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Tanzarella ES, Cutuli SL, Lombardi G, Cammarota F, Caroli A, Franchini E, Sancho Ferrando E, Grieco DL, Antonelli M, De Pascale G. Antimicrobial De-Escalation in Critically Ill Patients. Antibiotics (Basel) 2024; 13:375. [PMID: 38667051 PMCID: PMC11047373 DOI: 10.3390/antibiotics13040375] [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: 03/09/2024] [Revised: 04/03/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
Antimicrobial de-escalation (ADE) is defined as the discontinuation of one or more antimicrobials in empirical therapy, or the replacement of a broad-spectrum antimicrobial with a narrower-spectrum antimicrobial. The aim of this review is to provide an overview of the available literature on the effectiveness and safety of ADE in critically ill patients, with a focus on special conditions such as anti-fungal therapy and high-risk categories. Although it is widely considered a safe strategy for antimicrobial stewardship (AMS), to date, there has been no assessment of the effect of de-escalation on the development of resistance. Conversely, some authors suggest that prolonged antibiotic treatment may be a side effect of de-escalation, especially in high-risk categories such as neutropenic critically ill patients and intra-abdominal infections (IAIs). Moreover, microbiological documentation is crucial for increasing ADE rates in critically ill patients with infections, and efforts should be focused on exploring new diagnostic tools to accelerate pathogen identification. For these reasons, ADE can be safely used in patients with infections, as confirmed by high-quality and reliable microbiological samplings, although further studies are warranted to clarify its applicability in selected populations.
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Affiliation(s)
- Eloisa Sofia Tanzarella
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Salvatore Lucio Cutuli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Gianmarco Lombardi
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Fabiola Cammarota
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Alessandro Caroli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Emanuele Franchini
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | | | - Domenico Luca Grieco
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Massimo Antonelli
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
| | - Gennaro De Pascale
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (E.S.T.); (S.L.C.); (G.L.); (F.C.); (A.C.); (E.F.); (D.L.G.); (M.A.)
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2
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Wu W, Song J, Li T, Li W, Wang J, Wang S, Dong N, Shan A. Unlocking Antibacterial Potential: Key-Site-Based Regulation of Antibacterial Spectrum of Peptides. J Med Chem 2024; 67:4131-4149. [PMID: 38420875 DOI: 10.1021/acs.jmedchem.3c02404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
In the pursuit of combating multidrug-resistant bacteria, antimicrobial peptides (AMPs) have emerged as promising agents; however, their application in clinical settings still presents challenges. Specifically, the exploration of crucial structural parameters that influence the antibacterial spectrum of AMPs and the subsequent development of tailored variants with either broad- or narrow-spectrum characteristics to address diverse clinical therapeutic needs has been overlooked. This study focused on investigating the effects of amino acid sites and hydrophobicity on the peptide's antibacterial spectrum through Ala scanning and fixed-point hydrophobic amino acid substitution techniques. The findings revealed that specific amino acid sites played a pivotal role in determining the antibacterial spectrum of AMPs and confirmed that broadening the spectrum could be achieved only by increasing hydrophobicity at certain positions. In conclusion, this research provided a theoretical basis for future precise regulation of an antimicrobial peptide's spectrum by emphasizing the intricate balance between amino acid sites and hydrophobicity.
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Affiliation(s)
- Wanpeng Wu
- Animal Science and Technology College, Northeast Agricultural University, Harbin 150030, P. R. China
| | - Jing Song
- Animal Science and Technology College, Northeast Agricultural University, Harbin 150030, P. R. China
| | - Tong Li
- Animal Science and Technology College, Northeast Agricultural University, Harbin 150030, P. R. China
| | - Wenyu Li
- Animal Science and Technology College, Northeast Agricultural University, Harbin 150030, P. R. China
| | - Jiajun Wang
- Animal Science and Technology College, Northeast Agricultural University, Harbin 150030, P. R. China
| | - Shuo Wang
- Animal Science and Technology College, Northeast Agricultural University, Harbin 150030, P. R. China
| | - Na Dong
- Animal Science and Technology College, Northeast Agricultural University, Harbin 150030, P. R. China
| | - Anshan Shan
- Animal Science and Technology College, Northeast Agricultural University, Harbin 150030, P. R. China
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3
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Dräger S, Ewoldt TMJ, Abdulla A, Rietdijk WJR, Verkaik N, Ramakers C, de Jong E, Osthoff M, Koch BCP, Endeman H. Exploring the Impact of Model-Informed Precision Dosing on Procalcitonin Concentrations in Critically Ill Patients: A Secondary Analysis of the DOLPHIN Trial. Pharmaceutics 2024; 16:270. [PMID: 38399324 PMCID: PMC10891837 DOI: 10.3390/pharmaceutics16020270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/25/2024] Open
Abstract
Model-informed precision dosing (MIPD) might be used to optimize antibiotic treatment. Procalcitonin (PCT) is a biomarker for severity of infection and response to antibiotic treatment. The aim of this study was to assess the impact of MIPD on the course of PCT and to investigate the association of PCT with pharmacodynamic target (PDT) attainment in critically ill patients. This is a secondary analysis of the DOLPHIN trial, a multicentre, open-label, randomised controlled trial. Patients with a PCT value available at day 1 (T1), day 3 (T3), or day 5 (T5) after randomisation were included. The primary outcome was the absolute difference in PCT concentration at T1, T3, and T5 between the MIPD and the standard dosing group. In total, 662 PCT concentrations from 351 critically ill patients were analysed. There was no statistically significant difference in PCT concentration between the trial arms at T1, T3, or T5. The median PCT concentration was highest in patients who exceeded 10× PDT at T1 [13.15 ng/mL (IQR 5.43-22.75)]. In 28-day non-survivors and in patients that exceeded PDT at T1, PCT decreased significantly between T1 and T3, but plateaued between T3 and T5. PCT concentrations were not significantly different between patients receiving antibiotic treatment with or without MIPD guidance. The potential of PCT to guide antibiotic dosing merits further investigation.
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Affiliation(s)
- Sarah Dräger
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
- Department of Internal Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - Tim M. J. Ewoldt
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
- Department of Intensive Care Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
| | - Wim J. R. Rietdijk
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Institutional Affairs, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Nelianne Verkaik
- Department of Medical Microbiology and Infectious Diseases, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Christian Ramakers
- Department of Clinical Chemistry, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Evelien de Jong
- Department of Intensive Care, Rode Kruis Ziekenhuis, 1942 LE Beverwijk, The Netherlands
| | - Michael Osthoff
- Department of Internal Medicine, University Hospital Basel, 4031 Basel, Switzerland
| | - Birgit C. P. Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Rotterdam Clinical Pharmacometrics Group, 3015 GD Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
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Saito N, Tsuchiya J, Itoga M, Okamura Y, Tsuyama H, Kimura M, Inoue F, Kimura T, Ozaki H, Tono Y, Minakawa S, Tomita H. Multiple Blood Culture Sampling, Proper Antimicrobial Choice, and Adequate Dose in Definitive Therapy Supported by the Antimicrobial Stewardship Team Could Decrease 30-Day Sepsis Mortality Rates. Infect Drug Resist 2024; 17:207-219. [PMID: 38283110 PMCID: PMC10812706 DOI: 10.2147/idr.s445917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 01/11/2024] [Indexed: 01/30/2024] Open
Abstract
Objective This study aimed to identify factors that should be focused on by the antimicrobial stewardship team for treating patients with sepsis, by investigating the mortality of patients with sepsis within 30 days and the mortality-related factors in our hospital over a 10-year period from the perspective of appropriate antimicrobial use. Methods Factors associated with 30-day mortality were investigated using hierarchical multiple logistic regression in 1406 patients with pathogen-identified sepsis in Hirosaki University Hospital. These factors were clinical data, microbiological data, antimicrobials used in empiric and definitive therapies, presence/absence of ineffective use, underdosing as evaluated using Monte Carlo simulation, and practice of de-escalation. Results The ineffective use of antimicrobials in empiric therapy and the underdosing and ineffective use in definitive therapy were significantly associated with 30-day mortality (odds ratio [OR] = 2.70, 3.72, and 3.65, respectively). Multiple blood culture sampling was inversely associated with these inappropriate antimicrobial uses. Every year, the 30-day mortality rate has been decreasing, in line with the increase in multiple blood culture sampling and de-escalation; the inappropriate use of antimicrobials has also decreased. Conclusion Multiple blood culture sampling, proper choice of antimicrobial, and using an adequate dose in definitive therapy could decrease the 30-day mortality rate in patients with sepsis and these factors could be supported by the antimicrobial stewardship team.
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Affiliation(s)
- Norihiro Saito
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Junichiro Tsuchiya
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Masamichi Itoga
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yuji Okamura
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Hiromasa Tsuyama
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Masahiko Kimura
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Fumio Inoue
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Toshiyuki Kimura
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Hiromi Ozaki
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Yuka Tono
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Pharmacy, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Satoko Minakawa
- Division of Infection Control and Prevention, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Hirofumi Tomita
- Department of Clinical Laboratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
- Division of Clinical Laboratory, Hirosaki University Hospital, Hirosaki, Aomori, Japan
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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5
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Agnetti J, Büchler AC, Osthoff M, Helfenstein F, Weisser M, Siegemund M, Bassetti S, Bingisser R, Schaefer DJ, Clauss M, Hinic V, Tschudin-Sutter S, Bättig V, Khanna N, Egli A. Identification of microorganisms by a rapid PCR panel from positive blood cultures leads to faster optimal antimicrobial therapy - a before-after study. BMC Infect Dis 2023; 23:730. [PMID: 37884860 PMCID: PMC10601314 DOI: 10.1186/s12879-023-08732-9] [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: 06/21/2023] [Accepted: 10/20/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND The BioFire® FilmArray® Blood Culture Identification Panel 1 (BF-FA-BCIP) detects microorganisms with high accuracy in positive blood cultures (BC) - a key step in the management of patients with suspected bacteraemia. We aimed to compare the time to optimal antimicrobial therapy (OAT) for the BF-FA-BCIP vs. standard culture-based identification. METHODS In this retrospective single-centre study with a before-after design, 386 positive BC cases with identification by BF-FA-BCIP were compared to 414 controls with culture-based identification. The primary endpoint was the time from BC sampling to OAT. Secondary endpoints were time to effective therapy, length of stay, (re-)admission to ICU, in-hospital and 30-day mortality. Outcomes were assessed using Cox proportional hazard models and logistic regressions. RESULTS Baseline characteristics of included adult inpatients were comparable. Main sources of bacteraemia were urinary tract and intra-abdominal infection (19.2% vs. 22.0% and 16.8% vs. 15.7%, for cases and controls, respectively). Median (95%CI) time to OAT was 25.5 (21.0-31.2) hours with BF-FA-BCIP compared to 45.7 (37.7-51.4) hours with culture-based identification. We observed no significant difference for secondary outcomes. CONCLUSIONS Rapid microorganism identification by BF-FA-BCIP was associated with a median 20-h earlier initiation of OAT in patients with positive BC. No impact on length of stay and mortality was noted. TRIAL REGISTRATION Clinicaltrials.gov, NCT04156633, registered on November 5, 2019.
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Affiliation(s)
- Jessica Agnetti
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, Applied Microbiology Research, University of Basel, Basel, Switzerland
| | - Andrea C Büchler
- Infectious Diseases and Hospital Epidemiology, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Michael Osthoff
- Internal Medicine, University of Basel and University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Fabrice Helfenstein
- Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Maja Weisser
- Infectious Diseases and Hospital Epidemiology, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Stefano Bassetti
- Internal Medicine, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Roland Bingisser
- Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Dirk J Schaefer
- Plastic, Reconstructive, Aesthetic Surgery and Hand Surgery, University Hospital Basel, Basel, Switzerland
| | - Martin Clauss
- Center for Musculoskeletal Infections (ZMSI), University Hospital Basel, Basel, Switzerland
- Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Vladimira Hinic
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland
- Present Address: Institute for Medical Microbiology, University of Zurich, Gloriastrasse 28/30, CH-8006, Zurich, Switzerland
| | - Sarah Tschudin-Sutter
- Infectious Diseases and Hospital Epidemiology, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Veronika Bättig
- Infectious Diseases and Hospital Epidemiology, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Nina Khanna
- Infectious Diseases and Hospital Epidemiology, University of Basel and University Hospital Basel, Basel, Switzerland
| | - Adrian Egli
- Clinical Bacteriology and Mycology, University Hospital Basel, Basel, Switzerland.
- Department of Biomedicine, Applied Microbiology Research, University of Basel, Basel, Switzerland.
- Present Address: Institute for Medical Microbiology, University of Zurich, Gloriastrasse 28/30, CH-8006, Zurich, Switzerland.
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Giamarellou H, Galani L, Karavasilis T, Ioannidis K, Karaiskos I. Antimicrobial Stewardship in the Hospital Setting: A Narrative Review. Antibiotics (Basel) 2023; 12:1557. [PMID: 37887258 PMCID: PMC10604258 DOI: 10.3390/antibiotics12101557] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
The increasing global threat of antibiotic resistance, which has resulted in countless fatalities due to untreatable infections, underscores the urgent need for a strategic action plan. The acknowledgment that humanity is perilously approaching the "End of the Miracle Drugs" due to the unjustifiable overuse and misuse of antibiotics has prompted a critical reassessment of their usage. In response, numerous relevant medical societies have initiated a concerted effort to combat resistance by implementing antibiotic stewardship programs within healthcare institutions, grounded in evidence-based guidelines and designed to guide antibiotic utilization. Crucial to this initiative is the establishment of multidisciplinary teams within each hospital, led by a dedicated Infectious Diseases physician. This team includes clinical pharmacists, clinical microbiologists, hospital epidemiologists, infection control experts, and specialized nurses who receive intensive training in the field. These teams have evidence-supported strategies aiming to mitigate resistance, such as conducting prospective audits and providing feedback, including the innovative 'Handshake Stewardship' approach, implementing formulary restrictions and preauthorization protocols, disseminating educational materials, promoting antibiotic de-escalation practices, employing rapid diagnostic techniques, and enhancing infection prevention and control measures. While initial outcomes have demonstrated success in reducing resistance rates, ongoing research is imperative to explore novel stewardship interventions.
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Affiliation(s)
- Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Lamprini Galani
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Theodoros Karavasilis
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Konstantinos Ioannidis
- Clinical Pharmacists, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece;
| | - Ilias Karaiskos
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
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Yoo JS, Park JY, Chun HJ, Kim YR, Kim EJ, Choi YH, Ha KH, Heo JY. Impact of prolonged carbapenem use-focused antimicrobial stewardship on antimicrobial consumption and factors affecting acceptance of recommendations: a quasi-experimental study. Sci Rep 2023; 13:14501. [PMID: 37666900 PMCID: PMC10477184 DOI: 10.1038/s41598-023-41710-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/30/2023] [Indexed: 09/06/2023] Open
Abstract
This study aimed to assess the impact of a prolonged carbapenem use-focused antimicrobial stewardship program (ASP) on antimicrobial consumption and clinical outcomes and to analyze factors affecting adherence to interventions. Patients prescribed carbapenems for ≥ 2 weeks received intervention. Interrupted time-series analysis was performed to compare antimicrobial consumption before and after intervention. Factors associated with non-adherence to intervention were investigated. Of 273 patients who were eligible for intervention, discontinuation or de-escalation was recommended in 256 (94.1%) and intervention was accepted in 136 (53.1%) patients. Before intervention, carbapenem consumption significantly increased to 1.14 days of therapy (DOT)/1000 patient days (PD)/month (P = 0.018). However, it significantly declined by - 2.01 DOT/1000 PD/month without an increase in other antibiotic consumption (P < 0.001). Factors affecting non-adherence to intervention were younger age (odds ratio [OR] = 0.98; 95% confidence interval [CI] 0.96-1.00), solid organ malignancy (OR = 2.53, 95% CI 1.16-5.50), and pneumonia (OR = 2.59, 95% CI 1.08-6.17). However, ASP intervention was not associated with clinical outcomes such as length of hospital stay or mortality. Prolonged carbapenem prescription-focused ASP significantly reduced carbapenem consumption without adverse outcomes. Non-adherence to interventions was attributed more to prescriber-related factors, such as attitude, than patient-related factors including clinical severity.
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Affiliation(s)
- Jin Sae Yoo
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
- Department of Acute Care Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jeong Yong Park
- Department of Pharmaceutical Service, Ajou University Hospital, Suwon, Republic of Korea
| | - Ha-Jin Chun
- Department of Pharmaceutical Service, Ajou University Hospital, Suwon, Republic of Korea
| | - Young Rong Kim
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Eun Jin Kim
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Young Hwa Choi
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Kyoung Hwa Ha
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea.
| | - Jung Yeon Heo
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea.
