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Majigo MV, Mshana S, Komba E, Moremi N, Matee M. Protocol for surveillance of antimicrobial-resistant bacteria causing community-acquired urinary tract infections in low-income countries. PLoS One 2024; 19:e0304388. [PMID: 38820392 PMCID: PMC11142477 DOI: 10.1371/journal.pone.0304388] [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: 01/18/2024] [Accepted: 05/12/2024] [Indexed: 06/02/2024] Open
Abstract
The spread of drug-resistant bacteria into the community is an urgent threat. In most low-middle-income countries (LMICs) settings, community-acquired infection (CAI) is empirically treated with no data to support the choice of antibiotics, hence contributing to resistance development. Continuous antimicrobial resistance (AMR) data on community-acquired pathogens are needed to draft empirical treatment guidelines, especially for areas with limited culture and susceptibility testing. Despite the importance of addressing antibiotic-resistant pathogens in the community setting, protocols for the surveillance of AMR bacterial infections are lacking in most (LMICs). We present a protocol for surveillance of AMR in LMICs using urinary tract infection (UTI) as a proxy for CAI to enable users to quantify and establish the drivers of AMR bacteria causing UTI. The protocol intends to assist users in designing a sustainable surveillance program for AMR in the community involving children above two years of age and adults presenting to a primary health facility for healthcare. Implementation of the protocol requires initial preparation of the laboratories to be involved, surveillance areas, selection of priority bacteria and antimicrobials to be used, and the design of a coordinated sampling plan. Recruitment should occur continuously in selected health facilities for at least 12 months to observe seasonal trends of AMR. At least 10 mL of clean-catch mid-stream urine must be collected into 20 mL calibrated sterile screw-capped universal bottles lined with 0.2 mg boric acid and transported to the testing laboratory. Utilise the data system that generates standard reports for patient care to be shared internally and externally in the regions and the world through global platforms such as the Global Antimicrobial Resistance Surveillance System.
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Affiliation(s)
- Mtebe Venance Majigo
- SACIDS Foundation for One Health, Dar es Salaam, Tanzania
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Stephen Mshana
- SACIDS Foundation for One Health, Dar es Salaam, Tanzania
- Catholic University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Erick Komba
- SACIDS Foundation for One Health, Dar es Salaam, Tanzania
- Sokoine University of Agriculture, Morogoro, Tanzania
| | - Nyambura Moremi
- SACIDS Foundation for One Health, Dar es Salaam, Tanzania
- National Health Laboratory Quality Assurance and Training Centre, Dar es Salaam, Tanzania
| | - Mecky Matee
- SACIDS Foundation for One Health, Dar es Salaam, Tanzania
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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2
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Navarro F, Oliver A, Larrosa MN. Considerations to the comments on the recommendations of the Spanish Antibiogram Committee (COESANT) for the preparation of Cumulative Antibiotic Sensitivity Reports. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2024:S2529-993X(24)00125-4. [PMID: 38763864 DOI: 10.1016/j.eimce.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 05/21/2024]
Affiliation(s)
- Ferran Navarro
- Servicio de Microbiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Departamento de Genética y de Microbiología, Universitat Autònoma de Barcelona, Institut d'Investigació Biomèdica de Sant Pau (IIB Sant Pau), Barcelona, Spain.
