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Di Bella S, Beović B, Fabbiani M, Valentini M, Luzzati R. Antimicrobial Stewardship: From Bedside to Theory. Thirteen Examples of Old and More Recent Strategies from Everyday Clinical Practice. Antibiotics (Basel) 2020; 9:antibiotics9070398. [PMID: 32664288 PMCID: PMC7399849 DOI: 10.3390/antibiotics9070398] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/29/2022] Open
Abstract
“Antimicrobial stewardship” is a strategy that promotes the responsible use of antimicrobials. The objective of this paper is to focus on consolidated and more recent improvements in clinical strategies that should be adopted in hospitalized patients to ameliorate their infectious diseases’ outcome and to reduce the antibiotic resistance risk through judicious use of antibiotics. We present 13 common clinical scenarios, the respective suggested interventions and the explanations of the supporting evidence, in order to help clinicians in their decision-making process. Strategies including the choice of antibiotic and dose optimization, antibiotic spectrum narrowing (de-escalation), shortening of duration, shift to oral route or outpatient parenteral antibiotic (including elastomeric pumps), and biomarkers are described and discussed.
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Affiliation(s)
- Stefano Di Bella
- Department of Medical, Surgical and Health Sciences, Trieste University, 34127 Trieste, Italy;
- Correspondence:
| | - Bojana Beović
- Department of Infectious Diseases, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia;
| | - Massimiliano Fabbiani
- Infectious Disease Unit, Azienda Ospedaliero-Universitaria Senese, 53100 Siena, Italy;
| | - Michael Valentini
- Azienda Sanitaria Universitaria Giuliano Isontina, 34128 Trieste, Italy;
| | - Roberto Luzzati
- Department of Medical, Surgical and Health Sciences, Trieste University, 34127 Trieste, Italy;
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Fiori B, D'Inzeo T, Posteraro B, Menchinelli G, Liotti FM, De Angelis G, De Maio F, Fantoni M, Murri R, Scoppettuolo G, Ventura G, Tumbarello M, Pennestrì F, Taccari F, Sanguinetti M, Spanu T. Direct use of eazyplex ® SuperBug CRE assay from positive blood cultures in conjunction with inpatient infectious disease consulting for timely appropriate antimicrobial therapy in Escherichia coli and Klebsiella pneumoniae bloodstream infections. Infect Drug Resist 2019; 12:1055-1062. [PMID: 31118711 PMCID: PMC6506573 DOI: 10.2147/idr.s206323] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 04/08/2019] [Indexed: 02/05/2023] Open
Abstract
Objectives: To describe a rapid workflow based on the direct detection of Escherichia coli (Ec) and Klebsiella pneumoniae (Kp) producing CTX-M extended-spectrum β-lactamase (ESBL) and/or carbapenemases (eg, KPC, VIM) from blood cultures (BCs) and the infectious disease (ID) consulting for timely appropriate antimicrobial therapy. Methods: This observational, retrospective study included adult patients with a first episode of Ec or Kp bloodstream infection (BSI) in a large Italian university hospital, where an inpatient ID consultation team (IDCT) has been operational. Results from the BCs tested for detecting bla CTX-M, bla KPC, bla NDM, bla OXA-48-like, and bla VIM genes by the eazyplex® SuperBug CRE assay in Ec and Kp organisms had been notified for antimicrobial therapy consulting. Results: In 321 BSI episodes studied, we found that 151 (47.0%) of Ec or Kp organisms harbored bla CTX-M and/or bla KPC and/or bla VIM (meantime from BC collection: 18.5 h). Empirical antimicrobial treatment was appropriate in 21.8% (33/151) of BSIs, namely 5.9% (3/51) of BSIs caused by KPC/VIM producers and 30.0% (30/100) of BSIs caused by CTX-M producers. After notification of results, the IDCT modified antimicrobial therapy (mean time from BC collection: 20 h) such that the proportion of appropriate treatments increased to 84.8% (128/151) of BSIs, namely 70.6% (36/51) of BSIs caused by KPC/VIM producers and 92.0% (92/100) of BSIs caused by CTX-M producers. Conclusion: Our study shows that a rapid diagnostic-driven clinical strategy allowed for early prescription of potentially effective antimicrobial therapy in BSIs caused by CTX-M ESBL- and/or KPC/VIM carbapenemase-producing Ec and Kp organisms.
