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Kubo K, Sakuraya M, Sugimoto H, Takahashi N, Kano KI, Yoshimura J, Egi M, Kondo Y. Benefits and Harms of Procalcitonin- or C-Reactive Protein-Guided Antimicrobial Discontinuation in Critically Ill Adults With Sepsis: A Systematic Review and Network Meta-Analysis. Crit Care Med 2024:00003246-990000000-00355. [PMID: 38949476 DOI: 10.1097/ccm.0000000000006366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
OBJECTIVES In sepsis treatment, antibiotics are crucial, but overuse risks development of antibiotic resistance. Recent guidelines recommended the use of procalcitonin to guide antibiotic cessation, but solid evidence is insufficient. Recently, concerns were raised that this strategy would increase recurrence. Additionally, optimal protocol or difference from the commonly used C-reactive protein (CRP) are uncertain. We aimed to compare the effectiveness and safety of procalcitonin- or CRP-guided antibiotic cessation strategies with standard of care in sepsis. DATA SOURCES A systematic search of PubMed, Embase, CENTRAL, Igaku Chuo Zasshi, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform. STUDY SELECTION Randomized controlled trials involving adults with sepsis in intensive care. DATA EXTRACTION A systematic review with network meta-analyses was performed. The Grading of Recommendations, Assessments, Developments, and Evaluation method was used to assess certainty. DATA SYNTHESIS Eighteen studies involving 5023 participants were included. Procalcitonin-guided and CRP-guided strategies shortened antibiotic treatment (-1.89 days [95% CI, -2.30 to -1.47], -2.56 days [95% CI, -4.21 to -0.91]) with low- to moderate-certainty evidence. In procalcitonin-guided strategies, this benefit was consistent even in subsets with shorter baseline antimicrobial duration (7-10 d) or in Sepsis-3, and more pronounced in procalcitonin cutoff of "0.5 μg/L and 80% reduction." No benefit was observed when monitoring frequency was less than half of the initial 10 days. Procalcitonin-guided strategies lowered mortality (-27 per 1000 participants [95% CI, -45 to -7]) and this was pronounced in Sepsis-3, but CRP-guided strategies led to no difference in mortality. Recurrence did not increase significantly with either strategy (very low to low certainty). CONCLUSIONS In sepsis, procalcitonin- or CRP-guided antibiotic discontinuation strategies may be beneficial and safe. In particular, the usefulness of procalcitonin guidance for current Sepsis-3, where antimicrobials are used for more than 7 days, was supported. Well-designed studies are needed focusing on monitoring protocol and recurrence.
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Affiliation(s)
- Kenji Kubo
- Department of Emergency Medicine and Department of Infectious Diseases, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Hiroshi Sugimoto
- Department of Internal Medicine, National Hospital Organization Kinki-chuo Chest Medical Center, Osaka, Japan
| | - Nozomi Takahashi
- Centre for Heart Lung Innovation, St. Paul's Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Ken-Ichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Jumpei Yoshimura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Moritoki Egi
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
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Legros S, Vanoverschelde A, van Krieken J, Debaveye Y, Versporten A, Huis In 't Veld D, Westelinck V, Briquet C, Vercheval C, Spriet I, Denis O, Magerman K, De Schepper M, Buyle F. Development of quality indicators for antimicrobial stewardship in Belgian hospitals: a RAND - modified Delphi procedure. Acta Clin Belg 2024; 79:77-86. [PMID: 38146874 DOI: 10.1080/17843286.2023.2297123] [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: 08/17/2023] [Accepted: 12/15/2023] [Indexed: 12/27/2023]
Abstract
