Ideal and Actual Impact of Rapid Diagnostic Testing and Antibiotic Stewardship on Antibiotic Prescribing and Clinical Outcomes in Children With Positive Blood Cultures

Approaches to Reduce Use and Duration of Anti-MRSA Agents for Antimicrobial Stewardship Programs: A Review of Recent Literature

Antimicrobial stewardship programs (ASPs) have the potential to effectively deescalate unnecessary methicillin-resistant Staphylococcus aureus (MRSA) coverage. This review summarizes literature published from 2014 through 2021 describing contemporary ASP methods and their resulting effectiveness at reducing anti-MRSA agent use (ie vancomycin, linezolid, daptomycin, ceftaroline, and clindamycin). This review of the literature examined the following strategies, which had reports of success in either decreasing the use or duration of anti-MRSA agents: prospective review and feedback, antibiotic timeouts, health system or department protocol changes, polymerase chain reaction (PCR) and rapid testing of patient samples. Most of the current literature continue to support most ASP interventions including antibiotic timeouts, pathways, and molecular testing including MRSA nasal PCRs and rapid diagnostic testing can be successful at reducing unnecessary anti-MRSA use.

Molecular antimicrobial susceptibility testing in sepsis

Rapidly detecting and identifying pathogens is crucial for appropriate antimicrobial therapy in patients with sepsis. Conventional diagnostic methods have been a great asset to medicine, though they are time consuming and labor intensive. This work will enable healthcare professionals to understand the bacterial community better and enhance their diagnostic capacity by using novel molecular methods that make obtaining quicker, more precise results possible. The authors discuss and critically assess the merits and drawbacks of molecular testing and the added value of these tests, including the shift turnaround time, the implication for clinicians' decisions, gaps in knowledge, future research directions and novel insights or innovations. The field of antimicrobial molecular testing has seen several novel insights and innovations to improve the diagnosis and management of infectious diseases.

Optimizing antimicrobial therapy in urinary tract infections: A focus on urine culture and sensitivity testing

Objectives: This cross-sectional study was conducted at Jordan university hospital to evaluate the impact of microbial culture data and sensitivity results on optimizing UTI treatment. Methods: All positive urine cultures requested for adult patients (≥18 years) admitted to Jordan University Hospital (JUH) within the period from January 2019-July 2021 were evaluated. The antibiotics prescribed before and after culture data and sensitivity results were compared to evaluate the impact of these diagnostic measures on optimizing UTI treatment. Results: During the study period, 2400 urine cultures revealed positive results. Among those patients, 1,600 (66.7%) were discharged before the availability of culture results and excluded. Of the remaining 800 patients, 701 patients (87.6%) received empiric treatment. After culture and sensitivity results were available, overall, 84 (10.5%) patients had optimization (improvement) in their UTI management after culture results were known, while 6 (0.8%) patients had a worsening in their treatments. Based on the culture results, we found that only 12.4% of patients were appropriately treated before and after the culture results. Moreover, our results revealed that 31.9% were inappropriately treated for their UTIs before and after culture results. Conclusion: This study revealed an alarmingly high rate of inappropriate treatment of UTIs despite the availability of urine culture and sensitivity data, and that culture results were not used to optimize treatment strategies for UTI. This practice can potentially result in poor health-related outcomes and adversely affects efforts to battle AMR. Multifaceted strategies must be implemented to help clinicians follow the best current evidence and current guidelines in their selection of antibiotics for the management of UTIs.

