METHODS This is a retrospective cohort study on patients in medical ward Hospital Kuala Lumpur, admitted between January 2016 and June 2019. A Kaplan-Meier survival curve and Fleming-Harrington test were used to compare the overall survival rates between early, late, and those not de-escalated on antibiotics while multivariable Cox proportional hazards regression was used to determine prognostic factors associated with mortality and the impact of de-escalation on 30-day all-cause mortality. RESULTS Overall mortality rates were not significantly different when patients were not de-escalated on extended or restricted antibiotics, compared to those de-escalated early or later (p = 0.760). Variables associated with 30-day all-cause mortality were a Sequential Organ Function Assessment (SOFA) score on the day of antimicrobial stewardship (AMS) intervention and Charlson's comorbidity score (CCS). After controlling for confounders, early and late antibiotics were not associated with an increased risk of mortality. CONCLUSION The results of this study reinforce that restricted or extended antibiotic de-escalation in patients does not significantly affect 30-day all-cause mortality compared to continuation with extended and restricted antibiotics.
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Affiliation(s)
- Hwei Lin Teh
- Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur 50586, Malaysia; (R.A.K.); (A.R.)
- Correspondence: ; Tel.: +60-192778091
| | - Sarimah Abdullah
- Biostatistics and Research Methodology Unit, Universiti Sains Malaysia (Health Campus), Kota Bharu 16150, Malaysia; (S.A.); (A.K.G.)
| | - Anis Kausar Ghazali
- Biostatistics and Research Methodology Unit, Universiti Sains Malaysia (Health Campus), Kota Bharu 16150, Malaysia; (S.A.); (A.K.G.)
| | - Rahela Ambaras Khan
- Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur 50586, Malaysia; (R.A.K.); (A.R.)
| | - Anitha Ramadas
- Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur 50586, Malaysia; (R.A.K.); (A.R.)
| | - Chee Loon Leong
- Infectious Disease Unit, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur 50586, Malaysia;
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Abstract
OBJECTIVE The first 70 years of critical care can be considered a period of "industrial revolution-like" advancement in terms of progressing the understanding and care of critical illness. Unfortunately, like the industrial revolution's impact on the environment, advancing ICU care of increasingly elderly, immunosuppressed, and debilitated individuals has resulted in a greater overall burden and complexity of nosocomial infections within modern ICUs. Given the rapid evolution of nosocomial infections, the authors provide an updated review. DATA SOURCES AND STUDY SELECTION We searched PubMed and OVID for peer-reviewed literature dealing with nosocomial infections in the critically ill, as well as the websites of government agencies involved with the reporting and prevention of nosocomial infections. Search terms included nosocomial infection, antibiotic resistance, microbiome, antibiotics, and intensive care. DATA EXTRACTION AND DATA SYNTHESIS Nosocomial infections in the ICU setting are evolving in multiple domains including etiologic pathogens plus novel or emerging pathogens, prevalence, host risk factors, antimicrobial resistance, interactions of the host microbiome with nosocomial infection occurrence, and understanding of pathogenesis and prevention strategies. Increasing virulence and antimicrobial resistance of nosocomial infections mandate increasing efforts toward their prevention. CONCLUSIONS Nosocomial infections are an important determinant of outcome for patients in the ICU setting. Systematic research aimed at improving the prevention and treatment of nosocomial infections is still needed.
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Wu S, Huang G, de St Maurice A, Lehman D, Graber CJ, Goetz MB, Haake DA. The Impact of Rapid Species Identification on Management of Bloodstream Infections: What's in a Name? Mayo Clin Proc 2020; 95:2509-2524. [PMID: 32829901 DOI: 10.1016/j.mayocp.2020.02.011] [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: 11/09/2019] [Revised: 02/05/2020] [Accepted: 02/12/2020] [Indexed: 10/23/2022]
Abstract
Bloodstream infections are a leading cause of morbidity and mortality. Molecular rapid diagnostic tests (mRDTs) are transforming care for patients with bloodstream infection by providing the opportunity to dramatically shorten times to effective therapy and speeding de-escalation of overly broad empiric therapy. However, because of the novelty of these tests which provide information regarding microbial identification and whether specific antibiotic-resistance mutations were detected, many front-line providers still delay final decisions until complete phenotypic susceptibility results are available several days later. Thus the benefits of mRDTs have been largely limited to circumstances where antimicrobial stewardship programs closely monitor these tests and intervene as soon as the results are available. We searched PubMed and Google Scholar for articles published from 1980 to 2019 using the terms antibiotic, antifungal, bacteremia, bloodstream infection, candidemia, candidiasis, children, coagulase negative staphylococcus, consultation, contamination, costs, echocardiogram, endocarditis, enterobacteriaceae, enterococcus, Gram-negative, guidelines, IDSA, immunocompromised, infectious disease or ID, lumbar puncture, meningitis, mortality, MRSA, MSSA, neonatal, outcomes, pediatric, pneumococcal, polymicrobial, Pseudomonas, rapid diagnostic testing, resistance, risk factors, sepsis, Staphylococcus aureus, stewardship, streptococcus, and treatment. With the data from this search, we aim to provide guidance to front-line providers regarding the interpretation and immediate actions to be taken in response to the identification of common bloodstream pathogens by mRDTs. In addition to antimicrobial therapy, additional diagnostic or therapeutic interventions are recommended for particular organisms and clinical settings to either determine the extent of infection or control its source. Pediatric perspectives are offered for those bloodstream pathogens for which management differs from that in adults.
