Rational empiric antibiotic prescription in the ICU

Transportability of bacterial infection prediction models for critically ill patients

OBJECTIVE

Bacterial infections (BIs) are common, costly, and potentially life-threatening in critically ill patients. Patients with suspected BIs may require empiric multidrug antibiotic regimens and therefore potentially be exposed to prolonged and unnecessary antibiotics. We previously developed a BI risk model to augment practices and help shorten the duration of unnecessary antibiotics to improve patient outcomes. Here, we have performed a transportability assessment of this BI risk model in 2 tertiary intensive care unit (ICU) settings and a community ICU setting. We additionally explored how simple multisite learning techniques impacted model transportability.

METHODS

Patients suspected of having a community-acquired BI were identified in 3 datasets: Medical Information Mart for Intensive Care III (MIMIC), Northwestern Medicine Tertiary (NM-T) ICUs, and NM "community-based" ICUs. ICU encounters from MIMIC and NM-T datasets were split into 70/30 train and test sets. Models developed on training data were evaluated against the NM-T and MIMIC test sets, as well as NM community validation data.

RESULTS

During internal validations, models achieved AUROCs of 0.78 (MIMIC) and 0.81 (NM-T) and were well calibrated. In the external community ICU validation, the NM-T model had robust transportability (AUROC 0.81) while the MIMIC model transported less favorably (AUROC 0.74), likely due to case-mix differences. Multisite learning provided no significant discrimination benefit in internal validation studies but offered more stability during transport across all evaluation datasets.

DISCUSSION

These results suggest that our BI risk models maintain predictive utility when transported to external cohorts.

CONCLUSION

Our findings highlight the importance of performing external model validation on myriad clinically relevant populations prior to implementation.

The Role of Biomarkers and Scores in Describing Urosepsis

Background and Objectives: Patients with urinary tract obstruction (UTO) and systemic inflammatory response syndrome (SIRS) are at risk of developing urosepsis, whose evolution involves increased morbidity, mortality and cost. The aim of this study is to evaluate the ability of already existing scores and biomarkers to diagnose, describe the clinical status, and predict the evolution of patients with complicated urinary tract infection (UTI) and their risk of progressing to urosepsis. Materials and Methods: We conducted a retrospective study including patients diagnosed with UTI hospitalized in the urology department of” Sfântul Apostol Andrei” County Emergency Clinical Hospital (GCH) in Galati, Romania, from September 2019 to May 2022. The inclusion criteria were: UTI proven by urine culture or diagnosed clinically complicated with UTO, fever or shaking chills, and purulent collections, such as psoas abscess, Fournier Syndrome, renal abscess, and paraurethral abscess, showing SIRS. The exclusion criteria were: patients age < 18 years, pregnancy, history of kidney transplantation, hemodialysis or peritoneal dialysis, and patients with missing data. We used the Sequential (Sepsis-Related) Organ Failure Assessment (SOFA) and qSOFA (quick SOFA) scores, and procalcitonin (PCT) to describe the clinical status of the patients. The Charlson Comorbidity Index (CCI) was used to assesses pre-existing morbidities. The hospitalization days and costs and the days of intensive care were considered. Depending on the diagnosis at admission, we divided the patients into three groups: SIRS, sepsis and septic shock. The fourth group was represented by patients who died during hospitalization. Results: A total of 174 patients with complicated UTIs were enrolled in this study. From this total, 46 were enrolled in the SIRS group, 88 in the urosepsis group, and 40 in the septic shock group. A total of 23 patients died during hospitalization and were enrolled in the deceased group. An upward trend of age along with worsening symptoms was highlighted with an average of 56.86 years in the case of SIRS, 60.37 years in the sepsis group, 69.03 years in the septic shock, and 71.04 years in the case of deceased patients (p < 0.04). A statistically significant association between PCT and complex scores (SOFA, CCI and qSOFA) with the evolution of urosepsis was highlighted. Increased hospitalization costs can be observed in the case of deceased patients and those with septic shock and statistically significantly lower in the case of those with SIRS. The predictability of discriminating urosepsis stages was assessed by using the area under the ROC curve (AUC) and very good specificity and sensitivity was identified in predicting the risk of death for PCT (69.57%, 77.33%), the SOFA (91.33%, 76.82%), qSOFA (91.30%, 74.17%) scores, and CCI (65.22%, 88.74%). The AUC value was best for qSOFA (90.3%). For the SIRS group, the PCT (specificity 91.30%, sensitivity 85.71%) and SOFA (specificity 84.78%, sensitivity 78.74%), qSOFA scores (specificity 84.78%, sensitivity 76, 34%) proved to be relevant in establishing the diagnosis. In the case of the septic shock group, the qSOFA (specificity 92.5%, sensitivity 82.71%) and SOFA (specificity 97.5%, sensitivity 77.44%) as well as PCT (specificity 80%, sensitivity 85.61%) are statistically significant disease-defining variables. An important deficit in the tools needed to classify patients into the sepsis group is obvious. All the variables have an increased specificity but a low sensitivity. This translates into a risk of a false negative diagnosis. Conclusions: Although SOFA and qSOFA scores adequately describe patients with septic shock and they are independent prognostic predictors of mortality, they fail to be accurate in diagnosing sepsis. These scores should not replace the conventional triage protocol. In our study, PCT proved to be a disease-defining marker and an independent prognostic predictor of mortality. Patients with important comorbidities, CCI greater than 10, should be treated more aggressively because of increased mortality.

COVID-19 Lockdowns May Reduce Resistance Genes Diversity in the Human Microbiome and the Need for Antibiotics

Recently, much attention has been paid to the COVID-19 pandemic. Yet bacterial resistance to antibiotics remains a serious and unresolved public health problem that kills hundreds of thousands of people annually, being an insidious and silent pandemic. To contain the spreading of the SARS-CoV-2 virus, populations confined and tightened hygiene measures. We performed this study with computer simulations and by using mobility data of mobile phones from Google in the region of Lisbon, Portugal, comprising 3.7 million people during two different lockdown periods, scenarios of 40 and 60% mobility reduction. In the simulations, we assumed that the network of physical contact between people is that of a small world and computed the antibiotic resistance in human microbiomes after 180 days in the simulation. Our simulations show that reducing human contacts drives a reduction in the diversity of antibiotic resistance genes in human microbiomes. Kruskal–Wallis and Dunn’s pairwise tests show very strong evidence (p < 0.000, adjusted using the Bonferroni correction) of a difference between the four confinement regimes. The proportion of variability in the ranked dependent variable accounted for by the confinement variable was η² = 0.148, indicating a large effect of confinement on the diversity of antibiotic resistance. We have shown that confinement and hygienic measures, in addition to reducing the spread of pathogenic bacteria in a human network, also reduce resistance and the need to use antibiotics.

