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Diggs DT, Tribble AC, Same RG, Newland JG, Lee BR. Appropriateness of antibiotic prescribing varies by clinical services at United States children's hospitals. Infect Control Hosp Epidemiol 2023; 44:1711-1717. [PMID: 37905378 PMCID: PMC10665883 DOI: 10.1017/ice.2023.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVE To describe patterns of inappropriate antibiotic prescribing at US children's hospitals and how these patterns vary by clinical service. DESIGN Serial, cross-sectional study using quarterly surveys. SETTING Surveys were completed in quarter 1 2019-quarter 3 2020 across 28 children's hospitals in the United States. PARTICIPANTS Patients at children's hospitals with ≥1 antibiotic order at 8:00 a.m. on institution-selected quarterly survey days. METHODS Antimicrobial stewardship physicians and pharmacists collected data on antibiotic orders and evaluated appropriateness of prescribing. The primary outcome was percentage of inappropriate antibiotics, stratified by clinical service and antibiotic class. Secondary outcomes included reasons for inappropriate use and association of infectious diseases (ID) consultation with appropriateness. RESULTS Of 13,344 orders, 1,847 (13.8%) were inappropriate; 17.5% of patients receiving antibiotics had ≥1 inappropriate order. Pediatric intensive care units (PICU) and hospitalists contributed the most inappropriate orders (n = 384 and n = 314, respectively). Surgical subspecialists had the highest percentage of inappropriate orders (22.5%), and 56.8% of these were for prolonged or unnecessary surgical prophylaxis. ID consultation in the previous 7 days was associated with fewer inappropriate orders (15% vs 10%; P < .001); this association was most pronounced for hospitalist, PICU, and surgical and medical subspecialty services. CONCLUSIONS Inappropriate antibiotic use for hospitalized children persists and varies by clinical service. Across 28 children's hospitals, PICUs and hospitalists contributed the most inappropriate antibiotic orders, and surgical subspecialists' orders were most often judged inappropriate. Understanding service-specific prescribing patterns will enable antimicrobial stewardship programs to better design interventions to optimize antibiotic use.
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Affiliation(s)
- Devin T. Diggs
- College of Science, University of Notre Dame, Notre Dame, Indiana
| | - Alison C. Tribble
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Rebecca G. Same
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason G. Newland
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Brian R. Lee
- Division of Health Services and Outcomes Research, Department of Pediatrics, Children’s Mercy Kansas City, Kansas City, Missouri
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2
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Waagsbø B, Tranung M, Damås JK, Heggelund L. Antimicrobial therapy of community-acquired pneumonia during stewardship efforts and a coronavirus pandemic: an observational study. BMC Pulm Med 2022; 22:379. [PMID: 36242006 PMCID: PMC9569007 DOI: 10.1186/s12890-022-02178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 09/09/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is the most frequent infection diagnosis in hospitals. Antimicrobial therapy for CAP is depicted in clinical practice guidelines, but adherence data and effect of antibiotic stewardship measures are lacking. Methods A dedicated antibiotic team pointed out CAP as a potential target for antimicrobial stewardship (AMS) measures at a 1.000-bed, tertiary care, teaching university hospital in Norway from March until May for the years 2016 throughout 2021. The aim of the AMS program was to increase diagnostic and antimicrobial therapy adherence to national clinical practice guideline recommendations through multiple and continuous AMS efforts. Descriptive statistics were retrospectively used to delineate antimicrobial therapy for CAP. The primary outcomes were proportions that received narrow-spectrum beta-lactams, and broad-spectrum antimicrobial therapy. Results 1.112 CAP episodes were identified. The annual proportion that received narrow-spectrum beta-lactams increased from 56.1 to 74.4% (p = 0.045). Correspondingly, the annual proportion that received broad-spectrum antimicrobial therapy decreased from 34.1 to 17.1% (p = 0.002). Trends were affected by the coronavirus pandemic. Mortality and 30-day readmission rates remained unchanged. De-escalation strategies were frequently unutilized, and overall therapy duration exceeded clinical practice guideline recommendations substantially. Microbiologically confirmed CAP episodes increased from 33.7 to 56.2% during the study period. Conclusion CAP is a suitable model condition that is sensitive to AMS measures. A continuous focus on improved microbiological diagnostics and antimicrobial therapy initiation is efficient in increasing adherence to guideline recommendations. There is an unmet need for better antimicrobial de-escalation strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02178-6.
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Affiliation(s)
- Bjørn Waagsbø
- St. Olavs Hospital, Regional centre for disease control in Central Norway Regional Health Authority, Trondheim University hospital, Trondheim, Norway. .,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Morten Tranung
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway.,Central Norway Hospital Pharmacy Trust, Trondheim, Norway
| | - Jan Kristian Damås
- Department of Infectious Diseases, St. Olavs Hospital, Trondheim University hospital, Trondheim, Norway.,Centre of Molecular Inflammation Research, department of Clinical and Molecular Medicine, NTNU, Trondheim, Norway
| | - Lars Heggelund
- Department of Internal Medicine, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
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Dow G, MacLaggan T, Allard J. Impact of a bloodstream infection stewardship program in hospitalized patients. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2022; 7:196-207. [PMID: 36337596 PMCID: PMC9629734 DOI: 10.3138/jammi-2022-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/05/2022] [Accepted: 04/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Bloodstream infections (BSIs) in hospitalized patients represent sentinel events requiring timely and responsive antimicrobial prescribing. These infections represent an attractive but seldom-evaluated stewardship opportunity. METHODS Retrospective pre-post study design, with review of patient charts 18 months before and after initiation of a hospital Bloodstream Infection Stewardship Program (BSISP). Pre-intervention, the ward and attending physician were notified of all positive blood cultures. Post-intervention, an infectious disease (ID) pharmacist collaborating with an ID consultant was also notified. RESULTS Two hundred twenty-six eligible BSIs were identified pre-intervention and 195 post-intervention. The urinary tract was the most common source of infection; most common bloodstream isolates were Escherichia coli, Staphylococcus aureus, beta-hemolytic streptococci, and Klebsiella pneumoniae; 71.7% of infections were community acquired. Empiric therapy was not given in 17.3% of cases and inadequate in 16.4% of patients. Therapy was altered on the basis of Gram stain results ('directed therapy') in 54.6% of episodes and was inadequate in 3.5%. Compared to pre-intervention, the post-intervention cohort received directed therapy on average 4.36 hours earlier (p = 0.003), was more likely to receive appropriate definitive therapy (99.0% post versus 79.1% pre, p <0.001), stepped down to oral therapy earlier (6.0 versus 8.0 days, p = 0.031), and received fewer directed prescriptions (214 per 100 cases post versus 260 per 100 cases pre; p = 0.001), including fewer prescriptions of quinolones and clindamycin. CONCLUSIONS A BSISP could be an effective strategy for improving antimicrobial prescribing in hospitalized patients with a BSI.
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Affiliation(s)
- Gordon Dow
- Division of Infectious Diseases, The Moncton Hospital, Horizon Health Network, Moncton, New Brunswick, Canada
| | - Timothy MacLaggan
- Division of Infectious Diseases, The Moncton Hospital, Horizon Health Network, Moncton, New Brunswick, Canada
| | - Jacques Allard
- Division of Infectious Diseases, The Moncton Hospital, Horizon Health Network, Moncton, New Brunswick, Canada
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Sun KS, Lam TP, Chan TH, Lam KF, Kwok KW, Chan HY, Ho PL. Medical interns' views on the strategies for reducing antibiotic misuse in the hospitals-what guidelines do they follow? J Infect Prev 2022; 23:214-221. [PMID: 36003133 PMCID: PMC9393602 DOI: 10.1177/17571774221094154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 03/22/2022] [Indexed: 09/03/2023] Open
Abstract
Objectives Although the topic of antibiotic misuse is taught in medical schools, interns (fresh medical graduates) still encounter barriers to appropriate antibiotic prescription when they practice in hospitals under supervision. The impact of teaching in medical school, antibiotics stewardship program (ASP), and prescription guidelines was uncertain. This study explored the medical interns' views on antibiotic use and resistance, and their perceived enablers to appropriate antibiotic prescription. Methods Two focus groups were conducted among medical interns with rotation experiences in different public hospitals of Hong Kong. The identified themes about attitudes to antibiotic resistance and enablers to appropriate antibiotic prescription were further examined by a questionnaire survey with 77 respondents. Results The interns had lower preferences for tackling antibiotic resistance as they feared of delayed prescriptions. Guidelines provided by international evidence-based clinical resources and the interns' working hospitals were stronger enablers to appropriate antibiotic use than education materials from schools and the government. Qualitative findings revealed that the interns were aware of the existing ASP but doubted its effectiveness as it failed to get the prescribers' attention. They followed guidelines in their wards but perceived guidelines from local health authorities user-unfriendly. Knowledge from medical school was not very applicable. Varying prescribing practices between hospitals and the densely placed hospital beds made it difficult to prevent the spread of antimicrobial resistance. Conclusions Minimizing delayed prescription is of a higher priority than tackling antibiotic resistance in medical interns' perspective. Interventions should target guidelines in hospitals and simplify the interface of local guidelines.
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Affiliation(s)
- Kai Sing Sun
- Department of Family Medicine and Primary
Care, University of Hong Kong, Hong Kong
| | - Tai Pong Lam
- Department of Family Medicine and Primary
Care, University of Hong Kong, Hong Kong
| | - Tak Hon Chan
- Department of Family Medicine and Primary
Care, University of Hong Kong, Hong Kong
| | - Kwok Fai Lam
- Department of Statistics and Actuarial
Science, University of Hong Kong, Hong Kong
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Kit Wing Kwok
- Department of Family Medicine and Primary
Care, University of Hong Kong, Hong Kong
| | - Hoi Yan Chan
- Department of Family Medicine and Primary
Care, University of Hong Kong, Hong Kong
| | - Pak Leung Ho
- Department of Microbiology and Carol Yu
Center for Infection, University of Hong Kong, Hong Kong
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Polish Medical Doctors’ Opinions on Available Resources and Information Campaigns concerning Antibiotics and Antibiotic Resistance, a Cross-Sectional Study. Antibiotics (Basel) 2022; 11:antibiotics11070882. [PMID: 35884136 PMCID: PMC9311609 DOI: 10.3390/antibiotics11070882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Antibiotic resistance (ABR) is at the top of global health threats. This paper aims to assess Polish physicians’ readiness to impact ABR through prescribing routines. Methods: Surveying Polish physicians participating in specialization courses at the Center for Postgraduate Medical Education in Warsaw, Poland from October 2019 to March 2020. Results: Information was obtained from 504 physicians aged 25–59, mean 32.8 ± 5.9 years, mainly women (65%). Most doctors (78%) prescribed antibiotics at least once a week. Physicians indicated clinical practice guidelines as resources most often consulted in the management of infections (90%). However, clinical experience was also declared a powerful resource. In total, 54% of respondents recalled receiving information about the prudent use of antibiotics within 12 months, which partially translated into changing views (56%) and practice (42%). Physicians disagreed that national campaigns provide good promotion of prudent antibiotics use (75%) or that they are effective (61%). Only 40% of doctors were aware of the national campaign promoting responsible antibiotics use, 24% had heard about the European Antibiotic Awareness Day and 20% knew about the World Antimicrobial Awareness Week. Conclusions: Prescribers most often rely on clinical practice guidelines and their own experience as resources for antibiotics use. Doctors’ awareness of available resources and information campaigns concerning antibiotics and antibiotic resistance should be improved.
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Weis S, Hagel S, Palm J, Scherag A, Kolanos S, Bahrs C, Löffler B, Schmitz RPH, Rißner F, Brunkhorst FM, Pletz MW. Effect of Automated Telephone Infectious Disease Consultations to Nonacademic Hospitals on 30-Day Mortality Among Patients With Staphylococcus aureus Bacteremia: The SUPPORT Cluster Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2218515. [PMID: 35749114 PMCID: PMC9233240 DOI: 10.1001/jamanetworkopen.2022.18515] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Staphylococcus aureus bacteremia (SAB) is a common and potentially severe infectious disease (ID). Retrospective studies and derived meta-analyses suggest that bedside infectious disease consultation (IDC) for SAB is associated with improved survival; however, such IDCs might not always be possible because of the lack of ID specialists, particularly at nonacademic hospitals. OBJECTIVES To investigate whether unsolicited telephone IDCs (triggered by an automated blood stream infection reporting system) to nonacademic hospitals improved 30-day all-cause mortality in patients with SAB. DESIGN, SETTING, AND PARTICIPANTS This patient-blinded, multicenter, interventional, cluster randomized, controlled, crossover clinical trial was conducted in 21 rural, nonacademic hospitals in Thuringia, Germany. From July 1, 2016, to December 31, 2018, 1029 blood culture reports were assessed for eligibility. A total of 386 patients were enrolled, whereas 643 patients were not enrolled for the following reasons: death before enrollment (n = 59); palliative care (n = 41); recurrence of SAB (n = 9); discharge from the hospital before enrollment (n = 77); age younger than 18 years (n = 5); duplicate report from a single patient (n = 26); late report (n = 17); blood culture reported during the washout phase (n = 48); and no signed informed consent for other or unknown reasons (n = 361). INTERVENTIONS During the ID intervention phase, ID specialists from Jena University Hospital provided unsolicited telephone IDCs to physicians treating patients with SAB. During the control phase, patients were treated according to local standards. Crossover was performed after including 15 patients or, at the latest, 1 year after the first patient was included. MAIN OUTCOMES AND MEASURES Thirty-day all-cause mortality. RESULTS A total of 386 patients (median [IQR] age, 75 [63-82] years; 261 [67.6%] male) were included, with 177 randomized to the IDC group and 209 to the control group. The 30-day all-cause mortality rate did not differ between the IDC and control groups (relative risk reduction [RRR], 0.12; 95% CI, -2.17 to 0.76; P = .81). No evidence was found of a difference in secondary outcomes, including 90-day mortality (RRR, 0.17; 95% CI, -0.59 to 0.57; P = .62), 90-day recurrence (RRR, 0.10; 95% CI, -2.51 to 0.89; P = .89), and hospital readmission (RRR, 0.04; 95% CI, -0.63 to 0.48; P = .90). Exploratory evidence suggested that indicators of quality of care were potentially realized more often in the IDC group than in the control group (relative quality improvement, 0.16; 95% CI, 0.08-0.26; P = .01). CONCLUSIONS AND RELEVANCE In this cluster randomized clinical trial, unsolicited telephone IDC, although potentially enhancing quality of care, did not improve 30-day all-cause mortality in patients with SAB. TRIAL REGISTRATION drks.de Identifier: DRKS00010135.