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8
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Song JU, Lee J. The impact of antimicrobial de-escalation therapy in culture-negative pneumonia: a systematic review and meta-analysis. Korean J Intern Med 2023; 38:704-713. [PMID: 37586813 PMCID: PMC10493446 DOI: 10.3904/kjim.2023.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/07/2023] [Accepted: 06/09/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND/AIMS Antimicrobial de-escalation (ADE) remains a challenging strategy in the treatment of pneumonia. We investigated the outcomes of ADE as measured by mortality and duration of the use of antibiotics in patients with culture- negative pneumonia. METHODS We performed a systematic review and meta-analysis in accordance with PRISMA guidelines. The primary outcome was inpatient mortality. RESULTS We examined six studies comprising 11,933 subjects, of whom 1,152 received ADE. Overall, the ADE strategy was associated with a statistically lower risk of in-hospital mortality compared with non-ADE (risk ratio [RR] = 0.60, 95% confidence interval [CI] = 0.38 to 0.93). Although substantial heterogeneity was found among the included studies (I2 = 66%), a meta-regression analysis could not reveal plausible sources of heterogeneity. And ADE was associated with a shorter duration of total and initial antibiotic therapies and total length of hospital stay compared with non-ADE. CONCLUSION Our findings suggest that ADE seems to be significantly associated with better clinical outcomes compared with non-ADE. Caution is demanded when interpreting data of this study because of substantial between-study heterogeneity.
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Affiliation(s)
- Jae-Uk Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jonghoo Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju,
Korea
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Arain S, Khalawi F, Parakkal SA, AlHamad HS, Thorakkattil SA, Alghashmari FFJ, AlHarbi B, Bakhashwain N, Alzawad WM, AlHomoud A. Drug Utilization Evaluation and Impact of Pharmacist Interventions on Optimization of Piperacillin/Tazobactam Use: A Retrospective Analysis and Prospective Audit. Antibiotics (Basel) 2023; 12:1192. [PMID: 37508288 PMCID: PMC10376400 DOI: 10.3390/antibiotics12071192] [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: 06/08/2023] [Revised: 07/08/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Piperacillin/tazobactam is a broad-spectrum antimicrobial encompassing most Gram-positive and Gram-negative aerobic and anaerobic bacteria. The inappropriate use of such broad-spectrum antibiotics is an important contributor to the rising rates of antimicrobial drug resistance worldwide. Drug utilization evaluation studies and pharmacists' interventions are vital to assess, develop, and promote the rational use of antibiotics. This drug utilization study aimed to evaluate the current utilization practice of piperacillin/tazobactam in a hospital setting and assess the impact of pharmacist intervention in improving its appropriate use. (2) Methodology: In this study, we used a retrospective cohort and a prospective cohort, a cross-sectional, observational method. It included a retrospective (Cycle A/pre-intervention-CycA) phase followed by an educational interventional phase conducted by the pharmacists. During the 2 months of educational intervention, pharmacists used several methods, including workshops, lectures, oral presentations, and the development and reinforcement of clinical pathways to promote the judicious use of piperacillin/tazobactam. This was followed by a prospective (Cycle B/post-intervention-CycB) phase to improve piperacillin/tazobactam usage appropriateness. The appropriateness criteria for this drug utilization evaluation were established based on antimicrobial guidelines, the published literature, the institutional antibiogram, consultation from the antimicrobial stewardship committee, and the product monograph (Tazocin). The appropriateness of CycA and CycB patients was compared using the measurable elements, including indication and dose based on renal function, timely order for cultures, de-escalation, and use of extended infusion protocol. (3) Results: The study population comprised 100 patients in both CycA and CycB. The mean age of the patients was 66.28 ± 16.15 and 67.35 ± 17.98, and the ratios of men to women were found to be 49:51 and 61:39 in CycA and CycB, respectively. It was observed that inappropriate usage was high in CycA patients, and the appropriateness was improved in CycB patients. A total of 31% of inappropriate empirical broad-spectrum use was found in CycA, and it was reduced to 12% in CycB patients. The transition of appropriateness was observed in all measurable criteria, which includes the optimized dose according to the renal function (CycA = 49% to CycB = 94%), timely bacterial culture orders (CycA = 47% to CycB = 74%), prompt de-escalation (CycA = 31% to CycB = 53%), and adherence to extended infusion institutional guidelines (CycA = 34% to CycB = 86%). (4) Conclusions: The study highlighted important aspects of inappropriate piperacillin/tazobactam use. This can be considerably improved by proper education and timely interventions based on the pharmacists' vigilant approach. The study results emphasized the need for surveillance of piperacillin/tazobactam usage by conducting similar drug utilization evaluations and practice to improve quality and safety in healthcare organizations globally.
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Affiliation(s)
- Savera Arain
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Fahad Khalawi
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Sainul Abideen Parakkal
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Hassan S AlHamad
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Shabeer Ali Thorakkattil
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | | | - Bader AlHarbi
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Nujud Bakhashwain
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Weaam Mustafa Alzawad
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
| | - Ali AlHomoud
- Pharmacy Services Department, Johns Hopkins Aramco Healthcare (JHAH), Dhahran 34465, Saudi Arabia
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10
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Altaf U, Saleem Z, Akhtar MF, Altowayan WM, Alqasoumi AA, Alshammari MS, Haseeb A, Raees F, Imam MT, Batool N, Akhtar MM, Godman B. Using Culture Sensitivity Reports to Optimize Antimicrobial Therapy: Findings and Implications of Antimicrobial Stewardship Activity in a Hospital in Pakistan. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1237. [PMID: 37512049 PMCID: PMC10384799 DOI: 10.3390/medicina59071237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/01/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023]
Abstract
Background: There are concerns with inappropriate prescribing of antibiotics in hospitals especially broad spectrum in Pakistan and the subsequent impact on antimicrobial resistance rates. One recognized way to reduce inappropriate prescribing is for empiric therapy to be adjusted according to the result of culture sensitivity reports. Objective: Using culture sensitivity reports to optimize antibiotic prescribing in a teaching hospital in Pakistan. Methods: A retrospective observational study was undertaken in Ghurki Trust Teaching Hospital. A total of 465 positive cultures were taken from patients during the study period (May 2018 and December 2018). The results of pathogen identification and susceptibility testing from patient-infected sites were assessed. Additional data was collected from the patient's medical file. This included demographic data, sample type, causative microbe, antimicrobial treatment, and whether empiric or definitive treatment as well as medicine costs. Antimicrobial data was assessed using World Health Organization's Defined Daily Dose methodology. Results: A total of 497 isolates were detected from the 465 patient samples as 32 patients had polymicrobes, which included 309 g-negative rods and 188 g-positive cocci. Out of 497 isolates, the most common Gram-positive pathogen isolated was Staphylococcus aureus (Methicillin-sensitive Staphylococcus aureus) (125) (25.1%) and the most common Gram-negative pathogen was Escherichia coli (140) (28.1%). Most of the gram-negative isolates were found to be resistant to ampicillin and co-amoxiclav. Most of the Acinetobacter baumannii isolates were resistant to carbapenems. Gram-positive bacteria showed the maximum sensitivity to linezolid and vancomycin. The most widely used antibiotics for empiric therapy were cefoperazone plus sulbactam, ceftriaxone, amikacin, vancomycin, and metronidazole whereas high use of linezolid, clindamycin, meropenem, and piperacillin + tazobactam was seen in definitive treatment. Empiric therapy was adjusted in 220 (71.1%) cases of Gram-negative infections and 134 (71.2%) cases of Gram-positive infections. Compared with empiric therapy, there was a 13.8% reduction in the number of antibiotics in definitive treatment. The average cost of antibiotics in definitive treatment was less than seen with empiric treatment (8.2%) and the length of hospitalization also decreased. Conclusions: Culture sensitivity reports helped reduced antibiotic utilization and costs as well as helped select the most appropriate treatment. We also found an urgent need for implementing antimicrobial stewardship programs in hospitals and the development of hospital antibiotic guidelines to reduce unnecessary prescribing of broad-spectrum antibiotics.
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Affiliation(s)
- Ummara Altaf
- Riphah Institute of Pharmaceutical Sciences, Riphah International University, Lahore 54000, Pakistan; (U.A.); (M.F.A.)
- Department of Pharmaceutical Services, Ghurki Trust Teaching Hospital, Lahore 54000, Pakistan
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan 60800, Pakistan
| | - Muhammad Furqan Akhtar
- Riphah Institute of Pharmaceutical Sciences, Riphah International University, Lahore 54000, Pakistan; (U.A.); (M.F.A.)
| | - Waleed Mohammad Altowayan
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraydah 52571, Saudi Arabia; (W.M.A.); (A.A.A.)
| | - Abdulmajeed A. Alqasoumi
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraydah 52571, Saudi Arabia; (W.M.A.); (A.A.A.)
| | - Mohammed Salem Alshammari
- Department of Pharmacy Practice, Unaizah College of Pharmacy, Qassim University, Unaizah 56215, Saudi Arabia;
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 24382, Saudi Arabia;
| | - Fahad Raees
- Department of Medical Microbiology, Faculty of Medicine, Umm Al-Qura University, Makkah 24382, Saudi Arabia;
| | - Mohammad Tarique Imam
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al Kharj 11942, Saudi Arabia;
| | - Narjis Batool
- Center of Health Systems and Safety Research, Faculty of Medicine, Health and Human Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney 2109, Australia;
| | | | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow G4 0RE, UK;
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria 0208, South Africa;
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman 346, United Arab Emirates
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11
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Kadri SS, Warner S, Rhee C, Klompas M, Follmann D, Swihart BJ, Laxminarayan R, Klein E. Early Discontinuation of Antibiotics in Patients Admitted With Clinically Suspected Serious Infection but Negative Cultures: Retrospective Cohort Study of Practice Patterns and Outcomes at 111 US Hospitals. Open Forum Infect Dis 2023; 10:ofad286. [PMID: 37449298 PMCID: PMC10336666 DOI: 10.1093/ofid/ofad286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/19/2023] [Indexed: 07/18/2023] Open
Abstract
Background The optimal duration for antibiotics in patients hospitalized with culture-negative serious infection (CNSI) is unknown. We compared outcomes in patients with CNSI treated with 3 or 4 vs ≥5 days of antibiotics. Methods CNSI was identified among adults admitted to 111 US hospitals between 2009 and 2014 via electronic health record data, defined as suspected serious infection (blood cultures drawn and ≥3 days of antibiotics) and negative culture- and nonculture-based tests for infection. Patients treated with antibiotics on their last hospital day and patients with diagnosis codes for sepsis-mimicking conditions were excluded. Among patients without fevers/hypothermia or vasopressors by day 3, we calculated odds ratios for in-hospital mortality or discharge to hospice associated with 3 or 4 vs ≥5 days of antibiotics, adjusting for confounders. Results Antibiotics were discontinued in 3 or 4 days in 1862 (9%) of 20 714 patients with CNSI. Early discontinuation was not associated with higher mortality odds overall (adjusted odds ratio [aOR], 1.27; 95% CI, .98-1.65), in patients presenting with (1.39; .88-2.22) and without sepsis (1.17; .81-1.69), and in those with pulmonary (1.23; .65-2.34) and nonpulmonary CNSI (1.30; .99-1.72). Early discontinuation appeared detrimental with propensity score weighting (aOR, 1.36; 95% CI, 1.03-1.80) and when retaining patients with sepsis mimics (1.38; 1.16-1.65), but it was protective (0.48; .37-.64]) when retaining patients who received antibiotics on their last hospital day. Conclusions Early discontinuation of antibiotics in CNSI was not associated with significant harm in our primary analysis, but different conclusions based on alternative analytic decisions, as well as risk of residual confounding, indicate that randomized controlled trials are needed.
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Affiliation(s)
- Sameer S Kadri
- Clinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Sarah Warner
- Clinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dean Follmann
- Department of Biostatistics, National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - Bruce J Swihart
- Department of Biostatistics, National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | | | - Eili Klein
- One Health Trust, Washington, DC
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD
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12
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Ferdousi T, Dutta AK, Chowdhury MAH, Islam K, Islam MT, Islam MZ, Bulbul MRH, Khan AI, Qadri F. Role of TaqMan array card in determining causative organisms of acute febrile illness in hospitalized patients. J Clin Lab Anal 2023; 37:e24948. [PMID: 37496432 PMCID: PMC10492456 DOI: 10.1002/jcla.24948] [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: 02/13/2023] [Revised: 05/23/2023] [Accepted: 07/17/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Acute febrile illness (AFI) is a prevalent disease in developing countries that is difficult to diagnose due to the diversity of infectious organisms and the poor quality of clinical diagnosis. TaqMan array card (TAC) can detect up to 35 AFI-associated organisms in 1.5 h, addressing diagnostic demands. In this study, we aimed to evaluate the role of TAC in determining the causative organisms in hospitalized AFI patients. METHODS The study had a cross-sectional design and enrolled 120 admitted patients with persistent fever for three or more days from the medicine ward of Chittagong Medical College Hospital (CMCH) and Bangladesh Institute of Tropical and Infectious Diseases Hospital (BITID). Blood samples were collected and then subjected to automated BacT/Alert blood culture, microbial culture, TAC assay, and typhoid/paratyphoid test. RESULTS The total number of study participants was 120, among them 48 (40%) samples showed a positive result in TAC card, 29 (24.16%) were TP positive and nine (7.51%) were culture positive. The number of organisms detected by the TAC card was 13 bacteria, three viruses, one protozoan, and one fungus. The sensitivity and specificity of the TAC assay for different bacterial pathogen compared to blood culture was 44.44%, and 90.99%, respectively. In contrast, the TP test had a sensitivity and specificity of 100% and 80%, respectively, compared to the blood culture test. CONCLUSION TAC can be a handful tool for detecting multiple organisms in AFI with high specificity which can facilitate early diagnosis of different pathogens contributing to AFI.
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Affiliation(s)
- Tabassum Ferdousi
- Bangladesh Institute of Tropical and Infectious DiseasesChattogramBangladesh
| | | | | | - Kamrul Islam
- International Centre for Diarrheal Disease Research, Bangladesh (icddr,b)DhakaBangladesh
| | - Md. Taufiqul Islam
- International Centre for Diarrheal Disease Research, Bangladesh (icddr,b)DhakaBangladesh
| | - Md. Zahirul Islam
- Institute for Developing Science and Health Initiatives (ideSHi)DhakaBangladesh
| | | | - Ashraful Islam Khan
- International Centre for Diarrheal Disease Research, Bangladesh (icddr,b)DhakaBangladesh
| | - Firdausi Qadri
- International Centre for Diarrheal Disease Research, Bangladesh (icddr,b)DhakaBangladesh
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13
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Zhang Y, Cheng Z, Hu Y, Tang LV. Management of Complex Infections in Hemophagocytic Lymphohistiocytosis in Adults. Microorganisms 2023; 11:1694. [PMID: 37512867 PMCID: PMC10383929 DOI: 10.3390/microorganisms11071694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive immune system activation and inflammatory response due to a variety of primary and secondary factors that can cause a range of clinical symptoms and, in severe cases, life-threatening conditions. Patients with HLH are at increased risk of infection due to their abnormal immune function as well as chemotherapy and immunosuppressive therapy at the time of treatment. At the same time, the lack of specific clinical features makes complex infections in HLH challenging to diagnose and treat. The management of complex infections in HLH requires a multidisciplinary and integrated approach including the early identification of pathogens, the development of anti-infection protocols and regimens, and the elimination of potential infection factors. Especially in HLH patients with septic shock, empirical combination therapy against the most likely pathogens should be initiated, and appropriate anti-infective regimens should be determined based on immune status, site of infection, pathogens, and their drug resistance, with timely antibiotic adjustment by monitoring procalcitonin. In addition, anti-infection prophylaxis for HLH patients is needed to reduce the risk of infection such as prophylactic antibiotics and vaccinations. In conclusion, complex infection in HLH is a serious and challenging disease that requires vigilance, early identification, and timely anti-infective therapy.
