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Ghahramani A, Naghadian Moghaddam MM, Kianparsa J, Ahmadi MH. Overall status of carbapenem resistance among clinical isolates of Acinetobacter baumannii: a systematic review and meta-analysis. J Antimicrob Chemother 2024; 79:3264-3280. [PMID: 39392464 DOI: 10.1093/jac/dkae358] [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: 02/17/2024] [Accepted: 09/19/2024] [Indexed: 10/12/2024] Open
Abstract
BACKGROUND Resistance to carbapenems, the first-line treatment for infections caused by Acinetobacter baumannii, is increasing throughout the world. The aim of the present study was to determine the global status of resistance to carbapenems in clinical isolates of this pathogen, worldwide. METHODS Electronic databases were searched using the appropriate keywords, including: 'Acinetobacter' 'baumannii', 'Acinetobacter baumannii' and 'A. baumannii', 'resistance', 'antibiotic resistance', 'antibiotic susceptibility', 'antimicrobial resistance', 'antimicrobial susceptibility', 'carbapenem', 'carbapenems', 'imipenem', 'meropenem' and 'doripenem'. Finally, following some exclusions, 177 studies from various countries were included in this study. The data were then subjected to a meta-analysis. RESULTS The average resistance rate of A. baumannii to imipenem, meropenem and doripenem was 44.7%, 59.4% and 72.7%, respectively. A high level of heterogeneity (I2 > 50%, P value < 0.05) was detected in the studies representing resistance to imipenem, meropenem and doripenem in A. baumannii isolates. Begg's and Egger's tests did not indicate publication bias (P value > 0.05). CONCLUSIONS The findings of the current study indicate that the overall resistance to carbapenems in clinical isolates of A. baumannii is relatively high and prevalent throughout the world. Moreover, time trend analysis showed that the resistance has increased from the year 2000 to 2023. This emphasizes the importance of conducting routine antimicrobial susceptibility testing before selecting a course of treatment, as well as monitoring and controlling antibiotic resistance patterns in A. baumannii strains, and seeking novel treatment options to lessen the emergence and spread of resistant strains and to reduce the treatment failure.
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Affiliation(s)
- Ali Ghahramani
- Student Research Committee, School of Medicine, Shahed University, Tehran, Iran
| | | | - Joben Kianparsa
- Student Research Committee, School of Medicine, Shahed University, Tehran, Iran
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Shajiei A, Berends MS, Luz CF, van Oers JA, Harmsen HJM, Vos P, Klont R, Loef BG, Reidinga AC, Bormans-Russell L, Linsen K, Dormans T, Otten M, van der Bij A, Beishuizen A, de Lange DW, de Jong E, Nijsten MW. Impact of reduced antibiotic treatment duration on antimicrobial resistance in critically ill patients in the randomized controlled SAPS-trial. Front Med (Lausanne) 2023; 10:1080007. [PMID: 36817782 PMCID: PMC9932263 DOI: 10.3389/fmed.2023.1080007] [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: 10/25/2022] [Accepted: 01/09/2023] [Indexed: 02/05/2023] Open
Abstract
Background In the previously reported SAPS trial (https://clinicaltrials.gov/ct2/show/NCT01139489), procalcitonin-guidance safely reduced the duration of antibiotic treatment in critically ill patients. We assessed the impact of shorter antibiotic treatment on antimicrobial resistance development in SAPS patients. Materials and methods Cultures were assessed for the presence of multi-drug resistant (MDR) or highly resistant organisms (HRMO) and compared between PCT-guided and control patients. Baseline isolates from 30 days before to 5 days after randomization were compared with those from 5 to 30 days post-randomization. The primary endpoint was the incidence of new MDR/HRMO positive patients. Results In total, 8,113 cultures with 96,515 antibiotic test results were evaluated for 439 and 482 patients randomized to the PCT and control groups, respectively. Disease severity at admission was similar for both groups. Median (IQR) durations of the first course of antibiotics were 6 days (4-10) and 7 days (5-11), respectively (p = 0.0001). Antibiotic-free days were 7 days (IQR 0-14) and 6 days (0-13; p = 0.05). Of all isolates assessed, 13% were MDR/HRMO positive and at baseline 186 (20%) patients were MDR/HMRO-positive. The incidence of new MDR/HRMO was 39 (8.9%) and 45 (9.3%) in PCT and control patients, respectively (p = 0.82). The time courses for MDR/HRMO development were also similar for both groups (p = 0.33). Conclusions In the 921 randomized patients studied, the small but statistically significant reduction in antibiotic treatment in the PCT-group did not translate into a detectable change in antimicrobial resistance. Studies with larger differences in antibiotic treatment duration, larger study populations or populations with higher MDR/HRMO incidences might detect such differences.
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Affiliation(s)
- Arezoo Shajiei
- Department of Critical Care, University Medical Center Groningen, Groningen, Netherlands,Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands
| | - Matthijs S. Berends
- Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands,Department of Medical Epidemiology, Certe Foundation, Groningen, Netherlands
| | - Christian F. Luz
- Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands
| | - Jos A. van Oers
- Department of Intensive Care, Elisabeth-Tweesteden Ziekenhuis, Tilburg, Netherlands
| | - Hermie J. M. Harmsen
- Department of Medical Microbiology, University Medical Center Groningen, Groningen, Netherlands
| | - Piet Vos
- Department of Intensive Care, Elisabeth-Tweesteden Ziekenhuis, Tilburg, Netherlands
| | - Rob Klont
- Laboratorium Microbiologie Twente Achterhoek, Hengelo, Netherlands
| | - Bert G. Loef
- Department of Intensive Care, Martini Hospital Groningen, Groningen, Netherlands
| | - Auke C. Reidinga
- Department of Intensive Care, Martini Hospital Groningen, Groningen, Netherlands
| | | | - Kitty Linsen
- Department of Intensive Care, Zuyderland Medical Center, Heerlen, Netherlands
| | - Tom Dormans
- Department of Intensive Care, Zuyderland Medical Center, Heerlen, Netherlands
| | - Martine Otten
- Department of Intensive Care, Diakonessenhuis Utrecht, Utrecht, Netherlands
| | - Akke van der Bij
- Department of Microbiology and Immunology, Diakonessenhuis Utrecht, Utrecht, Netherlands
| | | | - Dylan W. de Lange
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Evelien de Jong
- Department of Intensive Care, Beverwijk Hospital, Beverwijk, Netherlands,Department of Intensive Care, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Maarten W. Nijsten
- Department of Critical Care, University Medical Center Groningen, Groningen, Netherlands,*Correspondence: Maarten W. Nijsten ✉
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Garnacho-Montero J, Amaya-Villar R. The problem of multi-resistance in gram-negative bacilli in intensive care units: Treatment and prevention strategies. Med Intensiva 2022; 46:326-335. [PMID: 35545496 DOI: 10.1016/j.medine.2022.04.006] [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] [Received: 12/03/2021] [Accepted: 12/04/2021] [Indexed: 06/15/2023]
Abstract
The rise of infections caused by multi-resistant gram-negative bacilli (MR-GNB), which includes carbapenems, represents one of the major current challenges worldwide. These MR-GNB include extended spectrum β-lactamase-producing Enterobacterales, derepressed AmpC-producing or carbapenemase-producing Enterobacterales as well as non-fermenting Gram-negative bacilli such as Pseudomonas aeruginosa or Acinetobacter baumannii. P. aeruginosa predominantly exhibits other resistance mechanisms different to β-lactamases such as expulsion pumps or loss of porins. A. baumannii frequently presents several of these resistance mechanisms. Mortality is high especially if empirical treatment is inadequate. In this review, treatment strategies are revised, describing the tools available to identify patients in whom empirical antibiotic treatment would be justified to cover MR-GNB, the importance of optimizing the administration of these antibiotics, as well as prevention strategies to avoid its spread from patients colonized or infected by a MR-GNB.
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Affiliation(s)
- J Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain.
| | - R Amaya-Villar
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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Goggs R, Robbins SN, LaLonde‐Paul DM, Menard JM. Serial analysis of blood biomarker concentrations in dogs with pneumonia, septic peritonitis, and pyometra. J Vet Intern Med 2022; 36:549-564. [PMID: 35103342 PMCID: PMC8965213 DOI: 10.1111/jvim.16374] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/18/2022] [Accepted: 01/20/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Prolonged antimicrobial drug (AMD) treatment is associated with antimicrobial resistance development. Biomarker measurement may aid treatment decision-making. OBJECTIVES Investigate temporal changes in blood biomarker concentrations in dogs undergoing treatment for pulmonary and intra-abdominal infections; compare time to biomarker concentration normalization with duration of clinician-directed AMD treatment. ANIMALS Forty-two client-owned dogs with pneumonia (n = 22), septic peritonitis (n = 10), or pyometra (n = 10). METHODS Plasma concentrations of C-reactive protein (CRP), serum amyloid A (SAA), haptoglobin, procalcitonin, nucleosomes, cell-free DNA (cfDNA), high-mobility group box-1 (HMGB1), CC-motif chemokine ligand-2 (CCL2), CXC-motif chemokine ligand-8 (CXCL8), and keratinocyte chemoattractant-like (KC-Like) were quantitated in samples collected on days 1, 3, 7, 14, 28, and 60. Treatment was directed by clinicians blinded to biomarker concentrations. RESULTS Concentrations of CCL2, CRP, and KC-Like were maximal on D1, concentrations of SAA, cfDNA, HMGB1, and nucleosomes were maximal on D3 and haptoglobin concentrations were maximal on D7. These maximal concentrations were significantly different from those on D60. Concentrations of CRP and SAA decreased by 80% from peak and into respective reference intervals before AMDs were discontinued. For CRP, the median (interquartile range [IQR]) times to 20% peak and normal were 7 (6-9) and 7 (6-12) days, respectively, and for SAA they were 4 (4, 5) and 6 (5-8) days, respectively, compared to a median (IQR) duration of AMD prescribing of 16 (12-23) days (all P < .0001). CONCLUSIONS AND CLINICAL IMPORTANCE Biomarker concentrations normalized within 7 to 14 days. Serial measurements of CRP and SAA might aid identification of disease resolution and could help guide AMD prescription decision-making.
