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Madran B, Keske Ş, Ferhanoğlu B, Mandel NM, Ergönül Ö. The long-term impact of an antimicrobial stewardship program in febrile neutropenia: an 8 years follow up. Eur J Clin Microbiol Infect Dis 2024:10.1007/s10096-024-04939-z. [PMID: 39264372 DOI: 10.1007/s10096-024-04939-z] [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: 07/04/2024] [Accepted: 09/04/2024] [Indexed: 09/13/2024]
Abstract
PURPOSE To describe the long-term effects of an ASP among febrile neutropenia (FN) patients. METHODS A quasi-experimental study was conducted between 2015 and 2023 at a tertiary care hospital in Istanbul, Türkiye. The ASP was implemented for FN patients, and the effects were assessed before and after the ASP interventions, which included FN clinical pathways and regular multi-disciplinary meetings with relevant healthcare workers. RESULTS A total of 489 FN episodes of 290 patients were included, 42% were female, and the mean age was 56 years (SD: 15, range: 18-89 years). After the intervention, the rate of appropriate antimicrobial therapy at the levels of starting (p = 0.005), switching (p < 0.001), and de-escalation/discontinuation, (p < 0.001) significantly increased. Another positive impact of the ASP was a significant reduction in candidemia (from 4.88 to 0.74, p = 0.004), as well as a significant reduction in the 90-day mortality rate (from 19 to 5%, p < 0.001). In multivariate analysis, having a gram-negative bloodstream infection, prolonged days with fever, and a high risk for neutropenia were found to be significant predictors of 90-day mortality, while follow-up with ASP significantly reduced mortality. CONCLUSION Implementation of ASP led to reduced candidemia and LOS without increasing mortality, even in a country with a high rate of antimicrobial resistance. Implementation of sustainable ASP for FN patients is critical in combating antimicrobial resistance.
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Affiliation(s)
- Bahar Madran
- Department of Public Health, Koç University School of Medicine, Istanbul, Türkiye
- Koç University İşbank Center for Infectious Diseases, Istanbul, Türkiye
| | - Şiran Keske
- Koç University İşbank Center for Infectious Diseases, Istanbul, Türkiye
- Department of Infectious Diseases and Clinical Microbiology, Koç University School of Medicine, Istanbul, Türkiye
| | | | - Nil M Mandel
- Medical Oncology Department, American Hospital, Istanbul, Türkiye
| | - Önder Ergönül
- Koç University İşbank Center for Infectious Diseases, Istanbul, Türkiye.
- Department of Infectious Diseases and Clinical Microbiology, Koç University School of Medicine, Istanbul, Türkiye.
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Herrera F, Torres D, Laborde A, Jordán R, Tula L, Mañez N, Pereyra ML, Suchowiercha N, Berruezo L, Gudiol C, Ibáñez MLG, Eusebio MJ, Lambert S, Barcán L, Rossi IR, Nicola F, Pennini M, Monge R, Blanco M, Visús M, Reynaldi M, Carbone R, Pasterán F, Corso A, Rapoport M, Carena AA. Seven-day antibiotic therapy for Enterobacterales bacteremia in high-risk neutropenic patients: toward a new paradigm. Eur J Clin Microbiol Infect Dis 2024; 43:1741-1751. [PMID: 38958809 DOI: 10.1007/s10096-024-04885-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/25/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE Data on short courses of antibiotic therapy for Enterobacterales bacteremia in high-risk neutropenic patients are limited. The aim of the study was to describe and compare the frequency of bacteremia relapse, 30-day overall and infection-related mortality, Clostridiodes difficile infection and length of hospital stay since bacteremia among those who received antibiotic therapy for 7 or 14 days. METHODS This is a multicenter, prospective, observational cohort study in adult high-risk neutropenic patients with hematologic malignancies or hematopoietic stem cell transplant and monomicrobial Enterobacterales bacteremia. They received appropriate empirical antibiotic therapy, had a clinical response within 7 days, and infection source control. Clinical, epidemiological and outcomes variables were compared based on 7 or 14 days of AT. RESULTS Two hundred patients were included (100, 7-day antibiotic therapy; 100, 14-day antibiotic therapy). Escherichia coli was the pathogen most frequently isolated (47.5%), followed by Klebsiella sp. (40.5%). Among those patients that received 7-day vs. 14-day antibiotic course, a clinical source of bacteremia was found in 54% vs. 57% (p = 0.66), multidrug-resistant Enterobacterales isolates in 28% vs. 30% (p = 0.75), and 40% vs. 47% (p = 0.31) received combined empirical antibiotic therapy. Overall mortality was 3% vs. 1% (p = 0.62), in no case related to infection; bacteremia relapse was 7% vs. 2% (p = 0.17), and length of hospital stay since bacteremia had a median of 9 days (IQR: 7-15) vs. 14 days (IQR: 13-22) (p = < 0.001). CONCLUSIONS These data suggest that seven-day antibiotic therapy might be adequate for patients with high-risk neutropenia and Enterobacterales bacteremia, who receive appropriate empirical therapy, with clinical response and infection source control.