Drug Therapy Problems and Predictors Among Patients Admitted to Medical Wards of Dilla University Referral Hospital, South Ethiopia: A Case of Antimicrobials

Purpose

To assess antimicrobial use-related problems and associated factors among patients admitted to medical wards of Dilla University Referral Hospital.

Patients and Methods

A hospital-based prospective observational study design was employed to assess the antimicrobial use-related problems among adult patients admitted to Dilla University Referral Hospital from 5 March to 4 September 2018. The antimicrobial therapy was reviewed to assure compliance with the recommendations of the national guidelines or evidence-based international clinical guidelines and drug therapy problem was identified. The logistic regression model was fit to determine the association between the different factors and the occurrence of drug therapy problems. Odds ratio was used to show a comparison of factors contributing to drug therapy problems. Statistical significance was considered at p-value <0.05.

Results

In this follow-up to 229 participants, the prevalence of antimicrobial therapy-related problem was 70.74%. “Noncompliance to therapy” was the most frequent DTP experienced by 68 (29.69%) of the patients followed by “needs additional drug therapy” seen among 31 (13.54%) patients. “Adverse drug reaction” was the least and experienced by 7 (3.06%) patients. Others include: dosage too low among 22 (9.61%), dose too high among 17 (8.30%), unnecessarily prescribed antimicrobials among 17 (7.42%) and ineffective antimicrobials among 8 (3.49%) patients. Compared with those who used less than four drugs, the use of four to six (AOR: 4.024) and seven and above (AOR: 13.516) drugs were determinants for antimicrobial use problems. Additionally, infectious cases not addressed by the national guideline (AOR: 3.328) and the unavailability of appropriate lab values results within 48 hours of hospital admission (AOR: 1.285) were determinants for antimicrobial use problems.

Conclusion

Antimicrobial use problem was prevalent with 0.94-problems-per-patient. Polypharmacy, coverage of national guidelines and availing laboratory values within 48 hours of hospital admission were independent determinants of antimicrobial use problems.

Serum Procalcitonin and C-reactive Protein as Markers of Sepsis and Outcome in Patients with Neurotrauma and Subarachnoid Haemorrhage

This prospective study evaluated serum procalcitonin (PCT) and C-reactive protein (CRP) as markers for systemic inflammatory response syndrome (SIRS)/sepsis and mortality in patients with traumatic brain injury and subarachnoid haemorrhage. Sixty-two patients were followed for 7 days. Serum PCT and CRP were measured on days 0, 1, 4, 5, 6 and 7.

Seventy-seven per cent of patients with traumatic brain injury and 83% with subarachnoid haemorrhage developed SIRS or sepsis (P=0.75). Baseline PCT and CRP were elevated in 35% and 55% of patients respectively (P=0.03). There was a statistically non-significant step-wise increase in serum PCT levels from no SIRS (0.4±0.6 ng/ml) to SIRS (3.05±9.3 ng/ml) to sepsis (5.5±12.5 ng/ml). A similar trend was noted in baseline PCT in patients with mild (0.06±0.9 ng/ml), moderate (0.8±0.7 ng/ml) and severe head injury (1.2±1.9 ng/ml). Such a gradation was not observed with serum CRP. There was a non-significant trend towards baseline PCT being a better marker of hospital mortality compared with baseline CRP (ROC-AUC 0.56 vs 0.31 respectively). This is the first prospective study to document the high incidence of SIRS in neurosurgical patients. In our study, serum PCT appeared to correlate with severity of traumatic brain injury and mortality. However, it could not reliably distinguish between SIRS and sepsis in this cohort. This is in part because baseline PCT elevation seemed to correlate with severity of injury. Only a small proportion of patients developed sepsis, thus necessitating a larger sample size to demonstrate the diagnostic usefulness of serum PCT as a marker of sepsis. Further clinical trials with larger sample sizes are required to confirm any potential role of PCT as a sepsis and outcome indicator in patients with head injuries or subarachnoid haemorrhage.

[Severe bilateral pseudomonas sclerokeratitis in comatose patient (clinical case)]

The article presents a clinical case of severe bilateral pseudomonas sclerokeratitis in a patient with occlusion hydrocephalus and intracranial hypertension, who was in a coma and on a ventilator for 20 days. At first examination (7 days after the onset of purulent keratitis, during which the process had been rapidly progressing), the clinical picture included lagophthalmos, severe purulent corneal ulcer, bilateral purulent scleromalacia, perforated cornea in the left eye. On the same day, in order to maintain eye integrity, urgent reconstructive penetrating sclerokeratoplasty with subsequent sclerocorneal coating was performed in both eyes right in the intensive care unit. Parts of the melted iris and ciliary body pars plana that were left in place were abundantly washed with BSS and moxifloxacin solutions - 150 µg/ml. Postoperative care included forced instillations of antibiotics and antiseptics. Two years after the first surgery, 2 more full-thickness corneal transplantations were performed in the patient's right eye aiming at restoration of its optical system. Thus, immediate sclerokeratoplasty with anterior segment irrigation and intraocular administration of highly diluted antibiotics appeared to be the only chance to save the vision in one eye. The fellow eye, where perforation occurred as a result of severe purulent sclerokeratitis and purulent iridocyclitis, despite all measures taken, lost its sight. After three surgeries (penetrating sclerokeratoplasty and two re-PK), visual acuity in the only seeing (right) eye was 0.1, which can be considered a satisfactory result.

Comparing External Ventricular Drains-Related Ventriculitis Surveillance Definitions

OBJECTIVE To evaluate the agreement between the current National Healthcare Safety Network (NHSN) definition for ventriculitis and others found in the literature among patients with an external ventricular drain (EVD) DESIGN Retrospective cohort study from January 2009 to December 2014 SETTING Neurology and neurosurgery intensive care unit of a large tertiary-care center PATIENTS Patients with an EVD were included. Patients with an infection prior to EVD placement or a permanent ventricular shunt were excluded. METHODS We reviewed the charts of patients with positive cerebrospinal fluid (CSF) cultures and/or abnormal CSF results while they had an EVD in place and applied various ventriculitis definitions. RESULTS We identified 48 patients with a total of 52 cases of ventriculitis (41 CSF culture-positive cases and 11 cases based on abnormal CSF test results) using the NHSN definition. The most common organisms causing ventriculitis were gram-positive commensals (79.2%); however, 45% showed growth of only 1 colony on 1 piece of media. Approximately 60% of the ventriculitis cases by the NHSN definition met the Honda criteria, approximately 56% met the Gozal criteria, and 23% met Citerio's definition. Cases defined using Honda versus Gozal definitions had a moderate agreement (κ=0.528; P<.05) whereas comparisons of Honda versus Citerio definitions (κ=0.338; P<.05) and Citerio versus Gozal definitions (κ=0.384; P<.05) had only fair agreements. CONCLUSIONS The agreement between published ventriculostomy-associated infection (VAI) definitions in this cohort was moderate to fair. A VAI surveillance definition that better defines contaminants is needed for more homogenous application of surveillance definitions between institutions and better comparison of rates. Infect Control Hosp Epidemiol 2017;38:574-579.