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Affiliation(s)
- Yi Zhang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
| | - Zhipeng Cheng
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
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14
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Okamoto M, Maejima M, Goto T, Mikawa T, Hosaka K, Nagakubo Y, Hirotsu Y, Amemiya K, Sueki H, Omata M. Impact of the FilmArray Rapid Multiplex PCR Assay on Clinical Outcomes of Patients with Bacteremia. Diagnostics (Basel) 2023; 13:diagnostics13111935. [PMID: 37296787 DOI: 10.3390/diagnostics13111935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/23/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
Bacteremia is a serious disease with a reported mortality of 30%. Appropriate antibiotic use with a prompt blood culture can improve patient survival. However, when bacterial identification tests based on conventional biochemical properties are used, it takes 2 to 3 days from positive blood culture conversion to reporting the results, which makes early intervention difficult. Recently, FilmArray (FA) multiplex PCR panel for blood culture identification was introduced to the clinical setting. In this study, we investigated the clinical impact of the FA system on decision making for treating septic diseases and its association with patients' survival. Our hospital introduced the FA multiplex PCR panel in July 2018. In this study, blood-culture-positive cases submitted between January and October 2018 were unbiasedly included, and clinical outcomes before and after the introduction of FA were compared. The outcomes included (i) the duration of use of broad-spectrum antibiotics, (ii) the time until the start of anti-MRSA therapy to MRSA bacteremia, and (iii) sixty-day overall survival. In addition, multivariate analysis was used to identify prognostic factors. In the FA group, overall, 122 (87.8%) microorganisms were concordantly retrieved with the FA identification panel. The duration of ABPC/SBT use and the start-up time of anti-MRSA therapy to MRSA bacteremia were significantly shorter in the FA group. Sixty-day overall survival was significantly improved by utilizing FA compared with the control group. In addition, multivariate analysis identified Pitt score, Charlson score, and utilization of FA as prognostic factors. In conclusion, FA can lead to the prompt bacterial identification of bacteremia and its effective treatment, thus significantly improving survival in patients with bacteremia.
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Affiliation(s)
- Mai Okamoto
- Department of Internal Medicine, Yamanashi Central Hospital, Kofu 400-8506, Japan
| | - Makoto Maejima
- Clinical Laboratory Center, Yamanashi Central Hospital, Kofu 400-8506, Japan
| | - Taichiro Goto
- Lung Cancer and Respiratory Disease Center, Yamanashi Central Hospital, Kofu 400-8506, Japan
| | - Takahiro Mikawa
- Department of Internal Medicine, Yamanashi Central Hospital, Kofu 400-8506, Japan
| | - Kazuhiro Hosaka
- Department of Internal Medicine, Yamanashi Central Hospital, Kofu 400-8506, Japan
| | - Yuki Nagakubo
- Clinical Laboratory Center, Yamanashi Central Hospital, Kofu 400-8506, Japan
| | - Yosuke Hirotsu
- Genome Analysis Center, Yamanashi Central Hospital, Kofu 400-8506, Japan
| | - Kenji Amemiya
- Genome Analysis Center, Yamanashi Central Hospital, Kofu 400-8506, Japan
| | - Hitomi Sueki
- Department of Internal Medicine, Yamanashi Central Hospital, Kofu 400-8506, Japan
| | - Masao Omata
- Genome Analysis Center, Yamanashi Central Hospital, Kofu 400-8506, Japan
- Department of Gastroenterology, The University of Tokyo, Tokyo 113-8655, Japan
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Mokrani D, Chommeloux J, Pineton de Chambrun M, Hékimian G, Luyt CE. Antibiotic stewardship in the ICU: time to shift into overdrive. Ann Intensive Care 2023; 13:39. [PMID: 37148398 PMCID: PMC10163585 DOI: 10.1186/s13613-023-01134-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/20/2023] [Indexed: 05/08/2023] Open
Abstract
Antibiotic resistance is a major health problem and will be probably one of the leading causes of deaths in the coming years. One of the most effective ways to fight against resistance is to decrease antibiotic consumption. Intensive care units (ICUs) are places where antibiotics are widely prescribed, and where multidrug-resistant pathogens are frequently encountered. However, ICU physicians may have opportunities to decrease antibiotics consumption and to apply antimicrobial stewardship programs. The main measures that may be implemented include refraining from immediate prescription of antibiotics when infection is suspected (except in patients with shock, where immediate administration of antibiotics is essential); limiting empiric broad-spectrum antibiotics (including anti-MRSA antibiotics) in patients without risk factors for multidrug-resistant pathogens; switching to monotherapy instead of combination therapy and narrowing spectrum when culture and susceptibility tests results are available; limiting the use of carbapenems to extended-spectrum beta-lactamase-producing Enterobacteriaceae, and new beta-lactams to difficult-to-treat pathogen (when these news beta-lactams are the only available option); and shortening the duration of antimicrobial treatment, the use of procalcitonin being one tool to attain this goal. Antimicrobial stewardship programs should combine these measures rather than applying a single one. ICUs and ICU physicians should be at the frontline for developing antimicrobial stewardship programs.
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Affiliation(s)
- David Mokrani
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Juliette Chommeloux
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Hékimian
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
- Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
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16
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Chiotos K, Blumenthal J, Boguniewicz J, Palazzi DL, Stalets EL, Rubens JH, Tamma PD, Cabler SS, Newland J, Crandall H, Berkman E, Kavanagh RP, Stinson HR, Gerber JS. Antibiotic Indications and Appropriateness in the Pediatric Intensive Care Unit: A 10-Center Point Prevalence Study. Clin Infect Dis 2023; 76:e1021-e1030. [PMID: 36048543 PMCID: PMC10169439 DOI: 10.1093/cid/ciac698] [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: 05/31/2022] [Revised: 08/04/2022] [Accepted: 08/24/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Antibiotics are prescribed to most pediatric intensive care unit (PICU) patients, but data describing indications and appropriateness of antibiotic orders in this population are lacking. METHODS We performed a multicenter point prevalence study that included children admitted to 10 geographically diverse PICUs over 4 study days in 2019. Antibiotic orders were reviewed for indication, and appropriateness was assessed using a standardized rubric. RESULTS Of 1462 patients admitted to participating PICUs, 843 (58%) had at least 1 antibiotic order. A total of 1277 antibiotic orders were reviewed. Common indications were empiric therapy for suspected bacterial infections without sepsis or septic shock (260 orders, 21%), nonoperative prophylaxis (164 orders, 13%), empiric therapy for sepsis or septic shock (155 orders, 12%), community-acquired pneumonia (CAP; 118 orders, 9%), and post-operative prophylaxis (94 orders, 8%). Appropriateness was assessed for 985 orders for which an evidence-based rubric for appropriateness could be created. Of these, 331 (34%) were classified as inappropriate. Indications with the most orders classified as inappropriate were empiric therapy for suspected bacterial infection without sepsis or septic shock (78 orders, 24%), sepsis or septic shock (55 orders, 17%), CAP (51 orders, 15%), ventilator-associated infections (47 orders, 14%), and post-operative prophylaxis (44 orders, 14%). The proportion of antibiotics classified as inappropriate varied across institutions (range, 19%-43%). CONCLUSIONS Most PICU patients receive antibiotics. Based on our study, we estimate that one-third of antibiotic orders are inappropriate. Improved antibiotic stewardship and research focused on strategies to optimize antibiotic use in critically ill children are needed.
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Affiliation(s)
- Kathleen Chiotos
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Blumenthal
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Juri Boguniewicz
- Section of Infectious Diseases and Epidemiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Debra L Palazzi
- Infectious Diseases Division, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Erika L Stalets
- Division of Critical Care Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jessica H Rubens
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pranita D Tamma
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephanie S Cabler
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jason Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Emily Berkman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Robert P Kavanagh
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State University College of Medicine, Hershey, Pennsylvania, USA
| | - Hannah R Stinson
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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17
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Baltogianni M, Giapros V, Kosmeri C. Antibiotic Resistance and Biofilm Infections in the NICUs and Methods to Combat It. Antibiotics (Basel) 2023; 12:antibiotics12020352. [PMID: 36830264 PMCID: PMC9951928 DOI: 10.3390/antibiotics12020352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Neonatal sepsis is an important cause of neonatal morbidity and mortality. A significant proportion of bacteria causing neonatal sepsis is resistant to multiple antibiotics, not only to the usual empirical first-line regimens, but also to second- and third-line antibiotics in many neonatal intensive care units (NICUs). NICUs have unique antimicrobial stewardship goals. Apart from antimicrobial resistance, NICUs have to deal with another problem, namely biofilm infections, since neonates often have central and peripheral lines, tracheal tubes and other foreign bodies for a prolonged duration. The aim of this review is to describe traditional and novel ways to fight antibiotic-resistant bacteria and biofilm infections in NICUs. The topics discussed will include prevention and control of the spread of infection in NICUs, as well as the wise use of antimicrobial therapy and ways to fight biofilm infections.
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Affiliation(s)
- Maria Baltogianni
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45500 Ioannina, Greece
| | - Vasileios Giapros
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 45500 Ioannina, Greece
- Correspondence: ; Tel.: +30-26-5100-7546
| | - Chrysoula Kosmeri
- Department of Pediatrics, University Hospital of Ioannina, 45500 Ioannina, Greece
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18
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Tarabichi S, Goh GS, Zanna L, Qadiri QS, Baker CM, Gehrke T, Citak M, Parvizi J. Time to Positivity of Cultures Obtained for Periprosthetic Joint Infection. J Bone Joint Surg Am 2023; 105:107-112. [PMID: 36574630 DOI: 10.2106/jbjs.22.00766] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite its well-established limitations, culture remains the gold standard for microbial identification in periprosthetic joint infection (PJI). However, there are no benchmarks for the time to positivity (TTP) on culture for specific microorganisms. This study aimed to determine the TTP for pathogens commonly encountered in PJI. METHODS This retrospective, multicenter study reviewed prospectively maintained institutional PJI databases to identify patients who underwent hip or knee revision arthroplasty from 2017 to 2021 at 2 tertiary centers in the United States and Germany. Only patients who met the 2018 International Consensus Meeting (ICM) criteria for PJI and had a positive intraoperative culture were included. TTP on culture media was recorded for each sample taken intraoperatively. The median TTP was compared among different microbial species and different specimen types. Data are presented either as the mean and the standard deviation or as the median and the interquartile range (IQR). RESULTS A total of 536 ICM-positive patients with positive cultures were included. The mean number of positive cultures per patient was 3.9 ± 2.6. The median TTP, in days, for all positive cultures was 3.3 (IQR, 1.9 to 5.4). Overall, gram-negative organisms (TTP, 1.99 [1.1 to 4.1]; n = 225) grew significantly faster on culture compared with gram-positive organisms (TTP, 3.33 [1.9 to 5.8]; n = 1,774). Methicillin-resistant Staphylococcus aureus (TTP, 1.42 [1.0 to 2.8]; n = 85) had the fastest TTP, followed by gram-negative rods (TTP, 1.92 [1.0 to 3.9]; n = 163), methicillin-sensitive Staphylococcus aureus (TTP, 1.95 [1.1 to 3.3] n = 393), Streptococcus species (TTP, 2.92 [1.2 to 4.3]; n = 230), Staphylococcus epidermidis (TTP, 4.20 [2.4 to 5.5]; n = 555), Candida species (TTP, 5.30 [3.1 to 10]; n = 63), and Cutibacterium acnes (TTP, 6.97 [5.9 to 8.2]; n = 197). When evaluating the median TTP according to specimen type, synovial fluid (TTP, 1.97 [1.1 to 3.1]; n = 112) exhibited the shortest TTP, followed by soft tissue (TTP, 3.17 [1.4 to 5.3]; n = 1,199) and bone (TTP, 4.16 [2.3 to 5.9]; n = 782). CONCLUSIONS To our knowledge, this is the first study to examine the TTP of common microorganisms that are known to cause PJI. Increased awareness of these data may help to guide the selection of appropriate antimicrobial therapy and to predict treatment outcomes in the future. Nonetheless, additional studies with larger cohorts are needed to validate these benchmarks. LEVEL OF EVIDENCE Diagnostic Level IV . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Luigi Zanna
- Traumatology and General Orthopedics Department, Careggi University Hospital, Florence, Italy.,Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Qudratullah S Qadiri
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Colin M Baker
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Javad Parvizi
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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19
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Pan Y, Fan Q. Clostridium Symbiosum Sepsis Diagnosed Using Next-Generation Sequencing in a 2 Year Old Child: A Case Report. Fetal Pediatr Pathol 2022; 42:518-521. [PMID: 36541613 DOI: 10.1080/15513815.2022.2158696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Sepsis is a severe illness that can affect preterm, term, and young infants, and is often associated with negative cultures.Case report: A 2-year-old boy, with a previous partial colectomy after birth, presented with abdominal complaints and clinical sepsis. We empirically treated with meropenem and linezolid. Blood cultures were sterile, and fecal cultures demonstrated no pathogenes. Metagenomic next-generation sequencing identified Clostridium symbiosum from blood sample. The result supported the continued use of the antibiotic regimen. After 1 week, CRP and PCT returned to normal and subsequent de-escalation therapy (cefotaxime sodium sulbactam and metronidazole) was used for anaerobic bacteria. Conclusions: mNGS identified an anaerobic agent responsible for sepsis. From the published sensitivities, the organism was sensitive to the original empiric antibiotic therapy.
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Affiliation(s)
- Yan Pan
- Department of Pediatrics, the First Affiliated Hospital of Yangtze University, Jingzhou, China
| | - Qihong Fan
- Department of Pediatrics, the First Affiliated Hospital of Yangtze University, Jingzhou, China
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20
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Donnars A, Eveillard M. [Rapid diagnosis of bacteremia by genomic identification]. ANNALES PHARMACEUTIQUES FRANÇAISES 2022; 81:425-432. [PMID: 36464071 DOI: 10.1016/j.pharma.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/23/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
Our objective was to make a focus on the methods for rapid diagnosis of bacteremia by genomic identification. We also aimed to evaluate the interest of using them in the laboratory practice. The different methods currently available have been presented according to their technologic approach. It is also possible to classify these methods according to the data provided, only bacterial and/or resistance gene identification or also bacterial susceptibility to antibiotics. In case of mono-microbial blood cultures, the performances recorded with these methods are very good as compared to the subcultures on agar media. Nevertheless, they are better for identifications (>90%) than for susceptibility to antibiotics (>80%). Numerous studies demonstrated the positive impact of these methods for decreasing the time necessary to the prescription of an appropriate antimicrobial treatment. However, it is noteworthy that an appropriate organization of the laboratory and a strategy of antimicrobial stewardship in the hospital are necessary. Concurrently, the impact on the patient outcome has not been clearly demonstrated. Lastly, few medico-economic studies have been reported. However, as these methods have a substantial cost, their utilization strategy must be economically viable.
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Affiliation(s)
- A Donnars
- Laboratoire de bactériologie, département de biologie des agents infectieux, centre hospitalier universitaire d'Angers, Angers, France
| | - M Eveillard
- Laboratoire de bactériologie, département de biologie des agents infectieux, centre hospitalier universitaire d'Angers, Angers, France.
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21
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Li Y, Ma M, Xu X, Li Q, Ji C. Value of digital PCR in the early diagnosis of sepsis: A systematic review and meta-analysis. J Crit Care 2022; 72:154138. [PMID: 36084378 DOI: 10.1016/j.jcrc.2022.154138] [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: 07/03/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND We systematically assessed whether a digital polymerase chain reaction (PCR) could detect pathogenic microorganisms in patients with sepsis early and accurately. METHODS We searched the Cochrane Library, MEDLINE, Embase, CNKI, CBM, and Wanfang Data databases for eligible studies to compare the detection of pathogenic microorganisms in blood samples by digital PCR with the gold standard. The Quality Assessment of Diagnostic Accuracy Studies 2 was used to evaluate bias risk, and a random-effects meta-analysis approach was used for sensitivity and specificity calculations. RESULTS Among the eight articles, there were eight identified studies with a total of 1278 subjects. The pooled sensitivity of digital PCR was 94% (95% confidence interval [CI], 85%-98%), the specificity was 87% (95% CI, 76%-94%), the positive likelihood ratio was 7.3 (95% CI, 3.8-14.2), the negative likelihood ratio was 0.07 (95% CI, 0.03-0.17), the positive predictive value was 84.7%, the negative predictive value was 89.2%, the diagnostic odds ratio was 105 (95% CI, 37-303), and the area under the receiver operating characteristic curve was 0.97 (95% CI, 0.95-1.00). Digital PCR can shorten the detection time of pathogenic microorganisms in patients with sepsis. CONCLUSIONS Digital PCR can detect pathogenic microorganisms in patients with sepsis earlier than blood culture. Therefore, digital PCR can be used as a potential strategy for the detection of pathogenic microorganisms in patients with sepsis.
