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Metersky ML, Kalil AC. Management of Ventilator-Associated Pneumonia: Guidelines. Infect Dis Clin North Am 2024; 38:87-101. [PMID: 38280768 DOI: 10.1016/j.idc.2023.12.004] [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] [Indexed: 01/29/2024]
Abstract
Two recent major guidelines on diagnosis and treatment of ventilator-associated pneumonia (VAP) recommend consideration of local antibiotic resistance patterns and individual patient risks for resistant pathogens when formulating an initial empiric antibiotic regimen. One recommends against invasive diagnostic techniques with quantitative cultures to determine the cause of VAP; the other recommends either invasive or noninvasive techniques. Both guidelines recommend short-course therapy be used for most patients with VAP. Although neither guideline recommends use of procalcitonin as an adjunct to clinical judgment when diagnosing VAP, they differ with respect to use of serial procalcitonin to shorten the length of antibiotic treatment.
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Affiliation(s)
- Mark L Metersky
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT 06030-1321, USA.
| | - Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198, USA
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Zhao X, Ge Y, Zhang Y, Zhang W, Hu H, Li L, Sha T, Zeng Z, Wu F, Chen Z. Pathogen Diagnosis Value of Nanopore Sequencing in Severe Hospital-Acquired Pneumonia Patients. Infect Drug Resist 2023; 16:3293-3303. [PMID: 37260782 PMCID: PMC10228525 DOI: 10.2147/idr.s410593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/09/2023] [Indexed: 06/02/2023] Open
Abstract
Background Next-generation sequencing of the metagenome (mNGS) is increasingly used in pathogen diagnosis for infectious diseases due to its short detection time. The time for Oxford Nanopore Technologies (ONT) sequencing-based etiology detection is further shortened compared with that of mNGS, but only a few studies have verified the time advantage and accuracy of ONT sequencing for etiology diagnosis. In 2022, a study confirmed that there was no significant difference in sensitivity and specificity between ONT and mNGS in suspected community-acquired pneumonia patients, which there was no clinical study verified in patients with SHAP. Methods From October 24 to November 20, 2022, 10 patients with severe hospital-acquired pneumonia (SHAP) in the Nanfang Hospital intensive care unit (ICU) were prospectively enrolled. Bronchoalveolar lavage fluid (BALF) was collected for ONT sequencing, mNGS, and traditional culture. The differences in pathogen detection time and diagnostic agreement among ONT sequencing, mNGS, traditional culture method, and clinical composite diagnosis were compared. Results Compared with mNGS and the traditional culture method, ONT sequencing had a significant advantage in pathogen detection time (9.6±0.7 h versus 24.7±2.7 h versus 132±58 h, P <0.05). The agreement rate between ONT sequencing and the clinical composite diagnosis was 73.3% (kappa value=0.737, P <0.05). Conclusion ONT sequencing has a potential advantage for rapidly identifying pathogens.
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Affiliation(s)
- Xin Zhao
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
- The First Clinical Medical School, Southern Medical University, Guangzhou, People’s Republic of China
| | - Yue Ge
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
- Department of School of Nursing, Southern Medical University, Guangzhou, People’s Republic of China
| | - Yuan Zhang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - WenJie Zhang
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - HongBin Hu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - LuLan Li
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Tong Sha
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - ZhenHua Zeng
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Feng Wu
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - ZhongQing Chen
- Department of Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
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Zilberberg MD, Nathanson BH, Puzniak LA, Dillon RJ, Shorr AF. The risk of inappropriate empiric treatment and its outcomes based on pathogens in non-ventilated (nvHABP), ventilated (vHABP) hospital-acquired and ventilator-associated (VABP) bacterial pneumonia in the US, 2012-2019. BMC Infect Dis 2022; 22:775. [PMID: 36199012 PMCID: PMC9533487 DOI: 10.1186/s12879-022-07755-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Inappropriate empiric antimicrobial treatment (IET) contributes to worsened outcomes. While IET’s differential impact across types of nosocomial pneumonia (NP: non-ventilated [nvHABP], ventilated [vHABP] hospital-acquired and ventilator-associated [VABP] bacterial pneumonia) is established, its potential interaction with the bacterial etiology is less clear.
Methods We conducted a multicenter retrospective cohort study in the Premier Healthcare Database using an administrative algorithm to identify NP. We paired respective pathogens with empiric treatments. Antimicrobial coverage was appropriate if a drug administered within 2 days of infection onset covered the recovered organism(s). All other treatment was IET. Results Among 17,819 patients with NP, 26.5% had nvHABP, 25.6% vHABP, and 47.9% VABP. Gram-negative (GN) organisms accounted for > 50% of all infections. GN pathogens were ~ 2 × as likely (7.4% vHABP to 10.7% nvHABP) to engender IET than Gram-positive (GP, 2.9% vHABP to 4.9% nvHABP) pathogens. Although rare (5.6% nvHABP to 8.3% VABP), GN + GP infections had the highest rates of IET (6.7% vHABP to 12.9% nvHABP). Carbapenem-resistant GNs were highly likely to receive IET (33.8% nvHABP to 40.2% VABP). Hospital mortality trended higher in the IET group, reaching statistical significance in GN + GP vHABP (47.8% IET vs. 29.3% non-IET, p = 0.016). 30-day readmission was more common with IET (16.0%) than non-IET (12.6%, p = 0.024) in GN VABP. Generally post-infection onset hospital length of stay and costs were higher with IET than non-IET. Conclusions IET is ~ 2 × more common in GN than GP infections. Although the magnitude of its impact varies by NP type, IET contributes to worsened clinical and economic outcomes.
Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07755-y.
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Affiliation(s)
| | | | | | | | - Andrew F Shorr
- Washington Hospital Center, 110 Irving St. NW, Washington, DC, 20010, USA.
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Barrera-Robledo ME, Uribe-Caputi JC. Prevalencia y factores asociados a neumonía nosocomial en la unidad de cuidado intensivo. MEDUNAB 2022. [DOI: 10.29375/01237047.4099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Introducción. La neumonía nosocomial o neumonía adquirida en el hospital, es una causa importante de infección intrahospitalaria que conlleva una alta morbimortalidad. Ocurre a una tasa de 5 a 10 por cada 1,000 ingresos hospitalarios y se considera la causa más común de infección intrahospitalaria en Europa y Estados Unidos. Más del 90% de los episodios de neumonía que se desarrollan en las unidades de cuidados intensivos (UCI) ocurren en pacientes ventilados. El objetivo del presente estudio es describir la prevalencia y los factores asociados como estancia hospitalaria en UCI, enfermedades concomitantes y situaciones en pacientes mayores de 18 años con neumonía nosocomial con estancia en unidad de cuidados intensivos en una clínica de tercer nivel de la ciudad de Cali, en el periodo enero 2015 y enero 2016. Metodología. Estudio observacional de corte transversal con componente analítico. Se revisaron 353 historias clínicas enfocadas en los factores asociados de neumonía nosocomial en la UCI, con una estancia mayor o igual a 48 horas. El análisis estadístico se realizó con Epi Info versión 7. Resultados. La edad promedio de los casos estudiados fue de 55.17 años. La prevalencia estimada para neumonía nosocomial fue de 26%, con un promedio de estancia en UCI de 9.94 días, una desviación estándar de 8.30 días y días de ventilación mecánica invasiva de 4.27, con una desviación estándar de 7.38 días, en la cual el 26.35% (IC 95%: 22.0-31.1) adquirió neumonía nosocomial en UCI, el 43.06%: (IC 95%: 38.0-48.2) fueron mujeres, requiriendo de ventilación mecánica invasiva el 37.68% (IC 95%: 32.7-42.8). Como antecedentes patológicos de importancia se observó una asociación entre las variables con respecto a la neumonía nosocomial evidenciándose una relación significativa con diabetes mellitus (OR: 25.6; IC: 95% 13.4-48.7), enfermedad renal crónica (OR: 8.4; IC 95%: 4.49-16.0), enfermedad pulmonar obstructiva crónica (OR: 22.2; IC 95% 11.7-42.1), antecedente patológico de sinusitis (OR: 30.9; IC 95%: 7-46.2), utilización de sonda nasogástrica (OR: 13; IC 95%: 5-32) y, finalmente, al correlacionar la mortalidad con este tipo de infección pulmonar (OR: 26.1; IC 95%: 13-49.1), evidenciando una relación entre las variables. Discusión. Los hallazgos muestran alta frecuencia de esta patología, lo que conlleva múltiples implicaciones en los pacientes como estancia prolongada y mortalidad, las cuales son condiciones que han sido identificadas por diferentes autores. Conclusiones. La neumonía nosocomial es un proceso infeccioso frecuente en la UCI, que tiene una alta morbimortalidad, relacionándose con los días de estancia y ventilación mecánica invasiva.
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T. Nguyen K, T. Pham S, P.M. Vo T, X. Duong C, A. Perwitasari D, H.K. Truong N, T.H. Quach D, N.P. Nguyen T, T.T. Duong V, M. Nguyen P, H. Nguyen T, Taxis K, Nguyen T. Pneumonia: Drug-Related Problems and Hospital Readmissions. Infect Dis (Lond) 2022. [DOI: 10.5772/intechopen.100127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Pneumonia is one of the most common infectious diseases and the fourth leading cause of death globally. According to US statistics in 2019, pneumonia is the most common cause of sepsis and septic shock. In the US, inpatient pneumonia hospitalizations account for the top 10 highest medical costs, totaling $9.5 billion for 960,000 hospital stays. The emergence of antibiotic resistance in the treatment of infectious diseases, including the treatment of pneumonia, is a globally alarming problem. Antibiotic resistance increases the risk of death and re-hospitalization, prolongs hospital stays, and increases treatment costs, and is one of the greatest threats in modern medicine. Drug-related problems (DRPs) in pneumonia - such as suboptimal antibiotic indications, prolonged treatment duration, and drug interactions - increase the rate of antibiotic resistance and adverse effects, thereby leading to an increased burden in treatment. In a context in which novel and effective antibiotics are scarce, mitigating DRPs in order to reduce antibiotic resistance is currently a prime concern. A variety of interventions proven useful in reducing DRPs are antibiotic stewardship programs, the use of biomarkers, computerized physician order entries and clinical decision support systems, and community-acquired pneumonia scores.