| | - Antonio Oliver
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - María Nieves Larrosa
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Servicio de Microbiología, Hospital Universitario Vall d'Hebron, Universitat Autònoma de Barcelona, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
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3
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Diño PET, Aquino SS, Depante DDM, Peña IG. Determination of the Enablers and Challenges in the Implementation of Pharmacy-based Antimicrobial Stewardship (AMS) Program in a Level 3 Hospital in Manila. ACTA MEDICA PHILIPPINA 2024; 58:50-66. [PMID: 38812766 PMCID: PMC11132291 DOI: 10.47895/amp.vi0.6658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Background and Objectives Antimicrobial resistance (AMR) is a global public health threat that results from misuse and overuse of antimicrobials. The Department of Health (DOH) institutionalized the Antimicrobial Stewardship (AMS) Program in hospitals, based on the core elements (1) Leadership, (2) Policies, Guidelines, and Pathways, (3) Surveillance Antimicrobial Use (AMU) & AMR, (4) Action, (5) Education, and (6) Performance Evaluation to ensure rational use of antimicrobials and improve patient outcomes. The program implementation will require the involvement of the AMS clinical pharmacist to positively influence the success of the program's implementation. This study aims to identify the enablers and challenges as perceived by AMS clinical pharmacists in the implementation of an AMS program in a level 3 hospital in Manila. Methods A quantitative descriptive study design was employed by administering an online 50-item survey questionnaire to AMS pharmacists, who have at least six (6) months of experience as an AMS pharmacist in the hospital. The survey questionnaire was validated by an expert consultant and underwent pre-testing (Cronbach α = 0.983) for acceptable internal consistency. Responses were collated, coded, and analyzed using median values and frequency distributions for each questionnaire item per Department of Health (DOH) Core Element. Items garnering a median of >3.50 up to 5 were considered as perceived enablers, while those ≤3.50 were identified as perceived challenges. Results Some perceived enablers by the AMS pharmacists include presence of a leader and/or clinician in the AMS team, Information Technology (IT) resource availability, clear roles of AMS pharmacists, readily available hospital AMS guidelines, engagement in AMR and AMU surveillance activities, regular performance of AMS interventions (e.g., IV-to-PO conversion, dose optimization, de-escalation of broad spectrum), regular monitoring and evaluating of prescriptions and prescribing behavior, and continuous education on infection, prevention, and control (IPC) and hygiene. On the other hand, some perceived challenges include insufficient funding, inadequate knowledge in interpreting antibiograms, lack of adequate and specialized training sessions, lack of coordination with medical and nursing staff to ensure timely drug administration and automatic stop order, prescribing of non-Philippine National Formulary (PNF) antimicrobials, lack of time to perform AMS activities, lack of qualified personnel, and lack of hospital management and information technology (IT) support. Conclusion Empowering AMS clinical pharmacists is vital to addressing the perceived challenges and maximizing the perceived enablers to ensure the successful implementation of the AMS program in the hospital.
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Affiliation(s)
| | | | | | - Imelda G Peña
- College of Pharmacy, University of the Philippines Manila
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4
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Abdel Hadi H, Eltayeb F, Al Balushi S, Daghfal J, Ahmed F, Mateus C. Evaluation of Hospital Antimicrobial Stewardship Programs: Implementation, Process, Impact, and Outcomes, Review of Systematic Reviews. Antibiotics (Basel) 2024; 13:253. [PMID: 38534688 DOI: 10.3390/antibiotics13030253] [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: 01/20/2024] [Revised: 02/21/2024] [Accepted: 02/29/2024] [Indexed: 03/28/2024] Open
Abstract
Antimicrobial Stewardship Programs (ASP) were introduced in healthcare as a public health priority to promote appropriate prescribing of antimicrobials, to reduce adverse events related to antimicrobials, as well as to control the escalating challenges of antimicrobial resistance. To deliver aimed outcome objectives, ASPs involve multiple connected implementation process measures. A systematic review was conducted to evaluate both concepts of ASPs. Guided by PRISMA frames, published systematic reviews (SR) focusing on ASPs restricted to secondary and tertiary healthcare were evaluated over the past 10 years involving all age groups. Out of 265 identified SR studies, 63 met the inclusion criteria. The majority were conducted in Europe and North America, with limited studies from other regions. In the reviewed studies, all age groups were examined, although they were conducted mainly on adults when compared to children and infants. Both process and outcomes measures of ASPs were examined equally and simultaneously through 25 different concepts, dominated by efficacy, antimicrobial resistance, and economic impact, while information technology as well as role of pharmacy and behavioral factors were equally examined. The main broad conclusions from the review were that, across the globe, ASPs demonstrated effectiveness, proved efficacy, and confirmed efficiency, while focused evaluation advocated that developed countries should target medium- and small-sized hospitals while developing countries should continue rolling ASPs across healthcare facilities. Additionally, the future of ASPs should focus on embracing evolving information technology to bridge the gaps in knowledge, skills, and attitude, as well as to enhance appropriate decision making.
