1
|
Pettit NN, Nguyen CT, Lew AK, Bhagat PH, Nelson A, Olson G, Ridgway JP, Pho MT, Pagkas-Bather J. Reducing the use of empiric antibiotic therapy in COVID-19 on hospital admission. BMC Infect Dis 2021; 21:516. [PMID: 34078301 PMCID: PMC8170434 DOI: 10.1186/s12879-021-06219-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 05/21/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Empiric antibiotics for community acquired bacterial pneumonia (CABP) are often prescribed to patients with COVID-19, despite a low reported incidence of co-infections. Stewardship interventions targeted at facilitating appropriate antibiotic prescribing for CABP among COVID-19 patients are needed. We developed a guideline for antibiotic initiation and discontinuation for CABP in COVID-19 patients. The purpose of this study was to assess the impact of this intervention on the duration of empiric CABP antibiotic therapy among patients with COVID-19. METHODS This was a single-center, retrospective, quasi-experimental study of adult patients admitted between 3/1/2020 to 4/25/2020 with COVID-19 pneumonia, who were initiated on empiric CABP antibiotics. Patients were excluded if they were initiated on antibiotics > 48 h following admission or if another source of infection was identified. The primary outcome was the duration of antibiotic therapy (DOT) prior to the guideline (March 1 to March27, 2020) and after guideline implementation (March 28 to April 25, 2020). We also evaluated the clinical outcomes (mortality, readmissions, length of stay) among those initiated on empiric CABP antibiotics. RESULTS A total of 506 patients with COVID-19 were evaluated, 102 pre-intervention and 404 post-intervention. Prior to the intervention, 74.5% (n = 76) of patients with COVID-19 received empiric antibiotics compared to only 42% of patients post-intervention (n = 170), p < 0.001. The median DOT in the post-intervention group was 1.3 days shorter (p < 0.001) than the pre-intervention group, and antibiotics directed at atypical bacteria DOT was reduced by 2.8 days (p < 0.001). More patients in the post-intervention group were initiated on antibiotics based on criteria consistent with our guideline (68% versus 87%, p = 0.001). There were no differences between groups in terms of clinical outcomes. CONCLUSION Following the implementation of a guideline outlining recommendations for initiating and discontinuing antibiotics for CABP among COVID-19 inpatients, we observed a reduction in antibiotic prescribing and DOT. The guideline also resulted in a significant increase in the rate of guideline-congruent empiric antibiotic initiation.
Collapse
Affiliation(s)
- Natasha N Pettit
- Department of Pharmacy, The University of Chicago Medicine, 5841 S Maryland Ave, Chicago, IL, 60637, USA.
| | - Cynthia T Nguyen
- Department of Pharmacy, The University of Chicago Medicine, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Alison K Lew
- Department of Pharmacy, The University of Chicago Medicine, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Palak H Bhagat
- Department of Pharmacy, The University of Chicago Medicine, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Allison Nelson
- Department of Pharmacy, The University of Chicago Medicine, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Gregory Olson
- Department of Medicine, Section of Infectious Diseases and Global Health, The University of Chicago Medicine, Chicago, IL, USA
| | - Jessica P Ridgway
- Department of Medicine, Section of Infectious Diseases and Global Health, The University of Chicago Medicine, Chicago, IL, USA
| | - Mai T Pho
- Department of Medicine, Section of Infectious Diseases and Global Health, The University of Chicago Medicine, Chicago, IL, USA
| | - Jade Pagkas-Bather
- Department of Medicine, Section of Infectious Diseases and Global Health, The University of Chicago Medicine, Chicago, IL, USA
| |
Collapse
|
2
|
Feldman C, Richards G. Appropriate antibiotic management of bacterial lower respiratory tract infections. F1000Res 2018; 7:F1000 Faculty Rev-1121. [PMID: 30079235 PMCID: PMC6058472 DOI: 10.12688/f1000research.14226.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2018] [Indexed: 01/05/2023] Open
Abstract
Lower respiratory tract infections are the leading cause of infectious disease deaths worldwide and are the fifth leading cause of death overall. This is despite conditions such as pneumococcal infections and influenza being largely preventable with the use of appropriate vaccines. The mainstay of treatment for the most important bacterial lower respiratory tract infections, namely acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and community-acquired pneumonia (CAP), is the use of antibiotics. Yet despite a number of recent publications, including clinical studies as well as several systematic literature reviews and meta-analyses, there is considerable ongoing controversy as to what the most appropriate antibiotics are for the empiric therapy of CAP in the different settings (outpatient, inpatient, and intensive care unit). Furthermore, in the case of AECOPD, there is a need for consideration of which of these exacerbations actually need antibiotic treatment. This article describes these issues and makes suggestions for appropriately managing these conditions, in the setting of the need for antimicrobial stewardship initiatives designed to slow current emerging rates of antibiotic resistance, while improving patient outcomes.