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Affiliation(s)
- Fabián Herrera
- Infectious Diseases Section, Internal Medicine Department, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Av. Galván 4102 (C1431), Buenos Aires, Argentina.
| | - Diego Torres
- Infectious Diseases Section, Internal Medicine Department, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Av. Galván 4102 (C1431), Buenos Aires, Argentina
| | - Ana Laborde
- Infectious Diseases Service, Fundación Para Combatir La Leucemia (FUNDALEU), Buenos Aires, Argentina
| | - Rosana Jordán
- Infectious Diseases Service, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Lucas Tula
- Infectious Diseases Service, Hospital de Alta Complejidad El Cruce, Buenos Aires, Argentina
| | - Noelia Mañez
- Infectious Diseases Section, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - María Laura Pereyra
- Infectious Diseases Service, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Nadia Suchowiercha
- Infectious Diseases Service, Hospital Interzonal General de Agudos (HIGA) Gral. San Martín de La Plata, Buenos Aires, Argentina
| | - Lorena Berruezo
- Infectious Diseases Service, Hospital Interzonal General de Agudos (HIGA), Prof. Dr. Rodolfo Rossi de La Plata, Buenos Aires, Argentina
| | - Carlota Gudiol
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, Barcelona, España
| | - María Luz González Ibáñez
- Infectious Diseases Service, Fundación Para Combatir La Leucemia (FUNDALEU), Buenos Aires, Argentina
| | - María José Eusebio
- Infectious Diseases Service, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Sandra Lambert
- Infectious Diseases Service, Hospital de Alta Complejidad El Cruce, Buenos Aires, Argentina
| | - Laura Barcán
- Infectious Diseases Section, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Inés Roccia Rossi
- Infectious Diseases Service, Hospital Interzonal General de Agudos (HIGA) Gral. San Martín de La Plata, Buenos Aires, Argentina
| | - Federico Nicola
- Microbiology Laboratory, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - Magdalena Pennini
- Microbiology Laboratory, Centro de Estudios Infectológicos (CEI) Dr. Stamboulian, Buenos Aires, Argentina
| | - Renata Monge
- Microbiology Service, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Miriam Blanco
- Microbiology Laboratory, Hospital de Alta Complejidad El Cruce, Buenos Aires, Argentina
| | - Mariángeles Visús
- Bacteriology Laboratory, Central Laboratory, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Mariana Reynaldi
- Microbiology Laboratory, Hospital Interzonal General de Agudos (HIGA), Gral. San Martín de La Plata, Buenos Aires, Argentina
| | - Ruth Carbone
- Bacteriology Laboratory, Hospital Interzonal General de Agudos (HIGA) Prof. Dr. Rodolfo Rossi de La Plata, Buenos Aires, Argentina
| | - Fernando Pasterán
- Antimicrobials Service, INEI-ANLIS Dr. Carlos Malbrán, Buenos Aires, Argentina
| | - Alejandra Corso
- Antimicrobials Service, INEI-ANLIS Dr. Carlos Malbrán, Buenos Aires, Argentina
| | - Melina Rapoport
- Antimicrobials Service, INEI-ANLIS Dr. Carlos Malbrán, Buenos Aires, Argentina
| | - Alberto Angel Carena
- Infectious Diseases Section, Internal Medicine Department, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Av. Galván 4102 (C1431), Buenos Aires, Argentina
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Wang X, Arya SV, Patel S, Saw S, Decena MA, Hirsh R, Pegues DA, Ziegler MJ. Antibiotic practice and stewardship in the management of neutropenic fever: a survey of US institutions. Infect Control Hosp Epidemiol 2024:1-8. [PMID: 39087709 DOI: 10.1017/ice.2024.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
OBJECTIVE To describe neutropenic fever management practices among healthcare institutions. DESIGN Survey. PARTICIPANTS Members of the Society for Healthcare Epidemiology of America Research Network (SRN) representing healthcare institutions within the United States. METHODS An electronic survey was distributed to SRN representatives, with questions pertaining to demographics, antimicrobial prophylaxis, supportive care, and neutropenic fever management. The survey was distributed from fall 2022 through spring 2023. RESULTS 40 complete responses were recorded (54.8% response rate), with respondent institutions accounting for approximately 15.7% of 2021 US hematologic malignancy hospitalizations and 14.9% of 2020 US bone marrow transplantations. Most entities have institutional guidelines for neutropenic fever management (35, 87.5%) and prophylaxis (31, 77.5%), and first-line treatment included IV antipseudomonal antibiotics (35, 87.5% cephalosporin; 5, 12.5% penicillin; 0, 0% carbapenem).We observed significant heterogeneity in treatment course decisions, with roughly half (18, 45.0%) of respondents continuing antibiotics until neutrophil recovery, while the remainder having criteria for de-escalation prior to neutrophil recovery. Respondents were more willing to de-escalate prior to neutrophil recovery in patients with identified clinical (27, 67.5% with pneumonia) or microbiological (30, 75.0% with bacteremia) sources after dedicated treatment courses. CONCLUSIONS We found substantial variation in the practice of de-escalation of empiric antibiotics relative to neutrophil recovery, highlighting a need for more robust evidence for and adoption of this practice. No respondents use carbapenems as first-line therapy, comparing favorably to prior survey studies conducted in other countries.
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Affiliation(s)
- Xiao Wang
- Division of Hematology & Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Swarn V Arya
- Division of Hospital Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sonal Patel
- Department of Pharmacy, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen Saw
- Department of Pharmacy, University of Pennsylvania, Philadelphia, PA, USA
| | - Mary A Decena
- Division of Hematology & Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca Hirsh
- Division of Hematology & Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew J Ziegler
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Tanzarella ES, Cutuli SL, Lombardi G, Cammarota F, Caroli A, Franchini E, Sancho Ferrando E, Grieco DL, Antonelli M, De Pascale G. Antimicrobial De-Escalation in Critically Ill Patients. Antibiotics (Basel) 2024; 13:375. [PMID: 38667051 PMCID: PMC11047373 DOI: 10.3390/antibiotics13040375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/03/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
Antimicrobial de-escalation (ADE) is defined as the discontinuation of one or more antimicrobials in empirical therapy, or the replacement of a broad-spectrum antimicrobial with a narrower-spectrum antimicrobial. The aim of this review is to provide an overview of the available literature on the effectiveness and safety of ADE in critically ill patients, with a focus on special conditions such as anti-fungal therapy and high-risk categories. Although it is widely considered a safe strategy for antimicrobial stewardship (AMS), to date, there has been no assessment of the effect of de-escalation on the development of resistance. Conversely, some authors suggest that prolonged antibiotic treatment may be a side effect of de-escalation, especially in high-risk categories such as neutropenic critically ill patients and intra-abdominal infections (IAIs). Moreover, microbiological documentation is crucial for increasing ADE rates in critically ill patients with infections, and efforts should be focused on exploring new diagnostic tools to accelerate pathogen identification. For these reasons, ADE can be safely used in patients with infections, as confirmed by high-quality and reliable microbiological samplings, although further studies are warranted to clarify its applicability in selected populations.
