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Kumar NR, Balraj TA, Kempegowda SN, Prashant A. Multidrug-Resistant Sepsis: A Critical Healthcare Challenge. Antibiotics (Basel) 2024; 13:46. [PMID: 38247605 PMCID: PMC10812490 DOI: 10.3390/antibiotics13010046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 12/25/2023] [Accepted: 12/28/2023] [Indexed: 01/23/2024] Open
Abstract
Sepsis globally accounts for an alarming annual toll of 48.9 million cases, resulting in 11 million deaths, and inflicts an economic burden of approximately USD 38 billion on the United States healthcare system. The rise of multidrug-resistant organisms (MDROs) has elevated the urgency surrounding the management of multidrug-resistant (MDR) sepsis, evolving into a critical global health concern. This review aims to provide a comprehensive overview of the current epidemiology of (MDR) sepsis and its associated healthcare challenges, particularly in critically ill hospitalized patients. Highlighted findings demonstrated the complex nature of (MDR) sepsis pathophysiology and the resulting immune responses, which significantly hinder sepsis treatment. Studies also revealed that aging, antibiotic overuse or abuse, inadequate empiric antibiotic therapy, and underlying comorbidities contribute significantly to recurrent sepsis, thereby leading to septic shock, multi-organ failure, and ultimately immune paralysis, which all contribute to high mortality rates among sepsis patients. Moreover, studies confirmed a correlation between elevated readmission rates and an increased risk of cognitive and organ dysfunction among sepsis patients, amplifying hospital-associated costs. To mitigate the impact of sepsis burden, researchers have directed their efforts towards innovative diagnostic methods like point-of-care testing (POCT) devices for rapid, accurate, and particularly bedside detection of sepsis; however, these methods are currently limited to detecting only a few resistance biomarkers, thus warranting further exploration. Numerous interventions have also been introduced to treat MDR sepsis, including combination therapy with antibiotics from two different classes and precision therapy, which involves personalized treatment strategies tailored to individual needs. Finally, addressing MDR-associated healthcare challenges at regional levels based on local pathogen resistance patterns emerges as a critical strategy for effective sepsis treatment and minimizing adverse effects.
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Affiliation(s)
- Nishitha R. Kumar
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India; (N.R.K.); (S.N.K.)
| | - Tejashree A. Balraj
- Department of Microbiology, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India;
| | - Swetha N. Kempegowda
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India; (N.R.K.); (S.N.K.)
| | - Akila Prashant
- Department of Biochemistry, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India; (N.R.K.); (S.N.K.)
- Department of Medical Genetics, JSS Medical College and Hospital, JSS Academy of Higher Education & Research, Mysuru 570004, India
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Monti G, Rezoagli E, Calini A, Nova A, Marchesi S, Nattino G, Carrara G, Morra S, Cortellaro F, Savioli M, Capra Marzani F, Tresoldi M, Villa P, Greco S, Bonfanti P, Spitoni MG, Vesconi S, Caironi P, Fumagalli R. Effect of a quality improvement program on compliance to the sepsis bundle in non-ICU patients: a multicenter prospective before and after cohort study. Front Med (Lausanne) 2023; 10:1215341. [PMID: 38020128 PMCID: PMC10680451 DOI: 10.3389/fmed.2023.1215341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Sepsis and septic shock are major challenges and economic burdens to healthcare, impacting millions of people globally and representing significant causes of mortality. Recently, a large number of quality improvement programs focused on sepsis resuscitation bundles have been instituted worldwide. These educational initiatives have been shown to be associated with improvements in clinical outcomes. We aimed to evaluate the impact of a multi-faceted quality implementing program (QIP) on the compliance of a "simplified 1-h bundle" (Sepsis 6) and hospital mortality of severe sepsis and septic shock patients out of the intensive care unit (ICU). Methods Emergency departments (EDs) and medical wards (MWs) of 12 academic and non-academic hospitals in the Lombardy region (Northern Italy) were involved in a multi-faceted QIP, which included educational and organizational interventions. Patients with a clinical diagnosis of severe sepsis or septic shock according to the Sepsis-2 criteria were enrolled in two different periods: from May 2011 to November 2011 (before-QIP cohort) and from August 2012 to June 2013 (after-QIP cohort). Measurements and main results The effect of QIP on bundle compliance and hospital mortality was evaluated in a before-after analysis. We enrolled 467 patients in the before-QIP group and 656 in the after-QIP group. At the time of enrollment, septic shock was diagnosed in 50% of patients, similarly between the two periods. In the after-QIP group, we observed increased compliance to the "simplified rapid (1 h) intervention bundle" (the Sepsis 6 bundle - S6) at three time-points evaluated (1 h, 13.7 to 18.7%, p = 0.018, 3 h, 37.1 to 48.0%, p = 0.013, overall study period, 46.2 to 57.9%, p < 0.001). We then analyzed compliance with S6 and hospital mortality in the before- and after-QIP periods, stratifying the two patients' cohorts by admission characteristics. Adherence to the S6 bundle was increased in patients with severe sepsis in the absence of shock, in patients with serum lactate <4.0 mmol/L, and in patients with hypotension at the time of enrollment, regardless of the type of admission (from EDs or MWs). Subsequently, in an observational analysis, we also investigated the relation between bundle compliance and hospital mortality by logistic regression. In the after-QIP cohort, we observed a lower in-hospital mortality than that observed in the before-QIP cohort. This finding was reported in subgroups where a higher adherence to the S6 bundle in the after-QIP period was found. After adjustment for confounders, the QIP appeared to be independently associated with a significant improvement in hospital mortality. Among the single S6 procedures applied within the first hour of sepsis diagnosis, compliance with blood culture and antibiotic therapy appeared significantly associated with reduced in-hospital mortality. Conclusion A multi-faceted QIP aimed at promoting an early simplified bundle of care for the management of septic patients out of the ICU was associated with improved compliance with sepsis bundles and lower in-hospital mortality.
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Affiliation(s)
- Gianpaola Monti
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca’ Granda, Milan, Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Angelo Calini
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca’ Granda, Milan, Italy
| | - Alice Nova
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Silvia Marchesi
- Intensiv och perioperativ vard, Skane Universitetssjukhus, Malmo, Sweden
| | - Giovanni Nattino
- Istituto di ricerche farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Greta Carrara
- Istituto di ricerche farmacologiche Mario Negri IRCCS, Ranica, Bergamo, Italy
| | - Sergio Morra
- Department of Anesthesia and Intensive Care, ASST Ovest Milano, Legnano, Italy
| | | | - Monica Savioli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCSC Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Capra Marzani
- Department of Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Moreno Tresoldi
- Unit of General Medicine and Advanced Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Villa
- Department of Emergency, ASST FBF - Sacco, Ospedale L. Sacco, Milan, Italy
| | - Stefano Greco
- Department of Anesthesia and Intensive Care, ASST Valle Olona, Ospedale Busto Arsitio, Busto Arsitio, Italy
| | - Paolo Bonfanti
- Infectious Diseases, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | - Sergio Vesconi
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca’ Granda, Milan, Italy
| | - Pietro Caironi
- Department of Anesthesia and Intensive Care, AOU S. Luigi Gonzaga, Università degli Studi di Torino, Orbassano, Italy
| | - Roberto Fumagalli
- Department of Anesthesia and Intensive Care, ASST GOM Niguarda Ca’ Granda, Milan, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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Moraes RB, Haas JS, Vidart J, Nicolaidis R, Deutschendorf C, Moretti MMS, Friedman G, Silva D. A Coordinated and Multidisciplinary Strategy can Reduce the Time for Antibiotics in Septic Patients at a University Hospital. Indian J Crit Care Med 2023; 27:465-469. [PMID: 37502294 PMCID: PMC10369314 DOI: 10.5005/jp-journals-10071-24483] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 06/06/2023] [Indexed: 07/29/2023] Open
Abstract
Objectives We carried out this work with the aim of assessing the effectiveness of a set of interventions over time for the administration of antibiotics. Design Prospective observational study. Setting Patients admitted to the emergency room and ICU of the hospital where the study was conducted are evaluated daily for some sociodemographic and clinical variables. Among them are some quality indicators, such as the time between the diagnosis of sepsis or septic shock until the start of the infusion of antibiotics. This indicator reflects several aspects related to a set of assistance measures (adequacy of antibiotic dispensation, rapid response team (RRT), sepsis care quality improvement program, antimicrobial management program, improvements in emergency department assistance). Patients or participants Patients with sepsis or septic shock were admitted to the ICU of a university and public hospital in southern Brazil. Main variables of interest The time between the diagnosis of sepsis or septic shock and the beginning of the infusion of antibiotics. Results Between 2013 and 2018, 1676 patients were evaluated. The mean time for antibiotic infusion decreased from 6.1 ± 8.6 hours to 1.7 ± 2.9 hours (p < 0.001). The percentage of patients who received antibiotics in the first hour increased from 20.7 to 59.0% (p < 0.001). Conclusion In this study, we demonstrated that a set of actions adopted in a large tertiary hospital was associated with decreased time to start antibiotic therapy in septic patients. How to cite this article Moraes RB, Haas JS, Vidart J, Nicolaidis R, Deutschendorf C, Moretti MMS, et al. A Coordinated and Multidisciplinary Strategy can Reduce the Time for Antibiotics in Septic Patients at a University Hospital. Indian J Crit Care Med 2023;27(7):465-469.