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Pan D, Niederman MS. Risk Factors and Algorithms for the Empirical Treatment of Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia. Semin Respir Crit Care Med 2022; 43:183-190. [PMID: 35042262 DOI: 10.1055/s-0041-1740335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) continue to be major concerns for morbidity and mortality, especially in patients treated in the intensive care unit. With the rise in multidrug-resistant organisms, HAP and VAP treatment is challenged by the need for early appropriate treatment, with broad-spectrum agents, while still being aware of the principles of antibiotic stewardship. The two major society guidelines proposed a series of risk factors in their most recent guidelines to help identify patients who can most benefit from narrow- or broad-spectrum initial empiric antibiotic therapy. The guidelines reveal differences in the proposed risk factors and treatment approaches, as well as major similarities.
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Affiliation(s)
- Di Pan
- Department of Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, New York
| | - Michael S Niederman
- Department of Pulmonary and Critical Care Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, New York
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Pouliot JD, Dortch MJ, Givens G, Tidwell W, Hamblin SE, May AK. Factors Associated With Prolonged Antibiotic Use in the Setting of Suspected Pneumonia and Negative Bronchoalveolar Lavage Cultures. Hosp Pharm 2021; 56:444-450. [PMID: 34720144 DOI: 10.1177/0018578720918548] [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: 11/17/2022]
Abstract
Background: Diagnostic criterion for pneumonia includes clinical data and bronchoalveolar lavage cultures (BALCx) to identify pathogens. Although ~60% of BALCx are negative, there may be reluctance to discontinue antibiotics, leading to prolonged antibiotic use (PAU). Objective: The purpose of this study is to compare outcomes of subjects with negative BALCx with PAU versus without prolonged antibiotic use (nPAU). Methods: A retrospective cohort study was conducted including subjects admitted to the intensive care unit (ICU), with suspected pneumonia, and negative BALCx. Data were compared based on length of exposure to antibiotics, PAU (antibiotics >4 days) versus nPAU (antibiotics <4 days). Results: A total of 128 subjects were included, 57 in the PAU group and 71 in the nPAU group. Baseline demographics were similar between groups. Severity of illness measured by multiple organ dysfunction scores at time of bronchoalveolar lavage (BAL) collection to final result showed a statistically significant decrease in the PAU group but not in the nPAU group. No differences were found in ICU days, ventilator-free days, or mortality; however, length of stay was longer for PAU (23 vs. 17, p = .04). In the PAU group, there were fewer BALCx results of "no growth" (23% vs. 45%, p = .04), more positive gram stains (83% vs. 60%, p = .01) and more positive non-BALCx (40% vs. 14%, p = .01). In a multivariate analysis, factors associated with PAU were positive BAL gram stains (adjusted odds ratio [aOR] 3.1, p = .037) and positive non-BALCx (aOR 4.7, p = .002). Conclusion: For subjects with suspected pneumonia and negative BALCx, positive non-BALCx and positive BALCx gram stain influenced the length of exposure of antibiotics.
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Affiliation(s)
- Jonathon D Pouliot
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
| | | | - Gabrielle Givens
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
| | - William Tidwell
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan E Hamblin
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
| | - Addison K May
- Atrium Health, Charlotte, NC, USA.,University of North Carolina School of Medicine, Charlotte, USA
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Short-Term Effects of Appropriate Empirical Antimicrobial Treatment with Ceftolozane/Tazobactam in a Swine Model of Nosocomial Pneumonia. Antimicrob Agents Chemother 2021; 65:AAC.01899-20. [PMID: 33168605 DOI: 10.1128/aac.01899-20] [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: 09/04/2020] [Accepted: 10/30/2020] [Indexed: 11/20/2022] Open
Abstract
The rising frequency of multidrug-resistant and extensively drug-resistant (MDR/XDR) pathogens is making more frequent the inappropriate empirical antimicrobial therapy (IEAT) in nosocomial pneumonia, which is associated with increased mortality. We aim to determine the short-term benefits of appropriate empirical antimicrobial treatment (AEAT) with ceftolozane/tazobactam (C/T) compared with IEAT with piperacillin/tazobactam (TZP) in MDR Pseudomonas aeruginosa pneumonia. Twenty-one pigs with pneumonia caused by an XDR P. aeruginosa strain (susceptible to C/T but resistant to TZP) were ventilated for up to 72 h. Twenty-four hours after bacterial challenge, animals were randomized to receive 2-day treatment with either intravenous saline (untreated) or 25 to 50 mg of C/T per kg body weight (AEAT) or 200 to 225 mg of TZP per kg (IEAT) every 8 h. The primary outcome was the P. aeruginosa burden in lung tissue and the histopathology injury. P. aeruginosa burden in tracheal secretions and bronchoalveolar lavage (BAL) fluid, the development of antibiotic resistance, and inflammatory markers were secondary outcomes. Overall, P. aeruginosa lung burden was 5.30 (range, 4.00 to 6.30), 4.04 (3.64 to 4.51), and 4.04 (3.05 to 4.88) log10CFU/g in the untreated, AEAT, and IEAT groups, respectively (P = 0.299), without histopathological differences (P = 0.556). In contrast, in tracheal secretions (P < 0.001) and BAL fluid (P = 0.002), bactericidal efficacy was higher in the AEAT group. An increased MIC to TZP was found in 3 animals, while resistance to C/T did not develop. Interleukin-1β (IL-1β) was significantly downregulated by AEAT in comparison to other groups (P = 0.031). In a mechanically ventilated swine model of XDR P. aeruginosa pneumonia, appropriate initial treatment with C/T decreased respiratory secretions' bacterial burden, prevented development of resistance, achieved the pharmacodynamic target, and may have reduced systemic inflammation. However, after only 2 days of treatment, P. aeruginosa tissue concentrations were moderately affected.
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Pezzani MD, Mazzaferri F, Compri M, Galia L, Mutters NT, Kahlmeter G, Zaoutis TE, Schwaber MJ, Rodríguez-Baño J, Harbarth S, Tacconelli E. Linking antimicrobial resistance surveillance to antibiotic policy in healthcare settings: the COMBACTE-Magnet EPI-Net COACH project. J Antimicrob Chemother 2020; 75:ii2-ii19. [PMID: 33280049 PMCID: PMC7719409 DOI: 10.1093/jac/dkaa425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To systematically summarize the evidence on how to collect, analyse and report antimicrobial resistance (AMR) surveillance data to inform antimicrobial stewardship (AMS) teams providing guidance on empirical antibiotic treatment in healthcare settings. METHODS The research group identified 10 key questions about the link between AMR surveillance and AMS using a checklist of 9 elements for good practice in health research priority settings and a modified 3D combined approach matrix, and conducted a systematic review of published original studies and guidelines on the link between AMR surveillance and AMS. RESULTS The questions identified focused on AMS team composition; minimum infrastructure requirements for AMR surveillance; organisms, samples and susceptibility patterns to report; data stratification strategies; reporting frequency; resistance thresholds to drive empirical therapy; surveillance in high-risk hospital units, long-term care, outpatient and veterinary settings; and surveillance data from other countries. Twenty guidelines and seven original studies on the implementation of AMR surveillance as part of an AMS programme were included in the literature review. CONCLUSIONS The evidence summarized in this review provides a useful basis for a more integrated process of developing procedures to report AMR surveillance data to drive AMS interventions. These procedures should be extended to settings outside the acute-care institutions, such as long-term care, outpatient and veterinary. Without proper AMR surveillance, implementation of AMS policies cannot contribute effectively to the fight against MDR pathogens and may even worsen the burden of adverse events from such interventions.
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Affiliation(s)
- Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Fulvia Mazzaferri
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Monica Compri
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Liliana Galia
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Nico T Mutters
- Bonn University Hospital, Institute for Hygiene and Public Health, Bonn, Germany
| | - Gunnar Kahlmeter
- Department of Clinical Microbiology, Växjö Central Hospital, Växjö, Sweden
| | - Theoklis E Zaoutis
- Perelman School of Medicine at the University of Pennsylvania, Infectious Diseases Division, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mitchell J Schwaber
- National Centre for Infection Control, Israel Ministry of Health and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jesús Rodríguez-Baño
- Division of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena/Department of Medicine, University of Seville/Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Stephan Harbarth
- Infection Control Program, World Health Organization Collaborating Centre on Patient Safety, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostic 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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Bassetti M, Rello J, Blasi F, Goossens H, Sotgiu G, Tavoschi L, Zasowski EJ, Arber MR, McCool R, Patterson JV, Longshaw CM, Lopes S, Manissero D, Nguyen ST, Tone K, Aliberti S. Systematic review of the impact of appropriate versus inappropriate initial antibiotic therapy on outcomes of patients with severe bacterial infections. Int J Antimicrob Agents 2020; 56:106184. [PMID: 33045353 DOI: 10.1016/j.ijantimicag.2020.106184] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 08/24/2020] [Accepted: 09/26/2020] [Indexed: 01/16/2023]
Abstract
We investigated the impact of appropriate versus inappropriate initial antimicrobial therapy on the clinical outcomes of patients with severe bacterial infections as part of a systematic review and meta-analyses assessing the impact of delay in appropriate antimicrobial therapy. Literature searches of MEDLINE and Embase, conducted on 24 July 2018, identified studies published after 2007 reporting the impact of delay in appropriate antibiotic therapy for hospitalised adult patients with bacterial infections. Results were statistically pooled for outcomes including mortality, hospital length of stay (LOS) and treatment failure. Subgroup analyses were explored by site of infection where data permitted. Inclusion criteria were met by 145 studies, of which 114 reported data on the impact of appropriate versus inappropriate initial therapy. In the pooled analysis, rates of mortality were significantly in favour of appropriate therapy [odds ratio (OR) = 0.44, 95% CI 0.38-0.50]. Across eight studies, LOS was shorter with appropriate therapy compared with inappropriate therapy [mean difference (MD) -2.54 days (95% CI -5.30 to 0.23)], but not significantly so. The incidence of treatment failure was significantly lower in patients who received appropriate therapy compared with patients who received inappropriate therapy (six studies: OR = 0.33, 95% CI 0.16-0.66) as was mean hospital costs (four studies: MD -7.38 thousand US$ or Euros, 95% CI -14.14 to -0.62). Initiation of appropriate versus inappropriate antibiotics can reduce mortality, reduce treatment failure and decrease LOS, highlighting the importance of broad‑spectrum empirical therapy and rapid diagnostics for early identification of the causative pathogen. [Study registration: PROSPERO: CRD42018104669].
