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de Araújo GC, Pardini A, Lima C. The impact of comorbidities and COVID-19 on the evolution of community onset sepsis. Sci Rep 2023; 13:10589. [PMID: 37391466 PMCID: PMC10313672 DOI: 10.1038/s41598-023-37709-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 06/26/2023] [Indexed: 07/02/2023] Open
Abstract
Sepsis is a disease with high mortality and morbidity despite advances in diagnostic procedures and therapeutic strategies. The aim of this study was to evaluate the profile and outcomes of community-onset sepsis. This retrospective, multicenter study included five 24-h health care units and was conducted from January 2018 to December 2021. Patients were diagnosed with sepsis or septic shock according to the Sepsis 3.0 criterion. A total of 2630 patients diagnosed as having sepsis (68.4%, 1800) or septic shock (31.6%, 830) in the 24-h health care unit were included; 43.76% of the patients were admitted to the intensive care unit, 12.2% died, 4.1% had sepsis and 30% had septic shock. The comorbidities that were independent predictors of septic shock were chronic kidney disease on dialysis (CKD-d), bone marrow transplantation and neoplasia. CKD and neoplasia were also independent predictors of mortality, with ORs of 2.00 (CI 1.10-3.68) p = 0.023 and 1.74 (CI 1.319-2.298) p = < 0.0001, respectively. Mortality according to the focus of primary infection was as follows: pulmonary 40.1%; COVID-19 35.7%; abdominal 8.1% and urinary 6.2%. Mortality due to the COVID-19 outbreak had an OR of 4.94 (CI 3.08-8.13) p ≤ 0.0001. Even though community-onset sepsis can be potentially fatal, this study revealed that some comorbidities lead to an increased risk of septic shock (d-CKD and neoplasia) and mortality. COVID-19 infection as the primary focus was an independent predictor of mortality in patients with sepsis when compared to other foci.
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Affiliation(s)
| | - Andrea Pardini
- Nursing Course, Israeli Faculty of Health Sciences Albert Einstein, São Paulo, São Paulo, Brazil
| | - Camila Lima
- Medical Surgical Nursing Department, Nursing School of the University of São Paulo, 419 Av. Doutor Enéas Carvalho de Aguiar, Third Floor, Cerqueira César, São Paulo, 05403-000, Brazil.
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Tang Y, Wu X, Cheng Q, Li X. Inappropriate initial antimicrobial therapy for hematological malignancies patients with Gram-negative bloodstream infections. Infection 2019; 48:109-116. [DOI: 10.1007/s15010-019-01370-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 10/23/2019] [Indexed: 12/17/2022]
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Ramsamy Y, Essack SY, Sartorius B, Patel M, Mlisana KP. Antibiotic resistance trends of ESKAPE pathogens in Kwazulu-Natal, South Africa: A five-year retrospective analysis. Afr J Lab Med 2018; 7:887. [PMID: 30568908 PMCID: PMC6295964 DOI: 10.4102/ajlm.v7i2.887] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/28/2018] [Indexed: 02/01/2023] Open
Abstract
Background To combat antimicrobial resistance, the World Health Organization developed a global priority pathogen list of antibiotic-resistant bacteria for prioritisation of research and development of new, effective antibiotics. Objective This study describes a five-year resistance trend analysis of the ESKAPE pathogens: Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter spp., from Kwazulu-Natal, South Africa. Methods This retrospective study used National Health Laboratory Services data on 64 502 ESKAPE organisms isolated between 2011 and 2015. Susceptibility trends were ascertained from minimum inhibitory concentrations and interpreted using Clinical and Laboratory Standards Institute guidelines. Results S. aureus was most frequently isolated (n = 24, 495, 38%), followed by K. pneumoniae (n = 14, 282, 22%). Decreasing rates of methicillin-resistant S. aureus (28% to 18%, p < 0.001) and increasing rates of extended spectrum beta-lactamase producing K. pneumoniae (54% to 65% p < 0.001) were observed. Carbapenem resistance among K. pneumoniae and Enterobacter spp. was less than 6% during 2011–2014, but increased from 4% in 2014 to 16% in 2015 (p < 0.001) among K. pneumoniae. P. aeruginosa increased (p = 0.002), but resistance to anti-pseudomonal antimicrobials decreased from 2013 to 2015. High rates of multi-drug resistance were observed in A. baumanni (> 70%). Conclusion This study describes the magnitude of antimicrobial resistance in KwaZulu-Natal and provides a South African perspective on antimicrobial resistance in the global priority pathogen list, signalling the need for initiation or enhancement of antimicrobial stewardship and infection control measures locally.
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Affiliation(s)
- Yogandree Ramsamy
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, Antimicrobial Research Unit, University of KwaZulu-Natal, National Health Laboratory Services, Durban, South Africa
| | - Sabiha Y Essack
- Antimicrobial Research Unit, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Benn Sartorius
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Miriam Patel
- Antimicrobial Research Unit, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Koleka P Mlisana
- National Health Laboratory Services, University of KwaZulu-Natal, Durban, South Africa
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Outpatient Treatment of Uncomplicated Urinary Tract Infections in the Emergency Department. Adv Emerg Nurs J 2018; 40:162-170. [PMID: 30059370 DOI: 10.1097/tme.0000000000000195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
One of the most commonly treated infections in the emergency department (ED) is an uncomplicated urinary tract infection. Multiple classes of antibiotics are frequently used to treat this condition, but not all have equivalent efficacy, and many may confer risks to not only the patient but society as a whole if used on a large scale. These antibiotic selections should also be guided by local antimicrobial susceptibility patterns, and general multidisciplinary recommendations for therapy should be developed on a local scale to assist prescribing patterns. The proactive development of a routine approach to reviewing and addressing positive cultures following discharge from the ED should also be developed and implemented in order to ensure that optimal patient care is provided. The objective of this review is to assess the available literature to isolate which antibiotics and approaches to care are the most appropriate options for treating uncomplicated outpatient urinary tract infections in the ED.
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Kulwicki BD, Brandt KL, Wolf LM, Weise AJ, Dumkow LE. Impact of an emergency medicine pharmacist on empiric antibiotic prescribing for pneumonia and intra-abdominal infections. Am J Emerg Med 2018; 37:839-844. [PMID: 30097272 DOI: 10.1016/j.ajem.2018.07.052] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/24/2018] [Accepted: 07/26/2018] [Indexed: 12/19/2022] Open
Abstract
PURPOSE It is critical to engage ED providers in antimicrobial stewardship programs (ASP). Emergency medicine pharmacists (EMPs) play an important role in ASP by working with providers to choose empiric antimicrobials. This study aimed to determine the impact of an EMP on appropriate empiric antibiotic prescribing for community-acquired pneumonia (CAP) and intra-abdominal infections (CA-IAI). METHODS A retrospective cohort study was conducted evaluating adult patients admitted with CAP or CA-IAI. The primary outcome of this study was to compare guideline-concordant empiric antibiotic prescribing when an EMP was present vs. absent. We also aimed to compare the impact of an EMP in an early-ASP vs. established-ASP. RESULTS 320 patients were included in the study (EMP n = 185, no-EMP n = 135). Overall empiric antibiotic prescribing was more likely to be guideline-concordant when an EMP was present (78% vs. 61%, p = 0.001); this was true for both the CAP (95% vs. 79%, p = 0.005) and CA-IAI subgroups (62% vs. 44%, p = 0.025). Total guideline-concordant prescribing significantly increased between the early-ASP and established-ASP (60% vs. 82.5%, p < 0.001) and was more likely when an EMP was present (early-ASP: 68.3% vs. 45.8%, p = 0.005; established-ASP: 90.5% vs. 73.7%, p = 0.005). Patients receiving guideline-concordant antibiotics in the ED continued appropriate therapy upon admission 82.5% of the time vs. 18.8% if the ED antibiotic was inappropriate (p < 0.001). CONCLUSION The presence of an EMP significantly improved guideline-concordant empiric antibiotic prescribing for CAP and CA-IAI in both an early and established ASP. Inpatient orders were more likely to be guideline-concordant if appropriate therapy was ordered in the ED.