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Affiliation(s)
| | | | - Josi Vidart
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Rafael Nicolaidis
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Gilberto Friedman
- Programa de Pos-graduacao em Ciencias Pneumologicas, Universidade Federal do Rio Grande do Sul – School of Medicine, Porto Alegre, Rio Grande do Sul, Brazil
| | - Daiandy Silva
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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Lennox L, Antonacci G, Harris M, Reed J. Unpacking the 'process of sustaining'-identifying threats to sustainability and the strategies used to address them: a longitudinal multiple case study. Implement Sci Commun 2023; 4:68. [PMID: 37337274 DOI: 10.1186/s43058-023-00445-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 05/25/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Although sustainability remains a recognised challenge for Quality Improvement (QI) initiatives, most available research continues to investigate sustainability at the end of implementation. As a result, the learning and continuous adjustments that shape sustainability outcomes are lost. With little understanding of the actions and processes that influence sustainability within QI initiatives, there is limited practical guidance and direction on how to enhance the sustainability of QI initiatives. This study aims to unpack the 'process of sustaining', by exploring threats to sustainability encountered throughout the implementation of QI Initiatives and identifying strategies used by QI teams to address these threats over time. METHODS A longitudinal multiple case study design was employed to follow 4 QI initiatives over a 3-year period. A standardised sustainability tool was used quarterly to collect perceptions of sustainability threats and actions throughout implementation. Interviews (n=38), observations (32.5 h), documentary analysis, and a focus group (n=10) were conducted to enable a greater understanding of how the process of sustaining is supported in practice. Data were analysed using the Consolidated Framework for Sustainability (CFS) to conduct thematic analysis. RESULTS Analysis identified five common threats to sustainability: workforce stability, improvement timelines, organisational priorities, capacity for improvement, and stakeholder support. Each of these threats impacted multiple sustainability constructs demonstrating the complexity of the issues encountered. In response to threats, 12 strategies to support the process of sustaining were identified under three themes: engagement (five strategies that promoted the development of relationships), integration (three strategies that supported initiatives to become embedded within local systems), and adaptation (four strategies that enhanced understanding of, and response to, emergent conditions and contextual needs). CONCLUSIONS Sustaining improvements from QI initiatives requires continuous investment in relationships, resilience to integrate improvements in local systems, and flexibility to understand emergent conditions. Findings provide practitioners, funders, and researchers with a better understanding of, and preparation for, the threats associated with sustaining improvements from QI initiatives and offer insight into specific actions that can be taken to mitigate these risks. This learning can be used to inform future initiative design and support, to optimise the sustainability of healthcare improvements. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Laura Lennox
- National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) for Northwest London, 369 Fulham Road, London, SW10 9NH, UK.
- Department of Primary Care and Public Health, Imperial College London, Charing Cross Campus, The Reynolds Building, St Dunstan's Road, London, W6 8RP, UK.
| | - Grazia Antonacci
- National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) for Northwest London, 369 Fulham Road, London, SW10 9NH, UK
- Department of Primary Care and Public Health, Imperial College London, Charing Cross Campus, The Reynolds Building, St Dunstan's Road, London, W6 8RP, UK
- Business School, Centre for Health Economics and Policy Innovation (CHEPI), Imperial College London, South Kensington Campus, Exhibition Rd, London, SW7 2AZ, UK
| | - Matthew Harris
- National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) for Northwest London, 369 Fulham Road, London, SW10 9NH, UK
- Department of Primary Care and Public Health, Imperial College London, Charing Cross Campus, The Reynolds Building, St Dunstan's Road, London, W6 8RP, UK
| | - Julie Reed
- Julie Reed Consultancy Ltd, 27 Molasses House, London, UK
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Tu KJ, Wymore C, Tchangalova N, Fuller BM, Mohr NM. The impact of telehealth in sepsis care: A systematic review. J Telemed Telecare 2023:1357633X231170038. [PMID: 37093782 PMCID: PMC11187410 DOI: 10.1177/1357633x231170038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Sepsis is associated with significant mortality. Telehealth may improve the quality of early sepsis care, but the use and impact of telehealth applications for sepsis remain unclear. We aim to describe the telehealth interventions that have been used to facilitate sepsis care, and to summarize the reported effect of telehealth on sepsis outcomes. DATA SOURCES We identified articles reporting telehealth use for sepsis using an English-language search of PubMed, CINAHL Plus (EBSCO), Academic Search Ultimate (EBSCO), APA PsycINFO (EBSCO), Public Health (ProQuest), and Web of Science databases with no restrictions on publication date. STUDY SELECTION Included studies described the use of telehealth as an intervention for treating sepsis. Only comparative effectiveness analyses were included. DATA EXTRACTION AND SYNTHESIS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines, two investigators independently selected articles for inclusion and abstracted data. A random-effects subgroup analysis was conducted on patient survival treated with and without telehealth. RESULTS A total of 15 studies were included, involving 188,418 patients with sepsis. Thirteen studies used observational study designs, and the most common telehealth applications were provider-to-provider telehealth consultation and intensive care unit telehealth. Clinical and methodological heterogeneity was significantly high. Telehealth use was associated with higher survival, especially in settings with low control group survival. The effect of telehealth on other care processes and outcomes were more varied and likely dependent on hospital-level factors. CONCLUSIONS Telehealth has been used in diverse applications for sepsis care, and it may improve patient outcomes in certain contexts. Additional interventional trials and cost-based analyses would clarify the causal role of telehealth in improving sepsis outcomes.
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Affiliation(s)
- Kevin J. Tu
- Department of Cell Biology and Molecular Genetics, University of Maryland, College Park, Maryland
| | - Cole Wymore
- Department of Emergency Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Nedelina Tchangalova
- Research and Academic Services, University of Maryland Libraries, College Park, Maryland
| | - Brian M. Fuller
- Division of Critical Care, Department of Anesthesiology, Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia Critical Care, and Epidemiology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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Lorente L, Martín MM, Ortiz-López R, Pérez-Cejas A, Ferrer-Moure C, Jiménez A, González-Rivero AF. Association between septic patient mortality and blood survivin concentrations. Med Intensiva 2023; 47:84-89. [PMID: 36272905 DOI: 10.1016/j.medine.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/26/2021] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Survivin is a member of inhibitors of apoptosis proteins family. There are not data about the association between mortality of septic patients and blood survivin concentrations. Therefore, the objective of this study was to determine whether exist that association. DESIGN Observational and prospective study. SETTING Three Spanish Intensive Care Units. PATIENTS Patients with sepsis or septic shock according to Sepsis-3 Consensus criteria. INTERVENTIONS Serum survivin concentrations were determined at moment of sepsis diagnosis. MAIN VARIABLE OF INTEREST Mortality at 30 days. RESULTS A total of 204 patients were included in the study, of which 75 (36.8%) died in the first 30 days. Lower age (p<0.001), serum lactic acid levels (p=0.001), rate of septic shock (p=0.001) and SOFA (p<0.001), and higher serum survivin levels (p=0.001) exhibited surviving (n=129) than non-surviving patients (n=75). We found in multiple logistic regression analysis an association between serum survivin concentrations and mortality independently of SOFA, lactic acid, age, INR, activated partial thromboplastin time (aPTT) and empiric antimicrobial treatment adequate (OR=0.968; 95% CI=0.946-0.990; p=0.005), and also independently of APACHE-II, lactic acid, platelet, INR, aPTT and empiric antimicrobial treatment adequate (OR=0.966; 95% CI=0.943-0.989; p=0.004). CONCLUSIONS There is an association between septic patient mortality and low blood survivin concentrations.