Early appropriate diagnostics and treatment of MDR Gram-negative infections

The term difficult-to-treat resistance has been recently coined to identify Gram-negative bacteria exhibiting resistance to all fluoroquinolones and all β-lactam categories, including carbapenems. Such bacteria are posing serious challenges to clinicians trying to identify the best therapeutic option for any given patient. Delayed appropriate therapy has been associated with worse outcomes including increase in length of stay, increase in total in-hospital costs and ∼20% increase in the risk of in-hospital mortality. In addition, time to appropriate antibiotic therapy has been shown to be an independent predictor of 30 day mortality in patients with resistant organisms. Improving and anticipating aetiological diagnosis through optimizing not only the identification of phenotypic resistance to antibiotic classes/agents, but also the identification of specific resistance mechanisms, would have a major impact on reducing the frequency and duration of inappropriate early antibiotic therapy. In light of these considerations, the present paper reviews the increasing need for rapid diagnosis of bacterial infections and efficient laboratory workflows to confirm diagnoses and facilitate prompt de-escalation to targeted therapy, in line with antimicrobial stewardship principles. Rapid diagnostic tests currently available and future perspectives for their use are discussed. Early appropriate diagnostics and treatment of MDR Gram-negative infections require a multidisciplinary approach that includes multiple different diagnostic methods and further consensus of algorithms, protocols and guidelines to select the optimal antibiotic therapy.

Antimicrobial Therapy in Pediatric Sepsis: What Is the Best Strategy?

Pediatric sepsis is a relevant cause of morbidity and mortality in this age group. Children are affected differently in high and low-income countries. Antibiotics are crucial for the treatment of sepsis, but indiscriminate use can increase resistance worldwide. The choice of a correct empiric therapy takes into consideration the site of infection, local epidemiology, host comorbidities and recent antibiotic exposure. Antibiotics should be administered in the first hour for patients with septic shock, and always intravenously or via intraosseous access. Culture results and clinical improvement will guide de-escalation and length of treatment. New diagnostic methods can help improve the prescription of adequate treatment. Prevention of sepsis includes vaccination and prevention of healthcare-associated infections. More research and education for awareness of sepsis is needed to improve care.

Multilabel hybridization probes for sequence-specific detection of sepsis-related drug resistance genes in plasmids

Emerging antimicrobial drug resistance is increasing the complexity involved in treating critical conditions such as bacterial induced sepsis. Methods for diagnosing specific drug resistance tend to be rapid or sensitive, but not both. Detection methods like sequence-specific single-molecule analysis could address this concern if they could be adapted to work on smaller targets similar to those produced in traditional clinical situations. In this work we demonstrate that a 120 bp double stranded polynucleotide with an overhanging single stranded 25 bp probe sequence can be created by immobilizing DNA with a biotin/streptavidin magnetic bead system, labeling with SYBR Gold, and rinsing the excess away while the probe retains multiple fluorophores. These probes with multiple fluorophores can then be used to label a bacterial plasmid target in a sequence-specific manner. These probes enabled the detection of 1 pM plasmid samples containing a portion of an antibiotic resistance gene sequence. This system shows the possibility of improving capture and fluorescence labeling of small nucleic acid fragments, generating lower limits of detection for clinically relevant samples while maintaining rapid processing times.

Performance and Impact on Initial Antibiotic Choice of Direct Identification of Pathogens from Pediatric Blood Culture Bottles Using an In-House MALDI-TOF MS Protocol

The performance and early therapeutic impact of direct identification by matrix-assisted laser desorption ionization–time-of-flight mass spectrometry (MALDI-TOF; DIMT) on pediatric blood culture bottles using in-house-developed methods to obtain microbial pellets for spectrometric analysis have seldom been studied. During a 2-year period (June 2018 to May 2020), DIMT was performed on broths from positive pediatric blood culture bottles using an in-house-developed method. Organism identifications with a score of ≥1.6 were notified to treating clinicians. Therapeutic modifications that occurred after the communication of DIMT were reviewed through the electronic medical records. DIMT was performed on 530 pediatric positive blood culture bottles. Among 505 monomicrobial bottles, identifications from 298 (97.7%) deemed as bloodstream infections (BSI) and 189 (94.5%) as contaminations had DIMT notified to clinicians. All identifications were correct except for one Streptococcus mitis incorrectly reported as Streptococcus pneumoniae. Therapy modifications resulting from DIMT occurred in 27 (8.3%) patients with BSI. Deescalation from effective or ineffective broad-spectrum regimens occurred mainly in Enterococcus faecalis bacteremia, whereas appropriate escalation from an ineffective regimen with narrower spectrum occurred mainly in bacteremia caused by AmpC-β-lactamase-producing Enterobacterales. Escalation therapy was instituted significantly faster than deescalation therapy (median time, 0.75 versus 10.5 h [P = 0.01]). DIMT also enabled clinicians to confirm contamination in nearly one-half of patients with contaminated blood cultures. Our DIMT method applied to positive pediatric blood culture bottles demonstrated reliable performance for the rapid identification of pathogens. Our DIMT approach allowed therapeutic optimization in BSI, especially involving microorganisms with intrinsic antibiotic resistance, and was helpful in the early identification of likely contaminants.