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Affiliation(s)
| | - Kasey L Brandt
- Pharmaceutical Services, Mercy Health Saint Mary's, Grand Rapids, MI, USA
| | - Lauren M Wolf
- Pharmaceutical Services, Mercy Health Saint Mary's, Grand Rapids, MI, USA
| | - Andrew J Weise
- Grand Rapids Emergency Medical Group, Grand Rapids, MI, USA
| | - Lisa E Dumkow
- Pharmaceutical Services, Mercy Health Saint Mary's, Grand Rapids, MI, USA.
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Dumkow LE, Beuschel TS, Brandt KL. Expanding Antimicrobial Stewardship to Urgent Care Centers Through a Pharmacist-Led Culture Follow-up Program. Infect Dis Ther 2017; 6:453-459. [PMID: 28853035 PMCID: PMC5595781 DOI: 10.1007/s40121-017-0168-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction Urgent care centers represent a high-volume outpatient setting where antibiotics are prescribed frequently but resources for antimicrobial stewardship may be scarce. In 2015, our pharmacist-led Emergency Department (ED) culture follow-up program was expanded to include two urgent care (UC) sites within the same health system. The UC program is conducted by ED and infectious diseases clinical pharmacists as well as PGY1 pharmacy residents using a collaborative practice agreement (CPA). The purpose of this study was to describe the pharmacist-led UC culture follow-up program and its impact on pharmacist workload. Methods This retrospective, descriptive study included all patients discharged to home from UC with a positive culture from any site resulting between 1 January and 31 December 2016. Data collected included the culture type, presence of intervention, and proportion of interventions made under the CPA. Additionally, pharmacist workload was reported as the number of call attempts made, new prescriptions written, and median time to complete follow-up per patient. Data were reported using descriptive statistics. Results A total of 1461 positive cultures were reviewed for antibiotic appropriateness as part of the UC culture follow-up program, with 320 (22%) requiring follow-up intervention. Culture types most commonly requiring intervention were urine cultures (25%) and sexually transmitted diseases (25%). A median of 15 min was spent per intervention, with a median of one call (range 1–6 calls) needed to reach each patient. Less than half of patients required a new antimicrobial prescription at follow-up. Conclusion A pharmacist-led culture follow-up program conducted using a CPA was able to be expanded to UC sites within the same health system using existing clinical pharmacy staff along with PGY1 pharmacy residents. Service expansion resulted in minimal increase in pharmacist workload. Adding UC culture follow-up services to an existing ED program can allow health systems to expand antimicrobial stewardship initiatives to satellite locations.
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Affiliation(s)
- Lisa E Dumkow
- Department of Pharmacy Services, Mercy Health Saint Mary's, Grand Rapids, Michigan, USA.
| | - Thomas S Beuschel
- Department of Pharmacy Services, Mercy Health Saint Mary's, Grand Rapids, Michigan, USA
| | - Kasey L Brandt
- Department of Pharmacy Services, Mercy Health Saint Mary's, Grand Rapids, Michigan, USA
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Trinh TD, Zasowski EJ, Claeys KC, Lagnf AM, Kidambi S, Davis SL, Rybak MJ. Multidrug-resistant Pseudomonas aeruginosa lower respiratory tract infections in the intensive care unit: Prevalence and risk factors. Diagn Microbiol Infect Dis 2017; 89:61-66. [PMID: 28716451 DOI: 10.1016/j.diagmicrobio.2017.06.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 06/09/2017] [Accepted: 06/12/2017] [Indexed: 12/26/2022]
Abstract
Intensive care unit (ICU) admission is a risk for multidrug-resistant (MDR) Pseudomonas aeruginosa, but factors specific to critically ill pneumonia patients are not fully characterized. Objective was to determine risk factors associated with MDR P. aeruginosa pneumonia among ICU patients. This was a retrospective case-control study of P. aeruginosa pneumonia in the ICU; cystic fibrosis and colonizers were excluded. Risk factors included comorbid conditions and prior healthcare exposure (anti-pseudomonal antibiotics, hospitalizations, nursing home, P. aeruginosa colonization/infection, mechanical ventilation). Of 200 patients, 47 (23.5%) had MDR P. aeruginosa pneumonia. Independent predictors for MDR were ≥24h antibiotics in the preceding 90days (carbapenems, fluoroquinolones, and piperacillin-tazobactam) (odds ratio, 3.6 [95% CI, 1.6-8.1]) and nursing home residence (2.3 [1.1-4.9]). MDR P. aeruginosa remains prevalent among ICU patients with pneumonia. Given poor outcomes with delayed therapy, patients should be thoroughly assessed for prior anti-pseudomonal antibiotic exposure and nursing home residency.
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Affiliation(s)
- Trang D Trinh
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave, Detroit, MI 48201, USA
| | - Evan J Zasowski
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave, Detroit, MI 48201, USA
| | - Kimberly C Claeys
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave, Detroit, MI 48201, USA
| | - Abdalhamid M Lagnf
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave, Detroit, MI 48201, USA
| | - Shravya Kidambi
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave, Detroit, MI 48201, USA
| | - Susan L Davis
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave, Detroit, MI 48201, USA; Department of Pharmacy, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI 48202, USA
| | - Michael J Rybak
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave, Detroit, MI 48201, USA.
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Comparison of rapid hybridization-based pathogen identification and resistance evaluation in sepsis using the Verigene® device paired with “good old culture”. Wien Klin Wochenschr 2017; 129:435-441. [DOI: 10.1007/s00508-016-1057-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 07/08/2016] [Indexed: 10/21/2022]
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Savage RD, Fowler RA, Rishu AH, Bagshaw SM, Cook D, Dodek P, Hall R, Kumar A, Lamontagne F, Lauzier F, Marshall J, Martin CM, McIntyre L, Muscedere J, Reynolds S, Stelfox HT, Daneman N. The Effect of Inadequate Initial Empiric Antimicrobial Treatment on Mortality in Critically Ill Patients with Bloodstream Infections: A Multi-Centre Retrospective Cohort Study. PLoS One 2016; 11:e0154944. [PMID: 27152615 PMCID: PMC4859485 DOI: 10.1371/journal.pone.0154944] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 04/21/2016] [Indexed: 12/18/2022] Open
Abstract
Hospital mortality rates are elevated in critically ill patients with bloodstream infections. Given that mortality may be even higher if appropriate treatment is delayed, we sought to determine the effect of inadequate initial empiric treatment on mortality in these patients. A retrospective cohort study was conducted across 13 intensive care units in Canada. We defined inadequate initial empiric treatment as not receiving at least one dose of an antimicrobial to which the causative pathogen(s) was susceptible within one day of initial blood culture. We evaluated the association between inadequate initial treatment and hospital mortality using a random effects multivariable logistic regression model. Among 1,190 patients (1,097 had bacteremia and 93 had candidemia), 476 (40%) died and 266 (22%) received inadequate initial treatment. Candidemic patients more often had inadequate initial empiric therapy (64.5% versus 18.8%), as well as longer delays to final culture results (4 vs 3 days) and appropriate therapy (2 vs 0 days). After adjustment, there was no detectable association between inadequate initial treatment and mortality among bacteremic patients (Odds Ratio (OR): 1.02, 95% Confidence Interval (CI) 0.70-1.48); however, candidemic patients receiving inadequate treatment had nearly three times the odds of death (OR: 2.89, 95% CI: 1.05-7.99). Inadequate initial empiric antimicrobial treatment was not associated with increased mortality in bacteremic patients, but was an important risk factor in the subgroup of candidemic patients. Further research is warranted to improve early diagnostic and risk prediction methods in candidemic patients.
