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Jorro-Baron F, Loudet CI, Cornistein W, Suarez-Anzorena I, Arias-Lopez P, Balasini C, Cabana L, Cunto E, Corral PRJ, Gibbons L, Guglielmino M, Izzo G, Lescano M, Meregalli C, Orlandi C, Perre F, Ratto ME, Rivet M, Rodriguez AP, Rodriguez VM, Vilca Becerra J, Villegas PR, Vitar E, Roberti J, García-Elorrio E, Rodriguez V. Optimising antibacterial utilisation in Argentine intensive care units: a quality improvement collaborative. BMJ Qual Saf 2024:bmjqs-2024-017069. [PMID: 39147572 DOI: 10.1136/bmjqs-2024-017069] [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: 01/02/2024] [Accepted: 08/05/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND There is limited evidence from antimicrobial stewardship programmes in less-resourced settings. This study aimed to improve the quality of antibacterial prescriptions by mitigating overuse and promoting the use of narrow-spectrum agents in intensive care units (ICUs) in a middle-income country. METHODS We established a quality improvement collaborative (QIC) model involving nine Argentine ICUs over 11 months with a 16-week baseline period (BP) and a 32-week implementation period (IP). Our intervention package included audits and feedback on antibacterial use, facility-specific treatment guidelines, antibacterial timeouts, pharmacy-based interventions and education. The intervention was delivered in two learning sessions with three action periods along with coaching support and basic quality improvement training. RESULTS We included 912 patients, 357 in BP and 555 in IP. The latter had higher APACHE II (17 (95% CI: 12 to 21) vs 15 (95% CI: 11 to 20), p=0.036), SOFA scores (6 (95% CI: 4 to 9) vs 5 (95% CI: 3 to 8), p=0.006), renal failure (41.6% vs 33.1%, p=0.009), sepsis (36.1% vs 31.6%, p<0.001) and septic shock (40.0% vs 33.8%, p<0.001). The days of antibacterial therapy (DOT) were similar between the groups (change in the slope from BP to IP 28.1 (95% CI: -17.4 to 73.5), p=0.2405). There were no differences in the antibacterial defined daily dose (DDD) between the groups (change in the slope from BP to IP 43.9, (95% CI: -12.3 to 100.0), p=0.1413).The rate of antibacterial de-escalation based on microbiological culture was higher during the IP (62.0% vs 45.3%, p<0.001).The infection prevention control (IPC) assessment framework was increased in eight ICUs. CONCLUSION Implementing an antimicrobial stewardship program in ICUs in a middle-income country via a QIC demonstrated success in improving antibacterial de-escalation based on microbiological culture results, but not on DOT or DDD. In addition, eight out of nine ICUs improved their IPC Assessment Framework Score.
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Affiliation(s)
- Facundo Jorro-Baron
- Quality of Care, Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
- PICU, Hospital General de Niños Pedro de Elizalde, Buenos Aires, Argentina
| | - Cecilia Inés Loudet
- Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
- Sociedad Argentina de Terapia Intensiva, Buenos Aires, Argentina
| | - Wanda Cornistein
- Sociedad Argentina de Infectología, Ciudad Autónoma de Buenos Aires, Argentina
| | - Inés Suarez-Anzorena
- Quality of Care, Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
| | | | - Carina Balasini
- Hospital General de Agudos Dr Ignacio Pirovano, Buenos Aires, Argentina
| | - Laura Cabana
- Intensive Care Unit, Hospital Pablo Soria, Jujuy, Argentina
| | - Eleonora Cunto
- Intensive Care Unit, Hospital de Infecciosas Dr Francisco Javier Muñiz, Buenos Aires, Argentina
| | | | - Luz Gibbons
- Instituto de Efectividad Clinica y Sanitaria, Ciudad Autónoma de Buenos Aires, Argentina
| | - Marina Guglielmino
- Quality of Care, Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
| | - Gabriela Izzo
- Intensive Care Unit, Hospital Simplemente Evita, Buenos Aires, Argentina
| | - Marianela Lescano
- Quality of Care, Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
| | | | - Cristina Orlandi
- Sociedad Argentina de Terapia Intensiva, Buenos Aires, Argentina
- Intensive Care Unit, Hospital Francisco López-Lima, Río Negro, Argentina
| | - Fernando Perre
- Intensive Care Unit, Hospital Provincial de Neuquén Dr Castro Rendón, Neuquen, Argentina
| | | | - Mariano Rivet
- Hospital General de Agudos Bernardino Rivadavia, Buenos Aires, Argentina
| | - Ana Paula Rodriguez
- Quality of Care, Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
| | | | | | | | - Emilse Vitar
- Instituto de Efectividad Clinica y Sanitaria, Ciudad Autónoma de Buenos Aires, Argentina
| | - Javier Roberti
- Instituto de Efectividad Clinica y Sanitaria, Ciudad Autónoma de Buenos Aires, Argentina
| | | | - Viviana Rodriguez
- Quality of Care, Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
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Jing C, Ding Y, Zhou J, Zhang Q, Wang M, Ou Q, Liu J, Xv T, Feng C, Yuan D, Wu T, Weng T, Xv X, Dai S, Qian Q, Sun W. Optimizing treatment administration strategies using negative mNGS results in corticosteroid-sensitive diffuse parenchymal lung diseases. iScience 2024; 27:110218. [PMID: 38993672 PMCID: PMC11237914 DOI: 10.1016/j.isci.2024.110218] [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: 02/23/2024] [Revised: 05/13/2024] [Accepted: 06/05/2024] [Indexed: 07/13/2024] Open
Abstract
Timely adjustments of antibiotic and corticosteroid treatments are vital for patients with diffuse parenchymal lung diseases (DPLDs). In this study, 41 DPLD patients with negative metagenomic next-generation sequencing (mNGS) results who were responsive to corticosteroids were enrolled. Among these patients, about 26.8% suffered from drug-induced DPLD, while 9.8% presented autoimmune-related DPLD. Following the report of the negative mNGS results, in 34 patients with complete antibiotics administration profiles, 79.4% (27/34) patients discontinued antibiotics after receiving negative mNGS results. Moreover, 70.7% (29/41) patients began or increased the administration of corticosteroid upon receipt of negative mNGS results. In the microbiota analysis, Staphylococcus and Stenotrophomonas showed higher detection rates in patients with oxygenation index (OI) below 300, while Escherichia and Stenotrophomonas had higher abundance in patients with pleural effusion. In summary, our findings demonstrated the clinical significance of mNGS in assisting the antibiotic and corticosteroid treatment adjustments in corticosteroid-responsive DPLD. Lung microbiota may imply the severity of the disease.
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Affiliation(s)
- Chuwei Jing
- Department of Respiratory Medicine, Jiangsu Province Hospital/Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
| | - Yuchen Ding
- Department of Respiratory Medicine, Jiangsu Province Hospital/Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
| | - Ji Zhou
- Department of Respiratory Medicine, Jiangsu Province Hospital/Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
| | - Qun Zhang
- Department of Respiratory Medicine, Jiangsu Province Hospital/Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
| | - Mingyue Wang
- Department of Respiratory Medicine, Jiangsu Province Hospital/Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
| | - Qiuxiang Ou
- Research & Development, Dinfectome Inc., Nanjing, Jiangsu, China
| | - Jia Liu
- Research & Development, Dinfectome Inc., Nanjing, Jiangsu, China
| | - Ting Xv
- Department of Respiratory Medicine, School of Southeast University Affiliated Nanjing Chest Hospital, Nanjing, Jiangsu, China
| | - Chunlai Feng
- Department of Respiratory and Critical Care Medicine, Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu, China
| | - Dongmei Yuan
- Department of Respiratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Ting Wu
- Department of Respiratory Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Ting Weng
- Nanjing Drum Tower Hospital Group Suqian Hospital, Jiangsu, China
| | - Xiaoyong Xv
- Second Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu, China
| | - Shanlin Dai
- Department of Respiratory Medicine, Jiangsu Province Hospital/Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
| | - Qian Qian
- Jiangsu Health Vocational College, Nanjing, Jiangsu, China
| | - Wenkui Sun
- Department of Respiratory Medicine, Jiangsu Province Hospital/Nanjing Medical University First Affiliated Hospital, Nanjing, Jiangsu, China
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Lee DG, Sobieszczyk MJ, Barsoumian AE, Marcus JE. The utility of sepsis scores for predicting blood stream infections in extracorporeal membrane oxygenation. Perfusion 2024; 39:921-926. [PMID: 36990456 DOI: 10.1177/02676591231168644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is an increasingly used modality of life support with high risk for nosocomial infections. The accuracy of sepsis prediction tools in identifying blood stream infections (BSI) in this population is unknown as measurement of multiple variables commonly associated with infection are altered by the circuit. METHODS This study compares all blood stream infections for patients receiving ECMO between January 2012 and December 2020 to timepoints when blood cultures were negative using the Sequential Organ Failure Assessment (SOFA), Logistic Organ Dysfunction Score (LODS), American Burn Association Sepsis Criteria (ABA), Systemic Inflammatory Response Syndrome (SIRS) scores. RESULTS Of the 220 patients who received ECMO during the study period, 40 (18%) had 51 blood stream infections and were included in this study. Gram-positive infections composed 57% (n = 29) of infections with E. faecalis (n = 12, 24%) being the most common organism isolated. There were no significant differences in sepsis prediction scores at the time of infection compared to infection-free time points for SOFA (median (IQR) 7 (5-9) vs. 6 (5-8), p = 0.22), LODS (median (IQR) 12 (10-14) vs. 12 (10-13), p = 0.28), ABA (median (IQR) 2 (1-3) vs. 2 (1-3) p = 0.75), or SIRS (median (IQR) 3 (2-3) vs. 3 (2-3), p = 0.20). CONCLUSIONS Our data shows that previously published sepsis scores are elevated throughout a patient's ECMO course, and do not correlate with bacteremia. Better predictive tools are needed to determine the appropriate timing for blood cultures in this population.
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Affiliation(s)
- Daniel G Lee
- Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Michal J Sobieszczyk
- Pulmonary and Critical Care Medicine Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Alice E Barsoumian
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Joseph E Marcus
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
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Albin OR, Troost JP, Saravolatz L, Thomas MP, Hyzy RC, Konkle MA, Weirauch AJ, Dickson RP, Rao K, Kaye KS. A quasi-experimental study of a bundled diagnostic stewardship intervention for ventilator-associated pneumonia. Clin Microbiol Infect 2024; 30:499-506. [PMID: 38163481 DOI: 10.1016/j.cmi.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/21/2023] [Accepted: 12/24/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES Diagnostic error in the use of respiratory cultures for ventilator-associated pneumonia (VAP) fuels misdiagnosis and antibiotic overuse within intensive care units. In this prospective quasi-experimental study (NCT05176353), we aimed to evaluate the safety, feasibility, and efficacy of a novel VAP-specific bundled diagnostic stewardship intervention (VAP-DSI) to mitigate VAP over-diagnosis/overtreatment. METHODS We developed and implemented a VAP-DSI using an interruptive clinical decision support tool and modifications to clinical laboratory workflows. Interventions included gatekeeping access to respiratory culture ordering, preferential use of non-bronchoscopic bronchoalveolar lavage for culture collection, and suppression of culture results for samples with minimal alveolar neutrophilia. Rates of adverse safety outcomes, positive respiratory cultures, and antimicrobial utilization were compared between mechanically ventilated patients (MVPs) in the 1-year post-intervention study cohort (2022-2023) and 5-year pre-intervention MVP controls (2017-2022). RESULTS VAP-DSI implementation did not associate with increases in adverse safety outcomes but did associate with a 20% rate reduction in positive respiratory cultures per 1000 MVP days (pre-intervention rate 127 [95% CI: 122-131], post-intervention rate 102 [95% CI: 92-112], p < 0.01). Significant reductions in broad-spectrum antibiotic days of therapy per 1000 MVP days were noted after VAP-DSI implementation (pre-intervention rate 1199 [95% CI: 1177-1205], post-intervention rate 1149 [95% CI: 1116-1184], p 0.03). DISCUSSION Implementation of a VAP-DSI was safe and associated with significant reductions in rates of positive respiratory cultures and broad-spectrum antimicrobial use. This innovative trial of a VAP-DSI represents a novel avenue for intensive care unit antimicrobial stewardship. Multicentre trials of VAP-DSIs are warranted.
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Affiliation(s)
- Owen R Albin
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Jonathan P Troost
- Michigan Institute for Clinical & Health Research, University of Michigan, Ann Arbor, MI, USA
| | - Louis Saravolatz
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael P Thomas
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Robert C Hyzy
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Mark A Konkle
- Department of Adult Respiratory Care, Michigan Medicine, Ann Arbor, MI, USA
| | - Andrew J Weirauch
- Department of Adult Respiratory Care, Michigan Medicine, Ann Arbor, MI, USA
| | - Robert P Dickson
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Krishna Rao
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Keith S Kaye
- Department of Internal Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Rafeq R, Igneri LA. Infectious Pulmonary Diseases. Infect Dis Clin North Am 2024; 38:1-17. [PMID: 38280758 DOI: 10.1016/j.idc.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Pneumonia is a lower respiratory tract infection caused by the inability to clear pathogens from the lower airway and alveoli. Cytokines and local inflammatory markers are released, causing further damage to the lungs through the accumulation of white blood cells and fluid congestion, leading to pus in the parenchyma. The Infectious Diseases Society of America defines pneumonia as the presence of new lung infiltrate with other clinical evidence supporting infection, including new fever, purulent sputum, leukocytosis, and decline in oxygenation. Importantly, lower respiratory infections remain the most deadly communicable disease. Pneumonia is subdivided into three categories: (1) community acquired, (2) hospital acquired, and (3) ventilator associated. Therapy for each differs based on the severity of the disease and the presence of risk factors for methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa.