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genova and Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Jordi Rello
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBERES), Barcelona, Spain; Clinical Research & Epidemiology in Pneumonia and Sepsis (CRIPS), Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Francesco Blasi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Herman Goossens
- Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem, and Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical Clinical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Lara Tavoschi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Evan J Zasowski
- Department of Clinical Sciences, Touro University California College of Pharmacy, Vallejo, California, USA
| | - Mick R Arber
- York Health Economics Consortium, University of York, York, UK
| | - Rachael McCool
- York Health Economics Consortium, University of York, York, UK
| | | | | | | | | | | | | | - Stefano Aliberti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
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Buell KG, Casey JD, Noto MJ, Rice TW, Semler MW, Stollings JL. Time to First Culture Positivity for Gram-Negative Rods Resistant to Ceftriaxone in Critically Ill Adults. J Intensive Care Med 2020; 36:51-57. [PMID: 33016193 DOI: 10.1177/0885066620963903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The optimal timing for the de-escalation of broad-spectrum antibiotics with activity against Pseudomonas aeruginosa and resistant Gram-negative rods (GNRs) in critically ill adults remains unknown. RESEARCH QUESTION We tested the hypothesis that cultures will identify GNRs that ultimately demonstrate resistance to ceftriaxone within 48 hours, potentially allowing safe de-escalation at this time point. STUDY DESIGN AND METHODS We conducted a secondary analysis of data from the Isotonic Solutions and Major Adverse Renal Events Trial: a pragmatic, cluster-randomized, multiple-crossover trial comparing balanced crystalloids versus saline for intravenous fluid administration in 15,802 critically ill adults at 5 intensive care units (ICUs) at Vanderbilt University Medical Center in Nashville, TN, USA. The primary endpoint was the time-to-positivity of respiratory and blood cultures that ultimately demonstrated growth of GNRs resistant to ceftriaxone. Multivariable logistic regression modeling was used to examine risk factors for the growth of cultures after 48 hours. RESULTS A total of 524 respiratory cultures had growth of GNRs, of which 284 (54.2%) had resistance to ceftriaxone. A total of 376 blood cultures grew GNRs, of which 70 (18.6%) had resistance to ceftriaxone. At 48 hours, 87% of respiratory cultures and 85% of blood cultures that ultimately grew GNRs resistant to ceftriaxone had demonstrated growth. Age, gender, predicted risk of inpatient mortality and prior use of antibiotics did not predict the growth of cultures after 48 hours. INTERPRETATION Among a cohort of critically ill adults, 13% of respiratory cultures and 15% of blood cultures that ultimately grew GNRs resistant to ceftriaxone did not demonstrate growth until at least 48 hours after collection. Further work is needed to determine the ideal time for critically ill adults to de-escalate from broad-spectrum antibiotics targeting Pseudomonas aeruginosa and extended-spectrum β-lactamase-producing gram-negative pathogens.
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Affiliation(s)
- Kevin G Buell
- Department of Internal Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael J Noto
- Division of Allergy, Pulmonary, and Critical Care Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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Moehring RW, Ashley ED, Davis AE, Dyer AP, Parish A, Ren X, Lokhnygina Y, Hicks LA, Srinivasan A, Anderson DJ. Development of an electronic definition for de-escalation of antibiotics in hospitalized patients. Clin Infect Dis 2020; 73:e4507-e4514. [PMID: 32639558 DOI: 10.1093/cid/ciaa932] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 07/01/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) promote the principle of de-escalation: moving from broad to narrow spectrum agents and stopping antibiotics when no longer indicated. A standard, objective definition of de-escalation applied to electronic data could be useful for ASP assessments. METHODS We derived an electronic definition of antibiotic de-escalation and performed a retrospective study among five hospitals. Antibiotics were ranked into 4 categories: narrow spectrum, broad spectrum, extended spectrum, and agents targeted for protection. Eligible adult patients were cared for on inpatient units, had antibiotic therapy for at least 2 days, and were hospitalized for at least 3 days after starting antibiotics. Number of antibiotics and rank were assessed at two time points: day of antibiotic initiation and either day of discharge or day 5. De-escalation was defined as reduction in either the number of antibiotics or rank. Escalation was an increase in either number or rank. Unchanged was either no change or discordant directions of change. We summarized outcomes among hospitals, units, and diagnoses. RESULTS Among 39,226 eligible admissions, de-escalation occurred in 14,138 (36%), escalation in 5,129 (13%), and antibiotics were unchanged in 19,959 (51%). De-escalation varied among hospitals (median 37%, range 31-39%, p<.001). Diagnoses with lower de-escalation rates included intra-abdominal (23%) and skin and soft tissue (28%) infections. Critical care had higher rates of both de-escalation and escalation compared with wards. CONCLUSIONS Our electronic de-escalation metric demonstrated variation among hospitals, units, and diagnoses. This metric may be useful for assessing stewardship opportunities and impact.
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Affiliation(s)
- Rebekah W Moehring
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
| | | | - Angelina E Davis
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
| | - April Pridgen Dyer
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
| | | | - Xinru Ren
- Duke BERD Methods Core, Durham, NC, USA
| | | | - Lauri A Hicks
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Deverick J Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
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Abstract
PURPOSE OF REVIEW In the last 2 years, two major guidelines for the management of nosocomial pneumonia have been published: The International European Respiratory Society/European Society of Intensive Care Medicine/European Society of Clinical Microbiology and Infectious Diseases/Asociación Latinoamericana de Toráx guidelines for the management of hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) and the American guidelines for management of adults with HAP and VAP; both the guidelines made important clinical recommendations for the management of patients. RECENT FINDINGS With the increasing emergence of multidrug resistant (MDR) organisms, paired with a relative reduction in new antibiotic development, nosocomial infections have become one of the most significant issues affecting global healthcare today. Despite several stark differences between the European and American guidelines, they are in agreement about many aspects of nosocomial pneumonia management. SUMMARY American and European guidelines promote prompt and appropriate empiric treatment which is immediately guided by local microbiological data, followed by an adequate de-escalation protocol based on culture results with a 1-week course of treatment. Both also questioned the use of biomarkers in HAP/VAP, whether as part of the diagnosis or daily assessment of patients. On the contrary, they have conflicting views in regards to the optimum method of diagnosis, the risk factors used to stratify patients, the use of clinical scoring systems and the various antibiotic classes used. All were presented with varying levels of evidence to support these differences in opinion, indicating that further research into these areas is required before a consensus can be agreed upon.
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Tabah A, Bassetti M, Kollef MH, Zahar JR, Paiva JA, Timsit JF, Roberts JA, Schouten J, Giamarellou H, Rello J, De Waele J, Shorr AF, Leone M, Poulakou G, Depuydt P, Garnacho-Montero J. Antimicrobial de-escalation in critically ill patients: a position statement from a task force of the European Society of Intensive Care Medicine (ESICM) and European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Critically Ill Patients Study Group (ESGCIP). Intensive Care Med 2019; 46:245-265. [PMID: 31781835 DOI: 10.1007/s00134-019-05866-w] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/12/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antimicrobial de-escalation (ADE) is a strategy of antimicrobial stewardship, aiming at preventing the emergence of antimicrobial resistance (AMR) by decreasing the exposure to broad-spectrum antimicrobials. There is no high-quality research on ADE and its effects on AMR. Its definition varies and there is little evidence-based guidance for clinicians to use ADE in the intensive care unit (ICU). METHODS A task force of 16 international experts was formed in November 2016 to provide with guidelines for clinical practice to develop questions targeted at defining ADE, its effects on the ICU population and to provide clinical guidance. Groups of 2 experts were assigned 1-2 questions each within their field of expertise to provide draft statements and rationale. A Delphi method, with 3 rounds and an agreement threshold of 70% was required to reach consensus. RESULTS We present a comprehensive document with 13 statements, reviewing the evidence on the definition of ADE, its effects in the ICU population and providing guidance for clinicians in subsets of clinical scenarios where ADE may be considered. CONCLUSION ADE remains a topic of controversy due to the complexity of clinical scenarios where it may be applied and the absence of evidence to the effects it may have on antimicrobial resistance.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe and Caboolture Hospitals, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Santa Maria Misericordia University Hospital, Udine, Italy
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Jean-Ralph Zahar
- Hygiène Hospitalière Et Prévention du Risque Infectieux, CHU Avicenne, AP-HP, 125 rue de Stalingrad, 93000, Bobigny, France
| | - José-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar Universitário São João, Faculty of Medicine and University of Porto, Grupo de Infecçao e Sépsis, Porto, Portugal
| | - Jean-Francois Timsit
- Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard University Hospital, Paris, France
- University of Paris, INSERM IAME, U1137, Team DesCID, Paris, France
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, and Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Jeroen Schouten
- Department of Intensive Care, Radboudumc, Nijmegen, The Netherlands
| | - Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, Athens, Greece
| | - Jordi Rello
- CIBERES and Vall d'Hebron Institute of Research, Barcelona, Spain
- Clinical Research in ICU, CHU Nîmes, University Montpellier, Montpellier, France
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Marc Leone
- Department of Anesthesiology and Intensive Care Medicine, Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Hôpital Nord, Marseille, France
| | - Garyphallia Poulakou
- 3rd Department of Medicine, National and Kapodistrian University of Athens, Medical School, Sotiria General Hospital, Athens, Greece
| | - Pieter Depuydt
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jose Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Seville, Spain
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15
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt C, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar J, Bruyère R, Chanques G. Pneumonies associées aux soins de réanimation* RFE commune SFAR–SRLF. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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16
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Abstract
Two recent major guidelines on diagnosis and treatment of ventilator-associated pneumonia (VAP) recommend consideration of local antibiotic resistance patterns and individual patient risks for resistant pathogens when formulating an initial empiric antibiotic regimen. One recommends against invasive diagnostic techniques with quantitative cultures to determine the cause of VAP; the other recommends either invasive or noninvasive techniques. Both guidelines recommend short-course therapy be used for most patients with VAP. Although neither guideline recommends use of procalcitonin as an adjunct to clinical judgment when diagnosing VAP, they differ with respect to use of serial procalcitonin to shorten the length of antibiotic treatment.
