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Endo H, Okamoto H, Hashimoto S, Miyata H. Association Between In-hospital Mortality and the Institutional Factors of Intensive Care Units with a Focus on the Intensivist- to-bed Ratio: A Retrospective Cohort Study. J Intensive Care Med 2024:8850666241245645. [PMID: 38567432 DOI: 10.1177/08850666241245645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Purpose: To elucidate the relationship between in-hospital mortality and the institutional factors of intensive care units (ICUs), with a focus on the intensivist-to-bed ratio. Methods: A retrospective cohort study was conducted using a Japanese ICU database, including adult patients admitted between April 1, 2020 and March 31, 2021. We used a multilevel logistic regression model to investigate the associations between in-hospital mortality and the following institutional factors: the intensivist-to-bed ratios on weekdays or over weekends/holidays, different work shifts, hospital-to-ICU-bed ratio, annual-ICU-admission-to-bed ratio, type of hospital, and the presence of other medical staff. Results: The study population comprised 46 503 patients admitted to 65 ICUs. The in-hospital mortality rate was 8.1%. The median numbers of ICU beds and intensivists were 12 (interquartile range [IQR] 8-14) and 4 (IQR 2-9), respectively. In-hospital mortality decreased significantly as the intensivist-to-bed ratio at 10 am on weekdays increased: the average contrast indicated a 20% (95% confidence interval [CI]: 1%-38%) reduction when the ratio increased from 0 to 0.5, and a 38% (95% CI: 9%-67%) reduction when the ratio increased from 0 to 1. The other institutional factors did not present a significant effect. Conclusions: The intensivist-to-bed ratio at 10 am on weekdays had a significant effect on in-hospital mortality. Further investigation is needed to understand the processes leading to improved outcomes.
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Affiliation(s)
- Hideki Endo
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Hiroshi Okamoto
- Department of Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Satoru Hashimoto
- Non Profit Organization, ICU Collaboration Network, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
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Reynolds D, Burnham JP, Vazquez Guillamet C, McCabe M, Yuenger V, Betthauser K, Micek ST, Kollef MH. The threat of multidrug-resistant/extensively drug-resistant Gram-negative respiratory infections: another pandemic. Eur Respir Rev 2022; 31:31/166/220068. [PMID: 36261159 DOI: 10.1183/16000617.0068-2022] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/09/2022] [Indexed: 12/22/2022] Open
Abstract
Antibiotic resistance is recognised as a global threat to human health by national healthcare agencies, governments and medical societies, as well as the World Health Organization. Increasing resistance to available antimicrobial agents is of concern for bacterial, fungal, viral and parasitic pathogens. One of the greatest concerns is the continuing escalation of antimicrobial resistance among Gram-negative bacteria resulting in the endemic presence of multidrug-resistant (MDR) and extremely drug-resistant (XDR) pathogens. This concern is heightened by the identification of such MDR/XDR Gram-negative bacteria in water and food sources, as colonisers of the intestine and other locations in both hospitalised patients and individuals in the community, and as agents of all types of infections. Pneumonia and other types of respiratory infections are among the most common infections caused by MDR/XDR Gram-negative bacteria and are associated with high rates of mortality. Future concerns are already heightened due to emergence of resistance to all existing antimicrobial agents developed in the past decade to treat MDR/XDR Gram-negative bacteria and a scarcity of novel agents in the developmental pipeline. This clinical scenario increases the likelihood of a future pandemic caused by MDR/XDR Gram-negative bacteria.
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Affiliation(s)
- Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jason P Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Mikaela McCabe
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Valerie Yuenger
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Kevin Betthauser
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Scott T Micek
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Affiliation(s)
- Chang-Eun Park
- Department of Biomedical Laboratory Science, Molecular Diagnostics Research Institute, Namseoul University, Cheonan, Korea
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4
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Tuon FF, Telles JP, Cieslinski J, Borghi MB, Bertoldo RZ, Ribeiro VST. Development and validation of a risk score for predicting positivity of blood cultures and mortality in patients with bacteremia and fungemia. Braz J Microbiol 2021; 52:1865-1871. [PMID: 34287809 PMCID: PMC8578208 DOI: 10.1007/s42770-021-00581-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 07/11/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Bacteremia is a major cause of morbidity and mortality in hospitalized patients. Predictors of mortality are critical for the management and survival of hospitalized patients. The objective of this study was to determine the factors related to blood culture positivity and the risk factors for mortality in patients whose blood cultures were collected. METHODS A prospective 2-cohort study (derivation with 784 patients and validation with 380 patients) based on the Pitt bacteremia score for all patients undergoing blood culture collection. The score was obtained from multivariate analysis. The Kaplan-Meier survival curve of the cohort derivation and the cohort validation groups was calculated, and the difference was assessed using a log-rank test. Mortality-related factors were older age, extended hospitalization, > 10% of immature cells in the leukogram, lower mean blood pressure, elevated heart rate, elevated WBC count, and elevated respiratory rate. These continuous variables were dichotomized according to their significance level, and a cut-off limit was created. RESULTS The area under the ROC curve (AUC) was 0.789. The score was validated in a group of 380 patients who were prospectively evaluated. CONCLUSION Prolonged hospitalization, body temperature, and elevated heart rate were related to positive blood cultures. The Pitt score can be used to assess the risk of death; however it can be individualized according to the epidemiology of each hospital.
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Affiliation(s)
- Felipe Francisco Tuon
- Laboratorio de Doenças Infecciosas Emergentes, Pontifícia Universidade Católica Do Paraná, Rua Imaculada Conceição 1155, Curitiba, Paraná, 80215-901, Brazil.
| | - João Paulo Telles
- Laboratorio de Doenças Infecciosas Emergentes, Pontifícia Universidade Católica Do Paraná, Rua Imaculada Conceição 1155, Curitiba, Paraná, 80215-901, Brazil
| | - Juliette Cieslinski
- Laboratorio de Doenças Infecciosas Emergentes, Pontifícia Universidade Católica Do Paraná, Rua Imaculada Conceição 1155, Curitiba, Paraná, 80215-901, Brazil
| | | | | | - Victoria Stadler Tasca Ribeiro
- Laboratorio de Doenças Infecciosas Emergentes, Pontifícia Universidade Católica Do Paraná, Rua Imaculada Conceição 1155, Curitiba, Paraná, 80215-901, Brazil
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5
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Garay OU, Guiñazú G, Cornistein W, Farina J, Valentini R, Levy Hara G. Budget impact analysis of using procalcitonin to optimize antimicrobial treatment for patients with suspected sepsis in the intensive care unit and hospitalized lower respiratory tract infections in Argentina. PLoS One 2021; 16:e0250711. [PMID: 33930050 PMCID: PMC8087000 DOI: 10.1371/journal.pone.0250711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/13/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic use represents a major global threat. Sepsis and bacterial lower respiratory tract infections (LRTIs) have been linked to antimicrobial resistance, carrying important consequences for patients and health systems. Procalcitonin-guided algorithms may represent helpful tools to reduce antibiotic overuse but the financial burden is unclear. The aim of this study was to estimate the healthcare and budget impact in Argentina of using procalcitonin-guided algorithms to guide antibiotic prescription. METHODS A decision tree was used to model health and cost outcomes for the Argentinean health system, over a one-year duration. Patients with suspected sepsis in the intensive care unit and hospitalized patients with LRTI were included. Model parameters were obtained from a focused, non-systematic, local and international bibliographic search, and validated by a panel of local experts. Deterministic and probabilistic sensitivity analyses were performed to analyze the uncertainty of parameters. RESULTS The model predicted that using procalcitonin-guided algorithms would result in 734.5 [95% confidence interval (CI): 1,105.2;438.8] thousand fewer antibiotic treatment days, 7.9 [95% CI: 18.5;8.5] thousand antibiotic-resistant cases avoided, and 5.1 [95% CI: 6.7;4.2] thousand fewer Clostridioides difficile cases. In total, this would save $422.4 US dollars (USD) [95% CI: $935;$267] per patient per year, meaning cost savings of $83.0 [95% CI: $183.6;$57.7] million USD for the entire health system and $0.4 [95% CI: $0.9;$0.3] million USD for a healthcare provider with 1,000 cases per year of sepsis and LRTI patients. The sensitivity analysis showed that the probability of cost-saving for the sepsis patient group was lower than for the LRTI patient group (85% vs. 100%). CONCLUSIONS Healthcare and financial benefits can be obtained by implementing procalcitonin-guided algorithms in Argentina. Although we found results to be robust on an aggregate level, some caution must be used when focusing only on sepsis patients in the intensive care unit.
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Affiliation(s)
- Osvaldo Ulises Garay
- Market Access and Medical Affairs, Roche Diagnostics, Buenos Aires, Argentina
- * E-mail:
| | - Gonzalo Guiñazú
- Ricardo Gutiérrez Children’s Hospital, Buenos Aires, Argentina
| | | | - Javier Farina
- Hospital Cuenca Alta Néstor Kirchner, Buenos Aires, Argentina
| | | | - Gabriel Levy Hara
- Unit of Infectious Diseases, Hospital Carlos G Durand, Buenos Aires, Argentina
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Haseeb A, Faidah HS, Al-Gethamy M, Iqbal MS, Barnawi AM, Elahe SS, Bukhari DN, Noor Al-Sulaimani TM, Fadaaq M, Alghamdi S, Almalki WH, Saleem Z, Elrggal ME, Khan AH, Algarni MA, Ashgar SS, Hassali MA. Evaluation of a Multidisciplinary Antimicrobial Stewardship Program in a Saudi Critical Care Unit: A Quasi-Experimental Study. Front Pharmacol 2021; 11:570238. [PMID: 33776750 PMCID: PMC7988078 DOI: 10.3389/fphar.2020.570238] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/30/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Antimicrobial stewardship programs (ASPs) are collaborative efforts to optimize antimicrobial use in healthcare institutions through evidence-based quality improvement strategies. With regard to critically ill patients, appropriate antimicrobial usage is of significance, and any delay in therapy increases their risk of mortality. Therefore, the implementation of structured multidisciplinary ASPs in critical care settings is of the utmost importance to promote the judicious use of antimicrobials. Methods: This quasi-experimental study evaluating a multidisciplinary ASP in a 20-bed critical care setting was conducted from January 1, 2016 to July 31, 2017. Outcomes were compared nine months before and after ASP implementation. The national antimicrobial stewardship toolkit by Ministry of health was reviewed and the hospital antibiotic prescribing policy was accordingly modified. The antimicrobial stewardship algorithm (Start Smart and Then Focus) and an ASP toolkit were distributed to all intensive care unit staff. Prospective audit and feedback, in addition to prescribing forms for common infectious diseases and education, were the primary antimicrobial strategies. Results: We found that the mean total monthly antimicrobial consumption measured as defined daily dose per 100 bed days was reduced by 25% (742.86 vs. 555.33; p = 0.110) compared to 7% in the control condition (tracer medications) (35.35 vs. 38.10; p = 0.735). Interestingly, there was a negative impact on cost in the post-intervention phase. Interestingly, the use of intravenous ceftriaxone measured as defined daily dose per 100 bed days was decreased by 82% (94.32 vs. 16.68; p = 0.008), whereas oral levofloxacin use was increased by 84% (26.75 vs. 172.29; p = 0.008) in the intensive care unit. Conclusion: Overall, involvement of higher administration in multidisciplinary ASP committees, daily audit and feedback by clinical pharmacists and physicians with infectious disease training, continuous educational activities about antimicrobial use and resistance, use of local antimicrobial prescribing guidelines based on up-to-date antibiogram, and support from the intensive care team can optimize antibiotic use in Saudi healthcare institutions.