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Affiliation(s)
- Yu Li
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, China
| | - Minjun Ma
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiujuan Xu
- Critical Care Department, Tongde Hospital of Zhejiang Province, Hangzhou, China.
| | - Qiushuang Li
- Clinical Evaluation Center, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Conghua Ji
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, China; Clinical Evaluation Center, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China.
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22
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SHEA statement on antibiotic stewardship in hospitals during public health emergencies. Infect Control Hosp Epidemiol 2022; 43:1541-1552. [PMID: 36102000 PMCID: PMC9672827 DOI: 10.1017/ice.2022.194] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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23
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Sakulkonkij P, Bruminhent J. Clinical outcome of rapid diagnosis and antibiotic stewardship in patients with bloodstream infection in Lampang Hospital. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e174. [PMID: 36483367 PMCID: PMC9726534 DOI: 10.1017/ash.2022.311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/08/2022] [Accepted: 09/08/2022] [Indexed: 06/17/2023]
Abstract
Bloodstream infection is a significant cause of morbidity and mortality. Early diagnosis and appropriate antibiotic treatment contribute to a favorable prognosis. We demonstrate a reduction of time to proper antibiotics and reduced mortality utilizing prompt diagnosis and antibiotic stewardship by infectious diseases physicians at a general hospital in Thailand.
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Affiliation(s)
- Parichart Sakulkonkij
- Division of Infectious Diseases, Internal Medicine Department, Lampang Hospital, Lampang, Thailand
| | - Jackrapong Bruminhent
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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24
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Dutta S, McEvoy DS, Rubins DM, Dighe AS, Filbin MR, Rhee C. Clinical decision support improves blood culture collection before intravenous antibiotic administration in the emergency department. J Am Med Inform Assoc 2022; 29:1705-1714. [PMID: 35877074 PMCID: PMC9471721 DOI: 10.1093/jamia/ocac115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 06/07/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Surviving Sepsis guidelines recommend blood cultures before administration of intravenous (IV) antibiotics for patients with sepsis or moderate to high risk of bacteremia. Clinical decision support (CDS) that reminds emergency department (ED) providers to obtain blood cultures when ordering IV antibiotics may lead to improvements in this process measure. METHODS This was a multicenter causal impact analysis comparing timely blood culture collections prior to IV antibiotics for adult ED patients 1 year before and after a CDS intervention implementation in the electronic health record. A Bayesian structured time-series model compared daily timely blood cultures collected compared to a forecasted synthetic control. Mixed effects models evaluated the impact of the intervention controlling for confounders. RESULTS The analysis included 54 538 patients over 2 years. In the baseline phase, 46.1% had blood cultures prior to IV antibiotics, compared to 58.8% after the intervention. Causal impact analysis determined an absolute increase of 13.1% (95% CI 10.4-15.7%) of timely blood culture collections overall, although the difference in patients with a sepsis diagnosis or who met CDC Adult Sepsis Event criteria was not significant, absolute difference 8.0% (95% CI -0.2 to 15.8). Blood culture positivity increased in the intervention phase, and contamination rates were similar in both study phases. DISCUSSION CDS improved blood culture collection before IV antibiotics in the ED, without increasing overutilization. CONCLUSION A simple CDS alert increased timely blood culture collections in ED patients for whom concern for infection was high enough to warrant IV antibiotics.
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Affiliation(s)
- Sayon Dutta
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Mass General Brigham Digital Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Dustin S McEvoy
- Mass General Brigham Digital Health, Boston, Massachusetts, USA
| | - David M Rubins
- Mass General Brigham Digital Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anand S Dighe
- Mass General Brigham Digital Health, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Chanu Rhee
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
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25
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Abelenda-Alonso G, Rombauts A, Gudiol C, García-Lerma E, Pallarés N, Ardanuy C, Calatayud L, Niubó J, Tebé C, Carratalà J. Effect of positive microbiological testing on antibiotic de-escalation and outcomes in community-acquired pneumonia: A propensity score analysis. Clin Microbiol Infect 2022; 28:1602-1608. [PMID: 35809784 DOI: 10.1016/j.cmi.2022.06.021] [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: 02/25/2022] [Revised: 06/03/2022] [Accepted: 06/18/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The usefulness of routine microbiological testing for rationalizing antibiotic use in hospitalized patients with community-acquired pneumonia (CAP) continues to be a subject of debate. We aim to determine the effect of positive microbiological testing on antimicrobial de-escalation and clinical outcomes in CAP. METHODS A retrospective analysis of a prospectively collected cohort of non-immunosuppressed adults hospitalized with CAP was performed. The primary study outcome was antimicrobial de-escalation. Secondary outcomes included 30-day case-fatality rate, adverse events, and CAP recurrence. Adjustment for confounders, was performed by inverse probability weighting propensity score (IPW-PS), logistic regression and cause-specific Cox model. RESULTS Of 3677 patients with CAP, 1924 (52.3%) had any positive microbiological test. Antimicrobial de-escalation was performed in 648/1924 (33.7%) of patients with positive microbiological testing and in 179/1753 (10.2%) of those with non positive results. When propensity score was entered into the multivariate analysis, positive microbiological testing (Adjusted Odds Ratio [AOR] 2.59 (1.96 - 3.41) and clinical stability at day 3 (AOR 1.87; 1.45 - 2.10) were two of the main factors independently associated with antimicrobial de-escalation. After applying an adjusted cause-specific Cox model, antimicrobial de-escalation was not associated with a higher 30-day case-fatality rate (Adjusted Hazard Ratio [AHR] 0.44; 0.14 - 1.43), higher frequency of adverse events (AHR 0.77; 0.53 - 1.12) or CAP recurrence (AHR 0.77; 0.45 - 1.28). CONCLUSIONS Antimicrobial de-escalation was more often performed in hospitalized patients with CAP who had positive microbiological tests than in those with non positive results, and it did not adversely affect relevant clinical outcomes.
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Affiliation(s)
- Gabriela Abelenda-Alonso
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Alexander Rombauts
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Carlota Gudiol
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; University of Barcelona; Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
| | | | | | - Carmen Ardanuy
- University of Barcelona; Department of Clinical Microbiology, Bellvitge University Hospital, Barcelona, Spain; Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Laura Calatayud
- Department of Clinical Microbiology, Bellvitge University Hospital, Barcelona, Spain; Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Jordi Niubó
- Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain; Department of Clinical Microbiology, Bellvitge University Hospital, Barcelona, Spain
| | | | - Jordi Carratalà
- Department of Infectious Diseases, Bellvitge University Hospital, Barcelona, Spain; Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain; University of Barcelona; Center for Biomedical Research in Infectious Diseases Network (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain.
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26
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Ngougni Pokem P, Wittebole X, Collienne C, Rodriguez-Villalobos H, Tulkens PM, Elens L, Van Bambeke F, Laterre PF. Population Pharmacokinetics of Temocillin Administered by Continuous Infusion in Patients with Septic Shock Associated with Intra-Abdominal Infection and Ascitic Fluid Effusion. Antibiotics (Basel) 2022; 11:antibiotics11070898. [PMID: 35884152 PMCID: PMC9311849 DOI: 10.3390/antibiotics11070898] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/16/2022] [Accepted: 06/30/2022] [Indexed: 02/04/2023] Open
Abstract
Temocillin is active against Gram-negative bacteria, including many extended-spectrum β-lactamase (ESBL)-producing Enterobacterales. We studied its pharmacokinetics in plasma and ascitic fluid after intravenous administration of a loading dose of 2 g over 30 min, followed by continuous infusion of 6 g/24 h, to 19 critically-ill patients with septic shock associated with complicated intra-abdominal infection. We established a pharmacokinetic model describing unbound temocillin concentrations in plasma and ascitic fluid and performed Monte-Carlo simulations to evaluate the probability of target attainment (PTA) of unbound concentrations (100% fT > MIC, i.e., unbound concentrations remaining above the MIC during 100% of the time) for the applied and hypothetical dosing regimens. The temocillin AUC in ascitic fluid was 46% of the plasma AUC. Plasma unbound concentrations were best described by a two-compartment model, and an additional compartment was added to describe unbound concentration in ascitic fluid, with renal clearance as a covariate. Dosing simulations showed that 90% PTA was achieved in the plasma with the current dosing regimen for MIC ≤ 16 mg/L (EUCAST susceptibility breakpoint) but not in the ascitic fluid if renal clearance was ≥40 mL/min. Hypothetical dosing with a higher (a) loading dose or (b) infused dose allowed to reach target concentrations in ascitic fluid (a) more rapidly or (b) sustainably, but these simulations need to be evaluated in the clinics for safety and efficacy.
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Affiliation(s)
- Perrin Ngougni Pokem
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université Catholique de Louvain, 1200 Brussels, Belgium; (P.N.P.); (P.M.T.)
- Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Louvain Drug Research Institute, Université Catholique de Louvain, 1200 Brussels, Belgium;
| | - Xavier Wittebole
- Department of Critical Care Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1200 Brussels, Belgium; (X.W.); (C.C.); (P.-F.L.)
| | - Christine Collienne
- Department of Critical Care Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1200 Brussels, Belgium; (X.W.); (C.C.); (P.-F.L.)
| | | | - Paul M. Tulkens
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université Catholique de Louvain, 1200 Brussels, Belgium; (P.N.P.); (P.M.T.)
| | - Laure Elens
- Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Louvain Drug Research Institute, Université Catholique de Louvain, 1200 Brussels, Belgium;
| | - Françoise Van Bambeke
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université Catholique de Louvain, 1200 Brussels, Belgium; (P.N.P.); (P.M.T.)
- Correspondence: ; Tel.: +32-2-764-73-78
| | - Pierre-François Laterre
- Department of Critical Care Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1200 Brussels, Belgium; (X.W.); (C.C.); (P.-F.L.)
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27
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Uejima Y, Suganuma E, Ohnishi T, Takei H, Furuichi M, Sato S, Kawano Y, Kitajima I, Niimi H. Prospective Study of the Detection of Bacterial Pathogens in Pediatric Clinical Specimens Using the Melting Temperature Mapping Method. Microbiol Spectr 2022; 10:e0019822. [PMID: 35674438 PMCID: PMC9241829 DOI: 10.1128/spectrum.00198-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/17/2022] [Indexed: 11/20/2022] Open
Abstract
The melting temperature (Tm) mapping method is a novel technique that uses seven primer sets without sequencing to detect dominant bacteria. This method can identify pathogenic bacteria in adults within 3 h of blood collection without using conventional culture methods. However, no studies have examined whether pathogenic bacteria can be detected in clinical specimens from pediatric patients with bacterial infections. Here, we designed a new primer set for commercial use, constructed a database with more bacterial species, and examined the agreement rate of bacterial species in vitro. Moreover, we investigated whether our system could detect pathogenic bacteria from pediatric patients using the Tm mapping method and compared the detection rates of the Tm mapping and culture methods. A total of 256 pediatric clinical specimens from 156 patients (94 males and 62 females; median age, 2 years [<18 years of age]) were used. The observed concordance rates between the Tm mapping method and the culture method for both positive and negative samples were 76.4% (126/165) in blood samples and 79.1% (72/91) in other clinical specimens. The Tm mapping detection rate was higher than that of culture using both blood and other clinical specimens. In addition, using the Tm mapping method, we identified causative bacteria in pediatric clinical specimens quicker than when using blood cultures. Hence, the Tm mapping method could be a useful adjunct for diagnosing bacterial infections in pediatric patients and may be valuable in antimicrobial stewardship for patients with bacterial infections, especially in culture-negative cases. IMPORTANCE This study provides novel insights regarding the use of the melting temperature (Tm) mapping method to identify the dominant bacteria in samples collected from pediatric patients. We designed a new set of primers for commercial use and developed a database of different bacteria that can be identified using these primers. We show that the Tm mapping method could identify bacteria from blood samples and other clinical specimens. Moreover, we provide evidence that the Tm mapping method has a higher detection rate than that of the culture-based methods and can achieve a relatively high agreement rate. We believe that our study makes a significant contribution to this field because rapid identification of the source of bacterial infections can drastically improve patient outcomes and impede the development of antibiotic-resistant bacteria.
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Affiliation(s)
- Yoji Uejima
- Division of Infectious Diseases and Immunology, Saitama Children’s Medical Center, Saitama, Japan
- Department of Clinical Laboratory and Molecular Pathology, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Eisuke Suganuma
- Division of Infectious Diseases and Immunology, Saitama Children’s Medical Center, Saitama, Japan
| | - Takuma Ohnishi
- Division of Infectious Diseases and Immunology, Saitama Children’s Medical Center, Saitama, Japan
| | - Haruka Takei
- Division of Infectious Diseases and Immunology, Saitama Children’s Medical Center, Saitama, Japan
| | - Mihoko Furuichi
- Division of Infectious Diseases and Immunology, Saitama Children’s Medical Center, Saitama, Japan
| | - Satoshi Sato
- Division of Infectious Diseases and Immunology, Saitama Children’s Medical Center, Saitama, Japan
| | - Yutaka Kawano
- Division of Infectious Diseases and Immunology, Saitama Children’s Medical Center, Saitama, Japan
| | - Isao Kitajima
- Department of Clinical Laboratory and Molecular Pathology, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Hideki Niimi
- Department of Clinical Laboratory and Molecular Pathology, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
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28
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Performance Evaluation of the Quantamatrix QMAC-dRAST System for Rapid Antibiotic Susceptibility Testing Directly from Blood Cultures. Microorganisms 2022; 10:microorganisms10061212. [PMID: 35744730 PMCID: PMC9229829 DOI: 10.3390/microorganisms10061212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/10/2022] [Accepted: 06/12/2022] [Indexed: 02/01/2023] Open
Abstract
Objectives: Rapid antibiotic susceptibility testing (AST) for positive blood cultures can improve patient clinical outcomes if the time to an effective antimicrobial therapy is shortened. In this study, we tested the Quantamatrix dRAST system (QMAC-dRAST), a rapid AST system based on time-lapse microscopic imagery of bacterial colony formation in agarose. Methods: Evaluation of the QMAC-dRAST was performed from 250 monobacterial blood cultures including 130 Enterobacterales, 20 non-fermentative Gram-negative bacteria, 69 staphylococci and 31 enterococci. Blood cultures were recovered from anonymous patients or from spiking experiments to enrich our study with bacterial species and resistant strains. Categorical agreement (CA), minor errors (me), major errors (ME) and very major errors (VME) were calculated in comparison to the results obtained from the BD Phoenix™ M50. Discrepancies between the Phoenix™ M50 and QMAC-dRAST results were investigated using the gradient strip method. The repeatability and reproducibility performance of the QMAC-dRAST was assessed for 16 strains, each strain being tested five times from a spiked blood culture. Results: The overall CAs for Enterobacterales, non-fermentative Gram-negative bacteria, staphylococci and enterococci were 95.1%, 91.2%, 93.4% and 94.5%, respectively. The VME percentage was below 4% for all the groups except for staphylococci, which showed a VME rate of 7%. The median time to result was 6.7 h (range: 4.7–7.9). Repeatability and reproducibility assays showed a high reliability of AST results with best and worst ratios of 98.8% and 99.6% and 95.0% and 98.3%, respectively. Conclusions: The QMAC-dRAST is a fast and reliable system to determine AST directly from monobacterial blood cultures with a major TAT reduction compared to conventional AST testing.
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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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Vélez JW, Aragon DC, Donadi EA, Carlotti APCP. Risk factors for mortality from sepsis in an intensive care unit in Ecuador: A prospective study. Medicine (Baltimore) 2022; 101:e29096. [PMID: 35356943 PMCID: PMC10684228 DOI: 10.1097/md.0000000000029096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/21/2022] [Indexed: 12/16/2022] Open
Abstract
ABSTRACT To investigate risk factors for mortality from sepsis in an intensive care unit (ICU) in Quito-Ecuador and their association to adherence to Surviving Sepsis Campaign recommendations.Prospective cohort study of patients with severe sepsis/septic shock admitted to the ICU of a public Ecuadorian hospital from March, 2018 to March, 2019. Demographic, clinical, treatment, and outcome data were collected from patients' health records. Patients were divided into 2 groups according to ICU survival or death. Log-binomial regression models were used to identify risk factors for mortality.In total, 154 patients were included. Patients who died in the ICU (n = 42; 27.3%) had higher sequential organ failure assessment score (median 11.5 vs 9; P<.01), more organ dysfunction (median 4 vs 3; P<.0001), and received greater volumes of fluid resuscitation in the first 6 hours (median 800 vs 600 mL; P = .01). Dysfunction of > 2 organs was a risk factor for mortality (relative risks [RR] 3.80, 95% CI 1.33-10.86), while successful early resuscitation (RR 0.32, 95% CI 0.15-0.70), successful empirical antibiotic treatment (RR 0.38, 95%CI 0.18-0.82), and antibiotic de-escalation (RR 0.28, 95%CI 0.13-0.61) were protective factors.Dysfunction of >2 organs was a risk factor for mortality from sepsis while successful early resuscitation and appropriate antibiotic treatment were protective.