Urosepsis: Overview of the Diagnostic and Treatment Challenges

Urosepsis is defined as sepsis caused by an infection in the urogenital tract. In approximately 30% of all septic patients the infectious focus is localized in the urogenital tract, mainly due to obstructions at various levels, such as ureteral stones. Urosepsis may also occur after operations in the urogenital tract. In urosepsis, complete bacteria and components of the bacterial cell wall from the urogenital tract trigger the host inflammatory event and act as exogenous pyrogens on eukaryotic target cells of patients. A burst of second messenger molecules leads to several different stages of the septic process, from hyperactivity to immunosuppression. As pyelonephritis is the most frequent cause for urosepsis, the kidney function is therefore most important in terms of cause and as a target organ for dysfunction in the course of the sepsis.Since effective antimicrobial therapy must be initiated early during sepsis, the empiric intravenous therapy should be initiated immediately after microbiological sampling. For the selection of appropriate antimicrobials, it is important to know risk factors for resistant organisms and whether the sepsis is primary or secondary and community or nosocomially acquired. In addition, the preceding antimicrobial therapies should be recorded as precisely as possible. Resistance surveillance should, in any case, be performed locally to adjust for the best suitable empiric treatment. Treatment challenges arise from the rapid increase of antibiotic resistance in Gram-negative bacteria, especially extended-spectrum β-lactamase (ESBL)-producing bacteria. Treatment of urosepsis comprises four basic strategies I) supportive therapy (stabilizing and maintaining blood pressure), II) antimicrobial therapy, III) control or elimination of the complicating factor, and IV) specific sepsis therapy.

Antimicrobial Use-Related Problems and Predictors among Hospitalized Medical In-Patients in Southwest Ethiopia: Prospective Observational Study

Background

The spread of antimicrobial resistance in developing countries is associated with complex and interconnected factors, such as excessive and unnecessary prescribing of antimicrobials, increased self-prescribing by the people and poor quality of available antimicrobials. Moreover, the failure to implement infection control practices and the dearth of routine susceptibility testing and surveillance magnify the problems. This may spread the inappropriateness of prescribing, ending up with the spread of antimicrobial resistance.

Objective

The aim of this study was to assess antimicrobial use related problems and associated factors among patients admitted at Jimma University specialized hospital.

Methods

A hospital based prospective observational study design was employed at medical wards of Jimma University specialized hospital, Ethiopia. Data collected from patient medication charts and from the patients was analyzed using SPSS, version 16.0. Logistic regression was used to determine the associations between variables. Statistical significance was considered at p-value <0.05.

Results

Out of 152 study participants, at least one antimicrobial use problem was identified among 115(75.7%). Accordingly, additional antimicrobials were needed by 45(29.6%) of the patients, whereas they were unnecessary among 44(28.9%). Similarly, 17% of the patients were noncompliant to at least one antimicrobial therapy, while 8.6% experienced at least one type of adverse drug reaction. On the other hand, the coverage of the infectious medical condition in the national guidelines (AOR = 4.888) and the duration of hospital stay (AOR = 3.086) were the determinants of the antimicrobial use problems.

Conclusion

Most of the antimicrobial use problems identified were related to delay of initiation of effective antimicrobials and excessive use; use without indication or using duplicates of broad spectrum antimicrobials or use for longer duration than recommended. The coverage of the infectious medical condition in the national treatment guidelines and the duration of hospital stay were the determinants of the antimicrobial use problems.

Trends of isolation of intrinsically resistant to colistin Enterobacteriaceae and association with colistin use in a tertiary hospital

The objective of this investigation was to evaluate the association between colistin consumption and the isolation of intrinsically resistant to colistin Enterobacteriaceae (IRCE) in a university hospital in Crete, Greece. The database of the microbiological laboratory was reviewed retrospectively during 2006-2010. All positive cultures for IRCE were retrieved. We assessed the total consumption of colistin in medical, surgical, and intensive care units (ICUs). A total of 1,304 single-patient IRCE isolates were recorded. Of these, 466 (35.7%) were hospital-acquired, while 838 (64.3%) were community-acquired. Proteus spp. accounted for 72% of them, Serratia spp. for 16.6%, Morganella morganii for 8.4%, and Providencia spp. for 3%. Urine (44.8%), pus (20.4%), and lower respiratory tract specimens (12.8%) accounted for the majority of specimens. IRCE isolated during the first half (2006 to 1st semester of 2008) and second half (2nd semester of 2008 to 2010) of the study period accounted for 5.8% and 7.4% of Gram-negative isolates, respectively (p < 0.001). Colistin consumption was not different in the two periods in the hospital, but in the ICU, it was higher in the second half of the study period (p = 0.013). Colistin consumption was associated with the isolation of hospital-acquired IRCE (p = 0.037); a trend was noted between colistin consumption and the isolation of IRCE in the ICU (p = 0.057). In this study, colistin consumption was associated with the isolation of hospital-acquired IRCE. The use of colistin increased in the ICU during the study period. Prudent use of colistin is essential for the prevention of nosocomial outbreaks due to resistant IRCE.

Diagnosis and management for urosepsis

Urosepsis is defined as sepsis caused by a urogenital tract infection. Urosepsis in adults comprises approximately 25% of all sepsis cases, and is in most cases due to complicated urinary tract infections. The urinary tract is the infection site of severe sepsis or septic shock in approximately 10-30% of cases. Severe sepsis and septic shock is a critical situation, with a reported mortality rate nowadays still ranging from 30% to 40%. Urosepsis is mainly a result of obstructed uropathy of the upper urinary tract, with ureterolithiasis being the most common cause. The complex pathogenesis of sepsis is initiated when pathogen or damage-associated molecular patterns recognized by pattern recognition receptors of the host innate immune system generate pro-inflammatory cytokines. A transition from the innate to the adaptive immune system follows until a T(H2) anti-inflammatory response takes over, leading to immunosuppression. Treatment of urosepsis comprises four major aspects: (i) early diagnosis; (ii) early goal-directed therapy including optimal pharmacodynamic exposure to antimicrobials both in the plasma and in the urinary tract; (iii) identification and control of the complicating factor in the urinary tract; and (iv) specific sepsis therapy. Early adequate tissue oxygenation, adequate initial antibiotic therapy, and rapid identification and control of the septic focus in the urinary tract are critical steps in the successful management of a patient with urosepsis, which includes early imaging, and an optimal interdisciplinary approach encompassing emergency unit, urological and intensive-care medicine specialists.

