1
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Ernst EJ. Carbapenem use in US hospitals: guidance and stewardship. THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00231-7. [PMID: 38679037 DOI: 10.1016/s1473-3099(24)00231-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 05/01/2024]
Affiliation(s)
- Erika J Ernst
- University of Iowa, College of Pharmacy, Iowa City, IA 52242, USA.
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2
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Claeys KC, Morgan DJ, Johnson MD. The importance of pharmacist engagement in diagnostic stewardship. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e43. [PMID: 38628377 PMCID: PMC11019581 DOI: 10.1017/ash.2024.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 04/19/2024]
Abstract
Diagnostic stewardship is increasingly recognized as a powerful tool to improve patient safety. Given the close relationship between diagnostic testing and antimicrobial misuse, antimicrobial stewardship (AMS) pharmacists should be key members of the diagnostic team. Pharmacists practicing in AMS already frequently engage with clinicians to improve the diagnostic process and have many skills needed for the implementation of diagnostic stewardship initiatives. As diagnostic stewardship becomes more broadly used, all infectious disease clinicians, including pharmacists, must collaborate to optimize patient care.
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Affiliation(s)
- Kimberly C. Claeys
- Associate Professor Infectious Diseases, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Veterans’ Affairs Maryland Healthcare System, Baltimore, MD, USA
| | - Melissa D. Johnson
- Professor in Medicine, Division of Infectious Diseases & International Health, Duke University School of Medicine, Durham, NC, USA
- Liaison Clinical Pharmacist, Duke Antimicrobial Stewardship Outreach Network (DASON), Duke University Medical Center, Durham, NC, USA
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3
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Otto C, Chen D. Point of Care Molecular Testing: Current State and Opportunities for Diagnostic Stewardship. Clin Lab Med 2024; 44:23-32. [PMID: 38280795 DOI: 10.1016/j.cll.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Inappropriate ordering practices, either under or over ordering of diagnostic tests, are recognized problems with possible negative downstream consequences. As the menu of clinical tests, especially molecular tests grows, it is becoming increasingly important to provide guidance to providers on the appropriate utilization. Diagnostic stewardship programs have been established at many institutions to help direct the appropriate utilization of laboratory testing to ultimately guide patient management and treatment decisions. Many molecular tests have now received Clinical Laboratory Improvement Amendments (CLIA)-waived status for use in a point-of-care (POC) setting; however, parallel diagnostic stewardship programs have not been established to help guide providers on how best to use these tests. In this article, we will discuss the available molecular POC tests and opportunities and challenges for establishing diagnostic stewardship programs for molecular testing performed in the POC setting.
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Affiliation(s)
- Caitlin Otto
- Department of Pathology, New York University Langone Health, 560 1st Avenue, New York, NY 10016, USA.
| | - Dan Chen
- Department of Pathology, New York University Langone Health, 560 1st Avenue, New York, NY 10016, USA
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4
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Itoh N, Akazawa N, Kawabata T, Yamaguchi M, Kodama EN, Ohmagari N. Improving diagnostic accuracy of blood culture-positive cases in a cancer center via an antimicrobial stewardship program and infectious disease consultations. Sci Rep 2024; 14:2869. [PMID: 38311620 PMCID: PMC10838907 DOI: 10.1038/s41598-024-53543-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/01/2024] [Indexed: 02/06/2024] Open
Abstract
The direct impact of antimicrobial stewardship programs (ASP) and infectious disease (ID) consultations on patients' clinical diagnoses remains unknown. We assessed their influence on improving the diagnostic accuracy of blood culture-positive inpatients at a Japanese cancer center. Our single-center, retrospective observational study was conducted from April 1, 2018 to March 31, 2022 to evaluate two phases: pre-intervention (notification of antimicrobials by the infection control team) and post-intervention (ASP implementation and ID consultation service establishment). There were 42,514 inpatients: 22,096 during the pre-intervention and 20,418 during the intervention periods. A total of 939 blood culture-positive episodes (pre-intervention, n = 434; post-intervention, n = 505) were analyzed. During the pre-intervention period, 28.1% of the patients had an unknown diagnosis, which decreased significantly to 1.2% post-intervention. Furthermore, hepatobiliary tract and other infections increased significantly post-intervention, and the mortality rate due to Staphylococcus aureus infection decreased from 28.6% pre-intervention to 10.4% post-intervention. The trend and level of the total number of culture specimens submitted per 1000 patient days for all culture specimens increased significantly post-intervention. Notably, the two-set rate of monthly blood cultures increased significantly. In conclusion, improving the overall diagnostic process with ASP and ID consultations at cancer centers could lead to the optimization of patient care.