IMPORTANCE We demonstrate the performance and early impact on the antimicrobial management of bloodstream infections of an inexpensive, in-house preparation method for direct identification of bloodstream pathogens in pediatric blood culture bottles by matrix-assisted laser desorption/ionization–time-of-flight mass spectrometry.

Fighting Antibiotic Resistance in Hospital-Acquired Infections: Current State and Emerging Technologies in Disease Prevention, Diagnostics and Therapy

Rising antibiotic resistance is a global threat that is projected to cause more deaths than all cancers combined by 2050. In this review, we set to summarize the current state of antibiotic resistance, and to give an overview of the emerging technologies aimed to escape the pre-antibiotic era recurrence. We conducted a comprehensive literature survey of >150 original research and review articles indexed in the Web of Science using "antimicrobial resistance," "diagnostics," "therapeutics," "disinfection," "nosocomial infections," "ESKAPE pathogens" as key words. We discuss the impact of nosocomial infections on the spread of multi-drug resistant bacteria, give an overview over existing and developing strategies for faster diagnostics of infectious diseases, review current and novel approaches in therapy of infectious diseases, and finally discuss strategies for hospital disinfection to prevent MDR bacteria spread.

Bibliometric analysis of peer-reviewed literature on antimicrobial stewardship from 1990 to 2019

BACKGROUND

The World Health Organization recommended the implementation of antimicrobial stewardship (AMS) in the clinical settings to minimize the development and spread of antimicrobial resistance (AMR). The current study aimed to assess global research activity on AMS as one measure for efforts dedicated to contain AMR.

METHOD

A bibliometric method was applied using Scopus. A validated search query was implemented. Bibliometric indicators and mapping were generated. The study period was from 1990 to 2019. The search query utilized the keywords "antimicrobial stewardship" or "antibiotic stewardship" in the titles or abstracts. In addition, documents with the term "restrict" or "restriction" if used with the terms "antimicrobial" or "antibiotic" were retrieved.

RESULTS

The search query returned 4402 documents. The keyword "antimicrobial stewardship" returned 2849 documents while the keyword "antibiotic stewardship" returned 1718 documents. The terms restrict/restriction and antimicrobial/antibiotics returned 209 documents. The number of publications and cumulative citations showed a steep and parallel increase in the last decade. The region of the Americas returned the most while the Eastern Mediterranean region returned the least. The United States (n = 1834, 41.7%) ranked first. Main research themes in the retrieved literature were the (1) impact of AMS on hospital length stay, (2) role of pharmacists, and (3) development of resistance of various pathogens. Clostridium difficile (n = 94) and Staphylococcus aureus (n = 76) were among the most frequently encountered author keywords. The Infection Control and Hospital Epidemiology journal ranked first (n = 245, 5.6%, h-index = 134) while documents published in the Clinical Infectious Diseases journal (h-index = 321) received the highest number of citations per document (70.7). At the institutional level, the US Centers for Disease Prevention and Control (n = 93, 2.1%) ranked first followed by the Imperial College London (n = 86, 2.0%). The main funding sponsors were the National Institute of Health. Pfizer, Merck, and Bayer pharmaceutical companies played a key role in funding AMS research. International research collaboration between developed (n = 3693, 83.9%) and developing countries (n = 759, 17.2%).