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Affiliation(s)
- Mark L Metersky
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Connecticut School of Medicine, UConn Health, 263 Farmington Avenue, Farmington, CT 06030-1321, USA.
| | - Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, 985400 Nebraska Medical Center, Omaha, NE 68198, USA
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Mathieu C, Pastene B, Cassir N, Martin-Loeches I, Leone M. Efficacy and safety of antimicrobial de-escalation as a clinical strategy. Expert Rev Anti Infect Ther 2018; 17:79-88. [PMID: 30570361 DOI: 10.1080/14787210.2019.1561275] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION De-escalation is a widely recommended strategy in regard to guidelines, with an associated adherence to guidelines being around 50%. This review discusses data supporting de-escalation and possible obstacles for its implementation. Areas covered: Although it does not have a consensual definition, de-escalation consists of reducing the spectrum of empirical antimicrobial treatment based on the microbiological findings. Many observational studies have suggested that this strategy is likely safe and efficient for treating various types of infection. However, randomized controlled trials published as of now have not shown any improvement on the outcomes. Regarding the adverse effects of de-escalation on ecological pressure and multidrug resistance emergence, the data are contradictory. The implementation of new techniques, such as rapid diagnosis, can help guide clinicians. Expert opinion: De-escalation should be included as part of a large antibiotic stewardship program to balance the risk and benefit of each administration, and each physician prescribing antibiotics should be challenged for the quality of her/his prescription on a daily basis. In the future, one of our duties will involve determining whether a delay of antimicrobial treatment - making it possible to improve diagnostic performance and obtain the first laboratory results - is either safe or unsafe for our patients.
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Affiliation(s)
- Calypso Mathieu
- a Assistance Publique Hôpitaux de Marseille, Service d'anesthésie et de réanimation , Aix-Marseille Université , Marseille , France
| | - Bruno Pastene
- a Assistance Publique Hôpitaux de Marseille, Service d'anesthésie et de réanimation , Aix-Marseille Université , Marseille , France
| | - Nadim Cassir
- b IRD, APHM, MEPHI, IHU-Méditerranée Infection , Aix-Marseille Université , Marseille , France
| | - Ignacio Martin-Loeches
- c Multidisciplinary Intensive Care Research Organization (MICRO) , St James's Hospital , Dublin , Ireland
| | - Marc Leone
- a Assistance Publique Hôpitaux de Marseille, Service d'anesthésie et de réanimation , Aix-Marseille Université , Marseille , France.,b IRD, APHM, MEPHI, IHU-Méditerranée Infection , Aix-Marseille Université , Marseille , France
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18
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Ambaras Khan R, Aziz Z. Antibiotic de-escalation in patients with pneumonia in the intensive care unit: A systematic review and meta-analysis. Int J Clin Pract 2018; 72:e13245. [PMID: 30144239 DOI: 10.1111/ijcp.13245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 07/16/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES OF THE REVIEW Antibiotic de-escalation is part of an antibiotic stewardship strategy to achieve adequate therapy for infections while avoiding the prolonged use of broad-spectrum antibiotics. However, there is a paucity of clinical evidence on the clinical impact of this strategy in pneumonia patients in the intensive care unit (ICU). This review aimed to evaluate the impact of antibiotic de-escalation therapy for adult patients diagnosed with pneumonia in the ICU. METHODS USED TO CONDUCT THE REVIEW This review was conducted in accordance with the Meta-analysis of Observational Studies in Epidemiology (MOOSE) recommendation. Electronic databases including MEDLINE, CINAHL, PubMed, Embase, Cochrane Databases and Cochrane Central Register of Controlled Trials were searched up to March 2017 for relevant trials. The methodological quality of included trials was assessed by using a modified version of the Newcastle-Ottawa Quality Assessment Scale for Case-Control and Cohort Studies. A meta-analysis was conducted using the random-effect model to combine the rate of mortality and length of stay outcomes. FINDINGS OF THE REVIEW Nine observational trials involving 2128 patients were considered eligible for inclusion. Although based on low quality evidence, there was a statistically significant difference in favour of the impact of de-escalation on hospital stay but not mortality (MD -5.96 days; 95% CI -8.39 to -3.52). INTERPRETATIONS AND IMPLICATIONS OF THE FINDINGS This review highlights the need for more rigorous studies to be carried out before a firm conclusion on the benefit of de-escalation therapy is supported.
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Affiliation(s)
- Rahela Ambaras Khan
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Zoriah Aziz
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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19
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Ambaras Khan R, Aziz Z. The methodological quality of guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia: A systematic review. J Clin Pharm Ther 2018; 43:450-459. [PMID: 29722052 DOI: 10.1111/jcpt.12696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 03/27/2018] [Indexed: 12/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Clinical practice guidelines serve as a framework for physicians to make decisions and to support best practice for optimizing patient care. However, if the guidelines do not address all the important components of optimal care sufficiently, the quality and validity of the guidelines can be reduced. The objectives of this study were to systematically review current guidelines for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), evaluate their methodological quality and highlight the similarities and differences in their recommendations for empirical antibiotic and antibiotic de-escalation strategies. METHODS This review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Electronic databases including MEDLINE, CINAHL, PubMed and EMBASE were searched up to September 2017 for relevant guidelines. Other databases such as NICE, Scottish Intercollegiate Guidelines Network (SIGN) and the websites of professional societies were also searched for relevant guidelines. The quality and reporting of included guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument. RESULTS AND DISCUSSION Six guidelines were eligible for inclusion in our review. Among 6 domains of AGREE-II, "clarity of presentation" scored the highest (80.6%), whereas "applicability" scored the lowest (11.8%). All the guidelines supported the antibiotic de-escalation strategy, whereas the majority of the guidelines (5 of 6) recommended that empirical antibiotic therapy should be implemented in accordance with local microbiological data. All the guidelines suggested that for early-onset HAP/VAP, therapy should start with a narrow spectrum empirical antibiotic such as penicillin or cephalosporins, whereas for late-onset HAP/VAP, the guidelines recommended the use of a broader spectrum empirical antibiotic such as the penicillin extended spectrum carbapenems and glycopeptides. WHAT IS NEW AND CONCLUSIONS Expert guidelines promote the judicious use of antibiotics and prevent antibiotic overuse. The quality and validity of available HAP/VAP guidelines would be enhanced by improving their adherence to accepted best practice for the management of HAP and VAP.
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Affiliation(s)
- R Ambaras Khan
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Z Aziz
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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20
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Leone M, Bouadma L, Bouhemad B, Brissaud O, Dauger S, Gibot S, Hraiech S, Jung B, Kipnis E, Launey Y, Luyt CE, Margetis D, Michel F, Mokart D, Montravers P, Monsel A, Nseir S, Pugin J, Roquilly A, Velly L, Zahar JR, Bruyère R, Chanques G. Hospital-acquired pneumonia in ICU. Anaesth Crit Care Pain Med 2018; 37:83-98. [DOI: 10.1016/j.accpm.2017.11.006] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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21
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Vochozka M, Maroušková A, Šuleř P. Moral Polemics of Far-Reaching Economic Consequences of Antibiotics Overuse. SCIENCE AND ENGINEERING ETHICS 2017; 23:1035-1040. [PMID: 27896609 DOI: 10.1007/s11948-016-9834-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 10/17/2016] [Indexed: 06/06/2023]
Abstract
The unethical overuse of antibiotics to seek to achieve a shortening of the treatment period raises the cost of health services and poses a threat to humanity due to the gradual development of antibiotic resistance. Other consequences of our modern passion for antibiotics have appeared. Small concentrations of antibiotic residues in sewage waters slow down the metabolism of anaerobic microorganism thereby reducing the overall performance of the anaerobic fermentation used to detoxify and digest sewage and other collected organic wastes. Reduced biogas yields represents a serious threat to the energy self-sufficiency of some waste-water treatment plants, so it might change them from energy producers into energy consumers. Morally justifiable production of renewable energy from bio-waste is also threatened by antibiotic residues that remain in the bio-waste.
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Affiliation(s)
- Marek Vochozka
- The Institute of Technology and Business in České Budějovice, Okružní 517/10, 370 01, Ceske Budejovice, Czech Republic.
| | - Anna Maroušková
- The Institute of Technology and Business in České Budějovice, Okružní 517/10, 370 01, Ceske Budejovice, Czech Republic
| | - Petr Šuleř
- Faculty of Management and Informatics, University of Žilina, Univerzitná 8215/1, 010 26, Zilina, Slovakia
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22
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Khan RA, Aziz Z. A retrospective study of antibiotic de-escalation in patients with ventilator-associated pneumonia in Malaysia. Int J Clin Pharm 2017. [DOI: 10.1007/s11096-017-0499-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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23
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Antibiotic Utilization Patterns in Patients with Ventilator-Associated Pneumonia: A Canadian Context. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2016; 2016:3702625. [PMID: 27525016 PMCID: PMC4971298 DOI: 10.1155/2016/3702625] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 11/13/2015] [Indexed: 12/29/2022]
Abstract
This retrospective cohort study describes the patterns of antibiotic use for the treatment of ventilator-associated pneumonia (VAP) in the Calgary Zone of Alberta Health Services. Timing, appropriateness, and duration of antibiotics were evaluated in two hundred consecutive cases of VAP derived from 4 adult intensive care units (ICU). Antibiotic therapy was initiated in less than 24 hours from VAP diagnosis in 83% of cases. Although most patients (89%) received empiric therapy that demonstrated in vitro sensitivity to the identified pathogens, only 24% of cases were congruent with the 2008 Association of Medical Microbiology and Infectious Disease (AMMI) guidelines. Both ICU (p = 0.001) and hospital (p = 0.015) mortality were significantly lower and there was a trend for shorter ICU length of stay (p = 0.051) in patients who received appropriate versus inappropriate initial antibiotics. There were no outcome differences related to compliance with AMMI guidelines. This exploratory study provides insight into the use of antimicrobials for the treatment of VAP in a large Canadian health region. The discordance between the assessments of appropriateness of empiric therapy based on recovered pathogens versus AMMI guidelines is notable, emphasizing the importance of using as much as possible local microbiologic and antimicrobial resistance data.