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Affiliation(s)
- Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Al-Abdia Campus, Makkah, Saudi Arabia
| | - Hani Saleh Faidah
- Department of Microbiology, Faculty of Medicine, Umm Al Qura University, Saudi Arabia
| | - Manal Al-Gethamy
- Department of Infection Prevention and Control Program, Alnoor Specialist Hospital Makkah, Makkah, Kingdom of Saudi Arabia
| | - Muhammad Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | | | - Shuruq S Elahe
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, United States
| | - Duha Nabeel Bukhari
- Department of Pharmacy, International Medical Center, Jeddah, Kingdom of Saudi Arabia
| | | | - Mohammad Fadaaq
- Ajyad Emergency Hospital, Ministry of Health, Makkah, Saudi Arabia
| | - Saad Alghamdi
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al Qura University, Makkah, Saudi Arabia
| | - Waleed Hassan Almalki
- Department of Toxicology and Pharmacology, College of Pharmacy, Umm Al Qura University, Makkah, Saudi Arabia
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, New Campus, Lahore, Pakistan
| | - Mahmoud Essam Elrggal
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Al-Abdia Campus, Makkah, Saudi Arabia
| | - Amer Hayat Khan
- Clinical Pharmacy Department, School of Pharmaceutical Sciences, Universiti Science Malaysia, Penang, Malaysia
| | - Mohammed A Algarni
- Microbiology Laboratory, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Sami S Ashgar
- Assistant Professor of Medical Microbiology, College of Medicine, Umm Al Qura University, Makkah, Saudi Arabia
| | - Mohamed Azmi Hassali
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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Thibeault C, Suttorp N, Opitz B. The microbiota in pneumonia: From protection to predisposition. Sci Transl Med 2021; 13:13/576/eaba0501. [PMID: 33441423 DOI: 10.1126/scitranslmed.aba0501] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 06/30/2020] [Indexed: 12/12/2022]
Abstract
Mucosal surfaces of the upper respiratory tract and gut are physiologically colonized with their own collection of microbes, the microbiota. The normal upper respiratory tract and gut microbiota protects against pneumonia by impeding colonization by potentially pathogenic bacteria and by regulating immune responses. However, antimicrobial therapy and critical care procedures perturb the microbiota, thus compromising its function and predisposing to lung infections (pneumonia). Interindividual variations and age-related alterations in the microbiota also affect vulnerability to pneumonia. We discuss how the healthy microbiota protects against pneumonia and how host factors and medical interventions alter the microbiota, thus influencing susceptibility to pneumonia.
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Affiliation(s)
- Charlotte Thibeault
- Department of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Norbert Suttorp
- Department of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Bastian Opitz
- Department of Internal Medicine/Infectious Diseases and Pulmonary Medicine, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany.
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8
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Heilmann E, Gregoriano C, Wirz Y, Luyt CE, Wolff M, Chastre J, Tubach F, Christ-Crain M, Bouadma L, Annane D, Damas P, Kristoffersen KB, Oliveira CF, Stolz D, Tamm M, de Jong E, Reinhart K, Shehabi Y, Verduri A, Nobre V, Nijsten M, deLange DW, van Oers JAH, Beishuizen A, Girbes ARJ, Mueller B, Schuetz P. Association of kidney function with effectiveness of procalcitonin-guided antibiotic treatment: a patient-level meta-analysis from randomized controlled trials. Clin Chem Lab Med 2020; 59:441-453. [PMID: 32986609 DOI: 10.1515/cclm-2020-0931] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/31/2020] [Indexed: 12/25/2022]
Abstract
Objectives Patients with impaired kidney function have a significantly slower decrease of procalcitonin (PCT) levels during infection. Our aim was to study PCT-guided antibiotic stewardship and clinical outcomes in patients with impairments of kidney function as assessed by creatinine levels measured upon hospital admission. Methods We pooled and analyzed individual data from 15 randomized controlled trials who were randomly assigned to receive antibiotic therapy based on a PCT-algorithms or based on standard of care. We stratified patients on the initial glomerular filtration rate (GFR, ml/min/1.73 m2) in three groups (GFR >90 [chronic kidney disease; CKD 1], GFR 15-89 [CKD 2-4] and GFR<15 [CKD 5]). The main efficacy and safety endpoints were duration of antibiotic treatment and 30-day mortality. Results Mean duration of antibiotic treatment was significantly shorter in PCT-guided (n=2,492) compared to control patients (n=2,510) (9.5-7.6 days; adjusted difference in days -2.01 [95% CI, -2.45 to -1.58]). CKD 5 patients had overall longer treatment durations, but a 2.5-day reduction in treatment duration was still found in patients receiving in PCT-guided care (11.3 vs. 8.6 days [95% CI -3.59 to -1.40]). There were 397 deaths in 2,492 PCT-group patients (15.9%) compared to 460 deaths in 2,510 control patients (18.3%) (adjusted odds ratio, 0.88 [95% CI 0.78 to 0.98)]. Effects of PCT-guidance on antibiotic treatment duration and mortality were similar in subgroups stratified by infection type and clinical setting (p interaction >0.05). Conclusions This individual patient data meta-analysis confirms that the use of PCT in patients with impaired kidney function, as assessed by admission creatinine levels, is associated with shorter antibiotic courses and lower mortality rates.
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Affiliation(s)
- Eva Heilmann
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Yannick Wirz
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Michel Wolff
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Jean Chastre
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Florence Tubach
- Département d'Epidémiologie Biostatistique et Recherche Clinique, AP-HP, Hôpitaux Universitaires Paris Nord Val de Seine, Paris, France
| | - Mirjam Christ-Crain
- Division of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Basel, Basel, Switzerland
| | - Lila Bouadma
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Djillali Annane
- Department of Critical Care, Hyperbaric Medicine and Home Respiratory Unit, Center for Neuromuscular Diseases, Raymond Poincaré Hospital (AP-HP), Garches, France
| | - Pierre Damas
- Department of General Intensive Care, University Hospital of Liege, Domaine universitaire de Liège, Liege, Belgium
| | | | - Carolina F Oliveira
- Department of Internal Medicine, School of Medcine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Daiana Stolz
- Clinic of Pneumology and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Michael Tamm
- Clinic of Pneumology and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Evelien de Jong
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Clinical Trial Centre Leipzig, University of Leipzig, Leipzig, Germany
| | - Yahya Shehabi
- Critical Care and Peri-operative Medicine, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Alessia Verduri
- Department of Medical and Surgical Sciences,Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Vandack Nobre
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Maarten Nijsten
- University Medical Centre, University of Groningen, Groningen, The Netherlands
| | | | | | | | - Armand R J Girbes
- Department of Intensive Care, VU University Medical Center, Amsterdam, The Netherlands
| | - Beat Mueller
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Gregoriano C, Heilmann E, Molitor A, Schuetz P. Role of procalcitonin use in the management of sepsis. J Thorac Dis 2020; 12:S5-S15. [PMID: 32148921 DOI: 10.21037/jtd.2019.11.63] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Important aspects of sepsis management include early diagnosis as well as timely and specific treatment in the first few hours of triage. However, diagnosis and differentiation from non-infectious causes often cause uncertainties and potential time delays. Correct use of antibiotics still represents a major challenge, leading to increased risk for opportunistic infections, resistances to multiple antimicrobial agents and toxic side effects, which in turn increase mortality and healthcare costs. Optimized procedures for reliable diagnosis and management of antibiotic therapy has great potential to improve patient care. Herein, biomarkers have been shown to improve infection diagnosis, help in early risk stratification and provide prognostic information which helps optimizing therapeutic decisions ("antibiotic stewardship"). In this context, the use of the blood infection marker procalcitonin (PCT) has gained much attention. There is still no gold standard for the detection of sepsis and use of conventional diagnostic approaches are restricted by some limitations. Therefore, additional tests are necessary to enable early and reliable diagnosis. PCT has good discriminatory properties to differentiate between bacterial and viral inflammations with rapidly available results. Further, PCT adds to risk stratification and prognostication, which may influence appropriate use of health-care resources and therapeutic options. PCT kinetics over time also improves the monitoring of critically ill patients with sepsis and thus influences decisions regarding de-escalation of antibiotics. Most importantly, PCT helps in guiding antibiotic use in patients with respiratory infection and sepsis by limiting initiation and by shortening treatment duration. To date, PCT is the best studied biomarker regarding antibiotic stewardship. Still, further research is needed to understand optimal use of PCT, also in combination with other remerging diagnostic tests for most efficient sepsis care.
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Affiliation(s)
- Claudia Gregoriano
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Switzerland
| | - Eva Heilmann
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Switzerland
| | - Alexandra Molitor
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Switzerland
| | - Philipp Schuetz
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
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10
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Antonelli M, Martin-Loeches I, Dimopoulos G, Gasbarrini A, Vallecoccia MS. Clostridioides difficile (formerly Clostridium difficile) infection in the critically ill: an expert statement. Intensive Care Med 2020; 46:215-224. [PMID: 31938827 DOI: 10.1007/s00134-019-05873-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 11/16/2019] [Indexed: 02/07/2023]
Abstract
Clostridioides difficile (formerly Clostridium difficile) infection (CDI) represents a worrisome condition, often underestimated, with severe clinical presentations, frequently requiring intensive care unit (ICU) admission. The aim of the present expert statement was to give an overview of the management of CDI in critically ill patients, for whom CDI represents a redoubtable problem, in large part related to the use and abuse of antibiotics. The available knowledge about pathophysiology, risk factors, diagnosis and treatment concerning critical care patients affected by CDI has been reviewed, even though most of the existing information come from studies performed outside the ICU and the evidence on several issues in this specific context is scarce. The adoption of potential preventive and therapeutic strategies aimed to stem the phenomenon were discussed, including the faecal microbiota transplantation. This possibility could represent a highly interesting option in critically ill patients, but current evidence is limited and future well designed studies are needed. A special insight on the specific challenges that the ICU physicians may face caring for the critically ill patients with CDI was also proposed.
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Affiliation(s)
- Massimo Antonelli
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, St James Street, Dublin 8, Dublin, Ireland
- Hospital Clinic, IDIBAPS, Universidad de Barcelona, Ciberes, Barcelona, Spain
| | - George Dimopoulos
- Critical Care Department, ATTIKON University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonio Gasbarrini
- Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Internal Medicine and Gastroenterology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Sole Vallecoccia
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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Rajar P, Saugstad OD, Berild D, Dutta A, Greisen G, Lausten-Thomsen U, Mande SS, Nangia S, Petersen FC, Dahle UR, Haaland K. Antibiotic Stewardship in Premature Infants: A Systematic Review. Neonatology 2020; 117:673-686. [PMID: 33271554 DOI: 10.1159/000511710] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/13/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Antibiotic treatment in premature infants is often empirically prescribed, and practice varies widely among otherwise comparable neonatal intensive care units. Unnecessary and prolonged antibiotic treatment is documented in numerous studies. Recent research shows serious side effects and suggests long-term adverse health effects in prematurely born infants exposed to antibiotics in early life. One preventive measure to reduce unnecessary antibiotic exposure is implementation of antibiotic stewardship programs. Our objective was to review the literature on implemented antibiotic stewardship programs including premature infants with gestational age ≤34 weeks. METHODS Six academic databases (PubMed [Medline], McMaster PLUS, Cochrane Database of Systematic Reviews, UpToDate, Cochrane Central Register of Controlled Trials, and National Institute for Health and Care Excellence) were systematically searched. PRISMA guidelines were applied. RESULTS The search retrieved 1,212 titles of which 12 fitted inclusion criteria (11 observational studies and 1 randomized clinical trial). Included articles were critically appraised. We grouped the articles according to common area of implemented stewardship actions: (1) focus on reducing initiation of antibiotic therapy, (2) focus on shortening duration of antibiotic therapy, (3) various organizational stewardship implementations. The heterogeneity of cohort composition, of implemented actions and of outcome measures made meta-analysis inappropriate. We provide an overview of the reduction in antibiotic use achieved. CONCLUSION Antibiotic stewardship programs can be effective for premature newborns especially when multifactorial and tailored to this population, focusing on reducing initiation or on shortening the duration of antibiotic therapy. Programs without specific measures were less effective.