A survey on infection management practices in Italian ICUs

Introduction

An online survey was conducted to characterize current infection management practices in Italian intensive care units (ICUs), including the antibacterial and antifungal drug regimens prescribed for various types of infections.

Methods

During February and March 2011, all 450 ICUs in public hospitals in Italy were invited to take part in an online survey. The questionnaire focused on ICU characteristics, methods used to prevent, diagnose, and treat infections, and antimicrobials prescribing policies. The frequency of each reported practice was calculated as a percentage of the total number of units answering the question. The overall response rate to the questionnaire was 38.8% (175 of the 450 ICUs contacted) with homogeneous distribution across the country and in terms of unit type.

Results

Eighty-eight percent of the responding facilities performed periodical surveillance cultures on all patients. In 71% of patients, cultures were also collected on admission. Endotracheal/bronchial aspirates were the most frequently cultured specimens at both time points. Two-thirds of the responding units had never performed screening cultures for methicillin-resistant Staphylococcus aureus. Around 67% of the ICUs reported the use of antimicrobial de-escalation strategies during the treatment phase. In general, the use of empirical antimicrobial drug regimens was appropriate. Although the rationale for the choice was not always clearly documented, the use of a combination therapy was preferred over antibiotic monotherapy. The preferred first-line agents for invasive candidiasis were fluconazole and an echinocandin (64% and 25%, respectively). Two-thirds of the ICUs monitored vancomycin serum levels and administered it by continuous infusion in 86% of cases. For certain antibiotics, reported doses were too low to ensure effective treatment of severe infections in critically ill patients; conversely, inappropriately high doses were administered for certain antifungal drugs.

Conclusions

Although infection control policies and management practices are generally appropriate in Italian ICUs, certain aspects, such as the extensive use of multidrug empirical regimens and the inappropriate antimicrobial dosing, deserve careful management and closer investigation.

Antimicrobial use in a critical care unit: a prospective observational study

OBJECTIVE

The purpose of this study was to describe antimicrobial utilization, consumption, indications and microbial resistance in a medical-surgical-trauma intensive care unit (ICU) of a teaching hospital to identify potential targets for antimicrobial stewardship.

METHODS

This was a 30-day prospective observational study enrolling adults admitted to the ICU for at least 24 h and having received antimicrobial therapy. Primary endpoints included utilization as percentage use of antimicrobials by class and agent, consumption measured as days of therapy per 1000 patient days (DOT/1000PD), indications for use and prescriber. Secondary endpoints included reasons for modifications to therapy and microbial resistance.

KEY FINDINGS

Eighty-three patients were screened and 61 enrolled, receiving 133 courses of antimicrobial therapy, mainly intravenously and prescribed by ICU staff. The most frequently prescribed agents were piperacillin/tazobactam (20%), cefazolin (17%) and vancomycin (13%). The indications for therapy were empirical (50%), directed (27%) and prophylactic (23%). Overall consumption was 1368.54 DOT/1000PD and was mainly attributed to empirical therapy (734.25). Prolonged durations were noted for carbapenems and for surgical prophylaxis. There were 86 therapy modifications involving indication (36), efficacy (25), safety (18) and route (7). Suboptimal or excessive dosing were common contributors to efficacy and safety modifications, respectively. Infections due to microorganisms with notable resistance included methicillin-resistant Staphylococcus aureus (5), Pseudomonas aeruginosa (1) and Streptococcus pneumoniae (1).

CONCLUSIONS

Antimicrobial utilization and consumption based on DOT/1000PD were prospectively determined providing a comparator for other ICUs. Potential targets identified for antimicrobial stewardship initiatives include empirical therapy, treatment duration, dosing and route.

Urosepsis--from the view of the urologist

Urosepsis accounts for approximately 25% of all sepsis cases and may develop from a community-or nosocomial-acquired urinary tract infection (UTI). The underlying UTI is almost exclusively a complicated one with involvement of parenchymatous urogenital organs (e.g. kidneys, prostate). In urosepsis, as in other types of sepsis, the severity of sepsis depends mostly upon the host response. The urological management of urosepsis comprises early diagnosis, early fluid and oxygen treatment, early antibiotic therapy and early control of the complicating factor in the urinary tract. Time from admission to therapy is critical. The shorter the time to effective treatment, the higher is the success rate. This aspect has to become incorporated into the organisational process, including urologists, radiologists and intensive care specialists amongst others. Adequate initial antibiotic therapy has to be insured. This goal implies, however, a wide array of measures over time to ensure a rational antibiotic policy, including microbiologists and clinical pharmacologists. Dosage of an antibiotic in the septic patient generally has to be high to ensure adequate pharmacological exposure in the individual patient.

Approach to a patient with urosepsis

Urinary tract infections can occur in all age groups and produce an exceptionally broad range of clinical syndromes ranging from asymptomatic bacteriuria to acute pyelonephritis with Gram negative sepsis to septic shock. In approximately one-quarter of all patients with sepsis, the focus of infection is localized to the urogenital tract. This may lead to substantial morbidity and significant economic implications. We present a review of the current approaches to managing urospesis.

Antimicrobial Utilisation in 37 Australian and New Zealand Intensive Care Units

This multi-centre point prevalence study reports on antimicrobial dosing patterns, including dose, mode of administration and type of infection, in 37 Australian and New Zealand intensive care units. Of 422 patients admitted to an intensive care unit on 8 May 2007, 195 patients (46%) received antimicrobial treatment, 123 patients (29%) received no antimicrobials and 104 patients (25%) received prophylactic antimicrobials only. Dosing data were available for 331 antimicrobials used to treat 225 infections in 193 patients. Respiratory (40%), abdominal (13%) and blood stream (12%) infections were most common. For adult patients, ticarcillin/clavulanate (23% or 40/177), meropenem (20% or 35/177) and vancomycin (18% or 32/177) were the most frequently used antibiotics; vancomycin was most commonly used in children (31% or 5/16). The majority of antimicrobials were administered as bolus doses or infusions of less than two hours (98% or 317/323); only six patients received extended or continuous infusions. The mode of administration was unknown in eight cases (4.1%). The total defined daily dose for adult patients receiving antimicrobial therapy was 2051 defined daily doses per 1000 patient days. Our results confirm that the use of continuous infusions remains rare, despite increased interest in continuous infusions for time-dependent antibiotics.