CONCLUSION

The fight against AMR is a global responsibility and implementation of AMS need to be carried out across the globe. International research collaboration between developing and developed countries should be encouraged.

Clinical Performance and Impact of Accelerate Pheno for Gram-negative Bacteremia in Hospitalized Children

PURPOSE

Accelerate Pheno provides rapid identification and antimicrobial susceptibility tests (ASTs) of pathogens that cause blood stream infections (BSIs). The study objective was to assess the accuracy of the Accelerate Pheno platform and its impact on antimicrobial modification in children with gram-negative BSIs.

METHODS

A retrospective review was conducted of patients at a children's hospital with gram-negative BSIs from November 2018 to November 2019. Proportion of agreement between Accelerate Pheno and standard of care (SOC) was determined for organism identification (matrix-assisted laser desorption ionization time-of-flight mass spectrometry) and susceptibilities (MicroScan). Time from culture collection to Gram stain, identification and AST by the Accelerate Pheno method, and AST results by MicroScan were calculated. Antibiotic modifications and opportunities to optimize antimicrobial stewardship were recorded.

FINDINGS

Of 115 BSIs from 90 patients, 90 monomicrobial gram-negative BSIs with an organism included on the Accelerate Pheno panel were found. Compared with SOC, the organism was correctly identified in 90 patients (100%). Overall, 5 of 732 ASTs (0.7%) reported susceptible by Accelerate Pheno were resistant by SOC, and 8 of 109 (7.3%) reported resistant by Accelerate Pheno were susceptible by SOC. On the basis of the Accelerate Pheno AST results, antibiotic spectrum was increased in 10 of 11 instances to correct organism-drug mismatch and narrowed in 16 of 33 instances. Median times from culture collection to reporting of Gram stain, Accelerate Pheno identification, Accelerate Pheno AST, and SOC AST were 12.6, 14.6, 19.9, and 60.6 h, respectively. Median time to optimal therapy was 21.8 h for infections with actionable AST data.

IMPLICATIONS

Accelerate Pheno was accurate and decreased time to optimal therapy by almost 40 h for children with gram-negative BSIs. Antibiotic spectrum was increased in multiple instances, but opportunities to decrease spectrum were underused.

Pediatric Antimicrobial Stewardship Programs: Current Perspectives

With the rapid growth of the field of pediatric antimicrobial stewardship, there has been a marked increase in the establishment of programs dedicated to this specialty. Shared objectives of all pediatric antimicrobial stewardship programs (ASPs) include optimization of antibiotic use and improvement in clinical outcomes for children, while certain core operational strategies and metrics used to measure program effectiveness are typically utilized by pediatric ASPs. Antimicrobial stewardship is the responsibility of every individual who prescribes, dispenses, and administers antibiotics to children, and pediatric ASP principles are rooted in collaboration and cooperation. Pediatric ASPs are uniquely suited to meet the needs of the local populations they serve and the environments within which they practice while also fostering an awareness of the interconnected global nature of pediatric stewardship. As such, pediatric ASPs are well positioned to confront the evolving challenges of antimicrobial overuse and resistance.

Impact of rapid diagnostics with antimicrobial stewardship support for children with positive blood cultures: A quasi-experimental study with time trend analysis

OBJECTIVE

Evaluate the clinical impact of the implementation of VERIGENE gram-positive blood culture testing (BC-GP) coupled with antimicrobial stewardship result notification for children with positive blood cultures.

DESIGN

Quasi-experimental study.

SETTING

Quaternary children's hospital.

PATIENTS

Hospitalized children aged 0-21 years with positive blood culture events 1 year before and 1 year after implementation of BC-GP testing.

METHODS

The primary outcome was time to optimal antibiotic therapy for positive blood cultures, defined as receiving definitive therapy without unnecessary antibiotics (pathogens) or no antibiotics (contaminants). Secondary outcomes were time to effective therapy, time to definitive therapy, and time to stopping vancomycin, length of stay, and 30-day mortality. Time-to-therapy outcomes before and after the intervention were compared using Cox regression models and interrupted time series analyses, adjusting for patient characteristics and trends over time. Gram-negative events were included as a nonequivalent dependent variable.