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Affiliation(s)
- Rachel Rafeq
- Emergency Medicine, Department of Pharmacy, Cooper University Healthcare, 1 Cooper Plaza, Camden, NJ 08103, USA.
| | - Lauren A Igneri
- Critical Care, Department of Pharmacy, Cooper University Healthcare, 1 Cooper Plaza, Camden, NJ 08103, USA
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Gao CA, Markov NS, Pickens C, Pawlowski A, Kang M, Walter JM, Singer BD, Wunderink RG. An observational cohort study of bronchoalveolar lavage fluid galactomannan and Aspergillus culture positivity in patients requiring mechanical ventilation. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.07.24302392. [PMID: 38370841 PMCID: PMC10871379 DOI: 10.1101/2024.02.07.24302392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Rationale Critically ill patients who develop invasive pulmonary aspergillosis (IPA) have high mortality rates despite antifungal therapy. Diagnosis is difficult in these patients. Bronchoalveolar lavage (BAL) fluid galactomannan (GM) is a helpful marker of infection, although the optimal cutoff for IPA is unclear. We aimed to evaluate the BAL fluid GM and fungal culture results, demographics, and outcomes among a large cohort of mechanically ventilated patients with suspected pneumonia. Methods A single-center cohort study of patients enrolled in the Successful Clinical Response in Pneumonia Therapy (SCRIPT) study from June 2018 to March 2023. Demographics, BAL results, and outcomes data were extracted from the electronic health record and compared between groups of patients who grew Aspergillus on a BAL fluid culture, those who had elevated BAL fluid GM levels (defined as >0.5 or >0.8) but did not grow Aspergillus on BAL fluid culture, and those with neither. Results Of over 1700 BAL samples from 688 patients, only 18 BAL samples grew Aspergillus. Patients who had a BAL sample grow Aspergillus (n=15) were older (median 71 vs 62 years, p=0.023), had more days intubated (29 vs 11, p=0.002), and more ICU days (34 vs 15, p=0.002) than patients whose BAL fluid culture was negative for Aspergillus (n=672). The BAL fluid galactomannan level was higher from samples that grew Aspergillus on culture than those that did not (median ODI 7.08 vs 0.11, p<0.001), though the elevation of BAL fluid GM varied across BAL samples for patients who had serial sampling. Patients who grew Aspergillus had a similar proportion of underlying immunocompromise compared with the patients who did not, and while no statistically significant difference in overall unfavorable outcome, had longer duration of ventilation and longer ICU stays. Conclusions In this large cohort of critically ill patients with a high number of BAL samples with GM levels, we found a relatively low rate of Aspergillus growth. Patients who eventually grew Aspergillus had inconsistently elevated BAL fluid GM, and many patients with elevated BAL fluid GM did not grow Aspergillus. These data suggest that the pre-test probability of invasive pulmonary aspergillosis should be considered low in a general ICU population undergoing BAL evaluation to define the etiology of pneumonia. Improved scoring systems are needed to enhance pre-test probability for diagnostic test stewardship purposes.
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Affiliation(s)
- Catherine A. Gao
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nikolay S. Markov
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chiagozie Pickens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anna Pawlowski
- Northwestern Medicine Enterprise Data Warehouse, Chicago, IL, USA
| | - Mengjia Kang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - James M. Walter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Benjamin D. Singer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard G. Wunderink
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Aslan AT, Ezure Y, Harris PNA, Paterson DL. Scoping review of risk-scoring tools for early prediction of bloodstream infections caused by carbapenem-resistant Enterobacterales: do we really have a reliable risk-scoring tool? JAC Antimicrob Resist 2024; 6:dlae032. [PMID: 38414813 PMCID: PMC10899000 DOI: 10.1093/jacamr/dlae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/10/2024] [Indexed: 02/29/2024] Open
Abstract
Background Bloodstream infections (BSIs) caused by carbapenem-resistant Enterobacterales (CRE) are a global health concern. Rapid identification of CRE may improve patient outcomes and reduce inappropriate antibiotic prescription. The use of risk-scoring tools (RSTs) can be valuable for optimizing the decision-making process for empirical antibiotic therapy of suspected CRE bacteraemia. These tools can also be used to triage use of expensive rapid diagnostic methods. Methods We systematically reviewed the relevant literature in PubMed/MEDLINE, CINAHL, Cochrane, Web of Science, Embase and Scopus up to 1 November 2022 to identify RSTs that predict CRE BSIs. The literature review and analysis of the articles were performed by two researchers; any inconsistencies were resolved through discussion. Results We identified 9 RSTs developed for early prediction of CRE BSIs and only logistic regression was used for most studies. These RSTs were quite different from each other in terms of their performance and the variables they included. They also had notable limitations and very few of them were externally validated. Conclusions RSTs for early prediction of CRE BSIs have limitations and lack of external validity outside the local setting in which they were developed. Future studies to identify optimal RSTs in high and low CRE-endemic settings are warranted. Approaches based on rapid diagnostics and RSTs should be compared with a treatment approach using both methods in a randomized controlled trial.
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Affiliation(s)
- Abdullah Tarik Aslan
- Faculty of Medicine, University of Queensland, UQ Centre for Clinical Research (UQCCR), Level 8, Building 71/918 Bowen Bridge Rd Herston, Brisbane, QLD 4029, Australia
| | - Yukiko Ezure
- Faculty of Medicine, University of Queensland, UQ Centre for Clinical Research (UQCCR), Level 8, Building 71/918 Bowen Bridge Rd Herston, Brisbane, QLD 4029, Australia
| | - Patrick N A Harris
- Faculty of Medicine, University of Queensland, UQ Centre for Clinical Research (UQCCR), Level 8, Building 71/918 Bowen Bridge Rd Herston, Brisbane, QLD 4029, Australia
- Central Microbiology, Pathology Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - David L Paterson
- ADVANCE-ID, Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Infectious Diseases Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Sung J, Rajendraprasad SS, Philbrick KL, Bauer BA, Gajic O, Shah A, Laudanski K, Bakken JS, Skalski J, Karnatovskaia LV. The human gut microbiome in critical illness: disruptions, consequences, and therapeutic frontiers. J Crit Care 2024; 79:154436. [PMID: 37769422 PMCID: PMC11034825 DOI: 10.1016/j.jcrc.2023.154436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/23/2023] [Accepted: 09/18/2023] [Indexed: 09/30/2023]
Abstract
With approximately 39 trillion cells and over 20 million genes, the human gut microbiome plays an integral role in both health and disease. Modern living has brought a widespread use of processed food and beverages, antimicrobial and immunomodulatory drugs, and invasive procedures, all of which profoundly disrupt the delicate homeostasis between the host and its microbiome. Of particular interest is the human gut microbiome, which is progressively being recognized as an important contributing factor in many aspects of critical illness, from predisposition to recovery. Herein, we describe the current understanding of the adverse impacts of standard intensive care interventions on the human gut microbiome and delve into how these microbial alterations can influence patient outcomes. Additionally, we explore the potential association between the gut microbiome and post-intensive care syndrome, shedding light on a previously underappreciated avenue that may enhance patient recuperation following critical illness. There is an impending need for future epidemiological studies to encompass detailed phenotypic analyses of gut microbiome perturbations. Interventions aimed at restoring the gut microbiome represent a promising therapeutic frontier in the quest to prevent and treat critical illnesses.
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Affiliation(s)
- Jaeyun Sung
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Kemuel L Philbrick
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Brent A Bauer
- Department of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Department of Pulmonary & Critical Care, Mayo Clinic, Rochester, MN, USA
| | - Aditya Shah
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
| | - Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN, USA
| | - Johan S Bakken
- Department of Infectious Diseases, St Luke's Hospital, Duluth, MN, United States of America
| | - Joseph Skalski
- Department of Pulmonary & Critical Care, Mayo Clinic, Rochester, MN, USA
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Ramasco F, Méndez R, Suarez de la Rica A, González de Castro R, Maseda E. Sepsis Stewardship: The Puzzle of Antibiotic Therapy in the Context of Individualization of Decision Making. J Pers Med 2024; 14:106. [PMID: 38248807 PMCID: PMC10820263 DOI: 10.3390/jpm14010106] [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: 12/23/2023] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 01/23/2024] Open
Abstract
The main recent change observed in the field of critical patient infection has been universal awareness of the need to make better use of antimicrobials, especially for the most serious cases, beyond the application of simple and effective formulas or rigid protocols. The increase in resistant microorganisms, the quantitative increase in major surgeries and interventional procedures in the highest risk patients, and the appearance of a significant number of new antibiotics in recent years (some very specifically directed against certain mechanisms of resistance and others with a broader spectrum of applications) have led us to shift our questions from "what to deal with" to "how to treat". There has been controversy about how best to approach antibiotic treatment of complex cases of sepsis. The individualized and adjusted dosage, the moment of its administration, the objective, and the selection of the regimen are pointed out as factors of special relevance in a critically ill patient where the frequency of resistant microorganisms, especially among the Enterobacterales group, and the emergence of multiple and diverse antibiotic treatment alternatives have made the appropriate choice of antibiotic treatment more complex, requiring a constant updating of knowledge and the creation of multidisciplinary teams to confront new infections that are difficult to treat. In this article, we have reviewed the phenomenon of the emergence of resistance to antibacterials and we have tried to share some of the ideas, such as stewardship, sparing carbapenems, and organizational, microbiological, pharmacological, and knowledge tools, that we have considered most useful and effective for individualized decision making that takes into account the current context of multidrug resistance. The greatest challenge, therefore, of decision making in this context lies in determining an effective, optimal, and balanced empirical antibiotic treatment.
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Affiliation(s)
- Fernando Ramasco
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain; (R.M.); (A.S.d.l.R.)
| | - Rosa Méndez
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain; (R.M.); (A.S.d.l.R.)
| | - Alejandro Suarez de la Rica
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain; (R.M.); (A.S.d.l.R.)
| | - Rafael González de Castro
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de León, 24071 León, Spain;
| | - Emilio Maseda
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario Quirón Sur Salud, 28922 Madrid, Spain;
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Eickelberg G, Sanchez-Pinto LN, Kline AS, Luo Y. Transportability of bacterial infection prediction models for critically ill patients. J Am Med Inform Assoc 2023; 31:98-108. [PMID: 37647884 PMCID: PMC10746321 DOI: 10.1093/jamia/ocad174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/20/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023] Open
Abstract
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.
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Affiliation(s)
- Garrett Eickelberg
- Department of Preventive Medicine (Health & Biomedical Informatics), Feinberg School of Medicine, Chicago, IL 60611, United States
| | - Lazaro Nelson Sanchez-Pinto
- Department of Preventive Medicine (Health & Biomedical Informatics), Feinberg School of Medicine, Chicago, IL 60611, United States
- Departments of Pediatrics (Critical Care), Chicago, IL 60611, United States
| | - Adrienne Sarah Kline
- Department of Preventive Medicine (Health & Biomedical Informatics), Feinberg School of Medicine, Chicago, IL 60611, United States
| | - Yuan Luo
- Department of Preventive Medicine (Health & Biomedical Informatics), Feinberg School of Medicine, Chicago, IL 60611, United States
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Tjilos M, Drainoni ML, Burrowes SAB, Butler JM, Damschroder LJ, Bidwell Goetz M, Madaras-Kelly K, Reardon CM, Samore MH, Shen J, Stenehjem EA, Zhang Y, Barlam TF. A qualitative evaluation of frontline clinician perspectives toward antibiotic stewardship programs. Infect Control Hosp Epidemiol 2023; 44:1995-2001. [PMID: 36987859 PMCID: PMC10755145 DOI: 10.1017/ice.2023.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 03/30/2023]
Abstract
OBJECTIVE To examine the perspectives of caregivers that are not part of the antibiotic stewardship program (ASP) leadership team (eg, physicians, nurses, and clinical pharmacists), but who interact with ASPs in their role as frontline healthcare workers. DESIGN Qualitative semistructured interviews. SETTING The study was conducted in 2 large national healthcare systems including 7 hospitals in the Veterans' Health Administration and 4 hospitals in Intermountain Healthcare. PARTICIPANTS We interviewed 157 participants. The current analysis includes 123 nonsteward clinicians: 47 physicians, 26 pharmacists, 29 nurses, and 21 hospital leaders. METHODS Interviewers utilized a semistructured interview guide based on the Consolidated Framework for Implementation Research (CFIR), which was tailored to the participant's role in the hospital as it related to ASPs. Qualitative analysis was conducted using a codebook based on the CFIR. RESULTS We identified 4 primary perspectives regarding ASPs. (1) Non-ASP pharmacists considered antibiotic stewardship activities to be a high priority despite the added burden to work duties: (2) Nurses acknowledged limited understanding of ASP activities or involvement with these programs; (3) Physicians criticized ASPs for their restrictions on clinical autonomy and questioned the ability of antibiotic stewards to make recommendations without the full clinical picture; And (4) hospital leaders expressed support for ASPs and recognized the unique challenges faced by non-ASP clinical staff. CONCLUSION Further understanding these differing perspectives of ASP implementation will inform possible ways to improve ASP implementation across clinical roles.
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Affiliation(s)
- Maria Tjilos
- Department of Community Health Sciences, School of Public Health, Boston University, BostonMassachusetts
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Department of Health Law, Policy and Management, School of Public Health, Boston University, Boston, Massachusetts
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Shana A. B. Burrowes
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Jorie M. Butler
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Education and Clinical Center and IDEAS Center of Innovation, Veterans’ Affairs (VA) Salt Lake City Health Care System, Salt Lake City, Utah
| | - Laura J. Damschroder
- VA Center for Clinical Management Research, Department of Veterans’ Affairs, Ann Arbor, Michigan
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Karl Madaras-Kelly
- Boise VA Medical Center, Boise, Idaho
- College of Pharmacy, Idaho State University, MeridianIdaho
| | - Caitlin M. Reardon
- VA Center for Clinical Management Research, Department of Veterans’ Affairs, Ann Arbor, Michigan
| | - Matthew H. Samore
- IDEAS Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Divison of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jincheng Shen
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Edward A. Stenehjem
- Division of Infectious Diseases and Epidemiology, Intermountain Healthcare, Salt Lake City, Utah
| | - Yue Zhang
- Divison of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Tamar F. Barlam
- Section of Infectious Diseases, Department of Medicine, Chobanian and Avedisian School of Medicine, Boston University, Boston, Massachusetts
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12
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Karimzadeh I, Strader M, Kane-Gill SL, Murray PT. Prevention and management of antibiotic associated acute kidney injury in critically ill patients: new insights. Curr Opin Crit Care 2023; 29:595-606. [PMID: 37861206 DOI: 10.1097/mcc.0000000000001099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Drug associated kidney injury (D-AKI) occurs in 19-26% of hospitalized patients and ranks as the third to fifth leading cause of acute kidney injury (AKI) in the intensive care unit (ICU). Given the high use of antimicrobials in the ICU and the emergence of new resistant organisms, the implementation of preventive measures to reduce the incidence of D-AKI has become increasingly important. RECENT FINDINGS Artificial intelligence is showcasing its capabilities in early recognition of at-risk patients for acquiring AKI. Furthermore, novel synthetic medications and formulations have demonstrated reduced nephrotoxicity compared to their traditional counterparts in animal models and/or limited clinical evaluations, offering promise in the prevention of D-AKI. Nephroprotective antioxidant agents have had limited translation from animal studies to clinical practice. The control of modifiable risk factors remains pivotal in avoiding D-AKI. SUMMARY The use of both old and new antimicrobials is increasingly important in combating the rise of resistant organisms. Advances in technology, such as artificial intelligence, and alternative formulations of traditional antimicrobials offer promise in reducing the incidence of D-AKI, while antioxidant medications may aid in minimizing nephrotoxicity. However, maintaining haemodynamic stability using isotonic fluids, drug monitoring, and reducing nephrotoxic burden combined with vigilant antimicrobial stewardship remain the core preventive measures for mitigating D-AKI while optimizing effective antimicrobial therapy.