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Affiliation(s)
- Eloisa Sofia Tanzarella
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Gianmarco Lombardi
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Fabiola Cammarota
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Alessandro Caroli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Emanuele Franchini
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | | | - Domenico Luca Grieco
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Massimo Antonelli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Gennaro De Pascale
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
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5
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Stohs EJ, Abbas A, Freifeld A. Approach to febrile neutropenia in patients undergoing treatments for hematologic malignancies. Transpl Infect Dis 2024; 26:e14236. [PMID: 38349035 DOI: 10.1111/tid.14236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 04/12/2024]
Abstract
Febrile neutropenia (FN) is common among hematologic malignancy patients, including recipients of hematopoietic cell transplantation (HCT) and cellular therapies such as chimeric antigen receptor (CAR)-T-cell therapy. Prompt empiric antibiotic use has been the mainstay for decades but a "one-size-fits-all" approach is no longer broadly accepted, as treatment-related infectious risk are more understood. Growing antimicrobial resistance is an increasing clinical challenge. Evolving strategies on de-escalation of broad-spectrum antibiotics in FN without identified infection are areas of particular interest.
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Affiliation(s)
- Erica J Stohs
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Anum Abbas
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Alison Freifeld
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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6
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Durand C, Risso K, Loschi M, Retur N, Emery A, Courjon J, Cluzeau T, Carles M. Efficacy of an antimicrobial stewardship intervention for early adaptation of antibiotic therapy in high-risk neutropenic patients. Antimicrob Resist Infect Control 2024; 13:5. [PMID: 38233960 PMCID: PMC10795280 DOI: 10.1186/s13756-023-01354-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/11/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND The 4th European Conference on Infections in Leukemia recommends early adaptation of empirical antibiotic therapy (EAT) for febrile neutropenia in stable patients. OBJECTIVES To assess the efficacy of an antimicrobial stewardship (AMS) intervention promoting early de-escalation and discontinuation of EAT in high-risk neutropenic patients. METHODS This before-after study was conducted in the hematology department of the University Hospital of Nice, France. The AMS intervention included the development of clinical decision support algorithms, a twice-weekly face-to-face review of all antibiotic prescriptions and monthly feedback on the intervention. The primary endpoint was overall antibiotic consumption during hospital stay, expressed as days of therapy (DOT). RESULTS A total of 113 admissions were included: 56 during the pre-intervention period and 57 during the intervention period. Induction chemotherapy and conditioning for allogeneic stem cell transplantation were the most frequent reasons for admission. In the intervention period, there was a significant decrease in overall antibiotic consumption (median DOT 20 vs. 28 days, p = 0.006), carbapenem consumption (median DOT 5.5 vs. 9 days, p = 0.017) and anti-resistant Gram-positive agents consumption (median DOT 8 vs. 11.5 days, p = 0.017). We found no statistical difference in the rates of intensive care unit admission (9% in each period) and 30-day mortality (5% vs. 0%, p = 0.243). Compliance with de-escalation and discontinuation strategies was significantly higher in the intervention period (77% vs. 8%, p < 0.001). CONCLUSION A multifaceted AMS intervention led to high compliance with early de-escalation and discontinuation of EAT and lower overall antibiotic consumption, without negatively affecting clinical outcomes.
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Affiliation(s)
- Claire Durand
- Infectious Disease Department, University Hospital of Nice, Cote D'Azur University, Nice, France.
| | - Karine Risso
- Infectious Disease Department, University Hospital of Nice, Cote D'Azur University, Nice, France
| | - Michael Loschi
- Hematology Department, University Hospital of Nice, Cote D'Azur University, Nice, France
- Université Côte d'Azur, INSERM U1065, Cote D'Azur University, Nice, C3M, France
| | - Nicolas Retur
- Pharmacy Department, University Hospital of Nice, Cote D'Azur University, Nice, France
| | - Audrey Emery
- Bacteriology Department, University Hospital of Nice, Cote D'Azur University, Nice, France
| | - Johan Courjon
- Infectious Disease Department, University Hospital of Nice, Cote D'Azur University, Nice, France
- Université Côte d'Azur, INSERM U1065, Cote D'Azur University, Nice, C3M, France
| | - Thomas Cluzeau
- Hematology Department, University Hospital of Nice, Cote D'Azur University, Nice, France
- Université Côte d'Azur, INSERM U1065, Cote D'Azur University, Nice, C3M, France
| | - Michel Carles
- Infectious Disease Department, University Hospital of Nice, Cote D'Azur University, Nice, France
- Université Côte d'Azur, INSERM U1065, Cote D'Azur University, Nice, C3M, France
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7
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Hand J, Imlay H. Antimicrobial Stewardship in Immunocompromised Patients: Current State and Future Opportunities. Infect Dis Clin North Am 2023; 37:823-851. [PMID: 37741735 DOI: 10.1016/j.idc.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2023]
Abstract
Immunocompromised (IC) patients are high risk for complications due to a high rate of antibiotic exposure. Antimicrobial stewardship interventions targeted to IC patients can be challenging due to limited data in this population and a high risk of severe infection-related outcomes. Here, the authors review immunocompromised antimicrobial stewardship barriers, metrics, and opportunities for antimicrobial use and testing optimization. Last, the authors highlight future steps in the field.
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Affiliation(s)
- Jonathan Hand
- Ochsner Health, New Orleans, LA, USA; University of Queensland School of Medicine, Ochsner Clinical School
| | - Hannah Imlay
- University of Utah Department of Internal Medicine, Salt Lake City, UT, USA.