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Affiliation(s)
- L Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain.
| | - M M Martín
- Intensive Care Unit, Hospital Universitario Nuestra Señora Candelaria, Santa Cruz Tenerife, Spain
| | - R Ortiz-López
- Intensive Care Unit, Hospital General de La Palma, Breña Alta, La Palma, Spain
| | - A Pérez-Cejas
- Laboratory Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - C Ferrer-Moure
- Laboratory Department, Hospital Universitario de Canarias, Tenerife, Spain
| | - A Jiménez
- Research Unit, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
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Empirical antibiotic therapy for difficult-to-treat Gram-negative infections: when, how, and how long? Curr Opin Infect Dis 2022; 35:568-574. [PMID: 36206149 DOI: 10.1097/qco.0000000000000884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW To discuss empirical therapy for severe infections due to Gram-negative bacteria with difficult-to-treat resistance (GNB-DTR) in current clinical practice, focusing in particular on the positioning of novel therapeutic agents and rapid diagnostic tests. RECENT FINDINGS The current era of novel agents active against GNB-DTR and showing differential activity against specific determinants of resistance is an unprecedented scenario, in which the clinical reasoning leading to the choice of the empirical therapy for treating severe GNB-DTR infections is becoming more complex, but it also allows for enhanced treatment precision. SUMMARY Novel agents should be used in line with antimicrobial stewardship principles, aimed at reducing selective pressure for antimicrobial resistance. However, this does not mean that they should not be used. Indeed, excesses in restrictive uses may be unethical by precluding access to the most effective and less toxic treatments for patients with severe GNB-DTR infections. Given these premises (the 'how'), empirical treatment with novel agents should be considered in all patients with risk factors for GNB-DTR and severe clinical presentation of acute infection (the 'when'). Furthermore, empirical novel agents should preferably be continued only for a few hours, until de-escalation, modification, or confirmation (as targeted therapy) is made possible by the results of rapid diagnostic tests (the 'how long').
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Lorencio Cárdenas C, Yébenes JC, Vela E, Clèries M, Sirvent JM, Fuster-Bertolín C, Reina C, Rodríguez A, Ruiz-Rodríguez JC, Trenado J, Esteban Torné E. Trends in mortality in septic patients according to the different organ failure during 15 years. Crit Care 2022; 26:302. [PMID: 36192781 PMCID: PMC9528124 DOI: 10.1186/s13054-022-04176-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/14/2022] [Indexed: 11/07/2022] Open
Abstract
Background The incidence of sepsis can be estimated between 250 and 500 cases/100.000 people per year and is responsible for up to 6% of total hospital admissions. Identified as one of the most relevant global health problems, sepsis is the condition that generates the highest costs in the healthcare system. Important changes in the management of septic patients have been included in recent years; however, there is no information about how changes in the management of sepsis-associated organ failure have contributed to reduce mortality. Methods A retrospective analysis was conducted from hospital discharge records from the Minimum Basic Data Set Acute-Care Hospitals (CMBD-HA in Catalan language) for the Catalan Health System (CatSalut). CMBD-HA is a mandatory population-based register of admissions to all public and private acute-care hospitals in Catalonia. Sepsis was defined by the presence of infection and at least one organ dysfunction. Patients hospitalized with sepsis were detected, according ICD-9-CM (since 2005 to 2017) and ICD-10-CM (2018 and 2019) codes used to identify acute organ dysfunction and infectious processes. Results Of 11.916.974 discharges from all acute-care hospitals during the study period (2005–2019), 296.554 had sepsis (2.49%). The mean annual sepsis incidence in the population was 264.1 per 100.000 inhabitants/year, and it increased every year, going from 144.5 in 2005 to 410.1 in 2019. Multiorgan failure was present in 21.9% and bacteremia in 26.3% of cases. Renal was the most frequent organ failure (56.8%), followed by cardiovascular (24.2%). Hospital mortality during the study period was 19.5%, but decreases continuously from 25.7% in 2005 to 17.9% in 2019 (p < 0.0001). The most important reduction in mortality was observed in cases with cardiovascular failure (from 47.3% in 2005 to 31.2% in 2019) (p < 0.0001). In the same way, mean mortality related to renal and respiratory failure in sepsis was decreased in last years (p < 0.0001). Conclusions The incidence of sepsis has been increasing in recent years in our country. However, hospital mortality has been significantly reduced. In septic patients, all organ failures except liver have shown a statistically significant reduction on associated mortality, with cardiovascular failure as the most relevant. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04176-w.
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Affiliation(s)
- Carolina Lorencio Cárdenas
- grid.411295.a0000 0001 1837 4818Intensive Care Department, Hospital Universitari Dr. Josep Trueta, Girona, Spain ,grid.5319.e0000 0001 2179 7512Universitat de Girona. UdG., Girona, Spain
| | - Juan Carlos Yébenes
- grid.414519.c0000 0004 1766 7514Intensive Care Department, Hospital de Mataró, Mataró, Spain
| | - Emili Vela
- grid.418284.30000 0004 0427 2257Digitalization for the Sustainability of the Healthcare System (DS3), IDIBELL., Barcelona, Spain ,grid.22061.370000 0000 9127 6969Àrea de Sistemes d’informació, Servei Català de la Salut (CatSalut), Barcelona, Spain
| | - Montserrat Clèries
- grid.418284.30000 0004 0427 2257Digitalization for the Sustainability of the Healthcare System (DS3), IDIBELL., Barcelona, Spain ,grid.22061.370000 0000 9127 6969Àrea de Sistemes d’informació, Servei Català de la Salut (CatSalut), Barcelona, Spain
| | - Josep Mª Sirvent
- grid.411295.a0000 0001 1837 4818Intensive Care Department, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Cristina Fuster-Bertolín
- grid.411295.a0000 0001 1837 4818Intensive Care Department, Hospital Universitari Dr. Josep Trueta, Girona, Spain
| | - Clara Reina
- grid.414519.c0000 0004 1766 7514Intensive Care Department, Hospital de Mataró, Mataró, Spain
| | - Alejandro Rodríguez
- grid.411435.60000 0004 1767 4677Intensive Care Department, Hospital Universitari Joan XXIII, Tarragona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- grid.411083.f0000 0001 0675 8654Intensive Care Department, Shock, Organ Dysfunction and Resuscitation Research Group, Vall d’Hebron, Vall d’Hebron Hospital Universitari, Vall d’Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Josep Trenado
- grid.414875.b0000 0004 1794 4956Intensive Care Department, Hospital Mútua de Terrassa, Terrassa, Spain
| | - Elisabeth Esteban Torné
- grid.411160.30000 0001 0663 8628Pediatric Intensive Care Department, Hospital Universitari Sant Joan de Déu, Barcelona, Spain
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Schwarzkopf D, Matthaeus-Kraemer CT, Thomas-Rüddel DO, Rüddel H, Poidinger B, Bach F, Gerlach H, Gründling M, Lindner M, Scheer C, Simon P, Weiss M, Reinhart K, Bloos F. A multifaceted educational intervention improved anti-infectious measures but had no effect on mortality in patients with severe sepsis. Sci Rep 2022; 12:3925. [PMID: 35273276 PMCID: PMC8913650 DOI: 10.1038/s41598-022-07915-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 02/28/2022] [Indexed: 11/28/2022] Open
Abstract
Sepsis is a major reason for preventable hospital deaths. A cluster-randomized controlled trial on an educational intervention did not show improvements of sepsis management or outcome. We now aimed to test an improved implementation strategy in a second intervention phase in which new intervention hospitals (former controls) received a multifaceted educational intervention, while controls (former intervention hospitals) only received feedback of quality indicators. Changes in outcomes from the first to the second intervention phase were compared between groups using hierarchical generalized linear models controlling for possible confounders. During the two phases, 19 control hospitals included 4050 patients with sepsis and 21 intervention hospitals included 2526 patients. 28-day mortality did not show significant changes between study phases in both groups. The proportion of patients receiving antimicrobial therapy within one hour increased in intervention hospitals, but not in control hospitals. Taking at least two sets of blood cultures increased significantly in both groups. During phase 2, intervention hospitals showed higher proportion of adequate initial antimicrobial therapy and de-escalation within 5 days. A survey among involved clinicians indicated lacking resources for quality improvement. Therefore, quality improvement programs should include all elements of sepsis guidelines and provide hospitals with sufficient resources for quality improvement. Trial registration: ClinicalTrials.gov, NCT01187134. Registered 23 August 2010, https://www.clinicaltrials.gov/ct2/show/study/NCT01187134.