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Affiliation(s)
- Sebastian Weis
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Stefan Hagel
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Julia Palm
- Institute of Medical Statistics, Computer, and Data Sciences, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - André Scherag
- Institute of Medical Statistics, Computer, and Data Sciences, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Steffi Kolanos
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Christina Bahrs
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Bettina Löffler
- Institute of Medical Microbiology, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Roland P. H. Schmitz
- Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Florian Rißner
- Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Frank M. Brunkhorst
- Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Mathias W. Pletz
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
- Center for Sepsis Control and Care, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
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7
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Di Giambenedetto S, Borghetti A, Quagliozzi L, Gallucci V, Lombardi F, Ciccullo A, Fagotti A, Tamburrini E, Scambia G. Implementing a Personalized Antimicrobial Stewardship Program for Women with Gynecological Cancers and Healthcare-Associated Infections. J Pers Med 2022; 12:jpm12040650. [PMID: 35455766 PMCID: PMC9027292 DOI: 10.3390/jpm12040650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/09/2022] [Accepted: 03/29/2022] [Indexed: 12/01/2022] Open
Abstract
Healthcare-associated infections (HCAIs) represent a major cause of morbidity and mortality in gynecologic cancer patients, requiring personalized cures. A retrospective study on gynecologic patients with HCAIs, managed through an antimicrobial stewardship program, was performed, focusing on rates of clinical cure, breakthrough/relapse of infections, death, and time of hospital stay (THS). In total, 27 patients (median 60 years, mainly suffering from ovarian, cervical, and uterine cancer) were evaluated by a specialist in infectious diseases and were mainly diagnosed with complicated urinary tract (cUTIs, 12 cases, 44.4%) and bloodstream infections (BSIs, 9 cases, 33.3%). A total of 15 cases (11 cUTIs, 73.3%) were managed with no need for hospitalization and received a median of 11 days of outpatient parenteral antimicrobial therapy (OPAT). In the remaining 12 cases (BSIs in 8 cases, 66.7%), the median THS was 11 days, with 15 days median overall duration of antimicrobial therapy (median 5-day reduction in THS). The management of patients also included source control and wound care. All patients reached clinical cure, with no case of breakthrough infection, one case of relapse, and one death within 30 days (not attributable to the infection). HCAIs in patients with gynecologic tumors can be managed through a patient-centered, multidisciplinary antimicrobial stewardship program.
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Affiliation(s)
- Simona Di Giambenedetto
- UOC Malattie Infettive, Dipartimento di Scienze di Laboratorio ed Infettivologiche, Fondazione Policlinico Universitario A, Gemelli IRCCS, 00168 Roma, Italy; (S.D.G.); (E.T.)
- Dipartimento di Sicurezza e Bioetica Sezione Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Alberto Borghetti
- UOC Malattie Infettive, Dipartimento di Scienze di Laboratorio ed Infettivologiche, Fondazione Policlinico Universitario A, Gemelli IRCCS, 00168 Roma, Italy; (S.D.G.); (E.T.)
- Correspondence: ; Tel.: +39-389-0241-178
| | - Lorena Quagliozzi
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A, Gemelli IRCCS, 00168 Roma, Italy; (L.Q.); (V.G.); (A.F.); (G.S.)
| | - Valeria Gallucci
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A, Gemelli IRCCS, 00168 Roma, Italy; (L.Q.); (V.G.); (A.F.); (G.S.)
| | - Francesca Lombardi
- Dipartimento di Sicurezza e Bioetica Sezione Malattie Infettive, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Arturo Ciccullo
- UOC Malattie Infettive, Ospedale San Salvatore, 67100 L’Aquila, Italy;
| | - Anna Fagotti
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A, Gemelli IRCCS, 00168 Roma, Italy; (L.Q.); (V.G.); (A.F.); (G.S.)
| | - Enrica Tamburrini
- UOC Malattie Infettive, Dipartimento di Scienze di Laboratorio ed Infettivologiche, Fondazione Policlinico Universitario A, Gemelli IRCCS, 00168 Roma, Italy; (S.D.G.); (E.T.)
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A, Gemelli IRCCS, 00168 Roma, Italy; (L.Q.); (V.G.); (A.F.); (G.S.)
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8
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Lalonde KM, Black C, Lam JC. Principles of empiric antimicrobial usage and dosing: Lessons learned. Clin Case Rep 2022; 10:e05594. [PMID: 35340652 PMCID: PMC8929268 DOI: 10.1002/ccr3.5594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/01/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022] Open
Abstract
A lack of clinical response to empiric antimicrobials behooves the clinician to reflect further on diagnostic considerations. When prescribing antibiotics, determining the correct dose, most optimal route of administration, and considering the pharmacokinetic properties of the drug with respect to clinical and patient factors are crucial. Improving antibiotic usage is paramount. Antibiotic prescribing is a purposeful process, requiring a clinical indication, determination of the optimal drug dosage/route of administration, and consideration of clinical pharmacokinetics in a patient.
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Affiliation(s)
| | - Cameron Black
- Faculty of Pharmacy & Pharmaceutical Sciences University of Alberta Edmonton Alberta Canada
| | - John C. Lam
- Department of Medicine University of Calgary Calgary Alberta Canada
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Hur B, Hardefeldt LY, Verspoor K, Baldwin T, Gilkerson JR. Overcoming challenges in extracting prescribing habits from veterinary clinics using big data and deep learning. Aust Vet J 2022; 100:220-222. [DOI: 10.1111/avj.13145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/02/2022] [Indexed: 11/27/2022]
Affiliation(s)
- B Hur
- Asia‐Pacific Centre for Animal Health, Melbourne Veterinary School University of Melbourne Melbourne Victoria Australia
- School of Computing and Information Systems University of Melbourne Melbourne Victoria Australia
| | - LY Hardefeldt
- Asia‐Pacific Centre for Animal Health, Melbourne Veterinary School University of Melbourne Melbourne Victoria Australia
| | - K Verspoor
- School of Computing and Information Systems University of Melbourne Melbourne Victoria Australia
- School of Computing Technologies RMIT University Melbourne Victoria Australia
| | - T Baldwin
- School of Computing and Information Systems University of Melbourne Melbourne Victoria Australia
| | - JR Gilkerson
- Asia‐Pacific Centre for Animal Health, Melbourne Veterinary School University of Melbourne Melbourne Victoria Australia
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10
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Howley F, Keating D, Kelly M, O’Connor R, O’Riordan R. A Service Evaluation of Adherence with Antimicrobial Guidelines in the Treatment of Community-Acquired Pneumonia Before and During the SARS-CoV-2 Outbreak. SN COMPREHENSIVE CLINICAL MEDICINE 2022; 4:225. [PMID: 36258797 PMCID: PMC9559268 DOI: 10.1007/s42399-022-01311-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 10/07/2022] [Indexed: 11/05/2022]
Abstract
Antimicrobial stewardship is essential to reducing antimicrobial resistance, reducing costs, and, crucially, ensuring good patient care. Community-acquired pneumonia (CAP) is a common medical condition, the symptoms of which show a significant overlap with those of COVID-19. Following the COVID-19 outbreak in Ireland, patients presenting to our hospital with features of a respiratory infection were more commonly reviewed within 24 hours (24h) of admission by an infectious disease (ID) or respiratory specialist. We aimed to assess how the change in service provision, involving frequent specialist reviews of patients admitted with features of CAP during the first wave of the COVID-19 pandemic, affected antimicrobial stewardship and prescribing practices. Patients admitted under general medical teams treated for CAP from March–April 2020 were included. Retrospective data including demographics, CURB-65 score, and antimicrobial therapy were collected, as well as information on whether the patient had undergone specialist review by an ID or respiratory physician. Data were compared to a similar cohort treated for CAP between November 2019 and January 2020, though in this cohort, before the era of COVID-19, none of the patients had undergone specialist review. Seventy-six patients were included from the March–April 2020 cohort, with 77 from November 2019–January 2020 for comparison. An ID or respiratory specialist reviewed 35 patients from the March–April cohort within 24 h of admission. There was a higher rate of appropriate escalation, de-escalation, and continuation of antibiotics among those reviewed. Less than 20% of patients were started on antibiotics in accordance with CAP guidelines on admission, though the antibiotics initiated were frequently deemed appropriate in the clinical setting. Specialist review increases rates of appropriate antimicrobial prescribing and adherence with hospital guidelines in patients with CAP.
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Affiliation(s)
- Fergal Howley
- grid.416409.e0000 0004 0617 8280Department of General Internal Medicine, St James’s Hospital, Dublin, Ireland
| | - Donal Keating
- grid.416409.e0000 0004 0617 8280Department of General Internal Medicine, St James’s Hospital, Dublin, Ireland
| | - Mary Kelly
- grid.416409.e0000 0004 0617 8280Pharmacy Department, St James’s Hospital, Dublin, Ireland
| | - Roisin O’Connor
- grid.416409.e0000 0004 0617 8280Pharmacy Department, St James’s Hospital, Dublin, Ireland
| | - Ruth O’Riordan
- grid.416409.e0000 0004 0617 8280Department of General Internal Medicine, St James’s Hospital, Dublin, Ireland
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11
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Gao T, Xu P, Chen R, Wang XC, Dzakpasu M. Environmental risk assessment by using disability adjusted life year via constructing of a generalized linear model for morbidity estimation of waterborne pathogens. JOURNAL OF ENVIRONMENTAL MANAGEMENT 2021; 299:113566. [PMID: 34425498 DOI: 10.1016/j.jenvman.2021.113566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 08/17/2021] [Accepted: 08/18/2021] [Indexed: 06/13/2023]
Abstract
The Environmental burden of disease (EBD) quantitatively evaluates the health impacts of pathogens by using the disability-adjusted life year (DALY) method. The life loss due to morbidity is a general expression for the EBD outcome and, thus, morbidity analysis is indispensable. Considering the deficiency of previous morbidity analysis methods, the objective of this study was to construct a linear morbidity model by using a generalized linear model (GLM) as a template and introducing exposure dose, pathogen toxicity and human immunity as impact variables. Human experimental data were collected for model fitting, and the results indicated a good fit of the majority of the pathogen data. Consequently, two practical cases of water reuse in Xi'an Siyuan University (Case 1) and Lake Cui, Kunming (Case 2) were selected for model validation. Results for case 1 indicated the major EBD to be attributed to rotaviruses (5.57 × 10-7 DALYs, 95% confidence interval (CI): 4.46 × 10-7-1.72 × 10-4 DALYs) and sprinkling irrigation (5.12 × 10-7 DALYs, 95% CI: 1.95 × 10-7-1.47 × 101 DALYs). Conversely, that for case 2 is mainly attributed to noroviruses (1.42 × 10-7 DALYs, 95% CI: 7.51 × 10-11-2.67 × 10-4 DALYs) and road flushing (1.62 × 10-7 DALYs, 95% CI: 1.16 × 10-7-2.67 × 10-4 DALYs). However, comparison with the suggested threshold of 10-6 DALYs indicated the EBDs for both cases are acceptable and, thus, water reuse is confirmed to be safe. The methodology for morbidity modelling proposed in this research can effectively compensate for missing data in DALY calculation and, thereby, help to optimize the process for EBD evaluation.
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Affiliation(s)
- Tingting Gao
- School of Environmental and Chemical Engineering, Xi'an Polytechnic University, No.19 South Jinhua Road, Xi'an, 710048, PR China; International S&T Cooperation Centre for Urban Alternative Water Resources Development, Key Lab of Environmental Engineering, Shaanxi Province, Xi'an University of Architecture and Technology, No.13 Yanta Road, Xi'an, 710055, PR China.
| | - Pengcheng Xu
- International S&T Cooperation Centre for Urban Alternative Water Resources Development, Key Lab of Environmental Engineering, Shaanxi Province, Xi'an University of Architecture and Technology, No.13 Yanta Road, Xi'an, 710055, PR China
| | - Rong Chen
- International S&T Cooperation Centre for Urban Alternative Water Resources Development, Key Lab of Environmental Engineering, Shaanxi Province, Xi'an University of Architecture and Technology, No.13 Yanta Road, Xi'an, 710055, PR China
| | - Xiaochang C Wang
- International S&T Cooperation Centre for Urban Alternative Water Resources Development, Key Lab of Environmental Engineering, Shaanxi Province, Xi'an University of Architecture and Technology, No.13 Yanta Road, Xi'an, 710055, PR China
| | - Mawuli Dzakpasu
- International S&T Cooperation Centre for Urban Alternative Water Resources Development, Key Lab of Environmental Engineering, Shaanxi Province, Xi'an University of Architecture and Technology, No.13 Yanta Road, Xi'an, 710055, PR China
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Munting A, Regina J, Lhopitallier L, Kritikos A, Guery B, Senn L, Viala B. Impact of 2020 EUCAST criteria on meropenem prescription for the treatment of Pseudomonas aeruginosa infections: an observational study in a university hospital. Clin Microbiol Infect 2021; 28:558-563. [PMID: 34826618 DOI: 10.1016/j.cmi.2021.03.034] [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] [Received: 01/06/2021] [Accepted: 03/14/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND In its 10th version of breakpoints table, released in January 2020, the European Committee on Antimicrobial Susceptibility Testing (EUCAST) changed breakpoints for most antipseudomonal drugs. Quinolones and beta-lactams, with the exception of meropenem and recent beta-lactam/beta-lactamase inhibitor combinations are no more categorised as "Susceptible, standard exposure" (S) but "Susceptible, increased exposure" (I). The aim of this study was to evaluate the impact these changes had on meropenem prescriptions for Pseudomonas aeruginosa infections. METHODS In this retrospective single-centre observational study, we analysed antimicrobial therapies prescribed after susceptibility testing in all consecutive adult patients treated for P. aeruginosa infections between 01.08.2019 and 30.07.2020 in Lausanne University Hospital, Switzerland. The primary outcome was the prescription of meropenem to treat P. aeruginosa infections after release of susceptibility testing results. RESULTS Among the 264 patients included, 40 (15.2%) received meropenem, 3.4% before EUCAST update versus 30.2% after (p<0.001). Multivariate regression showed that new EUCAST criteria were an independent risk factor for meropenem prescription (odds ratio 22.12, 95% CI [7.96 - 79.52], P<0.001), whereas, infectious diseases specialist consult was protective (odds ratio 0.20, 95% CI [0.07 - 0.49], P=0.001). CONCLUSION The change to 2020 EUCAST criteria led to a significant increase in meropenem prescription for the treatment of P. aeruginosa infections in Lausanne University Hospital. Infectious disease consultations had a major impact on meropenem prescription, stressing the importance of antimicrobial stewardship to prevent meropenem overuse.