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Affiliation(s)
- Polona Rajar
- Department of Paediatrics, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Oral Biology, University of Oslo, Oslo, Norway
| | - Ola D Saugstad
- Department of Paediatric Research, University of Oslo, Oslo, Norway
| | - Dag Berild
- Department of Infectious Diseases, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, Oslo University, Oslo, Norway
| | - Anirban Dutta
- TCS Research, Tata Consultancy Services Ltd, Pune, India
| | - Gorm Greisen
- Department of Neonatology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ulrik Lausten-Thomsen
- Department of Neonatology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Sushma Nangia
- Lady Hardinge Medical College and Kalawati Saran Hospital, New Delhi, India
| | | | - Ulf R Dahle
- Centre for Antimicrobial Resistance, Norwegian Institute of Public Health, Oslo, Norway
| | - Kirsti Haaland
- Department of Paediatrics, Oslo University Hospital Ullevål, Oslo, Norway,
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Jayalakshmi J, Priyadharshini MS. Restricting high-end antibiotics usage - challenge accepted! J Family Med Prim Care 2019; 8:3292-3296. [PMID: 31742158 PMCID: PMC6857393 DOI: 10.4103/jfmpc.jfmpc_626_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 08/21/2019] [Accepted: 09/03/2019] [Indexed: 11/04/2022] Open
Abstract
Objectives: Antimicrobial resistance (AMR) leads to increased morbidity, mortality, and healthcare expenditure. The rate of development of AMR is accelerated by the use and misuse of antimicrobials. Preauthorization and restricted use of high-end antibiotics are the key modalities of antimicrobial stewardship. Hence, choosing the right antibiotics is the key to better clinical outcomes and preventing resistance in hospitals as well as communities. The present study was done to assess the judicious usage of high-end antibiotics among inpatients treated at our hospital. Materials and Methods: A prospective observational study was conducted on high-end antibiotic usage using a structured proforma among inpatients treated at our hospital for a 3 month period. Department wise educational intervention was done and feedbacks were provided, after which reassessment was done. Results and Analysis: Meropenem was the most commonly used high-end antibiotics. After the feedback and intervention, there was 51.2% reduction in the unjustified antibiotic usage. The appropriateness of the usage increased from 77% observed during preintervention to 88% postintervention. Conclusion: The increasing compliance of judicious usage of high-end antibiotics needs to be sustained. Therefore, continuous strengthening of antimicrobial stewardship practices are crucial.
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Affiliation(s)
- J Jayalakshmi
- Department of Microbiology, P.S.G. Institute of Medical, Sciences and Research, Coimbatore, Tamil Nadu, India
| | - M S Priyadharshini
- Department of Microbiology, P.S.G. Institute of Medical, Sciences and Research, Coimbatore, Tamil Nadu, India
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Mushtaque M, Khalid F, Ishaqui AA, Masood R, Maqsood MB, Muhammad IN. Hospital Antibiotic Stewardship Programs - Qualitative analysis of numerous hospitals in a developing country. Infect Prev Pract 2019; 1:100025. [PMID: 34368682 PMCID: PMC8336195 DOI: 10.1016/j.infpip.2019.100025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 10/31/2019] [Indexed: 12/29/2022] Open
Abstract
Antimicrobial stewardship programs (ASP) are an essential practice to prevent increasing resistance against antibiotics. A successful ASP monitors not only prescribing patterns and practices but also contributes in minimizing the toxic effects of antibiotics. Moreover, ASP also facilitates the selection of disease specific antibiotics and enforces rules and regulations to rationalize the use of antibiotics. The aim of the study is to highlight the core elements of Hospital Antibiotic Stewardship Programs in Karachi. The key elements proposed by center of disease control (CDC) such as; leadership, accountability, drug expertise, actions to support optimal antibiotic use, tracking (monitoring antibiotic prescribing, use and resistance), reporting information to staff on improving antibiotic use and resistance and education were evaluated on Yes/No scale. The data was collected from 44 hospitals of different categories in Karachi and all the major elements were studied. It was observed that all the hospitals in one setting failed to comply with all the guidelines. It has been concluded that efforts should be made to design ASP at each hospital and implemented through suitable policies and procedures.
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Affiliation(s)
- Madiha Mushtaque
- Department of Pharmaceutics, Faculty of Pharmacy and Pharmaceutical Sciences, University of Karachi, Pakistan
| | - Farah Khalid
- Department of Pharmaceutics, Faculty of Pharmacy and Pharmaceutical Sciences, University of Karachi, Pakistan
| | - Azfar Ather Ishaqui
- Department of Pharmaceutics, Faculty of Pharmacy and Pharmaceutical Sciences, University of Karachi, Pakistan
| | - Rida Masood
- Department of Pharmaceutics, Faculty of Pharmacy and Pharmaceutical Sciences, University of Karachi, Pakistan
| | - Muhammad Bilal Maqsood
- King Abdullah International Medical Research Center, King Abdulaziz Hospital, Ministry of National Guard Health Affairs, Kingdom of Saudi Arabia
| | - Iyad Naeem Muhammad
- Department of Pharmaceutics, Faculty of Pharmacy and Pharmaceutical Sciences, University of Karachi, Pakistan
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Abstract
Biomarkers are increasingly used in patients with serious infections in the critical care setting to complement clinical judgment and interpretation of other diagnostic and prognostic tests. The main purposes of such blood markers are (1) to improve infection diagnosis (i.e., differentiation between bacterial vs. viral vs. fungal vs. noninfectious), (2) to help in the early risk stratification and thus provide prognostic information regarding the risk for mortality and other adverse outcomes, and (3) to optimize antibiotic tailoring to individual needs of patients ("antibiotic stewardship").Especially in critically ill patients, in whom sepsis is a major cause of morbidity and mortality, rapid diagnosis is desirable to start timely and specific treatment.Besides some biomarkers, such as procalcitonin, which is well established and has shown positive effects in regard to utilization of antimicrobials and clinical outcomes, there is a growing number of novel markers from different pathophysiological pathways, where the final proof of an added value to clinical judgment and ultimately clinical benefit to patients is still lacking.Without a doubt, the addition of blood biomarkers to clinical medicine has had a strong impact on the way we care for patients today. Recent trials show that as an adjunct to other clinical and laboratory parameters these markers provide important information about risks for bacterial infection and resolution of infection. Moreover, biomarkers can help to optimize management of patients with serious illness in the intensive care unit, thereby offering more individualized treatment courses with overall improvements in clinical outcomes.
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Affiliation(s)
- Eva Heilmann
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Claudia Gregoriano
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schuetz
- Medical University Department of Internal Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Switzerland
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Clinical impact of an antimicrobial stewardship program on high-risk pediatric patients. Infect Control Hosp Epidemiol 2019; 40:968-973. [PMID: 31311616 DOI: 10.1017/ice.2019.198] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate the clinical impact of an antimicrobial stewardship program (ASP) on high-risk pediatric patients. DESIGN Retrospective cohort study. SETTING Free-standing pediatric hospital. PATIENTS This study included patients who received an ASP review between March 3, 2008, and March 2, 2017, and were considered high-risk, including patients receiving care by the neonatal intensive care (NICU), hematology/oncology (H/O), or pediatric intensive care (PICU) medical teams. METHODS The ASP recommendations included stopping antibiotics; modifying antibiotic type, dose, or duration; or obtaining an infectious diseases consultation. The outcomes evaluated in all high-risk patients with ASP recommendations were (1) hospital-acquired Clostridium difficile infection, (2) mortality, and (3) 30-day readmission. Subanalyses were conducted to evaluate hospital length of stay (LOS) and tracheitis treatment failure. Multivariable generalized linear models were performed to examine the relationship between ASP recommendations and each outcome after adjusting for clinical service and indication for treatment. RESULTS The ASP made 2,088 recommendations, and 50% of these recommendations were to stop antibiotics. Recommendation agreement occurred in 70% of these cases. Agreement with an ASP recommendation was not associated with higher odds of mortality or hospital readmission. Patients with a single ASP review and agreed upon recommendation had a shorter median LOS (10.2 days vs 13.2 days; P < .05). The ASP recommendations were not associated with high rates of tracheitis treatment failure. CONCLUSIONS ASP recommendations do not result in worse clinical outcomes among high-risk pediatric patients. Most ASP recommendations are to stop or to narrow antimicrobial therapy. Further work is needed to enhance stewardship efforts in high-risk pediatric patients.
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de Carvalho FT, Rabello Filho R, Bulgarelli L, Serpa Neto A, Deliberato RO. Procalcitonin as a Diagnostic, Therapeutic, and Prognostic Tool: a Critical Review. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-0178-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Johnston D, Khan R, Miot J, Moch S, van Deventer Y, Richards G. Usage of antibiotics in the intensive care units of an academic tertiary-level hospital. S Afr J Infect Dis 2018. [DOI: 10.1080/23120053.2018.1482645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Deanne Johnston
- Department of Pharmacy and Pharmacology, University of the Witwatersrand, Johannesburg, South Africa
- Critical Care Infection Collaboration, University of the Witwatersrand, Johannesburg, South Africa
| | - Razeeya Khan
- Department of Pharmacy and Pharmacology, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacqui Miot
- Department of Pharmacy and Pharmacology, University of the Witwatersrand, Johannesburg, South Africa
- Critical Care Infection Collaboration, University of the Witwatersrand, Johannesburg, South Africa
| | - Shirra Moch
- Critical Care Infection Collaboration, University of the Witwatersrand, Johannesburg, South Africa
- Center for Health Science Education, University of the Witwatersrand, Johannesburg, South Africa
| | - Yolande van Deventer
- Department of Pharmacy and Pharmacology, University of the Witwatersrand, Johannesburg, South Africa
| | - Guy Richards
- Division of Critical Care, University of the Witwatersrand, Johannesburg, South Africa
- Department of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
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Ambaras Khan R, Aziz Z. Antibiotic de-escalation in patients with pneumonia in the intensive care unit: A systematic review and meta-analysis. Int J Clin Pract 2018; 72:e13245. [PMID: 30144239 DOI: 10.1111/ijcp.13245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 07/16/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES OF THE REVIEW Antibiotic de-escalation is part of an antibiotic stewardship strategy to achieve adequate therapy for infections while avoiding the prolonged use of broad-spectrum antibiotics. However, there is a paucity of clinical evidence on the clinical impact of this strategy in pneumonia patients in the intensive care unit (ICU). This review aimed to evaluate the impact of antibiotic de-escalation therapy for adult patients diagnosed with pneumonia in the ICU. METHODS USED TO CONDUCT THE REVIEW This review was conducted in accordance with the Meta-analysis of Observational Studies in Epidemiology (MOOSE) recommendation. Electronic databases including MEDLINE, CINAHL, PubMed, Embase, Cochrane Databases and Cochrane Central Register of Controlled Trials were searched up to March 2017 for relevant trials. The methodological quality of included trials was assessed by using a modified version of the Newcastle-Ottawa Quality Assessment Scale for Case-Control and Cohort Studies. A meta-analysis was conducted using the random-effect model to combine the rate of mortality and length of stay outcomes. FINDINGS OF THE REVIEW Nine observational trials involving 2128 patients were considered eligible for inclusion. Although based on low quality evidence, there was a statistically significant difference in favour of the impact of de-escalation on hospital stay but not mortality (MD -5.96 days; 95% CI -8.39 to -3.52). INTERPRETATIONS AND IMPLICATIONS OF THE FINDINGS This review highlights the need for more rigorous studies to be carried out before a firm conclusion on the benefit of de-escalation therapy is supported.