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Affiliation(s)
- Hamad Abdel Hadi
- Communicable Diseases Centre, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster LA1 4YW, UK
| | - Faiha Eltayeb
- Division of Microbiology, Department of Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar
| | - Sara Al Balushi
- Communicable Diseases Centre, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar
| | - Joanne Daghfal
- Communicable Diseases Centre, Hamad Medical Corporation, Doha P.O. Box 3050, Qatar
| | - Faraz Ahmed
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster LA1 4YW, UK
| | - Ceu Mateus
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster LA1 4YW, UK
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Nichols WW, Lahiri SD, Bradford PA, Stone GG. The primary pharmacology of ceftazidime/avibactam: resistance in vitro. J Antimicrob Chemother 2023; 78:569-585. [PMID: 36702744 DOI: 10.1093/jac/dkac449] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
This article reviews resistance to ceftazidime/avibactam as an aspect of its primary pharmacology, linked thematically with recent reviews of the basic in vitro and in vivo translational biology of the combination (J Antimicrob Chemother 2022; 77: 2321-40 and 2341-52). In Enterobacterales or Pseudomonas aeruginosa, single-step exposures to 8× MIC of ceftazidime/avibactam yielded frequencies of resistance from <∼0.5 × 10-9 to 2-8 × 10-9, depending on the host strain and the β-lactamase harboured. β-Lactamase structural gene mutations mostly affected the avibactam binding site through changes in the Ω-loop: e.g. Asp179Tyr (D179Y) in KPC-2. Other mutations included ones proposed to reduce the permeability to ceftazidime and/or avibactam through changes in outer membrane structure, up-regulated efflux, or both. The existence, or otherwise, of cross-resistance between ceftazidime/avibactam and other antibacterial agents was also reviewed as a key element of the preclinical primary pharmacology of the new agent. Cross-resistance between ceftazidime/avibactam and other β-lactam-based antibacterial agents was caused by MBLs. Mechanism-based cross-resistance was not observed between ceftazidime/avibactam and fluoroquinolones, aminoglycosides or colistin. A low level of general co-resistance to ceftazidime/avibactam was observed in MDR Enterobacterales and P. aeruginosa. For example, among 2821 MDR Klebsiella spp., 3.4% were resistant to ceftazidime/avibactam, in contrast to 0.07% of 8177 non-MDR isolates. Much of this was caused by possession of MBLs. Among 1151 MDR, XDR and pandrug-resistant isolates of P. aeruginosa from the USA, 11.1% were resistant to ceftazidime/avibactam, in contrast to 3.0% of 7452 unselected isolates. In this case, the decreased proportion susceptible was not due to MBLs.
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Affiliation(s)
| | - Sushmita D Lahiri
- Infectious Diseases and Vaccines, Johnson & Johnson, Cambridge, MA, USA
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Babu Rajendran N, Arieti F, Mena-Benítez CA, Galia L, Tebon M, Alvarez J, Gladstone BP, Collineau L, De Angelis G, Duro R, Gaze W, Göpel S, Kanj SS, Käsbohrer A, Limmathurotsakul D, Lopez de Abechuco E, Mazzolini E, Mutters NT, Pezzani MD, Presterl E, Renk H, Rodríguez-Baño J, Săndulescu O, Scali F, Skov R, Velavan TP, Vuong C, Tacconelli E, Avery L, Bonten M, Cassini A, Chauvin C, Compri M, Damborg P, De Greeff S, Del Toro MD, Filter M, Franklin A, Gonzalez-Zorn B, Grave K, Hocquet D, Hoelzle LE, Kalanxhi E, Laxminarayan R, Leibovici L, Malhotra-Kumar S, Mendelson M, Paul M, Muñoz Madero C, Murri R, Piddock LJ, Ruesen C, Sanguinetti M, Schilling T, Schrijver R, Schwaber MJ, Scudeller L, Torumkuney D, Van Boeckel T, Vanderhaeghen W, Voss A, Wozniak T. EPI-Net One Health reporting guideline for antimicrobial consumption and resistance surveillance data: a Delphi approach. THE LANCET REGIONAL HEALTH. EUROPE 2023; 26:100563. [PMID: 36895445 PMCID: PMC9989632 DOI: 10.1016/j.lanepe.2022.100563] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022]
Abstract
Strategic and standardised approaches to analysis and reporting of surveillance data are essential to inform antimicrobial resistance (AMR) mitigation measures, including antibiotic policies. Targeted guidance on linking full-scale AMR and antimicrobial consumption (AMC)/antimicrobial residues (AR) surveillance data from the human, animal, and environmental sectors is currently needed. This paper describes the initiative whereby a multidisciplinary panel of experts (56 from 20 countries-52 high income, 4 upper middle or lower income), representing all three sectors, elaborated proposals for structuring and reporting full-scale AMR and AMC/AR surveillance data across the three sectors. An evidence-supported, modified Delphi approach was adopted to reach consensus among the experts for dissemination frequency, language, and overall structure of reporting; core elements and metrics for AMC/AR data; core elements and metrics for AMR data. The recommendations can support multisectoral national and regional plans on antimicrobials policy to reduce resistance rates applying a One Health approach.