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Affiliation(s)
- Simon Wu
- VA Greater Los Angeles Healthcare System, California; David Geffen School of Medicine at the University of California, Los Angeles
| | - Glen Huang
- David Geffen School of Medicine at the University of California, Los Angeles
| | | | - Deborah Lehman
- David Geffen School of Medicine at the University of California, Los Angeles
| | - Christopher J Graber
- VA Greater Los Angeles Healthcare System, California; David Geffen School of Medicine at the University of California, Los Angeles
| | - Matthew B Goetz
- VA Greater Los Angeles Healthcare System, California; David Geffen School of Medicine at the University of California, Los Angeles
| | - David A Haake
- VA Greater Los Angeles Healthcare System, California; David Geffen School of Medicine at the University of California, Los Angeles.
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Rodríguez-Baño J, Palacios-Baena ZR, Pascual A. Reply to Woerther et al. Clin Infect Dis 2020; 71:1129-1130. [DOI: 10.1093/cid/ciz1054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena, Sevilla, Spain
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Woerther PL, Barbier F, Lepeule R, Fihman V, Ruppé É. Assessing the Ecological Benefit of Antibiotic De-escalation Strategies to Elaborate Evidence-Based Recommendations. Clin Infect Dis 2020; 71:1128-1129. [DOI: 10.1093/cid/ciz1052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Paul-Louis Woerther
- Department of Microbiology and Infection Control, Henri-Mondor Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Créteil, France
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, Centre Hospitalier Régional d’Orléans, Orléans, France
| | - Raphaël Lepeule
- Department of Microbiology and Infection Control, Henri-Mondor Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Créteil, France
| | - Vincent Fihman
- Department of Microbiology and Infection Control, Henri-Mondor Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Créteil, France
| | - Étienne Ruppé
- Department of Bacteriology, Bichat-Claude Bernard Hospital, APHP, Paris, France
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12
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Tabah A, Bassetti M, Kollef MH, Zahar JR, Paiva JA, Timsit JF, Roberts JA, Schouten J, Giamarellou H, Rello J, De Waele J, Shorr AF, Leone M, Poulakou G, Depuydt P, Garnacho-Montero J. Antimicrobial de-escalation in critically ill patients: a position statement from a task force of the European Society of Intensive Care Medicine (ESICM) and European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Critically Ill Patients Study Group (ESGCIP). Intensive Care Med 2019; 46:245-265. [PMID: 31781835 DOI: 10.1007/s00134-019-05866-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/12/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antimicrobial de-escalation (ADE) is a strategy of antimicrobial stewardship, aiming at preventing the emergence of antimicrobial resistance (AMR) by decreasing the exposure to broad-spectrum antimicrobials. There is no high-quality research on ADE and its effects on AMR. Its definition varies and there is little evidence-based guidance for clinicians to use ADE in the intensive care unit (ICU). METHODS A task force of 16 international experts was formed in November 2016 to provide with guidelines for clinical practice to develop questions targeted at defining ADE, its effects on the ICU population and to provide clinical guidance. Groups of 2 experts were assigned 1-2 questions each within their field of expertise to provide draft statements and rationale. A Delphi method, with 3 rounds and an agreement threshold of 70% was required to reach consensus. RESULTS We present a comprehensive document with 13 statements, reviewing the evidence on the definition of ADE, its effects in the ICU population and providing guidance for clinicians in subsets of clinical scenarios where ADE may be considered. CONCLUSION ADE remains a topic of controversy due to the complexity of clinical scenarios where it may be applied and the absence of evidence to the effects it may have on antimicrobial resistance.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe and Caboolture Hospitals, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Santa Maria Misericordia University Hospital, Udine, Italy
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Jean-Ralph Zahar
- Hygiène Hospitalière Et Prévention du Risque Infectieux, CHU Avicenne, AP-HP, 125 rue de Stalingrad, 93000, Bobigny, France
| | - José-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar Universitário São João, Faculty of Medicine and University of Porto, Grupo de Infecçao e Sépsis, Porto, Portugal
| | - Jean-Francois Timsit
- Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard University Hospital, Paris, France
- University of Paris, INSERM IAME, U1137, Team DesCID, Paris, France
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, and Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Jeroen Schouten
- Department of Intensive Care, Radboudumc, Nijmegen, The Netherlands
| | - Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Jordi Rello
- CIBERES and Vall d'Hebron Institute of Research, Barcelona, Spain
- Clinical Research in ICU, CHU Nîmes, University Montpellier, Montpellier, France
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Marc Leone
- Department of Anesthesiology and Intensive Care Medicine, Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | - Garyphallia Poulakou
- 3rd Department of Medicine, National and Kapodistrian University of Athens, Medical School, Sotiria General Hospital, Athens, Greece
| | - Pieter Depuydt
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jose Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