INTRODUCTION Inappropriate antibiotic use is a major cause of antibiotic resistance. Therefore, optimizing antibiotic usage is essential. In Belgium, optimization of antimicrobials for the fight against multidrug resistant organisms (MDROs) is followed up by national surveillance by public health authorities. To improve appropriate antimicrobial use in hospitals, an effective national Antimicrobial Stewardship (AMS) program should include indicators for measuring both the quantity and quality of antibiotic use. OBJECTIVES The aim of this study was to develop a set of process quality indicators (QIs) to evaluate and improve AMS in hospitals. METHODS A RAND-modified Delphi procedure was used. The procedure consisted of a structured narrative literature review to select the QIs, followed by two online questionnaires and an intermediate multidisciplinary panel discussion with experts in infectious diseases from general and teaching hospitals in Belgium. RESULTS A total of 38 QIs were selected after the RAND-modified Delphi procedure, from which 11 QIs were selected unanimously. These QIs address compliancy of antibiotic therapy and prophylaxis with local guidelines, documentation of the rationale for antibiotic treatment in the medical record, the availability of AMS Programs and Outpatient Parenteral Antibiotic Therapy, resistance patterns and antimicrobial prescribing during focused ward rounds. CONCLUSION Our study selected 38 relevant process QIs, from which 11 were unanimously selected. The QIs can contribute to the improvement of quality of antibiotic use by stimulating hospitals to present better outcomes and by providing a focus on how to intervene and to improve prescribing of antimicrobials.
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Affiliation(s)
- Sylvie Legros
- Pharmacy Department, Europe Hospitals, Brussels, Belgium
- Department of Antimicrobial Stewardship, Antimicrobial Stewardship, Europe Hospitals, Brussels, Belgium
| | - Anna Vanoverschelde
- Department of Bioanalysis, Pharmaceutical Care Unit, Ghent University, Ghent, Belgium
| | | | - Yves Debaveye
- Department of Intensive Care Medicine, KU Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Ann Versporten
- Belgian Antibiotic Policy Coordination Commission (BAPCOC), Quality and Patient Safety, Direction General Healthcare, Federal Public Service Health, Food Chain Safety and Environment, Brussels, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Diana Huis In 't Veld
- Department of Internal Medicine and Infectious Diseases, University Hospital Ghent, Ghent, Belgium
| | - Veerle Westelinck
- Department of Pharmacy, AZ Sint-Maarten, Mechelen, Belgium
- Antimicrobial Stewardship, AZ Sint-Maarten, Mechelen, Belgium
| | - Caroline Briquet
- Antimicrobial Stewardship, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
- Pharmacy Department, Cliniques Universitaires, Saint-Luc, UCLouvain, Brussels, Belgium
| | - Christelle Vercheval
- Department of Antimicrobial Stewardship, Hospital Outbreak Support Team (HOST), H.uni network, Brussels, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Olivier Denis
- Laboratory of microbiology, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Koen Magerman
- Department of Laboratory Medicine, Jessa Ziekenhuis vwz, Hasselt, Belgium
| | | | - Franky Buyle
- Pharmacy Department, Ghent University Hospital, Ghent, Belgium
- Antimicrobial Stewardship, Ghent University Hospital, Ghent, Belgium
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Geis D, Canova N, Lhopitallier L, Kronenberg A, Meuwly JY, Senn N, Mueller Y, Fasseur F, Boillat-Blanco N. Exploration of the Acceptance of the Use of Procalcitonin Point-of-Care Testing and Lung Ultrasonography by General Practitioners to Decide on Antibiotic Prescriptions for Lower Respiratory Infections: A Qualitative Study. BMJ Open 2023; 13:e063922. [PMID: 37169498 PMCID: PMC10186440 DOI: 10.1136/bmjopen-2022-063922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 04/12/2023] [Indexed: 05/13/2023] Open
Abstract