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Affiliation(s)
- Aline Munting
- Service of Infectious Diseases, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jean Regina
- Service of Infectious Diseases, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Loïc Lhopitallier
- Service of Infectious Diseases, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Antonios Kritikos
- Institute of Microbiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Benoît Guery
- Service of Infectious Diseases, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Laurence Senn
- Service of Hospital Preventive Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Benjamin Viala
- Service of Hospital Preventive Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
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Richards L, Spencer DC, Nel JS, Ive P. Infectious disease consultations at a South African academic hospital: A 6-month assessment of inpatient consultations. S Afr J Infect Dis 2021; 35:169. [PMID: 34485477 PMCID: PMC8378114 DOI: 10.4102/sajid.v35i1.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 06/25/2020] [Indexed: 11/01/2022] Open
Abstract
Background Infectious diseases (IDs) dominate the disease profile in South Africa (SA) and the ID department is increasingly valuable. There has been little evaluation of the IDs consultation services in SA hospitals. Methods A qualitative review of ID inpatient consultations was performed over 6 months at a SA tertiary hospital. Prospectively entered data from each consultation were recorded on a computerised database and retrospectively analysed. Results 749 ID consultations were analysed, 4.8% of hospital admissions. Most consultations included initiation of antiretroviral therapy (ART) (27.8%), lipoarabinomannan antigen testing (24.8%) and change of ART (21.6%). Of patients reviewed, 93.3% were human immunodeficiency virus (HIV) positive and the median CD4 count was 52 cells/mm3. The infectious diagnoses (excluding HIV) most frequently encountered were pulmonary and abdominal tuberculosis (TB) and acute gastroenteritis. When all subcategories of TB infection were combined, 42.9% were found to have TB. Patients had predominantly one (45.4%) or two (30.2%) infectious diagnoses in addition to HIV. Some (12%) had three infectious diagnoses during their admission. The number of diagnoses, both infectious (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.11-3.60) and non-infectious (OR 2.27; 95% CI 1.25-4.11), was associated with increased odds of death. Conclusion The IDs department sees a high volume of patients compared to most developed countries. HIV, TB and their management dominate the workload. This study shows that HIV patients still have significant morbidity and mortality. The complexity of these patients indicates that specific expertise is required beyond that of the general physician.
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Affiliation(s)
- Lauren Richards
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - David C Spencer
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa.,Clinical HIV Research Unit (CHRU), University of the Witwatersrand, Johannesburg, South Africa
| | - Jeremy S Nel
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Prudence Ive
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
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Walia K, Gangakhedkar RR. Infectious disease blocks in district hospitals to augment India's resolve to contain antimicrobial resistance. Indian J Med Res 2021; 153:416-420. [PMID: 34380787 PMCID: PMC8354047 DOI: 10.4103/ijmr.ijmr_4031_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Kamini Walia
- Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi 110 029, India
| | - Raman R Gangakhedkar
- Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi 110 029, India
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Jamaluddin NAH, Periyasamy P, Lau CL, Ponnampalavanar S, Lai PSM, Ramli R, Tan TL, Kori N, Yin MK, Azman NJ, James R, Thursky K, Naina-Mohamed I. Point Prevalence Survey of Antimicrobial Use in a Malaysian Tertiary Care University Hospital. Antibiotics (Basel) 2021; 10:531. [PMID: 34064457 PMCID: PMC8148015 DOI: 10.3390/antibiotics10050531] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/29/2021] [Accepted: 05/02/2021] [Indexed: 12/02/2022] Open
Abstract
Antimicrobial resistance remains a significant public health issue, and to a greater extent, caused by the misuse of antimicrobials. Monitoring and benchmarking antimicrobial use is critical for the antimicrobial stewardship team to enhance prudent use of antimicrobial and curb antimicrobial resistance in healthcare settings. Employing a comprehensive and established tool, this study investigated the trends and compliance of antimicrobial prescribing in a tertiary care teaching hospital in Malaysia to identify potential target areas for quality improvement. A point prevalence survey method following the National Antimicrobial Prescribing Survey (NAPS) was used to collect detailed data on antimicrobial prescribing and assessed a set of quality indicators associated with antimicrobial use. The paper-based survey was conducted across 37 adult wards, which included all adult in-patients on the day of the survey to form the study population. Of 478 patients surveyed, 234 (49%) patients received at least one antimicrobial agent, with 357 antimicrobial prescriptions. The highest prevalence of antimicrobial use was within the ICU (80%). Agents used were mainly amoxicillin/β-lactamase inhibitor (14.8%), piperacillin/β-lactamase inhibitor (10.6%) and third-generation cephalosporin (ceftriaxone, 9.5%). Intravenous administration was ordered in 62.7% of prescriptions. Many antimicrobials were prescribed empirically (65.5%) and commonly prescribed for pneumonia (19.6%). The indications for antimicrobials were documented in the patients' notes for 80% of the prescriptions; however, the rate of review/stop date recorded must be improved (33.3%). One-half of surgical antimicrobial prophylaxis was administered for more than 24 h. From 280 assessable prescriptions, 141 (50.4%) were compliant with guidelines. Treating specialties, administration route, class of antimicrobial, and the number of prescriptions per patient were contributing factors associated with compliance. On multivariate analysis, administering non-oral routes of antimicrobial administration, and single antimicrobial prescription prescribed per patient was independently associated with non-compliance. NAPS can produce robust baseline information and identifying targets for improvement in antimicrobial prescribing in reference to current AMS initiatives within the tertiary care teaching hospital. The findings underscore the necessity to expand the AMS efforts towards reinforcing compliance, documentation, improving surgical prophylaxis prescribing practices, and updating local antibiotic guidelines.
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Affiliation(s)
- Nurul Adilla Hayat Jamaluddin
- Pharmacoepidemiology and Drug Safety Unit, Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia;
- Department of Hospital and Clinical Pharmacy, Faculty of Pharmacy, University of Cyberjaya, Cyber 11, Cyberjaya, Selangor 63000, Malaysia
| | - Petrick Periyasamy
- Medical Department, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia; (P.P.); (N.K.)
| | - Chee Lan Lau
- Pharmacy Department, Hospital Canselor Tuanku Muhriz, Cheras, Kuala Lumpur 56000, Malaysia; (C.L.L.); (M.K.Y.); (N.J.A.)
| | | | - Pauline Siew Mei Lai
- Department of Primary Care Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia;
| | - Ramliza Ramli
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia;
| | - Toh Leong Tan
- Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia;
| | - Najma Kori
- Medical Department, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia; (P.P.); (N.K.)
| | - Mei Kuen Yin
- Pharmacy Department, Hospital Canselor Tuanku Muhriz, Cheras, Kuala Lumpur 56000, Malaysia; (C.L.L.); (M.K.Y.); (N.J.A.)
| | - Nur Jannah Azman
- Pharmacy Department, Hospital Canselor Tuanku Muhriz, Cheras, Kuala Lumpur 56000, Malaysia; (C.L.L.); (M.K.Y.); (N.J.A.)
| | - Rodney James
- National Centre for Antimicrobial Stewardship, Peter Doherty Research Institute for Infection and Immunity, Melbourne 3000, Australia; (R.J.); (K.T.)
| | - Karin Thursky
- National Centre for Antimicrobial Stewardship, Peter Doherty Research Institute for Infection and Immunity, Melbourne 3000, Australia; (R.J.); (K.T.)
| | - Isa Naina-Mohamed
- Pharmacoepidemiology and Drug Safety Unit, Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur 56000, Malaysia;
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Hur B, Hardefeldt LY, Verspoor KM, Baldwin T, Gilkerson JR. OUP accepted manuscript. JAC Antimicrob Resist 2021; 4:dlab194. [PMID: 35156027 PMCID: PMC8827557 DOI: 10.1093/jacamr/dlab194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/24/2021] [Indexed: 11/18/2022] Open
Abstract
Background As antimicrobial prescribers, veterinarians contribute to the emergence of MDR pathogens. Antimicrobial stewardship programmes are an effective means of reducing the rate of development of antimicrobial resistance. A key component of antimicrobial stewardship programmes is selecting an appropriate antimicrobial agent for the presenting complaint and using an appropriate dose rate for an appropriate duration. Objectives To describe antimicrobial usage, including dose, for common indications for antimicrobial use in companion animal practice. Methods Natural language processing (NLP) techniques were applied to extract and analyse clinical records. Results A total of 343 668 records for dogs and 109 719 records for cats administered systemic antimicrobials from 1 January 2013 to 31 December 2017 were extracted from the database. The NLP algorithms extracted dose, duration of therapy and diagnosis completely for 133 046 (39%) of the records for dogs and 40 841 records for cats (37%). The remaining records were missing one or more of these elements in the clinical data. The most common reason for antimicrobial administration was skin disorders (n = 66 198, 25%) and traumatic injuries (n = 15 932, 19%) in dogs and cats, respectively. Dose was consistent with guideline recommendations in 73% of cases where complete clinical data were available. Conclusions Automated extraction using NLP methods is a powerful tool to evaluate large datasets and to enable veterinarians to describe the reasons that antimicrobials are administered. However, this can only be determined when the data presented in the clinical record are complete, which was not the case in most instances in this dataset. Most importantly, the dose administered varied and was often not consistent with guideline recommendations.
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Affiliation(s)
- Brian Hur
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, University of Melbourne, Parkville, Victoria, Australia
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
- Corresponding author. E-mail:
| | - Laura Y. Hardefeldt
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, University of Melbourne, Parkville, Victoria, Australia
| | - Karin M. Verspoor
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
- School of Computing Technologies, RMIT University, Melbourne, Victoria, Australia
| | - Timothy Baldwin
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
| | - James R. Gilkerson
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, University of Melbourne, Parkville, Victoria, Australia
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Viala B, Villiet M, Redor A, Didelot MN, Makinson A, Reynes J, Le Moing V, Morquin D. Using the clinical information system and self-supervision to rationalize the need for antibiotic stewardship: An interventional study in a 2000-bed university hospital. Int J Antimicrob Agents 2020; 57:106233. [PMID: 33232732 DOI: 10.1016/j.ijantimicag.2020.106233] [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] [Received: 09/11/2020] [Revised: 10/24/2020] [Accepted: 11/14/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To describe the usefulness of electronic medical records (EMRs) and a computerized physician order entry (CPOE) system to support and assess an antimicrobial stewardship programme (ASP). METHODS At the study hospital, infectious diseases specialists supervise antimicrobial prescription when solicited by physicians in charge of patients. From January to October 2015, treatment days of antibiotic prescription, supervised or unsupervised by infectious disease specialists (SAP or UAP, respectively) in all wards, except intensive care units emergency department, bone marrow transplantation units, and paediatric units, were calculated. Embedding recommendations on carbapenem indications as a checklist into the CPOE system, a self-administered ASP was implemented in 2017. EMRs were reviewed to determine global compliance with carbapenem prescription guidelines (combining introduction of therapy and 72-h assessment) before and after implementation of a self-administered ASP in departments with a low SAP rate for these antibiotics. RESULTS Among 16 090 prescriptions extracted, 19.9% were SAPs. Three patterns of prescription were identified. The first pattern (amoxicillin-clavulanate, ceftriaxone) was characterized by a high UAP rate in every department, the second pattern (cloxacillin, rifampin) was characterized by a high SAP rate in every department, and the third pattern (broad-spectrum beta-lactams) was characterized by heterogeneous distribution of SAP/UAP among departments. Carbapenem prescription was reviewed in five departments with a low SAP rate for carbapenems over 6 months: 94 before and 107 after implementation of the self-administered ASP. Global compliance with guidelines increased significantly from 22% to 37% (risk difference 15%, 95% confidence interval 2.3-28.5%; P=0.02). CONCLUSION A clinical information system may help to rationalize antibiotic stewardship in a context of scarce medical resources. Mapping of antibiotic prescriptions and self-supervision are efficient, complementary and easy-to-implement tools.