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Affiliation(s)
- Rahela Ambaras Khan
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Zoriah Aziz
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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A new carbapenem drug dosage metric for carbapenem usage and correlation with carbapenem resistance of Pseudomonas aeruginosa. J Infect Chemother 2018; 24:949-953. [PMID: 30268412 DOI: 10.1016/j.jiac.2018.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/24/2018] [Accepted: 08/03/2018] [Indexed: 12/24/2022]
Abstract
The emergence and dissemination of antimicrobial resistance is a worldwide problem. Inappropriate antimicrobial use contributes to this resistance, and several metrics of drug usage have been used to monitor their consumption and rational use. We examined several existing drug metrics, and developed a new one, dose/duration-density (D/d2), for a the best correlation between carbapenem usage and carbapenem resistance of Pseudomonas aeruginosa. The annual changes of antimicrobial use density (AUD), days of therapy (DOT), daily dose (DD) and D/d2 for meropenem, imipenem and total carbapenems was analyzed for a correlation with carbapenem susceptibility of P. aeruginosa from 2006 through 2015 at a university hospital. The substitution of meropenem for imipenem usage, and an approximate 10% increase in carbapenem susceptibility of P. aeruginosa occurred over the study period. There were significant correlations of the meropenem susceptibility of P. aeruginosa and meropenem usage as measured by the meropenem DD, of imipenem susceptibility and imipenem AUD and DOT, and overall carbapenem susceptibility and imipenem DOT. The D/d2 for meropenem, imipenem and total carbapenems had significant correlations with individual and all carbapenem susceptibility of P. aeruginosa. These D/d2 is the best single carbapenem use metric for correlating carbapenem usage with P. aeruginosa resistance. Further studies are warranted to consider the value of D/d2 for other antimicrobials and bacteria.
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Antimicrobial prescribing in patients with advanced-stage illness in the antimicrobial stewardship era. Infect Control Hosp Epidemiol 2018; 39:1023-1029. [PMID: 30070197 DOI: 10.1017/ice.2018.167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Antimicrobials are frequently administered to patients with an advanced-stage illness. Understanding the current practice of antimicrobial use at the end of life and the factors influencing physicians' prescribing behavior is necessary to develop an effective antimicrobial stewardship program and to provide optimal end-of-life care for terminally ill patients. DESIGN A 1-year retrospective cohort study. SETTING A public tertiary-care center.PatientsThe study included 260 adult patients who were hospitalized and later died at the study institution with an advanced-stage illness. RESULTS Of 260 patients in our study cohort, 192 (73.8%) had an advanced-stage malignancy and 136 (52.3%) received antimicrobial therapy in the last 14 days of their life; of the latter, 60 (44.1%) received antimicrobials for symptom relief. Overall antimicrobial use in the last 14 days of life was 421.9 days of therapy per 1,000 patient days. Factors associated with antimicrobial use in this period included a history of antimicrobial use prior to the last 14 days of life during index hospitalization (adjusted odds ratio [aOR], 4.86; 95% confidence interval [CI], 2.67-8.84) and antipyretic use in the last 14 days of life (aOR, 4.19; 95% CI, 2.01-8.71). CONCLUSION Approximately half of the patients hospitalized with an advanced-stage illness received antimicrobials in the last 14 days of life. The factors associated with antimicrobial use at the end of life in this study are likely to explain physicians' prescribing behaviors. In the current era of antimicrobial stewardship, reconsidering antimicrobial use in terminally ill patients is necessary.
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Monnier AA, Eisenstein BI, Hulscher ME, Gyssens IC. Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure. J Antimicrob Chemother 2018; 73:vi3-vi16. [PMID: 29878216 PMCID: PMC5989615 DOI: 10.1093/jac/dky114] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project, this study aimed to identify key elements for a global definition of responsible antibiotic use based on diverse stakeholder input. Methods A three-step RAND-modified Delphi method was applied. First, a systematic review of antibiotic stewardship literature and relevant organization web sites identified definitions and synonyms of responsible use. Identified elements of definitions were presented by questionnaire to a multidisciplinary international stakeholder panel for appraisal of their relevance. Finally, questionnaire results were discussed in a consensus meeting. Results The systematic review and the web site search identified 17 synonyms (e.g. appropriate, correct) and 22 potential elements to include in a definition of responsible use. Elements were grouped into patient-level (e.g. Indication, Documentation) or societal-level elements (e.g. Education, Future Effectiveness). Forty-eight stakeholders with diverse backgrounds [medical community, public health, patients, antibiotic research and development (R&D), regulators, governments] from 18 countries across all continents participated in the questionnaire. Based on relevance scores, 21 elements were retained, 9 were rephrased and 1 was added. Together, the 22 elements and associated best-practice descriptions comprise an exhaustive list of elements to be considered when defining responsible use. Conclusions Combination of concepts from the literature and stakeholder opinion led to an international multidisciplinary consensus on a global definition of responsible antibiotic use. The widely diverging perspectives of stakeholders providing input should ensure the comprehensiveness and relevance of the definition for both individual patients and society. An aspirational goal would be to address all elements.
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Affiliation(s)
- Annelie A Monnier
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
| | | | - Marlies E Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge C Gyssens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
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Lesprit P. Place des référents en antibiothérapie en réanimation. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Dans les hôpitaux français, les référents antibiotiques ont comme principale mission d’assurer une activité de conseil sur le bon usage des antibiotiques sur avis sollicités ou à partir d’alertes générées par la microbiologie ou la pharmacie. À première vue, leurs contributions semblent donc importantes en réanimation, où près d’un patient sur deux reçoit une antibiothérapie pendant son séjour. Plusieurs études ont montré que les avis des infectiologues permettaient d’améliorer la qualité de l’antibiothérapie prescrite et de réduire l’exposition des patients aux antibiotiques. Cependant, les bénéfices de ces interventions sur l’évolution clinique des patients ou sur l’écologie bactérienne sont plus difficiles à démontrer. L’activité des référents antibiotiques doit s’intégrer dans un programme multidisciplinaire de bon usage des antibiotiques, intégrant d’autres intervenants et en premier lieu les réanimateurs, avec lesquels une collaboration étroite est fondamentale pour la réussite de ce programme.
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Efficacy and Safety of Procalcitonin Guidance in Patients With Suspected or Confirmed Sepsis. Crit Care Med 2018; 46:691-698. [DOI: 10.1097/ccm.0000000000002928] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Odermatt J, Friedli N, Kutz A, Briel M, Bucher HC, Christ-Crain M, Burkhardt O, Welte T, Mueller B, Schuetz P. Effects of procalcitonin testing on antibiotic use and clinical outcomes in patients with upper respiratory tract infections. An individual patient data meta-analysis. Clin Chem Lab Med 2017; 56:170-177. [PMID: 28665787 DOI: 10.1515/cclm-2017-0252] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/02/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Several trials found procalcitonin (PCT) helpful for guiding antibiotic treatment in patients with lower respiratory tract infections and sepsis. We aimed to perform an individual patient data meta-analysis on the effects of PCT guided antibiotic therapy in upper respiratory tract infections (URTI). METHODS A comprehensive search of the literature was conducted using PubMed (MEDLINE) and Cochrane Library to identify relevant studies published until September 2016. We reanalysed individual data of adult URTI patients with a clinical diagnosis of URTI. Data of two trials were used based on PRISMA-IPD guidelines. Safety outcomes were (1) treatment failure defined as death, hospitalization, ARI-specific complications, recurrent or worsening infection at 28 days follow-up; and (2) restricted activity within a 14-day follow-up. Secondary endpoints were initiation of antibiotic therapy, and total days of antibiotic exposure. RESULTS In total, 644 patients with a follow up of 28 days had a final diagnosis of URTI and were thus included in this analysis. There was no difference in treatment failure (33.1% vs. 34.0%, OR 1.0, 95% CI 0.7-1.4; p=0.896) and days with restricted activity between groups (8.0 vs. 8.0 days, regression coefficient 0.2 (95% CI -0.4 to 0.9), p=0.465). However, PCT guided antibiotic therapy resulted in lower antibiotic prescription (17.8% vs. 51.0%, OR 0.2, 95% CI 0.1-0.3; p<0.001) and in a 2.4 day (95% CI -2.9 to -1.9; p<0.001) shorter antibiotic exposure compared to control patients. CONCLUSIONS PCT guided antibiotic therapy in the primary care setting was associated with reduced antibiotic exposure in URTI patients without compromising outcomes.
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Retrospective evaluation of piperacillin-tazobactam, imipenem-cilastatin and meropenem used on surgical floors at a tertiary care hospital in Saudi Arabia. J Infect Public Health 2017; 11:486-490. [PMID: 29153444 DOI: 10.1016/j.jiph.2017.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 08/26/2017] [Accepted: 09/09/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The appropriate use of broad-spectrum antibiotics, including appropriate de-escalation, is essential to reduce the emergence of antibiotic resistance. In surgical floors antibiotics are prescribed for prophylaxis (mostly, single dose), empirical treatment (started if infection is suspected till bacteria are identified with its sensitivity to antibiotics), or treatment of well-defined infection of previously isolated bacteria with its sensitivity to antibiotics. In this study, we aimed to evaluate the use of broad-spectrum antibiotics based on requests for cultures and de-escalation based on sensitivity results of culture tests at tertiary care hospital. METHOD A retrospective cohort study was conducted to evaluate the utilization of broad-spectrum antibiotics on surgical floors at a tertiary care center in Jeddah, Saudi Arabia. Patients who are admitted to surgical floors were included if they received any of three broad-spectrum antibiotics (piperacillin-tazobactam, imipenem-cilastatin or meropenem) from 1 June 2014 to 31 August 2014. Data were collected on whether culture and sensitivity test requests were made within 24h of starting antibiotics, the duration of antibiotic therapy and the number of days to de-escalation after receiving culture and sensitivity results. RESULTS Of the 163 patients who received broad-spectrum antibiotics, culture tests were requested in 112. Before receiving culture results, one patient was discharged and one died. The results of culture tests justified continuation of broad-spectrum antibiotics in only 22 patients, whereas 24 showed no microbial growth in any culture. De-escalation was delayed >24h after culture results became available in 33 out of 64 eligible patients. On the other hand, 51 patients continued receiving broad spectrum antibiotics without any culture test during the whole treatment course. CONCLUSION The use of broad-spectrum antibiotics in surgical floors at a tertiary care hospital in Saudi Arabia was largely unjustified by culture-test result. Interventions are needed to enforce culture and sensitivity test requests within 24h of starting the broad spectrum antibiotics therapy with further follow up to ensure appropriate de-escalation and discontinuation whenever indicated.
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Schuetz P, Wirz Y, Sager R, Christ-Crain M, Stolz D, Tamm M, Bouadma L, Luyt CE, Wolff M, Chastre J, Tubach F, Kristoffersen KB, Burkhardt O, Welte T, Schroeder S, Nobre V, Wei L, Bucher HC, Annane D, Reinhart K, Falsey AR, Branche A, Damas P, Nijsten M, de Lange DW, Deliberato RO, Oliveira CF, Maravić-Stojković V, Verduri A, Beghé B, Cao B, Shehabi Y, Jensen JUS, Corti C, van Oers JAH, Beishuizen A, Girbes ARJ, de Jong E, Briel M, Mueller B. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. THE LANCET. INFECTIOUS DISEASES 2017; 18:95-107. [PMID: 29037960 DOI: 10.1016/s1473-3099(17)30592-3] [Citation(s) in RCA: 286] [Impact Index Per Article: 40.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/14/2017] [Accepted: 09/19/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND In February, 2017, the US Food and Drug Administration approved the blood infection marker procalcitonin for guiding antibiotic therapy in patients with acute respiratory infections. This meta-analysis of patient data from 26 randomised controlled trials was designed to assess safety of procalcitonin-guided treatment in patients with acute respiratory infections from different clinical settings. METHODS Based on a prespecified Cochrane protocol, we did a systematic literature search on the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase, and pooled individual patient data from trials in which patients with respiratory infections were randomly assigned to receive antibiotics based on procalcitonin concentrations (procalcitonin-guided group) or control. The coprimary endpoints were 30-day mortality and setting-specific treatment failure. Secondary endpoints were antibiotic use, length of stay, and antibiotic side-effects. FINDINGS We identified 990 records from the literature search, of which 71 articles were assessed for eligibility after exclusion of 919 records. We collected data on 6708 patients from 26 eligible trials in 12 countries. Mortality at 30 days was significantly lower in procalcitonin-guided patients than in control patients (286 [9%] deaths in 3336 procalcitonin-guided patients vs 336 [10%] in 3372 controls; adjusted odds ratio [OR] 0·83 [95% CI 0·70 to 0·99], p=0·037). This mortality benefit was similar across subgroups by setting and type of infection (pinteractions>0·05), although mortality was very low in primary care and in patients with acute bronchitis. Procalcitonin guidance was also associated with a 2·4-day reduction in antibiotic exposure (5·7 vs 8·1 days [95% CI -2·71 to -2·15], p<0·0001) and a reduction in antibiotic-related side-effects (16% vs 22%, adjusted OR 0·68 [95% CI 0·57 to 0·82], p<0·0001). INTERPRETATION Use of procalcitonin to guide antibiotic treatment in patients with acute respiratory infections reduces antibiotic exposure and side-effects, and improves survival. Widespread implementation of procalcitonin protocols in patients with acute respiratory infections thus has the potential to improve antibiotic management with positive effects on clinical outcomes and on the current threat of increasing antibiotic multiresistance. FUNDING National Institute for Health Research.