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Affiliation(s)
- Jorge W Vélez
- Division of Education and Research, Hospital de Especialidades Eugenio Espejo,Universidad Central del Ecuador, Quito, Ecuador,Division of Pediatric Critical Care, Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil,Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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Parra-Rodriguez L, Guillamet MCV. Antibiotic Decision-Making in the ICU. Semin Respir Crit Care Med 2022; 43:141-149. [PMID: 35172364 DOI: 10.1055/s-0041-1741014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
It is well established that Intensive Care Units (ICUs) are a focal point in antimicrobial consumption with a major influence on the ecological consequences of antibiotic use. With the high prevalence and mortality of infections in critically ill patients, and the clinical challenges of treating patients with septic shock, the impact of real life clinical decisions made by intensivists becomes more significant. Both under- and over-treatment with unnecessarily broad spectrum antibiotics can lead to detrimental outcomes. Even though substantial progress has been made in developing rapid diagnostic tests that can help guide antibiotic use, there is still a time window when clinicians must decide the empiric antibiotic treatment with insufficient clinical data. The continuous streams of data available in the ICU environment make antimicrobial optimization an ongoing challenge for clinicians but at the same time can serve as the input for sophisticated models. In this review, we summarize the evidence to help guide antibiotic decision-making in the ICU. We focus on 1) deciding IF: to start antibiotics, 2) choosing the spectrum of the empiric agents to use, and 3) de-escalating the chosen empiric antibiotics. We provide a perspective on the role of machine learning and artificial intelligence models for clinical decision support systems that can be incorporated seamlessly into clinical practice in order to improve the antibiotic selection process and, more importantly, current and future patients' outcomes.
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Affiliation(s)
- Luis Parra-Rodriguez
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - M Cristina Vazquez Guillamet
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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Poirier AC, Kuang D, Siedler BS, Borah K, Mehat JW, Liu J, Tai C, Wang X, van Vliet AHM, Ma W, Jenkins DR, Clark J, La Ragione RM, Qu J, McFadden J. Development of Loop-Mediated Isothermal Amplification Rapid Diagnostic Assays for the Detection of Klebsiella pneumoniae and Carbapenemase Genes in Clinical Samples. Front Mol Biosci 2022; 8:794961. [PMID: 35223985 PMCID: PMC8864245 DOI: 10.3389/fmolb.2021.794961] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/30/2021] [Indexed: 12/16/2022] Open
Abstract
Klebsiella pneumoniae is an important pathogenic bacterium commonly associated with human healthcare and community-acquired infections. In recent years, K. pneumoniae has become a significant threat to global public and veterinary health, because of its high rates of antimicrobial resistance (AMR). Early diagnosis of K. pneumoniae infection and detection of any associated AMR would help to accelerate directed therapy and reduce the risk of the emergence of multidrug-resistant isolates. In this study, we identified three target genes (yhaI, epsL, and xcpW) common to K. pneumoniae isolates from both China and Europe and designed loop-mediated isothermal amplification (LAMP) assays for the detection of K. pneumoniae in clinical samples. We also designed LAMP assays for the detection of five AMR genes commonly associated with K. pneumoniae. The LAMP assays were validated on a total of 319 type reference strains and clinical isolates of diverse genetic backgrounds, in addition to 40 clinical human sputum samples, and were shown to be reliable, highly specific, and sensitive. For the K. pneumoniae–specific LAMP assay, the calculated sensitivity, specificity, and positive and negative predictive values (comparison with culture and matrix-assisted laser desorption/ionization–time of flight mass spectrometry) were all 100% on clinical isolates and, respectively, of 100%, 91%, and 90%, and 100% when tested on clinical sputum samples, while being significantly faster than the reference methods. For the blaKPC and other carbapenemases’ LAMP assays, the concordance between the LAMP results and the references methods (susceptibility tests) was 100%, on both pure cultures (n = 125) and clinical samples (n = 18). In conclusion, we developed highly sensitive and specific LAMP assays for the clinical identification of K. pneumoniae and detection of carbapenem resistance.
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Affiliation(s)
- Aurore C. Poirier
- Department of Pathology and Infectious Diseases, Faculty of Health and Medical Sciences, School of Veterinary Medicine, University of Surrey, Guildford, United Kingdom
| | - Dai Kuang
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, School of Medicine, Institute of Respiratory Diseases, Shanghai Jiao Tong University, Shanghai, China
| | - Bianca S. Siedler
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Khushboo Borah
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Jai W. Mehat
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
- Centre for Microbial Genomics and Animal Microbiome Research, Department of Pathology and Infectious Diseases, Faculty of Health and Medical Sciences, School of Veterinary Medicine, University of Surrey, Guildford, United Kingdom
| | - Jialin Liu
- Department of Critical Care Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Cui Tai
- State Key Laboratory of Microbial Metabolism, School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoli Wang
- Department of Critical Care Medicine, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Arnoud H. M. van Vliet
- Department of Pathology and Infectious Diseases, Faculty of Health and Medical Sciences, School of Veterinary Medicine, University of Surrey, Guildford, United Kingdom
- Centre for Microbial Genomics and Animal Microbiome Research, Department of Pathology and Infectious Diseases, Faculty of Health and Medical Sciences, School of Veterinary Medicine, University of Surrey, Guildford, United Kingdom
| | - Wei Ma
- State Key Laboratory of Microbial Metabolism, School of Life Sciences and Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - David R. Jenkins
- Department of Medical Microbiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - John Clark
- Department of Medical Microbiology, Epsom and St Helier University Hospitals NHS Trust, Carshalton, United Kingdom
| | - Roberto M. La Ragione
- Department of Pathology and Infectious Diseases, Faculty of Health and Medical Sciences, School of Veterinary Medicine, University of Surrey, Guildford, United Kingdom
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
| | - Jieming Qu
- Department of Pulmonary and Critical Care Medicine, Ruijin Hospital, School of Medicine, Institute of Respiratory Diseases, Shanghai Jiao Tong University, Shanghai, China
- *Correspondence: Jieming Qu, ; Johnjoe McFadden,
| | - Johnjoe McFadden
- Faculty of Health and Medical Sciences, School of Biosciences and Medicine, University of Surrey, Guildford, United Kingdom
- *Correspondence: Jieming Qu, ; Johnjoe McFadden,
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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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Sustained Improvements in Antimicrobial Therapy and Clinical Outcomes following a Pharmacist-Led Antimicrobial Stewardship Intervention: Uncontrolled Before–After Study. J Clin Med 2022; 11:jcm11030566. [PMID: 35160018 PMCID: PMC8837014 DOI: 10.3390/jcm11030566] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/13/2022] [Accepted: 01/20/2022] [Indexed: 12/19/2022] Open
Abstract
Our antimicrobial pharmacist-led intervention included: (a) a structured review of antibiotic prescriptions; (b) educating prescribers on antimicrobial therapy; (c) monthly reporting of department-level rates of blood sampling for culture. Daily review began in May 2018 and was discontinued after 10 months; however, the other interventions were conducted throughout the study period. This study aimed to evaluate the sustained impact of pharmacist’s interventions on antimicrobial therapy and clinical outcomes between the baseline (May–December 2017), intervention (May–December 2018), and post-intervention (May–December 2019) periods. The rate of blood culture collections before starting antipseudomonal agent therapy was significantly increased from the baseline to post-intervention periods (71% vs. 85%, p < 0.001). Antipseudomonal agent therapy was more frequently de-escalated in the post-intervention period than in the baseline period (73% vs. 54%, p = 0.038). Total use of antipseudomonal agents was reduced from the baseline to intervention periods and persisted during the post-intervention period (50.5 vs. 41.8 and 42.6 DDD per 1000 patient-days, p = 0.016 and p = 0.022, respectively). During the study period, there were significant reductions in the incidence of hospital-acquired Clostridioides difficile infection (1.12, 0.54, and 0.51 per 10,000 patient-days, respectively, p = 0.031) and 30-day mortality with bacteremia (19%, 18%, and 12%, respectively, p = 0.005). Our pharmacist-led interventions sustainably achieved appropriate antimicrobial therapy and improved clinical outcomes.
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Antimicrobial Stewardship Program: Reducing Antibiotic's Spectrum of Activity Is not the Solution to Limit the Emergence of Multidrug-Resistant Bacteria. Antibiotics (Basel) 2022; 11:antibiotics11010070. [PMID: 35052947 PMCID: PMC8772858 DOI: 10.3390/antibiotics11010070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/20/2021] [Accepted: 12/30/2021] [Indexed: 12/10/2022] Open
Abstract
Overconsumption of antibiotics in hospitals has led to policy implementation, including the control of antibiotic prescriptions. The impact of these policies on the evolution of antimicrobial resistance remains uncertain. In this work, we review the possible limits of such policies and focus on the need for a more efficient approach. Establishing a causal relationship between the introduction of new antibiotics and the emergence of new resistance mechanisms is difficult. Several studies have demonstrated that many resistance mechanisms existed before the discovery of antibiotics. Overconsumption of antibiotics has worsened the phenomenon of resistance. Antibiotics are responsible for intestinal dysbiosis, which is suspected of being the source of bacterial resistance. The complexity of the intestinal microbiota composition, the impact of the pharmacokinetic properties of antibiotics, and the multiplicity of other factors involved in the acquisition and emergence of multidrug-resistant organisms, lead us to think that de-escalation, in the absence of studies proving its effectiveness, is not the solution to limiting the spread of multidrug-resistant organisms. More studies are needed to clarify the ecological risk caused by different antibiotic classes. In the meantime, we need to concentrate our efforts on limiting antibiotic prescriptions to patients who really need it, and work on reducing the duration of these treatments.
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Bruns N, Dohna-Schwake C. Antibiotics in critically ill children-a narrative review on different aspects of a rational approach. Pediatr Res 2022; 91:440-446. [PMID: 34873285 PMCID: PMC8816725 DOI: 10.1038/s41390-021-01878-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 11/09/2021] [Accepted: 11/13/2021] [Indexed: 12/19/2022]
Abstract
Especially critically ill children are exposed to antibiotic overtreatment, mainly caused by the fear of missing out a severe bacterial infection. Potential adverse effects and selection of multi-drug resistant bacteria play minor roles in decision making. This narrative review first describes harm from antibiotics and second focuses on different aspects that could help to reduce antibiotic overtreatment without harming the patient: harm from antibiotic treatment, diagnostic approaches, role of biomarkers, timing of antibiotic therapy, empiric therapy, targeted therapy, and therapeutic drug monitoring. Wherever possible, we linked the described evidence to the current Surviving Sepsis Campaign guidelines. Antibiotic stewardship programs should help guiding antibiotic therapy for critically ill children. IMPACT: Critically ill children can be harmed by inadequate or overuse of antibiotics. Hemodynamically unstable children with a suspicion of infection should be immediately treated with broad-spectrum antibiotics. In contrast, in hemodynamically stable children with sepsis and organ dysfunction, a time frame of 3 h for proper diagnostics may be adequate before starting antibiotics if necessary. Less and more targeted antibiotic treatment can be achieved via antibiotic stewardship programs.
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Affiliation(s)
- Nora Bruns
- grid.5718.b0000 0001 2187 5445Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany. .,Westdeutsches Zentrum für Infektiologie, University of Duisburg-Essen, Essen, Germany.
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Teh HL, Abdullah S, Ghazali AK, Khan RA, Ramadas A, Leong CL. Impact of Extended and Restricted Antibiotic Deescalation on Mortality. Antibiotics (Basel) 2021; 11:antibiotics11010022. [PMID: 35052899 PMCID: PMC8772729 DOI: 10.3390/antibiotics11010022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/01/2021] [Accepted: 12/07/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND More data are needed about the safety of antibiotic de-escalation in specific clinical situations as a strategy to reduce exposure to broad-spectrum antibiotics. This study aims to compare the survival curve of patient de-escalated (early or late) against those not de-escalated on antibiotics, to determine the association of patient related, clinical related, and pressure sore/device related characteristics on all-cause 30-day mortality and determine the impact of early and late antibiotic de-escalation on 30-day all-cause mortality. METHODS This is a retrospective cohort study on patients in medical ward Hospital Kuala Lumpur, admitted between January 2016 and June 2019. A Kaplan-Meier survival curve and Fleming-Harrington test were used to compare the overall survival rates between early, late, and those not de-escalated on antibiotics while multivariable Cox proportional hazards regression was used to determine prognostic factors associated with mortality and the impact of de-escalation on 30-day all-cause mortality. RESULTS Overall mortality rates were not significantly different when patients were not de-escalated on extended or restricted antibiotics, compared to those de-escalated early or later (p = 0.760). Variables associated with 30-day all-cause mortality were a Sequential Organ Function Assessment (SOFA) score on the day of antimicrobial stewardship (AMS) intervention and Charlson's comorbidity score (CCS). After controlling for confounders, early and late antibiotics were not associated with an increased risk of mortality. CONCLUSION The results of this study reinforce that restricted or extended antibiotic de-escalation in patients does not significantly affect 30-day all-cause mortality compared to continuation with extended and restricted antibiotics.
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Affiliation(s)
- Hwei Lin Teh
- Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur 50586, Malaysia; (R.A.K.); (A.R.)
- Correspondence: ; Tel.: +60-192778091
| | - Sarimah Abdullah
- Biostatistics and Research Methodology Unit, Universiti Sains Malaysia (Health Campus), Kota Bharu 16150, Malaysia; (S.A.); (A.K.G.)
| | - Anis Kausar Ghazali
- Biostatistics and Research Methodology Unit, Universiti Sains Malaysia (Health Campus), Kota Bharu 16150, Malaysia; (S.A.); (A.K.G.)
| | - Rahela Ambaras Khan
- Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur 50586, Malaysia; (R.A.K.); (A.R.)
| | - Anitha Ramadas
- Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur 50586, Malaysia; (R.A.K.); (A.R.)
| | - Chee Loon Leong
- Infectious Disease Unit, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur 50586, Malaysia;
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Schumann J, Johanns U, Ahmad-Nejad P, Ghebremedhin B, Woebker G. The Impact of the FilmArray-Based Detection of Microbial Pathogens from Positive Blood Culture Vials on the Time to Optimal Antimicrobial Regimen in Intensive Care Units of the Helios University Clinic Wuppertal, Germany. J Clin Med 2021; 10:jcm10245880. [PMID: 34945183 PMCID: PMC8704407 DOI: 10.3390/jcm10245880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 11/16/2022] Open
Abstract
The role of empirical therapy and time to first effective treatment, including the antimicrobial stewardship program, are decisive in patients presenting with bloodstream infections (BSI). The FilmArray® Blood Culture Identification Panel (FA BCID 1.0) detects 24 bacterial and fungal pathogens as well as 3 resistance genes from positive blood cultures in approximately 70 min. In this paper, we evaluate the impact of the additional FA BCID analysis on the time to an optimal antimicrobial therapy and on the length of stay in the ICU, ICU mortality, and PCT level reduction. This retro-/prospective trial was conducted in BSI patients in the ICU at a German tertiary care hospital. A total of 179 individual patients with 200 episodes of BSI were included in the prospective intervention group, and 150 patients with 170 episodes of BSI in the retrospective control group. In the intervention group, BSI data were analyzed including the MALDI-TOF MS (matrix assisted laser desorption ionization time-of-flight mass spectrometry) and FA BCID results from January 2019 to August 2020; the data from the control group, including the MALDI-TOF results, were collected retrospectively from the year 2018. The effective and appropriate antimicrobial regimen occurred in a median of 17 hours earlier in the intervention versus control group (p = 0.071). Furthermore, changes in the antimicrobial regimens of the intervention group that did not immediately lead to an optimal therapy occurred significantly earlier by a median of 24 hours (p = 0.029). Surrogate markers, indicating an earlier recovery of the patients from the intervention group, such as length of stay at the ICU, duration of mechanical ventilation, or an earlier reduction in PCT level, were not significantly affected. However, mortality did not differ between the patient groups. A postulated reduction of the antimicrobial therapy, in those cases in which coagulase-negative Staphylococcus species were identified, did occur in the control group, but not in the intervention group (p = 0.041). The implementation of FA BCID into the laboratory workflow can improve patient care by optimizing antimicrobial regimen earlier in BSI patients as it provides rapid and accurate results for key pathogens associated with BSI, as well as important antimicrobial resistance markers, e.g., mecA or vanA.