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Affiliation(s)
- Barbara Fiori
- Scuola Provinciale Superiore di Sanità Claudiana, Bolzano, Italy.,Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di Scienze di Laboratorio e Infettivologiche, Rome, Italy.,Università Cattolica del Sacro Cuore, Istituto di Microbiologia, Rome, Italy
| | - Tiziana D'Inzeo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di Scienze di Laboratorio e Infettivologiche, Rome, Italy.,Università Cattolica del Sacro Cuore, Istituto di Microbiologia, Rome, Italy
| | - Brunella Posteraro
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Rome, Italy.,Università Cattolica del Sacro Cuore Rome, Istituto di Patologia e Semeiotica Medica, Rome, Italy
| | - Giulia Menchinelli
- Università Cattolica del Sacro Cuore, Istituto di Microbiologia, Rome, Italy
| | - Flora Marzia Liotti
- Università Cattolica del Sacro Cuore, Istituto di Microbiologia, Rome, Italy
| | - Giulia De Angelis
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di Scienze di Laboratorio e Infettivologiche, Rome, Italy.,Università Cattolica del Sacro Cuore, Istituto di Microbiologia, Rome, Italy
| | - Flavio De Maio
- Università Cattolica del Sacro Cuore, Istituto di Microbiologia, Rome, Italy
| | - Massimo Fantoni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Malattie Infettive, Rome, Italy.,Istituto di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rita Murri
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Malattie Infettive, Rome, Italy.,Istituto di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giancarlo Scoppettuolo
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Malattie Infettive, Rome, Italy
| | - Giulio Ventura
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Malattie Infettive, Rome, Italy
| | - Mario Tumbarello
- Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC Malattie Infettive, Rome, Italy.,Istituto di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Pennestrì
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Rome, Italy
| | - Francesco Taccari
- Istituto di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maurizio Sanguinetti
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di Scienze di Laboratorio e Infettivologiche, Rome, Italy.,Università Cattolica del Sacro Cuore, Istituto di Microbiologia, Rome, Italy
| | - Teresa Spanu
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento di Scienze di Laboratorio e Infettivologiche, Rome, Italy.,Università Cattolica del Sacro Cuore, Istituto di Microbiologia, Rome, Italy
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Sasikumar M, Boyer S, Remacle-Bonnet A, Ventelou B, Brouqui P. The value of specialist care-infectious disease specialist referrals-why and for whom? A retrospective cohort study in a French tertiary hospital. Eur J Clin Microbiol Infect Dis 2016; 36:625-633. [PMID: 27858243 DOI: 10.1007/s10096-016-2838-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 10/31/2016] [Indexed: 11/25/2022]
Abstract
This study evaluated the impact of infectious disease (ID) specialist referrals on outcomes in a tertiary hospital in France. This study tackled methodological constraints (selection bias, endogeneity) using instrumental variables (IV) methods in order to obtain a quasi-experimental design. In addition, we investigated whether certain characteristics of patients have a bearing on the impact of the intervention. We used the payments database and ID department files to obtain data for adults admitted with an ID diagnosis in the North Hospital, Marseille from 2012 to 2014. Comparable cohorts were obtained using coarsened exact matching and analysed using IV models. Mortality, readmissions, cost (payer perspective) and length of stay (LoS) were analysed. We recorded 15,393 (85.97%) stays, of which 2,159 (14.03%) benefited from IDP consultations. The intervention was seen to significantly lower the risk of inpatient mortality (marginal effect (M.E) = -19.06%) and cost of stay (average treatment effect (ATE) = - €5,573.39). The intervention group was seen to have a longer LoS (ATE = +4.95 days). The intervention conferred a higher reduction in mortality and cost for stays that experienced ICU care (mortality: odds ratio (OR) =0.09, M.E cost = -8,328.84 €) or had a higher severity of illness (mortality: OR=0.35, M.E cost = -1,331.92 €) and for patients aged between 50 and 65 years (mortality: OR=0.28, M.E cost = -874.78 €). This study shows that ID referrals are associated with lower risk of inpatient mortality and cost of stay, especially when targeted to certain subgroups.
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Affiliation(s)
- M Sasikumar
- SESSTIM, UMR 912 INSERM, Aix-Marseille University (Aix-Marseille School of Economics), Marseille, France.
| | - S Boyer
- SESSTIM, UMR 912 INSERM-IRD, Aix-Marseille Université, Marseille, France
| | - A Remacle-Bonnet
- Service d'Information Médicale, APHM CHU Nord Marseille, Marseille, France
| | - B Ventelou
- CNRS & EHESS, Aix-Marseille University (Aix-Marseille School of Economics), Marseille, France
| | - P Brouqui
- IHU Méditerranée Infection; URMITE; UM63; CNRS 7278; IRD 198; Inserm 1095, Aix Marseille Université, Marseille, France
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Initial antifungal strategy does not correlate with mortality in patients with candidemia. Eur J Clin Microbiol Infect Dis 2015; 35:187-93. [PMID: 26634352 DOI: 10.1007/s10096-015-2527-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 11/08/2015] [Indexed: 02/04/2023]
Abstract
The incidence of Candida bloodstream infections (BSIs) has increased over time, especially in medical wards. The objective of this study was to evaluate the impact of different antifungal treatment strategies on 30-day mortality in patients with Candida BSI not admitted to intensive care units (ICUs) at disease onset. This prospective, monocentric, cohort study was conducted at an 1100-bed university hospital in Rome, Italy, where an infectious disease consultation team was implemented. All cases of Candida BSIs observed in adult patients from November 2012 to April 2014 were included. Patients were grouped according to the initial antifungal strategy: fluconazole, echinocandin, or liposomal amphotericin B. Cox regression analysis was used to identify risk factors significantly associated with 15-day and 30-day mortality. During the study period, 130 patients with candidemia were observed (58 % with C. albicans, 7 % with C. glabrata, and 23 % with C. parapsilosis). The first antifungal drug was fluconazole for 40 % of patients, echinocandin for 57.0 %, and liposomal amphotericin B for 4 %. During follow-up, 33 % of patients died. The cumulative mortality 30 days after the candidemia episode was 30.8 % and was similar among groups. In the Cox regression analysis, clinical presentation was the only independent factor associated with 15-day mortality, and Acute Physiology and Chronic Health Evaluation (APACHE) II score and clinical presentation were the independent factors associated with 30-day mortality. No differences in 15-day and 30-day mortality were observed between patients with and without C. albicans candidemia. In patients with candidemia admitted to medical or surgical wards, clinical severity but not the initial antifungal strategy were significantly correlated with mortality.
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