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Affiliation(s)
- Philipp Schuetz
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland.
| | - Yannick Wirz
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Ramon Sager
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Mirjam Christ-Crain
- Faculty of Medicine, University of Basel, Basel, Switzerland; Division of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Basel, Basel, Switzerland
| | - Daiana Stolz
- Faculty of Medicine, University of Basel, Basel, Switzerland; Clinic of Pneumology and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Michael Tamm
- Faculty of Medicine, University of Basel, Basel, Switzerland; Clinic of Pneumology and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Lila Bouadma
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, Assistance Publique Hôpitaux de Paris (AP-HP), Paris, France
| | - Charles E Luyt
- Service de Réanimation Médicale, Université Paris 6-Pierre-et-Marie-Curie, Paris, France
| | - Michel Wolff
- Service de Réanimation Médicale, Université Paris 7-Denis-Diderot, Assistance Publique Hôpitaux de Paris (AP-HP), Paris, France
| | - Jean Chastre
- Service de Réanimation Médicale, Université Paris 6-Pierre-et-Marie-Curie, Paris, France
| | - Florence Tubach
- Département de Biostatistique, Santé publique et Information médicale, AP-HP, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Sorbonne Universités, Paris, France
| | | | - Olaf Burkhardt
- Department of Pulmonary Medicine, Medizinische Hochschule Hannover, Member of the German Center of Lung Research, Hannover, Germany
| | - Tobias Welte
- Department of Pulmonary Medicine, Medizinische Hochschule Hannover, Member of the German Center of Lung Research, Hannover, Germany
| | - Stefan Schroeder
- Department of Anesthesiology and Intensive Care Medicine, Krankenhaus Dueren, Dueren, Germany
| | - Vandack Nobre
- Department of Intensive Care, Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Long Wei
- Department of Internal and Geriatric Medicine, Shanghai Jiao Tong University, Affiliated Sixth People's Hospital, Shanghai, China
| | - Heiner C Bucher
- Faculty of Medicine, University of Basel, Basel, Switzerland; Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Djillali Annane
- Critical Care Department, Hôpital Raymond Poincaré, AP-HP, Faculty of Health Science Simone Veil, UVSQ-University Paris Saclay, Garches, France
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Ann R Falsey
- Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Angela Branche
- Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Pierre Damas
- Department of General Intensive Care, University Hospital of Liege, Domaine Universitaire de Liège, Liège, Belgium
| | - Maarten Nijsten
- University Medical Centre, University of Groningen, Groningen, Netherlands
| | - Dylan W de Lange
- University Medical Center Utrecht and University of Utrecht, Utrecht, Netherlands
| | | | - Carolina F Oliveira
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Alessia Verduri
- Section of Respiratory Medicine, Department of Medical and Surgical Sciences, University Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Bianca Beghé
- Section of Respiratory Medicine, Department of Medical and Surgical Sciences, University Polyclinic of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Bin Cao
- Center for Respiratory Diseases, Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Yahya Shehabi
- Critical Care and Peri-operative Medicine, Monash Health, Melbourne, VIC, Australia; School of Clinical Sciences, Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Jens-Ulrik S Jensen
- Centre of Excellence for Health, Immunity and Infections, Department of Infectious Diseases and Rheumatology, Finsencentret, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Caspar Corti
- Department of Respiratory Medicine, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | | | | | | | | | - Matthias Briel
- Faculty of Medicine, University of Basel, Basel, Switzerland; Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Beat Mueller
- Medical University Department, Kantonsspital Aarau, Aarau, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland
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Schuetz P, Wirz Y, Sager R, Christ‐Crain M, Stolz D, Tamm M, Bouadma L, Luyt CE, Wolff M, Chastre J, Tubach F, Kristoffersen KB, Burkhardt O, Welte T, Schroeder S, Nobre V, Wei L, Bucher HCC, Bhatnagar N, Annane D, Reinhart K, Branche A, Damas P, Nijsten M, de Lange DW, Deliberato RO, Lima SSS, Maravić‐Stojković V, Verduri A, Cao B, Shehabi Y, Beishuizen A, Jensen JS, Corti C, Van Oers JA, Falsey AR, de Jong E, Oliveira CF, Beghe B, Briel M, Mueller B. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database Syst Rev 2017; 10:CD007498. [PMID: 29025194 PMCID: PMC6485408 DOI: 10.1002/14651858.cd007498.pub3] [Citation(s) in RCA: 142] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Acute respiratory infections (ARIs) comprise of a large and heterogeneous group of infections including bacterial, viral, and other aetiologies. In recent years, procalcitonin (PCT), a blood marker for bacterial infections, has emerged as a promising tool to improve decisions about antibiotic therapy (PCT-guided antibiotic therapy). Several randomised controlled trials (RCTs) have demonstrated the feasibility of using procalcitonin for starting and stopping antibiotics in different patient populations with ARIs and different settings ranging from primary care settings to emergency departments, hospital wards, and intensive care units. However, the effect of using procalcitonin on clinical outcomes is unclear. This is an update of a Cochrane review and individual participant data meta-analysis first published in 2012 designed to look at the safety of PCT-guided antibiotic stewardship. OBJECTIVES The aim of this systematic review based on individual participant data was to assess the safety and efficacy of using procalcitonin for starting or stopping antibiotics over a large range of patients with varying severity of ARIs and from different clinical settings. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, and Embase, in February 2017, to identify suitable trials. We also searched ClinicalTrials.gov to identify ongoing trials in April 2017. SELECTION CRITERIA We included RCTs of adult participants with ARIs who received an antibiotic treatment either based on a procalcitonin algorithm (PCT-guided antibiotic stewardship algorithm) or usual care. We excluded trials if they focused exclusively on children or used procalcitonin for a purpose other than to guide initiation and duration of antibiotic treatment. DATA COLLECTION AND ANALYSIS Two teams of review authors independently evaluated the methodology and extracted data from primary studies. The primary endpoints were all-cause mortality and treatment failure at 30 days, for which definitions were harmonised among trials. Secondary endpoints were antibiotic use, antibiotic-related side effects, and length of hospital stay. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) using multivariable hierarchical logistic regression adjusted for age, gender, and clinical diagnosis using a fixed-effect model. The different trials were added as random-effects into the model. We conducted sensitivity analyses stratified by clinical setting and type of ARI. We also performed an aggregate data meta-analysis. MAIN RESULTS From 32 eligible RCTs including 18 new trials for this 2017 update, we obtained individual participant data from 26 trials including 6708 participants, which we included in the main individual participant data meta-analysis. We did not obtain individual participant data for four trials, and two trials did not include people with confirmed ARIs. According to GRADE, the quality of the evidence was high for the outcomes mortality and antibiotic exposure, and quality was moderate for the outcomes treatment failure and antibiotic-related side effects.Primary endpoints: there were 286 deaths in 3336 procalcitonin-guided participants (8.6%) compared to 336 in 3372 controls (10.0%), resulting in a significantly lower mortality associated with procalcitonin-guided therapy (adjusted OR 0.83, 95% CI 0.70 to 0.99, P = 0.037). We could not estimate mortality in primary care trials because only one death was reported in a control group participant. Treatment failure was not significantly lower in procalcitonin-guided participants (23.0% versus 24.9% in the control group, adjusted OR 0.90, 95% CI 0.80 to 1.01, P = 0.068). Results were similar among subgroups by clinical setting and type of respiratory infection, with no evidence for effect modification (P for interaction > 0.05). Secondary endpoints: procalcitonin guidance was associated with a 2.4-day reduction in antibiotic exposure (5.7 versus 8.1 days, 95% CI -2.71 to -2.15, P < 0.001) and lower risk of antibiotic-related side effects (16.3% versus 22.1%, adjusted OR 0.68, 95% CI 0.57 to 0.82, P < 0.001). Length of hospital stay and intensive care unit stay were similar in both groups. A sensitivity aggregate-data analysis based on all 32 eligible trials showed similar results. AUTHORS' CONCLUSIONS This updated meta-analysis of individual participant data from 12 countries shows that the use of procalcitonin to guide initiation and duration of antibiotic treatment results in lower risks of mortality, lower antibiotic consumption, and lower risk for antibiotic-related side effects. Results were similar for different clinical settings and types of ARIs, thus supporting the use of procalcitonin in the context of antibiotic stewardship in people with ARIs. Future high-quality research is needed to confirm the results in immunosuppressed patients and patients with non-respiratory infections.