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Affiliation(s)
- Rachel D. Savage
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Robert A. Fowler
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Asgar H. Rishu
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sean M. Bagshaw
- Faculty of Medicine and Dentistry, Division of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Deborah Cook
- Department of Medicine, Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Peter Dodek
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Center for Health Evaluation and Outcome Sciences, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Richard Hall
- Faculty of Medicine, Department of Critical Care Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Anand Kumar
- Department of Medicine, Section of Critical Care Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pharmacology and Therapeutics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - François Lamontagne
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, Québec, Canada
- Département de médecine, Service de médecine interne, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - François Lauzier
- Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Québec, Canada
- Département de médecine, Université Laval, Québec, Québec, Canada
- Département d’anesthésiologie et de soins intensifs, Université Laval, Québec, Québec, Canada
| | - John Marshall
- St. Michael's Hospital, Toronto, Ontario, Canada
- Departments of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Claudio M. Martin
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Critical Care, London Health Sciences Centre, London, Ontario, Canada
| | - Lauralyn McIntyre
- Department of Medicine, Division of Critical Care, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - John Muscedere
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Critical Care Medicine, Kingston General Hospital, Kingston, Ontario, Canada
| | - Steven Reynolds
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Henry T. Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nick Daneman
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Division of Infectious Diseases, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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Does it Matter if we get it right? Impact of appropriateness of empiric antimicrobial therapy among surgical patients. Shock 2015; 42:185-91. [PMID: 24727868 DOI: 10.1097/shk.0000000000000192] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Previous studies have shown conflicting evidence regarding the impact of inappropriate, initial antibiotic therapy. The purpose of this study was to evaluate the impact of inappropriate empiric antimicrobial therapy for the treatment of infection among surgical patients. We hypothesized that inappropriate empiric antimicrobial therapy would predict increased mortality risk compared with appropriate therapy. This was a retrospective analysis of a prospectively maintained database of all surgical patients admitted to a tertiary care center from 1996 to 2007 and treated for sepsis. "Appropriate" empiric antibiotic treatment was determined by sensitivity testing. Demographics and comorbidities, infection sites, infection organisms, and outcomes were compared between inappropriately and appropriately treated groups. Multivariable log-binomial regression was performed. There were 2,855 patients (7,158 infectious episodes) identified by culture analysis as either appropriately or inappropriately treated. Three hundred seventeen (15%) inappropriately treated infectious episodes resulted in death compared with 718 (14%) of the appropriately treated infectious episodes. After adjusting for statistically significant variables, inappropriately treated episodes of infection were not found to be associated with an increased risk for mortality compared with appropriately treated episodes of infection (relative risk, 1.0; 95% confidence interval, 0.99 - 1.02; P = 0.36). Our study observed no difference in mortality between appropriately and inappropriately treated infections within a surgical population.
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Khan RA, Bakry MM, Islahudin F. Appropriate Antibiotic Administration in Critically Ill Patients with Pneumonia. Indian J Pharm Sci 2015; 77:299-305. [PMID: 26180275 PMCID: PMC4502144 DOI: 10.4103/0250-474x.159623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 01/07/2015] [Accepted: 05/26/2015] [Indexed: 12/02/2022] Open
Abstract
Inappropriate initial antibiotics for pneumonia infection are usually linked to extended intensive care unit stay and are associated with an increased risk of mortality. This study evaluates the impact of inappropriate initial antibiotics on the length of intensive care unit stay, risk of mortality and the co-predictors that influences these outcomes. This retrospective study was conducted in an intensive care unit of a teaching hospital. The types of pneumonia investigated were hospital-acquired pneumonia and ventilator-associated pneumonia. Three different time points were defined as the initiation of appropriate antibiotics at 24 h, between 24 to 48 h and at more than 48 h after obtaining a culture. Patients had either hospital-acquired pneumonia (59.1%) or ventilator-associated pneumonia (40.9%). The length of intensive care unit stay ranged from 1 to 52 days (mean; 9.78±10.02 days). Patients who received appropriate antibiotic agent at 24 h had a significantly shorter length of intensive care unit stay (5.62 d, P<0.001). The co-predictors that contributed to an extended intensive care unit stay were the time of availability of susceptibility results and concomitant diseases, namely cancer and sepsis. The only predictor of intensive care unit death was cancer. The results support the need for early appropriate initial antibiotic therapy in hospital-acquired pneumonia and ventilator-associated pneumonia infections.
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Affiliation(s)
- R A Khan
- Hospital SgBuloh, Jalan Hospital, 47000 SgBuloh, Selangor, Malaysia
| | - M M Bakry
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
| | - F Islahudin
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
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Abstract
Sepsis is one of the oldest and most elusive syndromes in medicine. With the confirmation of germ theory by Semmelweis, Pasteur, and others, sepsis was considered as a systemic infection by a pathogenic organism. Although the germ is probably the beginning of the syndrome and one of the major enemies to be identified and fought, sepsis is something wider and more elusive. In this chapter clinically relevant themes of sepsis will be approached to provide an insight of everyday clinical practice for healthcare workers often not directly involved in the patient's management.
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Affiliation(s)
- Giacomo Monti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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13
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Barrera-Vargas A, Gómez-Martín D, Merayo-Chalico J, Ponce-de-León A, Alcocer-Varela J. Risk factors for drug-resistant bloodstream infections in patients with systemic lupus erythematosus. J Rheumatol 2014; 41:1311-6. [PMID: 24882843 DOI: 10.3899/jrheum.131261] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To identify risk factors for developing drug-resistant bacterial infections in patients with systemic lupus erythematosus (SLE). METHODS A retrospective, case-control study was performed. Patients fulfilled American College of Rheumatology criteria for SLE and had an episode of bloodstream infection between 2001 and 2012. Cases were defined as those with bloodstream infection caused by drug-resistant bacteria (Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, or extended-spectrum-β-lactalamase-producing Escherichia coli); while controls had susceptible strains of S. aureus or E. coli. Differences between groups were analyzed by Student t test or Mann-Whitney U test. Association between variables was assessed by OR (CI 95%). Multivariate analysis was performed by binary logistic regression model. RESULTS Forty-four patients were included in each group. Variables associated with drug-resistant bloodstream infection were history of central nervous system activity; hematological activity, immunosuppressive treatment and prednisone dose at the time of the infection; and low C3 levels, antibiotic use, or hospitalization in the previous 3 months. In multivariate analysis, variables that remained significant were low C3 previous to infection (OR 3.12, CI 95% 1.91-8.22), previous hospitalization (OR 2.22, CI 95% 1.42-4.10), and prednisone dose at the time of infection (OR 1.10, CI 95% 1.04-1.22). CONCLUSION Low C3 levels, recent hospitalization, and prednisone dose at time of infection are independent risk factors for acquiring drug-resistant bacteria in patients with SLE. Although the present data do not fully support a change in initial treatment-decision strategies, this information could lead to prospective studies designed to address this issue, which could determine the best approach in clinical practice.