Pharmacokinetic and pharmacodynamic parameters of antimicrobials: potential for providing dosing regimens that are less vulnerable to resistance

Whereas infections caused by multidrug-resistant micro-organisms are increasing worldwide, there are few new molecules, especially ones that are active against Gram-negative strains. There are extensive data showing that the administration of antimicrobials according to pharmacokinetic/pharmacodynamic parameters improves the possibility of a positive clinical outcome, particularly in severely ill patients. Evidence is growing that when pharmacokinetic/pharmacodynamic parameters are used to target not only clinical cure but also eradication, the spread of resistance will also be contained. The present paper summarizes the most relevant papers published in this field and provides some suggestions for dosing regimens that can be adopted in the clinical setting to limit the spread of resistance.

Therapeutic challenges of urosepsis

Urosepsis accounts for approximately 25% of all sepsis cases and may develop from a community or nosocomial acquired urinary tract infection (UTI). The underlying UTI is almost exclusively a complicated one with involvement of parenchymatous urogenital organs (e.g. kidneys, prostate). In urosepsis, as in other types of sepsis, the severity of sepsis depends mostly upon the host response. The treatment of urosepsis comprises four major aspects: Early goal directed therapy, early optimal pharmacodynamic exposure to antimicrobials, early control of the complicating factor in the urinary tract and specific sepsis therapy. Following these prerequisites there appear two major challenges that need to be addressed: Firstly, time from admission to therapy is critical; the shorter the time to effective treatment, the higher the success rate. This aspect has to become incorporated into the organisational process. Secondly, adequate initial antibiotic therapy has to be insured. This goal implies however, a wide array of measures to ensure rational antibiotic policy. Both challenges are best targeted if an interdisciplinary approach at any level of the process is established, encompassing urologists, intensive care specialists, radiologists, microbiologists and clinical pharmacologists working tightly together at any time.

Optimal management of urosepsis from the urological perspective

Urosepsis in adults comprises approximately 25% of all sepsis cases and in most cases is due to complicated urinary tract infections (UTIs). In this paper we review the optimal management of urosepsis from the urological point of view. Urosepsis is often due to obstructed uropathy of the upper or lower urinary tract. The treatment of urosepsis comprises four major aspects: 1. Early goal-directed therapy; 2. Optimal pharmacodynamic exposure to antimicrobials both in blood and in the urinary tract; 3. Control of complicating factors in the urinary tract; 4. Specific sepsis therapy. Early tissue oxygenation, appropriate initial antibiotic therapy and rapid identification and control of the septic focus in the urinary tract are critical steps in the successful management of a patient with severe urosepsis. To achieve this goal an optimal interdisciplinary approach encompassing the emergency unit, urological specialties and intensive-care medicine is necessary.

Antimicrobial resistance in critical care

Patients presenting with active infections or at increased risk for infections pose a significant challenge in critical care nursing. It is important for critical care nurses to use effective antimicrobial strategies in patient management to reduce the potential development of antimicrobial resistance. They should be involved actively in promoting patient management through development of research-based nursing guidelines and protocols.

A new antimicrobial susceptibility testing method of Escherichia coli against ampicillin by MSPQC

A new antimicrobial susceptibility testing method by multi-channel series piezoelectric quartz crystal (MSPQC) was proposed. This method was used to test susceptibility of clinical Escherichia coli isolates against ampicillin. Both the minimum inhibitory concentrations (MICs) and interpretive categorization of clinical E. coli isolates were determined by proposed method. Comparing tests were run at the same time by the agar dilution method and the disk diffusion method. The experimental results showed that MSPQC method had a good agreement with the reference methods. Compared with those methods, the MSPQC method is simple, rapid, and convenient to perform. It can offer both a minimum inhibitory concentration (MIC) and an interpretive category result.

Pharmacokinetic Characteristics of Antimicrobials and Optimal Treatment of Urosepsis

Urosepsis accounts for approximately 25% of all sepsis cases and may develop from a community-acquired or nosocomial urinary tract infection (UTI). Nevertheless, the underlying UTI is almost exclusively a complicated one with involvement of the parenchymatous urogenital organs (e.g. kidneys, prostate) and mostly associated with any kind of obstructive uropathy. If urosepsis originates from a nosocomial infection, a broad spectrum of Gram-negative and Gram-positive pathogens have to be expected, which are often multiresistant. In urosepsis, as in other types of sepsis, the severity of sepsis depends mostly upon the host response. The treatment of urosepsis follows the generally accepted rules of the 'Surviving Sepsis' campaign guidelines. Early normalisation of blood pressure and early adequate empirical antibacterial therapy with optimised dosing are equally important to meet the requirements of early goal-directed therapy. In most cases of urosepsis, early control of the infectious focus is possible and as important. Optimal supportive measures need to follow the early phase of resuscitation. To lower mortality from urosepsis, an optimal interdisciplinary approach between intensive care, anti-infective therapy and urology is essential, assisted by easy access to the necessary laboratory and imaging diagnostic procedures. Although most antibacterials achieve high urinary concentrations, there are several unique features of complicated UTI, and thus urosepsis, that influence the activity of antibacterial substances: (i) renal pharmacokinetics differ in unilateral and bilateral renal impairment and in unilateral and bilateral renal obstruction; (ii) variations in pH may influence the activity of certain antibacterials; and (iii) biofilm infection is frequently found under these conditions, which may increase the minimal inhibitory concentrations (MIC) of the antibacterials at the site of infection by several hundred folds. Assessment of antibacterial pharmacodynamic properties in such situations should take into account not only the MIC as determined in vitro and the plasma concentrations of the free (unbound) drug, which are the guiding principles for many infections, but also the actual renal excretion and urinary bactericidal activity of the antibacterial substance. In the treatment of urosepsis, it is important to achieve optimal exposure to antibacterials both in plasma and in the urinary tract. The role of drugs with low renal excretion rates is therefore limited. Since urosepsis quite often originates from catheter-associated UTI and urological interventions, optimal catheter care and optimal strategies to prevent nosocomial UTI may be able to reduce the frequency of urosepsis.

[Impact of antibiotic use and prescribing policy in a Tunisian intensive care unit]

OBJECTIVE

The aim of this study was to assess the efficacy of local antibiotic policy in a Tunisian ICU. The predefined primary efficacy objectives were the decrease of antibiotic consumption, reduction of inappropriate antibiotic (ATB) use and antimicrobial resistance.

DESIGN

This prospective intervention study lasted from January 2002 to December 2004. In the first study period or the baseline phase (from January to December 2002) we focused on physician education for ATB prescription practice. The second period concerned intervention (control of all ATB use).