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8
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Huggins J, Barnett I, David MZ. Effects of antimicrobial therapy duration and class on risk of antimicrobial-resistant Gram-negative bacillus bloodstream infection in patients with AML. Transpl Infect Dis 2023; 25:e14115. [PMID: 37577960 DOI: 10.1111/tid.14115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/06/2023] [Accepted: 07/28/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Antimicrobial-resistant Gram-negative bacilli (ARGNB) bloodstream infection (BSI) has been associated with prior antibiotic exposure among hematologic malignancy patients. The relationships between days of therapy (DOT), antimicrobial class, and ARGNB BSI risk are poorly understood. METHODS This is a single-center, case-control study of acute myeloid leukemia (AML) patients including 115 cases with ARGNB BSI and 230 matched controls with non-ARGNB BSI between January 1, 2007 and December 31, 2018. Fixed- and mixed-effects logistic regression was used to examine relationships between antibiotic DOT and risk of ARGNB BSI. Admission to an intensive care unit (ICU) within 7 days, 30-day mortality, and Pitt Bacteremia Score (PBS) were secondary outcomes. RESULTS Prior isolation of a antimicrobial-resistant organism (ARO) (OR 4.45 95% CI 1.46, 13.54), surgery within 90 days (OR 3.71, 95% CI 1.57, 8.73), aminoglycoside DOT (OR 1.14, 95% CI 1.05, 1.23), cefepime DOT (OR 1.09, 95% CI 1.05, 1.13), and carbapenem DOT (OR 1.10, 95% CI 1.05, 1.16) were associated with increased odds of ARGNB BSI. Days since last antibiotic administration (OR 0.98, 95% CI 0.97, 0.99) and inpatient days within 90 days (OR 0.95, 95% CI 0.93, 0.98) showed reduced odds of ARGNB BSI. Total antimicrobial DOT regardless of class was not associated with ARGNB BSI. ARGNB BSI was associated with increased 30-day mortality (OR 2.86, 95% CI 1.57, 5.22) CONCLUSIONS: Among AML patients with GNB BSI, greater DOT of aminoglycosides, cefepime, and carbapenems in the 90 days prior to BSI were associated with increased odds of ARGNB BSI.
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Affiliation(s)
- Jonathan Huggins
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Duke University School of Medicine, Duke University, Durham, North Carolina, USA
| | - Ian Barnett
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Z David
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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9
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Ram R, Amit O, Adler A, Bar-On Y, Beyar-Katz O, Avivi I, Shasha D, Ben-Ami R. Early Antibiotic Deescalation and Discontinuation in Patients with Febrile Neutropenia after Cellular Therapy: A Single-Center Prospective Unblinded Randomized Trial. Transplant Cell Ther 2023; 29:708.e1-708.e8. [PMID: 37591446 DOI: 10.1016/j.jtct.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023]
Abstract
The optimal duration of empiric antimicrobial therapy of febrile neutropenia in patients after cellular therapy is unclear. Early deescalation has been suggested by some authorities; however, data are lacking for cellular therapy recipients. We performed a randomized controlled study of cellular therapy recipients with febrile neutropenia to evaluate the safety and noninferiority of an early deescalation and discontinuation antibiotic strategy (EDD arm) versus standard broad-spectrum antibiotic treatment until recovery of neutropenia (standard duration arm). The primary outcome was the fraction of antibiotic-free neutropenia days. We randomized 110 patients to the standard duration arm (n = 51) or EDD arm (n = 59). The fraction of antibiotic-free neutropenia days was higher in the EDD arm compared to the standard duration arm (median, .8 [interquartile range (IQR), .62 to .86] versus .51 [IQR, .17 to .86]; P = .016). This was true for the per-protocol, allogeneic hematopoietic cell transplantation (HCT), autologous HCT, and anti-CD19 chimeric antigen receptor T cell therapy subgroups. Treatment success rate, subsequent fever, death within 30 days, and other common cellular therapy-related toxicities were all similar between the 2 study arms. An EDD antibiotic strategy in patients after cellular therapy was safe and associated with a substantial reduction in broad-spectrum antibiotic utilization without compromising cellular therapy outcomes.
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Affiliation(s)
- Ron Ram
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Odelia Amit
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amos Adler
- Infection Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Bar-On
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofrat Beyar-Katz
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Avivi
- Bone Marrow Transplantation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Shasha
- Infection Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Ben-Ami
- Infection Disease Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty Of Medicine, Tel Aviv University, Tel Aviv, Israel
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Yoo JS, Park JY, Chun HJ, Kim YR, Kim EJ, Choi YH, Ha KH, Heo JY. Impact of prolonged carbapenem use-focused antimicrobial stewardship on antimicrobial consumption and factors affecting acceptance of recommendations: a quasi-experimental study. Sci Rep 2023; 13:14501. [PMID: 37666900 PMCID: PMC10477184 DOI: 10.1038/s41598-023-41710-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/30/2023] [Indexed: 09/06/2023] Open
Abstract
This study aimed to assess the impact of a prolonged carbapenem use-focused antimicrobial stewardship program (ASP) on antimicrobial consumption and clinical outcomes and to analyze factors affecting adherence to interventions. Patients prescribed carbapenems for ≥ 2 weeks received intervention. Interrupted time-series analysis was performed to compare antimicrobial consumption before and after intervention. Factors associated with non-adherence to intervention were investigated. Of 273 patients who were eligible for intervention, discontinuation or de-escalation was recommended in 256 (94.1%) and intervention was accepted in 136 (53.1%) patients. Before intervention, carbapenem consumption significantly increased to 1.14 days of therapy (DOT)/1000 patient days (PD)/month (P = 0.018). However, it significantly declined by - 2.01 DOT/1000 PD/month without an increase in other antibiotic consumption (P < 0.001). Factors affecting non-adherence to intervention were younger age (odds ratio [OR] = 0.98; 95% confidence interval [CI] 0.96-1.00), solid organ malignancy (OR = 2.53, 95% CI 1.16-5.50), and pneumonia (OR = 2.59, 95% CI 1.08-6.17). However, ASP intervention was not associated with clinical outcomes such as length of hospital stay or mortality. Prolonged carbapenem prescription-focused ASP significantly reduced carbapenem consumption without adverse outcomes. Non-adherence to interventions was attributed more to prescriber-related factors, such as attitude, than patient-related factors including clinical severity.