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Affiliation(s)
- Iman Karimzadeh
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Michael Strader
- Department of Medicine, School of Medicine, University College Dublin, Dublin, Ireland
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh
- Department of Pharmacy, UPMC, Pittsburgh, Pennsylvania, USA
| | - Patrick T Murray
- Department of Medicine, School of Medicine, University College Dublin, Dublin, Ireland
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13
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Ausman SE, Mara KC, Brown CS, Epps KL, Kooda K, Mendez J, Rivera CG. CLinician and patient characteristics effect on Antimicrobial Stewardship Interventions (CLASI) study. Infect Control Hosp Epidemiol 2023; 44:2002-2008. [PMID: 37222155 DOI: 10.1017/ice.2023.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To determine whether the gender of clinicians making antimicrobial stewardship recommendations has an impact on intervention acceptance rate. DESIGN A retrospective, multivariable analysis of antimicrobial stewardship prospective audit and feedback outcomes. SETTING A multisite healthcare system including Mayo Clinic Rochester (MN), Mayo Clinic Arizona, Mayo Clinic Florida and 17 health-system hospital sites, where prospective audit and feedback is performed and documented within an electronic tool embedded in the medical record. PARTICIPANTS The study included 143 Mayo Clinic clinicians (84 cisfemales and 59 cismales). METHODS Outcomes were analyzed from July 1, 2017, to June 30, 2022, for intervention rates, communication methods, and intervention acceptance by clinician gender, profession, patient age, and intensive care unit (ICU) status of patient. RESULTS Of 81,927 rules, 71,729 rules met study inclusion. There were 18,175 (25%) rules associated with an intervention. Most of the rules were reviewed by pharmacists (86.2%) and stewardship staff (85.5%). Of 10,363 interventions with an outcome documented, 8,829 (85.2%) were accepted and 1,534 (14.8%) were rejected. Female clinicians had 6,782 (86.5%) of 7,843 interventions accepted, and male clinicians had 2,047 (81.2%) of 2,520 interventions accepted (P = .19). Female patients had more interventions than male patients (female vs male: 25.9% vs 24.9%; OR, 1.04; 95% CI, 1.02-1.08; P = .001). Patients in the ICU had a significantly lower intervention acceptance rate (ICU vs non-ICU: 78.2% vs 86.7%; OR, 0.56; 95% CI, 0.45-0.7; P < .001). CONCLUSIONS Female and male clinicians were equally effective at prospective audit and feedback in a multisite antimicrobial stewardship program. Patients in the ICU were less likely to have stewardship interventions accepted.
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Affiliation(s)
- Sara E Ausman
- Department of Pharmacy, Mayo Clinic Health System, Eau Claire, Wisconsin
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin L Epps
- Department of Pharmacy, Mayo Clinic, Jacksonville, Florida
| | - Kirstin Kooda
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Julio Mendez
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Florida
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14
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Baghdadi JD, O'Hara LM, Johnson JK, Krein SL, Harris AD, Morgan DJ. Diagnostic stewardship to support optimal use of multiplex molecular respiratory panels: A survey from the Society for Healthcare Epidemiology of America Research Network. Infect Control Hosp Epidemiol 2023; 44:1823-1828. [PMID: 37129035 PMCID: PMC10862355 DOI: 10.1017/ice.2023.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Multiplex polymerase chain reaction (PCR) respiratory panels are rapid, highly sensitive tests for viral and bacterial pathogens that cause respiratory infections. In this study, we (1) described best practices in the implementation of respiratory panels based on expert perspectives and (2) identified tools for diagnostic stewardship to enhance the usefulness of testing. METHODS We conducted a survey of the Society for Healthcare Epidemiology of America Research Network to explore current and future approaches to diagnostic stewardship of multiplex PCR respiratory panels. RESULTS In total, 41 sites completed the survey (response rate, 50%). Multiplex PCR respiratory panels were perceived as supporting accurate diagnoses at 35 sites (85%), supporting more efficient patient care at 33 sites (80%), and improving patient outcomes at 23 sites (56%). Thirteen sites (32%) reported that testing may support diagnosis or patient care without improving patient outcomes. Furthermore, 24 sites (58%) had implemented diagnostic stewardship, with a median of 3 interventions (interquartile range, 1-4) per site. The interventions most frequently reported as effective were structured order sets to guide test ordering (4 sites), restrictions on test ordering based on clinician or patient characteristics (3 sites), and structured communication of results (2 sites). Education was reported as "helpful" but with limitations (3 sites). CONCLUSIONS Many hospital epidemiologists and experts in infectious diseases perceive multiplex PCR respiratory panels as useful tests that can improve diagnosis, patient care, and patient outcomes. However, institutions frequently employ diagnostic stewardship to enhance the usefulness of testing, including most commonly clinical decision support to guide test ordering.
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Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lyndsay M O'Hara
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sarah L Krein
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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15
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MacKenzie EL, Murillo C, Bartlett AH, Marrs R, Landon EM, Ridgway JP. Clostridioides difficile colonization and the frequency of subsequent treatment for C. difficile infection in critically ill patients. Infect Control Hosp Epidemiol 2023; 44:1782-1787. [PMID: 36658099 DOI: 10.1017/ice.2022.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To determine risk factors for Clostridioides difficile colonization and C. difficile infection (CDI) among patients admitted to the intensive care unit (ICU). DESIGN Retrospective observational cohort study. SETTING Tertiary-care facility. PATIENTS All adult patients admitted to an ICU from July 1, 2015, to November 6, 2019, who were tested for C. difficile colonization. Patients with CDI were excluded. METHODS Information was collected on patient demographics, comorbidities, laboratory results, and prescriptions. We defined C. difficile colonization as a positive nucleic acid amplification test for C. difficile up to 48 hours before or 24 hours after intensive care unit (ICU) admission without evidence of active infection. We defined active infection as the receipt of an antibiotic whose only indication is the treatment of CDI. The primary outcome measure was the development of CDI up to 30 days after ICU admission. Logistic regression was used to model associations between clinical variables and the development of CDI. RESULTS The overall C. difficile colonization rate was 4% and the overall CDI rate was 2%. Risk factors for the development of CDI included C. difficile colonization (aOR, 13.3; 95% CI, 8.3-21.3; P < .0001), increased ICU length of stay (aOR, 1.04; 95% CI, 1.03-1.05; P < .0001), and a history of inflammatory bowel disease (aOR, 3.8; 95% CI, 1.3-11.1; P = .02). Receipt of any antibiotic during the ICU stay was associated with a borderline increased odds of CDI (aOR, 1.9; 95% CI, 1.0-3.4; P = .05). CONCLUSION C. difficile colonization is associated with the development of CDI among ICU patients.
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Affiliation(s)
- Erica L MacKenzie
- Department of Medicine, Section of Infectious Diseases & Global Health, The University of Chicago Medicine, Chicago, Illinois
| | - Cynthia Murillo
- Department of Infection Control and Prevention, The University of Chicago Medicine, Chicago, Illinois
| | - Allison H Bartlett
- Department of Pediatrics, Section of Infectious Diseases, The University of Chicago Medicine, Chicago, Illinois
| | - Rachel Marrs
- Department of Infection Control and Prevention, The University of Chicago Medicine, Chicago, Illinois
| | - Emily M Landon
- Department of Medicine, Section of Infectious Diseases & Global Health, The University of Chicago Medicine, Chicago, Illinois
- Department of Infection Control and Prevention, The University of Chicago Medicine, Chicago, Illinois
| | - Jessica P Ridgway
- Department of Medicine, Section of Infectious Diseases & Global Health, The University of Chicago Medicine, Chicago, Illinois
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16
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Giamarellou H, Galani L, Karavasilis T, Ioannidis K, Karaiskos I. Antimicrobial Stewardship in the Hospital Setting: A Narrative Review. Antibiotics (Basel) 2023; 12:1557. [PMID: 37887258 PMCID: PMC10604258 DOI: 10.3390/antibiotics12101557] [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: 09/12/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
The increasing global threat of antibiotic resistance, which has resulted in countless fatalities due to untreatable infections, underscores the urgent need for a strategic action plan. The acknowledgment that humanity is perilously approaching the "End of the Miracle Drugs" due to the unjustifiable overuse and misuse of antibiotics has prompted a critical reassessment of their usage. In response, numerous relevant medical societies have initiated a concerted effort to combat resistance by implementing antibiotic stewardship programs within healthcare institutions, grounded in evidence-based guidelines and designed to guide antibiotic utilization. Crucial to this initiative is the establishment of multidisciplinary teams within each hospital, led by a dedicated Infectious Diseases physician. This team includes clinical pharmacists, clinical microbiologists, hospital epidemiologists, infection control experts, and specialized nurses who receive intensive training in the field. These teams have evidence-supported strategies aiming to mitigate resistance, such as conducting prospective audits and providing feedback, including the innovative 'Handshake Stewardship' approach, implementing formulary restrictions and preauthorization protocols, disseminating educational materials, promoting antibiotic de-escalation practices, employing rapid diagnostic techniques, and enhancing infection prevention and control measures. While initial outcomes have demonstrated success in reducing resistance rates, ongoing research is imperative to explore novel stewardship interventions.
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Affiliation(s)
- Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Lamprini Galani
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Theodoros Karavasilis
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Konstantinos Ioannidis
- Clinical Pharmacists, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece;
| | - Ilias Karaiskos
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
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17
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Sartelli M, Barie PS, Coccolini F, Abbas M, Abbo LM, Abdukhalilova GK, Abraham Y, Abubakar S, Abu-Zidan FM, Adebisi YA, Adamou H, Afandiyeva G, Agastra E, Alfouzan WA, Al-Hasan MN, Ali S, Ali SM, Allaw F, Allwell-Brown G, Amir A, Amponsah OKO, Al Omari A, Ansaloni L, Ansari S, Arauz AB, Augustin G, Awazi B, Azfar M, Bah MSB, Bala M, Banagala ASK, Baral S, Bassetti M, Bavestrello L, Beilman G, Bekele K, Benboubker M, Beović B, Bergamasco MD, Bertagnolio S, Biffl WL, Blot S, Boermeester MA, Bonomo RA, Brink A, Brusaferro S, Butemba J, Caínzos MA, Camacho-Ortiz A, Canton R, Cascio A, Cassini A, Cástro-Sanchez E, Catarci M, Catena R, Chamani-Tabriz L, Chandy SJ, Charani E, Cheadle WG, Chebet D, Chikowe I, Chiara F, Cheng VCC, Chioti A, Cocuz ME, Coimbra R, Cortese F, Cui Y, Czepiel J, Dasic M, de Francisco Serpa N, de Jonge SW, Delibegovic S, Dellinger EP, Demetrashvili Z, De Palma A, De Silva D, De Simone B, De Waele J, Dhingra S, Diaz JJ, Dima C, Dirani N, Dodoo CC, Dorj G, Duane TM, Eckmann C, Egyir B, Elmangory MM, Enani MA, Ergonul O, Escalera-Antezana JP, Escandon K, Ettu AWOO, Fadare JO, Fantoni M, Farahbakhsh M, Faro MP, Ferreres A, Flocco G, Foianini E, Fry DE, Garcia AF, Gerardi C, Ghannam W, Giamarellou H, Glushkova N, Gkiokas G, Goff DA, Gomi H, Gottfredsson M, Griffiths EA, Guerra Gronerth RI, Guirao X, Gupta YK, Halle-Ekane G, Hansen S, Haque M, Hardcastle TC, Hayman DTS, Hecker A, Hell M, Ho VP, Hodonou AM, Isik A, Islam S, Itani KMF, Jaidane N, Jammer I, Jenkins DR, Kamara IF, Kanj SS, Jumbam D, Keikha M, Khanna AK, Khanna S, Kapoor G, Kapoor G, Kariuki S, Khamis F, Khokha V, Kiggundu R, Kiguba R, Kim HB, Kim PK, Kirkpatrick AW, Kluger Y, Ko WC, Kok KYY, Kotecha V, Kouma I, Kovacevic B, Krasniqi J, Krutova M, Kryvoruchko I, Kullar R, Labi KA, Labricciosa FM, Lakoh S, Lakatos B, Lansang MAD, Laxminarayan R, Lee YR, Leone M, Leppaniemi A, Hara GL, Litvin A, Lohsiriwat V, Machain GM, Mahomoodally F, Maier RV, Majumder MAA, Malama S, Manasa J, Manchanda V, Manzano-Nunez R, Martínez-Martínez L, Martin-Loeches I, Marwah S, Maseda E, Mathewos M, Maves RC, McNamara D, Memish Z, Mertz D, Mishra SK, Montravers P, Moro ML, Mossialos E, Motta F, Mudenda S, Mugabi P, Mugisha MJM, Mylonakis E, Napolitano LM, Nathwani D, Nkamba L, Nsutebu EF, O’Connor DB, Ogunsola S, Jensen PØ, Ordoñez JM, Ordoñez CA, Ottolino P, Ouedraogo AS, Paiva JA, Palmieri M, Pan A, Pant N, Panyko A, Paolillo C, Patel J, Pea F, Petrone P, Petrosillo N, Pintar T, Plaudis H, Podda M, Ponce-de-Leon A, Powell SL, Puello-Guerrero A, Pulcini C, Rasa K, Regimbeau JM, Rello J, Retamozo-Palacios MR, Reynolds-Campbell G, Ribeiro J, Rickard J, Rocha-Pereira N, Rosenthal VD, Rossolini GM, Rwegerera GM, Rwigamba M, Sabbatucci M, Saladžinskas Ž, Salama RE, Sali T, Salile SS, Sall I, Kafil HS, Sakakushev BE, Sawyer RG, Scatizzi M, Seni J, Septimus EJ, Sganga G, Shabanzadeh DM, Shelat VG, Shibabaw A, Somville F, Souf S, Stefani S, Tacconelli E, Tan BK, Tattevin P, Rodriguez-Taveras C, Telles JP, Téllez-Almenares O, Tessier J, Thang NT, Timmermann C, Timsit JF, Tochie JN, Tolonen M, Trueba G, Tsioutis C, Tumietto F, Tuon FF, Ulrych J, Uranues S, van Dongen M, van Goor H, Velmahos GC, Vereczkei A, Viaggi B, Viale P, Vila J, Voss A, Vraneš J, Watkins RR, Wanjiru-Korir N, Waworuntu O, Wechsler-Fördös A, Yadgarova K, Yahaya M, Yahya AI, Xiao Y, Zakaria AD, Zakrison TL, Zamora Mesia V, Siquini W, Darzi A, Pagani L, Catena F. Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action. World J Emerg Surg 2023; 18:50. [PMID: 37845673 PMCID: PMC10580644 DOI: 10.1186/s13017-023-00518-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/23/2023] [Indexed: 10/18/2023] Open
Abstract
Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.