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Affiliation(s)
- Robert Goggs
- Department of Clinical Sciences, College of Veterinary MedicineCornell UniversityIthacaNew YorkUSA
| | - Sarah N. Robbins
- Department of Clinical Sciences, College of Veterinary MedicineCornell UniversityIthacaNew YorkUSA
| | - Denise M. LaLonde‐Paul
- Department of Clinical Sciences, College of Veterinary MedicineCornell UniversityIthacaNew YorkUSA
| | - Julie M. Menard
- Department of Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary MedicineUniversity of CalgaryCalgaryAlbertaCanada
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Garnacho-Montero J, Amaya-Villar R. El problema de la multi-resistencia en bacilos gram-negativos en las unidades de cuidados intensivos: estrategias de tratamiento y prevención. Med Intensiva 2022. [DOI: 10.1016/j.medin.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Smith DR, Temime L, Opatowski L. Microbiome-pathogen interactions drive epidemiological dynamics of antibiotic resistance: A modeling study applied to nosocomial pathogen control. eLife 2021; 10:68764. [PMID: 34517942 PMCID: PMC8560094 DOI: 10.7554/elife.68764] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 08/31/2021] [Indexed: 12/16/2022] Open
Abstract
The human microbiome can protect against colonization with pathogenic antibiotic-resistant bacteria (ARB), but its impacts on the spread of antibiotic resistance are poorly understood. We propose a mathematical modeling framework for ARB epidemiology formalizing within-host ARB-microbiome competition, and impacts of antibiotic consumption on microbiome function. Applied to the healthcare setting, we demonstrate a trade-off whereby antibiotics simultaneously clear bacterial pathogens and increase host susceptibility to their colonization, and compare this framework with a traditional strain-based approach. At the population level, microbiome interactions drive ARB incidence, but not resistance rates, reflecting distinct epidemiological relevance of different forces of competition. Simulating a range of public health interventions (contact precautions, antibiotic stewardship, microbiome recovery therapy) and pathogens (Clostridioides difficile, methicillin-resistant Staphylococcus aureus, multidrug-resistant Enterobacteriaceae) highlights how species-specific within-host ecological interactions drive intervention efficacy. We find limited impact of contact precautions for Enterobacteriaceae prevention, and a promising role for microbiome-targeted interventions to limit ARB spread.
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Affiliation(s)
- David Rm Smith
- Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), Paris, France.,Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective evasion and pharmacoepidemiology team, Montigny-Le-Bretonneux, France.,Modélisation, épidémiologie et surveillance des risques sanitaires (MESuRS), Conservatoire national des arts et métiers, Paris, France
| | - Laura Temime
- Modélisation, épidémiologie et surveillance des risques sanitaires (MESuRS), Conservatoire national des arts et métiers, Paris, France.,PACRI unit, Institut Pasteur, Conservatoire national des arts et métiers, Paris, France
| | - Lulla Opatowski
- Institut Pasteur, Epidemiology and Modelling of Antibiotic Evasion (EMAE), Paris, France.,Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective evasion and pharmacoepidemiology team, Montigny-Le-Bretonneux, France
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Carrara E, Conti M, Meschiari M, Mussini C. The role of antimicrobial stewardship in preventing KPC-producing Klebsiella pneumoniae. J Antimicrob Chemother 2021; 76:i12-i18. [PMID: 33534879 DOI: 10.1093/jac/dkaa493] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Antimicrobial stewardship programmes are widely considered to be a core component of the response to the antimicrobial resistance threat. However, a positive impact of these interventions in terms of microbiological outcomes remains difficult to demonstrate, especially when focusing on specific resistant phenotypes. The first part of this review aims to explore the complex relationship between antibiotic exposure and resistance development in KPC-producing Klebsiella pneumoniae. In the second part we aim to summarize published examples of antimicrobial stewardship interventions intended to impact on the epidemiology of KPC-producing K. pneumoniae. For this purpose, a literature search was performed and seven studies were included in the review. Both restrictive and non-restrictive interventions were associated with an overall reduction in antibiotic consumption, and a decrease in carbapenem resistance rates was observed in five studies. The overall quality of the evidence was low, mainly due to the poor reporting of microbiological outcomes, lack of a control group and suboptimal study design. Although the link between antibiotic use and resistance development is supported by strong evidence, demonstrating the impact of antimicrobial stewardship interventions on microbiological outcomes remains difficult. Studies with adequate design and appropriate outcome measures are needed to further promote antimicrobial stewardship and elucidate which interventions are more successful for controlling the spread of KPC-producing K. pneumoniae.
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Affiliation(s)
- Elena Carrara
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Michela Conti
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Marianna Meschiari
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Cristina Mussini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
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Pereira LB, Zanetti MOB, Sponchiado LP, Rodrigues JPV, Campos MSDA, Varallo FR, Pereira LRL. Antibiotic use in Brazilian hospitals in the 21st century: a systematic review. Rev Soc Bras Med Trop 2021; 54:e08612020. [PMID: 34133621 PMCID: PMC8282254 DOI: 10.1590/0037-8682-0861-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/29/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION This systematic review aimed to assess antibiotic use in Brazilian hospitals in the 21st century, as well as to understand the different drug utilization metrics adopted to assess the consumption of these drugs. METHODS We systematically reviewed five databases (MEDLINE [Medical Literature Analysis and Retrieval System Online], CENTRAL [The Cochrane Central Register of Controlled Trials], EMBASE® [Excerpta Medica Database], Scopus [Elsevier's abstract and citation database], and LILACS [Literatura Latino-Americana e do Caribe em Ciências da Saúde]) for observational or experimental studies that assessed antibiotic utilization in Brazilian hospitals. The main outcomes were the drug utilization metrics and the consumption of antibiotics. RESULTS We included 23 studies, of which 43.5% were carried out in adult and pediatric care units, 39.1% in adult units, and 17.4% in pediatric units. Regarding the complexity of healthcare, 26.1% of the studies were performed in intensive care units. Two drug utilization metrics were used in these studies: the defined daily dose (DDD) and the percentage of antibiotic prescriptions. The most commonly used antibiotic classes were third-generation cephalosporins, carbapenems, fluoroquinolones, and combinations of penicillins when the DDD was the adopted drug utilization metric. CONCLUSIONS Although few studies have been conducted, existing data indicate a high use of broad-spectrum antibiotics. We found that the lack of standardized antibiotic utilization metrics impaired the mapping of drug consumption at the national level.
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Affiliation(s)
- Lucas Borges Pereira
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Departamento de Ciências Farmacêuticas, Ribeirão Preto, SP, Brasil
| | - Maria Olívia Barboza Zanetti
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Departamento de Ciências Farmacêuticas, Ribeirão Preto, SP, Brasil
| | - Larissa Pombeiro Sponchiado
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Departamento de Ciências Farmacêuticas, Ribeirão Preto, SP, Brasil
| | - João Paulo Vilela Rodrigues
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Departamento de Ciências Farmacêuticas, Ribeirão Preto, SP, Brasil
| | - Marília Silveira de Almeida Campos
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Departamento de Ciências Farmacêuticas, Ribeirão Preto, SP, Brasil
| | - Fabiana Rossi Varallo
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Departamento de Ciências Farmacêuticas, Ribeirão Preto, SP, Brasil
| | - Leonardo Régis Leira Pereira
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Departamento de Ciências Farmacêuticas, Ribeirão Preto, SP, Brasil
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9
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Gutiérrez-Pizarraya A, León-García MDC, De Juan-Idígoras R, Garnacho-Montero J. Clinical impact of procalcitonin-based algorithms for duration of antibiotic treatment in critically ill adult patients with sepsis: a meta-analysis of randomized clinical trials. Expert Rev Anti Infect Ther 2021; 20:103-112. [PMID: 34027785 DOI: 10.1080/14787210.2021.1932462] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background: Our objective was to assess the impact on mortality, antibacterial therapy duration, and length of stay of using PCT to guide antibiotic cessation in critically ill patients with sepsis or septic shock.Research design and Methods: A systematic literature search was performed in PubMed, Embase, ISI Web of Knowledge, BioMed Central, ScienceDirect and the Cochrane Central Register of Controlled Trials, of clinical trials published in English before December 31, 2019. Eligible studies should be carried out in adults at ICU with sepsis, comparing the PCT-guided antimicrobial therapy with standard of care. A random effects model was used.Results: Twelve studies were eligible with a total of 4292 patients included. The combined relative risk for 28-day mortality was 0.89 (95% CI: 0.79; 0.99), for the duration of antimicrobial therapy was -1.98 days (95% CI: -2.76, -1.21) and for ICU- length of stay was-1.21 days (95% CI: -4.16, 1.74).Conclusions: In critically ill adults with sepsis, a procalcitonin-guided strategy is associated with a significant shorter duration of antimicrobial therapy. This reduction was associated with a significant decrease in mortality although the length of ICU stay was not affected.