OBJECTIVES We aimed to explore the acceptance and opinions of general practitioners (GPs) on the use of procalcitonin point-of-care and lung ultrasonography for managing patients with lower respiratory tract infections in primary care. We suppose that there are several factors that can influence the physician's antibiotic prescribing decision, and the implementation of a new tool will only be possible when it can be inserted into the physician's daily practice, helping him/her in the decision-making process. DESIGN Semistructured interviews; data analysis using the grounded theory method. SETTING Lausanne, Switzerland. PARTICIPANTS 12 GPs who participated in the randomised clinical trial UltraPro, which evaluated the impact of the use of procalcitonin only or an algorithm combining procalcitonin and lung ultrasonography on antibiotic prescription. RESULTS GPs had mostly positive attitudes towards the use of point-of-care procalcitonin in lower respiratory tract infections and uncertainties regarding the usefulness of ultrasonography. Physicians' prescribing decisions result from interactions between three kinds of TrustS (core category): 'self-confidence', 'trust in the results' and 'trust in the doctor-patient relationship'. Procalcitonin reinforced the three levels of trust, while ultrasonography only strengthened the physician-patient relationship. To facilitate implementation of procalcitonin, physicians pointed out the need of coverage by insurance and of clear guidelines describing the targeted patient population. CONCLUSIONS Our data show that there is a preference for the implementation of procalcitonin rather than lung ultrasonography for the management of patients with lower respiratory tract infections in primary care. Coverage by insurance plans and updated guidelines are prerequisite to the successful implementation of procalcitonin testing in primary care. TRIAL REGISTRATION NUMBER NCT03191071.
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Affiliation(s)
- Daniel Geis
- Research Center for Psychology of Health, Aging and Sport Examination (PHASE), University of Lausanne, Lausanne, Switzerland
| | - Nina Canova
- Research Center for Psychology of Health, Aging and Sport Examination (PHASE), University of Lausanne, Lausanne, Switzerland
| | - Loïc Lhopitallier
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
- gare10 medical practice, Lausanne, Switzerland
| | - Andreas Kronenberg
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
- Medix General Practice, Bern, Switzerland
| | - Jean-Yves Meuwly
- Department of Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nicolas Senn
- Department of Family Medicine, Center for Primary Care and Public Health, Lausanne, Switzerland
| | - Yolanda Mueller
- Department of Family Medicine, Center for Primary Care and Public Health, Lausanne, Switzerland
| | - Fabienne Fasseur
- Research Center for Psychology of Health, Aging and Sport Examination (PHASE), University of Lausanne, Lausanne, Switzerland
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The Role of Procalcitonin as an Antimicrobial Stewardship Tool in Patients Hospitalized with Seasonal Influenza. Antibiotics (Basel) 2023; 12:antibiotics12030573. [PMID: 36978440 PMCID: PMC10044820 DOI: 10.3390/antibiotics12030573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/10/2023] [Accepted: 03/12/2023] [Indexed: 03/17/2023] Open
Abstract
Background: Up to 60% of the antibiotics prescribed to patients hospitalized with seasonal influenza are unnecessary. Procalcitonin (PCT) has the potential as an antimicrobial stewardship program (ASP) tool because it can differentiate between viral and bacterial etiology. We aimed to explore the role of PCT as an ASP tool in hospitalized seasonal influenza patients. Methods: We prospectively included 116 adults with seasonal influenza from two influenza seasons, 2018–2020. All data was obtained from a single clinical setting and analyzed by descriptive statistics and regression models. Results: In regression analyses, we found a positive association of PCT with 30 days mortality and the amount of antibiotics used. Influenza diagnosis was associated with less antibiotic use if the PCT value was low. Patients with a low initial PCT (<0.25 µg/L) had fewer hospital and intensive care unit (ICU) days and fewer positive chest X-rays. PCT had a negative predictive value of 94% for ICU care stay, 98% for 30 days mortality, and 88% for bacterial coinfection. Conclusion: PCT can be a safe rule-out test for bacterial coinfection. Routine PCT use in seasonal influenza patients with an uncertain clinical picture, and rapid influenza PCR testing, may be efficient as ASP tools.