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Affiliation(s)
- Nithya Babu Rajendran
- Infectious Diseases, Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany
| | - Fabiana Arieti
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | | | - Liliana Galia
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maela Tebon
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Julio Alvarez
- VISAVET Health Surveillance Center and Department of Animal Health, Faculty of Veterinary Medicine, Complutense University, Madrid, Spain
| | - Beryl Primrose Gladstone
- Infectious Diseases, Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany.,German Centre for Infection Research (DZIF) Clinical Research Unit for Healthcare Associated and Antibiotic Resistant Bacterial Infections, Tübingen, Germany
| | - Lucie Collineau
- French Agency for Food, Environmental and Occupational Health and Safety, ANSES, Maisons-Alfort, France
| | - Giulia De Angelis
- Dipartimento di Scienze Biotecnologiche di base, Cliniche Intensivologiche e Perioperatorie, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Raquel Duro
- Unit for the Prevention and Control of Infection and Antimicrobial Resistance, Centro Hospitalar do Tâmega e Sousa, Penafiel, Porto, Portugal
| | - William Gaze
- The European Centre for Environment and Human Health, University of Exeter Medical School, University of Exeter, Penryn, Cornwall, UK
| | - Siri Göpel
- Infectious Diseases, Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany.,German Centre for Infection Research (DZIF) Clinical Research Unit for Healthcare Associated and Antibiotic Resistant Bacterial Infections, Tübingen, Germany
| | - Souha S Kanj
- Department of Internal Medicine, Division of Infectious Diseases, Infection Control Program, Antimicrobial Stewardship Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Annemarie Käsbohrer
- German Federal Institute for Risk Assessment (BfR), Department 4 - Biological Safety, Berlin, Germany
| | - Direk Limmathurotsakul
- Mahidol Oxford Tropical Medicine Research Unit and Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK
| | | | - Elena Mazzolini
- Department of Epidemiology, Istituto Zooprofilattico Sperimentale delle Venezie, Udine-Padova, Padua, Italy
| | - Nico T Mutters
- Institute for Hygiene and Public Health, Bonn University Hospital, Bonn, Germany.,European Committee on Infection Control, Basel, Switzerland
| | - Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elisabeth Presterl
- European Committee on Infection Control, Basel, Switzerland.,Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria.,ESCMID Study Group for Nosocomial Infections, Basel, Switzerland
| | - Hanna Renk
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Jesús Rodríguez-Baño
- Infectious Diseases and Microbiology Division, Hospital Universitario Virgen Macarena/Department of Medicine, School of Medicine, University of Seville/Biomedicine Institute of Seville (IBiS)/CSIC, Seville, Spain.,CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Oana Săndulescu
- Department of Infectious Diseases I, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania
| | - Federico Scali
- Istituto Zooprofilattico Sperimentale della Lombardia e Dell'Emilia Romagna, Brescia, Italy
| | - Robert Skov
- Epidemiological Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Thirumalaisamy P Velavan
- Institute of Tropical Medicine, Universitätsklinikum Tübingen, Tübingen, Germany.,Vietnamese - German Center for Medical Research, Hanoi, Vietnam
| | - Cuong Vuong
- AiCuris Anti-infective Cures GmbH, Wuppertal, Germany.,Jansen Pharmaceuticals, Beerse, Belgium
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.,European Committee on Infection Control, Basel, Switzerland
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7
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Carrara E, Sibani M, Barbato L, Mazzaferri F, Salerno ND, Conti M, Azzini AM, Dalbeni A, Pellizzari L, Fontana G, Di Francesco V, Bissoli L, Del Monte L, Zamboni M, Olivieri O, Minuz P, Maccacaro L, Ghirlanda G, Tacconelli E. How to 'SAVE' antibiotics: effectiveness and sustainability of a new model of antibiotic stewardship intervention in the internal medicine area. Int J Antimicrob Agents 2022; 60:106672. [PMID: 36103917 DOI: 10.1016/j.ijantimicag.2022.106672] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/12/2022] [Accepted: 09/09/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antibiotic stewardship (AS) is a cornerstone of the fight against antimicrobial resistance; however, evidence on the best practice to improve antibiotic prescription in various hospital settings is still scarce. This study aimed to measure the efficacy of a non-restrictive AS intervention in the internal medicine area of a tertiary-care hospital across a 3-year period. METHODS The intervention comprised a 3-month 'intensive phase' based on education and guidelines provision, followed by 9 months of audits and feedback activities. The primary outcome was the overall antibiotic consumption measured as days of therapy (DOTs) and defined daily doses (DDDs). Secondary outcomes were carbapenem and fluoroquinolone consumption, all-cause in-hospital mortality, length of stay, incidence of Clostridioides difficile and carbapenem-resistant Enterobacterales bloodstream infections (CRE-BSIs). All outcomes were measured in the intervention wards comparing the pre-phase with the post-phase using an interrupted time-series model. RESULTS A total of 145 337 patient days (PDs) and 14 159 admissions were included in