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Affiliation(s)
- Naoya Itoh
- Division of Infectious Diseases, Aichi Cancer Center Hospital, Nagoya, Japan.
- Collaborative Chairs Emerging and Reemerging Infectious Diseases, National Center for Global Health and Medicine, Graduate School of Medicine, Tohoku University, Miyagi, Japan.
| | - Nana Akazawa
- Division of Infectious Diseases, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takanori Kawabata
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Makoto Yamaguchi
- Division of Infectious Diseases, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Eiichi N Kodama
- Division of Infectious Diseases, International Research Institute of Disaster Science, and Graduate School of Medicine, Tohoku University and Tohoku Medical Megabank Organization, Sendai, Japan
| | - Norio Ohmagari
- Collaborative Chairs Emerging and Reemerging Infectious Diseases, National Center for Global Health and Medicine, Graduate School of Medicine, Tohoku University, Miyagi, Japan
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
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5
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Livorsi DJ, Branch-Elliman W, Drekonja D, Echevarria KL, Fitzpatrick MA, Goetz MB, Graber CJ, Jones MM, Kelly AA, Madaras-Kelly K, Morgan DJ, Stevens VW, Suda K, Trautner BW, Ward MJ, Jump RLP. Research agenda for antibiotic stewardship within the Veterans' Health Administration, 2024-2028. Infect Control Hosp Epidemiol 2024:1-7. [PMID: 38305034 DOI: 10.1017/ice.2024.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Affiliation(s)
- Daniel J Livorsi
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans' Affairs (VA) Health Care System, Iowa City, Iowa
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Westyn Branch-Elliman
- VA Boston Healthcare System, Department of Medicine, Section of Infectious Diseases. Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Dimitri Drekonja
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kelly L Echevarria
- VHA Pharmacy Benefits and Antimicrobial Stewardship Task Force, Department of Veterans' Affairs, Washington, DC
| | - Margaret A Fitzpatrick
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Christopher J Graber
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Makoto M Jones
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Allison A Kelly
- VHA Pharmacy Benefits and Antimicrobial Stewardship Task Force, Department of Veterans' Affairs, Washington, DC
- Cincinnati Veterans' Affairs Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Karl Madaras-Kelly
- Boise Veterans' Affairs Medical Center, Boise, Idaho
- Idaho State University, College of Pharmacy, Meridian, Idaho
| | - Daniel J Morgan
- Department of Medicine, VA Maryland Healthcare System, Baltimore, Maryland
- Center for Innovation in Diagnosis, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vanessa W Stevens
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Katie Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans' Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Michael J Ward
- Geriatric Research, Education, and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee
- Department of Emergency Medicine and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robin L P Jump
- Technology Enhancing Cognition and Health Geriatric Research Education and Clinical Center (TECH-GRECC) at the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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6
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Shamas N, Khamis F, Eljaaly K, Al Salmi Z, Al Bahrani M. Intermittent hemodialysis: a review of the top antimicrobial stewardship practices to be employed. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e2. [PMID: 38234415 PMCID: PMC10789993 DOI: 10.1017/ash.2023.525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/25/2023] [Accepted: 11/28/2023] [Indexed: 01/19/2024]
Abstract
The vulnerability of patients on hemodialysis (HD) to infections is evident by their increased susceptibility to infections in general and to resistant organisms in particular. Unnecessary, inappropriate, or suboptimal antimicrobial prescribing is common in dialysis units. This underscores the need for dedicated antimicrobial stewardship (AMS) interventions that can be implemented both in the inpatient and outpatient settings. In this review, we provide a comprehensive approach for clinicians with the most updated coordinated AMS principles in HD setting in six areas: prevention, diagnosis, treatment, education and empowerment, monitoring, and research.