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Alonso-Menchén D, Bouza E, Valerio M, de Alarcón A, Gutiérrez-Carretero E, Miró JM, Goenaga-Sánchez MÁ, Plata-Ciézar A, González-Rico C, López-Cortés LE, Rodríguez Esteban MÁ, Martínez-Marcos FJ, Muñoz P. Non-nosocomial Healthcare-Associated Infective Endocarditis: A Distinct Entity? Data From the GAMES Series (2008-2021). Open Forum Infect Dis 2023; 10:ofad393. [PMID: 37564744 PMCID: PMC10411035 DOI: 10.1093/ofid/ofad393] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Indexed: 08/12/2023] Open
Abstract
Background Patients who acquire infective endocarditis (IE) following contact with the healthcare system, but outside the hospital, are classified as having non-nosocomial healthcare-associated IE (HCIE). Our aim was to characterize HCIE and establish whether its etiology, diagnosis, and therapeutic approach suggest it should be considered a distinct entity. Methods This study retrospectively analyzes data from a nationwide, multicenter, prospective cohort including consecutive cases of IE at 45 hospitals across Spain from 2008 to 2021. HCIE was defined as IE detected in patients in close contact with the healthcare system (eg, patients receiving intravenous treatment, hemodialysis, or institutionalized). The prevalence and main characteristics of HCIE were examined and compared with those of community-acquired IE (CIE) and nosocomial IE (NIE) and with literature data. Results IE was diagnosed in 4520 cases, of which 2854 (63%) were classified as CIE, 1209 (27%) as NIE, and 457 (10%) as HCIE. Patients with HCIE showed a high burden of comorbidities, a high presence of intravascular catheters, and a predominant staphylococcal etiology, Staphylococcus aureus being identified as the most frequent causative agent (35%). They also experienced more persistent bacteremia, underwent fewer surgeries, and showed a higher mortality rate than those with CIE (32.4% vs 22.6%). However, mortality in this group was similar to that recorded for NIE (32.4% vs 34.9%, respectively, P = .40). Conclusions Our data do not support considering HCIE as a distinct entity. HCIE affects a substantial number of patients, is associated with a high mortality, and shares many characteristics with NIE.
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Affiliation(s)
- David Alonso-Menchén
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | - Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Medicine Department, Universidad Complutense de Madrid, Madrid, Spain
- CIBER (Centro de Investigación Biomédica en Red) de Enfermedades Respiratorias (CB06/06/0058), Instituto de Salud Carlos III, Madrid, Spain
| | - Maricela Valerio
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Medicine Department, Universidad Complutense de Madrid, Madrid, Spain
| | - Arístides de Alarcón
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Parasitología, University Hospital Virgen del Rocío, Institute of Biomedicine of Seville, University of Seville/CSIC (Consejo Superior de Investigaciones Científicas), Seville, Spain
- CIBER (Centro de Investigación Biomédica en Red) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Encarnación Gutiérrez-Carretero
- Cardiac Surgery Service, University Hospital Virgen del Rocío, Institute of Biomedicine of Seville, University of Seville/CSIC(Consejo Superior de Investigaciones Científicas), Seville, Spain
- CIBER (Centro de Investigación Biomédica en Red) de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - José M Miró
- CIBER (Centro de Investigación Biomédica en Red) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Service, Hospital Clínic–IDIBAPS (Institut d'Investigacions Biomèdiques August Pi Sunyer), University of Barcelona, Barcelona, Spain
| | | | - Antonio Plata-Ciézar
- Servicio de Enfermedades Infecciosas Hospital Regional Universitario de Málaga, IBIMA (Instituto de Investigación Biomédica de Málaga), Málaga, Spain
| | - Claudia González-Rico
- CIBER (Centro de Investigación Biomédica en Red) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla–IDIVAL (Instituto de Investigación Marqués de Valdecilla), Santander, Spain
| | - Luis Eduardo López-Cortés
- CIBER (Centro de Investigación Biomédica en Red) de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases and Microbiology Clinical Unit, University Hospital Virgen Macarena, Institute of Biomedicine of Seville, University of Seville/CSIC (Consejo Superior de Investigaciones Científicas), Seville, Spain
| | | | | | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
- Medicine Department, Universidad Complutense de Madrid, Madrid, Spain
- CIBER (Centro de Investigación Biomédica en Red) de Enfermedades Respiratorias (CB06/06/0058), Instituto de Salud Carlos III, Madrid, Spain
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Zuercher P, Moser A, Frey MC, Pagani JL, Buetti N, Eggimann P, Daneman N, Fowler R, Que YA, Prazak J. The effect of duration of antimicrobial treatment for bacteremia in critically ill patients on in-hospital mortality - Retrospective double center analysis. J Crit Care 2023; 74:154257. [PMID: 36696827 DOI: 10.1016/j.jcrc.2023.154257] [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: 11/03/2022] [Revised: 01/07/2023] [Accepted: 01/12/2023] [Indexed: 01/25/2023]
Abstract
PURPOSE Excessive duration of antibiotic treatment is a major factor for inappropriate antibiotic consumption. Although in some instances shorter antibiotic courses are as efficient as longer ones, no specific recommendations as to the duration of antimicrobial treatment for bloodstream infections currently exist. In the present study, we investigated the effect of antibiotic treatment duration on in-hospital mortality using retrospective data from two cohorts that included patients with bacteremia at two Swiss tertiary Intensive Care Units (ICUs). MATERIALS AND METHODS Overall 8227 consecutive patients requiring ICU admission were screened for bacteremia between 01/2012-12/2013 in Lausanne and between 07/2016-05/2017 in Bern. Patients with an infection known to require prolonged treatment or having single positive blood culture with common contaminant pathogens were excluded. The primary outcome of interest was the time from start of antimicrobial treatment to in-hospital death or hospital discharge, whichever comes first. The predictor of interest was adequate antimicrobial treatment duration, further divided into shorter (≤10 days) and longer (>10 days) durations. A time-dependent Cox model and a cloning approach were used to address immortality bias. The secondary outcomes were the median duration of antimicrobial treatment for patients with bacteremia overall and stratified by underlying infectious syndrome and pathogens in the case of secondary bacteremia. RESULTS Out of the 707 patients with positive blood cultures, 382 were included into the primary analysis. Median duration of antibiotic therapy was 14 days (IQR, 7-20). Most bacteremia (84%) were monomicrobial; 18% of all episodes were primary bacteremia. Respiratory (28%), intra-abdominal (23%) and catheter infections (17%) were the most common sources of secondary bacteremia. Using methods to mitigate the risk of confounding associated with antibiotic treatment durations, shorter versus longer treatment groups showed no differences in in-hospital survival (time-dependent Cox-model: HR 1.5, 95% CI (0.8, 2.7), p = 0.20; Cloning approach: HR 1.0, 95% CI (0.7,1.5) p = 0.83). Sensitivity analyses showed that the interpretation did not change when using a 7 days cut-off. CONCLUSIONS In this restrospective study, we found no evidence for a survival benefit of longer (>10 days) versus shorter treatment course in ICU patients with bacteremia. TRIAL REGISTRATION The study was retrospectively registered on clinicatrials.gov (NCT05236283), 11 February 2022. The respective cantonal ethics commission (KEK Bern # 2021-02302) has approved the study.
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Affiliation(s)
- Patrick Zuercher
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | | | - Michael C Frey
- Department of Surgery, Kantonsspital Baden, Baden, Switzerland
| | - Jean-Luc Pagani
- Department of Intensive Care Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Niccolo Buetti
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philippe Eggimann
- Department of Locomotor Apparatus, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Nick Daneman
- Department of Medicine and Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Rob Fowler
- Department of Medicine and Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Yok-Ai Que
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Josef Prazak
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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20
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Ahmed WM, Fenn D, White IR, Dixon B, Nijsen TME, Knobel HH, Brinkman P, Van Oort PMP, Schultz MJ, Dark P, Goodacre R, Felton T, Bos LDJ, Fowler SJ. Microbial Volatiles as Diagnostic Biomarkers of Bacterial Lung Infection in Mechanically Ventilated Patients. Clin Infect Dis 2023; 76:1059-1066. [PMID: 36310531 PMCID: PMC10029988 DOI: 10.1093/cid/ciac859] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/18/2022] [Accepted: 10/27/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Early and accurate recognition of respiratory pathogens is crucial to prevent increased risk of mortality in critically ill patients. Microbial-derived volatile organic compounds (mVOCs) in exhaled breath could be used as noninvasive biomarkers of infection to support clinical diagnosis. METHODS In this study, we investigated the diagnostic potential of in vitro-confirmed mVOCs in the exhaled breath of patients under mechanical ventilation from the BreathDx study. Samples were analyzed by thermal desorption-gas chromatography-mass spectrometry. RESULTS Pathogens from bronchoalveolar lavage (BAL) cultures were identified in 45 of 89 patients and Staphylococcus aureus was the most commonly identified pathogen (n = 15). Of 19 mVOCs detected in the in vitro culture headspace of 4 common respiratory pathogens (S. aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Escherichia coli), 14 were found in exhaled breath samples. Higher concentrations of 2 mVOCs were found in the exhaled breath of patients infected with S. aureus compared to those without (3-methylbutanal: P < .01, area under the receiver operating characteristic curve [AUROC] = 0.81-0.87; and 3-methylbutanoic acid: P = .01, AUROC = 0.79-0.80). In addition, bacteria identified from BAL cultures that are known to metabolize tryptophan (E. coli, Klebsiella oxytoca, and Haemophilus influenzae) were grouped and found to produce higher concentrations of indole compared to breath samples with culture-negative (P = .034) and other pathogen-positive (P = .049) samples. CONCLUSIONS This study demonstrates the capability of using mVOCs to detect the presence of specific pathogen groups with potential to support clinical diagnosis. Although not all mVOCs were found in patient samples within this small pilot study, further targeted and qualitative investigation is warranted using multicenter clinical studies.
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Affiliation(s)
- Waqar M Ahmed
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, and Manchester Academic Health Science Centre and National Institute for Health Research Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Dominic Fenn
- Department of Respiratory Medicine, Amsterdam UMC-location AMC, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Center (UMC), Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Iain R White
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, and Manchester Academic Health Science Centre and National Institute for Health Research Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- Laboratory for Environmental and Life Science, University of Nova Gorica, Nova Gorica, Slovenia
| | - Breanna Dixon
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, and Manchester Academic Health Science Centre and National Institute for Health Research Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | | | - Hugo H Knobel
- Eurofins Materials Science Netherlands BV, High Tech Campus, Eindhoven, The Netherlands
| | - Paul Brinkman
- Department of Respiratory Medicine, Amsterdam UMC-location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pouline M P Van Oort
- Department of Anaesthesiology, Amsterdam UMC Location VU Medical Center, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Intensive Care, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Department of Clinical Affairs, Hamilton Medical AG, Chur, Switzerland
| | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, and Manchester Academic Health Science Centre and National Institute for Health Research Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
- Critical Care Unit, Salford Royal NHS Foundation Trust, Northern Care Alliance NHS Group, Manchester, United Kingdom
| | - Royston Goodacre
- Centre for Metabolomics Research, Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Timothy Felton
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, and Manchester Academic Health Science Centre and National Institute for Health Research Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Lieuwe D J Bos
- Department of Respiratory Medicine, Amsterdam UMC-location AMC, University of Amsterdam, Amsterdam, The Netherlands
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam University Medical Center (UMC), Academic Medical Center (AMC), Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Stephen J Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, and Manchester Academic Health Science Centre and National Institute for Health Research Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
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Barie PS, Kao LS, Moody M, Sawyer RG. Infection or Inflammation: Are Uncomplicated Acute Appendicitis, Acute Cholecystitis, and Acute Diverticulitis Infectious Diseases? Surg Infect (Larchmt) 2023; 24:99-111. [PMID: 36656157 DOI: 10.1089/sur.2022.363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: It is recognized increasingly that common surgical infections of the peritoneal cavity may be treated with antibiotic agents alone, or source control surgery with short-course antimicrobial therapy. By extension, testable hypotheses have emerged that such infections may not actually be infectious diseases, but rather represent inflammation that can be treated successfully with neither surgery nor antibiotic agents. The aim of this review is to examine extant data to determine which of uncomplicated acute appendicitis (uAA), uncomplicated acute calculous cholecystitis (uACC), or uncomplicated mild acute diverticulitis (umAD) might be amenable to management using supportive therapy alone, consistent with the principles of antimicrobial stewardship. Methods: Review of pertinent English-language literature and expert opinion. Results: Only two small trials have examined whether uAA can be managed with observation and supportive therapy alone, one of which is underpowered and was stopped prematurely because of challenging patient recruitment. Data are insufficient to determine the safety and efficacy of non-antibiotic therapy of uAA. Uncomplicated acute calculous cholecystitis is not primarily an infectious disease; infection is a secondary phenomenon. Even when bactibilia is present, there is no high-quality evidence to suggest that mild disease should be treated with antibiotic agents. There is evidence to indicate that antibiotic prophylaxis is indicated for urgent/emergency cholecystectomy for uACC, but not in the post-operative period. Uncomplicated mild acute diverticulitis, generally Hinchey 1a or 1b in current nomenclature, does not benefit from antimicrobial agents based on multiple clinical studies. The implication is that umAD is inflammatory and not an infectious disease. Non-antimicrobial management is reasonable. Conclusions: Among the considered disease entities, the evidence is strongest that umAD is not an infectious disease and can be treated without antibiotic agents, intermediate regarding uACC, and lacking for uAA. A plausible hypothesis is that these inflammatory conditions are related to disruption of the normal microbiome, resulting in dysbiosis, which is defined as an imbalance of the natural microflora, especially of the gut, that is believed to contribute to a range of conditions of ill health. As for restorative pre- or probiotic therapy to reconstitute the microbiome, no recommendation can be made in terms of treatment, but it is not recommended for prevention of primary or recurrent disease.