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Affiliation(s)
- Jin Sae Yoo
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
- Department of Acute Care Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jeong Yong Park
- Department of Pharmaceutical Service, Ajou University Hospital, Suwon, Republic of Korea
| | - Ha-Jin Chun
- Department of Pharmaceutical Service, Ajou University Hospital, Suwon, Republic of Korea
| | - Young Rong Kim
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Eun Jin Kim
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Young Hwa Choi
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Kyoung Hwa Ha
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea.
| | - Jung Yeon Heo
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea.
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11
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Bansal N, Sachdeva N, Bhurani D, Agarwal N, Ahmed R, Mehta P, Halder R. Effect of antibiotic de-escalation on clinical outcomes in patients with carbapenem-resistant Enterobacteriaceae bacteremia (CRE) in the hematology-oncology setting. Germs 2023; 13:221-228. [PMID: 38146379 PMCID: PMC10748835 DOI: 10.18683/germs.2023.1388] [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: 12/07/2022] [Revised: 05/25/2023] [Accepted: 07/10/2023] [Indexed: 12/27/2023]
Abstract
Introduction Carbapenem-resistant Enterobacteriaceae (CRE) infections are associated with poor outcomes, particularly among hematology-oncology patients. Appropriate use (selection and de-escalation) of antibiotics is a key component of management of febrile neutropenia particularly in high CRE prevalence regions like India. Methods This was a retrospective study done (April 2019-December 2021) in a dedicated oncology center in North India, which assessed the case records of the patients undergoing therapy for hematological malignancies who were diagnosed with CRE bacteremia. Demographic, clinical and microbiological data, as well as antibiotic prescription patterns were studied. Inter-group analysis was done between an antibiotic stewardship cohort (avoiding CRE therapy empirically or stopping CRE therapy if cultures negative; as per suggestions of the AMS team) and a non-antibiotic stewardship cohort (continuation of empirical CRE therapy; de-escalation advice was not followed). Results A total of 139 patients were identified, with median age of 41 years (range 13-74) out of which 82 (58.9%) were males. Acute myeloid leukemia (66.2%) was the most common malignancy, followed by lymphoma (8.6%) and myeloma (8.6%). Nearly 30% of patients were post allogenic stem cell transplant. Klebsiella pneumoniae was the predominant organism (78.4%) and combination of NDM+OXA-48 (46.3%) was the most common carbapenemase gene detected followed by OXA-48 alone (34.7%). Overall, 28-day mortality was 26.6%. On binary logistic regression analysis, lack of compliance with antibiotic stewardship intervention was an independent predictor of mortality (p=0.005). Conclusions Prior exposure to empirical CRE therapy or failure to de-escalate was associated with poor outcomes in patients with CRE bacteremia, which gives us a window of antibiotic stewardship in febrile neutropenia.
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Affiliation(s)
- Nitin Bansal
- MD Infectious Diseases, Rajiv Gandhi Cancer Institute, Sir Chotu Ram Marg, Rohini, Sector 5, New Delhi, 110085, India
| | - Neelam Sachdeva
- MD Microbiology, Rajiv Gandhi Cancer Institute, Sir Chotu Ram Marg, Rohini, Sector 5, New Delhi, 110085, India
| | - Dinesh Bhurani
- MD, DM, Hematology, Rajiv Gandhi Cancer Institute, Sir Chotu Ram Marg, Rohini, Sector 5, New Delhi, 110085, India
| | - Narendra Agarwal
- MD, DM, Hematology, Rajiv Gandhi Cancer Institute, Sir Chotu Ram Marg, Rohini, Sector 5, New Delhi, 110085, India
| | - Rayaz Ahmed
- MD, DM, Hematology, Rajiv Gandhi Cancer Institute, Sir Chotu Ram Marg, Rohini, Sector 5, New Delhi, 110085, India
| | - Pallavi Mehta
- MD, DM, Hematology, Rajiv Gandhi Cancer Institute, Sir Chotu Ram Marg, Rohini, Sector 5, New Delhi, 110085, India
| | - Rohan Halder
- MD, DM, Hematology, Rajiv Gandhi Cancer Institute, Sir Chotu Ram Marg, Rohini, Sector 5, New Delhi, 110085, India
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12
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Sakaguchi M, Atsuta Y, Sekiya N, Najima Y, Fukushima K, Shingai N, Toya T, Kobayashi T, Ohashi K, Doki N. Clinical impact and early prediction of carbapenem-resistant Pseudomonas aeruginosa bacteraemia in allogeneic hematopoietic stem cell transplantation recipients. J Glob Antimicrob Resist 2023; 32:187-194. [PMID: 36806701 DOI: 10.1016/j.jgar.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/29/2023] [Accepted: 02/05/2023] [Indexed: 02/19/2023] Open
Abstract
OBJECTIVE Although antipseudomonal agents are administered in high-risk patients, no reports have focused on the risk of carbapenem-resistant (CR) Pseudomonas aeruginosa bacteraemia in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients. METHODS We retrospectively studied a cohort of adult allo-HSCT recipients with P. aeruginosa bacteraemia, focusing on a comparison between carbapenem-sensitive (CS) and CR P. aeruginosa after initiating conditioning chemotherapy at our institute between January 2005 and December 2020. The incidence, all-cause 30-d mortality of P. aeruginosa bacteraemia, and risk factors for carbapenem resistance among patients with P. aeruginosa bacteraemia in allo-HSCT recipients were evaluated. RESULTS Forty-eight patients with P. aeruginosa bacteraemia were included, with an incidence of 3.84/100 recipients (CS = 1.92 vs. CR = 1.92). The all-cause 30-d mortality was significantly higher in CR P. aeruginosa bacteraemia (CS = 4.2% vs. CR = 39.1%; P = 0.003). The factor significantly associated with CR P. aeruginosa bacteraemia was carbapenem use for at least 3 d within 30 d before the onset of bacteraemia (odds ratio = 8.92; 95% confidence interval: 1.35-58.90). Inappropriate antimicrobial selection was significantly more frequent in CR P. aeruginosa bacteraemia (CS = 0% vs. CR = 29.2%; P ˂ 0.009). CONCLUSION Empirical combination therapy with reference to antimicrobial susceptibility profiles in each institution should be considered when CR P. aeruginosa bacteraemia is suspected in allo-HSCT recipients based on the risk of carbapenem exposure.