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Affiliation(s)
- Benjamin Viala
- Infectious and Tropical Diseases Department, CHU Montpellier, Montpellier, France.
| | - Maxime Villiet
- Clinical Pharmacy Department, CHU Montpellier, Montpellier, France
| | - Alexis Redor
- Infectious and Tropical Diseases Department, CHU Montpellier, Montpellier, France
| | | | - Alain Makinson
- Infectious and Tropical Diseases Department, CHU Montpellier, Montpellier, France
| | - Jacques Reynes
- Infectious and Tropical Diseases Department, CHU Montpellier, Montpellier, France
| | - Vincent Le Moing
- Infectious and Tropical Diseases Department, CHU Montpellier, Montpellier, France
| | - David Morquin
- Infectious and Tropical Diseases Department, CHU Montpellier, Montpellier, France
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Cona A, Gazzola L, Viganò O, Bini T, Marchetti GC, d'Arminio Monforte A. Impact of daily versus weekly service of infectious diseases consultation on hospital antimicrobial consumption: a retrospective study. BMC Infect Dis 2020; 20:812. [PMID: 33160320 PMCID: PMC7648268 DOI: 10.1186/s12879-020-05550-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To verify whether a daily service of Infectious Diseases consultation (ID-cons) is more effective than a weekly service in reducing antibiotic (ATB) consumption without worsening of clinical outcomes. METHODS Two-year observational analysis of the ID-cons provided in a hospital setting in Milan, Italy. ID-cons resulted in: start-of-ATB; no-ATB; confirmation; modification-of-ATB. The impact of a weekly (September 1, 2016 - August 31, 2017 versus a daily (September 1, 2017 - September 30, 2018) service of ID-cons was evaluated in terms of: time-from-admission-to-first-ID-cons, type of ATB-intervention and number-of-ID-cons per 100 bed-days (bd). Primary outcomes: reduction of hospital ATB consumption overall and by department and classes expressed as Defined Daily Dose (DDD)/100bd (by Wilcoxon test for paired data). SECONDARY OUTCOMES overall and sepsis-related in-hospital annual mortality rates (as death/patient's admissions). RESULTS Overall 2552 ID-cons in 1111 patients (mean, 2.3 ID-cons per patient) were performed (18.6% weekly vs 81.4% daily). No differences in patient characteristics were observed. In the daily-service, compared to the weekly-service, patients were seen by the ID-consultant earlier (time-from-admission-to-ID-cons: 6 days (IQR 2-13) vs 10 days (IQR 6-19), p < 0.001) and ATB was more often started by the ID-consultant (Start-of-ATB: 11.6% vs 8%, p = 0.02), rather than treating physicians. After switching to daily-service, the number-of-ID-cons increased from 0.4/100bd to 1.5/100bd (p = 0.01), with the greatest increase in the emergency department (1.5/100bd vs 6.7/100bd, p < 0.001). Total ATB consumption decreased from 64 to 60 DDD/100bd. As for the number-of-cons, the consumption of ATB decreased mainly in the emergency area. According to ATB classes, glycopeptides consumption was reduced from 3.1 to 2.1 DDD/100bd (p = 0.02) while carbapenem use decreased from 3.7 to 3.1 DDD/100bd (p = 0.07). No changes in overall mortality (5.2% vs 5.2%) and sepsis-related mortality (19.3% vs 20.9%; p = 0.7) were observed among the two time-period. CONCLUSIONS Daily-ID-cons resulted in a more comprehensive management of the infected patient by the ID-consultant, especially in the emergency area where we also observed the highest rate of reduction of ATB-usage. No change in mortality was observed.
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Affiliation(s)
- Andrea Cona
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Via A. di Rudinì 8, 20142, Milan, Italy.
| | - Lidia Gazzola
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Via A. di Rudinì 8, 20142, Milan, Italy
| | - Ottavia Viganò
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Via A. di Rudinì 8, 20142, Milan, Italy
| | - Teresa Bini
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Via A. di Rudinì 8, 20142, Milan, Italy
| | - Giulia Carla Marchetti
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Via A. di Rudinì 8, 20142, Milan, Italy
| | - Antonella d'Arminio Monforte
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Via A. di Rudinì 8, 20142, Milan, Italy
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[Organisational and staff requirements for antimicrobial stewardship activities in hospitals : Position paper of the Commission on Anti-Infectives, Resistance and Therapy (Commission ART) at the Robert Koch Institute, with advice from professional associations]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:749-760. [PMID: 32468301 DOI: 10.1007/s00103-020-03152-5] [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: 10/24/2022]
Abstract
Increased awareness of the rising antimicrobial resistance problem and impending loss of suitable treatment options for infectious diseases have changed patient care. Antimicrobial/antibiotic stewardship (ABS) activities aiming to optimize antimicrobial treatment were specified in international (WHO, ECDC) and national programmes and evidence-based practice guidelines. In Germany, ABS in hospitals is enshrined in the Infection Protection Act §23 and in a national guideline. The position paper presents the goals and tasks of ABS as well as the necessary organisational and staff requirements.Qualified training and education, mandates and support from hospital directors, and the provision of sufficient resources are essential prerequisites for the successful work of the ABS team. The ABS team should work hospital-wide across clinical services. Their main tasks are developing and implementing an ABS programme tailored to local needs and the conditions of the hospital, taking into account anti-infective drug prescribing, the resistance situation and case mix. Their tasks also include drafting and implementing in-house recommendations for diagnosis, prophylaxis and treatment of important infectious diseases. The ABS team should be interdisciplinary and include specially qualified doctors and pharmacists. Doctors commissioned for ABS should support this team and take the department-specific concerns into account. The document specifies a minimum ABS staff of one full-time equivalent (FTE) per 500 beds. Depending on the case mix and specialties, additional staff may be required. It proposes that there should be 0.1 FTE doctors commissioned for ABS per 100 beds.
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O'Kelly B, Conway A, McNally C, McConkey S, Kelly A, de Barra E. Rapid diagnosis of seasonal Influenza virus and cohorting of hospitalised patients on a 'flu ward'. A prospective analysis of outcomes. J Hosp Infect 2020; 105:S0195-6701(20)30122-5. [PMID: 32311407 DOI: 10.1016/j.jhin.2020.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/19/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The influenza season of 2017/2018 was burdensome in comparison to previous years. In patient management of seasonal influenza patients is poorly described. AIM To assess the impact of managing influenza patients on a dedicated influenza ward on antimicrobial use and duration, and length of stay (LOS). METHODS A prospective cohort study from Jan 1st to Feb 28th 2018. Patients diagnosed with influenza in the Emergency Department (ED) were cohorted under infectious disease (ID) or a general internal medicine (GIM) firms on a 35 bed influenza ward. At times of maximum capacity some patients were managed on other wards by other firms 'non flu ward'. FINDINGS 91 patients were admitted to the influenza ward from ED (64 ID, 27 GIM), 38 had influenza A. Patients managed by ID were more likely to be switched to oral antibiotics sooner median 3 vs 5 days p=.049. Antibiotic duration was shorter for patients managed by the ID firm median 7 vs 9 days p=.016. LOS was shorter for patients managed by the ID firm on the flu ward vs 'non flu ward', median 5 vs 9 days p=.007. No significant difference was seen between ID and GIM LOS on the flu ward, median 5 vs 7 days p=0.30. CONCLUSION Influenza patients managed by an infectious disease service on an influenza ward had reduced length of intravenous (IV) and total antimicrobial use compared to a GIM service and had reduced LOS compared to the standard of care, 'non flu ward' influenza patients.
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Affiliation(s)
| | | | | | - Samuel McConkey
- Beaumont Hospital, Beaumont Rd, Beaumont; Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin
| | - Adam Kelly
- Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin
| | - Eoghan de Barra
- Beaumont Hospital, Beaumont Rd, Beaumont; Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin
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Hur BA, Hardefeldt LY, Verspoor KM, Baldwin T, Gilkerson JR. Describing the antimicrobial usage patterns of companion animal veterinary practices; free text analysis of more than 4.4 million consultation records. PLoS One 2020; 15:e0230049. [PMID: 32168354 PMCID: PMC7069610 DOI: 10.1371/journal.pone.0230049] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 02/20/2020] [Indexed: 01/30/2023] Open
Abstract
Antimicrobial Resistance is a global crisis that veterinarians contribute to through their use of antimicrobials in animals. Antimicrobial stewardship has been shown to be an effective means to reduce antimicrobial resistance in hospital environments. Effective monitoring of antimicrobial usage patterns is an essential part of antimicrobial stewardship and is critical in reducing the development of antimicrobial resistance. The aim of this study is to describe how frequently antimicrobials were used in veterinary consultations and identify the most frequently used antimicrobials. Using VetCompass Australia, Natural Language Processing techniques, and the Australian Strategic Technical Advisory Group’s (ASTAG) Rating system to classify the importance of antimicrobials, descriptive analysis was performed on the antimicrobials prescribed in consultations from 137 companion animal veterinary clinics in Australia between 2013 and 2017 (inclusive). Of the 4,400,519 consultations downloaded there were 595,089 consultations where antimicrobials were prescribed to dogs or cats. Antimicrobials were dispensed in 145 of every 1000 canine consultations; and 38 per 1000 consultations involved high importance rated antimicrobials. Similarly with cats, 108 per 1000 consultations had antimicrobials dispensed, and in 47 per 1000 consultations an antimicrobial of high importance rating was administered. The most common antimicrobials given to cats and dogs were cefovecin and amoxycillin clavulanate, respectively. The most common topical antimicrobial and high-rated topical antimicrobial given to dogs and cats was polymyxin B. This study provides a descriptive analysis of the antimicrobial usage patterns in Australia using methods that can be automated to inform antimicrobial use surveillance programs and promote antimicrobial stewardship.
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Affiliation(s)
- Brian A. Hur
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, University of Melbourne, Parkville, Victoria, Australia
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
- * E-mail:
| | - Laura Y. Hardefeldt
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, University of Melbourne, Parkville, Victoria, Australia
| | - Karin M. Verspoor
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
- Centre for the Digital Transformation of Health, University of Melbourne, Parkville, Victoria, Australia
| | - Timothy Baldwin
- School of Computing and Information Systems, University of Melbourne, Parkville, Victoria, Australia
| | - James R. Gilkerson
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, University of Melbourne, Parkville, Victoria, Australia
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Martin A, Ruch Y, Douiri N, Boyer P, Argemi X, Hansmann Y, Lefebvre N. Factors associated with treatment failure after advice from infectious disease specialists. Med Mal Infect 2019; 50:696-701. [PMID: 31812296 DOI: 10.1016/j.medmal.2019.11.003] [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: 09/23/2018] [Revised: 01/30/2019] [Accepted: 11/06/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Risk factors associated with treatment failure after the infectious disease specialist's (IDS) advice remain unknown. We aimed to identify these risk factors. METHODS We included patients hospitalized in our tertiary care center who consulted an infectious disease specialist between January 2013 and April 2015. Treatment failure was defined by a composite criterion: signs of sepsis beyond Day 3, ICU admission, or death. Treatment success was defined by the patient's sustained clinical improvement. RESULTS A total of 240 IDS recommendations were made. Diagnosis was changed for 64 patients (26.7%) and 50 patients experienced treatment failure after the IDS advice. In multivariate analysis, compliance with the IDS advice was associated with a higher rate of success (OR=0.09, 95%CI [0.01-0.67]). Variables associated with treatment failure in the multivariate analysis were Charlson comorbidity score at admission (OR=1.24, 95%CI [1.03-1.50]), a history of infection or colonization with multidrug-resistant bacteria (OR=8.27, 95%CI [1.37-49.80]), and deterioration of the patient's status three days after the IDS advice (OR=12.50, 95%CI [3.16-49.46]). CONCLUSION Reassessing IDS recommendations could be interesting for specific patients to further adapt and improve them.
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Affiliation(s)
- A Martin
- Maladies infectieuses et tropicales, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France.
| | - Y Ruch
- Maladies infectieuses et tropicales, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - N Douiri
- Maladies infectieuses et tropicales, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - P Boyer
- Laboratoire de microbiologie, hôpitaux universitaires de Strasbourg, 3, rue Koeberlé, 67000 Strasbourg, France
| | - X Argemi
- Maladies infectieuses et tropicales, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - Y Hansmann
- Maladies infectieuses et tropicales, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
| | - N Lefebvre
- Maladies infectieuses et tropicales, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg cedex, France
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Saleem Z, Saeed H, Hassali MA, Godman B, Asif U, Yousaf M, Ahmed Z, Riaz H, Raza SA. Pattern of inappropriate antibiotic use among hospitalized patients in Pakistan: a longitudinal surveillance and implications. Antimicrob Resist Infect Control 2019; 8:188. [PMID: 31768252 PMCID: PMC6873729 DOI: 10.1186/s13756-019-0649-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 11/11/2019] [Indexed: 01/21/2023] Open
Abstract
Background The inappropriate use of antibiotics in hospitals increases resistance, morbidity, and mortality. Little is currently known about appropriate antibiotic use among hospitals in Lahore, the capital city of Pakistan. Methods Longitudinal surveillance was conducted over a period of 2 months among hospitals in Lahore, Pakistan. Antibiotic treatment was considered inappropriate on the basis of a wrong dosage regimen, wrong indication, or both based on the British National Formulary. Results A total of 2022 antibiotics were given to 1185 patients. Out of the total prescribed, approximately two-thirds of the study population (70.3%) had at least one inappropriate antimicrobial. Overall, 27.2% of patients had respiratory tract infections, and out of these, 62.8% were considered as having inappropriate therapy. Cephalosporins were extensively prescribed among patients, and in many cases, this was inappropriate (67.2%). Penicillins were given to 283 patients, out of which 201 (71.0%) were prescribed for either the wrong indication or dosage or both. Significant variations were also observed regarding inappropriate prescribing for several antimicrobials including the carbapenems (70.9%), aminoglycosides (35.8%), fluoroquinolones (64.2%), macrolides (74.6%) and other antibacterials (73.1%). Conclusion Educational interventions, institutional guidelines, and antimicrobial stewardship programs need to be developed to enhance future appropriate antimicrobial use in hospitals in Pakistan. Policies by healthcare and Government officials are also needed to minimize inappropriate antibiotic use.