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Aslan AT, Akova M. Extended spectrum β-lactamase producing enterobacteriaceae: carbapenem sparing options. Expert Rev Anti Infect Ther 2019; 17:969-981. [PMID: 31722185 DOI: 10.1080/14787210.2019.1693258] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Carbapenems have an important place in our antibiotic armamentarium and have been trusted to effectively treat infections caused by ESBL-producing Enterobacteriaceae for many years. However, the utility of carbapenems has been compromised by the emergence of resistance especially in Enterobacteriaceae. Therefore, carbapenem-sparing alternative antibiotics are of extreme importance in clinical practice.Areas covered: We reviewed studies addressing currently available antibiotic options used as both empiric and definitive therapy for the treatment of infections due to ESBL-producing Enterobacteriaceae published in the PubMed/MEDLINE, Web of Science and Scopus databases without any date restriction. Current treatment alternatives included beta-lactam/beta-lactamase inhibitor combinations, cefepime, cephamycins, fluoroquinolones, aminoglycosides, fosfomycin, pivmecillinam, temocillin and, various oral alternative agents. We also summarized the clinical and molecular epidemiology, early prediction methods and impact of initial empirical therapy and de-escalation approach for ESBL-producing Enterobacteriaceae infections.Expert opinion: The current literature would endorse the carbapenem utilization for patients with severe and high inoculum-high risk infections. However, for milder infections particularly for urinary tract infections, various carbapenem-sparing antibiotics can be considered in selected cases. For infections including easily drainable intra-abdominal infections and catheter-related infections in which catheter removal is readily available more reliable data are needed to recommend non-carbapenem antibiotics confidently.
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Affiliation(s)
| | - Murat Akova
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Hacettepe University Sıhhıye Campus, Sihhiye, Ankara, Turkey
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14
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Direct Measurement of Performance: A New Era in Antimicrobial Stewardship. Antibiotics (Basel) 2019; 8:antibiotics8030127. [PMID: 31450576 PMCID: PMC6784134 DOI: 10.3390/antibiotics8030127] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/20/2019] [Accepted: 08/21/2019] [Indexed: 01/23/2023] Open
Abstract
For decades, the performance of antimicrobial stewardship programs (ASPs) has been measured by incidence rates of hospital-onset Clostridioides difficile and other infections due to multidrug-resistant bacteria. However, these represent indirect and nonspecific ASP metrics. They are often confounded by factors beyond an ASP’s control, such as changes in diagnostic testing methods or algorithms and the potential of patient-to-patient transmission. Whereas these metrics remain useful for global assessment of healthcare systems, antimicrobial use represents a direct metric that separates the performance of an ASP from other safety and quality teams within an institution. The evolution of electronic medical records and healthcare informatics has made measurements of antimicrobial use a reality. The US Centers for Disease Control and Prevention’s initiative for reporting antimicrobial use and standardized antimicrobial administration ratio in hospitals is highly welcomed. Ultimately, ASPs should be evaluated based on what they do best and what they can control, that is, antimicrobial use within their own institution. This narrative review critically appraises existing stewardship metrics and advocates for adopting antimicrobial use as the primary performance measure. It proposes novel formulas to adjust antimicrobial use based on quality of care and microbiological burden at each institution to allow for meaningful inter-network and inter-facility comparisons.
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15
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Jiménez-Aguilar P, López-Cortés LE, Rodríguez-Baño J. Impact of infectious diseases consultation on the outcome of patients with bacteraemia. Ther Adv Infect Dis 2019; 6:2049936119893576. [PMID: 31839942 PMCID: PMC6900613 DOI: 10.1177/2049936119893576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 11/15/2019] [Indexed: 12/29/2022] Open
Abstract
Bacteraemia or bloodstream infections (BSI) are associated with much morbidity and mortality. Management of patients with bacteraemia is complex, and the increase in immunosuppressed patients and multidrug-resistant organisms poses additional challenges. The objective of this review is to assess the available published information about the impact of different aspects of management on the outcome of patients with BSI, and, specifically, the importance of infectious diseases specialists (IDS) consultation. The impact of management by IDS on different aspects, including interpretation of newer rapid techniques, early evaluation and treatment, and follow up, are reviewed. Overall, the available data suggest that IDS intervention improves the management and outcome of patients with BSI, either through consultation or structured unsolicited interventions in the context of multidisciplinary bacteraemia programmes.
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Affiliation(s)
- Patricia Jiménez-Aguilar
- Unidad Clínica de Enfermedades Infecciosas,
Hospital Universitario Puerto Real, Puerto Real, Cádiz, Spain
- Instituto de Investigación e Innovación
Biomédica de Cádiz (INiBICA), Cádiz, Spain
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas,
Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena,
Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
| | - Jesús Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas,
Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena,
Instituto de Biomedicina de Sevilla (IBiS), Sevilla, Spain
- Departamento de Medicina, Universidad de
Sevilla, Sevilla, Spain
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