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Affiliation(s)
- Ana Barrera-Vargas
- From the Department of Immunology and Rheumatology and Department of Infectology and Microbiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.A. Barrera-Vargas, MD, Department of Immunology and Rheumatology; D. Gómez-Martín, MD, PhD, Research Associate, Department of Immunology and Rheumatology; J. Merayo-Chalico, MD, Fellow in Rheumatology, Department of Immunology and Rheumatology; A. Ponce-de-León, MD, Attending Physician, Department of Infectology and Microbiology; J. Alcocer-Varela, MD, PhD, Professor and Chairman, Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
| | - Diana Gómez-Martín
- From the Department of Immunology and Rheumatology and Department of Infectology and Microbiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.A. Barrera-Vargas, MD, Department of Immunology and Rheumatology; D. Gómez-Martín, MD, PhD, Research Associate, Department of Immunology and Rheumatology; J. Merayo-Chalico, MD, Fellow in Rheumatology, Department of Immunology and Rheumatology; A. Ponce-de-León, MD, Attending Physician, Department of Infectology and Microbiology; J. Alcocer-Varela, MD, PhD, Professor and Chairman, Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
| | - Javier Merayo-Chalico
- From the Department of Immunology and Rheumatology and Department of Infectology and Microbiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.A. Barrera-Vargas, MD, Department of Immunology and Rheumatology; D. Gómez-Martín, MD, PhD, Research Associate, Department of Immunology and Rheumatology; J. Merayo-Chalico, MD, Fellow in Rheumatology, Department of Immunology and Rheumatology; A. Ponce-de-León, MD, Attending Physician, Department of Infectology and Microbiology; J. Alcocer-Varela, MD, PhD, Professor and Chairman, Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
| | - Alfredo Ponce-de-León
- From the Department of Immunology and Rheumatology and Department of Infectology and Microbiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.A. Barrera-Vargas, MD, Department of Immunology and Rheumatology; D. Gómez-Martín, MD, PhD, Research Associate, Department of Immunology and Rheumatology; J. Merayo-Chalico, MD, Fellow in Rheumatology, Department of Immunology and Rheumatology; A. Ponce-de-León, MD, Attending Physician, Department of Infectology and Microbiology; J. Alcocer-Varela, MD, PhD, Professor and Chairman, Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
| | - Jorge Alcocer-Varela
- From the Department of Immunology and Rheumatology and Department of Infectology and Microbiology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.A. Barrera-Vargas, MD, Department of Immunology and Rheumatology; D. Gómez-Martín, MD, PhD, Research Associate, Department of Immunology and Rheumatology; J. Merayo-Chalico, MD, Fellow in Rheumatology, Department of Immunology and Rheumatology; A. Ponce-de-León, MD, Attending Physician, Department of Infectology and Microbiology; J. Alcocer-Varela, MD, PhD, Professor and Chairman, Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán.
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Azuhata T, Kinoshita K, Kawano D, Komatsu T, Sakurai A, Chiba Y, Tanjho K. Time from admission to initiation of surgery for source control is a critical determinant of survival in patients with gastrointestinal perforation with associated septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R87. [PMID: 24886954 PMCID: PMC4057117 DOI: 10.1186/cc13854] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Accepted: 04/24/2014] [Indexed: 12/29/2022]
Abstract
Introduction We developed a protocol to initiate surgical source control immediately after admission (early source control) and perform initial resuscitation using early goal-directed therapy (EGDT) for gastrointestinal (GI) perforation with associated septic shock. This study evaluated the relationship between the time from admission to initiation of surgery and the outcome of the protocol. Methods This examination is a prospective observational study and involved 154 patients of GI perforation with associated septic shock. We statistically analyzed the relationship between time to initiation of surgery and 60-day outcome, examined the change in 60-day outcome associated with each 2 hour delay in surgery initiation and determined a target time for 60-day survival. Results Logistic regression analysis demonstrated that time to initiation of surgery (hours) was significantly associated with 60-day outcome (Odds ratio (OR), 0.31; 95% Confidence intervals (CI)), 0.19-0.45; P <0.0001). Time to initiation of surgery (hours) was selected as an independent factor for 60-day outcome in multiple logistic regression analysis (OR), 0.29; 95% CI, 0.16-0.47; P <0.0001). The survival rate fell as surgery initiation was delayed and was 0% for times greater than 6 hours. Conclusions For patients of GI perforation with associated septic shock, time from admission to initiation of surgery for source control is a critical determinant, under the condition of being supported by hemodynamic stabilization. The target time for a favorable outcome may be within 6 hours from admission. We should not delay in initiating EGDT-assisted surgery if patients are complicated with septic shock.
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Dumkow LE, Kenney RM, MacDonald NC, Carreno JJ, Malhotra MK, Davis SL. Impact of a Multidisciplinary Culture Follow-up Program of Antimicrobial Therapy in the Emergency Department. Infect Dis Ther 2014; 3:45-53. [PMID: 25134811 PMCID: PMC4108117 DOI: 10.1007/s40121-014-0026-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Indexed: 12/21/2022] Open
Abstract
Introduction Antimicrobial prescribing in the emergency department is predominantly empiric, with final microbiology results either unavailable or reported after most patients are discharged home. Systematic follow-up processes are needed to ensure appropriate antimicrobial therapy at this transition of care. The objective of this study was to assess the impact of a culture follow-up (CFU) program on the frequency of emergency department (ED) revisits within 72 h and hospital admissions within 30 days compared to the historical standard of care (SOC). Additionally, infection characteristics and antimicrobial therapy were compared. Methods A single group, pre-test post-test quasi-experimental study was conducted comparing a retrospective SOC group to a prospective CFU group. CFU was implemented using computerized decision-support software and a multidisciplinary team of pharmacists and emergency physician staff. Results Over the four-month intervention period the CFU group evaluated 197 cultures and modified antimicrobial therapy in 25.5%. The rate of combined ED revisits within 72 h and hospital admissions within 30 days was 16.9% in the SOC group and 10.2% in the CFU group (p = 0.079). When evaluating the uninsured population alone, revisits to the ED within 72 h were reduced from 15.3% in the SOC group to 2.4% in the CFU group (p = 0.044). Conclusion Implementation of a multidisciplinary CFU program was associated with a reduction in ED revisits within 72 h and hospital admissions within 30 days. One-fourth of patients required post-discharge intervention, representing a large need for antimicrobial stewardship expansion to ED practice models. Electronic supplementary material The online version of this article (doi:10.1007/s40121-014-0026-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lisa E. Dumkow
- Mercy Health St. Mary’s, Grand Rapids, MI USA
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI USA
| | - Rachel M. Kenney
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI USA
| | | | - Joseph J. Carreno
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University and Henry Ford Hospital, 259 Mack Ave, Detroit, MI 48201 USA
- Albany College of Pharmacy and Health Sciences, Albany, NY USA
| | - Manu K. Malhotra
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI USA
| | - Susan L. Davis
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI USA
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University and Henry Ford Hospital, 259 Mack Ave, Detroit, MI 48201 USA
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Vasudevan A, Chuang L, Jialiang L, Mukhopadhyay A, Goh EYY, Tambyah PA. Inappropriate empirical antimicrobial therapy for multidrug-resistant organisms in critically ill patients with pneumonia is not an independent risk factor for mortality: Results of a prospective observational study of 758 patients. J Glob Antimicrob Resist 2013; 1:123-130. [PMID: 27873622 DOI: 10.1016/j.jgar.2013.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 02/26/2013] [Accepted: 03/08/2013] [Indexed: 10/26/2022] Open
Abstract
The benefits of broad-spectrum initial empirical antibiotic therapy for all patients in intensive care units (ICUs) with high rates of multidrug-resistant organisms (MDROs) have not been critically evaluated. In this study, 758 ICU patients with pneumonia were prospectively evaluated. Of 349 positive respiratory cultures, 119 (34.1%) were with MDRO isolates. These were associated with increased mortality [adjusted hazard ratio (HR)=1.65, 95% confidence interval (CI) 1.01-2.68; P=0.04] as was increasing age and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Among the patients with MDRO-associated pneumonia, increasing age, APACHE II score and inappropriate definitive antimicrobial therapy (IDAT) were found to be significant risk factors for mortality (in-ICU mortality, adjusted HR=2.8, 95% CI 1.3-5.8; P=0.007), but inappropriate empirical antimicrobial therapy (IEAT) was not (in-ICU mortality, unadjusted HR=1.6, 95% CI 0.7-3.6; P=0.3). In conclusion, we found that among critically ill patients with MDRO-associated pneumonia, IEAT is not an independent risk factor for ICU mortality. Hence, we do not recommend the use of broad-spectrum initial empirical antimicrobial therapy for all patients, as its benefits may not outweigh the potential risks. Early microbiological diagnosis to facilitate implementation of early definitive antimicrobial therapy through use of novel technologies is likely to have a major impact.