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Affiliation(s)
- Zikria Saleem
- 1School of Pharmaceutical Sciences, Universiti Sains Malaysia, Gelugor, Malaysia.,2Hamdard Institute of Pharmaceutical Sciences, Hamdard University, Islamabad, Pakistan
| | - Hamid Saeed
- 3University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | - Mohamed Azmi Hassali
- 1School of Pharmaceutical Sciences, Universiti Sains Malaysia, Gelugor, Malaysia
| | - Brian Godman
- 1School of Pharmaceutical Sciences, Universiti Sains Malaysia, Gelugor, Malaysia.,Division of Clinical Pharmacology, Karolinska University Hospital Huddinge, Karolinska Institute, Stockholm, Sweden.,5Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK.,6Health Economics Centre, University of Liverpool Management School, Liverpool, UK
| | - Usama Asif
- Medical Centre, Agha Khan University Hospital, Karachi, Pakistan
| | - Mahrukh Yousaf
- Medical Centre, Agha Khan University Hospital, Karachi, Pakistan
| | - Zakiuddin Ahmed
- Ripha Institute of Healthcare Improvement & Safety, Ripha University, Islamabad, Pakistan
| | - Humayun Riaz
- Rashid Latif College of Pharmacy, Lahore, Pakistan
| | - Syed Atif Raza
- 3University College of Pharmacy, University of the Punjab, Lahore, Pakistan
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24
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Russell CD, Laurenson IF, Evans MH, Mackintosh CL. Tractable targets for meropenem-sparing antimicrobial stewardship interventions. JAC Antimicrob Resist 2019; 1:dlz042. [PMID: 34222916 PMCID: PMC8210134 DOI: 10.1093/jacamr/dlz042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/27/2019] [Accepted: 07/11/2019] [Indexed: 12/15/2022] Open
Abstract
Background As meropenem is a restricted antimicrobial, lessons learned from its real-life usage will be applicable to antimicrobial stewardship (AMS) more generally. Objectives To retrospectively evaluate meropenem usage at our institution to identify targets for AMS interventions. Methods Patients receiving meropenem documented with an ‘alert antimicrobial’ form at two tertiary care UK hospitals were identified retrospectively. Clinical records and microbiology results were reviewed. Results A total of 107 adult inpatients receiving meropenem were identified. This was first-line in 47% and escalation therapy in 53%. Source control was required in 28% of cases after escalation, for predictable reasons. Those ultimately requiring source control had received more prior antimicrobial agents than those who did not (P = 0.03). Meropenem was rationalized in 24% of cases (after median 4 days). Positive microbiology enabled rationalization (OR 12.3, 95% CI 2.7–55.5, P = 0.001) but rates of appropriate sampling varied. In cases with positive microbiology where meropenem was not rationalized, continuation was retrospectively considered clinically and microbiologically necessary in 8/40 cases (0/17 empirical first-line usage). Rationalization was more likely when meropenem susceptibility was not released on the microbiology report (OR 5.2, 95% CI 1.3–20.2, P = 0.02). Input from an infection specialist was associated with a reduced duration of meropenem therapy (P < 0.0001). Early review by an infection specialist has the potential to further facilitate rationalization. Conclusions In real-life clinical practice, core aspects of infection management remain tractable targets for AMS interventions: microbiological sampling, source control and infection specialist input. Further targets include supporting rationalization to less familiar carbapenem-sparing antimicrobials, restricting first-line meropenem usage and selectively reporting meropenem susceptibility.
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Affiliation(s)
- Clark D Russell
- Regional Infectious Diseases Unit, NHS Lothian Infection Service, Western General Hospital, Edinburgh, UK.,University of Edinburgh Centre for Inflammation Research, Queen's Medical Research Institute, Edinburgh BioQuarter, Edinburgh, UK.,Clinical Microbiology, NHS Lothian Infection Service, Laboratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ian F Laurenson
- Clinical Microbiology, NHS Lothian Infection Service, Laboratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Morgan H Evans
- Regional Infectious Diseases Unit, NHS Lothian Infection Service, Western General Hospital, Edinburgh, UK
| | - Claire L Mackintosh
- Regional Infectious Diseases Unit, NHS Lothian Infection Service, Western General Hospital, Edinburgh, UK
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25
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How to start an antimicrobial stewardship programme in a hospital. Clin Microbiol Infect 2019; 26:447-453. [PMID: 31445209 DOI: 10.1016/j.cmi.2019.08.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/09/2019] [Accepted: 08/10/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Antimicrobial stewardship (AMS) describes a coherent set of actions that ensure optimal use of antimicrobials to improve patient outcomes, while limiting the risk of adverse events (including antimicrobial resistance (AMR)). Introduction of AMS programmes in hospitals is part of most national action plans to mitigate AMR, yet the optimal components and actions of such a programme remain undetermined. OBJECTIVES To describe how health-care professionals can start an AMS programme in their hospital, the components of such a programme and the evidence base for its implementation. SOURCES National and society-led guidelines on AMS, peer-reviewed publications and experience of AMS experts conducting AMS programmes. CONTENT We provide a step-by-step pragmatic guide to setting up and implementing a hospital AMS programme in high-income or low-and-middle-income countries. IMPLICATIONS Antimicrobial stewardship programmes in hospitals are a vital component of national action plans for AMR, and have been shown to significantly reduce AMR, particularly when coupled with infection prevention and control interventions. This step-by-step guide of 'how to' set up an AMS programme will help health-care professionals involved in AMS to optimally design and implement their actions.
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26
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Saleem Z, Hassali MA, Hashmi FK, Godman B, Ahmed Z. Snapshot of antimicrobial stewardship programs in the hospitals of Pakistan: findings and implications. Heliyon 2019; 5:e02159. [PMID: 31384689 PMCID: PMC6664037 DOI: 10.1016/j.heliyon.2019.e02159] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 05/18/2019] [Accepted: 07/23/2019] [Indexed: 12/15/2022] Open
Abstract
Objective We are unaware of the extent of antimicrobial stewardship programs (ASPs) among hospitals in Pakistan, which is a concern given the population size, high use of antibiotics across sectors and increasing antimicrobial resistance (AMR) rates. Consequently, we sought to address this by undertaking a comprehensive survey. Method In this cross-sectional observational study in Punjab, an instrument of the measure was developed based on health care facility characteristics and ASPs after an extensive literature review. The questionnaire was circulated by mail or through drop off surveys to medical superintendents or directors/heads of pharmacy departments of hospitals. Results Out of 254, a total of 137 hospitals fully completed the questionnaire - 11 primary, 65 secondary, 46 tertiary and 15 specialized hospitals. The use of antimicrobial prescribing guidelines (68.7%), provision of infectious diseases consultation services (66.4%), clinical pharmacy service (65.7%), use of drug and therapeutics committees to approve antimicrobial prescribing (65.5%), regular audit by doctors on antimicrobial prescribing (54.1%) and use of a restricted formulary for antimicrobial (50.4%) were the most common ASPs. However, most of these activities were only somewhat or moderately successful. Whereas, electronic antimicrobial prescribing approval systems (15.3%), using a sticker to notify prescribers regarding the need to obtain approval for the antimicrobial prescribed (16.1%) and participation in the national antimicrobial utilization surveillance program (19.7%) were only seen in a few hospitals. Conclusion Study inferred that there are inadequate ASPs in the hospitals of Pakistan. A multidisciplinary approach, clinical leadership and availability of motivated and trained individuals are essential elements for the success of future ASPs.
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Affiliation(s)
- Zikria Saleem
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Malaysia.,Rashid Latif College of Pharmacy, Lahore, Pakistan
| | | | | | - Brian Godman
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Malaysia.,Department of Clinical Pharmacology, Karolinska Institute, Stockholm, Sweden.,Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK.,Health Economics Centre, University of Liverpool Management School, Liverpool, UK
| | - Zakkiudin Ahmed
- Ripha Institute of Healthcare Improvement & Safety, Ripha University, Pakistan
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27
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Vargas-Alzate CA, Higuita-Gutiérrez LF, Jiménez-Quiceno JN. Direct medical costs of urinary tract infections by Gram-negative bacilli resistant to beta-lactams in a tertiary care hospital in Medellín, Colombia. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2019; 39:35-49. [PMID: 31529847 DOI: 10.7705/biomedica.v39i1.3981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Indexed: 06/10/2023]
Abstract
Introduction: Urinary tract infections are very frequent in the hospital environment and given the emergence of antimicrobial resistance, they have made care processes more complex and have placed additional pressure on available healthcare resources. Objective: To describe and compare excess direct medical costs of urinary tract infections due to Klebsiella pneumoniae, Enterobacter cloacae and Pseudomonas aeruginosa resistant to beta-lactams. Materials and methods: A cohort study was conducted in a third level hospital in Medellín, Colombia, from October, 2014, to September, 2015. It included patients with urinary tract infections caused by beta-lactam-susceptible bacteria, third and fourth generation cephalosporin-resistant, as well as carbapenem-resistant. Costs were analyzed from the perspective of the health system. Clinical-epidemiological information was obtained from medical records and the costs were calculated using standard tariff manuals. Excess costs were estimated with multivariate analyses. Results: We included 141 patients: 55 (39%) were sensitive to beta-lactams, 54 (38.3%) were resistant to cephalosporins and 32 (22.7%) to carbapenems. The excess total adjusted costs of patients with urinary tract infections due to cephalosporin- and carbapenem-resistant bacteria were US$ 193 (95% confidence interval (CI): US$ -347-734) and US$ 633 (95% CI: US$ -50-1316), respectively, compared to the group of patients with beta-lactam sensitive urinary tract infections. The differences were mainly found in the use of broad-spectrum antibiotics such as meropenem, colistin, and fosfomycin. Conclusion: Our results show a substantial increase in the direct medical costs of patients with urinary tract infections caused by beta-lactam-resistant Gram-negative bacilli (cephalosporins and carbapenems). This situation is of particular concern in endemic countries such as Colombia, where the high frequencies of urinary tract infections and the resistance to beta-lactam antibiotics can generate a greater economic impact on the health sector.
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Affiliation(s)
- Carlos Andrés Vargas-Alzate
- Línea de Epidemiología Molecular Bacteriana, Grupo de Microbiología Básica y Aplicada, Escuela de Microbiología, Universidad de Antioquia, Medellín, Colombia.
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28
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Practices, organisation, and regulatory aspects in advising on antibiotic prescription: the international ESCMID AntibioLegalMap survey. Infection 2019; 47:749-760. [PMID: 30903590 DOI: 10.1007/s15010-019-01298-2] [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: 11/25/2018] [Accepted: 03/16/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Giving advice about antibiotic prescription through dedicated consultations is a cornerstone of antibiotic stewardship programmes. Our objective was to explore practices, organisation, and regulatory requirements related to antibiotic advising. METHODS We performed an international, exploratory, Internet-based, cross-sectional survey targeting infectious diseases and clinical microbiology specialists. It was disseminated through ESCMID and ESGAP networks. RESULTS Answers from 830 participants (74 countries, 77% of participants from Europe) were collected. Consultations were mostly given on demand (81%, 619/764), while unsolicited consultations targeting specific conditions (e.g., positive blood culture) were less frequent (66%, 501/764). Consultations usually included indications on diagnostic work-up and follow-up (> 79%). Curbside consultations (i.e., without examining the patient) were reported by 82% (598/733) of respondents, mainly by phone (89%, 531/598). The referring physician was considered authorised not to follow the advice by 57% (383/676). Direct consultations (i.e., after examining the patient) were recorded in the medical file more frequently than curbside consultations (69%, 472/689 vs 35%, 206/592). Concerning legal liability, the majority of respondents considered that it is shared between the adviser and the referring physician, who, however, is considered primarily responsible. The advisers' liability was considered to be lower in cases of curbside and unrecorded consultations. Significant inter-countries and intra-country variability were identified, suggesting that the setting markedly influenced practices. CONCLUSION Significant variability exists in the practice of antibiotic advising. This concerns both the organisation of care and how advisers perceive regulatory requirements. These elements must be taken into account when implementing antibiotic stewardship programmes and when training stewards.
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29
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Heard KL, Hughes S, Mughal N, Azadian BS, Moore LSP. Evaluating the impact of the ICNET® clinical decision support system for antimicrobial stewardship. Antimicrob Resist Infect Control 2019; 8:51. [PMID: 30886704 PMCID: PMC6404285 DOI: 10.1186/s13756-019-0496-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 02/13/2019] [Indexed: 01/21/2023] Open
Abstract
Background Antimicrobial resistance (AMR) is an ecological and economic crisis and stewardship of available antimicrobials is required. Electronic prescribing, where available, enables auditing of practice, yet in order to be efficient and effective in addressing inappropriate antimicrobial prescribing, better use of current and new technological interventions is needed. This retrospective observational evaluation looked at the impact of a commercial clinical decision support system (CDSS) on the workflow of an established antimicrobial stewardship (AMS) team. Material/methods Clinical, workflow, and pharmaceutical data from 3 months post implementation of CDSS were collated, and compared to the same 3 month periods in preceding years. The evaluation considered total interventions made, the types of intervention made, impact of said interventions, and time spent executing interventions. All antimicrobial data were adjusted for total daily defined doses (DDD) of intravenous antimicrobials. Results Productivity: In the 3 month evaluation period (Jun-Aug 2016) a total of 264 case reviews resulting in 298 AMS interventions were made. Compared to preceding years where 138 and 169 interventions were made (2013 and 2014 respectively). In 2013 49% of interventions were stopping medication and 30% change of therapy based on cultures and sensitivities compared to 25 and 17% in 2016. In contrast to previous years’, the CDSS instead enabled a greater number of dose/drug optimisation (13%), escalation of antimicrobials (12%) and intravenous (IV) to oral switch (11%) interventions. Patient Identification: Despite increased patient numbers post-CDSS, on average 46 min per day was spent compiling a patient list for review, compared to 59 min in 2014. The use of CDSS facilitated 15 interventions/1000DDD, compared to pre-intervention (9.4/1000DDD in 2013; 11.5/1000DDD in 2014). Conclusions Initial evaluation of the impact of this CDSS on AMS at the organisation has demonstrated effectiveness in terms of case finding, AMS team productivity, and workflow auditing. More importantly, patient infection management has been optimised with a shift in the emphasis of AMS interventions. It has contributed to the success of the healthcare provider achieving nationally set remunerated AMS targets.