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24
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Ohji G, Doi A, Yamamoto S, Iwata K. Is de-escalation of antimicrobials effective? A systematic review and meta-analysis. Int J Infect Dis 2016; 49:71-9. [PMID: 27292606 DOI: 10.1016/j.ijid.2016.06.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/16/2016] [Accepted: 06/04/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND De-escalation therapy is a strategy used widely to treat infections while avoiding the use of broad-spectrum antimicrobials. However, there is a paucity of clinical evidence to demonstrate the effectiveness and safety of de-escalation therapy compared to conventional therapy. METHODS A systematic review and meta-analysis was conducted on de-escalation therapy for a variety of infections. A search of the MEDLINE (via PubMed), EMBASE, and Cochrane Library databases up to July 2015 for relevant studies was performed. The primary outcome was relevant mortality, such as 30-day mortality and in-hospital mortality. A meta-analysis was to be conducted for the pooled odds ratio using the random-effects model when possible. Both randomized controlled trials and observational studies were included in the analysis. RESULTS A total of 23 studies were included in the analysis. There was no difference in mortality for most infections, and some studies favored de-escalation over non-de-escalation for better survival. The quality of most studies included was not high. CONCLUSIONS This review and analysis suggests that de-escalation therapy is safe and effective for most infections, although higher quality studies are needed in the future.
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Affiliation(s)
- Goh Ohji
- Division of Infectious Diseases Therapeutics, Kobe University Graduate School of Medicine, Kusunokicho 7-5-2, Chuoku, Kobe, Hyogo 650-0017, Japan
| | - Asako Doi
- Division of Infectious Diseases, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shungo Yamamoto
- Division of Infectious Diseases Therapeutics, Kobe University Graduate School of Medicine, Kusunokicho 7-5-2, Chuoku, Kobe, Hyogo 650-0017, Japan
| | - Kentaro Iwata
- Division of Infectious Diseases Therapeutics, Kobe University Graduate School of Medicine, Kusunokicho 7-5-2, Chuoku, Kobe, Hyogo 650-0017, Japan.
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25
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Montravers P, Augustin P, Grall N, Desmard M, Allou N, Marmuse JP, Guglielminotti J. Characteristics and outcomes of anti-infective de-escalation during health care-associated intra-abdominal infections. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:83. [PMID: 27052675 PMCID: PMC4823898 DOI: 10.1186/s13054-016-1267-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/16/2016] [Indexed: 12/26/2022]
Abstract
Background De-escalation is strongly recommended for antibiotic stewardship. No studies have addressed this issue in the context of health care-associated intra-abdominal infections (HCIAI). We analyzed the factors that could interfere with this process and their clinical consequences in intensive care unit (ICU) patients with HCIAI. Methods All consecutive patients admitted for the management of HCIAI who survived more than 3 days following their diagnosis, who remained in the ICU for more than 3 days, and who did not undergo early reoperation during the first 3 days were analyzed prospectively in an observational, single-center study in a tertiary care university hospital. Results Overall, 311 patients with HCIAI were admitted to the ICU. De-escalation was applied in 110 patients (53 %), and no de-escalation was reported in 96 patients (47 %) (escalation in 65 [32 %] and unchanged regimen in 31 [15 %]). Lower proportions of Enterococcus faecium, nonfermenting Gram-negative bacilli (NFGNB), and multidrug-resistant (MDR) strains were cultured in the de-escalation group. No clinical difference was observed at day 7 between patients who were de-escalated and those who were not. Determinants of de-escalation in multivariate analysis were adequate empiric therapy (OR 9.60, 95 % CI 4.02–22.97) and empiric use of vancomycin (OR 3.39, 95 % CI 1.46–7.87), carbapenems (OR 2.64, 95 % CI 1.01–6.91), and aminoglycosides (OR 2.31 95 % CI 1.08–4.94). The presence of NFGNB (OR 0.28, 95 % CI 0.09–0.89) and the presence of MDR bacteria (OR 0.21, 95 % CI 0.09–0.52) were risk factors for non-de-escalation. De-escalation did not change the overall duration of therapy. The risk factors for death at day 28 were presence of fungi (HR 2.64, 95 % CI 1.34–5.17), Sequential Organ Failure Assessment score on admission (HR 1.29, 95 % CI 1.16–1.42), and age (HR 1.03, 95 % CI 1.01–1.05). The survival rate expressed by a Kaplan-Meier curve was similar between groups (log-rank test p value 0.176). Conclusions De-escalation is a feasible option in patients with polymicrobial infections such as HCIAI, but MDR organisms and NFGNB limit its implementation.
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Affiliation(s)
- Philippe Montravers
- Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France. .,Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.
| | - Pascal Augustin
- Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France
| | - Nathalie Grall
- Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.,INSERM, UMR 1137, Infection, Antimicrobiens, Modélisation, Evolution, Paris, France.,Laboratoire de Microbiologie, AP-HP, CHU Bichat-Claude Bernard, Paris, France
| | - Mathieu Desmard
- Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France.,Service de Réanimation, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Nicolas Allou
- Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France
| | - Jean-Pierre Marmuse
- Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.,Service de Chirurgie Générale, APHP, CHU Bichat-Claude Bernard, Paris, France
| | - Jean Guglielminotti
- Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France.,Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.,INSERM, UMR 1137, Infection, Antimicrobiens, Modélisation, Evolution, Paris, France
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Weiss E, Zahar JR, Lesprit P, Ruppe E, Leone M, Chastre J, Lucet JC, Paugam-Burtz C, Brun-Buisson C, Timsit JF, Brun-Buisson C, Bruneel F, Chastre J, Lasocki S, Leone M, Montravers P, Nseir S, Paugam-Burtz C, Pease S, Timsit JF, Weiss E, Wolff M, Alfandari S, Fantin B, Gachot B, Lesprit P, Lucet JC, Potel G, Pulcini C, Rabaud C, Tattevin P, Armand-Lefevre L, Cavallo JD, Jarlier V, Joint-Lambert O, Robert J, Ruppé E, Woerther PL. Elaboration of a consensual definition of de-escalation allowing a ranking of β-lactams. Clin Microbiol Infect 2015; 21:649.e1-10. [DOI: 10.1016/j.cmi.2015.03.013] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 01/05/2015] [Accepted: 03/05/2015] [Indexed: 01/22/2023]
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Carugati M, Franzetti F, Wiemken T, Kelley RR, Kelly R, Peyrani P, Blasi F, Ramirez J, Aliberti S. De-escalation therapy among bacteraemic patients with community-acquired pneumonia. Clin Microbiol Infect 2015; 21:936.e11-8. [PMID: 26115864 DOI: 10.1016/j.cmi.2015.06.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 06/05/2015] [Accepted: 06/12/2015] [Indexed: 10/23/2022]
Abstract
There is no evidence supporting the use of de-escalation therapy (DET) among patients with community-acquired pneumonia (CAP). We assessed the outcomes associated with DET among bacteraemic CAP patients. We performed a secondary analysis of the Community-Acquired Pneumonia Organization database, which contains data on 660 bacteraemic patients hospitalized because of CAP in 35 countries (2001-2013). Exclusion criteria were death within 72 h from admission and an inappropriate empirical antibiotic regimen. DET was defined as changing an appropriate empirical broad-spectrum regimen to a narrower-spectrum regimen according to culture results within 7 days from hospital admission. Two study groups were identified: patients whose antibiotic therapy was de-escalated (the DET group), and patients whose antibiotic therapy was not de-escalated (the N-DET group). The primary study outcome was 30-day mortality. Two hundred and sixty-one bacteraemic CAP patients were included. Gram-positive bacteria were responsible for 88.1% of the cases (Streptococcus pneumoniae, 75.9%). Gram-negative bacteria were responsible for for 7.3% of the cases. DET was performed in 165 patients (63.2%). The N-DET group was characterized by a more severe presentation at admission. After adjustment for confounders, DET was not associated with an increased risk of 30-day mortality. DET seems to be safe among bacteraemic patients with CAP. Randomized clinical trials are warranted to further explore these findings.
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Affiliation(s)
- M Carugati
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, Milan, Italy.
| | - F Franzetti
- Department of Biomedical and Clinical Sciences, Università degli Studi di Milano, Milan, Italy
| | - T Wiemken
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | | | - R Kelly
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - P Peyrani
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - F Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - J Ramirez
- Division of Infectious Diseases, University of Louisville, Louisville, KY, USA
| | - S Aliberti
- Department of Health Sciences, University of Milano - Bicocca, Respiratory Unit, AO San Gerardo, Monza, Italy
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Filipiak W, Beer R, Sponring A, Filipiak A, Ager C, Schiefecker A, Lanthaler S, Helbok R, Nagl M, Troppmair J, Amann A. Breath analysis for
in vivo
detection of pathogens related to ventilator-associated pneumonia in intensive care patients: a prospective pilot study. J Breath Res 2015; 9:016004. [DOI: 10.1088/1752-7155/9/1/016004] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Schulz L, Osterby K, Fox B. The Use of Best Practice Alerts with the Development of an Antimicrobial Stewardship Navigator to Promote Antibiotic De-escalation in the Electronic Medical Record. Infect Control Hosp Epidemiol 2015; 34:1259-65. [DOI: 10.1086/673977] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objective.Develop a clinical decision support tool comprised of an electronic medical record alert and antimicrobial stewardship navigator to facilitate antimicrobial stewardship.Design.We analyzed alerts targeting antimicrobial de-escalation to assess the effectiveness of the navigator as a stewardship tool. The alert provides antimicrobial recommendations, then directs providers to the navigator, which includes order management, relevant patient information, evidence-based clinical information, and bidirectional communication capability.Setting.Academic, tertiary care medical center with an electronic medical record.Intervention.Alerts containing stewardship recommendations and immediate access to the navigator were created.Results.Antibiotic use and response data were collected 1 day before stewardship recommendation via the best practice alert (BPA) tool and 1 day after the BPA tool response. A total of 1,285 stewardship BPAs were created. Two hundred and forty-four (18.9%) of the BPAs were created and acted upon within 72 hours for the purpose of de-escalation: 169 (69%) were accepted, 30 (12%) were accepted with modification, and 45 (18%) were rejected. Statistically significant decreases in total antibiotic use as well as in use of broad-spectrum (anti-methicillin-resistant Staphylococcus aureus and anti-pseudomonal) agents occurred when accepted recommendations were compared with rejected recommendations.Conclusions.We describe the successful development of a clinical decision support tool to perform prospective audit and feedback comprised of an alert and navigator system featuring evidence-based recommendations and clinical and educational information. We demonstrate that this tool improves antibiotic use through our example of de-escalation.Clinical Trials Identifier.This project was registered at ClinicalTrials.gov (NCT01573195).