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Affiliation(s)
- Anupama Vasudevan
- Division of Infectious Diseases, University Medicine Cluster, National University Health System, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Leyland Chuang
- Department of Medicine, Alexandra Hospital, Jurong Health Services, Singapore.
| | - Li Jialiang
- Department of Statistics and Applied Probability, National University of Singapore, Singapore
| | - Amartya Mukhopadhyay
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Health System, Singapore
| | | | - Paul A Tambyah
- Division of Infectious Diseases, University Medicine Cluster, National University Health System, 5 Lower Kent Ridge Road, Singapore 119074, Singapore.
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Llaca-Díaz JM, Mendoza-Olazarán S, Camacho-Ortiz A, Flores S, Garza-González E. One-year surveillance of ESKAPE pathogens in an intensive care unit of Monterrey, Mexico. Chemotherapy 2013; 58:475-81. [PMID: 23548324 DOI: 10.1159/000346352] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 12/03/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND Bacterial species from the ESKAPE group (i.e. Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species) are frequently resistant to antibiotics. The purpose of this study was to monitor the incidence of ESKAPE pathogens at the intensive care unit (ICU) of a tertiary care hospital in Monterrey, Mexico. METHODS All clinically relevant organisms isolated from June 2011 to June 2012 were included. Identification and susceptibility testing was performed using panels from Sensititre. Resistance to oxacillin, for S. aureus, and the production of extended spectrum β-lactamases (ESBLs), for K. pneumonia, were determined as defined by the Clinical Laboratory Standards Institute. Also, the presence of vanA and vanB genes was determined in E. faecium vancomycin (VAN)-resistant isolates. RESULTS The majority of pathogens (64.5%) isolated in the ICU unit were from the ESKAPE group. The organisms most frequently isolated were A. baumannii (15.8%) and P. aeruginosa (14.3%). A high resistance to carbapenems was detected for A. baumannii (75.3%) while 62% of S. aureus isolates were confirmed to be methicillin resistant. Of the K. pneumoniae isolates, 36.9% were ESBL producers. We detected three E. faecium VAN-resistant isolates, all of which contained the vanA gene. CONCLUSION The presence of the ESKAPE group of pathogens is a major problem in the ICU setting. The results of this study support the implementation of special antimicrobial strategies to specifically target these microorganisms.
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Affiliation(s)
- Jorge Martín Llaca-Díaz
- Departamento de Patología Clínica, Hospital Universitario Dr. José Eleuterio González Universidad Autónoma de Nuevo León, Monterrey, México
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18
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Tseng CC, Liu SF, Wang CC, Tu ML, Chung YH, Lin MC, Fang WF. Impact of clinical severity index, infective pathogens, and initial empiric antibiotic use on hospital mortality in patients with ventilator-associated pneumonia. Am J Infect Control 2012; 40:648-52. [PMID: 22243991 DOI: 10.1016/j.ajic.2011.08.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Revised: 08/23/2011] [Accepted: 08/23/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND The prompt initial use of appropriate antibiotics should improve mortality rates in adults with ventilator-associated pneumonia (VAP). However, the incidence of multidrug-resistant (MDR) pathogen infections is on the rise, and the choice of the initial empiric antibiotic may be challenging. We investigated whether appropriate initial antibiotic therapy, infective pathogens, and the clinical severity index influence hospital mortality in patients with VAP and determined independent risk factors for the same. METHODS This study evaluated 163 adult patients (aged ≥ 18 years) at Chang Gung Memorial Hospital, Kaohsiung, Taiwan, from January 1, 2007, to January 31, 2008. Eligibility was evaluated based on criteria for VAP. Sequential Organ Failure Assessment (SOFA) scores, Acute Physiological Assessment and Chronic Health Evaluation II (APACHE II) scores, oxygenation index, underlying comorbidities, septic shock status, previous tracheostomy status, and factors related to pneumonia were collected for analysis. RESULTS Ninety-two patients survived from a total 163 patients with VAP during the course of their confinement in the intensive care unit. Multivariable logistic regression analysis identified that a pre-existing Charlson Comorbidity Index score (P = .011), initial oxygenation index (P = .025), SOFA score (P = .043), VAP caused by Acinetobacter baumanii (P = .030), and infection with MDR pathogens (P = .003) were independent risk factors for hospital mortality in patients with VAP. CONCLUSION High Charlson Comorbidity Index score, high initial oxygenation index, high SOFA score, and infection with Acinetobacter baumannii or MDR pathogens significantly affect hospital mortality in patients with VAP.
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Affiliation(s)
- Chia-Cheng Tseng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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19
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Tseng CC, Huang KT, Chen YC, Wang CC, Liu SF, Tu ML, Chung YH, Fang WF, Lin MC. Factors predicting ventilator dependence in patients with ventilator-associated pneumonia. ScientificWorldJournal 2012; 2012:547241. [PMID: 22919335 PMCID: PMC3417186 DOI: 10.1100/2012/547241] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 05/27/2012] [Indexed: 01/08/2023] Open
Abstract
Objectives. To determine risk factors associated with ventilator dependence in patients with ventilator-associated pneumonia (VAP). Study Design. A retrospective study was conducted at Chang Gung Memorial Hospital, Kaohsiung, from January 1, 2007 to January 31, 2008. Methods. This study evaluated 163 adult patients (aged ≥18 years). Eligibility was evaluated according to the criterion for VAP, Sequential Organ Failure Assessment (SOFA) score, Acute Physiological Assessment and Chronic Health Evaluation II (APACHE II) score. Oxygenation index, underlying comorbidities, septic shock status, previous tracheostomy status, and factors related to pneumonia were collected for analysis. Results. Of the 163 VAP patients in the study, 90 patients survived, yielding a mortality rate of 44.8%. Among the 90 surviving patients, only 36 (40%) had been weaned off ventilators at the time of discharge. Multivariate logistic regression analysis was used to identify underlying factors such as congestive cardiac failure (P = 0.009), initial high oxygenation index value (P = 0.04), increased SOFA scores (P = 0.01), and increased APACHE II scores (P = 0.02) as independent predictors of ventilator dependence. Results from the Kaplan-Meier method indicate that initial therapy with antibiotics could increase the ventilator weaning rate (log Rank test, P < 0.001). Conclusions. Preexisting cardiopulmonary function, high APACHE II and SOFA scores, and high oxygenation index were the strongest predictors of ventilator dependence. Initial empiric antibiotic treatment can improve ventilator weaning rates at the time of discharge.