Collapse
Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | - Guy Richards
- Division of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital, and Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| |
Collapse
|
3
|
Foolad F, Nagel JL, Eschenauer G, Patel TS, Nguyen CT. Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management. J Antimicrob Chemother 2018; 72:3232-3244. [PMID: 29177489 DOI: 10.1093/jac/dkx266] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Although new antimicrobial stewardship programmes (ASPs) often begin by targeting the reduction of antimicrobial use, an increasing focus of ASPs is to improve the management of specific infectious diseases. Disease-based antimicrobial stewardship emphasizes improving patient outcomes by optimizing antimicrobial use and increasing compliance with performance measures. Directing efforts towards the comprehensive management of specific infections allows ASPs to promote the shift in healthcare towards improving quality, safety and patient outcome metrics for specific diseases. This review evaluates published active and passive disease-based antimicrobial stewardship interventions and their impact on antimicrobial use and associated patient outcomes for patients with pneumonia, acute bacterial skin and skin structure infections, bloodstream infections, urinary tract infections, asymptomatic bacteriuria, Clostridium difficile infection and intra-abdominal infections. Current literature suggests that disease-based antimicrobial stewardship effects on medical management and patient outcomes vary based on infectious disease syndrome, resource availability and intervention type.
Collapse
Affiliation(s)
- Farnaz Foolad
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Jerod L Nagel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Gregory Eschenauer
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA.,College of Pharmacy, University of Michigan, 428 Church St., Ann Arbor, MI 48109, USA
| | - Twisha S Patel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Cynthia T Nguyen
- Department of Pharmacy, University of Chicago Medicine, 5841 S. Maryland Ave. MC0010, Chicago, IL 60637, USA
| |
Collapse
|
4
|
Foolad F, Huang AM, Nguyen CT, Colyer L, Lim M, Grieger J, Li J, Revolinski S, Mack M, Gandhi T, Wainaina JN, Eschenauer G, Patel TS, Marshall VD, Nagel J. A multicentre stewardship initiative to decrease excessive duration of antibiotic therapy for the treatment of community-acquired pneumonia. J Antimicrob Chemother 2018; 73:1402-1407. [DOI: 10.1093/jac/dky021] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/05/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
- Farnaz Foolad
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Angela M Huang
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Cynthia T Nguyen
- Department of Pharmacy, University of Chicago Medicine, Chicago, IL, USA
| | - Lindsay Colyer
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Megan Lim
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Jessica Grieger
- Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA, USA
| | - Julius Li
- Department of Pharmacy, Ochsner Medical Center, New Orleans, LA, USA
| | - Sara Revolinski
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
- Medical College of Wisconsin School of Pharmacy, Milwaukee, WI, USA
| | - Megan Mack
- Division of Hospital Medicine, Michigan Medicine, Ann Arbor, MI, USA
| | - Tejal Gandhi
- Division of Infectious Diseases, Michigan Medicine, Ann Arbor, MI, USA
| | - J Njeri Wainaina
- Section of Perioperative Medicine and Division of Infectious Diseases, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Gregory Eschenauer
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Twisha S Patel
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Vincent D Marshall
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Jerod Nagel
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
5
|
Marcos PJ, Restrepo MI, González-Barcala FJ, Soni NJ, Vidal I, Sanjuàn P, Llinares D, Ferreira-Gonzalez L, Rábade C, Otero-González I, Marcos P, Verea-Hernando H. Discordance of physician clinical judgment vs. pneumonia severity index (PSI) score to admit patients with low risk community-acquired pneumonia: a prospective multicenter study. J Thorac Dis 2017; 9:1538-1546. [PMID: 28740667 DOI: 10.21037/jtd.2017.05.44] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The relationship between clinical judgment and the pneumonia severity index (PSI) score in deciding the site of care for patients with community-acquired pneumonia (CAP) has not been well investigated. The objective of the study was to determine the clinical factors that influence decision-making to hospitalize low-risk patients (PSI ≤2) with CAP. METHODS An observational, prospective, multicenter study of consecutive CAP patients was performed at five hospitals in Spain. Patients admitted with CAP and a PSI ≤2 were identified. Admitting physicians completed a patient-specific survey to identify the clinical factors influencing the decision to admit a patient. The reason for admission was categorized into 1 of 6 categories. We also assessed whether the reason for admission was associated with poorer clinical outcomes [intensive care unit (ICU) admission, 30-day mortality or readmission]. RESULTS One hundred and fifty-five hospitalized patients were enrolled. Two or more reasons for admission were seen in 94 patients (60.6%), including abnormal clinical test results (60%), signs of clinical deterioration (43.2%), comorbid conditions (28.4%), psychosocial factors (28.4%), suspected H1N1 pneumonia (20.6%), and recent visit to the emergency department (ED) in the past 2 weeks (7.7%). Signs of clinical deterioration and abnormal clinical test results were associated with poorer clinical outcomes (P<0.005). CONCLUSIONS Low-risk patients with CAP and a PSI ≤2 are admitted to the hospital for multiple reasons. Abnormal clinical test results and signs of clinical deterioration are two specific reasons for admission that are associated with poorer clinical outcomes in low risk CAP patients.