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Affiliation(s)
- Philip S Barie
- Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Lillian S Kao
- Department of Surgery, UTHealth Houston John P. and Kathrine G. McGovern Medical School, Houston, Texas, USA
| | - Mikayla Moody
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
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22
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Rello J, Paiva JA. Antimicrobial stewardship at the emergency department: Dead bugs do not mutate! Eur J Intern Med 2023; 109:30-32. [PMID: 36669904 DOI: 10.1016/j.ejim.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Affiliation(s)
- Jordi Rello
- Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Research Institute, Barcelona, Spain; Recherche in Pôle Reánimation, Urgences et Douleur, CHU Nîmes, Nîmes, France.
| | - José Artur Paiva
- Intensive Care Department, Centro Hospitalar Universitário Sao Joao, Porto, Portugal; Medicine Departement, Faculty of Medicine, University of Porto, Portugal.
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23
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Keck JM, Cretella DA, Stover KR, Wagner JL, Barber KE, Jhaveri TA, Vijayvargiya P, Garrigos ZE, Wingler MJB. Evaluation of an Antifungal Stewardship Initiative Targeting Micafungin at an Academic Medical Center. Antibiotics (Basel) 2023; 12:antibiotics12020193. [PMID: 36830104 PMCID: PMC9952013 DOI: 10.3390/antibiotics12020193] [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: 12/28/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023] Open
Abstract
Delays in the treatment of proven invasive fungal disease have been shown to be harmful. However, empiric treatment for all patients at risk of infection has not demonstrated benefit. This study evaluates the effects of a micafungin stewardship initiative on the duration of therapy and clinical outcomes at the University of Mississippi Medical Center in Jackson, Mississippi. This single-center quasi-experiment evaluated patients who received micafungin. Adult inpatients who received at least one treatment dose of micafungin in the pre-intervention (1 October 2020 to 30 September 2021) or post-intervention (1 October 2021 to 30 April 2022) groups were included. Patients were placed on micafungin for prophylaxis and those who required definitive micafungin therapy were excluded. An algorithm was used to provide real-time recommendations in order to assess change in the treatment days of micafungin therapy. A total of 282 patients were included (141 pre-group versus 141 post-group). Over 80% of the patients included in the study were in an intensive care unit, and other baseline characteristics were similar. The median number of treatment days with micafungin was 4 [IQR 3-6] in the pre-group and 3 [IQR 2-6] in the post-group (p = 0.005). Other endpoints, such as time to discontinuation or de-escalation, hospital mortality, and hospital length of stay, were not significantly different between the groups. An antifungal stewardship initiative can be an effective way to decrease unnecessary empiric antifungal therapy for patients who are at risk of invasive fugal disease.
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Affiliation(s)
- J. Myles Keck
- Department of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA
| | - David A. Cretella
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Kayla R. Stover
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS 39216, USA
- Correspondence:
| | - Jamie L. Wagner
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS 39216, USA
| | - Katie E. Barber
- Department of Pharmacy Practice, University of Mississippi School of Pharmacy, Jackson, MS 39216, USA
| | - Tulip A. Jhaveri
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Prakhar Vijayvargiya
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Zerelda Esquer Garrigos
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Mary Joyce B. Wingler
- Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS 39216, USA
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Reynolds D, Burnham JP, Vazquez Guillamet C, McCabe M, Yuenger V, Betthauser K, Micek ST, Kollef MH. The threat of multidrug-resistant/extensively drug-resistant Gram-negative respiratory infections: another pandemic. Eur Respir Rev 2022; 31:31/166/220068. [PMID: 36261159 DOI: 10.1183/16000617.0068-2022] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/09/2022] [Indexed: 12/22/2022] Open
Abstract
Antibiotic resistance is recognised as a global threat to human health by national healthcare agencies, governments and medical societies, as well as the World Health Organization. Increasing resistance to available antimicrobial agents is of concern for bacterial, fungal, viral and parasitic pathogens. One of the greatest concerns is the continuing escalation of antimicrobial resistance among Gram-negative bacteria resulting in the endemic presence of multidrug-resistant (MDR) and extremely drug-resistant (XDR) pathogens. This concern is heightened by the identification of such MDR/XDR Gram-negative bacteria in water and food sources, as colonisers of the intestine and other locations in both hospitalised patients and individuals in the community, and as agents of all types of infections. Pneumonia and other types of respiratory infections are among the most common infections caused by MDR/XDR Gram-negative bacteria and are associated with high rates of mortality. Future concerns are already heightened due to emergence of resistance to all existing antimicrobial agents developed in the past decade to treat MDR/XDR Gram-negative bacteria and a scarcity of novel agents in the developmental pipeline. This clinical scenario increases the likelihood of a future pandemic caused by MDR/XDR Gram-negative bacteria.
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Affiliation(s)
- Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jason P Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Mikaela McCabe
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Valerie Yuenger
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Kevin Betthauser
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Scott T Micek
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Vieceli T, Rello J. Optimization of antimicrobial prescription in the hospital. Eur J Intern Med 2022; 106:39-44. [PMID: 36100471 DOI: 10.1016/j.ejim.2022.08.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/17/2022] [Accepted: 08/29/2022] [Indexed: 11/03/2022]
Abstract
Internal Medicine wards are an appropriate focus of antibiotic stewardship, along with emergency departments and intensive care units, because a large proportion of patients are with parenteral broad-spectrum antibiotics. Given the unmet clinical need of antibiotic optimization in the hospital and the importance of front-line practitioners for antibiotic stewardship, the barriers and tactics to overcome them were discussed in a round table at the European Congress of Internal Medicine. Better rapid diagnostic tests should help to increase appropriate early antibiotic rates, favoring diversity in antibiotic choices adapted to the awareness of local resistance patterns. Providing such is a greater challenge in low-resource settings. Prescriptions should be personalized, adjusting dosage and source control to specific patients' conditions. Shorter antibiotic duration and de-escalation are major drivers to reduce adverse events, with mortality and recurrence rates being independent of antimicrobial duration. Appropriate diagnostic tests with quick turnaround times decrease excessive antibiotic use. Antimicrobial optimization requires a multidisciplinary approach and it should be a core competence of training specialists, improving opportunities to provide safer patient care.
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Affiliation(s)
- T Vieceli
- Infectious Diseases Department, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, 90035-007, Porto Alegre, RS, Brazil.
| | - J Rello
- Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Research Institute, Barcelona, Spain; Clinical Research, CHU Nîmes, Nîmes, France; Medicine Department, Universitat Internacional de Catalunya, Sant Cugat del Valles, Barcelona, Spain.
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26
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Bussolati E, Cultrera R, Quaranta A, Cricca V, Marangoni E, La Rosa R, Bertacchini S, Bellonzi A, Ragazzi R, Volta CA, Spadaro S, Scaramuzzo G. Effect of the Pandemic Outbreak on ICU-Associated Infections and Antibiotic Prescription Trends in Non-COVID19 Acute Respiratory Failure Patients. J Clin Med 2022; 11:jcm11237080. [PMID: 36498656 PMCID: PMC9739506 DOI: 10.3390/jcm11237080] [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: 11/08/2022] [Revised: 11/25/2022] [Accepted: 11/25/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic had a relevant impact on the organization of intensive care units (ICU) and may have reduced the overall compliance with healthcare-associated infections (HAIs) prevention programs. Invasively ventilated patients are at high risk of ICU-associated infection, but there is little evidence regarding the impact of the pandemic on their occurrence in non-COVID-19 patients. Moreover, little is known of antibiotic prescription trends in the ICU during the first wave of the pandemic. The purpose of this investigation is to assess the incidence, characteristics, and risk factors for ICU-associated HAIs in a population of invasively ventilated patients affected by non-COVID-19 acute respiratory failure (ARF) admitted to the ICU in the first wave of the COVID-19 pandemic, and to evaluate the ICU antimicrobial prescription strategies. Moreover, we compared HAIs and antibiotic use to a cohort of ARF patients admitted to the ICU the year before the pandemic during the same period. METHODS this is a retrospective, single-centered cohort study conducted at S. Anna University Hospital (Ferrara, Italy). We enrolled patients admitted to the ICU for acute respiratory failure requiring invasive mechanical ventilation (MV) between February and April 2020 (intra-pandemic group, IP) and February and April 2019 (before the pandemic group, PP). We excluded patients admitted to the ICU for COVID-19 pneumonia. We recorded patients' baseline characteristics, ICU-associated procedures and devices. Moreover, we evaluated antimicrobial therapy and classified it as prophylactic, empirical or target therapy, according to the evidence of infection at the time of prescription and to the presence of a positive culture sample. We compared the results of the two groups (PP and IP) to assess differences between the two years. RESULTS One hundred and twenty-eight patients were screened for inclusion and 83 patients were analyzed, 45 and 38 in the PP and I group, respectively. We found a comparable incidence of HAIs (62.2% vs. 65.8%, p = 0.74) and multidrug-resistant (MDR) isolations (44.4% vs. 36.8% p= 0.48) in the two groups. The year of ICU admission was not independently associated with an increased risk of developing HAIs (OR = 0.35, 95% CI 0.16-1.92, p = 0.55). The approach to antimicrobial therapy was characterized by a significant reduction in total antimicrobial use (21.4 ± 18.7 vs. 11.6 ± 9.4 days, p = 0.003), especially of target therapy, in the IP group. CONCLUSIONS ICU admission for non-COVID-19 ARF during the first wave of the SARS-CoV-2 pandemic was not associated with an increased risk of ICU-associated HAIs. Nevertheless, ICU prescription of antimicrobial therapy changed and significantly decreased during the pandemic.
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Affiliation(s)
- Enrico Bussolati
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
| | - Rosario Cultrera
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Infectious Diseases Unit, Azienda Ospedaliera Universitaria Sant’Anna, 44121 Ferrara, Italy
| | - Alessandra Quaranta
- Intensive Care Unit, Azienda Ospedaliera Universitaria Sant’Anna, 44121 Ferrara, Italy
| | - Valentina Cricca
- Intensive Care Unit, Azienda Ospedaliera Universitaria Sant’Anna, 44121 Ferrara, Italy
| | - Elisabetta Marangoni
- Intensive Care Unit, Azienda Ospedaliera Universitaria Sant’Anna, 44121 Ferrara, Italy
| | - Riccardo La Rosa
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
| | - Sara Bertacchini
- Intensive Care Unit, Azienda Ospedaliera Universitaria Sant’Anna, 44121 Ferrara, Italy
| | - Alessandra Bellonzi
- Intensive Care Unit, Azienda Ospedaliera Universitaria Sant’Anna, 44121 Ferrara, Italy
| | - Riccardo Ragazzi
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Intensive Care Unit, Azienda Ospedaliera Universitaria Sant’Anna, 44121 Ferrara, Italy
| | - Carlo Alberto Volta
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Intensive Care Unit, Azienda Ospedaliera Universitaria Sant’Anna, 44121 Ferrara, Italy
| | - Savino Spadaro
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Intensive Care Unit, Azienda Ospedaliera Universitaria Sant’Anna, 44121 Ferrara, Italy
| | - Gaetano Scaramuzzo
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy
- Intensive Care Unit, Azienda Ospedaliera Universitaria Sant’Anna, 44121 Ferrara, Italy
- Correspondence:
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Rodríguez-Alarcón A, Barceló-Vidal J, Echeverría-Esnal D, Sorli L, Güerri-Fernández R, Ramis Fernández SM, Benitez-Cano A, Sendra E, López Montesinos I, Membrilla-Fernández E, Ferrández O, Adalia R, Horcajada JP, Escolano F, Gómez-Zorrilla S, Grau S. Antibiotic desensitization as a potential tool in antimicrobial stewardship programs: retrospective data analysis and systematic literature review. Expert Rev Anti Infect Ther 2022; 20:1491-1500. [PMID: 36069242 DOI: 10.1080/14787210.2022.2122443] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Antibiotic allergy labels (AAL) are related to worse therapeutic results. Strategies to improve the management of these patients, such as the implementation of antibiotic desensitization, are essential for Antimicrobial Stewardship Programs (ASP). The aim of our study is to evaluate the efficacy and safety of antibiotic desensitization procedures for the management of patients with AAL. METHODS A retrospective study from 2015 to 2022 was performed to describe all antibiotic desensitization conducted in our institution, within the framework of ASP. A systematic literature review using electronic databases, such as PubMed, was also done to identify studies describing antibiotic desensitization between 2000 and 2022. RESULTS Sixteen antibiotic desensitization protocols were carried out in our institution. In fourteen cases, the desensitization was successfully completed, and the antibiotic could be used to treat the infection. In the systematic review, twenty-two studies were included, with a total of 202 desensitization episodes . In 97% of them, the desensitization was completed successfully. No desensitization-related mortality was observed neither in our cohort nor in literature review. CONCLUSIONS Antibiotic desensitization strategies should be considered a safe and effective tool that can be included in ASP for patients with a high risk of or confirmed allergy to penicillin.