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Affiliation(s)
| | | | - Reyes De Juan-Idígoras
- Anesthesiology and Reanimation Clinical Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - J Garnacho-Montero
- Intensive Care Clinical Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
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Faraone A, Poggi A, Cappugi C, Tofani L, Riccobono E, Giani T, Fortini A. Inappropriate use of carbapenems in an internal medicine ward: Impact of a carbapenem-focused antimicrobial stewardship program. Eur J Intern Med 2020; 78:50-57. [PMID: 32303455 DOI: 10.1016/j.ejim.2020.03.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 02/21/2020] [Accepted: 03/19/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE Carbapenem consumption is a major driver for selection and spread of carbapenem-resistant Enterobacterales (CRE). We assessed the impact of a carbapenem-focused multimodal antimicrobial stewardship program (ASP) in the internal medicine unit of a medium-size acute-care hospital. METHODS We compared the percentage of inappropriate carbapenem prescriptions and the proportion of carbapenem treated patients registered in a 12-month pre-intervention and in a 24-month post-intervention period by using an interrupted time series analysis. The consumption of carbapenems, expressed in defined daily doses (DDD), was also assessed. As a secondary objective, the incidence of infections by carbapenem-resistant Klebsiella pneumoniae (CRKP) and the percentage of CRKP invasive isolates in the same time periods were compared. RESULTS After the ASP intervention, the mean monthly percentage of inappropriate carbapenem prescriptions dropped from 59% to 25%, and the mean monthly proportion of carbapenem treated patients decreased from 3% to 1%. The interrupted time series analysis confirmed a significant decrease in the percentage of inappropriate carbapenem prescriptions (-41.6%, p = 0.0262) and in the proportion of carbapenem treated patients (-2.1%, p < 0.0001). Carbapenem consumption decreased from 5.2 to 1.6 DDD x 100 patient-days. The incidence of CRKP infections remained unchanged (29.1 × 100,000 patient-days vs 28.9 × 100,000 patient-days, p = 0.9864) and the percentage of CRKP invasive isolates decreased, though not significantly, from 36.4% to 13.3% (p = 0.3478). CONCLUSIONS The implementation of a carbapenem-focused ASP was effective at limiting the inappropriate use of carbapenems and was associated with a significant decrease in carbapenem consumption. Such effects were sustained during a 24-month post-intervention period.
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Affiliation(s)
- Antonio Faraone
- Department of Internal Medicine, San Giovanni di Dio Hospital, Via di Torregalli 3, Florence, 50143, Italy.
| | | | - Chiara Cappugi
- Department of Internal Medicine, Florence Careggi University Hospital, Florence, Italy
| | - Lorenzo Tofani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Eleonora Riccobono
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Tommaso Giani
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alberto Fortini
- Department of Internal Medicine, San Giovanni di Dio Hospital, Via di Torregalli 3, Florence, 50143, Italy
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11
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Cipko K, Cuenca J, Wales E, Harris J, Bond S, Newton P, Miyakis S. Implementation of an antimicrobial stewardship programme and reduction in carbapenemase-producing Enterobacterales in an Australian local health district. JAC Antimicrob Resist 2020; 2:dlaa041. [PMID: 34223004 PMCID: PMC8210183 DOI: 10.1093/jacamr/dlaa041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 03/09/2020] [Accepted: 04/05/2020] [Indexed: 11/14/2022] Open
Abstract
Background Carbapenemase-producing Enterobacterales (CPE) are increasingly seen in Australian hospitals. Antimicrobial stewardship (AMS) interventions have been shown to reduce rates of carbapenem-resistant organisms; data on their effect on CPE rates are limited. Objectives To explore the effect of a multi-site computer-supported AMS programme on the rates of CPE in an Australian local health district. Methods All laboratory CPE isolates between 2008 and 2018 were identified. Microbiological and demographic data, CPE risk factors and outcomes were collected. Monthly carbapenem use was expressed as DDD per 1000 occupied bed days (OBD). Hand hygiene compliance rates among healthcare workers were analysed. A computer-supported AMS programme was implemented district-wide in 2012. Bivariate relationships were examined using Pearson's r and predictors of CPE isolates using time series linear regression. Results We identified 120 isolates from 110 patients. Numbers of CPE isolates and carbapenem use both showed a strong downward trend during the study period; the decreases were strongly correlated (r = 0.80, P = 0.006). The positive relationship between carbapenem use and CPE isolation was maintained while adjusting for time (b = 0.05, P < 0.001). Average yearly consumption of carbapenems fell by 20%, from 18.4 to 14.7 DDD/1000 OBD following implementation of the AMS programme. Hand hygiene compliance rates remained high throughout. Conclusions We demonstrated a reduction of CPE isolates in conjunction with reduced carbapenem use, longitudinally consolidated by a formal AMS programme. Prospective studies are needed to validate the effect of AMS on carbapenem resistance, especially in high-prevalence settings.
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Affiliation(s)
- Kimberly Cipko
- Department of Infectious Diseases, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Crown Street, Wollongong, New South Wales 2500, Australia.,Graduate School of Medicine, University of Wollongong, Northfields Avenue, Wollongong, New South Wales 2522, Australia
| | - Jose Cuenca
- Research Central, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Crown Street, Wollongong, New South Wales 2500, Australia
| | - Erica Wales
- Department of Pharmacy, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Crown Street, Wollongong, New South Wales 2500, Australia
| | - Joanna Harris
- Infection Management and Control Service, Illawarra Shoalhaven Local Health District, Crown Street, Wollongong, New South Wales 2500, Australia
| | - Stuart Bond
- Graduate School of Medicine, University of Wollongong, Northfields Avenue, Wollongong, New South Wales 2522, Australia.,Department of Pharmacy, Pinderfields Hospital, Mid Yorkshire Hospitals NHS Trust, Aberford Road, Wakefield WF1 4DG, UK
| | - Peter Newton
- Graduate School of Medicine, University of Wollongong, Northfields Avenue, Wollongong, New South Wales 2522, Australia.,NSW Health Pathology, Microbiology, Wollongong Hospital, Crown Street, Wollongong, New South Wales 2500, Australia
| | - Spiros Miyakis
- Department of Infectious Diseases, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Crown Street, Wollongong, New South Wales 2500, Australia.,Graduate School of Medicine, University of Wollongong, Northfields Avenue, Wollongong, New South Wales 2522, Australia
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Chu SM, Hsu JF, Lai MY, Huang HR, Chiang MC, Fu RH, Tsai MH. Risk Factors of Initial Inappropriate Antibiotic Therapy and the Impacts on Outcomes of Neonates with Gram-Negative Bacteremia. Antibiotics (Basel) 2020; 9:antibiotics9040203. [PMID: 32340241 PMCID: PMC7235779 DOI: 10.3390/antibiotics9040203] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/16/2020] [Accepted: 04/21/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Timely appropriate empirical antibiotic plays an important role in critically ill patients with gram-negative bacteremia. However, the relevant data and significant impacts have not been well studied in the neonatal intensive care unit (NICU). METHODS An 8-year (1 January 2007-31 December 2014) cohort study of all NICU patients with gram-negative bacteremia (GNB) in a tertiary-care medical center was performed. Inadequate empirical antibiotic therapy was defined when a patient did not receive any antimicrobial agent to which the causative microorganisms were susceptible within 24 h of blood culture sampling. Neonates with GNB treated with inadequate antibiotics were compared with those who received initial adequate antibiotics. RESULTS Among 376 episodes of Gram-negative bacteremia, 75 (19.9%) received inadequate empirical antibiotic therapy. The cause of inadequate treatment was mostly due to the pathogen resistance to prescribed antibiotics (88.0%). Bacteremia caused by Pseudomonas aeruginosa (Odds ratio [OR]: 20.8, P < 0.001) and extended spectrum β-lactamase (ESBL)-producing bacteria (OR: 18.4, P < 0.001) had the highest risk of inadequate treatment. Previous exposure with third generation cephalosporin was identified as the only independent risk factor (OR: 2.52, 95% CI: 1.18-5.37, P = 0.018). Empirically inadequately treated bacteremias were significantly more likely to have worse outcomes than those with adequate therapy, including a higher risk of major organ damage (20.0% versus 6.6%, P < 0.001) and infectious complications (25.3% versus 9.3%, P < 0.001), and overall mortality (22.7% versus 11.0%, P = 0.013). Conclusions: Inadequate empirical antibiotic therapy occurs in one-fifth of Gram-negative bacteremias in the NICU, and is associated with worse outcomes. Additional prospective studies are needed to elucidate the optimal timing and aggressive antibiotic regimen for neonates who are at risk of antibiotic-resistant Gram-negative bacteremia.