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Affiliation(s)
- Jannik Schumann
- Center for Clinical and Translational Research (CCTR), Institute for Medical Laboratory Diagnostics, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany; (J.S.); (P.A.-N.); (B.G.)
| | - Ulrike Johanns
- Clinic for Intensive Care Medicine, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany;
| | - Parviz Ahmad-Nejad
- Center for Clinical and Translational Research (CCTR), Institute for Medical Laboratory Diagnostics, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany; (J.S.); (P.A.-N.); (B.G.)
| | - Beniam Ghebremedhin
- Center for Clinical and Translational Research (CCTR), Institute for Medical Laboratory Diagnostics, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany; (J.S.); (P.A.-N.); (B.G.)
| | - Gabriele Woebker
- Clinic for Intensive Care Medicine, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany;
- Correspondence: ; Tel.: +49-(0)-202-896-2720; Fax: +49-(0)-202-896-2718
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López-Pintor JM, Sánchez-López J, Navarro-San Francisco C, Sánchez-Díaz AM, Loza E, Cantón R. Real Life Clinical Impact of Antimicrobial Stewardship Actions on the Blood Culture Workflow from a Microbiology Laboratory. Antibiotics (Basel) 2021; 10:antibiotics10121511. [PMID: 34943723 PMCID: PMC8698396 DOI: 10.3390/antibiotics10121511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/04/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Accelerating the diagnosis of bacteremia is one of the biggest challenges in clinical microbiology departments. The fast establishment of a correct treatment is determinant on bacteremic patients' outcomes. Our objective was to evaluate the impact of antimicrobial therapy and clinical outcomes of a rapid blood culture workflow protocol in positive blood cultures with Gram-negative bacilli (GNB). METHODS A quasi-experimental before-after study was performed with two groups: (i) control group (conventional work-protocol) and (ii) intervention group (rapid workflow-protocol: rapid identification by Matrix-Assisted Laser Desorption/Ionization-Time-Of-Flight (MALDI-TOF) and antimicrobial susceptibility testing (AST) from bacterial pellet without overnight incubation). Patients were divided into different categories according to the type of intervention over treatment. Outcomes were compared between both groups. RESULTS A total of 313 patients with GNB-bacteremia were included: 125 patients in the control group and 188 in the intervention. The time from positive blood culture to intervention on antibiotic treatment decreased from 2.0 days in the control group to 1.0 in the intervention group (p < 0.001). On the maintenance of correct empirical treatment, the control group reported 2.0 median days until the clinical decision, while in the intervention group was 1.0 (p < 0.001). In the case of treatment de-escalation, a significant difference between both groups (4.0 vs. 2.0, p < 0.001) was found. A decreasing trend on the change from inappropriate treatments to appropriate ones was observed: 3.5 vs. 1.5; p = 0.12. No significant differences were found between both groups on 7-days mortality or on readmissions in the first 30-days. CONCLUSIONS Routine implementation of a rapid workflow protocol anticipates the report of antimicrobial susceptibility testing results in patients with GNB-bacteremia, decreasing the time to effective and optimal antibiotic therapy.
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Affiliation(s)
- Jose Maria López-Pintor
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Javier Sánchez-López
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Carolina Navarro-San Francisco
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Ana Maria Sánchez-Díaz
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Elena Loza
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
- Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, 28029 Madrid, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
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40
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Mu S, Hu L, Zhang Y, Liu Y, Cui X, Zou X, Wang Y, Lu B, Zhou S, Liang X, Liang C, Xiao N, O'Grady J, Lee S, Cao B. Prospective Evaluation of a Rapid Clinical Metagenomics Test for Bacterial Pneumonia. Front Cell Infect Microbiol 2021; 11:684965. [PMID: 34737971 PMCID: PMC8560692 DOI: 10.3389/fcimb.2021.684965] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 09/16/2021] [Indexed: 01/17/2023] Open
Abstract
Background The diagnosis of bacterial pathogens in lower respiratory tract infections (LRI) using conventional culture methods remains challenging and time-consuming. Objectives To evaluate the clinical performance of a rapid nanopore-sequencing based metagenomics test for diagnosis of bacterial pathogens in common LRIs through a large-scale prospective study. Methods We enrolled 292 hospitalized patients suspected to have LRIs between November 2018 and June 2019 in a single-center, prospective cohort study. Rapid clinical metagenomics test was performed on-site, and the results were compared with those of routine microbiology tests. Results 171 bronchoalveolar lavage fluid (BAL) and 121 sputum samples were collected from patients with six kinds of LRIs. The turnaround time (from sample registration to result) for the rapid metagenomics test was 6.4 ± 1.4 hours, compared to 94.8 ± 34.9 hours for routine culture. Compared with culture and real-time PCR validation tests, rapid metagenomics achieved 96.6% sensitivity and 88.0% specificity and identified pathogens in 63 out of 161 (39.1%) culture-negative samples. Correlation between enriched anaerobes and lung abscess was observed by Gene Set Enrichment Analysis. Moreover, 38 anaerobic species failed in culture was identified by metagenomics sequencing. The hypothetical impact of metagenomics test proposed antibiotic de-escalation in 34 patients compared to 1 using routine culture. Conclusions Rapid clinical metagenomics test improved pathogen detection yield in the diagnosis of LRI. Empirical antimicrobial therapy could be de-escalated if rapid metagenomics test results were hypothetically applied to clinical management.
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Affiliation(s)
- Shengrui Mu
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Long Hu
- State Key Laboratory of Translational Medicine and Innovative Drug Development, Simcere Diagnostics Co., Ltd., Nanjing, China
| | - Ye Zhang
- State Key Laboratory of Translational Medicine and Innovative Drug Development, Simcere Diagnostics Co., Ltd., Nanjing, China
| | - Yingmei Liu
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Xiaojing Cui
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Xiaohui Zou
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Yeming Wang
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Binghuai Lu
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Shuilian Zhou
- State Key Laboratory of Translational Medicine and Innovative Drug Development, Simcere Diagnostics Co., Ltd., Nanjing, China
| | - Xiaoxue Liang
- State Key Laboratory of Translational Medicine and Innovative Drug Development, Simcere Diagnostics Co., Ltd., Nanjing, China
| | - Chen Liang
- State Key Laboratory of Translational Medicine and Innovative Drug Development, Simcere Diagnostics Co., Ltd., Nanjing, China
| | - Nick Xiao
- State Key Laboratory of Translational Medicine and Innovative Drug Development, Simcere Diagnostics Co., Ltd., Nanjing, China
| | - Justin O'Grady
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom.,Quadram Institute Bioscience, Norwich Research Park, Norwich, United Kingdom
| | - Shela Lee
- State Key Laboratory of Translational Medicine and Innovative Drug Development, Simcere Diagnostics Co., Ltd., Nanjing, China
| | - Bin Cao
- China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Clinical Center for Pulmonary Infections, Capital Medical University, Beijing, China.,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.,Department of Pulmonary and Critical Care Medicine, Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China.,Tsinghua University-Peking University Joint Center for Life Sciences, Tsinghua University, Beijing, China
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Goto-Fujibayashi A, Niwa T, Yonetamari J, Ito-Takeichi S, Suzuki K, Ohta H, Niwa A, Tsuchiya M, Ito Y, Hatakeyama D, Hayashi H, Sugiyama T, Baba H, Suzuki A, Murakami N. Clinical impact of monitoring frequency per day as a prospective audit and feedback strategy for patients receiving antimicrobial agents by injection. Int J Clin Pract 2021; 75:e14785. [PMID: 34480837 DOI: 10.1111/ijcp.14785] [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] [Received: 01/28/2020] [Revised: 03/06/2021] [Accepted: 09/02/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Implementation of antimicrobial stewardship programmes improve antimicrobial therapies and thus result in better patient outcomes and safety. The impact of prospective audit and feedback (PAF) is likely dependent on how frequently it is conducted, and how quickly after antibiotic prescription it is initiated. To our knowledge, however, no report has yet investigated the impact of an increase in monitoring frequency per day on PAF strategy. Here, we evaluated the clinical impact of an increase in monitoring frequency per day as a PAF strategy in patients receiving antimicrobial injections. METHODS We conducted a single-centre, retrospective observational pre-post study to evaluate the impact of increasing the frequency of monitoring from once daily (once daily review group) to twice daily (twice daily review group). Time to intervention and clinical outcomes were compared before and after implementation of twice daily review. RESULTS Time to intervention for inappropriate antimicrobial therapy was significantly shorter in the twice daily review group than the once daily review group (5.1 ± 6.1 hours vs 29.9 ± 21.5 hours, HR: 4.53, 95% CI: 2.90-7.07, P < .001). The twice daily review group had a significantly lower rate of clinical failure (16.2% vs 38.3%, P = .004) and hepatotoxicity (4.1% vs 15.0%, P = .035) than the once daily review group. CONCLUSIONS An increase in monitoring frequency from once daily to twice daily significantly shortened the time to intervention for inappropriate antimicrobial therapy, with a concomitant reduction in clinical failure and hepatotoxicity.
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Affiliation(s)
- Ayasa Goto-Fujibayashi
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Takashi Niwa
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Jun Yonetamari
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Syuri Ito-Takeichi
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Keiko Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Hirotoshi Ohta
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Ayumi Niwa
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Mayumi Tsuchiya
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Yukiko Ito
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Daijiro Hatakeyama
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Hideki Hayashi
- Laboratory of Pharmacy Practice and Social Science, Gifu Pharmaceutical University, Gifu, Japan
| | - Tadashi Sugiyama
- Laboratory of Pharmacy Practice and Social Science, Gifu Pharmaceutical University, Gifu, Japan
| | - Hisashi Baba
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Nobuo Murakami
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
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Kollef MH, Shorr AF, Bassetti M, Timsit JF, Micek ST, Michelson AP, Garnacho-Montero J. Timing of antibiotic therapy in the ICU. Crit Care 2021; 25:360. [PMID: 34654462 PMCID: PMC8518273 DOI: 10.1186/s13054-021-03787-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 12/15/2022] Open
Abstract
Severe or life threatening infections are common among patients in the intensive care unit (ICU). Most infections in the ICU are bacterial or fungal in origin and require antimicrobial therapy for clinical resolution. Antibiotics are the cornerstone of therapy for infected critically ill patients. However, antibiotics are often not optimally administered resulting in less favorable patient outcomes including greater mortality. The timing of antibiotics in patients with life threatening infections including sepsis and septic shock is now recognized as one of the most important determinants of survival for this population. Individuals who have a delay in the administration of antibiotic therapy for serious infections can have a doubling or more in their mortality. Additionally, the timing of an appropriate antibiotic regimen, one that is active against the offending pathogens based on in vitro susceptibility, also influences survival. Thus not only is early empiric antibiotic administration important but the selection of those agents is crucial as well. The duration of antibiotic infusions, especially for β-lactams, can also influence antibiotic efficacy by increasing antimicrobial drug exposure for the offending pathogen. However, due to mounting antibiotic resistance, aggressive antimicrobial de-escalation based on microbiology results is necessary to counterbalance the pressures of early broad-spectrum antibiotic therapy. In this review, we examine time related variables impacting antibiotic optimization as it relates to the treatment of life threatening infections in the ICU. In addition to highlighting the importance of antibiotic timing in the ICU we hope to provide an approach to antimicrobials that also minimizes the unnecessary use of these agents. Such approaches will increasingly be linked to advances in molecular microbiology testing and artificial intelligence/machine learning. Such advances should help identify patients needing empiric antibiotic therapy at an earlier time point as well as the specific antibiotics required in order to avoid unnecessary administration of broad-spectrum antibiotics.
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Affiliation(s)
- Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Avenue, MSC 8052-43-14, St. Louis, MO, 63110, USA.
| | - Andrew F Shorr
- Pulmonary and Critical Care Medicine, Medstar Washington Hospital, Washington, DC, USA
| | - Matteo Bassetti
- Infectious Diseases Unit, Department of Health Sciences, San Martino Policlinico Hospital - IRCCS, University of Genoa, Genoa, Italy
| | - Jean-Francois Timsit
- AP-HP, Bichat Claude Bernard Hospital, Medical and Infectious Diseases ICU (MI2), IAME, INSERM, Université de Paris, Paris, France
| | - Scott T Micek
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Andrew P Michelson
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Avenue, MSC 8052-43-14, St. Louis, MO, 63110, USA
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Saarenkari HK, Sharp CR, Smart L. Retrospective evaluation of the utility of blood cultures in dogs (2009-2018): 45 cases. J Vet Emerg Crit Care (San Antonio) 2021; 32:141-145. [PMID: 34606667 DOI: 10.1111/vec.13144] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/04/2020] [Accepted: 07/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is no consensus on obtaining blood cultures routinely in companion animals with suspected sepsis, and there is a paucity of evidence concerning their utility. The objectives of this retrospective study were to determine the yield of positive blood cultures from hospitalized dogs, the prevalence of resistant bacteria, and the frequency and nature of changes to antimicrobial therapy once the culture result became available. KEY FINDINGS Forty-five dogs had a blood culture submitted over a 10-year period, of which 9(20%) yielded positive growth and 36 (80%) yielded no bacterial growth. The most frequent reasons for submission of blood culture were pyrexia of unknown origin (n = 14), suspected soft tissue infection (7), and suspected discospondylitis (7). The most frequent final diagnoses were soft tissue infection (n = 11), discospondylitis (7), and unknown (6). No significant difference was found between the culture-positive versus culture-negative groups with regard to the most frequent reasons for blood culture (P = 0.55), final diagnoses (P = 0.80), survival until the blood culture result (P = 0.37), or whether the infection was hospital- or community-acquired (P = 0.99). There were significantly more immunosuppressed dogs in the culture-positive group (P = 0.02). Resistance to one or more antimicrobials was documented in all dogs with susceptibility reported. In the culture-positive dogs, 63% had antimicrobial de-escalation and none had escalation, whereas 19% of the culture-negative dogs had de-escalation and 7% had escalation. CONCLUSION Blood cultures were submitted infrequently, but the proportion of resistance was higher than expected and supports the use of blood cultures in cases of suspected infection resulting in bacteremia.
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Affiliation(s)
- Heidi K Saarenkari
- School of Veterinary Medicine, Murdoch University, Murdoch, Western Australia, Australia
| | - Claire R Sharp
- School of Veterinary Medicine, Murdoch University, Murdoch, Western Australia, Australia
| | - Lisa Smart
- School of Veterinary Medicine, Murdoch University, Murdoch, Western Australia, Australia
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44
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Branstetter JW, Barker L, Yarbrough A, Ross S, Stultz JS. Challenges of Antibiotic Stewardship in the Pediatric and Neonatal Intensive Care Units. J Pediatr Pharmacol Ther 2021; 26:659-668. [PMID: 34588929 DOI: 10.5863/1551-6776-26.7.659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 07/01/2021] [Indexed: 12/14/2022]
Abstract
The goals of antimicrobial stewardship programs (ASPs) are to optimize antimicrobial prescribing habits in order to improve patient outcomes, reduce antimicrobial resistance, and reduce hospital costs. Multiple society-endorsed guidelines and government policies reinforce the importance of ASP implementation. Effective antimicrobial stewardship can impact unique patients, hospitals, and societal antibiotic-resistance burden. The role and subsequent success of these programs has largely been reported in the adult population. Pediatric and neonatal intensive care units present unique challenges for traditional antimicrobial stewardship approaches. The purpose of this review article is to explore the challenges of appropriate antibiotic use in the pediatric and neonatal intensive care units and to summarize strategies ASPs can use to overcome these challenges. These problems include non-specific disease presentations, limited evidence for definitive treatment durations in many pediatric infections, fewer pediatric-trained infectious disease physicians, and applicability of intensive laboratory obtainment, collection, and interpretation. Additionally, many ASP implementation studies evaluating the efficacy of ASPs exclude the PICU and NICU. Areas of focus for pediatric ASPs should likely include appropriate antibiotic initiation, appropriate antibiotic duration, and appropriate antibiotic de-escalation.