the analysis. The intervention was associated with reduced DOTs*1000PDs (-162.2/P = 0.005) and DDDs*1000PDs (-183.6/P ≤ 0.001). A sustained decrease in ward-related antibiotic consumption was also detected during the post-intervention phase and in the carbapenem/fluoroquinolone classes. The intervention was associated with an immediate reduction in length of stay (-1.72 days/P < 0.001) and all-cause mortality (-3.71 deaths*100 admissions/P = 0.002), with a decreasing trend over time. Rates of Clostridioides difficile infections and CRE-BSIs were not significantly impacted by the intervention. CONCLUSIONS The AS intervention was effective and safe in decreasing antibiotic consumption and length of stay in the internal medicine area. Enabling prescribers to judicious use of antimicrobials through active participation in AS initiatives is key to reach sustained results over time.
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Affiliation(s)
- Elena Carrara
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy.
| | - Marcella Sibani
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy; Infectious Diseases Department, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Lorenzo Barbato
- Department of Pharmacy, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Fulvia Mazzaferri
- Infectious Diseases Department, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Nicola Duccio Salerno
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Michela Conti
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Anna Maria Azzini
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
| | - Andrea Dalbeni
- Department of Medicine, General Medicine C Unit & Liver Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Luca Pellizzari
- Geriatric Unit A, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giorgia Fontana
- Geriatric Unit A, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | | | - Luisa Bissoli
- Department of Medicine, Section of Geriatrics, University of Verona, Verona, Italy
| | - Letizia Del Monte
- Department of Medicine, Section of Geriatrics, University of Verona, Verona, Italy
| | - Mauro Zamboni
- Department of Medicine, Section of Geriatrics, University of Verona, Verona, Italy
| | - Oliviero Olivieri
- Medicina Interna ad Indirizzo Immunoematologico ed Emocoagulativo, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Pietro Minuz
- Department of Medicine, Section of General Medicine and Hypertension, University of Verona, Verona, Italy
| | - Laura Maccacaro
- Unit of Microbiology and Virology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giovanna Ghirlanda
- Medical Direction, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Italy
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8
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Tiseo G, Brigante G, Giacobbe DR, Maraolo AE, Gona F, Falcone M, Giannella M, Grossi P, Pea F, Rossolini GM, Sanguinetti M, Sarti M, Scarparo C, Tumbarello M, Venditti M, Viale P, Bassetti M, Luzzaro F, Menichetti F, Stefani S, Tinelli M. Diagnosis and management of infections caused by multidrug-resistant bacteria: guideline endorsed by the Italian Society of Infection and Tropical Diseases (SIMIT), the Italian Society of Anti-Infective Therapy (SITA), the Italian Group for Antimicrobial Stewardship (GISA), the Italian Association of Clinical Microbiologists (AMCLI) and the Italian Society of Microbiology (SIM). Int J Antimicrob Agents 2022; 60:106611. [PMID: 35697179 DOI: 10.1016/j.ijantimicag.2022.106611] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 05/12/2022] [Accepted: 05/29/2022] [Indexed: 02/08/2023]
Abstract
Management of patients with infections caused by multidrug-resistant organisms is challenging and requires a multidisciplinary approach to achieve successful clinical outcomes. The aim of this paper is to provide recommendations for the diagnosis and optimal management of these infections, with a focus on targeted antibiotic therapy. The document was produced by a panel of experts nominated by the five endorsing Italian societies, namely the Italian Association of Clinical Microbiologists (AMCLI), the Italian Group for Antimicrobial Stewardship (GISA), the Italian Society of Microbiology (SIM), the Italian Society of Infectious and Tropical Diseases (SIMIT) and the Italian Society of Anti-Infective Therapy (SITA). Population, Intervention, Comparison and Outcomes (PICO) questions about microbiological diagnosis, pharmacological strategies and targeted antibiotic therapy were addressed for the following pathogens: carbapenem-resistant Enterobacterales; carbapenem-resistant Pseudomonas aeruginosa; carbapenem-resistant Acinetobacter baumannii; and methicillin-resistant Staphylococcus aureus. A systematic review of the literature published from January 2011 to November 2020 was guided by the PICO strategy. As data from randomised controlled trials (RCTs) were expected to be limited, observational studies were also reviewed. The certainty of evidence was classified using the GRADE approach. Recommendations were classified as strong or conditional. Detailed recommendations were formulated for each pathogen. The majority of available RCTs have serious risk of bias, and many observational studies have several limitations, including small sample size, retrospective design and presence of confounders. Thus, some recommendations are based on low or very-low certainty of evidence. Importantly, these recommendations should be continually updated to reflect emerging evidence from clinical studies and real-world experience.