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Affiliation(s)
- Shih-Ming Chu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (S.-M.C.); (J.-F.H.); (M.-Y.L.); (H.-R.H.); (M.-C.C.); (R.-H.F.)
- Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Chiayi 613, Taiwan
| | - Jen-Fu Hsu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (S.-M.C.); (J.-F.H.); (M.-Y.L.); (H.-R.H.); (M.-C.C.); (R.-H.F.)
- Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Chiayi 613, Taiwan
| | - Mei-Yin Lai
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (S.-M.C.); (J.-F.H.); (M.-Y.L.); (H.-R.H.); (M.-C.C.); (R.-H.F.)
- Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Chiayi 613, Taiwan
| | - Hsuan-Rong Huang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (S.-M.C.); (J.-F.H.); (M.-Y.L.); (H.-R.H.); (M.-C.C.); (R.-H.F.)
- Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Chiayi 613, Taiwan
| | - Ming-Chou Chiang
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (S.-M.C.); (J.-F.H.); (M.-Y.L.); (H.-R.H.); (M.-C.C.); (R.-H.F.)
- Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Chiayi 613, Taiwan
| | - Ren-Huei Fu
- Division of Pediatric Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (S.-M.C.); (J.-F.H.); (M.-Y.L.); (H.-R.H.); (M.-C.C.); (R.-H.F.)
- Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Chiayi 613, Taiwan
| | - Ming-Horng Tsai
- Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Chiayi 613, Taiwan
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Yunlin 638, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Yunlin Chang Gung Memorial Hospital, 707, Gongye Rd, Sansheng, Mailiao Township, Yunlin 638, Taiwan
- Correspondence: ; Tel.: +886-5-691-5151 (ext. 2879); Fax: +886-5-691-3222
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Stocker H, Mehlhorn C, Jordan K, Eckholt L, Jefferys L, Arastéh K. Clinical and economic effects of an antimicrobial stewardship intervention in a surgical intensive care unit. Infection 2020; 48:509-519. [PMID: 32277409 DOI: 10.1007/s15010-020-01421-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To study the effects of an Antimicrobial Stewardship (AMS) programme designed as a once-weekly "Prospective Audit with Feedback and Intervention" in a surgical intensive care unit. METHODS Retrospective, pre-/post-observational comparison of antimicrobial drug use, patient safety, and cost of care. RESULTS During the 12-month AMS period the consumption of antimicrobials dropped by 18.3%. While the consumption of broad-spectrum antibiotics decreased by 17.4% the consumption of narrow spectrum penicillins increased by 89.9%, reaching 26.3% of the total antibiotic consumption. Treatment outcomes and rates of Clostridioides difficile infections before and during the programme were not significantly different. The reduction in antimicrobial costs of 46,393€ was offset by an expenditure of 8,047€, for both human resources and additional radiological procedures, resulting in a net saving of 38,346€. 92% of the antibiotic related savings were due to the reduced use of tigecycline and linezolid, and decreases in drug retail prices. CONCLUSIONS AMS programmes can both reduce the consumption of antimicrobials and modify their spectrum in intensive care without negatively affecting treatment outcomes. The resulting cost savings are negligible. The incentive to implement such programmes cannot, therefore, be immediate institutional cost savings, but should be rather the long-term goal of reducing antibiotic resistance, and its consequences, in terms of long-term health care costs.
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Affiliation(s)
- Hartmut Stocker
- Department of Infectious Diseases, Vivantes Auguste-Viktoria-Klinikum, Rubensstraße 125, 12157, Berlin, Germany. .,Department of Infectious Diseases, St. Joseph Krankenhaus, Wüsthoffstraße 15, 12101, Berlin, Germany.
| | - Cornelia Mehlhorn
- Department of Anaesthesiology and Intensive Care, Vivantes Auguste-Viktoria-Klinikum, Rubensstraße 125, 12157, Berlin, Germany
| | - Kati Jordan
- Department of Anaesthesiology and Intensive Care, Vivantes Auguste-Viktoria-Klinikum, Rubensstraße 125, 12157, Berlin, Germany
| | - Leila Eckholt
- Department of Anesthesiology and Intensive Care, Vivantes Klinikum Am Urban, Dieffenbachstraße 1, 10967, Berlin, Germany
| | - Laura Jefferys
- Department of Infectious Diseases, Vivantes Auguste-Viktoria-Klinikum, Rubensstraße 125, 12157, Berlin, Germany
| | - Keikawus Arastéh
- Department of Infectious Diseases, Vivantes Auguste-Viktoria-Klinikum, Rubensstraße 125, 12157, Berlin, Germany
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14
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Effect of antibiotic stewardship programs on reduction of antimicrobial resistance in China. Am J Infect Control 2020; 48:233-234. [PMID: 31839275 DOI: 10.1016/j.ajic.2019.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/14/2019] [Accepted: 11/14/2019] [Indexed: 11/23/2022]
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15
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Walker AS, Budgell E, Laskawiec-Szkonter M, Sivyer K, Wordsworth S, Quaddy J, Santillo M, Krusche A, Roope LSJ, Bright N, Mowbray F, Jones N, Hand K, Rahman N, Dobson M, Hedley E, Crook D, Sharland M, Roseveare C, Hobbs FDR, Butler C, Vaughan L, Hopkins S, Yardley L, Peto TEA, Llewelyn MJ, on behalf of the ARK trial team. Antibiotic Review Kit for Hospitals (ARK-Hospital): study protocol for a stepped-wedge cluster-randomised controlled trial. Trials 2019; 20:421. [PMID: 31296255 PMCID: PMC6625068 DOI: 10.1186/s13063-019-3497-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/05/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To ensure patients continue to get early access to antibiotics at admission, while also safely reducing antibiotic use in hospitals, one needs to target the continued need for antibiotics as more diagnostic information becomes available. UK Department of Health guidance promotes an initiative called 'Start Smart then Focus': early effective antibiotics followed by active 'review and revision' 24-72 h later. However in 2017, < 10% of antibiotic prescriptions were discontinued at review, despite studies suggesting that 20-30% of prescriptions could be stopped safely. METHODS/DESIGN Antibiotic Review Kit for Hospitals (ARK-Hospital) is a complex 'review and revise' behavioural intervention targeting healthcare professionals involved in antibiotic prescribing or administration in inpatients admitted to acute/general medicine (the largest consumers of non-prophylactic antibiotics in hospitals). The primary study objective is to evaluate whether ARK-Hospital can safely reduce the total antibiotic burden in acute/general medical inpatients by at least 15%. The primary hypotheses are therefore that the introduction of the behavioural intervention will be non-inferior in terms of 30-day mortality post-admission (relative margin 5%) for an acute/general medical inpatient, and superior in terms of defined daily doses of antibiotics per acute/general medical admission (co-primary outcomes). The unit of observation is a hospital organisation, a single hospital or group of hospitals organised with one executive board and governance framework (National Health Service trusts in England; health boards in Northern Ireland, Wales and Scotland). The study comprises a feasibility study in one organisation (phase I), an internal pilot trial in three organisations (phase II) and a cluster (organisation)-randomised stepped-wedge trial (phase III) targeting a minimum of 36 organisations in total. Randomisation will occur over 18 months from November 2017 with a further 12 months follow-up to assess sustainability. The behavioural intervention will be delivered to healthcare professionals involved in antibiotic prescribing or administration in adult inpatients admitted to acute/general medicine. Outcomes will be assessed in adult inpatients admitted to acute/general medicine, collected through routine electronic health records in all patients. DISCUSSION ARK-Hospital aims to provide a feasible, sustainable and generalisable mechanism for increasing antibiotic stopping in patients who no longer need to receive them at 'review and revise'. TRIAL REGISTRATION ISRCTN Current Controlled Trials, ISRCTN12674243 . Registered on 10 April 2017.