RESULTS

The number of infection episodes significantly decreased from 2002 to 2004; 198 infection episodes in 2002 (1.63+/-1.15 episodes/patient) versus 124 in 2003 (1.22+/-0.93) (P<0.0008) versus 121 in 2004 (1.23+/-0.8) (P1<0.0008). The number of ATB/prescription also significantly decreased from 1.85+/-1.3 in 2002 to 1.5+/-0.9 in 2003 (P=0.02) and 1.5+/-1.4 in 2004 (P1=0.05). Appropriateness of antibiotherapy improved during the intervention period: 65% in 2002 versus 86% in 2003 (P=0.0003) and 81% in 2004 (P1=0.02). The length of antibiotherapy in survivors was considerably reduced: 14.1+/-2.9 days in 2002 versus 11.9+/-1.2 days in 2003 (P<10(-5)) and 10.9+/-2.5 days in 2004 (P1<10(-5)) with a significant reduction of antibiotherapy cost and length of stay (20.4+/-9 days in 2002 versus 18.3+/-6 days in 2003 and 16.9+/-8 days in 2004; P=0.05; P1=0.02). There was a significant decrease of carbapenem resistant Enterobacteriaceae esbeta, Pseudomonas aeruginosa and Acinetobacter baumannii.

Nosocomial infections at Kenyatta National Hospital Intensive-Care Unit in Nairobi, Kenya

The objective of this study was to identify the common bacteria isolated from patients, antibiotics used, sensitivity patterns, therapeutic procedures and cleaning protocols practised in Kenyatta National Hospital Intensive-Care Unit (ICU). Kenyatta National Hospital is a 1,800-bed referral and tertiary-care hospital which is also the Teaching University Hospital. The ICU has 20 beds. Two members of staff, a consultant and a senior nurse, did the study. Out of 195 patients admitted to the unit during the study period, 137 (70.3%) received antibiotics. The most frequently prescribed antibiotics included meropenem, ceftazidime, cefuroxime, piperacillin tazobactam, vancomycin, Augmentin and Flagyl. The most common bacteria isolated were Pseudomonas aeruginosa,Klebsiella, Citrobacter, Staphylococcus aureus, Staphylococcus pneumoniae, Acinetobactor and Escherichia coli isolated from tracheal aspirate, urine, blood and pus swabs.

Antimicrobial therapy in critically ill patients: a review of pathophysiological conditions responsible for altered disposition and pharmacokinetic variability

Antimicrobials are among the most important and commonly prescribed drugs in the management of critically ill patients. Selecting the appropriate antimicrobial at the commencement of therapy, both in terms of spectrum of activity and dose and frequency of administration according to concentration or time dependency, is mandatory in this setting. Despite appropriate standard dosage regimens, failure of the antimicrobial treatment may occur because of the inability of the antimicrobial to achieve adequate concentrations at the infection site through alterations in its pharmacokinetics due to underlying pathophysiological conditions. According to the intrinsic chemicophysical properties of antimicrobials, hydrophilic antimicrobials (beta-lactams, aminoglycosides, glycopeptides) have to be considered at much higher risk of inter- and intraindividual pharmacokinetic variations than lipophilic antimicrobials (macrolides, fluoroquinolones, tetracyclines, chloramphenicol, rifampicin [rifampin]) in critically ill patients, with significant frequent fluctuations of plasma concentrations that may require significant dosage adjustments. For example, underexposure may occur because of increased volume of distribution (as a result of oedema in sepsis and trauma, pleural effusion, ascites, mediastinitis, fluid therapy or indwelling post-surgical drainage) and/or enhanced renal clearance (as a result of burns, drug abuse, hyperdynamic conditions during sepsis, acute leukaemia or use of haemodynamically active drugs). On the other hand, overexposure may occur because of a drop in renal clearance caused by renal impairment. Care with all these factors whenever choosing an antimicrobial may substantially improve the outcome of antimicrobial therapy in critically ill patients. However, since these situations may often coexist in the same patient and pharmacokinetic variability may be unpredictable, the antimicrobial policy may further benefit from real-time application of therapeutic drug monitoring, since this practice, by tailoring exposure to the individual patient, may consequently be helpful both in improving the outcome of antimicrobial therapy and in containing the spread of resistance in the hospital setting.

Evaluation of antibiotic use in intensive care units of a tertiary care hospital in Turkey

The object of this study was to evaluate the appropriateness of antibiotic use in relation to diagnosis and bacteriological findings in the intensive care units (ICUs) of a 1100-bed referral and tertiary care hospital with an antibiotic restriction policy in Turkey. Between June and December 2002, patients who received antibiotics in the medical and surgical ICUs were evaluated prospectively. Two infectious diseases (ID) specialists assessed the antibiotics ordered daily. Of the 368 patients admitted to the ICUs, 223 (60.6%) received 440 antibiotics. The most frequently prescribed antibiotics were first-generation cephalosporins (16.1%), third-generation cephalosporins (15.2%), aminoglycosides (12.1%), carbapenems (10.7%) and ampicillin-sulbactam (8.7%). Antibiotic use was inappropriate in 47.3% of antibiotics. ID specialists recommended the use of 47% of all antibiotics. An antibiotic order without an ID consultation was more likely to be inappropriate [odds ratio (OR)=13.2, P<0.001, confidence intervals (CI)=4.4-39.5]. Antibiotics ordered empirically were found to be less appropriate than those ordered with evidence of culture and susceptibility results (OR=3.8, P=0.038, CI=1.1-13.1). Inappropriate antibiotic use was significantly higher in patients who had surgical interventions (OR=3.6, P=0.025, CI=1.2-10.8). Irrational antibiotic use was high for unrestricted antibiotics. In particular, antibiotic use was inappropriate in surgical ICUs. Additional interventions such as postgraduate training programmes and elaboration of local guidelines could be beneficial.

Judicious Use of Antimicrobials in the Critical Care Setting

This article reviews the judicious use of antibiotics in an intensive care setting. Risk factors for both infection and antimicrobial resistance are discussed. Various methods hospitals can apply to promote the optimal use of antibiotics also are reviewed. These methods include empiric therapy, antibiotic cycling, treatment guidelines and protocols, and antibiotic susceptibility monitoring.

Epidemiology of Nosocomial Pneumonia in Infants After Cardiac Surgery

BACKGROUND

The pattern of nosocomial pneumonia (NP) in infants in a pediatric surgical ICU after cardiac surgery may differ from that seen in adult ICUs.

STUDY OBJECTIVES

The primary aim of this study was to describe the epidemiology of NP in infants after cardiac surgery and, secondarily, to describe the changes of the distribution and antibiotic resistance of the pathogen during the last 3 years.

METHODS

Data were collected between June 1999 and June 2002 from 311 consecutive infants who underwent open-heart surgery in our hospital. We retrospectively analyzed the distribution and antibiotic resistance pattern of all the pathogenic microbial isolates cultured from lower respiratory tract aspirations.