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Affiliation(s)
- Chia-Cheng Tseng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
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20
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Gupta D, Agarwal R, Aggarwal AN, Singh N, Mishra N, Khilnani GC, Samaria JK, Gaur SN, Jindal SK. Guidelines for diagnosis and management of community- and hospital-acquired pneumonia in adults: Joint ICS/NCCP(I) recommendations. Lung India 2012; 29:S27-62. [PMID: 23019384 PMCID: PMC3458782 DOI: 10.4103/0970-2113.99248] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Dheeraj Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Narayan Mishra
- Department of Pulmonary Medicine, Indian Chest Society, India
| | - G. C. Khilnani
- Department of Pulmonary Medicine, National College of Chest Physicians, India
| | - J. K. Samaria
- Department of Pulmonary Medicine, Indian Chest Society, India
| | - S. N. Gaur
- Department of Pulmonary Medicine, National College of Chest Physicians, India
| | - S. K. Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - for the Pneumonia Guidelines Working Group
- Pneumonia Guidelines Working Group Collaborators (43) A. K. Janmeja, Chandigarh; Abhishek Goyal, Chandigarh; Aditya Jindal, Chandigarh; Ajay Handa, Bangalore; Aloke G. Ghoshal, Kolkata; Ashish Bhalla, Chandigarh; Bharat Gopal, Delhi; D. Behera, Delhi; D. Dadhwal, Chandigarh; D. J. Christopher, Vellore; Deepak Talwar, Noida; Dhruva Chaudhry, Rohtak; Dipesh Maskey, Chandigarh; George D’Souza, Bangalore; Honey Sawhney, Chandigarh; Inderpal Singh, Chandigarh; Jai Kishan, Chandigarh; K. B. Gupta, Rohtak; Mandeep Garg, Chandigarh; Navneet Sharma, Chandigarh; Nirmal K. Jain, Jaipur; Nusrat Shafiq, Chandigarh; P. Sarat, Chandigarh; Pranab Baruwa, Guwahati; R. S. Bedi, Patiala; Rajendra Prasad, Etawa; Randeep Guleria, Delhi; S. K. Chhabra, Delhi; S. K. Sharma, Delhi; Sabir Mohammed, Bikaner; Sahajal Dhooria, Chandigarh; Samir Malhotra, Chandigarh; Sanjay Jain, Chandigarh; Subhash Varma, Chandigarh; Sunil Sharma, Shimla; Surender Kashyap, Karnal; Surya Kant, Lucknow; U. P. S. Sidhu, Ludhiana; V. Nagarjun Mataru, Chandigarh; Vikas Gautam, Chandigarh; Vikram K. Jain, Jaipur; Vishal Chopra, Patiala; Vishwanath Gella, Chandigarh
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Affiliation(s)
- Jung Hyun Choi
- Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
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22
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Wilke M, Grube RF, Bodmann KF. Guideline-adherent initial intravenous antibiotic therapy for hospital-acquired/ventilator-associated pneumonia is clinically superior, saves lives and is cheaper than non guideline adherent therapy. Eur J Med Res 2011; 16:315-23. [PMID: 21813372 PMCID: PMC3352003 DOI: 10.1186/2047-783x-16-7-315] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Hospital-acquired pneumonia (HAP) often occurring as ventilator-associated pneumonia (VAP) is the most frequent hospital infection in intensive care units (ICU). Early adequate antimicrobial therapy is an essential determinant of clinical outcome. Organisations like the German PEG or ATS/ IDSA provide guidelines for the initial calculated treatment in the absence of pathogen identification. We conducted a retrospective chart review for patients with HAP/VAP and assessed whether the initial intravenous antibiotic therapy (IIAT) was adequate according to the PEG guidelines. MATERIALS AND METHODS We collected data from 5 tertiary care hospitals. Electronic data filtering identified 895 patients with potential HAP/VAP. After chart review we finally identified 221 patients meeting the definition of HAP/VAP. Primary study endpoints were clinical improvement, survival and length of stay. Secondary endpoints included duration of mechanical ventilation, total costs, costs incurred on the intensive care unit (ICU), costs incurred on general wards and drug costs. RESULTS We found that 107 patients received adequate initial intravenous antibiotic therapy (IIAT) vs. 114 with inadequate IIAT according to the PEG guidelines. Baseline characteristics of both groups revealed no significant differences and good comparability. Clinical improvement was 64% over all patients and 82% (85/104) in the subpopulation with adequate IIAT while only 47% (48/103) inadequately treated patients improved (p< 0.001). The odds ratio of therapeutic success with GA versus NGA treatment was 5.821 (p<0.001, [95% CI: 2.712-12.497]). Survival was 80% for the total population (n = 221), 86% in the adequately treated (92/107) and 74% in the inadequately treated subpopulation (84/114) (p = 0.021). The odds ratio of mortality for GA vs. NGA treatment was 0.565 (p=0.117, [95% CI: 0.276-1.155]). Adequately treated patients had a significantly shorter length of stay (LOS) (23.9 vs. 28.3 days; p = 0.022), require significantly less hours of mechanical ventilation (175 vs. 274; p = 0.001), incurred lower total costs (EUR 28,033 vs. EUR 36,139, p = 0.006) and lower ICU-related costs (EUR 13,308 vs. EUR 18,666, p = 0.003). Drug costs for the hospital stay were also lower (EUR 4,069 vs. EUR 4,833) yet not significant. The most frequent types of inadequate therapy were monotherapy instead of combination therapy, wrong type of penicillin and wrong type of cephalosporin. DISCUSSION These findings are consistent with those from other studies analyzing the impact of guideline adherence on survival rates, clinical success, LOS and costs. However, inadequately treated patients had a higher complicated pathogen risk score (CPRS) compared to those who received adequate therapy. This shows that therapy based on local experiences may be sufficient for patients with low CPRS but inadequate for those with high CPRS. Linear regression models showed that single items of the CPRS like extrapulmonary organ failure or late onset had no significant influence on the results. CONCLUSION Guideline-adherent initial intravenous antibiotic therapy is clinically superior, saves lives and is less expensive than non guideline adherent therapy. Using a CPRS score can be a useful tool to determine the right choice of initial intravenous antibiotic therapy. The net effect on the German healthcare system per year is estimated at up to 2,042 lives and EUR 125,819,000 saved if guideline-adherent initial therapy for HAP/VAP were established in all German ICUs.
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Affiliation(s)
- Michael Wilke
- Dr. Wilke GmbH, inspiring.health, Joseph-Wild-Str. 13, 81829 Munich, Germany.
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23
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Marcos M, Fernández C, Soriano À, Marco F, Martínez JA, Almela M, Cervera R, Mensa J, Espinosa G. Epidemiology and clinical outcomes of bloodstream infections among lupus patients. Lupus 2011; 20:965-71. [DOI: 10.1177/0961203311403345] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Infection is an important cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). This study was aimed at characterizing bloodstream infections in these patients and analysing factors associated with long term outcome. For this purpose, episodes of significant bacteraemia diagnosed from January 1991 to December 2006 among patients with SLE at a single centre were identified through a central database and clinical and analytical variables were recorded regarding short- and long-term follow-up. Univariate and multivariable analysis were performed to identify factors associated with long-term outcome. Thirty-eight SLE patients had 48 episodes of significant bacteraemia, with a 30-day mortality rate of 6.25%. Escherichia coli and Staphylococcus aureus were the leading Gram-negative and Gram-positive pathogens, respectively. After a median follow-up of 25 months, eight of these 38 patients (21.1%) had a further episode of bacteraemia and 13 of them (34.21%) died. Community-acquired bacteraemia and C reactive protein levels lower than 8 mg/dl during episodes were factors associated with lower long-term mortality. These results reinforce previous findings suggesting that lupus patients with bacteraemia episodes have poor long-term outcomes
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Affiliation(s)
- M Marcos
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - C Fernández
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - À Soriano
- Department of Infectious Diseases, Hospital Clinic, Barcelona, Spain
| | - F Marco
- Department of Clinical Microbiology, Hospital Clinic, Barcelona, Spain
| | - JA Martínez
- Department of Infectious Diseases, Hospital Clinic, Barcelona, Spain
| | - M Almela
- Department of Clinical Microbiology, Hospital Clinic, Barcelona, Spain
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - J Mensa
- Department of Infectious Diseases, Hospital Clinic, Barcelona, Spain
| | - G Espinosa
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
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Son JS, Song JH, Ko KS, Yeom JS, Ki HK, Kim SW, Chang HH, Ryu SY, Kim YS, Jung SI, Shin SY, Oh HB, Lee YS, Chung DR, Lee NY, Peck KR. Bloodstream infections and clinical significance of healthcare-associated bacteremia: a multicenter surveillance study in Korean hospitals. J Korean Med Sci 2010; 25:992-8. [PMID: 20592888 PMCID: PMC2890898 DOI: 10.3346/jkms.2010.25.7.992] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Accepted: 01/06/2010] [Indexed: 11/20/2022] Open
Abstract
Recent changes in healthcare systems have changed the epidemiologic paradigms in many infectious fields including bloodstream infection (BSI). We compared clinical characteristics of community-acquired (CA), hospital-acquired (HA), and healthcare-associated (HCA) BSI. We performed a prospective nationwide multicenter surveillance study from 9 university hospitals in Korea. Total 1,605 blood isolates were collected from 2006 to 2007, and 1,144 isolates were considered true pathogens. HA-BSI accounted for 48.8%, CA-BSI for 33.2%, and HCA-BSI for 18.0%. HA-BSI and HCA-BSI were more likely to have severe comorbidities. Escherichia coli was the most common isolate in CA-BSI (47.1%) and HCA-BSI (27.2%). In contrast, Staphylococcus aureus (15.2%), coagulase-negative Staphylococcus (15.1%) were the common isolates in HA-BSI. The rate of appropriate empiric antimicrobial therapy was the highest in CA-BSI (89.0%) followed by HCA-BSI (76.4%), and HA-BSI (75.0%). The 30-day mortality rate was the highest in HA-BSI (23.0%) followed by HCA-BSI (18.4%), and CA-BSI (10.2%). High Pitt score and inappropriate empirical antibiotic therapy were the independent risk factors for mortality by multivariate analysis. In conclusion, the present data suggest that clinical features, outcome, and microbiologic features of causative pathogens vary by origin of BSI. Especially, HCA-BSI shows unique clinical characteristics, which should be considered a distinct category for more appropriate antibiotic treatment.