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Affiliation(s)
- Masahiro Sakaguchi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan; Department of Infection Prevention and Control, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuya Atsuta
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Noritaka Sekiya
- Department of Infection Prevention and Control, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan; Department of Clinical Laboratory, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan.
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazuaki Fukushima
- Department of Infection Prevention and Control, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan; Department of Infectious Diseases, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Naoki Shingai
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takeshi Kobayashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
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13
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Shorter antibiotic courses in the immunocompromised: the impossible dream? Clin Microbiol Infect 2023; 29:143-149. [PMID: 35988852 DOI: 10.1016/j.cmi.2022.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND A growing number of studies have demonstrated similar outcomes with shorter courses of antibiotics for bacterial infections. Immunocompromised patients are frequently excluded from these studies despite anticipated benefits associated with shortening antibiotic courses (including lower risks of antibiotic toxicity, Clostridioides difficile infection, drug-resistant pathogens, and microbiome alterations). OBJECTIVES To critically review the literature that assesses shorter antibiotic courses in immunocompromised patients, specifically among solid organ transplant recipients and neutropenic fever (NF) syndromes among patients on antineoplastic chemotherapy and undergoing haematopoietic cell transplant. SOURCES References were identified through searches of PubMed, Embase, MEDLINE, and clinical guidelines documents. CONTENT Among organ transplant recipients, the majority of studies assessing outcomes associated with shorter antibiotic courses have been retrospective but have demonstrated similar rates of clinically relevant endpoints. Patients with high- and low-risk NF have been well-studied, including enrolment in randomized studies, albeit with heterogeneous patient populations and outcomes assessed. Clinical improvement-guided adoption of shorter courses has been associated with fewer antibiotic days and similar rates of fever recurrence and mortality. IMPLICATIONS Similar to studies demonstrating efficacy in immunocompetent patients, shorter antibiotic courses should be considered for immunocompromised hosts with presumed bacterial infections. Organ recipients and patients with NF syndromes should be prioritized for study in randomized controlled clinical trials assessing shorter course therapy.
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14
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Gorsline CA, Miller RM, Bobbitt LJ, Satyanarayana G, Baljevic M, Staub MBO. Development and implementation of "handshake rounds": An antibiotic stewardship intervention for hospitalized adult patients with hematologic malignancies. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e76. [PMID: 37113201 PMCID: PMC10127239 DOI: 10.1017/ash.2023.125] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/14/2023] [Accepted: 01/17/2023] [Indexed: 04/29/2023]
Abstract
Objective To design and implement "handshake rounds" as an antibiotic stewardship intervention to reduce inpatient intravenous (IV) antibiotic use in patients with hematologic malignancies. Design Quasi-experimental analysis of antibiotic use (AU) and secondary outcomes before and and after handshake rounds were implemented. Setting Quaternary-care, academic medical center. Patients Hospitalized adults with hematologic malignancies receiving IV antibiotics. Methods We performed a retrospective review of a preintervention cohort prior to the intervention. A multidisciplinary team developed criteria for de-escalation of antibiotics, logistics of handshake rounds, and outcome metrics. Eligible patients were discussed during scheduled handshake rounds between a hematology-oncology pharmacist and transplant-infectious diseases (TID) physician. Prospective data were collected over 30 days in the postintervention cohort. Due to small sample size, 2:1 matching was used to compare pre- to and postintervention AU. Total AU in days of therapy per 1,000 patient days (DOT/1,000 PD) was reported. Mean AU per patient was analyzed using Wilcoxon rank-sum test. A descriptive analysis of secondary outcomes of pre- and postintervention cohorts was performed. Results Total AU was substantially lower after the intervention, with 517 DOT/1,000 PD compared to 865 DOT/1,000 PD before the intervention. There was no statistically significant difference in the mean AU per patient between the 2 cohorts. There was a lower rate of 30-day mortality in the postintervention cohort and rates of ICU admissions were similar. Conclusions Conducting handshake rounds is a safe and effective way to implement an antibiotic stewardship intervention among high-risk patient population such as those with hematologic malignancies.