RESULTS

Of 311 infants, 67 patients (21.5%) acquired NP after cardiac surgery. The incidence of NP was more frequently associated with complex congenital heart defect (CHD) compared to simple CHD (43% vs 15.9%, chi(2) = 22.47, p < 0.0001). The proportion of late-onset NP was higher in patients with complex CHD (chi(2) = 6.02, p = 0.014). A total of 79 pathogenic microbial strains were isolated. Gram-negative bacilli (GNB) were the most frequent isolates (68 isolates, 86.1%), followed by fungi (6 isolates, 7.6%) and Gram-positive cocci (5 isolates, 6.3%). The main GNB were Acinetobacter baumanii (11 isolates, 13.9%), Pseudomonas aeruginosa (10 isolates, 12.7%); other commonly seen GNB were Flavobacterium meningosepticum (7 isolates, 8.9%), Klebsiella pneumoniae (7 isolates, 8.9%), Escherichia coli (6 isolates, 7.6%), and Xanthomonas maltophilia (5 isolates, 6.2%). The most commonly seen Gram-positive cocci were Staphylococcus aureus (2 isolates, 2.5%) and Staphylococcus epidermidis (2 isolates, 2.5%). The frequent fungi were Candida albicans (5 isolates, 6.3%). Most GNB were sensitive to cefoperazone-sulbactum, piperacillin-tazobactam, imipenem, ciprofloxacin, amikacin. The bacteria producing extended spectrum beta-lactamases were mainly from K pneumoniae and E coli; the susceptibility of ESBL-producing strains to imipenem was 100%. There were one case of methicillin-resistant S aureus (MRSA) and 1 case of methicillin-resistant S epidermidis; their susceptibility to vancomycin, gentamycin, and ciprofloxacin were 100%. From 1999 to 2002 in infants with NP after open-heart surgery, there was a trend of increasing frequency of multiresistant GNB such as A baumanii, P aeruginosa, and K pneumoniae. However, no remarkable changes of distribution were found in Gram-positive cocci and fungi in the 3-year period. Early onset episodes of NP were frequently caused by Haemophilus influenzae, methicillin-sensitive S aureus, and other susceptible Enterobacteriaceae. Conversely, in patients who acquired late-onset NP, P aeruginosa, A baumannii, other multiresistant GNB, MRSA, and fungi were the predominant organisms.

CONCLUSIONS

The pattern of pathogens and their antibiotic-resistance patterns in NP in infants after cardiac surgery had not shown an increasing prevalence of Gram-positive pathogens as reported by several adult ICUs. GNB still remained the most common pathogens during the last 3 years in our hospital. There was a trend of increasing antibiotic resistance in these isolates.

Spectrum of microbes and antimicrobial resistance in a surgical intensive care unit, Barbados

BACKGROUND

To survey the epidemiologic findings of infections and antibiotic resistance patterns in the surgical intensive care unit (ICU) of a tertiary care university teaching hospital.

METHODS

The microbiologic culture-sensitivity reports of patients admitted to a surgical ICU were prospectively studied for 6 months each of 3 consecutive years. The antibiotic usage for these patients also was studied concurrently. Reports from general surgical wards for 6 months of 1 year also were analyzed for comparison. The common specimens assayed microbiologically were tracheal aspirate, urine, blood, wound swabs, invasive catheter tips, and screening swabs for methicillin-resistant Staphylococcus aureus.

RESULTS

The organisms reported were Enterobacteriaceae, Pseudomonas species, S aureus, and enterococci. Organisms were highly resistant to amoxicillin and first-generation cephalosporins because of the wide use of these drugs in the hospital. Pseudomonas species showed a 25% increase in resistance to piperacillin-tazobactam and an 18% increase to ciprofloxacin, which was correlated with the increased use of these antimicrobial agents (82% and 200% increases, respectively) in the unit during the 3 years. There was no increase in the resistance to ceftazidime because it is used less often. The resistance to ciprofloxacin, piperacillin-tazobactam, and ceftazidime was significantly greater in the ICU than in the general surgical wards in the same study period.

CONCLUSIONS

The study provided data of antimicrobial resistance in a developing country with tourism as the main industry for epidemiologic comparison with other countries.

Prevalence and in-vitro antimicrobial susceptibility patterns of Acinetobacter strains isolated from patients in intensive care units

Fifty-six Acinetobacter species strains (49 Acinetobacter baumanii, 5 Acinetobacter calcoaceticus, 2 Acinetobacter iwoffii) were detected using both conventional methods and gas chromatography of bacterial fatty acids with the MIDI Sherlock Microbial Identification System. The susceptibilities of these strains to 16 antimicrobial agents were investigated by the disc-diffusion method according to the National Committee for Clinical Laboratory Standards. The production of extended-spectrum beta-lactamases (ESBLs) and inducible beta-lactamases (IBLs) by the strains were investigated by the double-disc-synergy and disc-approximation methods, respectively. Imipenem was the most effective agent for Acinetobacter baumanii strains (95.9% of strains were sensitive), while meropenem and netilmicin showed moderate activity (87.7% and 79.6% of strains, respectively, responded). Acinetobacter baumanii strains were less sensitive to cefoperazone-sulbactam (53.1%), ofloxacin (51.0%), ciprofloxacin (42.8%), and amikacin (36.7%). Acinetobacter calcoaceticus and Acinetobacter iwoffii strains were sensitive to imipenem, meropenem and netilmicin. IBLs and ESBLs were produced, respectively, by 8.9% and 7.1% of all bacterial strains. The strains isolated were sufficiently sensitive to imipenem, but not to ofloxacin or ciprofloxacin, and were very resistant to amikacin.

Evaluation of antibiotic use in a hospital with an antibiotic restriction policy

The study was designed to evaluate rational antibiotic use in relation to diagnosis and bacteriological findings. All hospitalized patients who received antibiotics were evaluated by a cross-sectional study. Of the 713 patients hospitalized, 281 (39.4%) patients received 377 antibiotics. Among 30 different antibiotics the most frequently requested were first generation cephalosporins (19.9%), ampicillin-sulbactam (19.1%) and aminoglycosides (11.7%). Antibiotic use was appropriate in 64.2% of antibiotic requests. In analysis of appropriate use, a request after an infectious diseases consultation was a frequent reason (OR=14, P<0.001, CI=0.02-0.24). Antibiotics requested in conjunction with susceptibility results were found to be more appropriate than those ordered empirically (OR=4.5, P=0.017, CI=0.06-0.76). Inappropriate antibiotic use was significantly higher among unrestricted antibiotics than restricted ones (P<0.001). Irrational antibiotic use was high for unrestricted antibiotics. Additional interventions such as postgraduate training programmes and elaboration of local guidelines could be beneficial.