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Affiliation(s)
- Jun Seong Son
- Division of Infectious Diseases, East-West Neo Medical Center, Kyunghee University School of Medicine, Seoul, Korea
| | - Jae-Hoon Song
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Asian-Pacific Research Foundation for Infectious Diseases (ARFID) in Samsung Medical Center, Seoul, Korea
| | - Kwan Soo Ko
- Department of Molecular Cell Biology, Sungkyunkwan University School of Medicine, Seoul, Korea
- Asian-Pacific Research Foundation for Infectious Diseases (ARFID) in Samsung Medical Center, Seoul, Korea
| | - Joon Sup Yeom
- Division of Infectious Diseases, Kangbuk Samung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Kyun Ki
- Division of Infectious Diseases, Konkuk University Hospital, Seoul, Korea
| | - Shin-Woo Kim
- Division of Infectious Diseases, Kyungpook National University Hospital, Daegu, Korea
| | - Hyun-Ha Chang
- Division of Infectious Diseases, Kyungpook National University Hospital, Daegu, Korea
| | - Seong Yeol Ryu
- Division of Infectious Diseases, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Yeon-Sook Kim
- Division of Infectious Diseases, Chungnam National University Hospital, Daejeon, Korea
| | - Sook-In Jung
- Division of Infectious Diseases, Chonnam National University Medical School, Gwangju, Korea
| | - Sang Yop Shin
- Division of Infectious Diseases, Jeju National University Hospital, Cheju, Korea
| | - Hee Bok Oh
- Center for Infectious Diseases, Korea Centers for Disease Control and Prevention, Seoul, Korea
| | - Yeong Seon Lee
- Center for Infectious Diseases, Korea Centers for Disease Control and Prevention, Seoul, Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nam Yong Lee
- Department of Laboratory Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyong Ran Peck
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Traditionally, pneumonia developing in patients who receive health care services in the outpatient environment, such as nursing homes, long-term care facilities, and dialysis centers, has been classified and treated as community-acquired pneumonia (CAP). Recent studies, however, have shown that this type of infection, known as health care-associated pneumonia (HCAP) is distinct from CAP in terms of its epidemiology and etiology, and increases the risk for infection with multidrug-resistant (MDR) pathogens. A review of available clinical data about HCAP was conducted to determine effective empiric treatment strategies and improve clinical outcomes. Analysis of multi-institutional clinical data showed that mortality associated with HCAP is higher than with CAP, suggesting that patients with HCAP may have been treated as hospitalized patients with CAP and received inappropriate initial empiric antibiotic treatment. All patients presenting to the hospital with suspected HCAP or CAP should be evaluated for their underlying risk of infection with MDR pathogens. Because HCAP may be similar to hospital-acquired pneumonia (HAP) both clinically and etiologically, it should be treated as HAP until culture data become available. A greater recognition of HCAP as a new class of pneumonia with a distinct epidemiologic, microbiologic, and clinical profile should lead physicians to initiate appropriate empiric antibiotic therapy more often, thereby improving the likelihood for optimal clinical outcomes and patient care.
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Affiliation(s)
- Alpesh Amin
- University of California, Irvine School of Medicine, Orange, CA 92868, USA.
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26
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Suárez C, Peña C, Tubau F, Gavaldà L, Manzur A, Dominguez MA, Pujol M, Gudiol F, Ariza J. Clinical impact of imipenem-resistant Pseudomonas aeruginosa bloodstream infections. J Infect 2009; 58:285-90. [DOI: 10.1016/j.jinf.2009.02.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 02/17/2009] [Accepted: 02/22/2009] [Indexed: 01/08/2023]
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27
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Ortega M, Marco F, Soriano A, Almela M, Martínez JA, Muñoz A, Mensa J. Analysis of 4758 Escherichia coli bacteraemia episodes: predictive factors for isolation of an antibiotic-resistant strain and their impact on the outcome. J Antimicrob Chemother 2009; 63:568-74. [DOI: 10.1093/jac/dkn514] [Citation(s) in RCA: 144] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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28
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Marquardt DJ, Hall MW, Sargel CL. Broad-spectrum antibiotic use in the pediatric intensive care unit: Balancing patient interests against intensive care unit ecology. Pediatr Crit Care Med 2009; 10:136-7. [PMID: 19131875 DOI: 10.1097/pcc.0b013e3181937705] [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: 11/25/2022]
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29
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Kollef MH. Update on the appropriate use of meropenem for the treatment of serious bacterial infections. Clin Infect Dis 2008; 47 Suppl 1:S1-2. [PMID: 18713044 DOI: 10.1086/590060] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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30
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Kuti EL, Patel AA, Coleman CI. Impact of inappropriate antibiotic therapy on mortality in patients with ventilator-associated pneumonia and blood stream infection: a meta-analysis. J Crit Care 2008; 23:91-100. [PMID: 18359426 DOI: 10.1016/j.jcrc.2007.08.007] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Revised: 08/23/2007] [Accepted: 08/25/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Studies have found that initial treatment of ventilator-associated pneumonia (VAP) and blood stream infections (BSI) with inappropriate antimicrobial therapy is associated with higher rates of mortality, but additional studies have failed to confirm this. METHODS Databases were searched to identify studies that met the following criteria: observational trials, patients with VAP or BSI receiving appropriate and inappropriate antimicrobial therapy, and mortality data. We conducted random-effects model meta-analyses, both with and without adjustment. RESULTS Meta-analyses of VAP studies using unadjusted and adjusted data indicated that inappropriate therapy significantly increased patients' odds of mortality (odds ratio [OR], 2.34; 95% confidence interval [CI], 1.51-3.63; P = .0001, I 2 = 28.5% and OR, 3.03; 95% CI, 1.12-8.19; P = .0292, I 2 = 89.2%, respectively). Meta-analyses of BSI studies using unadjusted and adjusted data showed that inappropriate therapy significantly increased patients' odds of mortality (OR, 2.33; 95% CI, 1.96-2.76; P < .0001, I 2 = 48.7% and OR, 2.28; 95% CI, 1.43-3.65; P = .0006, I 2 = 88.2%, respectively). CONCLUSIONS There appears to be an association between initial inappropriate antimicrobial therapy and increased mortality in patients with VAP and BSI.