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Plethora of Antibiotics Usage and Evaluation of Carbapenem Prescribing Pattern in Intensive Care Units: A Single-Center Experience of Malaysian Academic Hospital. Antibiotics (Basel) 2022; 11:antibiotics11091172. [PMID: 36139951 PMCID: PMC9495017 DOI: 10.3390/antibiotics11091172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/28/2022] Open
Abstract
Excessive antibiotic consumption is still common among critically ill patients admitted to intensive care units (ICU), especially during the coronavirus disease 2019 (COVID-19) period. Moreover, information regarding antimicrobial consumption among ICUs in South-East Asia remains scarce and limited. This study aims to determine antibiotics utilization in ICUs by measuring antibiotics consumption over the past six years (2016−2021) and specifically evaluating carbapenems prescribed in a COVID-19 ICU and a general intensive care unit (GICU) during the second year of the COVID-19 pandemic. (2) Methods: This is a retrospective cross-sectional observational analysis of antibiotics consumption and carbapenems prescriptions. Antibiotic utilization data were estimated using the WHO Defined Daily Doses (DDD). Carbapenems prescription information was extracted from the audits conducted by ward pharmacists. Patients who were prescribed carbapenems during their admission to COVID-19 ICU and GICU were included. Patients who passed away before being reviewed by the pharmacists were excluded. (3) Results: In general, antibiotics consumption increased markedly in the year 2021 when compared to previous years. Majority of carbapenems were prescribed empirically (86.8%). Comparing COVID-19 ICU and GICU, the reasons for empirical carbapenems therapy in COVID-19 ICU was predominantly for therapy escalation (64.7% COVID-19 ICU vs. 34% GICU, p < 0.001), whereas empirical prescription in GICU was for coverage of extended-spectrum beta-lactamases (ESBL) gram-negative bacteria (GNB) (45.3% GICU vs. 22.4% COVID-19 ICU, p = 0.005). Despite microbiological evidence, the empirical carbapenems were continued for a median (interquartile range (IQR)) of seven (5−8) days. This implies the need for a rapid diagnostic assay on direct specimens, together with comprehensive antimicrobial stewardship (AMS) discourse with intensivists to address this issue.
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Chen DC, Potok OA, Rifkin D, Estrella MM. Advantages, Limitations, and Clinical Considerations in Using Cystatin C to Estimate GFR. KIDNEY360 2022; 3:1807-1814. [PMID: 36514729 PMCID: PMC9717651 DOI: 10.34067/kid.0003202022] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/17/2022] [Indexed: 01/12/2023]
Abstract
Cystatin C has been shown to be a reliable and accurate marker of kidney function across diverse populations. The 2012 Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommended using cystatin C to confirm the diagnosis of chronic kidney disease (CKD) determined by creatinine-based estimated glomerular filtration rate (eGFR) and to estimate kidney function when accurate eGFR estimates are needed for clinical decision-making. In the efforts to remove race from eGFR calculations in the United States, the National Kidney Foundation (NKF) and American Society of Nephrology (ASN) Joint Task Force recommended increasing availability and clinical adoption of cystatin C to assess kidney function. This review summarizes the key advantages and limitations of cystatin C use in clinical practice. Our goals were to review and discuss the literature on cystatin C; understand the evidence behind the recommendations for its use as a marker of kidney function to diagnose CKD and risk stratify patients for adverse outcomes; discuss the challenges of its use in clinical practice; and guide clinicians on its interpretation.