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Affiliation(s)
- Ann Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Eric Budgell
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Magda Laskawiec-Szkonter
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Katy Sivyer
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jack Quaddy
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Marta Santillo
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Adele Krusche
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Laurence S. J. Roope
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicole Bright
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Fiona Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Nicola Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kieran Hand
- University of Southampton, Southampton, UK
- University Hospital Southampton NHS Trust, Southampton, UK
| | - Najib Rahman
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Melissa Dobson
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Emma Hedley
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Derrick Crook
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - F. D. Richard Hobbs
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chris Butler
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Susan Hopkins
- Royal Free London NHS Foundation Trust, London, UK
- National Infection Service, Public Health England, London, UK
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, Clifton, UK
| | - Timothy E. A. Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - on behalf of the ARK trial team
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- University of Southampton, Southampton, UK
- University Hospital Southampton NHS Trust, Southampton, UK
- St George’s, University of London, London, UK
- Southern Health NHS Foundation Trust, Southampton, UK
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- The Nuffield Trust, London, UK
- Royal Free London NHS Foundation Trust, London, UK
- School of Psychological Science, University of Bristol, Clifton, UK
- National Infection Service, Public Health England, London, UK
- Brighton and Sussex Medical School, Brighton, UK
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16
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Hood G, Hand KS, Cramp E, Howard P, Hopkins S, Ashiru-Oredope D. Measuring Appropriate Antibiotic Prescribing in Acute Hospitals: Development of a National Audit Tool Through a Delphi Consensus. Antibiotics (Basel) 2019; 8:antibiotics8020049. [PMID: 31035663 PMCID: PMC6627925 DOI: 10.3390/antibiotics8020049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 11/16/2022] Open
Abstract
This study developed a patient-level audit tool to assess the appropriateness of antibiotic prescribing in acute National Health Service (NHS) hospitals in the UK. A modified Delphi process was used to evaluate variables identified from published literature that could be used to support an assessment of appropriateness of antibiotic use. At a national workshop, 22 infection experts reached a consensus to define appropriate prescribing and agree upon an initial draft audit tool. Following this, a national multidisciplinary panel of 19 infection experts, of whom only one was part of the workshop, was convened to evaluate and validate variables using questionnaires to confirm the relevance of each variable in assessing appropriate prescribing. The initial evidence synthesis of published literature identified 25 variables that could be used to support an assessment of appropriateness of antibiotic use. All the panel members reviewed the variables for the first round of the Delphi; the panel accepted 23 out of 25 variables. Following review by the project team, one of the two rejected variables was rephrased, and the second neutral variable was re-scored. The panel accepted both these variables in round two with a 68% response rate. Accepted variables were used to develop an audit tool to determine the extent of appropriateness of antibiotic prescribing at the individual patient level in acute NHS hospitals through infection expert consensus based on the results of a Delphi process.
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Affiliation(s)
| | - Kieran S Hand
- University Hospital Southampton NHS Foundation Trust and School of Health Sciences, University of Southampton, Southampton SO16 6YD, UK.
| | - Emma Cramp
- University Hospitals of Leicester NHS Trust, Leicester LE1 5WW, UK.
| | - Philip Howard
- Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds LS1 3EX, UK.
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17
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Harder T, Eckmanns T, Schmidt N, Kern W, Sin MA. Human resources estimates for antibiotic stewardship teams: evidence-based approaches for recommendations are needed. Clin Microbiol Infect 2018; 24:554-556. [DOI: 10.1016/j.cmi.2017.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 10/18/2022]
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18
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Teerawattanapong N, Kengkla K, Dilokthornsakul P, Saokaew S, Apisarnthanarak A, Chaiyakunapruk N. Prevention and Control of Multidrug-Resistant Gram-Negative Bacteria in Adult Intensive Care Units: A Systematic Review and Network Meta-analysis. Clin Infect Dis 2018; 64:S51-S60. [PMID: 28475791 DOI: 10.1093/cid/cix112] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background This study evaluated the relative efficacy of strategies for the prevention of multidrug-resistant gram-negative bacteria (MDR-GNB) in adult intensive care units (ICUs). Methods A systematic review and network meta-analysis was performed; searches of the Cochrane Library, PubMed, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) included all randomized controlled trials and observational studies conducted in adult patients hospitalized in ICUs and evaluating standard care (STD), antimicrobial stewardship program (ASP), environmental cleaning (ENV), decolonization methods (DCL), or source control (SCT), simultaneously. The primary outcomes were MDR-GNB acquisition, colonization, and infection; secondary outcome was ICU mortality. Results Of 3805 publications retrieved, 42 met inclusion criteria (5 randomized controlled trials and 37 observational studies), involving 62068 patients (median age, 58.8 years; median APACHE [Acute Physiology and Chronic Health Evaluation] II score, 18.9). The majority of studies reported extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae and MDR Acinetobacter baumannii. Compared with STD, a 4-component strategy composed of STD, ASP, ENV, and SCT was the most effective intervention (rate ratio [RR], 0.05 [95% confidence interval {CI}, .01-.38]). When ENV was added to STD+ASP or SCT was added to STD+ENV, there was a significant reduction in the acquisition of MDR A. baumannii (RR, 0.28 [95% CI, .18-.43] and 0.48 [95% CI, .35-.66], respectively). Strategies with ASP as a core component showed a statistically significant reduction the acquisition of ESBL-producing Enterobacteriaceae (RR, 0.28 [95% CI, .11-.69] for STD+ASP+ENV and 0.23 [95% CI, .07-.80] for STD+ASP+DCL). Conclusions A 4-component strategy was the most effective intervention to prevent MDR-GNB acquisition. As some strategies were differential for certain bacteria, our study highlighted the need for further evaluation of the most effective prevention strategies.
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Affiliation(s)
| | - Kirati Kengkla
- Center of Health Outcomes Research and Therapeutic Safety, School of Pharmaceutical Sciences, University of Phayao, and
| | - Piyameth Dilokthornsakul
- Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety, School of Pharmaceutical Sciences, University of Phayao, and.,Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor
| | - Anucha Apisarnthanarak
- Division of Infectious Diseases, Faculty of Medicine, Thammasat University Hospital, Pathumthani, Thailand
| | - Nathorn Chaiyakunapruk
- Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand.,School of Pharmacy, Monash University Malaysia, Selangor.,School of Pharmacy, University of Wisconsin- Madison ; and.,School of Population Health, University of Queensland, Brisbane, Australia
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van Loon K, Voor In 't Holt AF, Vos MC. A Systematic Review and Meta-analyses of the Clinical Epidemiology of Carbapenem-Resistant Enterobacteriaceae. Antimicrob Agents Chemother 2018; 62:e01730-17. [PMID: 29038269 PMCID: PMC5740327 DOI: 10.1128/aac.01730-17] [Citation(s) in RCA: 166] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/29/2017] [Indexed: 01/23/2023] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) are major health care-associated pathogens and responsible for hospital outbreaks worldwide. To prevent a further increase in CRE infections and to improve infection prevention strategies, it is important to summarize the current knowledge about CRE infection prevention in hospital settings. This systematic review aimed to identify risk factors for CRE acquisition among hospitalized patients. In addition, we summarized the environmental sources/reservoirs and the most successful infection prevention strategies related to CRE. A total of 3,983 potentially relevant articles were identified and screened. Finally, we included 162 studies in the systematic review, of which 69 studies regarding risk factors for CRE acquisition were included in the random-effects meta-analysis studies. The meta-analyses regarding risk factors for CRE acquisition showed that the use of medical devices generated the highest pooled estimate (odds ratio [OR] = 5.09; 95% confidence interval [CI] = 3.38 to 7.67), followed by carbapenem use (OR = 4.71; 95% CI = 3.54 to 6.26). To control hospital outbreaks, bundled interventions, including the use of barrier/contact precautions for patients colonized or infected with CRE, are needed. In addition, it is necessary to optimize the therapeutic approach, which is an important message to infectious disease specialists, who need to be actively involved in a timely manner in the treatment of patients with known CRE infections or suspected carriers of CRE.
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Affiliation(s)
- Karlijn van Loon
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anne F Voor In 't Holt
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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20
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Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2017. [PMID: 28629876 DOI: 10.1016/s1473-3099(17)30325-0] [Citation(s) in RCA: 500] [Impact Index Per Article: 62.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antibiotic stewardship programmes have been shown to reduce antibiotic use and hospital costs. We aimed to evaluate evidence of the effect of antibiotic stewardship on the incidence of infections and colonisation with antibiotic-resistant bacteria. METHODS For this systematic review and meta-analysis, we searched PubMed, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Web of Science for studies published from Jan 1, 1960, to May 31, 2016, that analysed the effect of antibiotic stewardship programmes on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infections in hospital inpatients. Two authors independently assessed the eligibility of trials and extracted data. Studies involving long-term care facilities were excluded. The main outcomes were incidence ratios (IRs) of target infections and colonisation per 1000 patient-days before and after implementation of antibiotic stewardship. Meta-analyses were done with random-effect models and heterogeneity was calculated with the I2 method. FINDINGS We included 32 studies in the meta-analysis, comprising 9 056 241 patient-days and 159 estimates of IRs. Antibiotic stewardship programmes reduced the incidence of infections and colonisation with multidrug-resistant Gram-negative bacteria (51% reduction; IR 0·49, 95% CI 0·35-0·68; p<0·0001), extended-spectrum β-lactamase-producing Gram-negative bacteria (48%; 0·52, 0·27-0·98; p=0·0428), and meticillin-resistant Staphylococcus aureus (37%; 0·63, 0·45-0·88; p=0·0065), as well as the incidence of C difficile infections (32%; 0·68, 0·53-0·88; p=0·0029). Antibiotic stewardship programmes were more effective when implemented with infection control measures (IR 0·69, 0·54-0·88; p=0·0030), especially hand-hygiene interventions (0·34, 0·21-0·54; p<0·0001), than when implemented alone. Antibiotic stewardship did not affect the IRs of vancomycin-resistant enterococci and quinolone-resistant and aminoglycoside-resistant Gram-negative bacteria. Significant heterogeneity between studies was detected, which was partly explained by the type of interventions and co-resistance patterns of the target bacteria. INTERPRETATION Antibiotic stewardship programmes significantly reduce the incidence of infections and colonisation with antibiotic-resistant bacteria and C difficile infections in hospital inpatients. These results provide stakeholders and policy makers with evidence for implementation of antibiotic stewardship interventions to reduce the burden of infections from antibiotic-resistant bacteria. FUNDING German Center for Infection Research.