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Affiliation(s)
- Nour Shamas
- Infection Prevention and Control Department, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Faryal Khamis
- Division of Infectious Diseases, Department of Internal Medicine, Royal Hospital, Muscat, Oman
| | - Khalid Eljaaly
- Department of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Zaher Al Salmi
- Department of Pharmaceutical Care, Royal Hospital, Muscat, Oman
| | - Maher Al Bahrani
- Department of Anesthesia and Critical Care, Royal Hospital, Muscat, Oman
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7
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House SA, Marin JR, Coon ER, Ralston SL, Hall M, Gruhler De Souza H, Ho T, Reyes M, Schroeder AR. Trends in Low-Value Care Among Children's Hospitals. Pediatrics 2024; 153:e2023062492. [PMID: 38130171 DOI: 10.1542/peds.2023-062492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Longitudinal pediatric low-value care (LVC) trends are not well established. We used the Pediatric Health Information System LVC Calculator, which measures utilization of 30 nonevidenced-based services, to report 7-year LVC trends. METHODS This retrospective cohort study applied the LVC Calculator to emergency department (ED) and hospital encounters from January 1, 2016, to December 31, 2022. We used generalized estimating equation models accounting for hospital clustering to assess temporal changes in LVC. RESULTS There were 5 265 153 eligible ED encounters and 1 301 613 eligible hospitalizations. In 2022, of 21 LVC measures applicable to the ED cohort, the percentage of encounters with LVC had increased for 11 measures, decreased for 1, and remained unchanged for 9 as compared with 2016. Computed tomography for minor head injury had the largest increase (17%-23%; P < .001); bronchodilators for bronchiolitis decreased (22%-17%; P = .001). Of 26 hospitalization measures, LVC increased for 6 measures, decreased for 9, and was unchanged for 11. Inflammatory marker testing for pneumonia had the largest increase (23%-38%; P = .003); broad-spectrum antibiotic use for pneumonia had the largest decrease (60%-48%; P < .001). LVC remained unchanged or decreased for most medication and procedure measures, but remained unchanged or increased for most laboratory and imaging measures. CONCLUSIONS LVC improved for a minority of services between 2016 and 2022. Trends were more favorable for therapeutic (medications and procedures) than diagnostic measures (imaging and laboratory studies). These data may inform prioritization of deimplementation efforts.
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Affiliation(s)
- Samantha A House
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, and New Hampshire Dartmouth Health Children's, Lebanon, New Hampshire
| | - Jennifer R Marin
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eric R Coon
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Shawn L Ralston
- Department of Pediatrics, University of Washington, Seattle, Washington
| | | | | | - Timmy Ho
- Department of Neonatology, Beth Israel Deaconess Medical Center; Harvard Medical School, Boston, Massachusetts
| | - Mario Reyes
- Department of Pediatrics, Division of Hospital Medicine, Nicklaus Children's Hospital, Miami, Florida
| | - Alan R Schroeder
- Department of Pediatrics, Stanford University, Stanford, California
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8
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Bork JT, Heil EL. What Is Left to Tackle in Inpatient Antimicrobial Stewardship Practice and Research. Infect Dis Clin North Am 2023; 37:901-915. [PMID: 37586930 DOI: 10.1016/j.idc.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Despite widespread uptake of antimicrobial stewardship in acute care hospitals, there is ongoing need for innovation and optimization of ASPs. This article discusses current antimicrobial stewardship practice challenges and ways to improve current antimicrobial stewardship workflows. Additionally, we propose new workflows that further engage front line clinicians in optimizing their own antibiotic decision making.
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Affiliation(s)
- Jacqueline T Bork
- Division of Infectious Diseases, Institute of Human Virology in the Department of Medicine, University of Maryland, School of Medicine, 22 S Greene Street, Baltimore, MD 21201, USA
| | - Emily L Heil
- Department of Practice, Sciences, and Health-Outcomes Research, University of Maryland, School of Pharmacy, 20 N Pine Street, Baltimore, MD 21201, USA.
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9
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Affiliation(s)
- Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- VA Maryland Healthcare System, Baltimore
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- University of Maryland Medical Center, Baltimore
| | - Kimberly C Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore
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10
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Callado GY, Lin V, Thottacherry E, Marins TA, Martino MDV, Salinas JL, Marra AR. Diagnostic Stewardship: A Systematic Review and Meta-analysis of Blood Collection Diversion Devices Used to Reduce Blood Culture Contamination and Improve the Accuracy of Diagnosis in Clinical Settings. Open Forum Infect Dis 2023; 10:ofad433. [PMID: 37674630 PMCID: PMC10478151 DOI: 10.1093/ofid/ofad433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/09/2023] [Indexed: 09/08/2023] Open
Abstract
Background Blood culture contamination may lead to misdiagnosis, overutilization of antibiotics, and prolonged length of stay. Blood specimen diversion devices can reduce contamination rates during blood culture collection procedures. We performed a systematic literature review and meta-analysis evaluating the influence of blood specimen diversion devices in blood culture contamination rates. Methods We searched Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Scopus, and Web of Science, from database inception to 1 March 2023, for studies evaluating the impact of a diversion device on blood culture contamination. Blood culture contamination was a positive blood culture with microorganisms not representative of true bacteremia, but rather introduced during collection or processing the blood sample. Random-effects models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 test. Results Of 1768 screened studies, 12 met inclusion criteria for this systematic literature review. Of them, 9 studies were included in the meta-analysis. Studies were substantially heterogeneous, but stratified analyses considering only high-quality studies revealed that venipuncture using a diversion device was associated with a significant reduction in blood culture contamination in comparison to the standard procedure of collection (pooled odds ratio [OR], 0.26 [95% confidence interval {CI}, .13-.54]; I2 = 19%). Furthermore, the stratified analysis showed that the adoption of a diversion device did not reduce the detection of true infection (pooled OR, 0.85 [95% CI, .65-1.11]; I2 = 0%). Conclusions Blood culture diversion devices was associated with decreased contamination rates and could improve quality of care, reduce costs, and avoid unnecessary antibiotic use.