Collapse
Affiliation(s)
- Pedro J Marcos
- Servicio de Neumología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC), Universidade da Coruña (UDC), A Coruña, Spain
| | - Marcos I Restrepo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, South Texas Veterans Health Care System, Audie L. Murphy VA Hospital, and University of Texas Health Science Center, San Antonio, Texas, USA
| | | | - Nilam J Soni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, South Texas Veterans Health Care System, Audie L. Murphy VA Hospital, and University of Texas Health Science Center, San Antonio, Texas, USA
| | - Iria Vidal
- Servicio de Neumología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC), Universidade da Coruña (UDC), A Coruña, Spain
| | - Pilar Sanjuàn
- Servicio de Neumología, Hospital Universitario Lucus Augusti, Lugo, Spain
| | - Diego Llinares
- Servicio de Medicina Interna, Hospital Universitario de A Coruña, A Coruña, Spain
| | - Lucía Ferreira-Gonzalez
- Servicio de Medicina Interna, Hospital Arquitecto Marcide, Area Sanitaria de Ferrol, A Coruña, Spain
| | - Carlos Rábade
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Isabel Otero-González
- Servicio de Neumología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC), Universidade da Coruña (UDC), A Coruña, Spain
| | - Pedro Marcos
- Servicio de Neumología, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Héctor Verea-Hernando
- Servicio de Neumología, Instituto de Investigación Biomédica de A Coruña (INIBIC), Complejo Hospitalario Universitario de A Coruña (CHUAC), Universidade da Coruña (UDC), A Coruña, Spain
| |
Collapse
|
6
|
Bohan JG, Hunt L, Madaras-Kelly K. Antimicrobial Stewardship Guidelines: Syndrome-Specific Strategies. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2017. [DOI: 10.1007/s40506-017-0107-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
7
|
Viasus D, Vecino-Moreno M, De La Hoz JM, Carratalà J. Antibiotic stewardship in community-acquired pneumonia. Expert Rev Anti Infect Ther 2016; 15:351-359. [PMID: 28002979 DOI: 10.1080/14787210.2017.1274232] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Community-acquired pneumonia (CAP) continues to be associated with significant mortality and morbidity. As with other infectious diseases, in recent years there has been a marked increase in resistance to the antibiotics commonly used against the pathogens that cause CAP. Antimicrobial stewardship denotes coordinated interventions to improve and measure the appropriate use of antibiotics by encouraging the selection of optimal drug regimens. Areas covered: Several elements can be applied to antibiotic stewardship strategies for CAP in order to maintain or improve patient outcomes. In this regard, antibiotic de-escalation, duration of antibiotic treatment, adherence to CAP guidelines recommendations about empirical treatment, and switching from intravenous to oral antibiotic therapy may each be relevant in this context. Antimicrobial stewardship strategies, such as prospective audit with intervention and feedback, clinical pathways, and dedicated multidisciplinary teams, that have included some of these elements have demonstrated improvements in antimicrobial use for CAP without negatively affecting clinical outcomes. Expert commentary: Although there are a limited number of randomized clinical studies addressing antimicrobial stewardship strategies in CAP, there is evidence that antibiotic stewardship initiatives can be securely applied, providing benefits to both healthcare systems and patients.
Collapse
Affiliation(s)
- Diego Viasus
- a Faculty of Medicine, Health Sciences Division , Hospital Universidad del Norte and Universidad del Norte , Barranquilla , Colombia
| | - Milly Vecino-Moreno
- a Faculty of Medicine, Health Sciences Division , Hospital Universidad del Norte and Universidad del Norte , Barranquilla , Colombia
| | - Juan M De La Hoz
- a Faculty of Medicine, Health Sciences Division , Hospital Universidad del Norte and Universidad del Norte , Barranquilla , Colombia
| | - Jordi Carratalà
- b Infectious Disease Department, Hospital Universitari de Bellvitge, IDIBELL, Spanish Network for Research in Infectious Diseases (REIPI), and Clinical Science Department, Faculty of Medicine , University of Barcelona , Barcelona , Spain
| |
Collapse
|
8
|
Pneumonies aiguës communautaires (PAC) de l’adulte : focus sur les PAC virales. REVUE DES MALADIES RESPIRATOIRES ACTUALITÉS 2016; 8:263-267. [PMID: 32288906 PMCID: PMC7140245 DOI: 10.1016/s1877-1203(16)30108-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
|