RESULTS

We included 264 preintervention events (191 gram-positive, 73 gram-negative) and 257 postintervention events (168 gram-positive, 89 gram-negative). The median age was 2.9 years (interquartile range, 0.3-10.1), and 418 pediatric patients (80.2%) had ≥1 complex chronic condition. For gram-positive isolates, implementation of BC-GP testing was associated with an immediate reduction in time to optimal therapy and time to stopping vancomycin for both analyses. BC-GP testing was associated with decreased time to definitive therapy in interrupted time series analysis but not Cox modeling. No such changes were observed for gram-negative isolates. No changes in time to effective therapy, length of stay, or mortality were associated with BC-GP.

CONCLUSIONS

The implementation of BC-GP testing coupled with antimicrobial stewardship result notification was associated with decreased time to optimal therapy and time to stopping vancomycin for hospitalized children with gram-positive blood culture isolates.

Improving the Quality of Hospital Antibiotic Use: Impact on Multidrug-Resistant Bacterial Infections in Children

Antimicrobial resistance (AMR) is considered a rapidly growing global public health emergency. Neonates and children are among patients for whom antibiotics are largely prescribed and for whom the risk of AMR development is high. The phenomenon of increasing AMR has led to the need to develop measures aimed at the rational and effective use of the available drugs also in children and antimicrobial stewardship (AS), which is one of the measures that in adults has showed the highest efficacy in reducing antibiotic abuse and misuse, appears as an attractive approach. The aim of this manuscript is to analyze the basic principles and strategies of pediatric AS. To this end, we searched in PubMed articles published in years 2000 to 2019 containing "antimicrobial resistance," "antibiotic use," "antimicrobial stewardship," and "children" or "pediatric" as keywords. Our review showed that the balance between multi-resistant organisms and new antimicrobials is extremely precarious. The AS tools are the most important weapon at our disposal to stem the phenomenon. Careful monitoring of prescriptions, continuous training of prescribing physicians and collaboration with highly qualified multidisciplinary staff, creation of local and national guidelines, use of rapid diagnostic tests, technological means of support, and research activities by testing new broad-spectrum antibiotics are mandatory. However, all of these measures must be supported by adequate investment by national and international health organizations. Only by making AS daily practice, through the use of financial resources and dedicated staff, we can fight AMR to ensure safe and effective care for our young patients.

Antimicrobial stewardship in children: more shadows than lights?

Introduction: The aim of this review is to evaluate the effectiveness of antimicrobial stewardship (AMS) programmes in the pediatric population in improving clinical outcomes, altering prescribing behavior, controlling antimicrobial resistance and measuring the cost-effectiveness.Areas covered: Medline Ovid MEDLINE(R), Embase, and Cochrane Library were searched on 30 September 2018 combining MeSH and free terms for 'antimicrobial stewardship', 'clinical outcomes', 'antimicrobial resistance', 'cost-effectiveness' and 'prescribing behavior'. Several studies have been conducted on the impact of antimicrobial stewardship programmes (ASPs) in children, which showed a positive impact on length of hospital stay and days of therapy. Together with ASP bundles, the introduction of fast microbiology and point-of-care tests showed a positive impact in terms of rapid identification of the pathogen, time to optimal antimicrobial therapy and reduction of antibiotic use, without worsening clinical outcomes. These improvements turned out to be limited over time. Conflicting results were observed regarding the impact of ASPs on antimicrobial resistance and on cost-effectiveness and cost-benefits, due to the lack of homogeneity between studies.Expert opinion: Evidence regarding the impact of ASPs in children is limited to single center studies, with different study designs, making it impossible to draw unequivocal conclusions. High quality studies are needed. More feasable approaches should be designed both for inpatients and outpatients and for critical patients.