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Affiliation(s)
- Giusy Tiseo
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Gioconda Brigante
- Clinical Pathology Laboratory, ASST Valle Olona, Busto Arsizio, Italy
| | - Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy; Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Floriana Gona
- Emerging Bacterial Pathogens Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Paolo Grossi
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery, University of Insubria-ASST-Sette Laghi, Varese, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; SSD Clinical Pharmacology, Department for Integrated Infectious Risk Management, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy, and Microbiology and Virology Unit, Careggi University Hospital, Florence, Italy
| | - Maurizio Sanguinetti
- Microbiology Unit, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Università Cattolica del Sacro Cuore, Largo 'A. Gemelli', Rome, Italy
| | - Mario Sarti
- Clinical Microbiology Laboratory, University of Modena and Reggio Emilia, Modena, Italy
| | - Claudio Scarparo
- Clinical Microbiology Laboratory, Angel's Hospital, AULSS3 Serenissima, Mestre, Venice, Italy
| | - Mario Tumbarello
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Mario Venditti
- Policlinico 'Umberto I', Department of Public Health and Infectious Diseases, 'Sapienza' University of Rome, Rome, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy; Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesco Luzzaro
- Clinical Microbiology and Virology Unit, A. Manzoni Hospital, Lecco, Italy
| | - Francesco Menichetti
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy.
| | - Stefania Stefani
- Medical Molecular Microbiology and Antibiotic Resistance Laboratory (MMARLab), Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Catania, Italy
| | - Marco Tinelli
- Infectious Diseases Consultation Service, IRCCS Istituto Auxologico Italiano, Milan, Italy
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Pezzani MD, Carrara E, Sibani M, Presterl E, Gastmeier P, Renk H, Kanj SS, Velavan TP, Song LH, Leibovici L, Torumkuney D, Kostyanev T, Mendelson M, Tacconelli E. White Paper: Bridging the gap between human and animal surveillance data, antibiotic policy and stewardship in the hospital sector-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks. J Antimicrob Chemother 2021; 75:ii20-ii32. [PMID: 33280046 PMCID: PMC7719407 DOI: 10.1093/jac/dkaa426] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Antimicrobial surveillance and antimicrobial stewardship (AMS) are essential pillars in the fight against antimicrobial resistance (AMR), but practical guidance on how surveillance data should be linked to AMS activities is lacking. This issue is particularly complex in the hospital setting due to structural heterogeneity of hospital facilities and services. The JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks have joined efforts to formulate a set of target actions for linking surveillance data with AMS activities. METHODS A scoping review of the literature was carried out addressing research questions on three areas: (i) AMS leadership and accountability; (ii) antimicrobial usage and AMS; (iii) AMR and AMS. Consensus on the target actions was reached through a RAND-modified Delphi process involving over 40 experts in different fields from 18 countries. RESULTS Evidence was retrieved from 51 documents. Initially 38 targets were proposed, differentiated as essential or desirable according to clinical relevance, feasibility and applicability to settings and resources. In the first consultation round, preliminary agreement was reached for 32 targets. Following a second consultation, 27 targets were approved, 11 were deleted and 4 were suggested for rephrasing, leading to a final approved list of 34 target actions in the form of a practical checklist. CONCLUSIONS This White Paper provides a pragmatic and flexible tool to guide the development of calibrated hospital-surveillance-based AMS interventions. The strength of this tool is that it is a comprehensive perspective that takes into account the hospital patient case-mix and the related epidemiology, which ultimately drives antimicrobial usage, and the feasibility in low-resource settings.