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45
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Rashidzada Z, Cairns KA, Peel TN, Jenney AW, Doyle JS, Dooley MJ, Cheng AC. Early antimicrobial stewardship team intervention on appropriateness of antimicrobial therapy in suspected sepsis: a randomized controlled trial. JAC Antimicrob Resist 2021; 3:dlab097. [PMID: 34458731 PMCID: PMC8390781 DOI: 10.1093/jacamr/dlab097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/17/2021] [Indexed: 01/01/2023] Open
Abstract
Objectives There has been concern that the imperative to administer rapid antimicrobials in septic patients may result in inappropriate antimicrobial use. We aimed to determine the impact of early antimicrobial stewardship (AMS) team intervention in patients with Medical Emergency Team (MET) calls for suspected sepsis. Methods We performed a randomized controlled trial of non-ICU inpatients who had a MET call for suspected sepsis. Patients were randomized to standard care (management of antimicrobial therapy by the treating team) or early targeted intervention (AMS review 48 h post-MET call). The primary outcome was appropriateness of antimicrobial therapy 72 h post-MET call, as determined by a panel of blinded infectious diseases physicians. Results In total, 90 patients were enrolled; 45 were randomly allocated to the intervention group, and 45 to the control group. More patients in the AMS intervention group were receiving appropriate antimicrobials 72 h following the MET call (67% versus 44%, P = 0.03). In the intervention group, 27 recommendations were made by the AMS team; 74% of recommendations were accepted, including 30% of cases where antimicrobials were discontinued or de-escalated. There were non-significant differences in total duration of antimicrobial therapy (8.7 versus 10.7 days, P = 0.39), sepsis-related ICU-admission rates (13% versus 18%, P = 0.56) and sepsis-related in-hospital mortality (7% versus 9%, P = 0.71) between intervention and control groups, respectively. Conclusions AMS team intervention resulted in significant improvement in appropriateness of antimicrobial therapy following MET calls due to suspected sepsis. Targeted AMS review should be implemented to support early antimicrobial de-escalation and optimization in patients with suspected sepsis.
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Affiliation(s)
- Zohal Rashidzada
- Pharmacy Department, Alfred Health, Melbourne, Australia.,Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Kelly A Cairns
- Pharmacy Department, Alfred Health, Melbourne, Australia
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia.,Department of Infectious Diseases, Monash University, Melbourne, Australia
| | - Adam W Jenney
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia.,Department of Infectious Diseases, Monash University, Melbourne, Australia
| | - Joseph S Doyle
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia.,Department of Infectious Diseases, Monash University, Melbourne, Australia.,Burnet Institute, Melbourne, Australia
| | - Michael J Dooley
- Pharmacy Department, Alfred Health, Melbourne, Australia.,Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Allen C Cheng
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia.,Department of Infectious Diseases, Monash University, Melbourne, Australia.,Department of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
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Eichenberger EM, de Vries CR, Ruffin F, Sharma-Kuinkel B, Park L, Hong D, Scott ER, Blair L, Degner N, Hollemon D, Blauwkamp TA, Ho C, Seng H, Shah P, Wanda L, Fowler VG, Ahmed AA. Microbial Cell-Free DNA Identifies Etiology of Bloodstream Infections, Persists Longer Than Conventional Blood Cultures, and its Duration of Detection is Associated with Metastatic Infection in Patients with Staphylococcus aureus and Gram-Negative Bacteremia. Clin Infect Dis 2021; 74:2020-2027. [PMID: 34460909 DOI: 10.1093/cid/ciab742] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Microbial cell-free DNA (mcfDNA) sequencing of plasma can identify presence of a pathogen in a host. This study evaluated the duration of pathogen detection by mcfDNA sequencing vs. conventional blood culture in patients with bacteremia. METHODS Blood samples from patients with culture-confirmed bloodstream infection were collected within 24 hours of the index positive blood culture and 48 to 72 hours thereafter. mcfDNA was extracted from plasma and next-generation sequencing (NGS) applied. Reads were aligned against a curated pathogen database. Statistical significance was defined with Bonferroni adjustment for multiple comparisons (p < 0.0033). RESULTS A total of 175 patients with Staphylococcus aureus bacteremia (SAB; n=66), Gram-negative bacteremia (GNB; n=74), or non-infected controls (n=35) were enrolled. The overall sensitivity of mcfDNA sequencing compared to index blood culture was 89.3% (125/140) and the specificity was 74.3%. Among patients with bacteremia, pathogen specific mcfDNA remained detectable for significantly longer than conventional blood cultures (median 15 days vs. 2 days; p<0.0001). Each additional day of mcfDNA detection significantly increased the odds of metastatic infection (Odds Ratio [OR]: 2.89; 95% Confidence Interval [CI]: 1.53-5.46; p=0.0011). CONCLUSIONS Pathogen mcfDNA identified the bacterial etiology of bloodstream infection for a significantly longer interval than conventional cultures, and its duration of detection was associated with increased risk for metastatic infection. mcfDNA could play a role in the diagnosis of partially treated endovascular infections.
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Affiliation(s)
- Emily M Eichenberger
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Felicia Ruffin
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Batu Sharma-Kuinkel
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Lawrence Park
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - David Hong
- Karius, Inc., Redwood City, California, USA
| | | | - Lily Blair
- Karius, Inc., Redwood City, California, USA
| | | | | | | | - Carine Ho
- Karius, Inc., Redwood City, California, USA
| | - Hon Seng
- Karius, Inc., Redwood City, California, USA
| | - Pratik Shah
- Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Lisa Wanda
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Vance G Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Sellers LA, Fitton KM, Segovia MF, Forehand CC, Dobbin KK, Newsome AS. Time to blood, respiratory and urine culture positivity in the intensive care unit: Implications for de-escalation. SAGE Open Med 2021; 9:20503121211040702. [PMID: 34434557 PMCID: PMC8381457 DOI: 10.1177/20503121211040702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/02/2021] [Indexed: 11/15/2022] Open
Abstract
Objectives Concern for late detection of bacterial pathogens is a barrier to early de-escalation efforts. The purpose of this study was to assess blood, respiratory and urine culture results at 72 h to test the hypothesis that early negative culture results have a clinically meaningful negative predictive value. Methods We retrospectively reviewed all patients admitted to the medical intensive care unit between March 2012 and July 2018 with blood cultures obtained. Blood, respiratory and urine culture results were assessed for time to positivity, defined as the time between culture collection and preliminary species identification. The primary outcome was the negative predictive value of negative blood culture results at 72 h. Secondary outcomes included sensitivity, specificity, positive predictive value and negative predictive value of blood, respiratory and urine culture results. Results The analysis included 1567 blood, 514 respiratory and 1059 urine cultures. Of the blood, respiratory and urine cultures ultimately positive, 90.3%, 76.2% and 90.4% were positive at 72 h. The negative predictive value of negative 72-h blood, respiratory and urine cultures were 0.99, 0.82 and 0.97, respectively. Antibiotic de-escalation had good specificity, positive predictive value and negative predictive value for finalized negative cultures. Conclusion Negative blood and urine culture results at 72 h had a high negative predictive value. These findings have important ramifications for antimicrobial stewardship efforts and support protocolized re-evaluation of empiric antibiotic therapy at 72 h. Caution should be used in patients with clinically suspected pneumonia, since negative respiratory culture results at 72 h were weakly predictive of finalized negative cultures.
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Affiliation(s)
- Lindsey A Sellers
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
| | | | | | - Christy C Forehand
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA.,Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Athens, GA, USA
| | - Kevin K Dobbin
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Andrea Sikora Newsome
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA.,Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Athens, GA, USA
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Egi M, Ogura H, Yatabe T, Atagi K, Inoue S, Iba T, Kakihana Y, Kawasaki T, Kushimoto S, Kuroda Y, Kotani J, Shime N, Taniguchi T, Tsuruta R, Doi K, Doi M, Nakada TA, Nakane M, Fujishima S, Hosokawa N, Masuda Y, Matsushima A, Matsuda N, Yamakawa K, Hara Y, Sakuraya M, Ohshimo S, Aoki Y, Inada M, Umemura Y, Kawai Y, Kondo Y, Saito H, Taito S, Takeda C, Terayama T, Tohira H, Hashimoto H, Hayashida K, Hifumi T, Hirose T, Fukuda T, Fujii T, Miura S, Yasuda H, Abe T, Andoh K, Iida Y, Ishihara T, Ide K, Ito K, Ito Y, Inata Y, Utsunomiya A, Unoki T, Endo K, Ouchi A, Ozaki M, Ono S, Katsura M, Kawaguchi A, Kawamura Y, Kudo D, Kubo K, Kurahashi K, Sakuramoto H, Shimoyama A, Suzuki T, Sekine S, Sekino M, Takahashi N, Takahashi S, Takahashi H, Tagami T, Tajima G, Tatsumi H, Tani M, Tsuchiya A, Tsutsumi Y, Naito T, Nagae M, Nagasawa I, Nakamura K, Nishimura T, Nunomiya S, Norisue Y, Hashimoto S, Hasegawa D, Hatakeyama J, Hara N, Higashibeppu N, Furushima N, Furusono H, Matsuishi Y, Matsuyama T, Minematsu Y, Miyashita R, Miyatake Y, Moriyasu M, Yamada T, Yamada H, Yamamoto R, Yoshida T, Yoshida Y, Yoshimura J, Yotsumoto R, Yonekura H, Wada T, Watanabe E, Aoki M, Asai H, Abe T, Igarashi Y, Iguchi N, Ishikawa M, Ishimaru G, Isokawa S, Itakura R, Imahase H, Imura H, Irinoda T, Uehara K, Ushio N, Umegaki T, Egawa Y, Enomoto Y, Ota K, Ohchi Y, Ohno T, Ohbe H, Oka K, Okada N, Okada Y, Okano H, Okamoto J, Okuda H, Ogura T, Onodera Y, Oyama Y, Kainuma M, Kako E, Kashiura M, Kato H, Kanaya A, Kaneko T, Kanehata K, Kano KI, Kawano H, Kikutani K, Kikuchi H, Kido T, Kimura S, Koami H, Kobashi D, Saiki I, Sakai M, Sakamoto A, Sato T, Shiga Y, Shimoto M, Shimoyama S, Shoko T, Sugawara Y, Sugita A, Suzuki S, Suzuki Y, Suhara T, Sonota K, Takauji S, Takashima K, Takahashi S, Takahashi Y, Takeshita J, Tanaka Y, Tampo A, Tsunoyama T, Tetsuhara K, Tokunaga K, Tomioka Y, Tomita K, Tominaga N, Toyosaki M, Toyoda Y, Naito H, Nagata I, Nagato T, Nakamura Y, Nakamori Y, Nahara I, Naraba H, Narita C, Nishioka N, Nishimura T, Nishiyama K, Nomura T, Haga T, Hagiwara Y, Hashimoto K, Hatachi T, Hamasaki T, Hayashi T, Hayashi M, Hayamizu A, Haraguchi G, Hirano Y, Fujii R, Fujita M, Fujimura N, Funakoshi H, Horiguchi M, Maki J, Masunaga N, Matsumura Y, Mayumi T, Minami K, Miyazaki Y, Miyamoto K, Murata T, Yanai M, Yano T, Yamada K, Yamada N, Yamamoto T, Yoshihiro S, Tanaka H, Nishida O. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020). J Intensive Care 2021; 9:53. [PMID: 34433491 PMCID: PMC8384927 DOI: 10.1186/s40560-021-00555-7] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/10/2021] [Indexed: 02/08/2023] Open
Abstract
The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.
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Affiliation(s)
- Moritoki Egi
- Department of Surgery Related, Division of Anesthesiology, Kobe University Graduate School of Medicine, Kusunoki-cho 7-5-2, Chuo-ku, Kobe, Hyogo, Japan.
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Medical School, Yamadaoka 2-15, Suita, Osaka, Japan.