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Affiliation(s)
- Alicia Rodríguez-Alarcón
- Pharmacy Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Jaime Barceló-Vidal
- Pharmacy Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Daniel Echeverría-Esnal
- Pharmacy Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Luisa Sorli
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital Del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Centro de Investigacion Biomedica en Red Enfermedades Infecciosas, CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Roberto Güerri-Fernández
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital Del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Centro de Investigacion Biomedica en Red Enfermedades Infecciosas, CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Sofía Martina Ramis Fernández
- Pediatrics Service, Hospital del Mar de Barcelona. Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra, Barcelona, Spain
| | - Adela Benitez-Cano
- Department of Anesthesiology and Surgical Intensive Care, Hospital del Mar, Parc de Salut Mar. Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Elena Sendra
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital Del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Inmaculada López Montesinos
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital Del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Estela Membrilla-Fernández
- Surgery Service, Parc de Salut Mar. Institut Hospital del Mar d'Investigacions Mèdiques (IMIM) Fabra, Barcelona, Spain
| | - Olivia Ferrández
- Pharmacy Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Ramón Adalia
- Department of Anesthesiology and Surgical Intensive Care, Hospital del Mar, Parc de Salut Mar. Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Juan Pablo Horcajada
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital Del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Centro de Investigacion Biomedica en Red Enfermedades Infecciosas, CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Fernando Escolano
- Department of Anesthesiology and Surgical Intensive Care, Hospital del Mar, Parc de Salut Mar. Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Silvia Gómez-Zorrilla
- Infectious Diseases Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital Del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Centro de Investigacion Biomedica en Red Enfermedades Infecciosas, CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Santiago Grau
- Pharmacy Service, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona (UAB), Universitat Pompeu Fabra (UPF), Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI), Centro de Investigacion Biomedica en Red Enfermedades Infecciosas, CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
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Bellazreg F, Ben Lasfar N, Abid M, Rouis S, Hachfi W, Letaief A. Antibiotic stewardship team in a Tunisian university hospital: A four-year experience. LA TUNISIE MEDICALE 2022; 100:403-409. [PMID: 36206090 PMCID: PMC9552246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Association between antibiotic use and antimicrobial resistance has been demonstrated in several studies; hence the importance of antibiotic stewardship programs (ASPs) to reduce the burden of this resistance. AIM To describe the antibiotic stewardship team (AST) interventions in a Tunisian university hospital. METHODS a cross-sectional study was conducted in the infectious diseases department in Sousse-Tunisia between 2016 and 2020. Hospital and private practice doctors have been informed of the existence of an antibiotic stewardship team. Interventions consisted of some helps to antibiotic therapy (i.e.; prescription, change or discontinuation) and/or diagnosis (i.e.; further investigations). RESULTS Two thousand five hundred and fourteen interventions were made including 2288 (91%) in hospitalized patients, 2152 (86%) in university hospitals and 1684 (67%) in medical wards. The most common intervention consisted of help to antibiotic therapy (80%). The main sites of infections were skin and soft tissues (28%) and urinary tract (14%). Infections were microbiologically documented in 36% of cases. The most frequently isolated microorganisms were Enterobactriaceae (41%). Antibiotic use restriction was made in 44% of cases including further investigations (16%), antibiotic de-escalation (11%), no antibiotic prescription (9%) and antibiotic discontinuation (8%). In cases where antibiotics have been changed (N=475), the intervention was associated with an overall decrease in the prescription of broad-spectrum antibiotics from 61% to 50% with a decrease in the prescription of third generation cephalosporins from 22% to 15%. CONCLUSIONS The majority of antibiotic stewardship team's interventions were made in hospitalized patients, university hospitals and medical wards. These interventions resulted in an overall and broad-spectrum antibiotic use reduction.
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No Crystal Ball? Using Risk Factors and Scoring Systems to Predict Extended-Spectrum Beta-Lactamase Producing Enterobacterales (ESBL-E) and Carbapenem-Resistant Enterobacterales (CRE) Infections. Curr Infect Dis Rep 2022. [DOI: 10.1007/s11908-022-00785-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Roshdy A, Elsayed AS, Saleh AS. Intensivists' perceptions and attitudes towards infectious diseases management in the ICU: An international survey. Med Intensiva 2022; 46:549-558. [PMID: 36155678 DOI: 10.1016/j.medine.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/08/2021] [Accepted: 06/19/2021] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Exploring infectious diseases (ID) practice in Intensive Care Unit (ICU) to identify gaps and opportunities. DESIGN Online international survey (PRACT-INF-ICU) endorsed by the ESICM and open from July 30, 2019 to October 19, 2019. SETTING International study conducted in 78 countries. PARTICIPANTS Physicians working in ICU. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Practice variations were assessed according to respondents' countries income class, training, and years of practice. Univariate and multivariate ordinal logistic regression were used to estimate associations between respondents' characteristics and their perceptions regarding adequacy of training. RESULTS 466 intensivists with a median practice of 10 years (interquartile range, 5-19) completed the survey. A third reported no antimicrobial stewardship program and 40% had no regular microbiological rounds in their ICUs. Intensivists were mostly the decision makers for the initial antimicrobial therapy which in 70% of cases were based on guidelines or protocols. Non-ICU expertise were sought more frequently on reviewing (48/72h, culture adjustment and discontinuation in 32%, 39% and 21% respectively) rather than antimicrobial therapy initiation (16%). Only 42% described ID training as adequate. Multivariate ordinal logistic regression showed that low- to middle-income countries (OR: 0.41, 95% CI: 0.28-0.61), ICU practice ≤10 years (OR: 0.55, 95% CI: 0.39-0.79), and dual training with anaesthesia (OR: 0.52, 95% CI: 0.34-0.79) or medicine (OR: 0.49, 95% CI: 0.32-0.76) were associated with less training satisfaction. CONCLUSION ID practice is heterogeneous across ICUs while antimicrobial stewardship program is not universally implemented. From intensivists' perspective, ID training and knowledge need improvement.
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Affiliation(s)
- A Roshdy
- Intensive Care Unit, North Middlesex University Hospital, London, UK; Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - A S Elsayed
- Intensive Care Unit, King Fahd Military Medical Complex, Dhahran, Saudi Arabia
| | - A S Saleh
- Alhayat Clinic, Edku, el-Beheira, Egypt
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Lanckohr C, Bracht H. Antimicrobial stewardship. Curr Opin Crit Care 2022; 28:551-556. [PMID: 35942707 DOI: 10.1097/mcc.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The optimal use of antimicrobials is necessary to slow resistance development and improve patient outcomes. Antimicrobial stewardship (AMS) is a bundle of interventions aimed at promoting the responsible use of antiinfectives. The ICU is an important field of activity for AMS because of high rates of antimicrobial use, high prevalence of resistant pathogens and complex pharmacology. This review discusses aims and interventions of AMS with special emphasis on the ICU. RECENT FINDINGS AMS-interventions can improve the quality and quantity of antimicrobial prescribing in the ICU without compromising patient outcomes. The de-escalation of empiric therapy according to microbiology results and the limitation of treatment duration are important steps to reduce resistance pressure. Owing to the complex nature of critical illness, the pharmacological optimization of antimicrobial therapy is an important goal in the ICU. AMS-objectives and strategies are also applicable to patients with sepsis. This is reflected in the most recent guidelines by the Surviving Sepsis Campaign. AMS-interventions need to be adapted to their respective setting and be mindful of local prescribing cultures and prescribers' attitudes. SUMMARY AMS in the ICU is effective and safe. Intensivists should be actively involved in AMS-programs and propagate responsible use of antimicrobials.
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Affiliation(s)
- Christian Lanckohr
- Antibiotic Stewardship Team, Institute of Hygiene, University Hospital Münster, Münster
| | - Hendrik Bracht
- Central Emergency Services, University Hospital Ulm, Ulm, Germany
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Manning ML, Fitzpatrick E, Delengowski AM, Hou CM, Vyas N, Pogorzelska-Maziarz M. Advancing Antibiotic Stewardship Nursing Practice Through Standardized Education: A Pilot Study. J Contin Educ Nurs 2022; 53:417-423. [PMID: 36041206 DOI: 10.3928/00220124-20220805-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Antibiotic resistance is a leading global public health threat. Nurses are well positioned to optimize antibiotic use via targeted antibiotic stewardship (AS) nursing practices. However, standardized AS education for nurses is lacking. The objective of this study was to evaluate the effect of an online AS for nurses continuing education program on nurses' antibiotic resistance, antibiotic, and AS knowledge and their intent to integrate AS into their clinical practice. Method A quasi-experiential pretest-posttest design was used with a convenience sample of nurses at a U.S. academic medical center. Focus groups were conducted with those completing the program. Results Forty-seven of 100 eligible nurses completed the program and the pre- and posttest surveys. Participation resulted in statistically significant increases (p < .05) in antibiotic resistance, antibiotic, and AS knowledge, confidence, and perceptions related to the role of nursing in AS. Focus group participants had multiple recommendations for ways to integrate AS in daily nursing practice. Conclusion Completing a comprehensive AS nursing continuing education program could prove instrumental to motivating nurses to adopt AS nursing practices. [J Contin Educ Nurs. 2022;53(9):417-423.].
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Pickens CI, Wunderink RG. Clinical impact of bacterial syndromic testing in pneumonia. THE LANCET. RESPIRATORY MEDICINE 2022; 10:816-818. [PMID: 35617985 DOI: 10.1016/s2213-2600(22)00095-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Chiagozie I Pickens
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| | - Richard G Wunderink
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Plethora of Antibiotics Usage and Evaluation of Carbapenem Prescribing Pattern in Intensive Care Units: A Single-Center Experience of Malaysian Academic Hospital. Antibiotics (Basel) 2022; 11:antibiotics11091172. [PMID: 36139951 PMCID: PMC9495017 DOI: 10.3390/antibiotics11091172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/28/2022] Open
Abstract
Excessive antibiotic consumption is still common among critically ill patients admitted to intensive care units (ICU), especially during the coronavirus disease 2019 (COVID-19) period. Moreover, information regarding antimicrobial consumption among ICUs in South-East Asia remains scarce and limited. This study aims to determine antibiotics utilization in ICUs by measuring antibiotics consumption over the past six years (2016−2021) and specifically evaluating carbapenems prescribed in a COVID-19 ICU and a general intensive care unit (GICU) during the second year of the COVID-19 pandemic. (2) Methods: This is a retrospective cross-sectional observational analysis of antibiotics consumption and carbapenems prescriptions. Antibiotic utilization data were estimated using the WHO Defined Daily Doses (DDD). Carbapenems prescription information was extracted from the audits conducted by ward pharmacists. Patients who were prescribed carbapenems during their admission to COVID-19 ICU and GICU were included. Patients who passed away before being reviewed by the pharmacists were excluded. (3) Results: In general, antibiotics consumption increased markedly in the year 2021 when compared to previous years. Majority of carbapenems were prescribed empirically (86.8%). Comparing COVID-19 ICU and GICU, the reasons for empirical carbapenems therapy in COVID-19 ICU was predominantly for therapy escalation (64.7% COVID-19 ICU vs. 34% GICU, p < 0.001), whereas empirical prescription in GICU was for coverage of extended-spectrum beta-lactamases (ESBL) gram-negative bacteria (GNB) (45.3% GICU vs. 22.4% COVID-19 ICU, p = 0.005). Despite microbiological evidence, the empirical carbapenems were continued for a median (interquartile range (IQR)) of seven (5−8) days. This implies the need for a rapid diagnostic assay on direct specimens, together with comprehensive antimicrobial stewardship (AMS) discourse with intensivists to address this issue.
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Antimicrobial stewardship for sepsis in the intensive care unit: Survey of critical care and infectious diseases physicians. Infect Control Hosp Epidemiol 2022; 43:1368-1374. [PMID: 35959529 PMCID: PMC9588438 DOI: 10.1017/ice.2021.389] [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] [Indexed: 11/05/2022]
Abstract
Objective: To evaluate the attitudes of infectious diseases (ID) and critical care physicians toward antimicrobial stewardship in the intensive care unit (ICU). Design: Anonymous, cross-sectional, web-based surveys. Setting: Surveys were completed in March–November 2017, and data were analyzed from December 2017 to December 2019. Participants: ID and critical care fellows and attending physicians. Methods: We included 10 demographic and 17 newly developed, 5-point, Likert-scaled items measuring attitudes toward ICU antimicrobial stewardship and transdisciplinary collaboration. Exploratory principal components analysis (PCA) was used for data reduction. Multivariable linear regression models explored demographic and attitudinal variables. Results: Of 372 respondents, 315 physicians had complete data (72% attendings, 28% fellows; 63% ID specialists, and 37% critical care specialists). Our PCA yielded a 3-item factor measuring which specialty should assume ICU antimicrobial stewardship (Cronbach standardized α = 0.71; higher scores indicate that ID physicians should be stewards), and a 4-item factor measuring value of ICU transdisciplinary collaborations (α = 0.62; higher scores indicate higher value). In regression models, ID physicians (vs critical care physicians), placed higher value on ICU collaborations and expressed discomfort with uncertain diagnoses. These factors were independently associated with stronger agreement that ID physicians should be ICU antimicrobial stewards. The following factors were independently associated with higher value of transdisciplinary collaboration: female sex, less discomfort with uncertain diagnoses, and stronger agreement with ID physicians as ICU antimicrobial stewards. Conclusions: ID and critical care physicians endorsed their own group for antimicrobial stewardship, but both groups placed high value on ICU transdisciplinary collaborations. Physicians who were more uncomfortable with uncertain diagnoses reported preference for ID physicians to coordinate ICU antimicrobial stewardship; however, physicians who were less uncomfortable with uncertain diagnoses placed greater value on ICU collaborations.
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Kenaa B, O’Hara NN, O’Hara LM, Claeys KC, Leekha S. Understanding healthcare provider preferences for ordering respiratory cultures to diagnose ventilator associated pneumonia: A discrete choice experiment. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e120. [PMID: 36483413 PMCID: PMC9726546 DOI: 10.1017/ash.2022.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Ventilator-associated pneumonia (VAP) can be overdiagnosed on the basis of positive respiratory cultures in the absence of clinical findings of pneumonia. We determined the perceived diagnostic importance of 6 clinical attributes in ordering a respiratory culture to identify opportunities for diagnostic stewardship. DESIGN A discrete choice experiment presented participants with a vignette consisting of the same "stem" plus variations in 6 clinical attributes associated with VAP: chest imaging, oxygenation, sputum, temperature, white blood cell count, and blood pressure. Each attribute had 3-4 levels, resulting in 32 total scenarios. Participants indicated whether they would order a respiratory culture, and if yes, whether they preferred the bronchoalveolar lavage or endotracheal aspirate sample-collection method. We calculated diagnostic utility of attribute levels and relative importance of each attribute. SETTING AND PARTICIPANTS The survey was administered electronically to critical-care clinicians via a Qualtrics survey at a tertiary-care academic center in the United States. RESULTS In total, 59 respondents completed the survey. New radiograph opacity (utility, 1.15; 95% confidence interval [CI], 0.99-1.3), hypotension (utility, 0.88; 95% CI, 0.74-1.03), fever (utility, 0.76; 95% CI, 0.62-0.91) and copious sputum (utility, 0.75; 95% CI, 0.60-0.90) had the greatest perceived diagnostic value that favored ordering a respiratory culture. Radiograph changes (23%) and temperature (20%) had the highest relative importance. New opacity (utility, 0.35; 95% CI, 0.17-0.52) and persistent opacity on radiograph (utility, 0.32; 95% CI, 0.05-0.59) had the greatest value favoring bronchoalveolar lavage over endotracheal aspirate. CONCLUSION Perceived high diagnostic value of fever and hypotension suggest that sepsis vigilance may drive respiratory culturing and play a role in VAP overdiagnosis.