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Affiliation(s)
- Debbie C. Chen
- Kidney Health Research Collaborative, University of California, San Francisco and San Francisco VA Health Care System, San Francisco, California
| | - O. Alison Potok
- University of California, San Diego and San Diego VA Health Care System, San Francisco, California
| | - Dena Rifkin
- University of California, San Diego and San Diego VA Health Care System, San Francisco, California
| | - Michelle M. Estrella
- Kidney Health Research Collaborative, University of California, San Francisco and San Francisco VA Health Care System, San Francisco, California
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Lim SYC, Zhou YP, Yii D, Chin DZ, Hung KC, Lee LW, Lim JL, Loo LW, Koomanan N, Chua NG, Liew Y, Cherng BPZ, Thien SY, Lee WHL, Kwa ALH, Chung SJ. Stemming the Rise of Antibiotic Use for Community-Acquired Acute Respiratory Infections during COVID-19 Pandemic. Antibiotics (Basel) 2022; 11:846. [PMID: 35884100 PMCID: PMC9312342 DOI: 10.3390/antibiotics11070846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/19/2022] [Accepted: 06/21/2022] [Indexed: 01/08/2023] Open
Abstract
At the start of the COVID-19 pandemic, there was an increase in the use of antibiotics for the treatment of community-acquired respiratory tract infection (CA-ARI) in patients admitted for suspected or confirmed COVID-19, raising concerns for misuse. These antibiotics are not under the usual purview of the antimicrobial stewardship unit (ASU). Serum procalcitonin, a biomarker to distinguish viral from bacterial infections, can be used to guide antibiotic recommendations in suspected lower respiratory tract infection. We modified our stewardship approach, and used a procalcitonin-guided strategy to identify “high yield” interventions for audits in patients admitted with CA-ARI. With this approach, there was an increase in the proportion of patients with antibiotics discontinued within 4 days (16.5% vs. 34.9%, p < 0.001), and the overall duration of antibiotic therapy was significantly shorter [7 (6−8) vs. 6 (3−8) days, p < 0.001]. There was a significant decrease in patients with intravenous-to-oral switch of antibiotics to “complete the course” (45.3% vs. 34.4%, p < 0.05). Of the patients who had antibiotics discontinued, none were restarted on antibiotics within 48 h, and there was no-30-day readmission or 30-day mortality attributed to respiratory infection. This study illustrates the importance of the antimicrobial stewardship during the pandemic and the need for ASU to remain attuned to prescriber’s practices, and adapt accordingly to address antibiotic misuse to curb antimicrobial resistance.
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Affiliation(s)
- Shena Y. C. Lim
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Yvonne P. Zhou
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Daphne Yii
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - De Zhi Chin
- Department of Clinical Quality and Performance Management, Singapore General Hospital, Singapore 169608, Singapore;
| | - Kai Chee Hung
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Lai Wei Lee
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Jia Le Lim
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Li Wen Loo
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Narendran Koomanan
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Nathalie Grace Chua
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Yixin Liew
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Benjamin P. Z. Cherng
- Department of Infectious Diseases, Singapore General Hospital, Singapore 169608, Singapore; (B.P.Z.C.); (S.Y.T.)
| | - Siew Yee Thien
- Department of Infectious Diseases, Singapore General Hospital, Singapore 169608, Singapore; (B.P.Z.C.); (S.Y.T.)
| | - Winnie H. L. Lee
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Andrea L. H. Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Shimin J. Chung
- Department of Infectious Diseases, Singapore General Hospital, Singapore 169608, Singapore; (B.P.Z.C.); (S.Y.T.)
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Kyriazopoulou E, Giamarellos-Bourboulis EJ. Antimicrobial Stewardship Using Biomarkers: Accumulating Evidence for the Critically Ill. Antibiotics (Basel) 2022; 11:antibiotics11030367. [PMID: 35326830 PMCID: PMC8944654 DOI: 10.3390/antibiotics11030367] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 12/28/2022] Open
Abstract
This review aims to summarize current progress in the management of critically ill, using biomarkers as guidance for antimicrobial treatment with a focus on antimicrobial stewardship. Accumulated evidence from randomized clinical trials (RCTs) and observational studies in adults for the biomarker-guided antimicrobial treatment of critically ill (mainly sepsis and COVID-19 patients) has been extensively searched and is provided. Procalcitonin (PCT) is the best studied biomarker; in the majority of randomized clinical trials an algorithm of discontinuation of antibiotics with decreasing PCT over serial measurements has been proven safe and effective to reduce length of antimicrobial treatment, antibiotic-associated adverse events and long-term infectious complications like infections by multidrug-resistant organisms and Clostridioides difficile. Other biomarkers, such as C-reactive protein and presepsin, are already being tested as guidance for shorter antimicrobial treatment, but more research is needed. Current evidence suggests that biomarkers, mainly procalcitonin, should be implemented in antimicrobial stewardship programs even in the COVID-19 era, when, although bacterial coinfection rate is low, antimicrobial overconsumption remains high.