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Affiliation(s)
- Philipp Schuetz
- Kantonsspital AarauMedical University DepartmentAarauSwitzerland
- Kantonsspital AarauDepartment of Endocrinology/Metabolism/Clinical Nutrition, Department of Internal MedicineAarauSwitzerland
- University of BaselMedical FacultyBaselSwitzerland
| | - Yannick Wirz
- Kantonsspital AarauMedical University DepartmentAarauSwitzerland
| | - Ramon Sager
- Kantonsspital AarauMedical University DepartmentAarauSwitzerland
| | - Mirjam Christ‐Crain
- University Hospital Basel, University of BaselClinic for Endocrinology, Diabetes and Metabolism, Department of Clinical ResearchPetersgraben 4BaselSwitzerlandCH‐4031
| | - Daiana Stolz
- University Hospital BaselClinic of Pneumology and Pulmonary Cell ResearchPetersgraben 4BaselSwitzerlandCH‐4031
| | - Michael Tamm
- University Hospital BaselClinic of Pneumology and Pulmonary Cell ResearchPetersgraben 4BaselSwitzerlandCH‐4031
| | - Lila Bouadma
- Hôpital Bichat‐Claude Bernard, Université Paris 7‐Denis‐DiderotService de Réanimation MédicaleParisFrance
| | - Charles E Luyt
- Groupe Hospitalier Pitié‐Salpêtrière, Assistance Publique–Hôpitaux de Paris, Université Paris 6‐Pierre‐et‐Marie‐CurieService de Réanimation MédicaleParisFrance
| | - Michel Wolff
- Université Paris 7‐Denis‐DiderotService de Réanimation MédicaleHôpital Bichat‐Claude‐BernardAssistance Publique‐Hôpitaux de Paris (AP‐HP)ParisFrance
| | - Jean Chastre
- Université Paris 6‐Pierre‐et‐Marie‐CurieService de Réanimation MédicaleHôpital Pitié?Salpêtrière (AP‐HP)ParisFrance
| | - Florence Tubach
- Santé Publique et Information Médicale, AP‐HP, Groupe Hospitalier Pitié‐Salpêtrière Charles‐Foix, INSERM CIC‐P 1421, Sorbonne Universités, UPMC Univ Paris 06Département BiostatistiqueParisFrance
| | - Kristina B Kristoffersen
- Aarhus University HospitalDepartment of Infectious DiseasesSkejbyBrendstrupgaardvej 100Aarhus NDenmark8200
| | - Olaf Burkhardt
- Medizinische Hochschule HannoverDepartment of Pulmonary MedicineCarl‐Neuberg‐Str. 1HannoverNiedersachsenGermany30625
| | - Tobias Welte
- Medizinische Hochschule HannoverDepartment of Pulmonary MedicineCarl‐Neuberg‐Str. 1HannoverNiedersachsenGermany30625
- German Center for Lung Reearch (DZL)Aulweg 130GießenGermany35392
| | - Stefan Schroeder
- Krankenhaus DuerenDepartment of Anesthesiology and Intensive Care MedicineDuerenGermany
| | - Vandack Nobre
- Universidade Federal de Minas GeraisDepartment of Internal Medicine, School of MedicineMinas GeraisBelo HorizonteBrazil
| | - Long Wei
- Shanghai Jiao Tong University Affiliated Sixth People's Hospital (East campus)Department of Internal and Geriatric MedicineShanghaiChina
| | - Heiner C C Bucher
- University Hospital Basel and University of BaselBasel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical ResearchPetersgraben 4BaselSwitzerlandCH‐4031
- University Hospital BaselMedical FacultyBaselSwitzerland
| | - Neera Bhatnagar
- McMaster UniversityDepartment of Clinical Epidemiology and Biostatistics1200 Main Street WestHamiltonONCanadaL8N 3Z5
| | - Djillali Annane
- Center for Neuromuscular Diseases; Raymond Poincaré Hospital (AP‐HP)Department of Critical Care, Hyperbaric Medicine and Home Respiratory UnitFaculty of Health Sciences Simone Veil, University of Versailles SQY‐ University of Paris Saclay104 Boulevard Raymond PoincaréGarchesFrance92380
| | - Konrad Reinhart
- Jena University HospitalDepartment of Anesthesiology and Intensive Care MedicineErlanger Allee 101JenaGermany07747
| | - Angela Branche
- University of Rochester School of MedicineDepartment of Medicine, Division of Infectious DiseasesRochesterNYUSA
| | - Pierre Damas
- University Hospital of Liege, Domaine universitaire de LiègeDepartment of General Intensive CareLiegeBelgium
| | - Maarten Nijsten
- University of GroningenUniversity Medical CentreGroningenNetherlands
| | - Dylan W de Lange
- University Medical Center UtrechtDepartment of Intensive CareHeidelberglaan 100UtrechtNetherlands3584 CX
| | | | - Stella SS Lima
- Universidade Federal de Minas GeraisGraduate Program in Infectious Diseases and Tropical Medicine, Department of Internal Medicine, School of MedicineBelo HorizonteBrazil
| | | | - Alessia Verduri
- University of Modena and Reggio EmiliaDepartment of Medical and Surgical Sciences, Policlinico di ModenaModenaItaly
| | - Bin Cao
- China‐Japan Friendship Hospital, National Clinical Research Center of Respiratory Diseases, Capital Medical UniversityCenter for Respiratory Diseases, Department of Pulmonary and Critical Care MedicineBeijingChina
| | - Yahya Shehabi
- Monash HealthCritical Care and Peri‐operative MedicineMelbourneVictoriaAustralia
- Monash UniversitySchool of Clinical Sciences, Faculty of Medicine Nursing and Health SciencesMelbourneVictoriaAustralia
| | | | - Jens‐Ulrik S Jensen
- Copenhagen University Hospital, Bispebjerg og FrederiksbergDepartment of Respiratory MedicineBispebjerg BakkeCopenhagen NVCapitol RegionDenmarkDK 2400
- Rigshospitalet, University of CopenhagenCHIP, Department of Infectious Diseases and Rheumatology, FinsencentretBlegdamsvej 9, DK‐2100CopenhagenDenmarkDK‐2100
| | - Caspar Corti
- Copenhagen University Hospital, Bispebjerg og FrederiksbergDepartment of Respiratory MedicineBispebjerg BakkeCopenhagen NVCapitol RegionDenmarkDK 2400
| | - Jos A Van Oers
- Elisabeth Tweesteden ZiekenhuisIntensive Care UnitTilburgNetherlands5022 GC
| | - Ann R Falsey
- University of Rochester School of MedicineDepartment of Medicine, Division of Infectious DiseasesRochesterNYUSA
| | - Evelien de Jong
- VU University Medical CenterDepartment of Intensive CareAmsterdamNetherlands1081HV
| | - Carolina F Oliveira
- Federal University of Minas GeraisDepartment of Internal Medicine, School of MedcineBelo HorizonteBrazil31130‐100
| | - Bianca Beghe
- AOU Policlinico di ModenaDepartment of Medical and Surgical SciencesModernaItaly41124
| | - Matthias Briel
- University of BaselMedical FacultyBaselSwitzerland
- University Hospital Basel and University of BaselBasel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical ResearchPetersgraben 4BaselSwitzerlandCH‐4031
| | - Beat Mueller
- Kantonsspital AarauMedical University DepartmentAarauSwitzerland
- Kantonsspital AarauDepartment of Endocrinology/Metabolism/Clinical Nutrition, Department of Internal MedicineAarauSwitzerland
- University of BaselMedical FacultyBaselSwitzerland
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Davis S, Verheyden C, Cooper M, Desai D. Navigating the New Antimicrobial Stewardship Regulations. Hosp Pharm 2017; 52:527-531. [PMID: 29276284 PMCID: PMC5735729 DOI: 10.1177/0018578717721541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: Many health care facilities are navigating their way through the new antimicrobial stewardship standards and guidelines. The purpose of this article is to provide information for health care facilities to improve patient care. Summary: New regulations and guidelines surrounding antimicrobial stewardship have prompted facilities to review their process related to antimicrobial stewardship. In setting up a program, there are many factors to consider including involving key personnel, obtaining leadership support, identifying an infectious disease physician to chair or cochair the committee, and meeting agenda, metrics, and educational needs. Conclusion: Antimicrobial stewardship plays a vital role in both our hospital and community setting. Pharmacists are uniquely positioned to improve optimal patient care through rounding, review of patients' chart, and contribute to the improvement of antimicrobial stewardship by working with a multidisciplinary team. These efforts may improve the utilization of antimicrobial agents.
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Ramsamy Y, Muckart DJJ, Han KSS, Mlisana KP. The effect of prior antimicrobial therapy for community acquired infections on the aetiology of early and late onset ventilator-associated pneumonia in a level I trauma intensive care unit. S Afr J Infect Dis 2017. [DOI: 10.1080/23120053.2017.1313933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Yogandree Ramsamy
- Department of Microbiology, Prince Mshiyeni Memorial Hospital, Durban, South Africa
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, National Health Laboratory Services (KZN Academic Complex), Durban, South Africa
| | - David JJ Muckart
- Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Khine Swe Swe Han
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, National Health Laboratory Services (KZN Academic Complex), Durban, South Africa
| | - Koleka P Mlisana
- Department of Medical Microbiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, National Health Laboratory Services (KZN Academic Complex), Durban, South Africa
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Khan RA, Aziz Z. A retrospective study of antibiotic de-escalation in patients with ventilator-associated pneumonia in Malaysia. Int J Clin Pharm 2017. [DOI: 10.1007/s11096-017-0499-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Zilahi G, McMahon MA, Povoa P, Martin-Loeches I. Duration of antibiotic therapy in the intensive care unit. J Thorac Dis 2016; 8:3774-3780. [PMID: 28149576 DOI: 10.21037/jtd.2016.12.89] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
There are certain well defined clinical situations where prolonged therapy is beneficial, but prolonged duration of antibiotic therapy is associated with increased resistance, medicalising effects, high costs and adverse drug reactions. The best way to decrease antibiotic duration is both to stop antibiotics when not needed (sterile invasive cultures with clinical improvement), not to start antibiotics when not indicated (treating colonization) and keep the antibiotic course as short as possible. The optimal duration of antimicrobial treatment for ventilator-associated pneumonia (VAP) is unknown, however, there is a growing evidence that reduction in the length of antibiotic courses to 7-8 days can minimize the consequences of antibiotic overuse in critical care, including antibiotic resistance, adverse effects, collateral damage and costs. Biomarkers like C-reactive protein (CRP) and procalcitonin (PCT) do have a valuable role in helping guide antibiotic duration but should be interpreted cautiously in the context of the clinical situation. On the other hand, microbiological criteria alone are not reliable and should not be used to justify a prolonged antibiotic course, as clinical cure does not equate to microbiological eradication. We do not recommend a 'one size fits all' approach and in some clinical situations, including infection with non-fermenting Gram-negative bacilli (NF-GNB) clinical evaluation is needed but shortening the antibiotic course is an effective and safe way to decrease inappropriate antibiotic exposure.
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Affiliation(s)
- Gabor Zilahi
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's University Hospital, Dublin, Ireland
| | - Mary Aisling McMahon
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's University Hospital, Dublin, Ireland
| | - Pedro Povoa
- Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal;; NOVA Medical School, Faculdade de Ciências Médicas, CEDOC, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), St James's University Hospital, Dublin, Ireland;; Welcome Trust-HRB Clinical Research, Dublin, Ireland;; Department of Clinical Medicine, Trinity Centre for Health Sciences, Dublin, Ireland
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Abstract
Purpose
– Worldwide situation analysis on antimicrobial resistance (AMR) released in 2015 by the World Health Organisation (WHO) has revealed inadequate capability to respond to AMR in African region. Report of antibiotics use and resistance in Tanzania revealed rising levels of healthcare associated Methicilin Resistant Staphylococcus aureus infections; while other studies have reported high prevalence of Expanded Spectrum Beta-Lactamase (ESBL). The purpose of this paper is to review the current situation of antimicrobial stewardship (AMS) in Tanzania using strengths, weaknesses, opportunities and challenges (SWOC) analysis.
Design/methodology/approach
– General literature review was done on use of antimicrobials in Google Scholar, websites of key organisations including WHO, and grey literature. Conceptual framework designed by the authors was used to inform SWOC analysis of the Tanzanian health sector.
Findings
– The SWOC analysis has revealed much strength in the Tanzanian health sector indicating that increasing investments in laboratory services, in medicines Regulatory Authority and Pharmacy Council, and strengthening management teams at all levels of service delivery, including Medicines and Therapeutics Committees; and strengthening advocacy on rational use of antimicrobials both in humans and livestock will improve AMS.
Research limitations/implications
– This is a general literature review. No interview of experts or use of questionnaires was used. However, based on the literature found and author’s experience in the health sector, the information contained is valid for consideration in making policy decisions about AMR in Tanzania.
Practical implications
– Designing policy interventions to prevent development of AMR to commonly used antimicrobials.
Social implications
– Improving social wellbeing in the community through prevention of morbidity and mortality resulting from multi-resistant pathogens.
Originality/value
– This is the authors original idea backed by available literature.
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Chen IL, Lee CH, Su LH, Wang YCL, Liu JW. Effects of implementation of an online comprehensive antimicrobial-stewardship program in ICUs: A longitudinal study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 51:55-63. [PMID: 27553448 DOI: 10.1016/j.jmii.2016.06.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 05/26/2016] [Accepted: 06/13/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND/PURPOSE The long-term effects of antimicrobial-stewardship programs in the intensive care units (ICUs) have not been adequately examined. We evaluated the impact of an online comprehensive antimicrobial stewardship program (OCASP) on the outcomes of patients in 200-bed medical/surgical ICUs over the course of 11 years. METHODS We analyzed the records of adult patients admitted to ICUs during the 5 years before (n = 27,499) and the 6 years after (n = 33,834) implementation of an OCASP. Antimicrobial consumption, expenditures, duration of treatment, incidence of healthcare-associated infections (HAIs), prevalence of HAIs caused by antimicrobial-resistant strains, and crude or sepsis-related mortality of patients were analyzed. Segmented regression analyses of interrupted time series were used to assess the significance of changes in antimicrobial use. RESULTS Compared to the patients in the pre-OCASP period, the patients in the post-OCASP period were older, had greater disease severity, longer ICU stays, and were more likely to receive antimicrobials, but had lower antimicrobial expenditures and crude and sepsis-related mortality. The trend of overall antimicrobial use [slope of defined daily dose/1000 patient-days vs. time) increased significantly before OCASP implementation (p < 0.001), but decreased significantly after implementation (p < 0.01). The administration duration of all classes of antibiotics were significantly shorter (p < 0.001) and the incidences of HAIs were significantly lower (p < 0.001) after implementation. However, there was an increase in the proportion of HAIs caused by carbapenem-resistant Acinetobacter baumannii relative to all A. baumannii infections. CONCLUSION Implementation of an OCASP in the ICUs reduced antimicrobial consumption and expenditures, but did not compromise healthcare quality.