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Affiliation(s)
- Chelsea A. Gorsline
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Infectious Diseases, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas
- Author for correspondence: Chelsea A. Gorsline, MD, University of Kansas Medical Center, 2060 W 39th Ave, Kansas City, KS66103. E-mail:
| | - Ryan M. Miller
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Laura J. Bobbitt
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Muhamed Baljevic
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Milner B. O. Staub
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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15
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Davar K, Clark D, Centor RM, Dominguez F, Ghanem B, Lee R, Lee TC, McDonald EG, Phillips MC, Sendi P, Spellberg B. Can the Future of ID Escape the Inertial Dogma of Its Past? The Exemplars of Shorter Is Better and Oral Is the New IV. Open Forum Infect Dis 2022; 10:ofac706. [PMID: 36694838 PMCID: PMC9853939 DOI: 10.1093/ofid/ofac706] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/28/2022] [Indexed: 12/31/2022] Open
Abstract
Like all fields of medicine, Infectious Diseases is rife with dogma that underpins much clinical practice. In this study, we discuss 2 specific examples of historical practice that have been overturned recently by numerous prospective studies: traditional durations of antimicrobial therapy and the necessity of intravenous (IV)-only therapy for specific infectious syndromes. These dogmas are based on uncontrolled case series from >50 years ago, amplified by the opinions of eminent experts. In contrast, more than 120 modern, randomized controlled trials have established that shorter durations of therapy are equally effective for many infections. Furthermore, 21 concordant randomized controlled trials have demonstrated that oral antibiotic therapy is at least as effective as IV-only therapy for osteomyelitis, bacteremia, and endocarditis. Nevertheless, practitioners in many clinical settings remain refractory to adopting these changes. It is time for Infectious Diseases to move beyond its history of eminent opinion-based medicine and truly into the era of evidenced-based medicine.
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Affiliation(s)
- Kusha Davar
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Devin Clark
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Robert M Centor
- Department of Medicine, Birmingham Veterans Affairs (VA) Medical Center, Birmingham, Alabama, Birmingham, Alabama, USA
| | - Fernando Dominguez
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | | | - Rachael Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Todd C Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montreal, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Matthew C Phillips
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Brad Spellberg
- Correspondence: Brad Spellberg, MD, Hospital Administration, 2051 Marengo Street, Los Angeles, CA 90033 ()
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16
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Duration of antibiotic therapy in Gram-negative infections with a particular focus on multidrug-resistant pathogens. Curr Opin Infect Dis 2022; 35:614-620. [PMID: 35942853 DOI: 10.1097/qco.0000000000000861] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Antimicrobial overuse is a major health problem that contributes to antimicrobial resistance (AMR). Infections with Gram-negative bacilli (GNB) and multidrug-resistant organisms (MDRs) are associated with high morbidity and mortality, particularly in patients with underlying medical conditions. RECENT FINDINGS Although many recent studies have been published about the novel antibiotics in treating infections including those due to MDR-GNB, the optimal duration of treatment (DOT) remains inconclusive. Recent observation has supported that short antibiotic therapy (SAT) decreases AMR and adverse effects. This narrative review provides an overview of the most recent published studies on the duration of therapy in the treatment of GNB infections, including hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), intra-abdominal infections (IAIs), bloodstream infections (BSIs) and urinary tract infections (UTIs), with a particular focus on MDR-GNB. SUMMARY Studies showed different outcomes when comparing SAT to long antimicrobial therapy (LAT). No generalization can be made on all sites of infections and different GNBs. Further studies are needed to address the optimal DOT in MDR-GNB, as this group is underrepresented in recent studies.
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17
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Douglas A, Thursky K, Slavin M. New approaches to management of fever and neutropenia in high-risk patients. Curr Opin Infect Dis 2022; 35:500-516. [PMID: 35947070 DOI: 10.1097/qco.0000000000000872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Patients receiving treatment for acute leukaemia and haematopoietic cell transplantation (HCT) have prolonged neutropenia and are at high risk of neutropenic fever, with bacterial and particularly invasive fungal infections as feared complications, possessing potentially serious consequences including intensive care admission and mortality. Concerns for these serious complications often lead to long durations of broad-spectrum antimicrobial therapy and escalation to even broader therapy if fever persists. Further, the default approach is to continue neutropenic fever therapy until count recovery, leaving many patients who have long defervesced on prolonged antibiotics. RECENT FINDINGS This article details recent progress in this field with particular emphasis on early discontinuation studies in resolved neutropenic fever and improved imaging techniques for the investigation of those with persistent neutropenic fever. Recent randomized controlled trials have shown that early cessation of empiric neutropenic fever therapy is well tolerated in acute leukaemia and autologous HCT patients who are clinically stable and afebrile for 72 h. Delineation of the best approach to cessation (timing and/or use of fluoroquinolone prophylaxis) and whether this approach is well tolerated in the higher risk allogeneic HCT setting is still required. Recent RCT data demonstrate utility of FDG-PET/CT to guide management and rationalize antimicrobial therapy in high-risk patient groups with persistent neutropenic fever. SUMMARY Acute leukaemic and autologous HCT patients with resolved neutropenic fever prior to count recovery can have empiric therapy safely discontinued or de-escalated. There is an emerging role of FDG-PET/CT to support decision-making about antibiotic and antifungal use in high-risk persistent/recurrent neutropenic fever patients.
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Affiliation(s)
- Abby Douglas
- National Centre for Infections in Cancer.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne
| | - Karin Thursky
- National Centre for Infections in Cancer.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne.,National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne.,Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Monica Slavin
- National Centre for Infections in Cancer.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne.,Victorian Infectious Diseases Service, Royal Melbourne Hospital.,Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
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18
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Imlay H, Spellberg B. Shorter is better: The case for short antibiotic courses for common infections in solid organ transplant recipients. Transpl Infect Dis 2022; 24:e13896. [DOI: 10.1111/tid.13896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/09/2022] [Accepted: 06/17/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Hannah Imlay
- Department of Medicine University of Utah Salt Lake City Utah USA
| | - Brad Spellberg
- Los Angeles County and University of Southern California Medical Center Los Angeles California USA
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19
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Teh BW. The long and short of antibiotic management for neutropenic fever in patients with haematological malignancy. Lancet Haematol 2022; 9:e548-e549. [PMID: 35691327 DOI: 10.1016/s2352-3026(22)00179-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Benjamin W Teh
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, VIC 3000, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia.