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Grover V, Pantelidis P, Soni N, Takata M, Shah PL, Wells AU, Henderson DC, Kelleher P, Singh S. A biomarker panel (Bioscore) incorporating monocytic surface and soluble TREM-1 has high discriminative value for ventilator-associated pneumonia: a prospective observational study. PLoS One 2014; 9:e109686. [PMID: 25289689 PMCID: PMC4188746 DOI: 10.1371/journal.pone.0109686] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 09/08/2014] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Ventilator-associated pneumonia (VAP) increases mortality in critical illness. However, clinical diagnostic uncertainty persists. We hypothesised that measuring cell-surface and soluble inflammatory markers, incorporating Triggering Receptor Expressed by Myeloid cells (TREM)-1, would improve diagnostic accuracy. METHODS A single centre prospective observational study, set in a University Hospital medical-surgical intensive Care unit, recruited 91 patients into 3 groups: 27 patients with VAP, 33 ventilated controls without evidence of pulmonary sepsis (non-VAP), and 31 non-ventilated controls (NVC), without clinical infection, attending for bronchoscopy. Paired samples of Bronchiolo-alveolar lavage fluid (BALF) and blood from each subject were analysed for putative biomarkers of infection: Cellular (TREM-1, CD11b and CD62L) and soluble (IL-1β, IL-6, IL-8, sTREM-1, Procalcitonin). Expression of cellular markers on monocytes and neutrophils were measured by flow cytometry. Soluble inflammatory markers were determined by ELISA. A biomarker panel ('Bioscore'), was constructed, tested and validated, using Fisher's discriminant function analysis, to assess its value in distinguishing VAP from non VAP. RESULTS The expression of TREM-1 on monocytes (mTREM-1) and neutrophils (nTREM-1) and concentrations of IL-1β, IL-8, and sTREM-1 in BALF were significantly higher in VAP compared with non-VAP and NVC (p<0.001). The BALF/blood mTREM-1 was significantly higher in VAP patients compared to non-VAP and NVC (0.8 v 0.4 v 0.3 p<0.001). A seven marker Bioscore (BALF/blood ratio mTREM-1 and mCD11b, BALF sTREM-1, IL-8 and IL-1β, and serum CRP and IL-6) correctly identified 88.9% of VAP cases and 100% of non-VAP cases. CONCLUSION A 7-marker bioscore, incorporating cellular and soluble TREM-1, accurately discriminates VAP from non-pulmonary infection.
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Affiliation(s)
- Vimal Grover
- Magill Department of Anaesthesia, Critical Care and Pain, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, United Kingdom
- Immunology Section, Department of Medicine, Imperial College, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Panagiotis Pantelidis
- Immunology Section, Department of Medicine, Imperial College, London, United Kingdom
- Department of Immunology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Neil Soni
- Magill Department of Anaesthesia, Critical Care and Pain, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Masao Takata
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Pallav L. Shah
- Department of Respiratory Medicine, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, United Kingdom
- Department of Respiratory Medicine, Royal Brompton & Harefield Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Athol U. Wells
- Department of Respiratory Medicine, Royal Brompton & Harefield Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Don C. Henderson
- Immunology Section, Department of Medicine, Imperial College, London, United Kingdom
- Department of Immunology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Peter Kelleher
- Immunology Section, Department of Medicine, Imperial College, London, United Kingdom
- Department of Immunology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Suveer Singh
- Magill Department of Anaesthesia, Critical Care and Pain, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, United Kingdom
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
- Department of Respiratory Medicine, Chelsea and Westminster Hospital National Health Service Foundation Trust, London, United Kingdom
- * E-mail:
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De-escalation of antimicrobial treatment in neutropenic patients with severe sepsis: results from an observational study. Intensive Care Med 2014; 40:41-9. [PMID: 24231857 DOI: 10.1007/s00134-013-3148-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Accepted: 10/26/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND In severe sepsis, guidelines recommend de-escalating the empirical antimicrobial treatment as soon as the microbiological results are available. We aimed to determine the rate of de-escalation of the empirical antimicrobial treatment in neutropenic patients with severe sepsis. The characteristics of antimicrobial treatment associated with de-escalation and its impact on short- and long-term survival were also determined. METHODS In the intensive care unit (ICU) of a cancer referral center, we prospectively collected observational data related to the antimicrobial management in neutropenic patients who developed severe sepsis and were admitted to ICU for at least 48 h. De-escalation of antimicrobial therapy consisted either of deleting one of the empirical antibiotics of a combined treatment, or, whenever possible, to use a betalactam antibiotic with a narrower spectrum of activity. Multivariate logistic regression was conducted to determine the factors associated with de-escalation, while a Cox proportional hazards model with a time-dependent covariate was fitted to assess the effect of de-escalation on 30-day survival. Finally 1-year survival after ICU discharge was compared across de-escalation groups. RESULTS Cumulative incidence of de-escalation of the empirical antimicrobial treatment among the 101 patients of the cohort was 44%, [95% confidence interval (CI) 38-53%], including 30 (68%) patients with ongoing neutropenia. A microbiological documentation was available in 63 (63%) patients. Factors associated with de-escalation were the adequation of the empirical antimicrobial treatment in ICU [OR = 10.8 (95% CI 1.20-96)] for adequate documented treatment versus appropriate empirical treatment, the compliance with guidelines regarding the empirical choice of the anti-pseudomonal betalactam [OR = 10.8 (95% CI 1.3-89.5)]. De-escalation did not significantly modify the hazard of death within the first 30 days [HR = 0.51 (95% CI 0.20-1.33)], nor within 1 year after ICU discharge [HR = 1.06 (95% CI 0.54-2.08)]. CONCLUSION Our data suggest that, in ICU, de-escalation of the empirical antimicrobial treatment is frequently applied in neutropenic cancer patients with severe sepsis. No evidence of any prognostic impact of this de-escalation was found.
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Brown J. Potential pitfalls of basing specific antibiotic therapy on rapid susceptibility reporting. Am J Health Syst Pharm 2014; 71:1247. [DOI: 10.2146/ajhp140272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Jack Brown
- Department of Pharmacy Practice and Administration Wegmans School of Pharmacy St. John Fisher College Rochester, NY
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Pailhoriès H, Lemarié C, Kouatchet A, Lasocki S, Sargentini C, Kempf M, Coron N, Mahaza C, Joly-Guillou ML, Eveillard M. The impact of performing bacterial identification and antimicrobial susceptibility testing on bronchoalveolar fluid cultures 24 h a day in a microbiology laboratory. Diagn Microbiol Infect Dis 2014; 80:216-21. [PMID: 25149417 DOI: 10.1016/j.diagmicrobio.2014.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 06/27/2014] [Accepted: 07/22/2014] [Indexed: 10/25/2022]
Abstract
We previously demonstrated the positive impact of performing bacterial identification and antimicrobial susceptibility testing (AST) after day hours (night service [NS]) for certain clinical samples on the treatment of infected patients. Our objective was to evaluate the impact of including positive bronchoalveolar lavage (BAL) cultures in our NS. Two major positive consequences were recorded: initiation of earlier appropriate treatment and earlier change to a reduced-spectrum but still effective regimen. Reductions in delay were defined as the differences between the hours actually spent and hours estimated as though laboratory tests had been performed in the absence of NS. Fifty BALs were included. The NS led to the implementation of earlier appropriate therapy in 10 cases (20%), to earlier de-escalation in 15 cases (30%), and to earlier appropriate therapy and de-escalation in 4 cases (8%). In conclusion, performing bacterial identification and AST for positive BAL after laboratory opening hours could be relevant.
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Affiliation(s)
| | - Carole Lemarié
- CHU d'Angers, Laboratoire de Bactériologie, F-49000 Angers, France
| | - Achille Kouatchet
- CHU d'Angers, Service de Réanimation médicale, F-49000 Angers, France
| | - Sigismond Lasocki
- CHU d'Angers, Service de Réanimation Chirurgicale A, F-49000 Angers, France
| | - Cyril Sargentini
- CHU d'Angers, Service de Réanimation Chirurgicale B, F-49000 Angers, France
| | - Marie Kempf
- CHU d'Angers, Laboratoire de Bactériologie, F-49000 Angers, France
| | - Noémie Coron
- CHU d'Angers, Laboratoire de Bactériologie, F-49000 Angers, France
| | - Chetaou Mahaza
- CHU d'Angers, Laboratoire de Bactériologie, F-49000 Angers, France
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Razazi K, Brun-Buisson C. Désescalade de l’antibiothérapie en réanimation. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0865-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Cotta MO, Roberts JA, Tabah A, Lipman J, Vogelaers D, Blot S. Antimicrobial stewardship of β-lactams in intensive care units. Expert Rev Anti Infect Ther 2014; 12:581-95. [DOI: 10.1586/14787210.2014.902308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Nussenblatt V, Avdic E, Berenholtz S, Daugherty E, Hadhazy E, Lipsett PA, Maragakis LL, Perl TM, Speck K, Swoboda SM, Ziai W, Cosgrove SE. Ventilator-associated pneumonia: overdiagnosis and treatment are common in medical and surgical intensive care units. Infect Control Hosp Epidemiol 2014; 35:278-84. [PMID: 24521594 DOI: 10.1086/675279] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Diagnosing ventilator-associated pneumonia (VAP) is difficult, and misdiagnosis can lead to unnecessary and prolonged antibiotic treatment. We sought to quantify and characterize unjustified antimicrobial use for VAP and identify risk factors for continuation of antibiotics in patients without VAP after 3 days. METHODS Patients suspected of having VAP were identified in 6 adult intensive care units (ICUs) over 1 year. A multidisciplinary adjudication committee determined whether the ICU team's VAP diagnosis and therapy were justified, using clinical, microbiologic, and radiographic data at diagnosis and on day 3. Outcomes included the proportion of VAP events misdiagnosed as and treated for VAP on days 1 and 3 and risk factors for the continuation of antibiotics in patients without VAP after day 3. RESULTS Two hundred thirty-one events were identified as possible VAP by the ICUs. On day 1, 135 (58.4%) of them were determined to not have VAP by the committee. Antibiotics were continued for 120 (76%) of 158 events without VAP on day 3. After adjusting for acute physiology and chronic health evaluation II score and requiring vasopressors on day 1, sputum culture collection on day 3 was significantly associated with antibiotic continuation in patients without VAP. Patients without VAP or other infection received 1,183 excess days of antibiotics during the study. CONCLUSIONS Overdiagnosis and treatment of VAP was common in this study and led to 1,183 excess days of antibiotics in patients with no indication for antibiotics. Clinical differences between non-VAP patients who had antibiotics continued or discontinued were minimal, suggesting that clinician preferences and behaviors contribute to unnecessary prescribing.