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Affiliation(s)
- Katie L Heard
- 1Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK
| | - Stephen Hughes
- 1Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK
| | - Nabeela Mughal
- 1Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK.,North West London Pathology, Fulham Palace Road, London, W6 8RF UK
| | - Berge S Azadian
- 1Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK
| | - Luke S P Moore
- 1Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK.,North West London Pathology, Fulham Palace Road, London, W6 8RF UK.,3National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN UK
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30
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Alghamdi S, Shebl NA, Aslanpour Z, Shibl A, Berrou I. Hospital adoption of antimicrobial stewardship programmes in Gulf Cooperation Council countries: A review of existing evidence. J Glob Antimicrob Resist 2018; 15:196-209. [DOI: 10.1016/j.jgar.2018.07.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 07/12/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022] Open
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31
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Hwang H, Kim B. Impact of an infectious diseases specialist-led antimicrobial stewardship programmes on antibiotic use and antimicrobial resistance in a large Korean hospital. Sci Rep 2018; 8:14757. [PMID: 30283084 PMCID: PMC6170479 DOI: 10.1038/s41598-018-33201-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 09/25/2018] [Indexed: 01/18/2023] Open
Abstract
The aim of this study was to evaluate the impact of an infectious diseases specialist (IDS)-led antimicrobial stewardship programmes (ASPs) in a large Korean hospital. An interrupted time series analysis assessing the trends in antibiotic use and antimicrobial resistance rate of major pathogens between September 2015 and August 2017 was performed in an 859-bed university-affiliated hospital in Korea. The restrictive measure for designated antibiotics led by an IDS reduced carbapenems usage by -4.57 days of therapy (DOT)/1,000 patient-days per month in general wards (GWs) (95% confidence interval [CI], -6.69 to -2.46; P < 0.001), and by -41.50 DOT/1,000 patient-days per month in intensive care units (ICUs) (95% CI, -57.91 to -25.10; P < 0.001). Similarly, glycopeptides usage decreased by -2.61 DOT/1,000 patient-days per month in GWs (95% CI, -4.43 to -0.79; P = 0.007), and -27.41 DOT/1,000 patient-days per month in ICUs (95% CI, -47.03 to -7.79; P = 0.009). Use of 3rd generation cephalosporins, beta-lactam/beta-lactamase inhibitors, and fluoroquinolones in GWs showed change comparable with that of carbapenems or glycopeptides use. Furthermore, trends of antimicrobial resistance rate of Staphylococcus aureus to gentamicin in GWs, Staphylococcus aureus to ciprofloxacin and oxacillin in ICUs, and Pseudomonas aeruginosa to imipenem in ICUs decreased in slope in the intervention period. The in-hospital mortality rate per 1,000 patient-days among ICU patients remained stable between the pre-intervention and intervention periods. In conclusion, an IDS-led ASPs could enact a meaningful reduction in antibiotic use, and a decrease in antibiotic resistance rate, without changing mortality rates in a large Korean hospital.
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Affiliation(s)
- Hyeonjun Hwang
- School of Economic Sciences, Washington State University, Pullman, USA
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea.
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32
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Antimicrobial stewardship for acute-care hospitals: An Asian perspective. Infect Control Hosp Epidemiol 2018; 39:1237-1245. [PMID: 30227898 DOI: 10.1017/ice.2018.188] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Inappropriate use of antibiotics is contributing to a serious antimicrobial resistance problem in Asian hospitals. Despite resource constraints in the region, all Asian hospitals should implement antimicrobial stewardship (AMS) programs to optimize antibiotic treatment, improve patient outcomes, and minimize antimicrobial resistance. This document describes a consensus statement from a panel of regional experts to help multidisciplinary AMS teams design programs that suit the needs and resources of their hospitals. In general, AMS teams must decide on appropriate interventions (eg, prospective audit and/or formulary restriction) for their hospital, focusing on the most misused antibiotics and problematic multidrug-resistant organisms. This focus is likely to include carbapenem use with the goal to reduce carbapenem-resistant gram-negative bacteria. Rather than initially trying to introduce a comprehensive, hospital-wide AMS program, it would be practical to begin by pilot testing a simple program based on 1 achievable core intervention for the hospital. AMS team members must work together to determine the most suitable AMS interventions to implement in their hospitals and how best to put them into practice. Continuous monitoring and feedback of outcomes to the AMS teams, hospital administration, and prescribers will enhance sustainability of the AMS programs.
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33
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Rieg S, Hitzenbichler F, Hagel S, Suarez I, Kron F, Salzberger B, Pletz M, Kern WV, Fätkenheuer G, Jung N. Infectious disease services: a survey from four university hospitals in Germany. Infection 2018; 47:27-33. [PMID: 30120718 DOI: 10.1007/s15010-018-1191-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/09/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE Involvement of infectious disease (ID) specialists in the care of hospitalized patients with infections through consultation services improves the quality of care and the outcome of patients. This survey aimed to describe activities and utilization of ID consultations at four German tertiary care hospitals. METHODS A 1-month (March 2016) retrospective cross-sectional study at four university hospitals (Freiburg, Jena, Cologne and Regensburg) was performed. Only ID consultations with written documentation and bedside patient evaluation were included. Consultations were analyzed with regard to requesting departments, infections, case severity, and diagnostic and therapeutic recommendations. RESULTS In the study period, 638 ID consultations were performed in 479 patients-corresponding to 3-4 consultations per 100 inpatient cases. Patients were characterized by a high disease complexity-the mean case mix index in patients with consultation was 10.1 compared to 1.6 for all patients. ID consultations were requested by many different specialties, with approximately half of the requests coming from surgical disciplines. ID consultations resulted in revised diagnoses in 34% of the cases, provided recommendations for additional diagnostic procedures in 66%, and for modifications of antimicrobial regimens in 70% of the cases. CONCLUSIONS Infectious disease consultations were requested for patients with severe and complicated diseases and resulted in recommendations that highly impacted the diagnostic work-up and therapeutic management of patients. The results of this survey may help to estimate requirements for establishment of such services in Germany.
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Affiliation(s)
- Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany.
| | | | - Stefan Hagel
- Infectious Disease, University Hospital of Jena, Jena, Germany
| | - Isabelle Suarez
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany.,German Center for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - Florian Kron
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Bernd Salzberger
- Infectious Diseases Unit, University Hospital of Regensburg, Regensburg, Germany
| | - Mathias Pletz
- Infectious Disease, University Hospital of Jena, Jena, Germany
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Gerd Fätkenheuer
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany.,German Center for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - Norma Jung
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
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Kim I, Kim WY, Jeoung ES, Lee K. Current Status and Survival Impact of Infectious Disease Consultation for Multidrug-Resistant Bacteremia in Ventilated Patients: A Single-Center Experience in Korea. Acute Crit Care 2018; 33:73-82. [PMID: 31723866 PMCID: PMC6849055 DOI: 10.4266/acc.2017.00591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/28/2018] [Accepted: 03/14/2018] [Indexed: 12/15/2022] Open
Abstract
Background We evaluated the current status and survival impact of infectious disease consultation (IDC) in ventilated patients with multidrug-resistant (MDR) bacteremia. Methods One hundred sixty-one consecutive patients from a single tertiary care hospital were enrolled over a 5-year period. Patients with at least one of the following six MDR bacteremias were included: methicillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase-producing gram-negative bacteria (Escherichia coli and Klebsiella pneumonia), carbapenem-resistant gram-negative rods (Acinetobacter baumannii and Pseudomonas aeruginosa), and vancomycin-resistant Enterococcus faecium. Results Median patient age was 66 years (range, 18 to 95), and 57.8% of subjects were male. The 28-day mortality after the day of blood culture was 52.2%. An IDC was requested for 96 patients based on a positive blood culture (59.6%). Patients without IDC had significantly higher rate of hemato-oncologic diseases as a comorbidity (36.9% vs. 11.5%, P < 0.001). Patients without an IDC had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (median, 20; range, 8 to 38 vs. median, 16; range, 5 to 34, P < 0.001) and Sequential Organ Failure Assessment (SOFA) score (median, 9; range, 2 to 17 vs. median, 7; range, 2 to 20; P = 0.020) on the day of blood culture and a higher 28-day mortality rate (72.3% vs. 38.5%, P < 0.001). In patients with SOFA ≥9 (cut-off level based on Youden's index) on the day of blood culture and gram-negative bacteremia, IDC was also significantly associated with lower 28-day mortality (hazard ratio [HR], 0.298; 95% confidence interval [CI], 0.167 to 0.532 and HR, 0.180; 95% CI, 0.097 to 0.333; all P < 0.001) based on multivariate Cox regression analysis. Conclusions An IDC for MDR bacteremia was requested less often for ventilated patients with greater disease severity and higher 28-day mortality after blood was drawn. In patients with SOFA ≥9 on the day of blood culture and gram-negative bacteremia, IDC was associated with improved 28-day survival after blood draw for culture.
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Affiliation(s)
- Insu Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Won-Young Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Eun Suk Jeoung
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Kwangha Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
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Mizrahi A, Amzalag J, Couzigou C, Péan De Ponfilly G, Pilmis B, Le Monnier A. Clinical impact of rapid bacterial identification by MALDI-TOF MS combined with the bêta-LACTA™ test on early antibiotic adaptation by an antimicrobial stewardship team in bloodstream infections. Infect Dis (Lond) 2018; 50:668-677. [DOI: 10.1080/23744235.2018.1458147] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- A. Mizrahi
- Laboratoire de Microbiologie clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - J. Amzalag
- Laboratoire de Microbiologie clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - C. Couzigou
- Equipe mobile de Microbiologie clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - G. Péan De Ponfilly
- Laboratoire de Microbiologie clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - B. Pilmis
- Equipe mobile de Microbiologie clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - A. Le Monnier
- Laboratoire de Microbiologie clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
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TELE-EXPERTISE SYSTEM BASED ON THE USE OF THE ELECTRONIC PATIENT RECORD TO SUPPORT REAL-TIME ANTIMICROBIAL USE. Int J Technol Assess Health Care 2018; 34:156-162. [PMID: 29490710 DOI: 10.1017/s0266462318000089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The aims of this study are (i) to present the design of a tele-expertise system, based on the telephone and electronic patient record (EPR), which supports the counseling of the infectious diseases specialist (IDS) for appropriate antimicrobial use, in a French University hospital; and (ii) to assess the diffusion of the system, the users' adherence, and their perceived utility. METHODS A prospective observational study was conducted to measure (i) the number and patterns of telephone calls for tele-expertise council, the number of initial and secondary assessments from the IDS and multidisciplinary meetings; (ii) the clinicians' adherence rate to therapeutic proposals by the IDS and the number of clinical situations for which the IDS decided to move to bedside; and (iii) the perceived utility of the system by the medical managers of the most demanding departments. RESULTS The review of patients' records for 1 year period indicates that 87 percent of the therapeutic recommendations were fully followed. The adherence was high, despite the IDS moving to the bedside only in 6 percent of cases. Medical managers of the most demanding departments considered the system to be useful. Moreover, 6,994 tele-expertise notifications have been recorded into the EPR for 48 months. CONCLUSIONS The tele-expertise system is an original way to design information technology supported antimicrobial stewardship intervention based on the remote access to relevant information by the IDS and on the traceability of the medical counseling for the clinicians.
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Caeiro JP, Garzón MI. Controlling infectious disease outbreaks in low-income and middle-income countries. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018; 10:55-64. [PMID: 32226321 PMCID: PMC7100832 DOI: 10.1007/s40506-018-0154-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
When an infectious disease outbreak is detected or suspected, a healthcare facility’s infection control personnel should be notified and an outbreak control team formed that is pertinent to the size and severity of the outbreak and healthcare facility. Management of an infectious disease outbreak in a middle- or low-income country is challenging. Cost-effective recommendations that are easy to carry out and that have been stratified according to the type of infection and prevention and control intervention used are provided in this paper and constitute basic practices.
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Affiliation(s)
- Juan Pablo Caeiro
- Hospital Privado Universitario, Naciones Unidades 346, Córdoba, Argentina
| | - María I. Garzón
- Hospital Privado Universitario, Naciones Unidades 346, Córdoba, Argentina
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Gouriet F, Tissot-Dupont H, Casalta JP, Hubert S, Fournier PE, Edouard S, Theron A, Lepidi H, Grisoli D, Habib G, Raoult D. Marseille scoring system for empiric treatment of infective endocarditis. Eur J Clin Microbiol Infect Dis 2018; 37:841-849. [PMID: 29397446 DOI: 10.1007/s10096-017-3177-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 12/25/2017] [Indexed: 10/18/2022]
Abstract
Despite advances in medical, surgical, and critical care, infective endocarditis (IE) remains associated with considerable morbidity and mortality. We evaluated the performance of the Marseille score, including clinical data and biological tests obtained within 2 h, to identify patients at high risk of IE in order to initiate early antimicrobial treatment. This was secondarily confirmed using modified ESC criteria combined with molecular testing and (18)fluorodeoxyglucose-positron emission tomography/computed tomography as diagnostic tools. In a prospective cohort study, we enrolled 484 patients with cardiovascular predisposition and clinical suspicion of IE from 2011 to 2013. The final diagnosis was definite IE in 123 patients and possible IE in 107. Marseille score was calculated adding one point for each present parameter (range 0-9). This score includes clinical, epidemiological (male, fever, splenomegaly, clubbing, vascular disease and stroke) and biological criteria (Leucocytes >10,000/mm3, sedimentation rate (SR) > 50/mm or C reactive protein >10 mg/L and hemoglobin <100 g/l). A score of 2 or more performed best in predicting IE in patients with predisposing heart lesions. Sensitivity was better on left-side heart lesions (94%) than on right-side heart lesions (85%) (p = 0.04) and better for valvulopathy (94%) than intra cardiac devices (84%) (p = 0.02). The predictive positive value of prosthetic valves was greater than that of native valves (p = 0.02). Using our simple Marseille score combined with our standardized diagnostic procedures would help improve IE management by focusing on early empiric treatment within 2 h of admission for patients with cardiac predisposition factors.