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Affiliation(s)
- Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elena Carrara
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Marcella Sibani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elisabeth Presterl
- European Committee on Infection Control, Basel, Switzerland.,ESCMID Study group for nosocomial infections, Basel, Switzerland.,Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - Petra Gastmeier
- German Centre for Infection Research Association (DZIF), Braunschweig, Germany.,Institute for Hygiene and Environmental Medicine, Charité - Universitätsmedizin Berlin, Germany, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Hanna Renk
- University Children's Hospital Tübingen, Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, Tübingen, Germany
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine, and Infection Control and Prevention Program, and Antimicrobial Stewardship Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Thirumalaisamy P Velavan
- Institute of Tropical Medicine, Universitätsklinikum Tübingen, Germany.,Vietnamese German Center for Medical Research, Hanoi, Vietnam.,Faculty of Medicine, Duy Tan University, Da Nang, Vietnam
| | - Le Huu Song
- Vietnamese German Center for Medical Research, Hanoi, Vietnam.,108 Military Central Hospital, Hanoi, Vietnam
| | - Leonard Leibovici
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Didem Torumkuney
- International Federation of Pharmaceuticals and Manufacturers & Associations (IFPMA), Geneva, Switzerland
| | - Tomislav Kostyanev
- Department of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.,Division of Infectious Diseases, Department of Internal Medicine, and Infection Control and Prevention Program, and Antimicrobial Stewardship Program, American University of Beirut Medical Center, Beirut, Lebanon.,Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
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10
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Arieti F, Göpel S, Sibani M, Carrara E, Pezzani MD, Murri R, Mutters NT, Lòpez-Cerero L, Voss A, Cauda R, Tacconelli E. White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in the outpatient sector-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks. J Antimicrob Chemother 2021; 75:ii42-ii51. [PMID: 33280045 PMCID: PMC7719405 DOI: 10.1093/jac/dkaa428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background The outpatient setting is a key scenario for the implementation of antimicrobial stewardship (AMS) activities, considering that overconsumption of antibiotics occurs mainly outside hospitals. This publication is the result of a joint initiative by the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks, which is aimed at formulating a set of target actions for linking surveillance data with AMS activities in the outpatient setting. Methods A scoping review of the literature was carried out in three research areas: AMS leadership and accountability; antimicrobial usage and AMS; antimicrobial resistance and AMS. Consensus on the actions was reached through a RAND-modified Delphi process involving over 40 experts in infectious diseases, clinical microbiology, AMS, veterinary medicine or public health, from 18 low-, middle- and high-income countries. Results Evidence was retrieved from 38 documents, and an initial 25 target actions were proposed, differentiating between essential or desirable targets according to clinical relevance, feasibility and applicability to settings and resources. In the first consultation round, preliminary agreement was reached for all targets. Further to a second review, 6 statements were re-considered and 3 were deleted, leading to a final list of 22 target actions in the form of a practical checklist. Conclusions This White Paper is a pragmatic and flexible tool to guide the development of calibrated surveillance-based AMS interventions specific to the outpatient setting, which is characterized by substantial inter- and intra-country variability in the organization of healthcare structures, maintaining a global perspective and taking into account the feasibility of the target actions in low-resource settings.
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Affiliation(s)
- Fabiana Arieti
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Siri Göpel
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany.,German Centre for Infection Research (DZIF), Clinical Research Unit for healthcare associated infections, Tübingen, Germany
| | - Marcella Sibani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elena Carrara
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Rita Murri
- Institute of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Universitá Cattolica del Sacro Cuore, Rome, Italy
| | - Nico T Mutters
- Institute of Hygiene and Public Health, Bonn University Hospital, Bonn, Germany
| | - Lorena Lòpez-Cerero
- Microbiology and Infectious Diseases Unit, University Hospital Virgen Macarena, Sevilla, Spain
| | - Andreas Voss
- Department of Clinical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Roberto Cauda
- Institute of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Universitá Cattolica del Sacro Cuore, Rome, Italy
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.,Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany.,German Centre for Infection Research (DZIF), Clinical Research Unit for healthcare associated infections, Tübingen, Germany
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11
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Sibani M, Mazzaferri F, Carrara E, Pezzani MD, Arieti F, Göpel S, Paul M, Tacconelli E, Mutters NT, Voss A. White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in long-term care facilities-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks. J Antimicrob Chemother 2020; 75:ii33-ii41. [PMID: 33280047 PMCID: PMC7719406 DOI: 10.1093/jac/dkaa427] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In long-term care facilities (LTCFs) residents often receive inappropriate antibiotic treatment and infection prevention and control practices are frequently inadequate, thus favouring acquisition of MDR organisms. There is increasing evidence in the literature describing antimicrobial stewardship (AMS) activities in LTCFs, but practical guidance on how surveillance data should be linked with AMS activities in this setting is lacking. To bridge this gap, the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks joined their efforts to provide practical guidance for linking surveillance data with AMS activities. MATERIALS AND METHODS Considering the three main topics [AMS leadership and accountability, antimicrobial usage (AMU) and AMS, and antimicrobial resistance (AMR) and AMS], a literature review was performed and a list of target actions was developed. Consensus on target actions was reached through a RAND-modified Delphi process involving 40 experts from 18 countries and different professional backgrounds adopting a One Health approach. RESULTS From the 25 documents identified, 25 target actions were retrieved and proposed for expert evaluation. The consensus process produced a practical checklist including 23 target actions, differentiating between essential and desirable targets according to clinical relevance and feasibility. Flexible proposals for AMS team composition and leadership were provided, with a strong emphasis on the need for well-defined and adequately supported roles and responsibilities. Specific antimicrobial classes, AMU metrics, pathogens and resistance patterns to be monitored are addressed. Effective reporting strategies are described. CONCLUSIONS The proposed checklist represents a practical tool to support local AMS teams across a wide range of care delivery organization and availability of resources.