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Affiliation(s)
- Veronique Nussenblatt
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Hashimoto S, Shime N. Evaluation of semi-quantitative scoring of Gram staining or semi-quantitative culture for the diagnosis of ventilator-associated pneumonia: a retrospective comparison with quantitative culture. J Intensive Care 2013; 1:2. [PMID: 25705397 PMCID: PMC4336129 DOI: 10.1186/2052-0492-1-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 09/13/2013] [Indexed: 12/02/2022] Open
Abstract
Background Semi-quantitative Gram stain and culture methods are still commonly used for diagnosing ventilator-associated pneumonia (VAP), due to its convenience. Only a few studies, however, have assessed the reliability of these methods when compared with quantitative cultures, a current standard for the diagnosis of VAP. The objective of this study was to assess the utility of semi-quantitative scores obtained using Gram stains and cultures of endotracheal aspirates when compared with quantitative cultures in the diagnosis of VAP. Methods A retrospective chart review of mechanically ventilated patients with clinically suspected VAP in a single intensive care unit was performed. Semi-quantitative scores of Gram stains or culture results were compared with quantitative culture results of endotracheal aspirate for the diagnosis of VAP in 136 samples for 51 patients. Results The semi-quantitative scores of Gram stains and the semi-quantitative culture results significantly correlated with the log value of the quantitative culture results (rs = 0.64 and 0.75). When using a log count ≥6 of quantitative cultures as the reference standard for the diagnosis of VAP, the sensitivity and specificity was 95% and 61% for Gram stain score of ≥1+, and was 42% and 96% for Gram stain score ≥3+, respectively. The sensitivity and specificity was 96% and 40% for the semi-quantitative culture score of ≥2+, and was 59% and 86% for the semi-quantitative culture score of ≥3+, respectively. Conclusions Absence of bacteria in semi-quantitative Gram stain and poor growth (≤1+) in semi-quantitative culture method could be utilized to exclude the possibility of VAP, whereas detection of abundant (≥3+) bacteria in semi-quantitative Gram stain could be utilized to strongly suspect VAP.
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Affiliation(s)
- Soshi Hashimoto
- Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555 Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555 Japan ; Department of Emergency and Critical Care Medicine, National Hospital Organization Kyoto Medical Center, Kyoto, 612-8555 Japan
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Hui C, Lin MC, Jao MS, Liu TC, Wu RG. Previous antibiotic exposure and evolution of antibiotic resistance in mechanically ventilated patients with nosocomial infections. J Crit Care 2013; 28:728-34. [DOI: 10.1016/j.jcrc.2013.04.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Revised: 04/07/2013] [Accepted: 04/13/2013] [Indexed: 11/28/2022]
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Routine use of Staphylococcus aureus rapid diagnostic test in patients with suspected ventilator-associated pneumonia. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R170. [PMID: 23919575 PMCID: PMC4056790 DOI: 10.1186/cc12849] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 08/06/2013] [Indexed: 01/03/2023]
Abstract
INTRODUCTION In patients with ventilator-associated pneumonia (VAP), administration of an appropriate empirical antimicrobial treatment is associated with improved outcomes, leading to the prescription of broad-spectrum antibiotics, including a drug active against methicillin resistant Staphylococcus aureus (MRSA). In order to avoid the overuse of antibiotics, the present study aimed to evaluate the technical characteristics of a rapid diagnostic test (Cepheid Xpert assay) in patients with suspected VAP. METHODS From June 2011 to June 2012, in patients with suspected VAP, a sample from the bronchialalveolar lavage (BAL) or miniBAL was tested in a point-of-care laboratory for a rapid diagnostic test of methicillin susceptible Staphylococcus aureus (MSSA) and MRSA. Then, the result was compared to the quantitative culture with a threshold at 10⁴ colony-forming units per milliliter for bronchoalveolar lavage and 10³ colony-forming units per milliliter for minibronchoalveolar lavage. The study was performed in three intensive care units at two institutions. RESULTS Four hundred, twenty-two samples from 328 patients were analyzed. The culture of 6 (1.1%) and 28 (6.5%) samples were positive for MRSA and MSSA. The test was not interpretable in 41 (9.3%) patients. The negative predictive values of the rapid detection test were 99.7% (98.1 to 99.9%) and 99.8% (98.7 to 99.9%) for MSSA and MRSA, respectively. CONCLUSION The rapid diagnostic test is reliable in excluding the presence of MSSA and MRSA in the samples of patients with suspected VAP. Its utility should be regarded depending on the prevalence of MRSA.
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Gonzalez L, Cravoisy A, Barraud D, Conrad M, Nace L, Lemarié J, Bollaert PE, Gibot S. Factors influencing the implementation of antibiotic de-escalation and impact of this strategy in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R140. [PMID: 23849321 PMCID: PMC4055984 DOI: 10.1186/cc12819] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 07/12/2013] [Indexed: 12/29/2022]
Abstract
Introduction A rational use of antibiotics is of paramount importance in order to prevent the emergence of multidrug resistant bacteria that can lead to therapeutic impasse, especially in intensive care units (ICUs). A de-escalation strategy is therefore naturally advocated as part of better antibiotics usage. However, the clinical impact of such a strategy has not been widely studied. We aimed to assess the feasibility and the clinical impact of a de-escalation strategy in a medical ICU and to identify factors associated when de-escalation was possible. Methods We performed a retrospective study of patients hospitalized in a medical ICU over a period of six months. Independent factors associated with de-escalation and its clinical impact were assessed. Results Two hundred and twenty-nine patients were included in the study. Antibiotics were de-escalated in 117 patients (51%). The appropriateness of initial antibiotic therapy was the only independent factor associated with the performance of de-escalation (OR = 2.9, 95% CI, 1.5-5.7; P = 0.002). By contrast, inadequacy of initial antibiotic therapy (OR = 0.1, 0.0 to 0.1, P <0.001) and the presence of multidrug resistant bacteria (OR = 0.2, 0.1 to 0.7, P = 0.006) prevented from de-escalation. There were no differences in terms of short (ICU) or long-term (at 1 year) mortality rates or any secondary criteria such as ICU length of stay, duration of antibiotic therapy, mechanical ventilation, incidence of ICU-acquired infection, or multi-drug resistant bacteria emergence. Conclusions De-escalation appears feasible in most cases without any obvious negative clinical impact in a medical ICU.
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Silva BNG, Andriolo RB, Atallah AN, Salomão R. De-escalation of antimicrobial treatment for adults with sepsis, severe sepsis or septic shock. Cochrane Database Syst Rev 2013; 2013:CD007934. [PMID: 23543557 PMCID: PMC6517189 DOI: 10.1002/14651858.cd007934.pub3] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Mortality rates among patients with sepsis, severe sepsis or septic shock are highly variable throughout different regions or services and can be upwards of 50%. Empirical broad-spectrum antimicrobial treatment is aimed at achieving adequate antimicrobial therapy, thus reducing mortality; however, there is a risk that empirical broad-spectrum antimicrobial treatment can expose patients to overuse of antimicrobials. De-escalation has been proposed as a strategy to replace empirical broad-spectrum antimicrobial treatment by using a narrower antimicrobial therapy. This is done by reviewing the patient's microbial culture results and then making changes to the pharmacological agent or discontinuing a pharmacological combination. OBJECTIVES To evaluate the effectiveness and safety of de-escalation antimicrobial treatment for adult patients diagnosed with sepsis, severe sepsis or septic shock caused by any micro-organism. SEARCH METHODS In this updated version, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); MEDLINE via PubMed (from inception to October 2012); EMBASE (from inception to October 2012); LILACS (from inception to October 2012); Current Controlled Trials; bibliographic references of relevant studies; and specialists in the area. We applied no language restriction. We had previously searched the databases to August 2010. SELECTION CRITERIA We planned to include randomized controlled trials (RCTs) comparing de-escalation (based on culture results) versus standard therapy for adults with sepsis, severe sepsis or septic shock. The primary outcome was mortality (at 28 days, hospital discharge or at the end of the follow-up period). Studies including patients initially treated with an empirical but not adequate antimicrobial therapy were not considered for inclusion. DATA COLLECTION AND ANALYSIS Two authors planned to independently select and extract data and to evaluate methodological quality of all studies. We planned to use relative risk (risk ratio) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals. We planned to use the random-effects statistical model when the estimate effects of two or more studies could be combined in a meta-analysis. MAIN RESULTS Our search strategy retrieved 493 studies. No published RCTs testing de-escalation of antimicrobial treatment for adult patients diagnosed with sepsis, severe sepsis or septic were included in this review. We found one ongoing RCT. AUTHORS' CONCLUSIONS There is no adequate, direct evidence as to whether de-escalation of antimicrobial agents is effective and safe for adults with sepsis, severe sepsis or septic shock. This uncertainty warrants further research via RCTs and the authors are awaiting the results of an ongoing RCT testing the de-escalation of empirical antimicrobial therapy for severe sepsis.
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Affiliation(s)
- Brenda N G Silva
- Brazilian Cochrane Centre, Centro de Estudos de Medicina Baseada em Evidências e Avaliação Tecnológica de Saúde, São Paulo,Brazil.