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Affiliation(s)
- Daniel Schwarzkopf
- Integrated Research and Treatment Center-Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany. .,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany. .,Center for Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
| | - Claudia Tanja Matthaeus-Kraemer
- Integrated Research and Treatment Center-Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Daniel O Thomas-Rüddel
- Integrated Research and Treatment Center-Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Hendrik Rüddel
- Integrated Research and Treatment Center-Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Bernhard Poidinger
- Integrated Research and Treatment Center-Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Friedhelm Bach
- Department for Infectious Diseases, Protestant Hospital of Bethel Foundation University Hospital, University of Bielefeld, Bethesdaweg 10, 33617, Bielefeld, Germany
| | - Herwig Gerlach
- Department for Anaesthesia, Intensive Care Medicine and Pain Management, Vivantes-Klinikum Neukoelln, Rudower Strasse 48, 12351, Berlin, Germany
| | - Matthias Gründling
- Department of Anaesthesiology, University Hospital of Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Matthias Lindner
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Christian Scheer
- Department of Anaesthesiology, University Hospital of Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Philipp Simon
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, Liebigstraße 20, 04103, Leipzig, Germany
| | - Manfred Weiss
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Konrad Reinhart
- Department of Anaesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.,Berlin Institute of Health, Campus Virchow-Klinikum, Anna-Louisa-Karsch-Straße 2, 10178, Berlin, Germany
| | - Frank Bloos
- Integrated Research and Treatment Center-Center for Sepsis Control and Care (CSCC), Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
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10
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Lorente L, Martín M, Ortiz-López R, Pérez-Cejas A, Ferrer-Moure C, Jiménez A, González-Rivero A. Association between septic patient mortality and blood survivin concentrations. Med Intensiva 2022. [DOI: 10.1016/j.medin.2021.12.014] [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]
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11
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Plata-Menchaca EP, Ruiz-Rodríguez JC, Ferrer R. Evidence for the Application of Sepsis Bundles in 2021. Semin Respir Crit Care Med 2021; 42:706-716. [PMID: 34544188 DOI: 10.1055/s-0041-1733899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sepsis represents a severe condition that predisposes patients to a high risk of death if its progression is not ended. As with other time-dependent conditions, the performance of determinant interventions has led to significant survival benefits and quality-of-care improvements in acute emergency care. Thus, the initial interventions in sepsis are a cornerstone for prognosis in most patients. Even though the evidence supporting the hour-1 bundle is perfectible, real-life application of thoughtful and organized sepsis care has improved survival and quality of care in settings promoting compliance to evidence-based treatments. Current evidence for implementing the Surviving Sepsis Campaign bundles for early sepsis management is moving forward to better approaches as more substantial evidence evolves.
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Affiliation(s)
- Erika P Plata-Menchaca
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Hospital Universitari, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital Universitari, Vall d'Hebron, Barcelona, Spain.,Department of Medicine, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, Spain
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12
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Bringué J, Guillamat-Prats R, Martinez ML, Torrents E, Camprubí-Rimblas M, Blanch L, Artigas A. Methotrexate Ameliorates Systemic Inflammation and Septic Associated-Lung Damage in a Cecal Ligation and Puncture Septic Rat Model. Int J Mol Sci 2021; 22:9612. [PMID: 34502521 PMCID: PMC8431751 DOI: 10.3390/ijms22179612] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/27/2021] [Accepted: 09/01/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Sepsis is a serious, heterogeneous clinical entity produced by a severe and systemic host inflammatory response to infection. Methotrexate (MTX) is a folate-antagonist that induces the generation of adenosine and also inhibits JAK/STAT pathway; MTX it is widely used as an anti-inflammatory drug to control the immune system. OBJECTIVE The aim of this study was to assess the beneficial effects of a single and low dose of MTX in the systemic response and acute lung injury (ALI) induced by sepsis. As in the clinics, we treated our animals with antibiotics and fluids and performed the source control to mimic the current clinic treatment. METHODS AND MAIN RESULTS Sepsis was induced in rats by a cecal ligation puncture (CLP) procedure. Six hours after induction of sepsis, we proceeded to the source control; fluids and antibiotics were administered at 6 h and 24 h after CLP. MTX (2.5 mg/Kg) was administered 6 h after the first surgery in one CLP experimental group and to one Sham group. A protective effect of MTX was observed through a significant reduction of pro-inflammatory cytokines and a decrease infiltration of inflammatory cells in the lung. In addition, we found a regulation in adenosine receptor A2aR and the metalloproteinases by MTX. CONCLUSION A single, low dose of MTX attenuates sepsis lung-associated damage by decreasing pro-inflammatory response, infiltration of pro-inflammatory cells and avoiding defective tissue lung remodeling.
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Affiliation(s)
- Josep Bringué
- Institut d’ Investigació i Innovació Parc Taulí (I3PT), 08201 Sabadell, Spain; (J.B.); (M.C.-R.); (L.B.); (A.A.)
- CIBER de Enfermedades Respiratorias (CIBERES), 08201 Sabadell, Spain
- Facultat de Medicina, Universitat Autonoma de Barcelona, 08193 Bellaterra, Spain
| | - Raquel Guillamat-Prats
- Institut d’ Investigació i Innovació Parc Taulí (I3PT), 08201 Sabadell, Spain; (J.B.); (M.C.-R.); (L.B.); (A.A.)
- CIBER de Enfermedades Respiratorias (CIBERES), 08201 Sabadell, Spain
| | - Maria Luisa Martinez
- Critical Care Center—Hospital Universitario General de Catalunya, 08190 Sant Cugat del Valles, Spain;
| | - Eva Torrents
- Critical Care Center—Corporació Sanitària i Universitària Parc Taulí, 08201 Sabadell, Spain;
| | - Marta Camprubí-Rimblas
- Institut d’ Investigació i Innovació Parc Taulí (I3PT), 08201 Sabadell, Spain; (J.B.); (M.C.-R.); (L.B.); (A.A.)
- CIBER de Enfermedades Respiratorias (CIBERES), 08201 Sabadell, Spain
- Facultat de Medicina, Universitat Autonoma de Barcelona, 08193 Bellaterra, Spain
| | - Lluís Blanch
- Institut d’ Investigació i Innovació Parc Taulí (I3PT), 08201 Sabadell, Spain; (J.B.); (M.C.-R.); (L.B.); (A.A.)
- CIBER de Enfermedades Respiratorias (CIBERES), 08201 Sabadell, Spain
- Critical Care Center—Corporació Sanitària i Universitària Parc Taulí, 08201 Sabadell, Spain;
| | - Antonio Artigas
- Institut d’ Investigació i Innovació Parc Taulí (I3PT), 08201 Sabadell, Spain; (J.B.); (M.C.-R.); (L.B.); (A.A.)