Resolution of ventilator-associated pneumonia: prospective evaluation of the clinical pulmonary infection score as an early clinical predictor of outcome

OBJECTIVES

To prospectively evaluate the performance of the Clinical Pulmonary Infection Score (CPIS) and its components to identify early in the hospital course of ventilator-associated pneumonia (VAP) which patients are responding to therapy.

DESIGN

Prospective, multicenter, in a cohort of mechanically ventilated patients.

SETTING

The intensive care unit of six hospitals located in the metropolitan area of Buenos Aires, Argentina.

PATIENTS

Sixty-three patients, from a cohort of 472 mechanically ventilated patients hospitalized for >72 hrs, had clinical evidence of VAP and bacteriologic confirmation by bronchoalveolar lavage (BAL) or blood cultures.

INTERVENTIONS

Bronchoscopy with BAL fluid culture and blood cultures after establishing a clinical diagnosis of VAP. All patients received antibiotics, 46 before bronchoscopy and 17 immediately after bronchoscopy.

MEASUREMENTS AND RESULTS

CPIS was measured at 3 days before VAP (VAP-3); at the onset of VAP (VAP); and at 3 (VAP+3), 5 (VAP+5), and 7 (VAP+7) days after onset. CPIS rose from VAP-3 to VAP and then fell progressively in the population as a whole (p <.001), and the fall in CPIS was significant in 31 survivors, but not in 32 nonsurvivors. From the individual components of the CPIS, only the Pao /Fio ratio distinguished survivors from nonsurvivors, beginning at VAP+3. When CPIS was <6 at 3 or 5 days after VAP onset, mortality was lower than in the remaining patients (p =.018). These differences also related to the finding that those receiving adequate therapy had a slight fall in CPIS and a significant increase of Pao /Fio at VAP+3, whereas those getting inadequate therapy did not.

CONCLUSIONS

Serial measurements of CPIS can define the clinical course of VAP resolution, identifying those with good outcome as early as day 3, and could possibly be of help to define strategies to shorten the duration of therapy.

What do physicians think about evidence-based antibiotic use in critical care? A survey of Australian intensivists and infectious disease practitioners

BACKGROUND

The analysis of factors that influence prescribing decisions is increasingly important. Antibiotic use is often based on limited evidence and lack of information about clinical decision-making processes is an important obstacle to improving antibiotic utilization.

AIMS

To compare the attitudes of intensive care unit practitioners (ICUP) and infectious disease practitioners (IDP) to antibiotic use and to the evidence-based information support.

METHOD

A postal survey conducted between March and July 2000 of ICUP and IDP representing all States and Territories in Australia.

RESULTS

One hundred and fifty-three of 224 clinicians returned the questionnaire (68.3% response rate). In choosing an antibiotic, IDP placed significantly more weight than ICUP on the in vitro susceptibility of the pathogen (P = 0.001), antibiotic cost (P = 0.05) and possible development of antibiotic resistance (P = 0.007). More than 95% of both groups believed that unit-specific antibiotic susceptibility of endemic pathogens was an essential factor in rational prescribing, but only 68.5% of IDP and 38.7% of ICUP use microbiology laboratory databases. When in doubt about appropriate antibiotic use, 63.8% of ICUP seek and 76.3% usually follow the advice of IDP. Both groups agree that published antibiotic guidelines are useful, but IDP were more likely to consult them. ICUP were more likely to believe that guidelines are used to control clinicians rather than to improve quality of care (P = 0.001). A greater proportion of IDP (71.2%) than ICUP (52.5%) believed that antibiotic prescribing in their intensive care unit (ICU) was evidence based but most (91.8% and 86.9%, respectively) agreed that it should be.

CONCLUSIONS

Australian clinicians have positive views about evidence-based prescribing and antibiotic guidelines. However, there are clinically significant differences in prescribing behaviour between ICUP and IDP. These may be explained by different disease spectra managed by each group or different cultures, training and/or cognitive styles. Improvements in the understanding of physicians' information and decision support needs are required to strengthen evidence-based prescribing.

Experience with a clinical guideline for the treatment of ventilator-associated pneumonia

OBJECTIVE

To evaluate a clinical guideline for the treatment of ventilator-associated pneumonia.

DESIGN

Prospective before-and-after study design.

SETTING

A medical intensive care unit from a university-affiliated, urban teaching hospital.

PATIENTS

Between April 1999 and January 2000, 102 patients were prospectively evaluated.

INTERVENTIONS

Prospective patient surveillance, data collection, and implementation of an antimicrobial guideline for the treatment of ventilator-associated pneumonia.

MEASUREMENTS AND MAIN RESULTS

The main outcome evaluated was the initial administration of adequate antimicrobial treatment as determined by respiratory tract cultures. Secondary outcomes evaluated included the duration of antimicrobial treatment for ventilator-associated pneumonia, hospital mortality, intensive care unit and hospital lengths of stay, and the occurrence of a second episode of ventilator-associated pneumonia. Fifty consecutive patients with ventilator-associated pneumonia were evaluated in the before period and 52 consecutive patients with ventilator-associated pneumonia were evaluated in the after period. Severity of illness using Acute Physiology and Chronic Health Evaluation II (25.8 +/- 5.7 vs. 25.4 +/- 8.1, p =.798) and the clinical pulmonary infection scores (6.6 +/- 1.0 vs. 6.9 +/- 1.2, p =.105) were similar for patients during the two treatment periods. The initial administration of adequate antimicrobial treatment was statistically greater during the after period compared with the before period (94.2% vs. 48.0%, p <.001). The duration of antimicrobial treatment was statistically shorter during the after period compared with the before period (8.6 +/- 5.1 days vs. 14.8 +/- 8.1 days, p <.001). A second episode of ventilator-associated pneumonia occurred statistically less often among patients in the after period (7.7% vs. 24.0%, p =.030).

CONCLUSIONS

The application of a clinical guideline for the treatment of ventilator-associated pneumonia can increase the initial administration of adequate antimicrobial treatment and decrease the overall duration of antibiotic treatment. These findings suggest that similar types of guidelines employing local microbiological data can be used to improve overall antibiotic utilization for the treatment of ventilator-associated pneumonia.

Nosocomial Pneumonia: More Than Just Ventilator-Associated

We reviewed literature published from 1995 through 2000 on developments in ventilator-associated pneumonia. There is no gold standard with which to compare the accuracy of various invasive procedures performed for diagnosis. Moreover, leaders in the field are calling for an outcomes-based analysis to assess the utility of invasive procedures. Two things are clear: 1) adequate empiric therapy is beneficial, and 2) changes in therapy based on recovery of pathogens by invasive means do not affect outcome. Clinicians are urged to review local antimicrobial resistance patterns and to initiate empiric therapy on the basis of those data.