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Affiliation(s)
- Marcella Sibani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Fulvia Mazzaferri
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elena Carrara
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Fabiana Arieti
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Siri Göpel
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
- German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany
| | - Mical Paul
- Diseases Institute, Rambam Health Care Campus, Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
- German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany
| | - Nico T Mutters
- Institute for Hygiene and Public Health, Bonn University Hospital, Bonn, Germany
| | - Andreas Voss
- Department of Medical Microbiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Compri M, Mader R, Mazzolini E, de Angelis G, Mutters NT, Babu Rajendran N, Galia L, Tacconelli E, Schrijver R. White Paper: Bridging the gap between surveillance data and antimicrobial stewardship in the animal sector-practical guidance from the JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks. J Antimicrob Chemother 2020; 75:ii52-ii66. [PMID: 33280048 PMCID: PMC7719408 DOI: 10.1093/jac/dkaa429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The JPIAMR ARCH and COMBACTE-MAGNET EPI-Net networks have joined efforts to formulate a set of target actions to link the surveillance of antimicrobial usage (AMU) and antimicrobial resistance (AMR) with antimicrobial stewardship (AMS) activities in four different settings. This White Paper focuses on the veterinary setting and embraces the One Health approach. METHODS A review of the literature was carried out addressing research questions in three areas: AMS leadership and accountability; AMU surveillance and AMS; and AMR surveillance and AMS. Consensus on target actions was reached through a RAND-modified Delphi process involving over 40 experts in infectious diseases, clinical microbiology, AMS, veterinary medicine and public health, from 18 countries. RESULTS/DISCUSSION Forty-six target actions were developed and qualified as essential or desirable. Essential actions included the setup of AMS teams in all veterinary settings, building government-supported AMS programmes and following specific requirements on the production, collection and communication of AMU and AMR data. Activities of AMS teams should be tailored to the local situation and capacities, and be linked to local or national surveillance systems and infection control programmes. Several research priorities were also identified, such as the need to develop more clinical breakpoints in veterinary medicine. CONCLUSIONS This White Paper offers a practical tool to veterinary practitioners and policy makers to improve AMS in the One Health approach, thanks to surveillance data generated in the veterinary setting. This work may also be useful to medical doctors wishing to better understand the specificities of the veterinary setting and facilitate cross-sectoral collaborations.
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Affiliation(s)
- Monica Compri
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Rodolphe Mader
- University of Lyon, French Agency for Food, Environmental and Occupational Health and Safety (ANSES), Laboratory of Lyon, Antimicrobial Resistance and Bacterial Virulence Unit, Lyon, France
| | - Elena Mazzolini
- Department of Epidemiology, Istituto Zooprofilattico Sperimentale delle Venezie, Legnaro, Padua, Italy
| | - Giulia de Angelis
- Dipartimento di Scienze Biotecnologiche di base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Nico T Mutters
- Institute for Hygiene and Public Health, Bonn University Hospital, Bonn, Germany
| | - Nithya Babu Rajendran
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
- German Centre for Infection Research (DZIF), Clinical Research Unit for healthcare associated infections, Tübingen, Germany
| | - Liliana Galia
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
- German Centre for Infection Research (DZIF), Clinical Research Unit for healthcare associated infections, Tübingen, Germany
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