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21
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de With K, Allerberger F, Amann S, Apfalter P, Brodt HR, Eckmanns T, Fellhauer M, Geiss HK, Janata O, Krause R, Lemmen S, Meyer E, Mittermayer H, Porsche U, Presterl E, Reuter S, Sinha B, Strauß R, Wechsler-Fördös A, Wenisch C, Kern WV. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2017; 44:395-439. [PMID: 27066980 PMCID: PMC4889644 DOI: 10.1007/s15010-016-0885-z] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. Materials and methods A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. Conclusion The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.
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Affiliation(s)
- K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - F Allerberger
- Division Public Health, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - S Amann
- Hospital Pharmacy, Munich Municipal Hospital, Munich, Germany
| | - P Apfalter
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - H-R Brodt
- Department of Infectious Disease Medical Clinic II, Goethe-University Frankfurt, Frankfurt, Germany
| | - T Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - M Fellhauer
- Hospital Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - H K Geiss
- Department of Hospital Epidemiology and Infectiology, Sana Kliniken AG, Ismaning, Germany
| | - O Janata
- Department for Hygiene and Infection Control, Danube Hospital, Vienna, Austria
| | - R Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
| | - S Lemmen
- Division of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany
| | - E Meyer
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Berlin, Germany
| | - H Mittermayer
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - U Porsche
- Department for Clinical Pharmacy and Drug Information, Landesapotheke, Landeskliniken Salzburg (SALK), Salzburg, Austria
| | - E Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - S Reuter
- Clinic for General Internal Medicine, Infectious Diseases, Pneumology and Osteology, Klinikum Leverkusen, Leverkusen, Germany
| | - B Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Strauß
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Erlangen, Germany
| | - A Wechsler-Fördös
- Department of Antibiotics and Infection Control, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Wenisch
- Medical Department of Infection and Tropical Medicine, Kaiser Franz Josef Hospital, Vienna, Austria
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, Freiburg University Medical Center, Freiburg, Germany
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Lopes LP, Pio DPM, Reinato LAF, Gaspar GG, Prado MAD, Gir E. STAPHYLOCOCCUS AUREUS IN NURSING PROFESSIONALS AND THE MICROORGANISM’S SUSCEPTIBILITY PROFILE TO ANTIMICROBIALS. TEXTO & CONTEXTO ENFERMAGEM 2017. [DOI: 10.1590/0104-07072017000400016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: to identify the carrier’s state and the susceptibility profile of Staphylococcus aureus isolated from saliva and nasal secretion of nursing professionals to antibiotics. Method: cross-sectional study that used saliva and nasal secretion samples of 100 nursing professionals who provide care for patients with HIV/Aids. Results: forty-three percent of the participants presented positive saliva or nasal secretion samples for Staphylococcus aureus. Of the 74 nasal secretion samples with Staphylococcus aureus, 14.9% presented oxacillin resistance; 91.9% presented penicillin resistance; 44.6% presented erythromycin resistance, and 41.9% presented clindamycin resistance. Of the 12 positive saliva samples, 16.7% presented oxacillin resistance; 100.0% presented penicillin resistance; 33.4% presented erythromycin resistance, and 25.0% presented clindamycin resistance. Conclusion: nursing professionals, once aware of their carrier state of multi-resistant microorganisms, will supervise their care practices and more efficiently adopt measures for prevention and control of the epidemiological chain of these bacteria in their work environment.
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Saavedra-Trujillo CH, Arias-León G, Gualtero-Trujillo SM, Leal AL, Saavedra-Rojas SY, Murcia MI. Factores de riesgo para infección o colonización por Acinetobacter baumannii resistente a carbapenémicos en pacientes adultos hospitalizados en Unidades de Cuidado Intensivo, Bogotá, Colombia. INFECTIO 2016. [DOI: 10.1016/j.infect.2015.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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De Oliveira AC, Oliveira de Paula A, Farnetano Rocha R. Custos com antimicrobianos no tratamento de pacientes com infecção. AVANCES EN ENFERMERÍA 2016. [DOI: 10.15446/av.enferm.v33n3.37356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
<p>Os custos relacionados ao tratamento antimicrobiano de pacientes com infecções da corrente sanguínea causadas por microrganismos resistentes têm sido pouco explorados. Objetivo: Comparar os custos diretos do tratamento antimicrobiano de pacientes com infecção da corrente sanguínea causada por Staphylococcus aureus resistente e sensível à oxacilina (MRSA e MSSA, respectivamente). Metodologia: Tratou-se de uma coorte histórica, realizada em uma unidade de terapia intensiva. Foram incluídos pacientes com infecção da corrente sanguínea por Staphylococcus aureus, entre março de 2007 e março de 2011. Utilizaram-se os registros dos prontuários, da comissão de controle de infecção hospitalar e do sistema de finanças do hospital, sendo realizada análise univariada. Resultados: Fizeram parte do estudo 31 pacientes tanto no grupo infectado por MRSA, quanto naquele infectado por MSSA. De acordo com a análise univariada, o direcionamento do tratamento reduziu o espectro de ação dos antibióticos utilizados e os custos (0,001) e a resistência bacteriana esteve relacionada a um maior gasto com o tratamento antimicrobiano empírico (= 0,05), não sendo encontrada associação para tratamentos direcionado e total. Conclusão: A resistência bacteriana pode influenciar os custos com tratamento antimicrobiano, sendo necessários mais estudos sobre o tema, avaliando especificamente tratamento antimicrobiano.</p>
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Taggart LR, Leung E, Muller MP, Matukas LM, Daneman N. Differential outcome of an antimicrobial stewardship audit and feedback program in two intensive care units: a controlled interrupted time series study. BMC Infect Dis 2015; 15:480. [PMID: 26511839 PMCID: PMC4625716 DOI: 10.1186/s12879-015-1223-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/15/2015] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Antimicrobial decision making in intensive care units (ICUs) is challenging. Unnecessary antimicrobials contribute to the development of resistant pathogens, Clostridium difficile infection and drug related adverse events. However, inadequate antimicrobial therapy is associated with mortality in critically ill patients. Antimicrobial stewardship programs are increasingly being implemented to improve antimicrobial prescribing, but the optimal approach in the ICU setting is unknown. We assessed the impact of an audit and feedback antimicrobial stewardship intervention on antimicrobial use, antimicrobial costs, clinical outcomes and microbiologic outcomes in two ICUs with different patient populations. METHODS The audit and feedback intervention was implemented in a trauma and neurosurgery ICU (TNICU) and a medical surgical ICU (MSICU) at a 465-bed teaching hospital in Toronto, Canada. ICU patients were reviewed Monday to Friday by a physician and pharmacist with infectious diseases training. Recommendations related to appropriate antimicrobial use were presented to ICU teams during a dedicated daily meeting. A controlled interrupted time series analysis was used to compare outcomes in the 12 months before and after the intervention. Cardiovascular and coronary care ICUs served as control units. RESULTS Mean total monthly antimicrobial use in defined daily doses (DDD) per 1000 patient days was reduced 28% in the TNICU (1433 vs. 1037) but increased 14% in the MSICU (1705 vs. 1936). In the time series analysis, total monthly antimicrobial use in the TNICU decreased by 375 DDD per 1000 patient days (p < 0.0009) immediately following the intervention, followed by a non-significant downward trend in use of -9 DDD per 1000 patient days (p = 0.56). No significant changes in antimicrobial use were identified in the MSICU. Antimicrobial use temporarily increased in one control unit and remained unchanged in the other. There were no changes in mortality, length of stay, readmission rate, incidence of C. difficile infection or resistance patterns of E. coli and P. aeruginosa in either intervention unit. CONCLUSIONS Audit and feedback antimicrobial stewardship programs can lead to significant reductions in total antimicrobial use in the ICU setting. However, this effect may be context-dependent and further work is needed to determine the ingredients necessary for success.
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Affiliation(s)
- Linda R Taggart
- Division of Infectious Diseases, Department of Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
- Department of Medicine, University of Toronto, Toronto, Canada.
| | - Elizabeth Leung
- Department of Pharmacy, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
| | - Matthew P Muller
- Division of Infectious Diseases, Department of Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
- Department of Medicine, University of Toronto, Toronto, Canada.
| | - Larissa M Matukas
- Division of Microbiology, Department of Laboratory Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada.
| | - Nick Daneman
- Department of Medicine, University of Toronto, Toronto, Canada.