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Affiliation(s)
- Frédérique Gouriet
- URMITE, Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, AP-HM, URMITE, IHU - Méditerranée Infection, 9-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France. .,IHU - Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France.
| | - Hervé Tissot-Dupont
- URMITE, Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, AP-HM, URMITE, IHU - Méditerranée Infection, 9-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France.,IHU - Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France
| | - Jean-Paul Casalta
- URMITE, Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, AP-HM, URMITE, IHU - Méditerranée Infection, 9-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France.,IHU - Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France
| | - Sandrine Hubert
- Service de Cardiologie, Hôpital de la Timone, 13385, Marseille, France
| | - Pierre-Edouard Fournier
- URMITE, Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, AP-HM, URMITE, IHU - Méditerranée Infection, 9-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France.,IHU - Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France
| | - Sophie Edouard
- URMITE, Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, AP-HM, URMITE, IHU - Méditerranée Infection, 9-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France.,IHU - Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France
| | - Alexis Theron
- Service de Chirurgie Cardiaque, Hôpital de la Timone, 13385, Marseille, France
| | - Hubert Lepidi
- URMITE, Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, AP-HM, URMITE, IHU - Méditerranée Infection, 9-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France
| | - Dominique Grisoli
- Service de Chirurgie Cardiaque, Hôpital de la Timone, 13385, Marseille, France
| | - Gilbert Habib
- Service de Cardiologie, Hôpital de la Timone, 13385, Marseille, France
| | - Didier Raoult
- URMITE, Aix Marseille Université, UM63, CNRS 7278, IRD 198, INSERM 1095, AP-HM, URMITE, IHU - Méditerranée Infection, 9-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France.,IHU - Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13385, Marseille Cedex 05, France
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Management of bloodstream infections by infection specialists in France and Germany: a cross-sectional survey. Infection 2018; 46:333-339. [PMID: 29397537 DOI: 10.1007/s15010-018-1122-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 01/29/2018] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Bloodstream infections (BSI) are frequent infections worldwide. Our objective was to explore variation in the management of patients with BSI by infection specialists in France and Germany. METHODS This work is part of an international ESCMID cross-sectional internet-based questionnaire survey that was opened from December 2016 to February 2017. All hospital-based infection specialists, senior or trainees, giving at least weekly advice on positive blood cultures could participate. Their practices were evaluated using six clinical vignettes presenting an uncomplicated BSI due to different pathogens. RESULTS A hundred and ninety-six professionals (125 from Germany and 71 from France) participated. Systematic expert advice for positive blood cultures was more often available in Germany as compared with France (73 vs. 56%, p = 0.004). In Germany, the professional providing the expert advice was more often a microbiologist or a pharmacist as compared with France (p = 0.001 and p = 0.037, respectively) where it was more often an infectious diseases specialist. Fewer German respondents reported to advise systematic IV-oral switch of antibiotic therapy. German respondents also recommended less often combination therapy: for example for Enterococcus faecalis (64 vs. 43%, p = 0.015), ESBL E. coli (94 vs. 67%, p < 0.001) and Pseudomonas aeruginosa (76 vs. 37%, p < 0.001). Overall, management of candidaemia was more often compliant with the IDSA guidelines in France as compared with Germany, but no difference was noted for MRSA bacteraemia. CONCLUSION Our survey shows that wide variations exist between two neighboring countries in the recommendations by infection specialists for the management of BSI. International guidelines are needed.
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Tärnvik A. Management of complicated skin and skin structure infections – a call for infectious disease specialists. Infect Dis (Lond) 2018; 50:117-118. [DOI: 10.1080/23744235.2017.1363405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Arne Tärnvik
- Department of Clinical Microbiology, Umeå University, Umeå, Sweden
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Diallo K, Thilly N, Luc A, Beraud G, Ergonul Ö, Giannella M, Kofteridis D, Kostyanev T, Paňo-Pardo JR, Retamar P, Kern W, Pulcini C. Management of bloodstream infections by infection specialists: an international ESCMID cross-sectional survey. Int J Antimicrob Agents 2018; 51:794-798. [PMID: 29309899 DOI: 10.1016/j.ijantimicag.2017.12.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/19/2017] [Accepted: 12/16/2017] [Indexed: 12/17/2022]
Abstract
Bloodstream infections (BSIs) are common, however international guidelines are available only for methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and candidaemia. This international ESCMID cross-sectional survey, open from December 2016 to February 2017, explored the management of BSIs by infection specialists. All infection specialists (senior or trainees) giving at least weekly advice on positive blood cultures could participate. Their practices were evaluated using six clinical vignettes presenting uncomplicated BSI cases. A total of 616 professionals from 56 countries participated [333/616 (54%) infectious diseases specialists, 188/616 (31%) clinical microbiologists], of whom 76% (468/616) were members of an antimicrobial stewardship team. Large variations in practice were noted, in particular for the Escherichia coli, Enterococcus faecalis and Pseudomonas aeruginosa vignettes. Echocardiography was considered standard of care by 81% (373/459) of participants for MRSA, 78% (400/510) for methicillin-susceptible S. aureus and 60% (236/395) for Candida albicans. Antimicrobial combination therapy was recommended by 2% (8/360) of respondents for C. albicans, 11% (43/378) for E. coli, 27% (114/420) for MRSA and 39% (155/393) for E. faecalis. Intravenous-to-oral switch was considered in 68% (285/418) for MRSA, 79% (306/388) for E. faecalis, 72% (264/366) for P. aeruginosa and 75% (270/362) for C. albicans. In multivariable analysis, IDSA guideline-compliant practice was more frequent among participants belonging to an antimicrobial stewardship team (aOR = 1.7, P = 0.018 for the MRSA vignette; and aOR = 2.0, P = 0.008 for the candidaemia vignette). This survey showed large variations in practice among infection specialists. International guidelines on management of BSI are urgently needed.
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Affiliation(s)
- Kévin Diallo
- Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, F-54000 Nancy, France
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, F-54000 Nancy, France; Université de Lorraine, CHRU-Nancy, Plateforme d'Aide à la Recherche Clinique, F-54000 Nancy, France
| | - Amandine Luc
- Université de Lorraine, CHRU-Nancy, Plateforme d'Aide à la Recherche Clinique, F-54000 Nancy, France
| | - Guillaume Beraud
- Centre de recherche du CHU de Québec-Université Laval, Hôpital Saint-Sacrement, Chemin Sainte-Foy (Québec), Canada; CHU de Poitiers, Médecine Interne et Maladies Infectieuses, Poitiers, France; Hasselt University, CenStat, Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt, Belgium
| | - Önder Ergonul
- Koç University, School of Medicine, Department of Infectious Diseases, Istanbul, Turkey
| | - Maddalena Giannella
- Sant'Orsola-Malpighi Hospital, University of Bologna, Department of Medical and Surgical Sciences, Infectious Disease Unit, Bologna, Italy
| | - Diamantis Kofteridis
- University Hospital of Heraklion and University of Crete, Faculty of Medicine, Department of Internal Medicine, Heraklion, Crete, Greece
| | - Tomislav Kostyanev
- University of Antwerp, Vaccine & Infectious Disease Institute, Department of Medical Microbiology, Wilrijk, Belgium
| | | | - Pilar Retamar
- Hospital Virgen Macarena-IBiS, Clinical Microbiology and Infectious Diseases Unit, Seville, Spain
| | - Winfried Kern
- University of Freiburg, Faculty of Medicine and Medical Center, Division of Infectious Diseases, Department of Medicine II, Freiburg, Germany
| | - Céline Pulcini
- Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, F-54000 Nancy, France; Université de Lorraine, APEMAC, F-54000 Nancy, France.
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Launay E, Gras-Le Guen C, Caillon J, Flamant C, Navas D, Ovetchkine P. Antibio-gouvernance en néonatalogie. Arch Pediatr 2017; 24 Suppl 3:S9-S13. [DOI: 10.1016/s0929-693x(18)30038-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Evaluating antibiotic therapies prescribed to adult patients in the emergency department. Med Mal Infect 2017; 46:207-14. [PMID: 27210280 DOI: 10.1016/j.medmal.2016.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/12/2016] [Accepted: 04/18/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The proper use of antibiotics is a public health priority to preserve their effectiveness. Little data is available on outpatient antibiotic prescriptions, especially in the emergency department. We aimed to assess the quality of outpatient antibiotic prescriptions in our hospital. PATIENTS AND METHODS Retrospective monocentric study of antibiotic prescriptions written to adult patients managed at the emergency department without hospitalization (November 15th, 2012-November 15th, 2013). Prescriptions were evaluated by an infectious disease specialist and an emergency physician on the basis of local recommendations compiled from national and international guidelines. RESULTS A total of 760 prescriptions were reviewed. The most frequent indications were urinary tract infections (n=263; 34.6%), cutaneous infections (n=198; 26.05%), respiratory tract infections (n=101; 13.28%), and ENT infections (n=62; 8.15%). The most frequently prescribed antibiotics were fluoroquinolones (n=314; 40.83%) and amoxicillin-clavulanic acid (n=245; 31.85%). Overall, 455 prescriptions (59.86%) did not comply with guidelines. The main reasons for inadequacy were the absence of an indication for antibiotic therapy (n=197; 40.7%), an inadequate spectrum of activity, i.e. too broad, (n=95; 19.62%), and excessive treatment duration (n=87; 17.97%). Rates of inadequate prescriptions were 82.26% for ENT infections, 71.2% for cutaneous infections, 46.53% for respiratory tract infections, and 38.4% for urinary tract infections. CONCLUSION Antibiotic prescriptions written to outpatients in the emergency department are often inadequate. Enhancing prescribers' training and handing out guidelines is therefore necessary. The quality of these prescriptions should then be re-assessed.
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Tang G, Huang L, Zong Z. Impact of Infectious Disease Consultation on Clinical Management and Outcome of Patients with Bloodstream Infection: a Retrospective Cohort Study. Sci Rep 2017; 7:12898. [PMID: 29018215 PMCID: PMC5635120 DOI: 10.1038/s41598-017-13055-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 09/18/2017] [Indexed: 02/05/2023] Open
Abstract
The impact of consultation by infectious diseases (ID) physicians on management and outcomes of patients has not been determined in China. We assembled a retrospective cohort of 995 consecutive adult cases with bloodstream infections (BSI) in a major teaching hospital in China. Survival analysis was performed with Cox regression and the Kaplan-Meier curves. Among the 995 patients with BSI, 421 (42.3%) received consultation by ID physicians and 574 (57.7%) did not. ID consultation led to a significant lower hazard of death (hazard ratio [HR], 0.575; P < 0.05) and more appropriate antimicrobial use (95.0% vs 67.6%, P < 0.05). ID consultation was a protective factor among patients with BSI due to Gram-positive (HR, 0.551; P < 0.05) or Gram-negative (HR, 0.331; P < 0.05) bacteria. Multiple ID consultation was a protective factor (HR, 0.51; P < 0.05), while single consultation was not. In conclusion, ID consultation led to significant lower risk for patients with BSI and improved management. Multiple rather than single ID consultations reduced the hazard of death.
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Affiliation(s)
- Guangmin Tang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China
| | - Liang Huang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China
| | - Zhiyong Zong
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, China.
- Department of Infection Control, West China Hospital, Sichuan University, Chengdu, China.
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Cantey JB, Vora N, Sunkara M. Prevalence, Characteristics, and Perception of Nursery Antibiotic Stewardship Coverage in the United States. J Pediatric Infect Dis Soc 2017; 6:e30-e35. [PMID: 27422868 DOI: 10.1093/jpids/piw040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/13/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Prolonged or unnecessary antibiotic use is associated with adverse outcomes in infants. Antibiotic stewardship programs (ASPs) aim to prevent these adverse outcomes and optimize antibiotic prescribing. However, data evaluating ASP coverage of nurseries are limited. The objectives of this study were to describe the characteristics of nurseries with and without ASP coverage and to determine perceptions of and barriers to nursery ASP coverage. METHODS The 2014 American Hospital Association annual survey was used to randomly select a level III neonatal intensive care unit from all 50 states. A level I and level II nursery from the same city as the level III nursery were then randomly selected. Hospital, nursery, and ASP characteristics were collected. Nursery and ASP providers (pharmacists or infectious disease providers) were interviewed using a semistructured template. Transcribed interviews were analyzed for themes. RESULTS One hundred forty-six centers responded; 104 (71%) provided nursery ASP coverage. In multivariate analysis, level of nursery, university affiliation, and number of full-time equivalent ASP staff were the main predictors of nursery ASP coverage. Several themes were identified from interviews: unwanted coverage, unnecessary coverage, jurisdiction issues, need for communication, and a focus on outcomes. Most providers had a favorable view of nursery ASP coverage. CONCLUSIONS Larger, higher-acuity nurseries in university-affiliated hospitals are more likely to have ASP coverage. Low ASP staffing and a perceived lack of importance were frequently cited as barriers to nursery coverage. Most nursery ASP coverage is viewed favorably by providers, but nursery providers regard it as less important than ASP providers.