- CIBER de Enfermedades Respiratorias (CIBERES), 08201 Sabadell, Spain
- Facultat de Medicina, Universitat Autonoma de Barcelona, 08193 Bellaterra, Spain
- Critical Care Center—Corporació Sanitària i Universitària Parc Taulí, 08201 Sabadell, Spain;
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13
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14
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Nunnally ME, Ferrer R, Martin GS, Martin-Loeches I, Machado FR, De Backer D, Coopersmith CM, Deutschman CS. The Surviving Sepsis Campaign: research priorities for the administration, epidemiology, scoring and identification of sepsis. Intensive Care Med Exp 2021; 9:34. [PMID: 34212256 PMCID: PMC8249046 DOI: 10.1186/s40635-021-00400-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/07/2021] [Indexed: 12/15/2022] Open
Abstract
Objective To identify priorities for administrative, epidemiologic and diagnostic research in sepsis. Design As a follow-up to a previous consensus statement about sepsis research, members of the Surviving Sepsis Campaign Research Committee, representing the European Society of Intensive Care Medicine and the Society of Critical Care Medicine addressed six questions regarding care delivery, epidemiology, organ dysfunction, screening, identification of septic shock, and information that can predict outcomes in sepsis. Methods Six questions from the Scoring/Identification and Administration sections of the original Research Priorities publication were explored in greater detail to better examine the knowledge gaps and rationales for questions that were previously identified through a consensus process. Results The document provides a framework for priorities in research to address the following questions: (1) What is the optimal model of delivering sepsis care?; (2) What is the epidemiology of sepsis susceptibility and response to treatment?; (3) What information identifies organ dysfunction?; (4) How can we screen for sepsis in various settings?; (5) How do we identify septic shock?; and (6) What in-hospital clinical information is associated with important outcomes in patients with sepsis? Conclusions There is substantial knowledge of sepsis epidemiology and ways to identify and treat sepsis patients, but many gaps remain. Areas of uncertainty identified in this manuscript can help prioritize initiatives to improve an understanding of individual patient and demographic heterogeneity with sepsis and septic shock, biomarkers and accurate patient identification, organ dysfunction, and ways to improve sepsis care.
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Affiliation(s)
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation (SODIR) Research Group, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Grady Memorial Hospital and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Department of Intensive Care Medicine, St. James's University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland.,Hospital Clinic, IDIBAPS, Universidad de Barcelona, CIBERes, Barcelona, Spain
| | | | - Daniel De Backer
- Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA
| | - Clifford S Deutschman
- Department of Pediatrics, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY, USA.,The Feinstein Institute for Medical Research/ Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA
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15
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Schiek S, Ranft D, Truckenbrod C, Dürrbeck A, Chaberny I, Rodloff A, Lübbert C, Bertsche T. [Antibiotics Stewardship Team Recommendations - An Analysis under Routine Conditions in a University Hospital]. DAS GESUNDHEITSWESEN 2021; 84:503-509. [PMID: 33915578 DOI: 10.1055/a-1471-5311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM To evaluate recommendations of an antibiotic stewardship (ABS) team during routine weekly visits and to analyse their implementation and reasons for non-implementation by the ward physicians. METHODS Multiprofessional ABS Rounds (members: infectiology, microbiology, pharmacy and hospital epidemiology) were accompanied by an observer in nine intensive and peripheral wards of a university hospital (1451 beds) for eight weeks. The recommendations of the ABS team were prospectively analysed, and when these were not implemented, ward physicians in charge were asked to give reasons for non-implementation. RESULTS A total of 262 patients were visited in the course of 359 ABS visits. A median of four physicians and one pharmacist (Q25/Q75: 4/6) participated in the ABS rounds. In 177/359 (49%) of visits, at least one recommendation for anti-infective therapy was given; the total number of recommendations made was 210. The most frequent (38%, 80/210) recommendations were related to the prescribed therapy duration. The more different the professional groups participating in the ABS rounds, the larger was the number of recommendations given (p=0.016; odds ratio=1.018 (1.003-1.033)). 62/210 (30%) of the ABS recommendations were not implemented by the ward physicians in charge. The most frequent reason (32%: 20/62) for this was the deliberate decision by the physicians to deviate from the recommended therapy. CONCLUSIONS The high recommendation rate of 50% demonstrates the need for optimizing therapy by the ABS teams in routine practice. The larger the number of different specialists participating in single visits, the larger was the number of recommendations. Reasons for the lack of implementations need to be critically examined by both the ABS team and the ward physicians in charge.
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Affiliation(s)
- Susanne Schiek
- Abteilung für Klinische Pharmazie, Institut für Pharmazie, Medizinische Fakultät, Universität Leipzig, Leipzig, Deutschland.,Zentrum für Arzneimittelsicherheit, Universität und Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Donald Ranft
- Zentrum für Arzneimittelsicherheit, Universität und Universitätsklinikum Leipzig, Leipzig, Deutschland.,Apotheke, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Clemens Truckenbrod
- Abteilung für Klinische Pharmazie, Institut für Pharmazie, Medizinische Fakultät, Universität Leipzig, Leipzig, Deutschland.,Zentrum für Arzneimittelsicherheit, Universität und Universitätsklinikum Leipzig, Leipzig, Deutschland.,Apotheke, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Axel Dürrbeck
- Zentrum für Arzneimittelsicherheit, Universität und Universitätsklinikum Leipzig, Leipzig, Deutschland.,Apotheke, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Iris Chaberny
- Institut für Hygiene, Krankenhaushygiene und Umweltmedizin, Universitatsklinikum Leipzig, Leipzig, Deutschland
| | - Arne Rodloff
- Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Institut für Medizinische Mikrobiologie und Infektionsepidemiologie, Universitatsklinikum Leipzig, Leipzig, Deutschland
| | - Christoph Lübbert
- Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Bereich Infektiologie und Tropenmedizin, Medizinische Klinik 2 (Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie), Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Thilo Bertsche
- Interdisziplinäres Zentrum für Infektionsmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland.,Bereich Infektiologie und Tropenmedizin, Medizinische Klinik 2 (Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie), Universitätsklinikum Leipzig, Leipzig, Deutschland
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16
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Rothe K, Feihl S, Schneider J, Wallnöfer F, Wurst M, Lukas M, Treiber M, Lahmer T, Heim M, Dommasch M, Waschulzik B, Zink A, Querbach C, Busch DH, Schmid RM, Schneider G, Spinner CD. Rates of bacterial co-infections and antimicrobial use in COVID-19 patients: a retrospective cohort study in light of antibiotic stewardship. Eur J Clin Microbiol Infect Dis 2021; 40:859-869. [PMID: 33140176 PMCID: PMC7605734 DOI: 10.1007/s10096-020-04063-8] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/01/2020] [Indexed: 01/09/2023]
Abstract
The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide. Bacterial co-infections are associated with unfavourable outcomes in respiratory viral infections; however, microbiological and antibiotic data related to COVID-19 are sparse. Adequate use of antibiotics in line with antibiotic stewardship (ABS) principles is warranted during the pandemic. We performed a retrospective study of clinical and microbiological characteristics of 140 COVID-19 patients admitted between February and April 2020 to a German University hospital, with a focus on bacterial co-infections and antimicrobial therapy. The final date of follow-up was 6 May 2020. Clinical data of 140 COVID-19 patients were recorded: The median age was 63.5 (range 17-99) years; 64% were males. According to the implemented local ABS guidelines, the most commonly used antibiotic regimen was ampicillin/sulbactam (41.5%) with a median duration of 6 (range 1-13) days. Urinary antigen tests for Legionella pneumophila and Streptococcus peumoniae were negative in all cases. In critically ill patients admitted to intensive care units (n = 50), co-infections with Enterobacterales (34.0%) and Aspergillus fumigatus (18.0%) were detected. Blood cultures collected at admission showed a diagnostic yield of 4.2%. Bacterial and fungal co-infections are rare in COVID-19 patients and are mainly prevalent in critically ill patients. Further studies are needed to assess the impact of antimicrobial therapy on therapeutic outcome in COVID-19 patients to prevent antimicrobial overuse. ABS guidelines could help in optimising the management of COVID-19. Investigation of microbial patterns of infectious complications in critically ill COVID-19 patients is also required.