- Division of Infectious Diseases, Department of Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
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Sligl WI, Dragan T, Smith SW. Nosocomial Gram-negative bacteremia in intensive care: epidemiology, antimicrobial susceptibilities, and outcomes. Int J Infect Dis 2015; 37:129-34. [DOI: 10.1016/j.ijid.2015.06.024] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/03/2015] [Accepted: 06/28/2015] [Indexed: 10/23/2022] Open
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Casaroto E, Marra AR, Camargo TZS, de Souza ARA, de Almeida CES, Pedroti EP, Victor EDS, dos Santos OFP, Edmond MB, Campos AH. Agreement on the prescription of antimicrobial drugs. BMC Infect Dis 2015; 15:248. [PMID: 26123222 PMCID: PMC4484637 DOI: 10.1186/s12879-015-0992-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 06/19/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is universal awareness of the difficulties faced by doctors when prescribing antimicrobials. METHODS Over a six-month period patients hospitalized in the ICU and under treatment with antibiotics and/or antifungals were eligible to participate in the study. The data were assessed by two infectious diseases specialists. Once completed, all case forms were sent independently to both evaluators (TZSC and ARM) by e-mail. Based on the data received, the evaluator completed a form automatically generated on the e-mail and returned it to the original mailbox for further analysis. We assessed the level of agreement between infectious disease specialists and the physicians directly responsible for the decision to begin antimicrobial therapy, as well as to assess the appropriateness of the regimen prescribed. RESULTS Among the antimicrobial regimens prescribed to the 177 patients, 36% were considered inappropriate by specialist #1 and 38% were considered inappropriate by specialist #2. We found 78% agreement by at least one of the infectious disease specialists with the prescribed antimicrobial regimen, and in 49% of cases both specialists agreed with the prescribed regimen. Both disagreed with the prescribed regimen in 22% of the cases and they disagreed between themselves in 29% of the cases. CONCLUSION This study highlights the difficulties in prescribing effective empirical antimicrobial therapy--they are of such magnitude that even two specialists in infectious diseases, well acquainted with our hospital's resistance patterns and our patients' profiles have considerable disagreement.
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Affiliation(s)
- Eduardo Casaroto
- Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Alexandre R Marra
- Division of Medical Practice, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701 - 1st floor - Bloco A1 - Room 108 Morumbi, 05651-901, São Paulo, Brazil.
| | | | | | | | | | - Elivane da Silva Victor
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Oscar Fernando Pavão dos Santos
- Division of Medical Practice, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627/701 - 1st floor - Bloco A1 - Room 108 Morumbi, 05651-901, São Paulo, Brazil.
| | - Michael B Edmond
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | - Alexandre Holthausen Campos
- Instituto Israelita de Ensino e Pesquisa Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil.
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Okumura LM, da Silva MMG, Veroneze I. Effects of a bundled Antimicrobial Stewardship Program on mortality: a cohort study. Braz J Infect Dis 2015; 19:246-52. [PMID: 25892314 PMCID: PMC9425345 DOI: 10.1016/j.bjid.2015.02.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 01/22/2015] [Accepted: 02/11/2015] [Indexed: 10/31/2022] Open
Abstract
Objectives Data Method Results Conclusion
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Zhang YZ, Singh S. Antibiotic stewardship programmes in intensive care units: Why, how, and where are they leading us. World J Crit Care Med 2015; 4:13-28. [PMID: 25685719 PMCID: PMC4326760 DOI: 10.5492/wjccm.v4.i1.13] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 11/21/2014] [Accepted: 12/17/2014] [Indexed: 02/06/2023] Open
Abstract
Antibiotic usage and increasing antimicrobial resistance (AMR) mount significant challenges to patient safety and management of the critically ill on intensive care units (ICU). Antibiotic stewardship programmes (ASPs) aim to optimise appropriate antibiotic treatment whilst minimising antibiotic resistance. Different models of ASP in intensive care setting, include “standard” control of antibiotic prescribing such as “de-escalation strategies”through to interventional approaches utilising biomarker-guided antibiotic prescribing. A systematic review of outcomes related studies for ASPs in an ICU setting was conducted. Forty three studies were identified from MEDLINE between 1996 and 2014. Of 34 non-protocolised studies, [1 randomised control trial (RCT), 22 observational and 11 case series], 29 (85%) were positive with respect to one or more outcome: These were the key outcome of reduced antibiotic use, or ICU length of stay, antibiotic resistance, or prescribing cost burden. Limitations of non-standard antibiotic initiation triggers, patient and antibiotic selection bias or baseline demographic variance were identified. All 9 protocolised studies were RCTs, of which 8 were procalcitonin (PCT) guided antibiotic stop/start interventions. Five studies addressed antibiotic escalation, 3 de-escalation and 1 addressed both. Six studies reported positive outcomes for reduced antibiotic use, ICU length of stay or antibiotic resistance. PCT based ASPs are effective as antibiotic-stop (de-escalation) triggers, but not as an escalation trigger alone. PCT has also been effective in reducing antibiotic usage without worsening morbidity or mortality in ventilator associated pulmonary infection. No study has demonstrated survival benefit of ASP. Ongoing challenges to infectious disease management, reported by the World Health Organisation global report 2014, are high AMR to newer antibiotics, and regional knowledge gaps in AMR surveillance. Improved AMR surveillance data, identifying core aspects of successful ASPs that are transferable, and further well-conducted trials will be necessary if ASPs are to be an effective platform for delivering desired patient outcomes and safety through best antibiotic policy.
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Stratégies de réduction de l’utilisation des antibiotiques à visée curative en réanimation (adulte et pédiatrique). MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0916-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Cotta MO, Roberts JA, Tabah A, Lipman J, Vogelaers D, Blot S. Antimicrobial stewardship of β-lactams in intensive care units. Expert Rev Anti Infect Ther 2014; 12:581-95. [DOI: 10.1586/14787210.2014.902308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tacconelli E, Cataldo M, Dancer S, De Angelis G, Falcone M, Frank U, Kahlmeter G, Pan A, Petrosillo N, Rodríguez-Baño J, Singh N, Venditti M, Yokoe D, Cookson B. ESCMID guidelines for the management of the infection control measures to reduce transmission of multidrug-resistant Gram-negative bacteria in hospitalized patients. Clin Microbiol Infect 2014; 20 Suppl 1:1-55. [DOI: 10.1111/1469-0691.12427] [Citation(s) in RCA: 527] [Impact Index Per Article: 47.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 09/29/2013] [Accepted: 10/06/2013] [Indexed: 01/04/2023]
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Epidemiological interpretation of studies examining the effect of antibiotic usage on resistance. Clin Microbiol Rev 2013; 26:289-307. [PMID: 23554418 DOI: 10.1128/cmr.00001-13] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Bacterial resistance to antibiotics is a growing clinical problem and public health threat. Antibiotic use is a known risk factor for the emergence of antibiotic resistance, but demonstrating the causal link between antibiotic use and resistance is challenging. This review describes different study designs for assessing the association between antibiotic use and resistance and discusses strengths and limitations of each. Approaches to measuring antibiotic use and antibiotic resistance are presented. Important methodological issues such as confounding, establishing temporality, and control group selection are examined.
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Deliberato RO, Marra AR, Sanches PR, Martino MDV, Ferreira CEDS, Pasternak J, Paes AT, Pinto LM, dos Santos OFP, Edmond MB. Clinical and economic impact of procalcitonin to shorten antimicrobial therapy in septic patients with proven bacterial infection in an intensive care setting. Diagn Microbiol Infect Dis 2013; 76:266-71. [PMID: 23711530 DOI: 10.1016/j.diagmicrobio.2013.03.027] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 03/21/2013] [Accepted: 03/22/2013] [Indexed: 01/01/2023]
Abstract
Biomarkers such as procalcitonin (PCT) have been studied to guide duration of antibiotic therapy. We aimed to assess whether a decrease in PCT levels could be used to reduce the duration of antibiotic therapy in intensive care unit (ICU) patients with a proven infection without risking a worse outcome. We assessed 265 patients with suspected sepsis, severe sepsis, or septic shock in our ICU. Of those, we randomized 81 patients with a proven bacterial infection into 2 groups: an intervention group in which the duration of the antibiotic therapy was guided by a PCT protocol and a control group in which there was no PCT guidance. In the per-protocol analysis, the median antibiotic duration was 9 days in the PCT group (n = 20) versus 13 days in the non-PCT group (n = 31), P = 0.008. This study demonstrates that PCT can be a useful tool for limiting antimicrobial therapy in ICU patients with documented bacterial infection.