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Affiliation(s)
- Blaine Kenaa
- Division of Pulmonary and Critical Care, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathan N. O’Hara
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lyndsay M. O’Hara
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kimberly C. Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
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Serra Mitjà P, Centeno C, Garcia-Olivé I, Antuori A, Casadellà M, Tazi R, Armestar F, Fernández E, Andreo F, Rosell A. Bronchoscopy in Critically Ill COVID-19 Patients: Findings, Microbiological Profile, and Coinfection. J Bronchology Interv Pulmonol 2022; 29:186-190. [PMID: 35730778 DOI: 10.1097/lbr.0000000000000807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 08/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bronchoscopy is a widely use technique in critically ill patients. Nosocomial coinfections are a cause of morbidity and mortality in intensive care units. OBJECTIVES Our aim was to describe bronchoscopy findings and analyze microbiological profile and probably coinfection through bronchial aspirate (BA) samples in patients with coronavirus disease 2019 pneumonia requiring intensive care unit admission. METHODS Retrospective observational study analyzing the BA samples collected from intubated patients with coronavirus disease 2019 in a referral Hospital (Spain). RESULTS One hundred fifty-five consecutive BA samples were collected from 75 patients. Ninety (58%) were positive cultures for different microorganisms, 11 (7.1%) were polymicrobial, and 37 (23.7%) contained resistant microorganisms. There was a statistically significant association between increased days of orotracheal intubation and positive BA (18.9 vs. 10.9 d, P<0.01), polymicrobial infection (22.11 vs. 13.54, P<0.01) and isolation of resistant microorganisms (18.88 vs. 10.94, P<0.01). In 88% of the cases a new antibiotic or change in antibiotic treatment was made. CONCLUSION Bronchoscopy in critically ill patient was safe and could be useful to manage these patients and conduct the microbiological study, that seems to be higher and different than in nonepidemic periods. The longer the intubation period, the greater the probability of coinfection, isolation of resistant microorganisms and polymicrobial infection.
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Affiliation(s)
- Pere Serra Mitjà
- Pneumology Unit
- Germans Trias and Pujol Research Institute (IGTP)
- CibeRes, Cyber Respiratory Diseases, Bunyola, Spain
| | - Carmen Centeno
- Pneumology Unit
- Germans Trias and Pujol Research Institute (IGTP)
- CibeRes, Cyber Respiratory Diseases, Bunyola, Spain
| | - Ignasi Garcia-Olivé
- Pneumology Unit
- Germans Trias and Pujol Research Institute (IGTP)
- CibeRes, Cyber Respiratory Diseases, Bunyola, Spain
| | | | | | - Rachid Tazi
- Pneumology Unit
- Germans Trias and Pujol Research Institute (IGTP)
- CibeRes, Cyber Respiratory Diseases, Bunyola, Spain
| | - Fernando Armestar
- Servei de Medicina Intensiva
- Department of Medicine, Autonomous University of Barcelona, Barcelona
| | - Ester Fernández
- Thoracic Surgery Unit, Germans Trias i Pujol University Hospital
- Department of Medicine, Autonomous University of Barcelona, Barcelona
| | - Felipe Andreo
- Pneumology Unit
- Germans Trias and Pujol Research Institute (IGTP)
- Department of Medicine, Autonomous University of Barcelona, Barcelona
- CibeRes, Cyber Respiratory Diseases, Bunyola, Spain
| | - Antoni Rosell
- Pneumology Unit
- Germans Trias and Pujol Research Institute (IGTP)
- Department of Medicine, Autonomous University of Barcelona, Barcelona
- CibeRes, Cyber Respiratory Diseases, Bunyola, Spain
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Rafeq R, Igneri LA. Infectious Pulmonary Diseases. Emerg Med Clin North Am 2022; 40:503-518. [DOI: 10.1016/j.emc.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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T. Nguyen K, T. Pham S, P.M. Vo T, X. Duong C, A. Perwitasari D, H.K. Truong N, T.H. Quach D, N.P. Nguyen T, T.T. Duong V, M. Nguyen P, H. Nguyen T, Taxis K, Nguyen T. Pneumonia: Drug-Related Problems and Hospital Readmissions. Infect Dis (Lond) 2022. [DOI: 10.5772/intechopen.100127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Pneumonia is one of the most common infectious diseases and the fourth leading cause of death globally. According to US statistics in 2019, pneumonia is the most common cause of sepsis and septic shock. In the US, inpatient pneumonia hospitalizations account for the top 10 highest medical costs, totaling $9.5 billion for 960,000 hospital stays. The emergence of antibiotic resistance in the treatment of infectious diseases, including the treatment of pneumonia, is a globally alarming problem. Antibiotic resistance increases the risk of death and re-hospitalization, prolongs hospital stays, and increases treatment costs, and is one of the greatest threats in modern medicine. Drug-related problems (DRPs) in pneumonia - such as suboptimal antibiotic indications, prolonged treatment duration, and drug interactions - increase the rate of antibiotic resistance and adverse effects, thereby leading to an increased burden in treatment. In a context in which novel and effective antibiotics are scarce, mitigating DRPs in order to reduce antibiotic resistance is currently a prime concern. A variety of interventions proven useful in reducing DRPs are antibiotic stewardship programs, the use of biomarkers, computerized physician order entries and clinical decision support systems, and community-acquired pneumonia scores.
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Fontela PS, Gaudreault J, Dagenais M, Noël KC, Déragon A, Lacroix J, Razack S, Rennick J, Quach C, McNally JD, Carnevale FA. Clinical Reasoning Behind Antibiotic Use in PICUs: A Qualitative Study. Pediatr Crit Care Med 2022; 23:e126-e135. [PMID: 35013080 DOI: 10.1097/pcc.0000000000002886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the reasoning processes used by pediatric intensivists to make antibiotic-related decisions. DESIGN Grounded theory qualitative study. SETTING Three Canadian university-affiliated tertiary medical, surgical, and cardiac PICUs. PATIENTS Twenty-one PICU physicians. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We conducted field observation during morning rounds followed by semistructured interviews with participants to examine the clinical reasoning behind antibiotic-related decisions (starting/stopping antibiotics, or treatment duration) made for patients with a suspected/proven bacterial infection. We used a grounded theory approach for data collection and analysis. Thematic saturation was reached after 21 interviews. Of the 21 participants, 10 (48%) were female, 15 (71%) were PICU attending staff, and 10 (48%) had greater than 10 years in clinical practice. Initial clinical reasoning involves using an analytical approach to determine the likelihood of bacterial infection. In case of uncertainty, an assessment of patient safety is performed, which partly overlaps with the use of intuitive clinical reasoning. Finally, if uncertainty remains, physicians tend to consult infectious diseases experts. Factors that override this clinical reasoning process include disease severity, pressure from consultants, and the tendency to continue antibiotic treatment initiated by colleagues. CONCLUSIONS Antibiotic-related decisions for critically ill children are complex, and pediatric intensivists use several clinical reasoning strategies to decrease the uncertainty around the bacterial etiology of infections. However, disease severity and patient safety concerns may overrule decisions based on clinical evidence and lead to antibiotic use. Several cognitive biases were identified in the clinical reasoning processes.
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Affiliation(s)
- Patricia S Fontela
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | | | - Maryse Dagenais
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
| | - Kim C Noël
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | | | - Jacques Lacroix
- Division of Pediatric Critical Care, Department of Pediatrics, Université de Montréal, Montreal, QC, Canada
| | - Saleem Razack
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Janet Rennick
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
- Department of Nursing, The Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Caroline Quach
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montréal, Montreal, QC, Canada
| | - James D McNally
- Division of Pediatric Critical Care, Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Franco A Carnevale
- Division of Pediatric Critical Care, Department of Pediatrics, McGill University, Montreal, QC, Canada
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
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Murphy CV, Reed EE, Herman DD, Magrum B, Beatty JJ, Stevenson KB. Antimicrobial Stewardship in the ICU. Semin Respir Crit Care Med 2022; 43:131-140. [PMID: 35172363 DOI: 10.1055/s-0041-1740977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Increasing rates of infection and multidrug-resistant pathogens, along with a high use of antimicrobial therapy, make the intensive care unit (ICU) an ideal setting for implementing and supporting antimicrobial stewardship efforts. Overuse of antimicrobial agents is common in the ICU, as practitioners are challenged daily with achieving early, appropriate empiric antimicrobial therapy to improve patient outcomes. While early antimicrobial stewardship programs focused on the financial implications of antimicrobial overuse, current goals of stewardship programs align closely with those of critical care providers-to optimize patient outcomes, reduce development of resistance, and minimize adverse outcomes associated with antibiotic overuse and misuse such as acute kidney injury and Clostridioides difficile-associated disease. Significant opportunities exist in the ICU for critical care clinicians to support stewardship practices at the bedside, including thoughtful and restrained initiation of antimicrobial therapy, use of biomarkers in addition to rapid diagnostics, Staphylococcus aureus screening, and traditional microbiologic culture and susceptibilities to guide antibiotic de-escalation, and use of the shortest duration of therapy that is clinically appropriate. Integration of critical care practitioners into the initiatives of antimicrobial stewardship programs is key to their success. This review summarizes key components of antimicrobial stewardship programs and mechanisms for critical care practitioners to share the responsibility for antimicrobial stewardship.
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Affiliation(s)
- Claire V Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Erica E Reed
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Derrick D Herman
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - BrookeAnne Magrum
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Julia J Beatty
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kurt B Stevenson
- Division of Infectious Diseases, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio
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Richter DC, Heininger A, Chiriac U, Frey OR, Rau H, Fuchs T, Röhr AC, Brinkmann A, Weigand MA. Antibiotic Stewardship and Therapeutic Drug Monitoring of β-Lactam Antibiotics: Is There a Link? An Opinion Paper. Ther Drug Monit 2022; 44:103-111. [PMID: 34857694 DOI: 10.1097/ftd.0000000000000949] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/19/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE In critically ill patients, changes in the pharmacokinetics (PK) of β-lactams can lead to significant variations in serum concentrations, with possibly detrimental effects on outcomes. The utilization of individually calculated doses, extended infusion regimen, and therapeutic drug monitoring (TDM)-guided dose adjustments can mitigate the PK changes and help to achieve and attain an individual PK target. METHODS We reviewed relevant literature from 2004 to 2021 using 4 search engines (PubMed, Web of Science, Scopus, and Google Scholar). Unpublished clinical data were also examined. RESULTS TDM-guided, individualized dosing strategies facilitated PK target attainment and improved patient outcomes. TDM-guided therapy is a core concept of individualized dosing that increases PK target attainment and identifies possible toxic β-lactam concentrations. CONCLUSIONS Individualized dosing and TDM facilitate the rational use of β-lactams and are integral for antibiotic stewardship interventions in critical care, affording the optimal exposure of both pathogen and drugs, along with enhanced treatment efficacy and reduced emergence of antimicrobial resistance.
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Affiliation(s)
- Daniel C Richter
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg
| | - Alexandra Heininger
- Department of Infectious Diseases and Hygiene, Mannheim University Hospital, Mannheim
| | - Ute Chiriac
- Department of Pharmacy, Heidelberg University Hospital, Heidelberg; and
| | | | - Heike Rau
- Departments of Clinical Pharmacy, and
| | - Thomas Fuchs
- Anesthesiology, Heidenheim Hospital, Heidenheim, Germany
| | | | | | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg
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43
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Afsahi M, Sadegh M, Rafiei M, Hazrati E, Namazi M. Weaning of septic patients from the ventilator in the intensive care unit by attention approach to common antibiotic regimens. J Family Med Prim Care 2022; 11:1169-1173. [PMID: 35495784 PMCID: PMC9051689 DOI: 10.4103/jfmpc.jfmpc_1290_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/14/2021] [Accepted: 12/25/2021] [Indexed: 11/06/2022] Open
Abstract
Background: Sepsis is a chronic blood infection that is more common in patients with ventilatory and disability. This study aimed to evaluate the effect of common antibiotic regimens on weaning sepsis patients from mechanical ventilator. Methods: In this prospective cross-sectional study, we classified 70 sepsis patients under mechanical ventilation which sedates with midazolam and do not take muscle relaxants into two groups: meropenem and levofloxacin versus meropenem, levofloxacin, and clindamycin. The duration of intubation and the number of patients who needed re-intubation (and their duration of extubation) were recorded. Data were analyzed using SPSS software. Results: In the present study, 68.6% were male and 31.4% were female. The mean age was calculated to be 37.98. The mean duration of mechanical ventilation and stay in the ICU in the group of two drugs (meropenem + levofloxacin) showed a significant decrease compared to the group of three drugs (P < 0.05). But no significant difference was observed in terms of ventilator connection time (P < 0.05). Conclusion: The differences in terms of mean duration of mechanical ventilation and ICU stay between the groups indicate that the two-drug regimen (meropenem + levofloxacin) is more efficient in bringing [sepsis] patients back to recovery.