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Affiliation(s)
- I-Ling Chen
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Infection Control Team, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chen-Hsiang Lee
- Infection Control Team, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Li-Hsiang Su
- Infection Control Team, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yu-Chin Lily Wang
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jien-Wei Liu
- Infection Control Team, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Akrami K, Sweeney DA, Malhotra A. Antibiotic stewardship in the intensive care unit: tools for de-escalation from the American Thoracic Society Meeting 2016. J Thorac Dis 2016; 8:S533-5. [PMID: 27606085 PMCID: PMC4990674 DOI: 10.21037/jtd.2016.07.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 06/28/2016] [Indexed: 01/24/2023]
Affiliation(s)
- Kevan Akrami
- Department of Infectious Disease, University of California, San Diego, USA
- Critical Care Medicine, National Institute of Health, Bethesda, MD, USA
| | - Daniel A. Sweeney
- Department of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, USA
| | - Atul Malhotra
- Department of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, USA
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Vincent JL, Bassetti M, François B, Karam G, Chastre J, Torres A, Roberts JA, Taccone FS, Rello J, Calandra T, De Backer D, Welte T, Antonelli M. Advances in antibiotic therapy in the critically ill. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:133. [PMID: 27184564 PMCID: PMC4869332 DOI: 10.1186/s13054-016-1285-6] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Infections occur frequently in critically ill patients and their management can be challenging for various reasons, including delayed diagnosis, difficulties identifying causative microorganisms, and the high prevalence of antibiotic-resistant strains. In this review, we briefly discuss the importance of early infection diagnosis, before considering in more detail some of the key issues related to antibiotic management in these patients, including controversies surrounding use of combination or monotherapy, duration of therapy, and de-escalation. Antibiotic pharmacodynamics and pharmacokinetics, notably volumes of distribution and clearance, can be altered by critical illness and can influence dosing regimens. Dosing decisions in different subgroups of patients, e.g., the obese, are also covered. We also briefly consider ventilator-associated pneumonia and the role of inhaled antibiotics. Finally, we mention antibiotics that are currently being developed and show promise for the future.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium.
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, 33100, Udine, Italy
| | - Bruno François
- Service de Réanimation Polyvalente, CHU de Dupuytren, 87042, Limoges, France
| | - George Karam
- Infectious Disease Section, Louisiana State University School of Medicine, 70112, New Orleans, LA, USA
| | - Jean Chastre
- Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, 75013, Paris, France
| | - Antoni Torres
- Department of Pulmonary Medicine, Hospital Clinic of Barcelona, IDIBAPS-Ciberes, 08036, Barcelona, Spain
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Royal Brisbane and Women's Hospital, 4029 Herston, Brisbane, Australia
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium
| | - Jordi Rello
- Department of Intensive care, CIBERES, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, 08035, Barcelona, Spain
| | - Thierry Calandra
- Infectious Diseases Service, Centre Hospitalier Universitaire Vaudois, University of Lausanne, 1011, Lausanne, Switzerland
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospital, Université Libre de Bruxelles, 1420, Braine L'Alleud, Belgium
| | - Tobias Welte
- Department of Respiratory Medicine, Medizinische Hochschule, 30625, Hannover, Germany
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli University Hospital, Rome, Italy
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Chaves NJ, Ingram RJ, MacIsaac CM, Buising KL. Sticking to minimum standards: implementing antibiotic stewardship in intensive care. Intern Med J 2015; 44:1180-7. [PMID: 25070720 DOI: 10.1111/imj.12539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 07/20/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND In Australia, antimicrobial stewardship programmes are a compulsory component of hospital accreditation. Good documentation around anti-microbial prescribing aids communication and can improve prescribing practice in environments with multiple decision makers. AIM This study aims to develop and implement an intervention to improve antimicrobial prescribing practice in a 24-bed intensive care unit in a tertiary referral adult hospital. METHODS We conducted a four-phase (observation, reflection, implementation, evaluation) prospective collaborative before-after quality improvement study. Baseline audits and surveys of antimicrobial prescribing practices identified barriers to and enablers of good prescribing practice. A customised intervention was then implemented over 6 weeks and included a yellow medication record sticker, quarterly education sessions and intensive care unit-specific empiric antimicrobial prescribing guidelines. Post-implementation, the effects were monitored by serial antimicrobial prescribing audits for 1 year. The primary outcomes were clear documentation of the start date, the planned stop date or review date and the indication for an antibiotic. These were all considered the 'minimum standards' for an antimicrobial prescription on the medication record. RESULTS Documentation of minimum standards specifically addressed by the sticker improved (start date (72% to 90%, P < 0.001), stop date (16% to 63%, P < 0.001), antimicrobial indication documented on medication chart (58% to 83%, P < 0.01)). Overall, adherence to all three minimum standards (start date, stop date and indication) improved from 41/306 (13%) to 306/492 (63%) (P < 0.001). One-year post-implementation, the yellow sticker had become embedded into daily practice. CONCLUSION A systematic approach to quality improvement combined with the implementation of a tailored, multi-faceted intervention can improve antimicrobial prescribing practices.
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Affiliation(s)
- N J Chaves
- Victorian Infectious Diseases Service, Melbourne Health, Melbourne, Victoria, Australia
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Shehabi Y, Sterba M, Garrett PM, Rachakonda KS, Stephens D, Harrigan P, Walker A, Bailey MJ, Johnson B, Millis D, Ding G, Peake S, Wong H, Thomas J, Smith K, Forbes L, Hardie M, Micallef S, Fraser JF. Procalcitonin algorithm in critically ill adults with undifferentiated infection or suspected sepsis. A randomized controlled trial. Am J Respir Crit Care Med 2015; 190:1102-10. [PMID: 25295709 DOI: 10.1164/rccm.201408-1483oc] [Citation(s) in RCA: 128] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
RATIONALE The role of procalcitonin (PCT), a widely used sepsis biomarker, in critically ill patients with sepsis is undetermined. OBJECTIVES To investigate the effect of a low PCT cut-off on antibiotic prescription and to describe the relationships between PCT plasma concentration and sepsis severity and mortality. METHODS This was a multicenter (11 Australian intensive care units [ICUs]), prospective, single-blind, randomized controlled trial involving 400 patients with suspected bacterial infection/sepsis and expected to receive antibiotics and stay in ICU longer than 24 hours. The primary outcome was the cumulative number of antibiotics treatment days at Day 28. MEASUREMENTS AND MAIN RESULTS PCT was measured daily while in the ICU. A PCT algorithm, including 0.1 ng/ml cut-off, determined antibiotic cessation. Published guidelines and antimicrobial stewardship were used in all patients. Primary analysis included 196 (PCT) versus 198 standard care patients. Ninety-three patients in each group had septic shock. The overall median (interquartile range) number of antibiotic treatment days were 9 (6-21) versus 11 (6-22), P = 0.58; in patients with positive pulmonary culture, 11 (7-27) versus 15 (8-27), P = 0.33; and in patients with septic shock, 9 (6-22) versus 11 (6-24), P = 0.64; with an overall 90-day all-cause mortality of 35 (18%) versus 31 (16%), P = 0.54 in the PCT versus standard care, respectively. Using logistic regression, adjusted for age, ventilation status, and positive culture, the decline rate in log(PCT) over the first 72 hours independently predicted hospital and 90-day mortality (odds ratio [95% confidence interval], 2.76 [1.10-6.96], P = 0.03; 3.20 [1.30-7.89], P = 0.01, respectively). CONCLUSIONS In critically ill adults with undifferentiated infections, a PCT algorithm including 0.1 ng/ml cut-off did not achieve 25% reduction in duration of antibiotic treatment. Clinical trial registered with http://www.anzctr.org.au (ACTRN12610000809033).
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Affiliation(s)
- Yahya Shehabi
- 1 University of New South Wales Clinical School, Randwick, Australia
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Zhang YZ, Singh S. Antibiotic stewardship programmes in intensive care units: Why, how, and where are they leading us. World J Crit Care Med 2015; 4:13-28. [PMID: 25685719 PMCID: PMC4326760 DOI: 10.5492/wjccm.v4.i1.13] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 11/21/2014] [Accepted: 12/17/2014] [Indexed: 02/06/2023] Open
Abstract
Antibiotic usage and increasing antimicrobial resistance (AMR) mount significant challenges to patient safety and management of the critically ill on intensive care units (ICU). Antibiotic stewardship programmes (ASPs) aim to optimise appropriate antibiotic treatment whilst minimising antibiotic resistance. Different models of ASP in intensive care setting, include “standard” control of antibiotic prescribing such as “de-escalation strategies”through to interventional approaches utilising biomarker-guided antibiotic prescribing. A systematic review of outcomes related studies for ASPs in an ICU setting was conducted. Forty three studies were identified from MEDLINE between 1996 and 2014. Of 34 non-protocolised studies, [1 randomised control trial (RCT), 22 observational and 11 case series], 29 (85%) were positive with respect to one or more outcome: These were the key outcome of reduced antibiotic use, or ICU length of stay, antibiotic resistance, or prescribing cost burden. Limitations of non-standard antibiotic initiation triggers, patient and antibiotic selection bias or baseline demographic variance were identified. All 9 protocolised studies were RCTs, of which 8 were procalcitonin (PCT) guided antibiotic stop/start interventions. Five studies addressed antibiotic escalation, 3 de-escalation and 1 addressed both. Six studies reported positive outcomes for reduced antibiotic use, ICU length of stay or antibiotic resistance. PCT based ASPs are effective as antibiotic-stop (de-escalation) triggers, but not as an escalation trigger alone. PCT has also been effective in reducing antibiotic usage without worsening morbidity or mortality in ventilator associated pulmonary infection. No study has demonstrated survival benefit of ASP. Ongoing challenges to infectious disease management, reported by the World Health Organisation global report 2014, are high AMR to newer antibiotics, and regional knowledge gaps in AMR surveillance. Improved AMR surveillance data, identifying core aspects of successful ASPs that are transferable, and further well-conducted trials will be necessary if ASPs are to be an effective platform for delivering desired patient outcomes and safety through best antibiotic policy.
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Chunnilall D, Peer A, Naidoo I, Essack S. An evaluation of antibiotic prescribing patterns in adult intensive care units in a private hospital in KwaZulu-Natal. S Afr J Infect Dis 2015. [DOI: 10.1080/23120053.2015.1103956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Jackson A, Carberry M. The advance nurse practitioner in critical care: a workload evaluation. Nurs Crit Care 2014; 20:71-7. [DOI: 10.1111/nicc.12133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 06/22/2014] [Accepted: 08/11/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Audrey Jackson
- PG Certificate Advanced Practice, Advanced Nurse Practitioner Critical Care, Monklands Hospital; Glasgow UK
| | - Martin Carberry
- Critical Care Nurse Consultant, NHS Lanarkshire, HECT Office, Hairmyres Hospital; Glasgow UK
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Burgmann H. [First-line anti-infective treatment in sepsis]. Med Klin Intensivmed Notfmed 2014; 109:577-82. [PMID: 25344412 DOI: 10.1007/s00063-014-0378-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/16/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND The Surviving Sepsis Campaign strongly recommends that intravenous antibiotic therapy should be started as early as possible, ideally within the first hour of recognition of severe sepsis or septic shock. There is ample evidence that failure to initiate early antimicrobial treatment correlates with increased morbidity and mortality. OBJECTIVES The purpose of this work was to review the recent literature regarding optimal initial antimicrobial treatment in patients with severe sepsis and sepsis shock. MATERIALS AND METHODS A literature review was performed. RESULTS The most frequently quoted papers claiming the overriding prognostic importance of early administered antibiotics are retrospective data analyses. However, an equivalent number of studies report that a group of septic patients do not benefit from early administration of antibiotics, but can also be harmed. In these patients, watchful waiting with administration of a targeted antibiotic can be used, thus, avoiding the possible collateral damage from excessive treatment with antibiotics. Treatment with monotherapy is adequate in most cases. CONCLUSION The administration of antibiotics based on the local epidemiology should be initiated quickly in critically ill patients with severe sepsis and septic shock. In patients who are not in septic shock, treatment can be withheld, while awaiting further studies or clinical assessment to confirm the suspicion of infection.