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Affiliation(s)
- Kathrin Rothe
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich, School of Medicine, Trogerstr. 30, 81675, Munich, Germany.
| | - Susanne Feihl
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich, School of Medicine, Trogerstr. 30, 81675, Munich, Germany
| | - Jochen Schneider
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, Munich, Germany
| | - Fabian Wallnöfer
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, Munich, Germany
| | - Milena Wurst
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, Munich, Germany
| | - Marina Lukas
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, Munich, Germany
| | - Matthias Treiber
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, Munich, Germany
| | - Tobias Lahmer
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, Munich, Germany
| | - Markus Heim
- Department of Anaesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Michael Dommasch
- Department of Internal Medicine I, Technical University of Munich, School of Medicine, Munich, Germany
| | - Birgit Waschulzik
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich, School of Medicine, Munich, Germany
| | - Alexander Zink
- Department of Dermatology and Allergology, Technical University of Munich, School of Medicine, Munich, Germany
| | - Christiane Querbach
- Hospital Pharmacy, Technical University of Munich, School of Medicine, Munich, Germany
| | - Dirk H Busch
- Institute for Medical Microbiology, Immunology and Hygiene, Technical University of Munich, School of Medicine, Trogerstr. 30, 81675, Munich, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Roland M Schmid
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, Munich, Germany
| | - Gerhard Schneider
- Department of Anaesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Munich, Germany
| | - Christoph D Spinner
- Department of Internal Medicine II, Technical University of Munich, School of Medicine, Munich, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany
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17
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Weinberger J, Rhee C, Klompas M. A Critical Analysis of the Literature on Time-to-Antibiotics in Suspected Sepsis. J Infect Dis 2021; 222:S110-S118. [PMID: 32691835 DOI: 10.1093/infdis/jiaa146] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The Surviving Sepsis Campaign recommends immediate antibiotics for all patients with suspected sepsis and septic shock, ideally within 1 hour of recognition. Immediate antibiotic treatment is lifesaving for some patients, but a substantial fraction of patients initially diagnosed with sepsis have noninfectious conditions. Aggressive time-to-antibiotic targets risk promoting antibiotic overuse and antibiotic-associated harms for this subset of the population. An accurate understanding of the precise relationship between time-to-antibiotics and mortality for patients with possible sepsis is therefore critical to finding the best balance between assuring immediate antibiotics for those patients who truly need them versus allowing clinicians some time for rapid investigation to minimize the risk of overtreatment and antibiotic-associated harms for patients who are not infected. More than 30 papers have been published assessing the relationship between time-to-antibiotics and outcomes, almost all of which are observational cohort studies. Most report significant associations but all have important limitations. Key limitations include focusing just on the sickest subset of patients (only patients requiring intensive care and/or patients with septic shock), blending together mortality estimates from patients with very long intervals until antibiotics with patients with shorter intervals and reporting a single blended (and thus inflated) estimate for the average increase in mortality associated with each hour until antibiotics, and failure to control for large potential confounders including patients' presenting signs and symptoms and granular measures of comorbidities and severity of illness. In this study, we elaborate on these potential sources of bias and try to distill a better understanding of what the true relationship between time-to-antibiotics and mortality may be for patients with suspected sepsis or septic shock.
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Affiliation(s)
- Jeremy Weinberger
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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18
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Plata-Menchaca EP, Ferrer R, Ruiz Rodríguez JC, Morais R, Póvoa P. Antibiotic treatment in patients with sepsis: a narrative review. Hosp Pract (1995) 2020; 50:203-213. [PMID: 32627615 DOI: 10.1080/21548331.2020.1791541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, with unacceptably high morbidity and mortality. Similar to acute myocardial infarction or cerebral vascular accident, sepsis is a severe and continuous time-dependent condition. Thus, in the case of sepsis, early and adequate administration of antimicrobials must be a priority, ideally within the first hour of diagnosis, simultaneously with organ support.As a consequence of the emergence of multidrug-resistant pathogens, the choice of antimicrobials should be performed according to the local pathogen patterns of resistance. Individual antimicrobial optimization is essential to achieve adequate concentrations of antimicrobials, to reduce adverse effects, and to ensure successful outcomes, as well as preventing the emergence of multidrug-resistant pathogens. The loading dose is the administration of an initial higher dose of antimicrobials, regardless of the presence of organ dysfunction. Further doses should be implemented according to pharmacokinetics/pharmacodynamics of antimicrobials and should be adjusted according to the presence of renal or liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring can help to achieve therapeutic levels of antimicrobials. Duration and adequacy of treatment must be reviewed at regular intervals to allow effective de-escalation and administration of short courses of antimicrobials for most patients. Antimicrobial stewardship frameworks, leadership, focus on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients the process of care and overall quality of care.
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Affiliation(s)
- Erika P Plata-Menchaca
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Juan Carlos Ruiz Rodríguez
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron Hospital, Barcelona, Spain
| | - Rui Morais
- Centro Hospitalar de Lisboa Ocidental - Polyvalent Intensive Care Unit, Hospital de S.Francisco Xavier, Lisboa, Portugal
| | - Pedro Póvoa
- Centro Hospitalar de Lisboa Ocidental - Polyvalent Intensive Care Unit, Hospital de S.Francisco Xavier, Lisboa, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
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19
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Lim R, Courtenay M, Deslandes R, Ferriday R, Gillespie D, Hodson K, Reid N, Thomas N, Chater A. Theory-based electronic learning intervention to support appropriate antibiotic prescribing by nurse and pharmacist independent prescribers: an acceptability and feasibility experimental study using mixed methods. BMJ Open 2020; 10:e036181. [PMID: 32606061 PMCID: PMC7328741 DOI: 10.1136/bmjopen-2019-036181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To assess the acceptability and feasibility of using a theory-based electronic learning intervention designed to support appropriate antibiotic prescribing by nurse and pharmacist independent prescribers for patients presenting with common, acute, uncomplicated self-limiting respiratory tract infections (RTIs). DESIGN Experimental with mixed methods; preintervention and postintervention online surveys and semistructured interviews. SETTING Primary care settings across the UK. PARTICIPANTS 11 nurse and 4 pharmacist prescribers. INTERVENTION A theory-based brief interactive animation electronic learning activity comprised a consultation scenario by a prescriber with an adult presenting with a common, acute, uncomplicated self-limiting RTI to support a 'no antibiotic prescribing strategy'. OUTCOME MEASURES Recruitment, response and attrition rates were assessed. The overall usefulness of the intervention was assessed by analysing prescribers' self-reported confidence and knowledge in treating patients with RTIs before and after undertaking the intervention, and views on the relevance of the intervention to their work. Acceptability of the intervention was assessed in semistructured interviews. The feasibility of data collection methods was assessed by recording the number of study components completed by prescribers. RESULTS 15 prescribers (maximum sample size) consented and completed all four stages of the study. Prescribers reported high to very high levels of confidence and knowledge preintervention and postintervention, with slight postintervention increases in communicating with patients and a slight reduction in building rapport. Qualitative findings supported quantitative findings; prescribers were reassured of their own practice which in turn increased their confidence and knowledge in consultations. The information in the intervention was not new to prescribers but was applicable and useful to consolidate learning and enable self-reflection. Completing the e-learning intervention was acceptable to prescribers. CONCLUSIONS It was feasible to conduct the study. The intervention was acceptable and useful to prescribers. Future work will add complex clinical content in the intervention before conducting a full trial.
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Affiliation(s)
- Rosemary Lim
- Reading School of Pharmacy, University of Reading, Reading, UK
| | - Molly Courtenay
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Rhian Deslandes
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff, UK
| | | | | | - Karen Hodson
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff, UK
| | | | - Neil Thomas
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Angel Chater
- Centre for Health, Wellbeing and Behaviour Change, University of Bedfordshire, Luton, UK
- University College London School of Pharmacy, London, UK
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20
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Kollef MH, Burnham JP. Antibiotic Thresholds for Sepsis and Septic Shock. Clin Infect Dis 2020; 69:938-940. [PMID: 30535353 DOI: 10.1093/cid/ciy1035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 12/03/2018] [Indexed: 12/29/2022] Open
Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine
| | - Jason P Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
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21
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Satterfield J, Miesner AR, Percival KM. The role of education in antimicrobial stewardship. J Hosp Infect 2020; 105:130-141. [PMID: 32243953 DOI: 10.1016/j.jhin.2020.03.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/23/2020] [Indexed: 02/03/2023]
Abstract
The role of antimicrobial stewardship programmes (ASPs) has expanded in health systems. ASP interventions often contain an educational component; however, current guidelines suggest that educational interventions should not be used alone but to support other stewardship interventions. Such interventions are most commonly directed towards prescribers (often general practice physicians) with few studies offering education towards other healthcare providers such as pharmacists, nurses, or even members of the stewardship team. Educational interventions are offered most frequently, but not exclusively, with concomitant stewardship interventions such as prospective audit and feedback. Such strategies appear to positively impact prescribing behaviours, but it is not possible to isolate the effect of education from other interventions. Common educational methods include one-time seminars and online e-learning modules, but unique strategies such as social media platforms, educational video games and problem-based learning modules have also been employed. Education directed towards patients often occurs in conjunction with education of local prescribers and wider community-based efforts to impact prescribing. Such studies evaluating patient education often include passive educational leaflets and focus most often on appropriate treatment of upper respiratory tract infections. Educational interventions appear to be an integral component of other interventions of ASPs; however, there is a paucity of evidence to support use as a stand-alone intervention outside of regional public health interventions. Future studies should focus on efficacy of educational interventions including providing education to non-prescribers and disease states beyond upper respiratory tract infections to demonstrate a broader role for education in ASP activities.