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Affiliation(s)
- Evdoxia Kyriazopoulou
- 2nd Department of Critical Care Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Evangelos J. Giamarellos-Bourboulis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
- Correspondence: ; Tel.: +30-210-5831994
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Isgren CM. Improving clinical outcomes via responsible antimicrobial use in horses. EQUINE VET EDUC 2021. [DOI: 10.1111/eve.13502] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- C. M. Isgren
- Department of Equine Clinical Science Faculty of Health & Life Sciences Institute of Infection, Veterinary and Ecological Sciences University of Liverpool Leahurst UK
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O'Riordan F, Shiely F, Byrne S, Fleming A. A qualitative process evaluation of the introduction of procalcitonin testing as an antimicrobial stewardship intervention. Int J Clin Pharm 2020; 43:532-540. [PMID: 33001314 DOI: 10.1007/s11096-020-01159-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
Background Successful antimicrobial stewardship interventions are imperative in today's environment of antimicrobial resistance. New antimicrobial stewardship interventions should include qualitative analysis such as a process evaluation to determine which elements within an intervention are effective and provide insight into the context in which the intervention is introduced. Objective To assess the implementation process and explore the contextual factors which influenced implementation. Setting An academic teaching hospital in Cork, Ireland. Methods A process evaluation was conducted on completion of a feasibility study of the introduction of a procalcitonin antimicrobial stewardship intervention. The process evaluation consisted of semi-structured face-to-face interviews of key stakeholders including participating (senior) doctors (5), medical laboratory scientists (3) and a hospital administrator. The Consolidated Framework for Implementation Research was used to guide data collection, analysis, and interpretation. Main outcome measures Qualitative assessment of the intervention implementation process, the contextual factors which influenced implementation and identification of improvements to the intervention and its implementation and determine if proceeding to a randomised controlled trial would be appropriate. Results Analysis of the interviews identified three main themes. (1) The procalcitonin intervention and implementation process was viewed positively to support prescribing decisions. Participants identified modifications to procalcitonin processing and availability to improve implementation and allow procalcitonin to be "more of a clinical influence". (2) In the antimicrobial stewardship context the concept of fear of missing an infection and risks of potentially serious outcomes for patients emerged. (3) The hospital context consisted of barriers such as available resources and facilitators including the hospital culture of quality improvement. Conclusion This process evaluation provides a detailed analysis of the implementation of procalcitonin testing as an antimicrobial stewardship intervention. The positive findings of this process evaluation and feasibility study should be built upon and a full randomised controlled trial and economic evaluation should be conducted in a variety of hospital settings to confirm the effectiveness of procalcitonin as an antimicrobial stewardship intervention.
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Affiliation(s)
- F O'Riordan
- Pharmacy Department, Mercy University Hospital, Grenville Place, Cork, Ireland. .,Clinical Pharmacy Research Group, School of Pharmacy, University College Cork, Cork, Ireland.
| | - F Shiely
- HRB Clinical Research Facility Cork, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - S Byrne
- Clinical Pharmacy Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - A Fleming
- Pharmacy Department, Mercy University Hospital, Grenville Place, Cork, Ireland.,Clinical Pharmacy Research Group, School of Pharmacy, University College Cork, Cork, Ireland
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