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Affiliation(s)
- Joseph B Cantey
- Department of Pediatrics, Divisions of Neonatal/Perinatal Medicine.,Pediatric Infectious Diseases, Texas A&M Health Science Center, Temple
| | - Niraj Vora
- Department of Pediatrics, Divisions of Neonatal/Perinatal Medicine
| | - Mridula Sunkara
- Department of Pediatrics, Divisions of Neonatal/Perinatal Medicine
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Baclet N, Ficheur G, Alfandari S, Ferret L, Senneville E, Chazard E, Beuscart JB. Explicit definitions of potentially inappropriate prescriptions of antibiotics in older patients: a compilation derived from a systematic review. Int J Antimicrob Agents 2017; 50:640-648. [PMID: 28803931 DOI: 10.1016/j.ijantimicag.2017.08.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/12/2017] [Accepted: 08/01/2017] [Indexed: 12/23/2022]
Abstract
Potentially inappropriate prescriptions (PIPs) of antibiotics (antibiotic-PIPs) are generally detected by applying implicit definitions based on expert opinion. Explicit definitions are less frequently used, even though this approach would enable the automated detection of antibiotic-PIPs in electronic health records. Here, explicit definitions of antibiotic-PIPs used in studies of older adults were systematically reviewed. The MEDLINE®, Scopus® and Web of ScienceTM core collection databases were searched with a combination of three terms and their synonyms: 'potentially inappropriate prescription' AND 'antibiotic treatment' AND 'older patients'. Following standardised selection of publications, explicit definitions of antibiotic-PIPs were extracted and were classified into infectious diseases domains and subdomains. A total of 600 search queries identified 4270 records, 93 of which were selected for review. A total of 160 mentions of antibiotic-PIPs were found, corresponding to 62 distinct definitions in 19 infectious diseases domains. Nearly one-half of the definitions were related to upper respiratory tract infections (n = 11 definitions; 17.7%), lower respiratory tract infections (n = 8; 12.9%) and drug-drug interactions (n = 11; 17.7%). Almost 75% of definitions (n = 46) were mentioned in a single study only. Only three definitions concerned critically important antibiotics such as third-generation cephalosporins and fluoroquinolones. This systematic review identified 62 explicit definitions of antibiotic-PIPs. Most of the definitions were not found in more than one study and they varied in the degree of precision. We advocate the implementation of an expert consensus on explicit definitions of antibiotic-PIPs that correspond to today's challenges in public health.
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Affiliation(s)
- Nicolas Baclet
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France; Lille Catholic Hospitals, Department of Infectious Diseases, F-59160 Lille, France.
| | - Grégoire Ficheur
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France
| | - Serge Alfandari
- Gustave Dron Hospital, University Department of Infectious Diseases, F-59200 Tourcoing, France
| | - Laurie Ferret
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France; Valenciennes General Hospital, Pharmacy Department, F-59300 Valenciennes, France
| | - Eric Senneville
- Gustave Dron Hospital, University Department of Infectious Diseases, F-59200 Tourcoing, France
| | - Emmanuel Chazard
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France
| | - Jean-Baptiste Beuscart
- Univ. Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, F-59000 Lille, France; CHU Lille, Department of Geriatric Medicine, F-59000 Lille, France
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47
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Hulscher MEJL, Prins JM. Antibiotic stewardship: does it work in hospital practice? A review of the evidence base. Clin Microbiol Infect 2017; 23:799-805. [PMID: 28750920 DOI: 10.1016/j.cmi.2017.07.017] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 07/13/2017] [Accepted: 07/15/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Guidelines for developing and implementing stewardship programmes include recommendations on appropriate antibiotic use to guide the stewardship team's choice of potential stewardship objectives. They also include recommendations on behavioural change interventions to guide the team's choice of potential interventions to ensure that professionals actually use antibiotics appropriately in daily practice. AIMS To summarize the evidence base of both appropriate antibiotic use recommendations (the 'what') and behavioural change interventions (the 'how') in hospital practice. SOURCES Published systematic reviews/Medline. CONTENT The literature shows low-quality evidence of the positive effects of appropriate antibiotic use in hospital patients. The literature shows that any behavioural change intervention might work to ensure that professionals actually perform appropriate antibiotic use recommendations in daily practice. Although effects were overall positive, there were large differences in improvement between studies that tested similar change interventions. IMPLICATIONS The literature showed a clear need for studies that apply appropriate study designs- (randomized) controlled designs-to test the effectiveness of appropriate antibiotic use on achieving meaningful outcomes. Most current studies used designs prone to confounding by indication. In the process of selecting behavioural change interventions that might work best in a chosen setting, much should be learned from behavioural sciences. The challenge for stewardship teams lies in selecting change interventions on the careful assessment of barriers and facilitators, and on a theoretical base while linking determinants to change interventions. Future studies should apply more robust designs and evaluations when assessing behavioural change interventions.
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Affiliation(s)
- M E J L Hulscher
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Trupka T, Fisher K, Micek ST, Juang P, Kollef MH. Enhanced antimicrobial de-escalation for pneumonia in mechanically ventilated patients: a cross-over study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:180. [PMID: 28709439 PMCID: PMC5513164 DOI: 10.1186/s13054-017-1772-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 06/26/2017] [Indexed: 12/29/2022]
Abstract
Background Antibiotics are commonly administered to hospitalized patients with infiltrates for possible bacterial pneumonia, often leading to unnecessary treatment and increasing the risk for resistance emergence. Therefore, we performed a study to determine if an enhanced antibiotic de-escalation practice could improve antibiotic utilization in mechanically ventilated patients with suspected pneumonia cared for in an academic closed intensive care unit (ICU). Methods This was a prospective cross-over trial comparing routine antibiotic management (RAM) and enhanced antimicrobial de-escalation (EAD) performed within two medical ICUs (total 34 beds) at Barnes-Jewish Hospital, an academic referral center. Patients in the EAD group had their antibiotic orders and microbiology results reviewed daily by a dedicated team comprised of a second-year critical care fellow, an ICU attending physician and an ICU pharmacist. Antibiotic de-escalation recommendations were made when appropriate based on microbiologic test results and clinical response to therapy. Results There were 283 patients evaluable, with suspected pneumonia requiring mechanical ventilation: 139 (49.1%) patients in the RAM group and 144 (50.9%) in the EAD group. Early treatment failure based on clinical deterioration occurred in 33 (23.7%) and 40 (27.8%) patients, respectively (P = 0.438). In the remaining patients, antimicrobial de-escalation occurred in 70 (66.0%) and 70 (67.3%), respectively (P = 0.845). There was no difference between groups in total antibiotic days ((median (interquartile range)) 7.0 days (4.0, 9.0) versus 7.0 days (4.0, 8.8) (P = 0.616)); hospital mortality (25.2% versus 35.4% (P = 0.061)); or hospital duration (12.0 days (6.0, 20.0) versus 11.0 days (6.0, 22.0) (P = 0.918). Conclusions The addition of an EAD program to a high-intensity daytime staffing model already practicing a high-level of antibiotic stewardship in an academic ICU was not associated with greater antibiotic de-escalation or a reduction in the overall duration of antibiotic therapy. Trial registration ClinicalTrials.gov, NCT02685930. Registered on 26 January 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1772-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tracy Trupka
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Ave, Campus Box 8052, St. Louis, MO, 63110, USA
| | - Kristen Fisher
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Ave, Campus Box 8052, St. Louis, MO, 63110, USA
| | - Scott T Micek
- Division of Pharmacy Practice, St. Louis College of Pharmacy, St. Louis, MO, USA
| | - Paul Juang
- Division of Pharmacy Practice, St. Louis College of Pharmacy, St. Louis, MO, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 4523 Clayton Ave, Campus Box 8052, St. Louis, MO, 63110, USA.
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49
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A Role for Antimicrobial Stewardship in Clinical Sepsis Pathways: a Prospective Interventional Study. Infect Control Hosp Epidemiol 2017; 38:1032-1038. [PMID: 28693625 DOI: 10.1017/ice.2017.139] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the impact of early infectious diseases (ID) antimicrobial stewardship (AMS) intervention on inpatient sepsis antibiotic management. DESIGN Interventional, nonrandomized, controlled study. SETTING Tertiary-care referral hospital, Sydney, Australia. PATIENTS Consecutive, adult, non-intensive care unit (non-ICU) inpatients triggering an institutional clinical sepsis pathway from May to August 2015. INTERVENTION All patients reviewed by an ID Fellow within 24 hours of sepsis pathway trigger underwent case review and clinic file documentation of recommendations. Those not reviewed by an ID Fellow were considered controls and received standard sepsis pathway care. The primary outcome was antibiotic appropriateness 48 hours after sepsis trigger. RESULTS In total, 164 patients triggered the sepsis pathway: 6 patients were excluded (previous sepsis trigger); 158 patients were eligible; 106 had ID intervention; and 52 were control cases. Of these 158 patients, 91 (58%) had sepsis, and 15 of these 158 (9.5%) had severe sepsis. Initial antibiotic appropriateness, assessable in 152 of 158 patients, was appropriate in 80 (53%) of these 152 patients and inappropriate in 72 (47%) of these patients. In the intervention arm, 93% of ID Fellow recommendations were followed or partially followed, including 53% of cases in which antibiotics were de-escalated. ID Fellow intervention improved antibiotic appropriateness at 48 hours by 24% (adjusted risk ratio, 1.24; 95% confidence interval, 1.04-1.47; P=.035). The appropriateness agreement among 3 blinded ID staff opinions was 95%. Differences in intervention and control group mortality (13% vs 17%) and median length of stay (13 vs 17.5 days) were not statistically significant. CONCLUSION Sepsis overdiagnosis and delayed antibiotic optimization may reduce sepsis pathway effectiveness. Early ID AMS improved antibiotic management of non-ICU inpatients with suspected sepsis, predominantly by de-escalation. Further studies are needed to evaluate clinical outcomes. Infect Control Hosp Epidemiol 2017;38:1032-1038.
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50
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Cristina ML, Alicino C, Sartini M, Faccio V, Spagnolo AM, Bono VD, Cassola G, De Mite AM, Crisalli MP, Ottria G, Schinca E, Pinto GL, Bottaro LC, Viscoli C, Orsi A, Giacobbe DR, Icardi G. Epidemiology, management, and outcome of carbapenem-resistant Klebsiella pneumoniae bloodstream infections in hospitals within the same endemic metropolitan area. J Infect Public Health 2017; 11:171-177. [PMID: 28668656 DOI: 10.1016/j.jiph.2017.06.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/13/2017] [Accepted: 06/09/2017] [Indexed: 01/11/2023] Open
Abstract
In the last decade, carbapenem-resistant Klebsiella pneumoniae (CR-Kp) has become endemic in several countries, including Italy. In the present study, we assessed the differences in epidemiology, management, and mortality of CR-Kp bloodstream infection (BSI) in the three main adult acute-care hospitals of the metropolitan area of Genoa, Italy. From January 2013 to December 2014, all patients with CR-Kp BSI were identified through the computerized microbiology laboratory databases of the three hospitals. The primary endpoints of the study were incidence and characteristics of CR-Kp BSI in hospitals within the same endemic metropolitan area. Secondary endpoints were characteristics of CR-Kp BSI in hospitals with and without internal infectious diseases consultants (IDCs) and 15-day mortality. During the study period, the incidence of healthcare-associated CR-Kp BSI in the entire study population was 1.35 episodes per 10,000 patient-days, with substantial differences between the three hospitals. Patients admitted to the two hospital with internal IDCs were more likely to receive post-susceptibility test combined therapy including carbapenems (77% vs. 26%, p<0.001), adequate post-susceptibility test therapies (86% vs. 52%, p<0.001), and post-susceptibility therapies prescribed by an infectious diseases specialist (84% vs. 14%, p<0.001). Overall, the crude 15-days mortality was 26%. In the final multivariable model, only septic shock at BSI presentation was unfavorably and independently associated with 15-days mortality (odds ratio [OR] 6.7, 95% confidence intervals [CI] 2.6-17.6, p<0.001), while a protective effect was observed for post-susceptibility test combined therapies including a carbapenem (OR 0.11, 95% CI 0.03-0.43, p=0.002). Mortality of CR-Kp remains high. Differences in the incidence of CR-Kp BSI were detected between acute-care centers within the same endemic metropolitan area. Efforts should be made to improve the collaboration and coordination between centers, to prevent further diffusion of CR-Kp.
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Affiliation(s)
- Maria L Cristina
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132, Italy; Hospital Hygiene Unit, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy.
| | - Cristiano Alicino
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132, Italy.
| | - Marina Sartini
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132, Italy; Hospital Hygiene Unit, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy.
| | - Valeria Faccio
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132, Italy.
| | - Anna M Spagnolo
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132, Italy.
| | - Valerio D Bono
- Infectious Diseases Unit, IRCCS AOU San Martino-IST Teaching Hospital, Largo R. Benzi 10, 16132 Genoa, Italy.
| | - Giovanni Cassola
- Infectious Diseases Unit, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy.
| | - Anna M De Mite
- Medical Directorate, Local Health Unit 3, Via Bertani 4, 16125 Genoa, Italy.
| | - Maria P Crisalli
- Infectious Diseases Unit, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy.
| | - Gianluca Ottria
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132, Italy; Hospital Hygiene Unit, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy.
| | - Elisa Schinca
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132, Italy; Hospital Hygiene Unit, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy.
| | - Giuliano L Pinto
- Medical Directorate, Galliera Hospital, Mura delle Cappuccine 14, 16128 Genoa, Italy.
| | - Luigi C Bottaro
- Medical Directorate, Local Health Unit 3, Via Bertani 4, 16125 Genoa, Italy.
| | - Claudio Viscoli
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132, Italy; Infectious Diseases Unit, IRCCS AOU San Martino-IST Teaching Hospital, Largo R. Benzi 10, 16132 Genoa, Italy.
| | - Andrea Orsi
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132, Italy; Hygiene and Infection Control Unit, IRCCS AOU San Martino-IST Teaching Hospital, Largo R. Benzi 10, 16132 Genoa, Italy.
| | - Daniele R Giacobbe
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132, Italy; Infectious Diseases Unit, IRCCS AOU San Martino-IST Teaching Hospital, Largo R. Benzi 10, 16132 Genoa, Italy.
| | - Giancarlo Icardi
- Department of Health Sciences, University of Genoa, Via Pastore 1, 16132, Italy; Hygiene and Infection Control Unit, IRCCS AOU San Martino-IST Teaching Hospital, Largo R. Benzi 10, 16132 Genoa, Italy.
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