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Affiliation(s)
- J Satterfield
- University of Iowa College of Pharmacy, Iowa City, IA, USA
| | - A R Miesner
- Drake University College of Pharmacy & Health Sciences, Department of Clinical Sciences, Des Moines, IA, USA.
| | - K M Percival
- University of Iowa Hospitals and Clinics, Department of Pharmaceutical Care, Iowa City, IA, USA
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22
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Impact of a Multidisciplinary Sepsis Initiative on Knowledge and Behavior in a Pediatric Center. Pediatr Qual Saf 2020; 5:e267. [PMID: 32426633 PMCID: PMC7190264 DOI: 10.1097/pq9.0000000000000267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 02/04/2020] [Indexed: 01/20/2023] Open
Abstract
Supplemental Digital Content is available in the text. Objective: Our institution performed an educational initiative targeting previously identified barriers to pediatric sepsis recognition and treatment. We hypothesized that provider knowledge, attitude, and behavior would be improved 1 year after implementation. Methods: This was a prospective, observational study of a multi-faceted quality initiative introduced to providers in the Emergency Department, inpatient wards, and Pediatric Intensive Care Unit of a tertiary care children’s hospital. Educational platforms consisted of quarterly electronic sepsis “newsletters,” brightly colored posters highlighting protocol and screening strategies displayed throughout the hospital, and low-fidelity simulation sessions (drills) led by trained staff and incorporated into daily workflows. The content was driven by feedback from a baseline needs assessment of sepsis education. One year after implementation, the needs assessment was repeated. Results: Over 3 months, facilitators conducted 197 drills and captured a majority of nurses (89%), pediatrics residents (96%), and respiratory therapists (62%). By 6 months, 241 sessions had been completed. Approximately 55.4% of the 442 eligible staff participated in our post-intervention survey. Overall, knowledge of diagnostic criteria for pediatric sepsis and septic shock increased from pre-intervention levels (P = 0.015). Among post-implementation respondents, drill participants outperformed their colleagues (P = 0.001). A greater percentage of post-intervention respondents indicated comfort with sepsis recognition (P < 0.001), and fewer reported hesitating to bring sepsis concerns to their care team (P < 0.01). Conclusions: Our findings suggest that a multidisciplinary curriculum balancing active education—through brief, targeted simulation—and general awareness—through electronic resources and a poster campaign—can improve sepsis-related knowledge, attitude, and behavior among pediatric practitioners.
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23
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Martínez ML, Plata-Menchaca EP, Ruiz-Rodríguez JC, Ferrer R. An approach to antibiotic treatment in patients with sepsis. J Thorac Dis 2020; 12:1007-1021. [PMID: 32274170 PMCID: PMC7139065 DOI: 10.21037/jtd.2020.01.47] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sepsis is a medical emergency and life-threatening condition due to a dysregulated host response to infection, which is time-dependent and associated with unacceptably high mortality. Thus, when treating suspicious or confirmed cases of sepsis, clinicians must initiate broad-spectrum antimicrobials within the first hour of diagnosis. Optimizing antibiotic use is essential to ensure successful outcomes and to reduce adverse antibiotic effects, as well as preventing drug resistance. All likely pathogens involved should be considered to provide an appropriate antibiotic coverage. Clinicians must investigate on the previous risk of multidrug-resistant (MDR) pathogens, and the principle of individualized dosing should replace the principle of standard dosing. The loading dose is an initial higher dose of an antibiotic for all patients, yet an individualized treatment approach for further doses should be implemented according to pharmacokinetics (PK)/pharmacodynamics (PD) and the presence of renal/liver dysfunction. Extended or continuous infusion of beta-lactams and therapeutic drug monitoring (TDM) can help to achieve therapeutic levels of antimicrobials. Reevaluation of duration and appropriateness of treatment at regular intervals are also necessary. De-escalation and shortened courses of antimicrobials must be considered for most patients, except in some justified circumstances. Leadership, teamwork, antimicrobial stewardship (AS) frameworks, guideline’s recommendations on the optimal duration of treatments, de-escalation, and novel diagnostic stewardship approaches will help us to improve patients’ quality of care.
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Affiliation(s)
- María Luisa Martínez
- Department of Intensive Care, Hospital Universitario General de Catalunya, Barcelona, Spain
| | - Erika P Plata-Menchaca
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ricard Ferrer
- Shock, Organ Dysfunction, and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain.,Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain.,Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Respiratorias, Barcelona, Spain
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24
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Rothe K, Wantia N, Spinner CD, Schneider J, Lahmer T, Waschulzik B, Schmid RM, Busch DH, Katchanov J. Antimicrobial resistance of bacteraemia in the emergency department of a German university hospital (2013-2018): potential carbapenem-sparing empiric treatment options in light of the new EUCAST recommendations. BMC Infect Dis 2019; 19:1091. [PMID: 31888581 PMCID: PMC6937826 DOI: 10.1186/s12879-019-4721-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/22/2019] [Indexed: 12/21/2022] Open
Abstract
Background This study investigated predominant microorganisms causing community-onset bacteraemia at the medical emergency department (ED) of a tertiary-care university hospital in Germany from 2013 to 2018 and their antimicrobial susceptibility patterns. Methods Antimicrobial resistance patterns in patients with positive blood cultures presenting to an internal medicine ED were retrospectively analysed. Results Blood cultures were obtained at 5191 of 66,879 ED encounters, with 1013 (19.5%) positive results, and true positive results at 740 encounters (diagnostic yield, 14.3%). The most frequently isolated relevant microorganisms were Enterobacterales (n = 439, 59.3%), Staphylococcus aureus (n = 92, 12.4%), Streptococcus pneumoniae (n = 34, 4.6%), Pseudomonas aeruginosa (n = 32, 4.3%), Streptococcus pyogenes (n = 16, 2.2%), Enterococcus faecalis (n = 18, 2.4%), and Enterococcus faecium (n = 12, 1.6%). Antimicrobial susceptibility testing revealed a high proportion of resistance against ampicillin-sulbactam in Enterobacterales (42.2%). The rate of methicillin-resistant Staphylococcus aureus was low (0.4%). Piperacillin-tazobactam therapy provided coverage for 83.2% of all relevant pathogens using conventional breakpoints. Application of the new European Committee on Antimicrobial Susceptibility Testing (EUCAST) recommendations increased the percentage of susceptible isolates to high-dose piperacillin-tazobactam to 92.8% (p < 0.001). Broad-spectrum carbapenems would only cover an additional 4.8%. The addition of vancomycin or linezolid extended coverage by just 1.7%. Conclusions Using an ureidopenicillin-beta-lactamase inhibitor combination at the high dose suggested by the new EUCAST recommendations provided nearly 93% coverage for relevant pathogens in patients with suspected bloodstream infection in our cohort. This might offer a safe option to reduce the empiric use of carbapenems. Our data support the absence of a general need for glycopeptides or oxazolidinones in empiric treatment.