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44
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Hirano Y, Shinmoto K, Okada Y, Suga K, Bombard J, Murahata S, Shrestha M, Ocheja P, Tanaka A. Machine Learning Approach to Predict Positive Screening of Methicillin-Resistant Staphylococcus aureus During Mechanical Ventilation Using Synthetic Dataset From MIMIC-IV Database. Front Med (Lausanne) 2021; 8:694520. [PMID: 34869405 PMCID: PMC8635043 DOI: 10.3389/fmed.2021.694520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 10/22/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Mechanically ventilated patients are susceptible to nosocomial infections such as ventilator-associated pneumonia. To treat ventilated patients with suspected infection, clinicians select appropriate antibiotics. However, decision-making regarding the use of antibiotics for methicillin-resistant Staphylococcus aureus (MRSA) is challenging, because of the lack of evidence-supported criteria. This study aims to derive a machine learning model to predict MRSA as a possible pathogen responsible for infection in mechanically ventilated patients. Methods: Data were collected from the Medical Information Mart for Intensive Care (MIMIC)-IV database (an openly available database of patients treated at the Beth Israel Deaconess Medical Center in the period 2008-2019). Of 26,409 mechanically ventilated patients, 809 were screened for MRSA during the mechanical ventilation period and included in the study. The outcome was positivity to MRSA on screening, which was highly imbalanced in the dataset, with 93.9% positive outcomes. Therefore, after dividing the dataset into a training set (n = 566) and a test set (n = 243) for validation by stratified random sampling with a 7:3 allocation ratio, synthetic datasets with 50% positive outcomes were created by synthetic minority over-sampling for both sets individually (synthetic training set: n = 1,064; synthetic test set: n = 456). Using these synthetic datasets, we trained and validated an XGBoost machine learning model using 28 predictor variables for outcome prediction. Model performance was evaluated by area under the receiver operating characteristic (AUROC), sensitivity, specificity, and other statistical measurements. Feature importance was computed by the Gini method. Results: In validation, the XGBoost model demonstrated reliable outcome prediction with an AUROC value of 0.89 [95% confidence interval (CI): 0.83-0.95]. The model showed a high sensitivity of 0.98 [CI: 0.95-0.99], but a low specificity of 0.47 [CI: 0.41-0.54] and a positive predictive value of 0.65 [CI: 0.62-0.68]. Important predictor variables included admission from the emergency department, insertion of arterial lines, prior quinolone use, hemodialysis, and admission to a surgical intensive care unit. Conclusions: We were able to develop an effective machine learning model to predict positive MRSA screening during mechanical ventilation using synthetic datasets, thus encouraging further research to develop a clinically relevant machine learning model for antibiotics stewardship.
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Affiliation(s)
- Yohei Hirano
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Keito Shinmoto
- Department of Internal Medicine, Tokyo bay Ichikawa Urayasu Medical Center, Chiba, Japan
| | - Yohei Okada
- Department of Primary Care and Emergency Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazuhiro Suga
- Department of Mechanical Engineering, Faculty of Engineering, Kogakuin University, Tokyo, Japan
| | | | | | | | - Patrick Ocheja
- Graduate School of Informatics, Kyoto University, Kyoto, Japan
| | - Aiko Tanaka
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
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45
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Suranadi IW, Panji PAS, Budayanti NNS, Senapathi TGA, Susatya AB. Evaluation of Empirical Meropenem Bolus Protocol in Pseudomonas aeruginosa: A Three-Year Analysis in Tertiary Intensive Care Unit. Int J Gen Med 2021; 14:7861-7867. [PMID: 34795507 PMCID: PMC8593592 DOI: 10.2147/ijgm.s341423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 10/21/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To describe meropenem empirical use, susceptibility trend, and associated factors for acquired nonsusceptibility in P. aeruginosa in the intensive care unit. Patients and Methods This study was conducted in the intensive and high care unit of a tertiary care hospital in Indonesia to evaluate empirical meropenem bolus administration protocol. All patients admitted during the 3 year study period from January 2018 through January 2021 with culture-confirmed P. aeruginosa infection were included in the study. Primary data were collected from hospital database electronic medical record and series of local biannual report of microorganism susceptibility pattern. Results The data suggested that there was increasing trend in meropenem nonsusceptibility and multidrug-resistance rates. A total of 135 patients with various primary diagnoses and comorbidities were studied. P. aeruginosa isolates were mostly (73.4%) obtained from sputum specimen. Empirical meropenem therapy was administrated in 24.4% of patients with standard- and high-dose as indicated. Nonsusceptibility was acquired in 37% patients who mostly received empirical therapy. Multivariable analysis revealed protocol being evaluated as a statistically significant risk factor for nonsusceptibility in P. aeruginosa (PR = 30.65; p <0.001). Conclusion Empirical meropenem administration protocol in this study was an independent determinant of nonsusceptibility acquisition in P. aeruginosa. These findings proved that empirical therapeutic strategy modification is indispensable and routine evaluation practice should be promulgated.
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Affiliation(s)
- I Wayan Suranadi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Udayana/Sanglah General Hospital, Denpasar, Bali, 80113, Indonesia
| | - Putu Agus Surya Panji
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Udayana/Sanglah General Hospital, Denpasar, Bali, 80113, Indonesia
| | - Ni Nyoman Sri Budayanti
- Department of Clinical Microbiology, Faculty of Medicine, Universitas Udayana, Denpasar, Bali, 80113, Indonesia
| | - Tjokorda Gde Agung Senapathi
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Udayana/Sanglah General Hospital, Denpasar, Bali, 80113, Indonesia
| | - Arif Budiman Susatya
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Udayana/Sanglah General Hospital, Denpasar, Bali, 80113, Indonesia
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46
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Diagnosis and Treatment of Bacterial Pneumonia in Critically Ill Patients with COVID-19 Using a Multiplex PCR Assay: A Large Italian Hospital's Five-Month Experience. Microbiol Spectr 2021; 9:e0069521. [PMID: 34756067 PMCID: PMC8579927 DOI: 10.1128/spectrum.00695-21] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Bacterial pneumonia is a challenging coronavirus disease 2019 (COVID-19) complication for intensive care unit (ICU) clinicians. Upon its implementation, the FilmArray pneumonia plus (FA-PP) panel's practicability for both the diagnosis and antimicrobial therapy management of bacterial pneumonia was assessed in ICU patients with COVID-19. Respiratory samples were collected from patients who were mechanically ventilated at the time bacterial etiology and antimicrobial resistance were determined using both standard-of-care (culture and antimicrobial susceptibility testing [AST]) and FA-PP panel testing methods. Changes to targeted and/or appropriate antimicrobial therapy were reviewed. We tested 212 samples from 150 patients suspected of bacterial pneumonia. Etiologically, 120 samples were positive by both methods, two samples were culture positive but FA-PP negative (i.e., negative for on-panel organisms), and 90 were negative by both methods. FA-PP detected no culture-growing organisms (mostly Staphylococcus aureus or Pseudomonas aeruginosa) in 19 of 120 samples or antimicrobial resistance genes in two culture-negative samples for S. aureus organisms. Fifty-nine (27.8%) of 212 samples were from empirically treated patients. Antibiotics were discontinued in 5 (33.3%) of 15 patients with FA-PP-negative samples and were escalated/deescalated in 39 (88.6%) of 44 patients with FA-PP-positive samples. Overall, antibiotics were initiated in 87 (72.5%) of 120 pneumonia episodes and were not administered in 80 (87.0%) of 92 nonpneumonia episodes. Antimicrobial-resistant organisms caused 78 (60.0%) of 120 episodes. Excluding 19 colistin-resistant Acinetobacter baumannii episodes, AST confirmed appropriate antibiotic receipt in 101 (84.2%) of 120 episodes for one or more FA-PP-detected organisms. Compared to standard-of-care testing, the FA-PP panel may be of great value in the management of COVID-19 patients at risk of developing bacterial pneumonia in the ICU. IMPORTANCE Since bacterial pneumonia is relatively frequent, suspicion of it in COVID-19 patients may prompt ICU clinicians to overuse (broad-spectrum) antibiotics, particularly when empirical antibiotics do not cover the suspected pathogen. We showed that a PCR-based, culture-independent laboratory assay allows not only accurate diagnosis but also streamlining of antimicrobial therapy for bacterial pneumonia episodes. We report on the actual implementation of rapid diagnostics and its real-life impact on patient treatment, which is a gain over previously published studies on the topic. A better understanding of the role of that or similar PCR assays in routine ICU practice may lead us to appreciate the effectiveness of their implementation during the COVID-19 pandemic.
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47
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Waterer G, Pickens CI, Wunderink R. Antibiotic-resistant bacteria: COVID-19 hasn't made the challenge go away. Respirology 2021; 26:1024-1026. [PMID: 34596927 PMCID: PMC8661559 DOI: 10.1111/resp.14166] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 12/17/2022]
Affiliation(s)
- Grant Waterer
- Faculty of Medicine, University of Western Australia, Royal Perth Hospital, Perth, Western Australia, Australia
| | | | - Richard Wunderink
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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48
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Bruni A, Garofalo E, Mazzitelli M, Voci CP, Puglisi A, Quirino A, Marascio N, Trecarichi EM, Matera G, Torti C, Longhini F. Multidisciplinary approach to a septic COVID-19 patient undergoing veno-venous extracorporeal membrane oxygenation and receiving thoracic surgery. Clin Case Rep 2021; 9:e04828. [PMID: 34631063 PMCID: PMC8489392 DOI: 10.1002/ccr3.4828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/23/2021] [Accepted: 08/30/2021] [Indexed: 11/06/2022] Open
Abstract
A multidisciplinary approach appears to be fundamental for the treatment of critically ill patients with COVID-19, improving clinical outcomes, even in the most severe cases. Such severe cases are advisable to be collegially discussed between intensivists, surgeons, infectious disease, and other physicians potentially involved.
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Affiliation(s)
- Andrea Bruni
- Anesthesia and Intensive Care Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Maria Mazzitelli
- Infectious and Tropical Disease Unit Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Carlo P Voci
- Thoracic Surgery Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Armando Puglisi
- Thoracic Surgery Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Angela Quirino
- Clinical Microbiology Unit Department of Health Sciences Magna Graecia University Catanzaro Italy
| | - Nadia Marascio
- Clinical Microbiology Unit Department of Health Sciences Magna Graecia University Catanzaro Italy
| | - Enrico M Trecarichi
- Infectious and Tropical Disease Unit Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Giovanni Matera
- Clinical Microbiology Unit Department of Health Sciences Magna Graecia University Catanzaro Italy
| | - Carlo Torti
- Infectious and Tropical Disease Unit Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
| | - Federico Longhini
- Anesthesia and Intensive Care Department of Medical and Surgical Sciences Magna Graecia University Catanzaro Italy
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49
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Marasine NR, Shrestha S, Sankhi S, Paudel N, Gautam A, Poudel A. Antibiotic utilization, sensitivity, and cost in the medical intensive care unit of a tertiary care teaching hospital in Nepal. SAGE Open Med 2021; 9:20503121211043710. [PMID: 34504707 PMCID: PMC8422810 DOI: 10.1177/20503121211043710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/15/2021] [Indexed: 11/17/2022] Open
Abstract
Background: High utilization and irrational use of antibiotics in an intensive care unit increases microbial resistance, morbidity, mortality, and costs. Objective: This study aimed to evaluate the utilization, sensitivity and cost analysis of antibiotics used in the medical intensive care unit of a tertiary care teaching hospital of Nepal. Methods: A prospective cohort study was conducted on patients admitted to the medical intensive care unit at a tertiary care teaching hospital in central Nepal from July to September 2016. Antibiotic utilization, defined daily dose per 100 bed-days and the cost of antibiotics per patient were calculated. Descriptive statistics were performed using IBM-SPSS 20.0. Results: A total of 365 antibiotics were prescribed in 157 patients during the study period, with an average of 2.34 prescriptions per patient. Total antibiotic utilization in terms of defined daily dose per 100 bed-days was 49.5. Piperacillin/tazobactam (45.2%) was the most commonly prescribed antibiotic, and meropenem was the most expensive antibiotics (US$4440.70). The median (interquartile range) cost of antibiotics used per patient was US$47.67 (US$63.73). Escherichia coli, Acinetobacter, and Pseudomonas sp. were the common organisms isolated and were found to be resistant to some of the commonly used antibiotics. Conclusion: This study suggests that the utilization and cost of antibiotics are high in medical intensive care unit of the hospital and E. coli was resistant to multiple antibiotics. The findings highlight an urgent need for the implementation of antibiotic stewardship program in order to improve antibiotic utilization in such hospital settings.
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Affiliation(s)
- Nirmal Raj Marasine
- Department of Pharmacy, Karnali College of Health Science, Kathmandu, Nepal.,School of Pharmacy, Chitwan Medical College, Bharatpur, Nepal
| | - Shakti Shrestha
- School of Pharmacy, University of Queensland, Brisbane, QLD, Australia
| | - Sabina Sankhi
- Department of Pharmacy, Modern Technical College, Lalitpur, Nepal
| | - Nabina Paudel
- School of Pharmacy, Kathmandu University, Dhulikhel, Nepal
| | - Ashish Gautam
- School of Pharmacy, Chitwan Medical College, Bharatpur, Nepal
| | - Arjun Poudel
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
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50
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Roshdy A, Elsayed AS, Saleh AS. Intensivists' perceptions and attitudes towards infectious diseases management in the ICU: An international survey. Med Intensiva 2021; 46:S0210-5691(21)00174-1. [PMID: 34417082 DOI: 10.1016/j.medin.2021.06.006] [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: 04/16/2021] [Revised: 06/08/2021] [Accepted: 06/19/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Exploring infectious diseases (ID) practice in Intensive Care Unit (ICU) to identify gaps and opportunities. DESIGN Online international survey (PRACT-INF-ICU) endorsed by the ESICM and open from July 30, 2019 to October 19, 2019. SETTING International study conducted in 78 countries. PARTICIPANTS Physicians working in ICU. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Practice variations were assessed according to respondents' countries income class, training, and years of practice. Univariate and multivariate ordinal logistic regression were used to estimate associations between respondents' characteristics and their perceptions regarding adequacy of training. RESULTS 466 intensivists with a median practice of 10 years (interquartile range, 5-19) completed the survey. A third reported no antimicrobial stewardship program and 40% had no regular microbiological rounds in their ICUs. Intensivists were mostly the decision makers for the initial antimicrobial therapy which in 70% of cases were based on guidelines or protocols. Non-ICU expertise were sought more frequently on reviewing (48/72h, culture adjustment and discontinuation in 32%, 39% and 21% respectively) rather than antimicrobial therapy initiation (16%). Only 42% described ID training as adequate. Multivariate ordinal logistic regression showed that low- to middle-income countries (OR: 0.41, 95% CI: 0.28-0.61), ICU practice ≤10 years (OR: 0.55, 95% CI: 0.39-0.79), and dual training with anaesthesia (OR: 0.52, 95% CI: 0.34-0.79) or medicine (OR: 0.49, 95% CI: 0.32-0.76) were associated with less training satisfaction. CONCLUSION ID practice is heterogeneous across ICUs while antimicrobial stewardship program is not universally implemented. From intensivists' perspective, ID training and knowledge need improvement.
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Affiliation(s)
- A Roshdy
- Intensive Care Unit, North Middlesex University Hospital, London, UK; Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - A S Elsayed
- Intensive Care Unit, King Fahd Military Medical Complex, Dhahran, Saudi Arabia
| | - A S Saleh
- Alhayat Clinic, Edku, el-Beheira, Egypt
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