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Affiliation(s)
- Gustavo Yano Callado
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Vivian Lin
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Elizabeth Thottacherry
- Division of Infectious Diseases & Geographic Medicine, Stanford University, Stanford, California, USA
| | - Tássia Aporta Marins
- Faculdade de Medicina, Centro Universitário de Adamantina, Adamantina, São Paulo, Brazil
| | - Marinês Dalla Valle Martino
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Jorge L Salinas
- Division of Infectious Diseases & Geographic Medicine, Stanford University, Stanford, California, USA
| | - Alexandre R Marra
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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11
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Schinas G, Dimopoulos G, Akinosoglou K. Understanding and Implementing Diagnostic Stewardship: A Guide for Resident Physicians in the Era of Antimicrobial Resistance. Microorganisms 2023; 11:2214. [PMID: 37764058 PMCID: PMC10537711 DOI: 10.3390/microorganisms11092214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
Antimicrobial resistance (AMR) poses a significant global health challenge, exacerbated by the COVID-19 pandemic. Antimicrobial stewardship programs (ASPs) are crucial in managing this crisis, with diagnostic stewardship (DS) emerging as a key component. DS refers to the appropriate use of diagnostic tests to optimize patient outcomes, improve antimicrobial use, and combat multi-drug-resistant (MDR) organisms. Despite its potential, understanding and application of DS remain ambiguous in multiple respects, which, however, do not directly implicate the implementation of such initiatives. DS is particularly important for resident physicians who are often at the forefront of patient care and can significantly influence future AMR strategies. This review provides a comprehensive overview of DS, discussing its importance, potential challenges, and future directions. It emphasizes the need for resident physicians to understand DS principles and integrate them into their clinical practice from the beginning of their careers. The review also highlights the role of various stakeholders in implementing DS and the importance of continuous education and training. Ultimately, DS is not just a clinical tool but a philosophy of care, essential for a more responsive, humane, and effective healthcare system.
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Affiliation(s)
| | - George Dimopoulos
- 3rd Department of Critical Care, EVGENIDIO Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Karolina Akinosoglou
- School of Medicine, University of Patras, 26504 Patras, Greece;
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Patras, Greece
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12
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Jeffrey M, Denny KJ, Lipman J, Conway Morris A. Differentiating infection, colonisation, and sterile inflammation in critical illness: the emerging role of host-response profiling. Intensive Care Med 2023; 49:760-771. [PMID: 37344680 DOI: 10.1007/s00134-023-07108-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/22/2023] [Indexed: 06/23/2023]
Abstract
Infection results when a pathogen produces host tissue damage and elicits an immune response. Critically ill patients experience immune activation secondary to both sterile and infectious insults, with overlapping clinical phenotypes and underlying immunological mechanisms. Patients also undergo a shift in microbiota with the emergence of pathogen-dominant microbiomes. Whilst the combination of inflammation and microbial shift has long challenged intensivists in the identification of true infection, the advent of highly sensitive molecular diagnostics has further confounded the diagnostic dilemma as the number of microbial detections increases. Given the key role of the host immune response in the development and definition of infection, profiling the host response offers the potential to help unravel the conundrum of distinguishing colonisation and sterile inflammation from true infection. This narrative review provides an overview of current approaches to distinguishing colonisation from infection using routinely available techniques and proposes matrices to support decision-making in this setting. In searching for new tools to better discriminate these states, the review turns to the understanding of the underlying pathobiology of the host response to infection. It then reviews the techniques available to assess this response in a clinically applicable context. It will cover techniques including profiling of transcriptome, protein expression, and immune functional assays, detailing the current state of knowledge in diagnostics along with the challenges and opportunities. The ultimate infection diagnostic tool will likely combine an assessment of both host immune response and sensitive pathogen detection to improve patient management and facilitate antimicrobial stewardship.
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Affiliation(s)
- Mark Jeffrey
- John V Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Anaesthesia, Department of Medicine, Level 4, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK
| | - Kerina J Denny
- Department of Intensive Care, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine, University of Queensland, Herston, Brisbane, Australia
| | - Jeffrey Lipman
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Jamieson Trauma Institute and Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Nimes University Hospital, University of Montpellier, Nimes, France
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
- Division of Anaesthesia, Department of Medicine, Level 4, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK.
- Division of Immunology, Department of Pathology, University of Cambridge, Cambridge, UK.
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