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20
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Paret R, Le Bourgeois A, Guillerm G, Tessoulin B, Rezig S, Gastinne T, Couturier MA, Boutoille D, Lecomte R, Ader F, Le Gouill S, Ansart S, Talarmin JP, Gaborit B. Safety and risk of febrile recurrence after early antibiotic discontinuation in high-risk neutropenic patients with haematological malignancies: a multicentre observational study. J Antimicrob Chemother 2022; 77:2546-2556. [PMID: 35748614 DOI: 10.1093/jac/dkac190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 05/16/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Early antibiotic discontinuation according to the Fourth European Conference on Infections in Leukaemia (ECIL-4) recommendations is not systematically applied in high-risk neutropenic patients with haematological malignancies. METHODS A retrospective multicentre observational study was conducted over 2 years to evaluate the safety of early antibiotic discontinuation for fever of unknown origin (FUO) during neutropenia after induction chemotherapy or HSCT, in comparison with a historical cohort. We used Cox proportional hazards models, censored on neutropenia resolution, to analyse factors associated with febrile recurrence. RESULTS Among 147 included patients in the ECIL-4 cohort, mainly diagnosed with acute leukaemia (n = 104, 71%), antibiotics were discontinued during 170 post-chemotherapy neutropenic episodes. In comparison with the historical cohort of 178 episodes of neutropenia without antibiotic discontinuation, no significant differences were observed regarding febrile recurrences [71.2% (121/170) versus 71.3% (127/178), P = 0.97], admission in ICUs [6.5% (11/170) versus 11.2% (20/178), P = 0.17], septic shock [0.6% (1/170) versus 3.9% (7/178), P = 0.07] and 30 day mortality [1.4% (2/147) versus 2.7% (4/150), P = 0.084]. In the ECIL-4 cohort, the rate of bacteraemia in case of febrile recurrence was higher [27.1% (46/170) versus 11.8% (21/178), P < 0.01] and antibiotic consumption was significantly lower (15.5 versus 19.9 days, P < 0.001). After early antibiotic discontinuation according to ECIL-4 recommendations, enterocolitis was associated with febrile recurrence [HR = 2.31 (95% CI = 1.4-3.8), P < 0.001] and stage III-IV oral mucositis with bacteraemia [HR = 2.26 (95% CI = 1.22-4.2), P = 0.01]. CONCLUSIONS After an FUO episode in high-risk neutropenia, compliance with ECIL-4 recommendations for early antibiotic discontinuation appears to be safe and mucosal damage was associated with febrile recurrence and bacteraemia. Prospective interventional studies are warranted to assess this strategy in high-risk neutropenic patients.
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Affiliation(s)
- Raphael Paret
- Department of Infectious Diseases, University Hospital of Brest, Brest, France
| | - Amandine Le Bourgeois
- Department of Haematology, University Hospital of Nantes, INSERM CRCINA Nantes-Angers, NeXT Université de Nantes, Nantes, France
| | - Gaëlle Guillerm
- Department of Haematology, University Hospital of Brest, Brest, France
| | - Benoit Tessoulin
- Department of Haematology, University Hospital of Nantes, INSERM CRCINA Nantes-Angers, NeXT Université de Nantes, Nantes, France
| | - Schéhérazade Rezig
- Department of Infectious Diseases, University Hospital of Brest, Brest, France
| | - Thomas Gastinne
- Department of Haematology, University Hospital of Nantes, INSERM CRCINA Nantes-Angers, NeXT Université de Nantes, Nantes, France
| | | | - David Boutoille
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, Nantes, France.,Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000 Nantes, France
| | - Raphael Lecomte
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, Nantes, France
| | - Florence Ader
- Department of Infectious Diseases, University Hospital of Lyon, Lyon, France
| | - Steven Le Gouill
- Department of Haematology, University Hospital of Nantes, INSERM CRCINA Nantes-Angers, NeXT Université de Nantes, Nantes, France
| | - Séverine Ansart
- Department of Infectious Diseases, University Hospital of Brest, Brest, France
| | - Jean Philippe Talarmin
- Department of Internal Medicine, Infectious Diseases and Haematology, Cornouaille Hospital Quimper, Quimper, France
| | - Benjamin Gaborit
- Department of Infectious Diseases, University Hospital of Nantes and CIC 1413, Nantes, France.,Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, F-44000 Nantes, France
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21
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Keck JM, Wingler MJB, Cretella DA, Vijayvargiya P, Wagner JL, Barber KE, Jhaveri TA, Stover KR. Approach to fever in patients with neutropenia: a review of diagnosis and management. Ther Adv Infect Dis 2022; 9:20499361221138346. [DOI: 10.1177/20499361221138346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/22/2022] [Indexed: 11/28/2022] Open
Abstract
Febrile neutropenia (FN) is associated with mortality rates as high as 40%, highlighting the importance of appropriate clinical management in this patient population. The morbidity and mortality of FN can be attributed largely to infectious processes, with specific concern for infections caused by pathogens with antimicrobial resistance. Expeditious identification of responsible pathogens and subsequent initiation of empiric antimicrobial therapy is imperative. There are four commonly used guidelines, which have variable recommendations for empiric therapy in these populations. All agree that changes could be made once patients are stable and/or with an absolute neutrophil count (ANC) over 500 cells/mcL. Diagnostic advances have the potential to improve knowledge of pathogens responsible for FN and decrease time to results. In addition, more recent data show that rapid de-escalation or discontinuation of empiric therapy, regardless of ANC, may reduce days of therapy, adverse effects, and cost, without affecting clinical outcomes. Antimicrobial and diagnostic stewardship should be performed to identify, utilize, and respond to appropriate rapid diagnostic tests that will aid in the definitive management of this population.
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Affiliation(s)
- J. Myles Keck
- University of Mississippi Medical Center, Jackson, MS, USA
| | | | | | | | - Jamie L. Wagner
- University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - Katie E. Barber
- University of Mississippi School of Pharmacy, Jackson, MS, USA
| | | | - Kayla R. Stover
- School of Pharmacy, University of Mississippi, 2500 N State Street, Jackson, MS 39216, USA
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