| | - Tomoaki Yatabe
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Kazuaki Atagi
- Department of Intensive Care Unit, Nara Prefectural General Medical Center, Nara, Japan
| | - Shigeaki Inoue
- Department of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University, Tokyo, Japan
| | - Yasuyuki Kakihana
- Department of Emergency and Intensive Care Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical Care, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Kuroda
- Department of Emergency, Disaster, and Critical Care Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Joji Kotani
- Department of Surgery Related, Division of Disaster and Emergency Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takumi Taniguchi
- Department of Anesthesiology and Intensive Care Medicine, Kanazawa University, Kanazawa, Japan
| | - Ryosuke Tsuruta
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kent Doi
- Department of Acute Medicine, The University of Tokyo, Tokyo, Japan
| | - Matsuyuki Doi
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Taka-Aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaki Nakane
- Department of Emergency and Critical Care Medicine, Yamagata University Hospital, Yamagata, Japan
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine, Tokyo, Japan
| | - Naoto Hosokawa
- Department of Infectious Diseases, Kameda Medical Center, Kamogawa, Japan
| | - Yoshiki Masuda
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Asako Matsushima
- Department of Advancing Acute Medicine, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Naoyuki Matsuda
- Department of Emergency and Critical Care Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College, Osaka, Japan
| | - Yoshitaka Hara
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshitaka Aoki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Mai Inada
- Member of Japanese Association for Acute Medicine, Tokyo, Japan
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | - Yusuke Kawai
- Department of Nursing, Fujita Health University Hospital, Toyoake, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Support and Practice, Hiroshima University Hospital, Hiroshima, Japan
| | - Chikashi Takeda
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Takero Terayama
- Department of Psychiatry, School of Medicine, National Defense Medical College, Tokorozawa, Japan
| | | | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine/Infectious Disease, Hitachi General Hospital, Hitachi, Japan
| | - Kei Hayashida
- The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Tomoya Hirose
- Emergency and Critical Care Medical Center, Osaka Police Hospital, Osaka, Japan
| | - Tatsuma Fukuda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tomoko Fujii
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Shinya Miura
- The Royal Children's Hospital Melbourne, Melbourne, Australia
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
| | - Kohkichi Andoh
- Division of Anesthesiology, Division of Intensive Care, Division of Emergency and Critical Care, Sendai City Hospital, Sendai, Japan
| | - Yuki Iida
- Department of Physical Therapy, School of Health Sciences, Toyohashi Sozo University, Toyohashi, Japan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Kentaro Ide
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kenta Ito
- Department of General Pediatrics, Aichi Children's Health and Medical Center, Obu, Japan
| | - Yusuke Ito
- Department of Infectious Disease, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yu Inata
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Akemi Utsunomiya
- Human Health Science, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Unoki
- Department of Acute and Critical Care Nursing, School of Nursing, Sapporo City University, Sapporo, Japan
| | - Koji Endo
- Department of Pharmacoepidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Akira Ouchi
- College of Nursing, Ibaraki Christian University, Hitachi, Japan
| | - Masayuki Ozaki
- Department of Emergency and Critical Care Medicine, Komaki City Hospital, Komaki, Japan
| | - Satoshi Ono
- Gastroenterological Center, Shinkuki General Hospital, Kuki, Japan
| | | | | | - Yusuke Kawamura
- Department of Rehabilitation, Showa General Hospital, Tokyo, Japan
| | - Daisuke Kudo
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenji Kubo
- Department of Emergency Medicine and Department of Infectious Diseases, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Kiyoyasu Kurahashi
- Department of Anesthesiology and Intensive Care Medicine, International University of Health and Welfare School of Medicine, Narita, Japan
| | | | - Akira Shimoyama
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Takeshi Suzuki
- Department of Anesthesiology, Tokai University School of Medicine, Isehara, Japan
| | - Shusuke Sekine
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Motohiro Sekino
- Division of Intensive Care, Nagasaki University Hospital, Nagasaki, Japan
| | - Nozomi Takahashi
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sei Takahashi
- Center for Innovative Research for Communities and Clinical Excellence (CiRC2LE), Fukushima Medical University, Fukushima, Japan
| | - Hiroshi Takahashi
- Department of Cardiology, Steel Memorial Muroran Hospital, Muroran, Japan
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School Musashi Kosugi Hospital, Kawasaki, Japan
| | - Goro Tajima
- Nagasaki University Hospital Acute and Critical Care Center, Nagasaki, Japan
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masanori Tani
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Yusuke Tsutsumi
- Department of Emergency and Critical Care Medicine, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Takaki Naito
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masaharu Nagae
- Department of Intensive Care Medicine, Kobe University Hospital, Kobe, Japan
| | | | - Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shin Nunomiya
- Department of Anesthesiology and Intensive Care Medicine, Division of Intensive Care, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Yasuhiro Norisue
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Daisuke Hasegawa
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Junji Hatakeyama
- Department of Emergency and Critical Care Medicine, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Naoki Hara
- Department of Pharmacy, Yokohama Rosai Hospital, Yokohama, Japan
| | - Naoki Higashibeppu
- Department of Anesthesiology and Nutrition Support Team, Kobe City Medical Center General Hospital, Kobe City Hospital Organization, Kobe, Japan
| | - Nana Furushima
- Department of Anesthesiology, Kobe University Hospital, Kobe, Japan
| | - Hirotaka Furusono
- Department of Rehabilitation, University of Tsukuba Hospital/Exult Co., Ltd., Tsukuba, Japan
| | - Yujiro Matsuishi
- Doctoral program in Clinical Sciences. Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Minematsu
- Department of Clinical Engineering, Osaka University Hospital, Suita, Japan
| | - Ryoichi Miyashita
- Department of Intensive Care Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yuji Miyatake
- Department of Clinical Engineering, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Megumi Moriyasu
- Division of Respiratory Care and Rapid Response System, Intensive Care Center, Kitasato University Hospital, Sagamihara, Japan
| | - Toru Yamada
- Department of Nursing, Toho University Omori Medical Center, Tokyo, Japan
| | - Hiroyuki Yamada
- Department of Primary Care and Emergency Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yuhei Yoshida
- Nursing Department, Osaka General Medical Center, Osaka, Japan
| | - Jumpei Yoshimura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka, Japan
| | | | - Hiroshi Yonekura
- Department of Clinical Anesthesiology, Mie University Hospital, Tsu, Japan
| | - Takeshi Wada
- Department of Anesthesiology and Critical Care Medicine, Division of Acute and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Eizo Watanabe
- Department of Emergency and Critical Care Medicine, Eastern Chiba Medical Center, Togane, Japan
| | - Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hideki Asai
- Department of Emergency and Critical Care Medicine, Nara Medical University, Kashihara, Japan
| | - Takakuni Abe
- Department of Anesthesiology and Intensive Care, Oita University Hospital, Yufu, Japan
| | - Yutaka Igarashi
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Masami Ishikawa
- Department of Anesthesiology, Emergency and Critical Care Medicine, Kure Kyosai Hospital, Kure, Japan
| | - Go Ishimaru
- Department of General Internal Medicine, Soka Municipal Hospital, Soka, Japan
| | - Shutaro Isokawa
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Ryuta Itakura
- Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hisashi Imahase
- Department of Biomedical Ethics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Haruki Imura
- Department of Infectious Diseases, Rakuwakai Otowa Hospital, Kyoto, Japan
- Department of Health Informatics, School of Public Health, Kyoto University, Kyoto, Japan
| | | | - Kenji Uehara
- Department of Anesthesiology, National Hospital Organization Iwakuni Clinical Center, Iwakuni, Japan
| | - Noritaka Ushio
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Takeshi Umegaki
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Yuko Egawa
- Advanced Emergency and Critical Care Center, Saitama Red Cross Hospital, Saitama, Japan
| | - Yuki Enomoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kohei Ota
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoshifumi Ohchi
- Department of Anesthesiology and Intensive Care, Oita University Hospital, Yufu, Japan
| | - Takanori Ohno
- Department of Emergency and Critical Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | | | - Nobunaga Okada
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yohei Okada
- Department of Primary care and Emergency medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiromu Okano
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo, Japan
| | - Jun Okamoto
- Department of ER, Hashimoto Municipal Hospital, Hashimoto, Japan
| | - Hiroshi Okuda
- Department of Community Medical Supports, Tohoku Medical Megabank Organization, Tohoku University, Sendai, Japan
| | - Takayuki Ogura
- Tochigi prefectural Emergency and Critical Care Center, Imperial Gift Foundation Saiseikai, Utsunomiya Hospital, Utsunomiya, Japan
| | - Yu Onodera
- Department of Anesthesiology, Faculty of Medicine, Yamagata University, Yamagata, Japan
| | - Yuhta Oyama
- Department of Internal Medicine, Dialysis Center, Kichijoji Asahi Hospital, Tokyo, Japan
| | - Motoshi Kainuma
- Anesthesiology, Emergency Medicine, and Intensive Care Division, Inazawa Municipal Hospital, Inazawa, Japan
| | - Eisuke Kako
- Department of Anesthesiology and Intensive Care Medicine, Nagoya-City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masahiro Kashiura
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Hiromi Kato
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Akihiro Kanaya
- Department of Anesthesiology, Sendai Medical Center, Sendai, Japan
| | - Tadashi Kaneko
- Emergency and Critical Care Center, Mie University Hospital, Tsu, Japan
| | - Keita Kanehata
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Ken-Ichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Hiroyuki Kawano
- Department of Gastroenterological Surgery, Onga Hospital, Fukuoka, Japan
| | - Kazuya Kikutani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hitoshi Kikuchi
- Department of Emergency and Critical Care Medicine, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takahiro Kido
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan
| | - Sho Kimura
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroyuki Koami
- Center for Translational Injury Research, University of Texas Health Science Center at Houston, Houston, USA
| | - Daisuke Kobashi
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Iwao Saiki
- Department of Anesthesiology, Tokyo Medical University, Tokyo, Japan
| | - Masahito Sakai
- Department of General Medicine Shintakeo Hospital, Takeo, Japan
| | - Ayaka Sakamoto
- Department of Emergency and Critical Care Medicine, University of Tsukuba Hospital, Tsukuba, Japan
| | - Tetsuya Sato
- Tohoku University Hospital Emergency Center, Sendai, Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Center for Advanced Joint Function and Reconstructive Spine Surgery, Graduate school of Medicine, Chiba University, Chiba, Japan
| | - Manabu Shimoto
- Department of Primary care and Emergency medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinya Shimoyama
- Department of Pediatric Cardiology and Intensive Care, Gunma Children's Medical Center, Shibukawa, Japan
| | - Tomohisa Shoko
- Department of Emergency and Critical Care Medicine, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Yoh Sugawara
- Department of Anesthesiology, Yokohama City University, Yokohama, Japan
| | - Atsunori Sugita
- Department of Acute Medicine, Division of Emergency and Critical Care Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Satoshi Suzuki
- Department of Intensive Care, Okayama University Hospital, Okayama, Japan
| | - Yuji Suzuki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomohiro Suhara
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Kenji Sonota
- Department of Intensive Care Medicine, Miyagi Children's Hospital, Sendai, Japan
| | - Shuhei Takauji
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kohei Takashima
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Sho Takahashi
- Department of Cardiology, Fukuyama City Hospital, Fukuyama, Japan
| | - Yoko Takahashi
- Department of General Internal Medicine, Koga General Hospital, Koga, Japan
| | - Jun Takeshita
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Yuuki Tanaka
- Fukuoka Prefectural Psychiatric Center, Dazaifu Hospital, Dazaifu, Japan
| | - Akihito Tampo
- Department of Emergency Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Taichiro Tsunoyama
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Kenichi Tetsuhara
- Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Kentaro Tokunaga
- Department of Intensive Care Medicine, Kumamoto University Hospital, Kumamoto, Japan
| | - Yoshihiro Tomioka
- Department of Anesthesiology and Intensive Care Unit, Todachuo General Hospital, Toda, Japan
| | - Kentaro Tomita
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Tominaga
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan
| | - Mitsunobu Toyosaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yukitoshi Toyoda
- Department of Emergency and Critical Care Medicine, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Isao Nagata
- Intensive Care Unit, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Tadashi Nagato
- Department of Respiratory Medicine, Tokyo Yamate Medical Center, Tokyo, Japan
| | - Yoshimi Nakamura
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Yuki Nakamori
- Department of Clinical Anesthesiology, Mie University Hospital, Tsu, Japan
| | - Isao Nahara
- Department of Anesthesiology and Critical Care Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Hiromu Naraba
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Japan
| | - Chihiro Narita
- Department of Emergency Medicine and Intensive Care Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoya Nishimura
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Kei Nishiyama
- Division of Emergency and Critical Care Medicine Niigata University Graduate School of Medical and Dental Science, Niigata, Japan
| | - Tomohisa Nomura
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Taiki Haga
- Department of Pediatric Critical Care Medicine, Osaka City General Hospital, Osaka, Japan
| | - Yoshihiro Hagiwara
- Department of Emergency and Critical Care Medicine, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Katsuhiko Hashimoto
- Research Associate of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
| | - Takeshi Hatachi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Toshiaki Hamasaki
- Department of Emergency Medicine, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Takuya Hayashi
- Division of Critical Care Medicine, Saitama Children's Medical Center, Saitama, Japan
| | - Minoru Hayashi
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui, Japan
| | - Atsuki Hayamizu
- Department of Emergency Medicine, Saitama Saiseikai Kurihashi Hospital, Kuki, Japan
| | - Go Haraguchi
- Division of Intensive Care Unit, Sakakibara Heart Institute, Tokyo, Japan
| | - Yohei Hirano
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Ryo Fujii
- Department of Emergency Medicine and Critical Care Medicine, Tochigi Prefectural Emergency and Critical Care Center, Imperial Foundation Saiseikai Utsunomiya Hospital, Utsunomiya, Japan
| | - Motoki Fujita
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Naoyuki Fujimura
- Department of Anesthesiology, St. Mary's Hospital, Our Lady of the Snow Social Medical Corporation, Kurume, Japan
| | - Hiraku Funakoshi
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Japan
| | - Masahito Horiguchi
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Jun Maki
- Department of Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Naohisa Masunaga
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yosuke Matsumura
- Department of Intensive Care, Chiba Emergency Medical Center, Chiba, Japan
| | - Takuya Mayumi
- Department of Internal Medicine, Kanazawa Municipal Hospital, Kanazawa, Japan
| | - Keisuke Minami
- Ishikawa Prefectual Central Hospital Emergency and Critical Care Center, Kanazawa, Japan
| | - Yuya Miyazaki
- Department of Emergency and General Internal Medicine, Saiseikai Kawaguchi General Hospital, Kawaguchi, Japan
| | - Kazuyuki Miyamoto
- Department of Emergency and Disaster Medicine, Showa University, Tokyo, Japan
| | - Teppei Murata
- Department of Cardiology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Machi Yanai
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takao Yano
- Department of Critical Care and Emergency Medicine, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan
| | - Kohei Yamada
- Department of Traumatology and Critical Care Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Naoki Yamada
- Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan
| | - Tomonori Yamamoto
- Department of Intensive Care Unit, Nara Prefectural General Medical Center, Nara, Japan
| | - Shodai Yoshihiro
- Pharmaceutical Department, JA Hiroshima General Hospital, Hatsukaichi, Japan
| | - Hiroshi Tanaka
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, Fujita Health University School of Medicine, Toyoake, Japan
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Corcione S, Mornese Pinna S, Lupia T, Trentalange A, Germanò E, Cavallo R, Lupia E, De Rosa FG. Antibiotic De-escalation Experience in the Setting of Emergency Department: A Retrospective, Observational Study. J Clin Med 2021; 10:jcm10153285. [PMID: 34362069 PMCID: PMC8347329 DOI: 10.3390/jcm10153285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Antimicrobial de-escalation (ADE) is a part of antimicrobial stewardship strategies aiming to minimize unnecessary or inappropriate antibiotic exposure to decrease the rate of antimicrobial resistance. Information regarding the effectiveness and safety of ADE in the setting of emergency medicine wards (EMW) is lacking. Methods: Adult patients admitted to EMW and receiving empiric antimicrobial treatment were retrospectively studied. The primary outcome was the rate and timing of ADE. Secondary outcomes included factors associated with early ADE, length of stay, and in-hospital mortality. Results: A total of 336 patients were studied. An initial regimen combining two agents was prescribed in 54.8%. Ureidopenicillins and carbapenems were the most frequently empiric treatment prescribed (25.1% and 13.6%). The rate of the appropriateness of prescribing was 58.3%. De-escalation was performed in 111 (33%) patients. Patients received a successful de-escalation on day 2 (21%), 3 (23%), and 5 (56%). The overall in-hospital mortality was 21%, and it was significantly lower among the de-escalation group than the continuation group (16% vs 25% p = 0.003). In multivariate analysis, de-escalation strategies as well as appropriate empiric and targeted therapy were associated with reduced mortality. Conclusions: ADE appears safe and effective in the setting of EMWs despite that further research is warranted to confirm these findings.
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Affiliation(s)
- Silvia Corcione
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (S.C.); (S.M.P.); (A.T.); (E.G.); (E.L.); (F.G.D.R.)
- Tufts University School of Medicine, Boston, MA 02129, USA
| | - Simone Mornese Pinna
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (S.C.); (S.M.P.); (A.T.); (E.G.); (E.L.); (F.G.D.R.)
| | - Tommaso Lupia
- Infectious Diseases Unit, Cardinal Massaia Hospital, 14100 Asti, Italy
- Correspondence: ; Tel.: +39-0141-486-404 or +39-3462-248-637
| | - Alice Trentalange
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (S.C.); (S.M.P.); (A.T.); (E.G.); (E.L.); (F.G.D.R.)
| | - Erika Germanò
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (S.C.); (S.M.P.); (A.T.); (E.G.); (E.L.); (F.G.D.R.)
| | - Rossana Cavallo
- Microbiology and Virology Unit, University of Turin, 10126 Turin, Italy;
| | - Enrico Lupia
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (S.C.); (S.M.P.); (A.T.); (E.G.); (E.L.); (F.G.D.R.)
| | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (S.C.); (S.M.P.); (A.T.); (E.G.); (E.L.); (F.G.D.R.)
- Tufts University School of Medicine, Boston, MA 02129, USA
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50
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Schmoch T, Westhoff JH, Decker SO, Skarabis A, Hoffmann GF, Dohna-Schwake C, Felderhoff-Müser U, Skolik C, Feisst M, Klose C, Bruckner T, Luntz S, Weigand MA, Sohn K, Brenner T. Next-generation sequencing diagnostics of bacteremia in pediatric sepsis. Medicine (Baltimore) 2021; 100:e26403. [PMID: 34160425 PMCID: PMC8238315 DOI: 10.1097/md.0000000000026403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/03/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Sepsis and septic shock are the most severe forms of infection affecting predominantly elderly people, preterm and term neonates, and young infants. Even in high-income countries sepsis causes about 8% of admissions to pediatric intensive care units (PICUs). Early diagnosis, rapid anti-infective treatment, and prompt hemodynamic stabilization are crucial for patient survival. In this context, it is essential to identify the causative pathogen as soon as possible to optimize antimicrobial treatment. To date, culture-based diagnostic procedures (e.g., blood cultures) represent the standard of care. However, they have 2 major problems: on the one hand, in the case of very small sample volumes (and thus usually in children), they are not sufficiently sensitive. On the other hand, with a time-to-result of 2 to 5 days, blood cultures need a relatively long time for the anti-infective therapy to be calculated. To overcome these problems, culture-independent molecular diagnostic procedures such as unbiased sequence analysis of circulating cell-free DNA (cfDNA) from plasma samples of septic patients by next-generation sequencing (NGS) have been tested successfully in adult septic patients. However, these results still need to be transferred to the pediatric setting. METHODS The Next GeneSiPS-Trial is a prospective, observational, non-interventional, multicenter study used to assess the diagnostic performance of an NGS-based approach for the identification of causative pathogens in (preterm and term) neonates (d1-d28, n = 50), infants (d29 to <1 yr, n = 50), and toddlers (1 yr to <5 yr, n = 50) with suspected or proven severe sepsis or septic shock (according to the pediatric sepsis definition) by the use of the quantitative sepsis indicating quantifier (SIQ) score in comparison to standard of care (culture-based) microbiological diagnostics. Potential changes in anti-infective treatment regimens based on these NGS results will be estimated retrospectively by a panel of 3 independent clinical specialists. DISCUSSION Neonates, infants, and young children are significantly affected by sepsis. Fast and more sensitive diagnostic approaches are urgently needed. This prospective, observational, non-interventional, multicenter study seeks to evaluate an NGS-based approach in critically ill children suffering from sepsis. TRIAL REGISTRATION DRKS-ID: DRKS00015705 (registered October 24, 2018). https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015705.
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Affiliation(s)
- Thomas Schmoch
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen
- Department of Anesthesiology, Heidelberg University Hospital
| | - Jens H. Westhoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg
| | | | - Annabell Skarabis
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen
| | - Georg F. Hoffmann
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Essen
| | | | - Manuel Feisst
- Institute of Medical Biometry, University of Heidelberg
| | | | | | - Steffen Luntz
- Coordination Centre for Clinical Trials (KKS), Ruprecht-Karls-University, Heidelberg
| | | | - Kai Sohn
- Fraunhofer Institute for Interfacial Engineering and Biotechnology, Stuttgart, Germany
| | - Thorsten Brenner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen
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