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Affiliation(s)
- Kathrin Rothe
- Technical University of Munich, School of Medicine, Institute for Medical Microbiology, Immunology and Hygiene, Trogerstr. 30, 81675, Munich, Germany. .,German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.
| | - Nina Wantia
- Technical University of Munich, School of Medicine, Institute for Medical Microbiology, Immunology and Hygiene, Trogerstr. 30, 81675, Munich, Germany.,German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Christoph D Spinner
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
| | - Jochen Schneider
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
| | - Tobias Lahmer
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
| | - Birgit Waschulzik
- Institute of Medical Informatics, Statistics, and Epidemiology, Technical University of Munich, Munich, Germany
| | - Roland M Schmid
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
| | - Dirk H Busch
- Technical University of Munich, School of Medicine, Institute for Medical Microbiology, Immunology and Hygiene, Trogerstr. 30, 81675, Munich, Germany.,German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Juri Katchanov
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany.,Department of Medicine II, Technical University of Munich, School of Medicine, University Hospital rechts der Isar, Munich, Germany
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25
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Singer M, Inada-Kim M, Shankar-Hari M. Sepsis hysteria: excess hype and unrealistic expectations. Lancet 2019; 394:1513-1514. [PMID: 31657730 DOI: 10.1016/s0140-6736(19)32483-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 08/28/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, London WC1E 6BT, UK.
| | - Matt Inada-Kim
- Department of Acute Medicine, Royal Hampshire County Hospital, Hampshire Hospitals NHS Foundation Trust, Winchester, UK; NHS England, UK
| | - Manu Shankar-Hari
- Department of Intensive Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK; Peter Gorer Department of Immunobiology, King's College London, London, UK
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26
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Courtenay M, Lim R, Deslandes R, Ferriday R, Gillespie D, Hodson K, Reid N, Thomas N, Chater A. Theory-based electronic learning intervention to support appropriate antibiotic prescribing by nurses and pharmacists: intervention development and feasibility study protocol. BMJ Open 2019; 9:e028326. [PMID: 31427324 PMCID: PMC6701627 DOI: 10.1136/bmjopen-2018-028326] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Nurse and pharmacist independent prescribers manage patients with respiratory tract infections and are responsible for around 8% of all primary care antibiotic prescriptions. A range of factors influence the prescribing behaviour of these professionals, however, there are no interventions available specifically to support appropriate antibiotic prescribing behaviour by these groups. The aims of this paper are to describe (1) the development of an intervention to support appropriate antibiotic prescribing by nurse and pharmacist independent prescribers and (2) an acceptability and feasibility study designed to test its implementation with these prescribers. METHOD AND ANALYSIS: Development of intervention: a three-stage, eight-step method was used to identify relevant determinants of behaviour change and intervention components based on the Behaviour Change Wheel. The intervention is an online resource comprising underpinning knowledge and an interactive animation with a variety of open and closed questions to assess understanding. Acceptability and feasibility of intervention: nurse and pharmacist prescribers (n=12-15) will use the intervention. Evaluation includes semi-structured interviews to capture information about how the user reacts to the design, delivery and content of the intervention and influences on understanding and engagement, and a pre-post survey to assess participants' perceptions of the impact of the intervention on knowledge, confidence and usefulness in terms of application to practice. Taking an initial inductive approach, data from interview transcripts will be coded and then analysed to derive themes. These themes will then be deductively mapped to the Capability, Opportunity, Motivation-Behaviour model. Descriptive statistics will be used to analyse the survey data, and trends identified. ETHICS AND DISSEMINATION Ethical approval for the study has been provided by the School of Healthcare Sciences Research Governance and Ethics Committee, Cardiff University. The findings will be disseminated via publication in peer-reviewed journals and through conference presentations.
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Affiliation(s)
- Molly Courtenay
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Rosemary Lim
- School of Pharmacy, Reading University, Reading, Berkshire, UK
| | - Rhian Deslandes
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
| | | | | | - Karen Hodson
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, UK
| | | | - Neil Thomas
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Angel Chater
- University of Bedfordshire, Centre for Health, Wellbeing and Behaviour Change, Bedford, UK
- University College London School of Pharmacy, London, UK
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27
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Heterogeneity in sepsis: new biological evidence with clinical applications. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:80. [PMID: 30850013 PMCID: PMC6408778 DOI: 10.1186/s13054-019-2372-2] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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28
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Timsit JF, Bassetti M, Cremer O, Daikos G, de Waele J, Kallil A, Kipnis E, Kollef M, Laupland K, Paiva JA, Rodríguez-Baño J, Ruppé É, Salluh J, Taccone FS, Weiss E, Barbier F. Rationalizing antimicrobial therapy in the ICU: a narrative review. Intensive Care Med 2019; 45:172-189. [PMID: 30659311 DOI: 10.1007/s00134-019-05520-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 01/04/2019] [Indexed: 12/13/2022]
Abstract
The massive consumption of antibiotics in the ICU is responsible for substantial ecological side effects that promote the dissemination of multidrug-resistant bacteria (MDRB) in this environment. Strikingly, up to half of ICU patients receiving empirical antibiotic therapy have no definitively confirmed infection, while de-escalation and shortened treatment duration are insufficiently considered in those with documented sepsis, highlighting the potential benefit of implementing antibiotic stewardship programs (ASP) and other quality improvement initiatives. The objective of this narrative review is to summarize the available evidence, emerging options, and unsolved controversies for the optimization of antibiotic therapy in the ICU. Published data notably support the need for better identification of patients at risk of MDRB infection, more accurate diagnostic tools enabling a rule-in/rule-out approach for bacterial sepsis, an individualized reasoning for the selection of single-drug or combination empirical regimen, the use of adequate dosing and administration schemes to ensure the attainment of pharmacokinetics/pharmacodynamics targets, concomitant source control when appropriate, and a systematic reappraisal of initial therapy in an attempt to minimize collateral damage on commensal ecosystems through de-escalation and treatment-shortening whenever conceivable. This narrative review also aims at compiling arguments for the elaboration of actionable ASP in the ICU, including improved patient outcomes and a reduction in antibiotic-related selection pressure that may help to control the dissemination of MDRB in this healthcare setting.
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Affiliation(s)
- Jean-François Timsit
- Medical and Infectious Diseases ICU, APHP, Bichat-Claude Bernard Hospital, 46 Rue Henri-Huchard, 75877, Paris Cedex 18, France.
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France.
| | - Matteo Bassetti
- Infectious Diseases Division, Department of Medicine, University of Udine and Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Olaf Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - George Daikos
- Scool of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan de Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andre Kallil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric Kipnis
- Surgical Critical Care Unit, Department of Anesthesiology, Critical Care and Perioperative Medicine, CHU Lille, Lille, France
| | - Marin Kollef
- Critical Care Research, Washington University School of Medicine and Respiratory Care Services, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Kevin Laupland
- Department of Medicine, Royal Inland Hospital, Kamloops, Canada
| | - Jose-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar São João and Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jesús Rodríguez-Baño
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena, Departament of Medicine, University of Sevilla, Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Étienne Ruppé
- INSERM, IAME, UMR 1137, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
- Bacteriology Laboratory, Bichat-Claude Bernard Hospital, APHP, Paris, France
| | - Jorge Salluh
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, IDOR, Rio De Janeiro, Brazil
| | | | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Beaujon Hospital, AP-HP, Clichy, France
- INSERM, CRI, UMR 1149, Paris-Diderot Sorbonne-Paris Cité University, Paris, France
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29
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Timsit JF, Ruppe E, Ferrer R. Focus on sepsis: new concepts and findings in sepsis care. Intensive Care Med 2018; 44:1997-1999. [PMID: 30306194 DOI: 10.1007/s00134-018-5406-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 10/01/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Jean-Francois Timsit
- Medical and Infectious Diseases ICU (MI2), APHP Hopital Bichat, 75018, Paris, France. .,U1137 IAME Inserm-Paris Diderot University, 75018, Paris, France.
| | - Etienne Ruppe
- U1137 IAME Inserm-Paris Diderot University, 75018, Paris, France.,Microbiological Department, APHP Hopital Bichat, 75018, Paris, France
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
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30
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Abstract
The last two to three years provided several “big steps” regarding our understanding and management of sepsis. The increasing insight into pathomechanisms of post-infectious defense led to some new models of host response. Besides hyper-, hypo-, and anti-inflammation as the traditional approaches to sepsis pathophysiology, tolerance and resilience were described as natural ways that organisms react to microbes. In parallel, huge data analyses confirmed these research insights with a new way to define sepsis and septic shock (called “Sepsis-3”), which led to discussions within the scientific community. In addition to these advances in understanding and defining the disease, follow-up protocols of the initial “sepsis bundles” from the Surviving Sepsis Campaign were created; some of them were part of quality management studies by clinicians, and some were in the form of mandatory procedures. As a result, new “bundles” were initiated with the goal of enabling standardized management of sepsis and septic shock, especially in the very early phase. This short commentary provides a brief overview of these two major fields as recent hallmarks of sepsis research.
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Affiliation(s)
- Daniela Berg
- Department of Anesthesia, Critical Care Medicine, and Pain Management, Vivantes - Klinikum Neukoelln, Berlin, Berlin, Germany
| | - Herwig Gerlach
- Department of Anesthesia, Critical Care Medicine, and Pain Management, Vivantes - Klinikum Neukoelln, Berlin, Berlin, Germany
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