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Moehring RW, Anderson DJ. Antimicrobial stewardship as part of the infection prevention effort. Curr Infect Dis Rep 2012; 14:592-600. [PMID: 22961224 DOI: 10.1007/s11908-012-0289-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Antimicrobial stewardship programs (ASPs) optimize antimicrobial use to decrease the incidence of infection with multidrug-resistant organisms (MDRO) and the emergence of drug resistance, to improve patient outcomes and safety, and to decrease hospital costs. ASPs achieve these goals through several types of interventions that can occur before or after the antimicrobial has been prescribed; interventions can also be "active" or "passive." We believe that active post-prescription interventions such as post-prescription audit and feedback have the most supportive evidence and most promise. Stewardship activities must be integrated into already established efforts for infection prevention. We believe it is critical that antimicrobial stewardship, infection control, pharmacy, information technology, and clinical microbiology work collaboratively in order to decrease the incidence of infection due to MDRO.
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Affiliation(s)
- Rebekah W Moehring
- Department of Medicine, Division of Infectious Diseases, Duke University Medical Center, Durham, NC, 27710, USA,
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Elligsen M, Walker SAN, Pinto R, Simor A, Mubareka S, Rachlis A, Allen V, Daneman N. Audit and feedback to reduce broad-spectrum antibiotic use among intensive care unit patients: a controlled interrupted time series analysis. Infect Control Hosp Epidemiol 2012; 33:354-61. [PMID: 22418630 DOI: 10.1086/664757] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE We aimed to rigorously evaluate the impact of prospective audit and feedback on broad-spectrum antimicrobial use among critical care patients. DESIGN Prospective, controlled interrupted time series. SETTING Single tertiary care center with 3 intensive care units. PATIENTS AND INTERVENTIONS A formal review of all critical care patients on their third or tenth day of broad-spectrum antibiotic therapy was conducted, and suggestions for antimicrobial optimization were communicated to the critical care team. OUTCOMES The primary outcome was broad-spectrum antibiotic use (days of therapy per 1000 patient-days; secondary outcomes included overall antibiotic use, gram-negative bacterial susceptibility, nosocomial Clostridium difficile infections, length of stay, and mortality. RESULTS The mean monthly broad-spectrum antibiotic use decreased from 644 days of therapy per 1,000 patient-days in the preintervention period to 503 days of therapy per 1,000 patient-days in the postintervention period (P < .0001); time series modeling confirmed an immediate decrease (± standard error) of 119 ± 37.9 days of therapy per 1,000 patient-days (P = .0054). In contrast, no changes were identified in the use of broad-spectrum antibiotics in the control group (nonintervention medical and surgical wards) or in the use of control medications in critical care (stress ulcer prophylaxis). The incidence of nosocomial C. difficile infections decreased from 11 to 6 cases in the study intensive care units, whereas the incidence increased from 87 to 116 cases in the control wards (P = .04). Overall gram-negative susceptibility to meropenem increased in the critical care units. Intensive care unit length of stay and mortality did not change. CONCLUSIONS Institution of a formal prospective audit and feedback program appears to be a safe and effective means to improve broad-spectrum antimicrobial use in critical care.
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Affiliation(s)
- Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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37
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Oliveira ACD, Paula AOD. Discontinuation of antimicrobials and costs of treating patients with infection. ACTA PAUL ENFERM 2012. [DOI: 10.1590/s0103-21002012000900011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: To evaluate the repercussions of discontinuation the cost with the antimicrobial treatment of patients with bloodstream infection. METHODS: A historical cohort study conducted in the intensive care unit of a hospital in Belo Horizonte (MG). The population included 62 patients with bloodstream infection caused by Staphylococcus aureus. Data were collected between March/2007 and March/2011 from patients' medical records, Commission of Hospital Infection Control and Sector of Costs, with descriptive and univariate analysis. RESULTS: Colonization was associated with the occurrence of infection with resistant microorganisms (p <0.05). The antimicrobial discontinuation reduced the spectrum of action of the antibiotic prescribed, and the treatment costs (R$ 2,673.12 to R$ 727.03, p = 0.001). CONCLUSION: The discontinuation of antimicrobials favored the redirection of patient therapy, reducing, where necessary, the spectrum of action of the prescribed antimicrobial and, consequently, the costs of treatment.
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Kaki R, Elligsen M, Walker S, Simor A, Palmay L, Daneman N. Impact of antimicrobial stewardship in critical care: a systematic review. J Antimicrob Chemother 2011; 66:1223-30. [PMID: 21460369 DOI: 10.1093/jac/dkr137] [Citation(s) in RCA: 269] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate the current state of evidence for antimicrobial stewardship interventions in the critical care unit. METHODS We performed a systematic search of OVID MEDLINE, Embase and Cochrane electronic databases from 1996-2010. Studies were included if they involved any experimental intervention to improve antimicrobial utilization in the critical care setting. RESULTS Thirty-eight studies met the inclusion criteria, of which 24 met our quality inclusion criteria. The quality of research was poor, with only 3 randomized controlled trials, 3 interrupted time series and 18 (75%) uncontrolled before-and-after studies. We identified six intervention types: studies of antibiotic restriction or pre-approval (six studies); formal infectious diseases physician consultation (five); implementation of guidelines or protocols for de-escalation (two); guidelines for antibiotic prophylaxis or treatment in intensive care (two); formal reassessment of antibiotics on a pre-specified day of therapy (three); and implementation of computer-assisted decision support (six). Stewardship interventions were associated with reductions in antimicrobial utilization (11%-38% defined daily doses/1000 patient-days), lower total antimicrobial costs (US$ 5-10/patient-day), shorter average duration of antibiotic therapy, less inappropriate use and fewer antibiotic adverse events. Stewardship interventions beyond 6 months were associated with reductions in antimicrobial resistance rates, although this differed by drug-pathogen combination. Antibiotic stewardship was not associated with increases in nosocomial infection rates, length of stay or mortality. CONCLUSIONS More rigorous research is needed, but available evidence suggests that antimicrobial stewardship is associated with improved antimicrobial utilization in the intensive care unit, with corresponding improvements in antimicrobial resistance and adverse events, and without compromise of short-term clinical outcomes.
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Affiliation(s)
- Reham Kaki
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Gandhi TN, DePestel DD, Collins CD, Nagel J, Washer LL. Managing antimicrobial resistance in intensive care units. Crit Care Med 2010; 38:S315-23. [PMID: 20647789 DOI: 10.1097/ccm.0b013e3181e6a2a4] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The challenges in managing patients with infection in the intensive care unit are increased in an era where there are dwindling antimicrobial choices for multidrug-resistant pathogens. Clinicians in the intensive care unit must balance between choosing appropriate antimicrobial treatment for patients with suspected infection and utilizing antimicrobials in a judicious fashion. Improving antimicrobial utilization is a critical component to reducing antimicrobial resistance. Although providing effective antimicrobial therapy and improving antimicrobial utilization may seem to be competing goals, there are effective strategies to accomplish both. Antimicrobial stewardship programs provide an organized way to implement these strategies and can enhance the intensive care unit physician's success in improving patient outcomes and combating antimicrobial resistance in the intensive care unit.
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Affiliation(s)
- Tejal N Gandhi
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.
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Boothe DM. Interpreting culture and susceptibility data in critical care: perks and pitfalls. J Vet Emerg Crit Care (San Antonio) 2010; 20:110-31. [PMID: 20230440 DOI: 10.1111/j.1476-4431.2009.00509.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PROBLEM The need for immediate, effective antimicrobial therapy in the critical care patient must be tempered by approaches which simultaneously minimize emergence of antimicrobial resistance. Ideally, therapy will successfully resolve clinical signs of infection, while eradicating infecting pathogens such that the risk of resistance is avoided. Increasing limitations associated with empirical antimicrobial choices direct the need for culture and susceptibility data as a basis of therapy. Even so, such in vitro data should be utilized within its limitations. OBJECTIVES To demonstrate the attributes and limitations of patient and population culture and susceptibility (pharmacodynamic) data in the selection of antimicrobial drugs and to demonstrate the design of individualized dosing regimens based on integration of pharmacodynamic (PD) and pharmacokinetic (PK) data. DIAGNOSIS Limitations in culture and susceptibility testing begin with sample collection and continue through drug selection and dose design. Among the challenges in interpretation is discrimination between pathogens and commensals. Properly collected samples are critical for generation of data relevant to the patient's infection. Data are presented as minimum inhibitory concentrations (MICs). The MIC facilitate selection of the most appropriate drug, particularly when considered in the context of antimicrobial concentrations achieved in the patient at a chosen dose. Integration of MIC data with key PK data yields the C(max):MIC important to efficacy of concentration-dependent drugs and T>MIC, which guides use of time-dependent drugs. These indices are then used to design dosing regimens that are more likely to kill all infecting pathogens. In the absence of patient MIC data, population data (eg, MIC(90)) may serve as a reasonable surrogate. CONCLUSIONS Properly collected, performed, and interpreted culture and susceptibility data are increasingly important in the selection of and design of dosing regimens for antimicrobial drugs. Integration of PK and PD data as modified by host and microbial factors supports a hit hard, exit fast approach to therapy that will facilitate efficacy while minimizing resistance.
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Affiliation(s)
- Dawn Merton Boothe
- Department of Anatomy, Physiology, Pharmacology, Auburn University, Auburn, AL 36849, USA.
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