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43
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Capellier G, Mockly H, Charpentier C, Annane D, Blasco G, Desmettre T, Roch A, Faisy C, Cousson J, Limat S, Mercier M, Papazian L. Early-onset ventilator-associated pneumonia in adults randomized clinical trial: comparison of 8 versus 15 days of antibiotic treatment. PLoS One 2012; 7:e41290. [PMID: 22952580 PMCID: PMC3432026 DOI: 10.1371/journal.pone.0041290] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 06/19/2012] [Indexed: 01/19/2023] Open
Abstract
PURPOSE The optimal treatment duration for ventilator-associated pneumonia is based on one study dealing with late-onset of the condition. Shortening the length of antibiotic treatment remains a major prevention factor for the emergence of multiresistant bacteria. OBJECTIVE To demonstrate that 2 different antibiotic treatment durations (8 versus 15 days) are equivalent in terms of clinical cure for early-onset ventilator-associated pneumonia. METHODS Randomized, prospective, open, multicenter trial carried out from 1998 to 2002. MEASUREMENTS The primary endpoint was the clinical cure rate at day 21. The mortality rate was evaluated on days 21 and 90. RESULTS 225 patients were included in 13 centers. 191 (84.9%) patients were cured: 92 out of 109 (84.4%) in the 15 day cohort and 99 out of 116 (85.3%) in the 8 day cohort (difference = 0.9%, odds ratio = 0.929). 95% two-sided confidence intervals for difference and odds ratio were [-8.4% to 10.3%] and [0.448 to 1.928] respectively. Taking into account the limits of equivalence (10% for difference and 2.25 for odds ratio), the objective of demonstrative equivalence between the 2 treatment durations was fulfilled. Although the rate of secondary infection was greater in the 8 day than the 15 day cohort, the number of days of antibiotic treatment remained lower in the 8 day cohort. There was no difference in mortality rate between the 2 groups on days 21 and 90. CONCLUSION Our results suggest that an 8-day course of antibiotic therapy is safe for early-onset ventilator-associated pneumonia in intubated patients. TRIAL REGISTRATION ClinicalTrials.gov NCT01559753.
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Affiliation(s)
- Gilles Capellier
- Réanimation médicale adulte, Pôle Urgences-SAMU-Réanimation CHU, Besancon, Doubs, France.
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44
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Gupta D, Agarwal R, Aggarwal AN, Singh N, Mishra N, Khilnani GC, Samaria JK, Gaur SN, Jindal SK. Guidelines for diagnosis and management of community- and hospital-acquired pneumonia in adults: Joint ICS/NCCP(I) recommendations. Lung India 2012; 29:S27-62. [PMID: 23019384 PMCID: PMC3458782 DOI: 10.4103/0970-2113.99248] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Dheeraj Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, Indian Chest Society, India
| | - G. C. Khilnani
- Department of Pulmonary Medicine, National College of Chest Physicians, India
| | - J. K. Samaria
- Department of Pulmonary Medicine, Indian Chest Society, India
| | - S. N. Gaur
- Department of Pulmonary Medicine, National College of Chest Physicians, India
| | - S. K. Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - for the Pneumonia Guidelines Working Group
- Pneumonia Guidelines Working Group Collaborators (43) A. K. Janmeja, Chandigarh; Abhishek Goyal, Chandigarh; Aditya Jindal, Chandigarh; Ajay Handa, Bangalore; Aloke G. Ghoshal, Kolkata; Ashish Bhalla, Chandigarh; Bharat Gopal, Delhi; D. Behera, Delhi; D. Dadhwal, Chandigarh; D. J. Christopher, Vellore; Deepak Talwar, Noida; Dhruva Chaudhry, Rohtak; Dipesh Maskey, Chandigarh; George D’Souza, Bangalore; Honey Sawhney, Chandigarh; Inderpal Singh, Chandigarh; Jai Kishan, Chandigarh; K. B. Gupta, Rohtak; Mandeep Garg, Chandigarh; Navneet Sharma, Chandigarh; Nirmal K. Jain, Jaipur; Nusrat Shafiq, Chandigarh; P. Sarat, Chandigarh; Pranab Baruwa, Guwahati; R. S. Bedi, Patiala; Rajendra Prasad, Etawa; Randeep Guleria, Delhi; S. K. Chhabra, Delhi; S. K. Sharma, Delhi; Sabir Mohammed, Bikaner; Sahajal Dhooria, Chandigarh; Samir Malhotra, Chandigarh; Sanjay Jain, Chandigarh; Subhash Varma, Chandigarh; Sunil Sharma, Shimla; Surender Kashyap, Karnal; Surya Kant, Lucknow; U. P. S. Sidhu, Ludhiana; V. Nagarjun Mataru, Chandigarh; Vikas Gautam, Chandigarh; Vikram K. Jain, Jaipur; Vishal Chopra, Patiala; Vishwanath Gella, Chandigarh
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45
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Abstract
Critically ill patients admitted to the intensive care unit (ICU) are frequently treated with antimicrobials. The appropriate and judicious use of antimicrobial treatment in the ICU setting is a constant clinical challenge for healthcare staff due to the appearance and spread of new multiresistant pathogens and the need to update knowledge of factors involved in the selection of multiresistance and in the patient's clinical response. In order to optimize the efficacy of empirical antibacterial treatments and to reduce the selection of multiresistant pathogens, different strategies have been advocated, including de-escalation therapy and pre-emptive therapy as well as measurement of pharmacokinetic and pharmacodynamic (pK/pD) parameters for proper dosing adjustment. Although the theoretical arguments of all these strategies are very attractive, evidence of their effectiveness is scarce. The identification of the concentration-dependent and time-dependent activity pattern of antimicrobials allow the classification of drugs into three groups, each group with its own pK/pD characteristics, which are the basis for the identification of new forms of administration of antimicrobials to optimize their efficacy (single dose, loading dose, continuous infusion) and to decrease toxicity. The appearance of new multiresistant pathogens, such as imipenem-resistant Pseudomonas aeruginosa and/or Acinetobacter baumannii, carbapenem-resistant Gram-negative bacteria harbouring carbapenemases, and vancomycin-resistant Enterococcus spp., has determined the use of new antibacterials, the reintroduction of other drugs that have been removed in the past due to toxicity or the use of combinations with in vitro synergy. Finally, pharmacoeconomic aspects should be considered for the choice of appropriate antimicrobials in the care of critically ill patients.
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Affiliation(s)
- Francisco Álvarez-Lerma
- Service of Intensive Care Medicine, Parc de Salut Mar, Universitat Autònoma de Barcelona, Barcelona, Spain.
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46
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Direct testing of bronchoalveolar lavages from ventilator-associated pneumonia patients. Diagn Microbiol Infect Dis 2012; 73:107-10. [PMID: 22483191 DOI: 10.1016/j.diagmicrobio.2012.02.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 02/14/2012] [Accepted: 02/23/2012] [Indexed: 11/22/2022]
Abstract
In line with a rapid de-escalation of empirical antimicrobial therapy, this study assessed the validity of an E-test-based direct specimen testing method on bronchoalveolar lavage (BAL) samples from ventilator-associated pneumonia (VAP) patients. E-test strips were directly applied onto Mueller-Hinton agar plates seeded with BAL samples and read after 24 h of incubation. In parallel, the BAL samples were analyzed by the routine diagnostic laboratory. The microbroth dilution approach was used as a control method. In a cohort of 20 patients, 135 microorganism-antibiotic combinations were studied. Total agreement between the 2 methods was achieved for 88.9% combinations, with 1.5% very major errors (isolates susceptible by E-test and reported resistant by the diagnostic laboratory) and 9.6% major errors (isolates resistant by E-test and reported susceptible by the diagnostic laboratory). These results indicate that applying E-test directly on BAL samples is a promising method for obtaining susceptibility data after 24 h in critical patients with VAP.
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47
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Healthcare-associated infection prevention in pediatric intensive care units: a review. Eur J Clin Microbiol Infect Dis 2012; 31:2481-90. [DOI: 10.1007/s10096-012-1611-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 03/19/2012] [Indexed: 10/28/2022]
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48
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Abstract
Ventilator-associated pneumonia (VAP) is the most frequent and severe infection acquired in the intensive care unit, leading to prolonged mechanical ventilation and excess mortality. This article reviews the different aspects of VAP, such as risk factors, causative agents, and approaches to diagnosis, treatment, and prevention. Several aspects of VAP are still considered controversial.
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Affiliation(s)
- Jean-Louis Trouillet
- Service de Réanimation Médicale, Institut de Cardiologie, Groupe Hospitalier Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Faculté de Médecine Paris 6-Pierre et Marie Curie, Paris, France.
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49
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Niederman MS, Soulountsi V. De-escalation therapy: is it valuable for the management of ventilator-associated pneumonia? Clin Chest Med 2012; 32:517-34. [PMID: 21867820 DOI: 10.1016/j.ccm.2011.05.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In therapy for ventilator-associated pneumonia, it is essential to get initial empiric therapy correct; this is challenging because many patients are infected with multidrug-resistant pathogens. The need for achieving appropriate therapy can lead to broad-spectrum empiric therapy, which can represent antibiotic overuse and promote even more resistance. In an effort to combat this problem, de-escalation therapy has been proposed, with the goals of reducing the number of drugs, the spectrum of therapy, and the duration of therapy. This review examines the factors associated with an effective de-escalation strategy and ways to increase the rates of de-escalation in the future.
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Affiliation(s)
- Michael S Niederman
- Department of Medicine, Winthrop-University Hospital, Mineola, NY 11501, USA.
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50
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Snydman DR. Empiric antibiotic selection strategies for healthcare-associated pneumonia, intra-abdominal infections, and catheter-associated bacteremia. J Hosp Med 2012; 7 Suppl 1:S2-S12. [PMID: 23677631 DOI: 10.1002/jhm.980] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 08/22/2011] [Accepted: 08/28/2011] [Indexed: 11/10/2022]
Abstract
Initial selection and early deployment of appropriate/adequate empiric antimicrobial therapy is critical to minimize the significant morbidity and mortality associated with hospital- or healthcare-associated infections (HAIs). Initial empiric therapy that inadequately covers the pathogen(s) causing a serious HAI has been associated with increased mortality, longer hospital stay, and elevated healthcare costs. Moreover, subsequent modification of initial inadequate therapy, later in the disease process when culture results become available, may not remedy the impact of the initial choice. Because of this, it is important that initial empiric therapy covers the most likely pathogens associated with infection in a particular patient, even if this initial regimen turns out to be unnecessarily broad, based on subsequent culture results. The current paradigm for management of serious HAIs is to initiate empiric therapy with a broad-spectrum regimen covering likely pathogens, based on local surveillance and susceptibility data, and presence of risk factors for involvement of a resistant microorganism. Subsequent modification (de-escalation) of the initial regimen becomes possible later, when culture results are available and clinical status can be better assessed, 2 to 4 days after initiation of empiric therapy. When possible, de-escalation and other steps to modify antimicrobial exposure are important for minimizing risk of antimicrobial resistance development. This article examines the general process for selection of initial empiric antibiotic therapy for patients with HAIs, illustrated through 3 case studies dealing with healthcare-associated pneumonia, complicated intra-abdominal infection, and catheter-associated bacteremia, respectively.
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Affiliation(s)
- David R Snydman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St,Boston, MA 02111, USA.
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