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Affiliation(s)
- H Burgmann
- Innere Medizin I, Klinische Abteilung für Infektionen und Tropenmedizin, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich,
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Luyt CE, Bréchot N, Trouillet JL, Chastre J. Antibiotic stewardship in the intensive care unit. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:480. [PMID: 25405992 PMCID: PMC4281952 DOI: 10.1186/s13054-014-0480-6] [Citation(s) in RCA: 188] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The rapid emergence and dissemination of antimicrobial-resistant microorganisms in ICUs worldwide constitute a problem of crisis dimensions. The root causes of this problem are multifactorial, but the core issues are clear. The emergence of antibiotic resistance is highly correlated with selective pressure resulting from inappropriate use of these drugs. Appropriate antibiotic stewardship in ICUs includes not only rapid identification and optimal treatment of bacterial infections in these critically ill patients, based on pharmacokinetic-pharmacodynamic characteristics, but also improving our ability to avoid administering unnecessary broad-spectrum antibiotics, shortening the duration of their administration, and reducing the numbers of patients receiving undue antibiotic therapy. Either we will be able to implement such a policy or we and our patients will face an uncontrollable surge of very difficult-to-treat pathogens.
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van Buul LW, Sikkens JJ, van Agtmael MA, Kramer MHH, van der Steen JT, Hertogh CMPM. Participatory action research in antimicrobial stewardship: a novel approach to improving antimicrobial prescribing in hospitals and long-term care facilities. J Antimicrob Chemother 2014; 69:1734-41. [DOI: 10.1093/jac/dku068] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Micek ST, Lang A, Fuller BM, Hampton NB, Kollef MH. Clinical implications for patients treated inappropriately for community-acquired pneumonia in the emergency department. BMC Infect Dis 2014; 14:61. [PMID: 24499035 PMCID: PMC3918233 DOI: 10.1186/1471-2334-14-61] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 02/04/2014] [Indexed: 12/12/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is one of the most common infections presenting to the emergency department (ED). Increasingly, antibiotic resistant bacteria have been identified as causative pathogens in patients treated for CAP, especially in patients with healthcare exposure risk factors. Methods We retrospectively identified adult subjects treated for CAP in the ED requiring hospital admission (January 2003-December 2011). Inappropriate antibiotic treatment, defined as an antibiotic regimen that lacked in vitro activity against the isolated pathogen, served as the primary end point. Information regarding demographics, severity of illness, comorbidities, and antibiotic treatment was recorded. Logistic regression was used to determine factors independently associated with inappropriate treatment. Results The initial cohort included 259 patients, 72 (27.8%) receiving inappropriate antibiotic treatment. There was no difference in hospital mortality between patients receiving inappropriate and appropriate treatment (8.3% vs. 7.0%; p = 0.702). Hospital length of stay (10.3 ± 12.0 days vs. 7.0 ± 8.9 days; p = 0.017) and 30-day readmission (23.6% vs. 12.3%; p = 0.024) were greater among patients receiving inappropriate treatment. Three variables were independently associated with inappropriate treatment: admission from long-term care (AOR, 9.05; 95% CI, 3.93-20.84), antibiotic exposure in the previous 30 days (AOR, 1.85; 95% CI, 1.35-2.52), and chronic obstructive pulmonary disease (AOR, 2.05; 95% CI, 1.52-2.78). Conclusion Inappropriate antibiotic treatment of presumed CAP in the ED negatively impacts patient outcome and readmission rate. Knowledge of risk factors associated with inappropriate antibiotic treatment of presumed CAP could advance the management of patients with pneumonia presenting to the ED and potentially improve patient outcomes.
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Affiliation(s)
| | | | | | | | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8052, St, Louis, MO 63110, USA.
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Amer MR, Akhras NS, Mahmood WA, Al-Jazairi AS. Antimicrobial stewardship program implementation in a medical intensive care unit at a tertiary care hospital in Saudi Arabia. Ann Saudi Med 2013; 33:547-54. [PMID: 24413857 PMCID: PMC6074906 DOI: 10.5144/0256-4947.2013.547] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Antimicrobial stewardship programs (ASPs) have shown to prevent the emergence of antimicrobial resistance associated with an inappropriate antimicrobial use. The primary objective of this study was to compare the prescribing appropriateness rate of the empirical antibiotic therapy before and after the ASP implementation in a tertiary care hospital. Secondary objectives include the rate of Clostridium difficile-associated diarrhea (CDAD), physicians' acceptance rate, patient's intensive care unit (ICU) course, total utilization using defined daily dose, and total direct cost of antibiotics. DESIGN AND SETTINGS This is a comparative, historically controlled study. Adult medical ICU patients were enrolled in a prospective fashion under the active ASP arm and compared with historical patients who were admitted to the same unit before the ASP implementation. This study was approved by the institutional review board, and the need for informed consent was waived because the interventions and recommendations were evidence based and considered the standard of care. The study was conducted at KFSHRC, Riyadh. METHODS Adult medical ICU patients were enrolled under the active ASP arm if they were on any of the 5 targeted antibiotics (piperacillin/tazobactam, imipenem/cilastatin, meropenem, vancomycin, tigecycline), and had no official infectious disease consultation. The interventions were conducted via prospective audit and feedback. RESULTS A total of 73 subjects were recruited, 49 in historical control and 24 in the active arm. The appropriateness of empirical antibiotics was improved from 30.6% (15/49) in the historical control arm to 100% (24/24) in the proactive ASP arm (P value < .05). For the ASP group, initially 79.1% (19/24) of the antibiotic uses were inappropriate and diminished by ASPs to 0% on the recommendations implementation. A total of 27 interventions were made with an acceptance rate of 96.3%. The rate of CDAD did not differ between the groups. A reduction in antibiotics utilization and direct cost were also noticed in the ASP arm. CONCLUSION A proactive ASP is a vital approach in optimizing the appropriate empirical antibiotics utilization in an ICU setting in tertiary care hospitals. This study highlights the importance of such a program and may serve as a foundation for further ASP initiatives particularly in our region.
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Affiliation(s)
| | | | | | - Abdulrazaq S Al-Jazairi
- Dr. Abdulrazaq S. Al-Jazairi, Head, Medical/Critical Pharmacy Department,, Division of Pharmacy Services,, King Faisal Specialist Hospital and Research Centre,, PO Box 3354, MBC-11, Riyadh 11211,, Saudi Arabia, T: +966-11-4427603, F: +966-11-4427608,
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Using procalcitonin-guided algorithms to improve antimicrobial therapy in ICU patients with respiratory infections and sepsis. Curr Opin Crit Care 2013; 19:453-60. [DOI: 10.1097/mcc.0b013e328363bd38] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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The role of procalcitonin as a guide for the diagnosis, prognosis, and decision of antibiotic therapy for lower respiratory tract infections. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2013; 62:687-695. [PMID: 32288126 PMCID: PMC7126862 DOI: 10.1016/j.ejcdt.2013.07.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 07/31/2013] [Indexed: 01/09/2023] Open
Abstract
Objectives To assess the value of PCT as a rapid and sensitive marker for diagnosis, prognosis, and therapy of lower respiratory tract bacterial infections necessitating antimicrobial treatment and comparing this marker with other markers of infections including C-reactive protein (CRP) and total white-blood cell counts (WBCs). Patients and methods Sixty Patients were enrolled in the study, they were subjected to complete history taking, physical examination, laboratory investigations including complete blood count, blood gases, blood chemistry, bacteriological culture for sputum and blood, serology for atypicals, and PCR for respiratory viruses, serum C-reactive protein (CRP) and PCT levels were measured. The patients were divided into two groups, group 1 included 26 patients who were culture negative for bacterial infection and group 2 included 34 patients who were culture positive. Group 2 patients were given antibiotic therapy according to the culture sensitivity. Result The results revealed that, there was no significant difference between group 1 and group 2 patients as regards age, sex, clinical manifestations, final diagnosis, white blood cell counts, blood gases, number of admitted patients, intensive care unit admission and length of hospital stay. A significant increase of PCT and CRP levels was detected in group 2 compared to group 1 at initial diagnosis. At cutoff value >0.5 ng/ml, PCT gave a sensitivity of 94.1%, specificity of 88.4%, positive predictive value (PPV) of 91.4%, negative predictive value (NPV) of 92% and diagnostic efficiency of 91.6% for diagnosis of respiratory tract bacterial infections. However, at a cutoff value >8 mg/L, CRP gave a sensitivity of 85.2%, specificity of 76.9%, PPV of 82.8%, NPV of 80% and diagnostic efficiency of 81.7%. After antibiotic therapy PCT and CRP levels dropped in group 2 patients as compared to their pre-treatment levels. Conclusion Serum PCT level could be used as a novel marker of lower respiratory tract bacterial infections for diagnosis, prognosis and follow up of therapy. This reduces side-effects of an unnecessary antibiotic use, lowers costs, and in the long-term, leads to diminishing drug resistance.
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Schuetz P, Muller B, Christ-Crain M, Stolz D, Tamm M, Bouadma L, Luyt CE, Wolff M, Chastre J, Tubach F, Kristoffersen KB, Burkhardt O, Welte T, Schroeder S, Nobre V, Wei L, Bhatnagar N, Bucher HC, Briel M. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. ACTA ACUST UNITED AC 2013; 8:1297-371. [DOI: 10.1002/ebch.1927] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Becher RD, Hoth JJ, Rebo JJ, Kendall JL, Miller PR. Locally derived versus guideline-based approach to treatment of hospital-acquired pneumonia in the trauma intensive care unit. Surg Infect (Larchmt) 2013; 13:352-9. [PMID: 23268613 DOI: 10.1089/sur.2011.056] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Appropriate initial antibiotic therapy for presumed pneumonia in critically ill patients decreases the mortality rate. To achieve this goal, treatment guidelines developed by groups such as the American Thoracic Society (ATS) have been stressed. However, often overlooked is the importance of incorporating local microbiologic data into an empiric algorithm. Our hypothesis was that an empiric algorithm supported by our locally-driven analysis would predict more accurate coverage than one defined strictly by an unmodified guideline-driven approach. METHODS Retrospective review of all first hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) pathogens in consecutive trauma intensive care unit (TICU) patients over 18 months. Microbiologic data were analyzed to update our TICU-specific empiric algorithm. The ATS guidelines define patients at risk for multidrug-resistant (MDR) organisms on the basis of standardized criteria and time since admission (early <5 days; late ≥5 days). RESULTS A total of 164 pathogens caused 117 pneumonias. For early coverage, ATS guidelines stress identification of MDR risks; these criteria failed to identify 8 of 13 (62%) early MDR pneumonias. For early HAP/VAP with no MDR risks, the ATS guidelines recommend monotherapy; susceptibility differed (49% to ciprofloxacin, 68% to ampicillin-sulbactam, 83% to ceftriaxone). A total of 15% of early pathogens were MDR gram-positive, so addition of vancomycin resulted in adequate predicted coverage of 100%, 79%, and 95% for ciprofloxacin, ampicillin-sulbactam, and ceftriaxone, respectively. For late HAP/VAP, ATS recommends regimens based on broad-spectrum drugs. Vancomycin with ciprofloxacin, cefepime, or piperacillin-tazobactam had predicted coverage of 95%, 94%, and 93%, respectively. CONCLUSIONS The empiric algorithm derived from analysis of local microbiologic data predicted significantly better coverage than one defined by an unmodified guideline-driven approach for early HAP/VAP. Our locally-derived TICU algorithm of ceftriaxone+vancomycin for early pneumonia and piperacillin-tazobactam+vancomycin for late pneumonia optimizes the adequacy of initial therapy. Understanding local patterns of pneumonia ensures the creation and maintenance of empiric algorithms that achieve the best clinical outcomes.
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Affiliation(s)
- Robert D Becher
- Acute Care Surgery Service, Department of General Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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