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Affiliation(s)
- Effie L Kuti
- University of Connecticut School of Pharmacy, Storrs, CT, USA
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31
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Fox BC, Shenk G, Peterson D, Spiegel CA, Maki DG. Choosing more effective antimicrobial combinations for empiric antimicrobial therapy of serious gram-negative rod infections using a dual cross-table antibiogram. Am J Infect Control 2008. [DOI: 10.1016/j.ajic.2007.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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32
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Aktaş Z, Bal Kayacan &C, Schneider I, Can B, Midilli K, Bauernfeind A. Carbapenem-Hydrolyzing Oxacillinase, OXA-48, Persists in Klebsiella pneumoniae in Istanbul, Turkey. Chemotherapy 2008; 54:101-6. [DOI: 10.1159/000118661] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Accepted: 06/03/2007] [Indexed: 11/19/2022]
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33
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Roveta S, Marchese A, Debbia E. Tigecycline in vitro Activity against Gram-Negative and Gram-Positive Pathogens Collected in Italy. Chemotherapy 2007; 54:43-9. [DOI: 10.1159/000112415] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2006] [Accepted: 02/25/2007] [Indexed: 11/19/2022]
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34
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McGregor JC, Rich SE, Harris AD, Perencevich EN, Osih R, Lodise TP, Miller RR, Furuno JP. A systematic review of the methods used to assess the association between appropriate antibiotic therapy and mortality in bacteremic patients. Clin Infect Dis 2007; 45:329-37. [PMID: 17599310 DOI: 10.1086/519283] [Citation(s) in RCA: 151] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Accepted: 04/04/2007] [Indexed: 01/25/2023] Open
Abstract
Studies of the association between inappropriate antibiotic therapy and mortality among bacteremic patients have generated conflicting findings. We systematically reviewed these studies to identify methodological heterogeneity that may explain the lack of agreement. We identified 51 articles that met the inclusion criteria, and we extracted the following data: study design, definition and measurement of variables, and statistical methods. Only 8 studies (16%) defined inappropriate antibiotic therapy as that which was inactive in vitro against the isolated organism(s) and not consistent with current clinical practice recommendations and distinguished between empiric and definitive treatment. Thirty-four studies (67%) measured the severity of illness, but only 6 (12%) specified the time at which it was measured. The methodological recommendations suggested in this article are intended to improve the validity and generalizability of future research. In brief, future studies should define "inappropriate" therapy on the basis of in vitro susceptibility data, should separately evaluate empiric and definitive therapy, and should control for the baseline severity of illness.
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35
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Yakovlev SV, Stratchounski LS, Woods GL, Adeyi B, McCarroll KA, Ginanni JA, Friedland IR, Wood CA, DiNubile MJ. Ertapenem versus cefepime for initial empirical treatment of pneumonia acquired in skilled-care facilities or in hospitals outside the intensive care unit. Eur J Clin Microbiol Infect Dis 2007; 25:633-41. [PMID: 17024505 DOI: 10.1007/s10096-006-0193-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The study presented here compared the efficacy and safety of ertapenem and cefepime as initial treatment for adults with pneumonia acquired in skilled-care facilities or in hospital environments outside the intensive care unit (ICU). Non-ventilated patients developing pneumonia in hospital environments outside the ICU, in nursing homes, or in other skilled-care facilities were enrolled in this double-blind non-inferiority study, stratified by APACHE II score (<or=15 vs >15) and randomized (1:1) to receive cefepime (2 g every 12 h with optional metronidazole 500 mg every 12 h) or ertapenem (1 g daily). After 3 days of parenteral therapy, participants demonstrating clinical improvement could be switched to oral ciprofloxacin or another appropriate oral agent. Probable pathogens were identified in 162 (53.5%) of the 303 randomized participants. The most common pathogens were Enterobacteriaceae, Streptococcus pneumoniae, and Staphylococcus aureus, isolated from 59 (19.5%), 39 (12.9%), and 35 (11.6%) participants, respectively. At the test-of-cure assessment 7-14 days after completion of all study therapy, pneumonia had resolved or substantially improved in 89 (87.3%) of 102 clinically evaluable ertapenem recipients and 80 (86%) of 93 clinically evaluable cefepime recipients (95% confidence interval for the difference, -9.4 to 11.8%), fulfilling pre-specified criteria for statistical non-inferiority. The frequency and severity of drug-related adverse events were generally similar in both treatment groups. In this study population, ertapenem was as well-tolerated and efficacious as cefepime for the initial treatment of pneumonia acquired in skilled-care facilities or in hospital environments outside the ICU.
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Affiliation(s)
- S V Yakovlev
- Municipal Hospital #7, Moscow, and Smolensk State Medical Academy, Russia
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36
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Renou P. Rôle de la médecine interne face aux maladies infectieuses émergentes. ANTIBIOTIQUES (PARIS, FRANCE : 1999) 2007; 9:4-8. [PMID: 32288531 PMCID: PMC7146780 DOI: 10.1016/s1294-5501(07)88761-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ph Renou
- 32 rue Beauverger, 72000 Le Mans
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37
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Abstract
PURPOSE OF REVIEW This review highlights recent advances in the aetiology of nosocomial pneumonia, and in strategies to increase accuracy of diagnosis and antibiotic prescription while limiting unnecessary antibiotic consumption. RECENT FINDINGS Bacterial pathogens still cause the bulk of nosocomial pneumonia and are of concern because of ever-rising antimicrobial resistance. Yet, the pathogenic role of fungal and viral organisms is increasingly recognized. Since early appropriate antimicrobial therapy is the cornerstone of an effective treatment, further studies have been conducted to improve appropriateness of early antibiotic therapy. De-escalation strategies combine initial broad-spectrum antibiotics to maximize early antibiotic coverage with a subsequent focusing of the antibiotic spectrum when the cause is identified. Invasive techniques probably do not alter the immediate outcome but have the potential to reduce unnecessary antibiotic exposure. Decisions to stop or change antibiotic therapy are hampered due to a lack of reliable parameters to assess the resolution of pneumonia. SUMMARY Increasing antimicrobial resistance in nosocomial pneumonia both challenges treatment and mandates limitation of selection pressure by reducing antibiotic burden. Treating physicians should be both aggressive in initiating antimicrobials when suspecting nosocomial pneumonia but willing to discontinue antimicrobials when diagnostic results point to an alternative diagnosis. Efforts should be made to limit duration of antibiotic therapy when possible.
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Affiliation(s)
- Pieter Depuydt
- Department of Intensive Care, Ghent University, De Pintelaan, Belgium.
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38
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Carlet J, Tabah A. Antibiothérapie des états infectieux graves. Med Mal Infect 2006; 36:299-303. [PMID: 16698210 DOI: 10.1016/j.medmal.2006.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2006] [Accepted: 02/13/2006] [Indexed: 11/23/2022]
Abstract
Severe sepsis, which is related to a high mortality rate, requires a very specific antibiotic strategy, which must be adapted to each case. The appropriateness of empiric therapy is based on the delay before administration of the molecule, the bacterial resistance profile, and the kinetic and/or dynamic properties of the available antibiotics.
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Affiliation(s)
- J Carlet
- Service de réanimation polyvalente, fondation hôpital Saint-Joseph, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France.
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Carlet J. Stratégie antibiotique au cours du choc septique. Presse Med 2006; 35:528-32. [PMID: 16550154 DOI: 10.1016/s0755-4982(06)74629-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Septic shock remains a true challenge to modern therapeutics. The quality and earliness of antibiotic administration are both fundamental elements. Treatment should be individually adapted to each patient. The pharmacokinetic indicators and predicted resistance of the bacteria targeted determine the choice of treatment, often empirical. Radical treatment of the source of infection, especially by surgery, should be combined with antibiotic treatment whenever possible.
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Affiliation(s)
- Jean Carlet
- Service de Réanimation Polyvalente, Fondation Hôpital Saint-Joseph, Paris.
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