1
|
Seok H, Park DW. Role of biomarkers in antimicrobial stewardship: physicians' perspectives. Korean J Intern Med 2024; 39:413-429. [PMID: 38715231 PMCID: PMC11076897 DOI: 10.3904/kjim.2023.558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/05/2024] [Accepted: 03/15/2024] [Indexed: 05/12/2024] Open
Abstract
Biomarkers are playing an increasingly important role in antimicrobial stewardship. Their applications have included use in algorithms that evaluate suspected bacterial infections or provide guidance on when to start or stop antibiotic therapy, or when therapy should be repeated over a short period (6-12 h). Diseases in which biomarkers are used as complementary tools to determine the initiation of antibiotics include sepsis, lower respiratory tract infection (LRTI), COVID-19, acute heart failure, infectious endocarditis, acute coronary syndrome, and acute pancreatitis. In addition, cut-off values of biomarkers have been used to inform the decision to discontinue antibiotics for diseases such as sepsis, LRTI, and febrile neutropenia. The biomarkers used in antimicrobial stewardship include procalcitonin (PCT), C-reactive protein (CRP), presepsin, and interleukin (IL)-1β/IL-8. The cut-off values vary depending on the disease and study, with a range of 0.25-1.0 ng/mL for PCT and 8-50 mg/L for CRP. Biomarkers can complement clinical diagnosis, but further studies of microbiological biomarkers are needed to ensure appropriate antibiotic selection.
Collapse
Affiliation(s)
- Hyeri Seok
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Dae Won Park
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| |
Collapse
|
2
|
Shinkins B, Allen AJ, Karichu J, Garrison LP, Monz BU. Evidence Synthesis and Linkage for Modelling the Cost-Effectiveness of Diagnostic Tests: Preliminary Good Practice Recommendations. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:131-144. [PMID: 38316713 PMCID: PMC10864520 DOI: 10.1007/s40258-023-00855-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/05/2023] [Indexed: 02/07/2024]
Abstract
OBJECTIVES To develop preliminary good practice recommendations for synthesising and linking evidence of treatment effectiveness when modelling the cost-effectiveness of diagnostic tests. METHODS We conducted a targeted review of guidance from key Health Technology Assessment (HTA) bodies to summarise current recommendations on synthesis and linkage of treatment effectiveness evidence within economic evaluations of diagnostic tests. We then focused on a specific case study, the cost-effectiveness of troponin for the diagnosis of myocardial infarction, and reviewed the approach taken to synthesise and link treatment effectiveness evidence in different modelling studies. RESULTS The Australian and UK HTA bodies provided advice for synthesising and linking treatment effectiveness in diagnostic models, acknowledging that linking test results to treatment options and their outcomes is common. Across all reviewed models for the case study, uniform test-directed treatment decision making was assumed, i.e., all those who tested positive were treated. Treatment outcome data from a variety of sources, including expert opinion, were utilised for linked clinical outcomes. Preliminary good practice recommendations for data identification, integration and description are proposed. CONCLUSION Modelling the cost-effectiveness of diagnostic tests poses unique challenges in linking evidence on test accuracy to treatment effectiveness data to understand how a test impacts patient outcomes and costs. Upfront consideration of how a test and its results will likely be incorporated into patient diagnostic pathways is key to exploring the optimal design of such models. We propose some preliminary good practice recommendations to improve the quality of cost-effectiveness evaluations of diagnostics tests going forward.
Collapse
Affiliation(s)
- Bethany Shinkins
- Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
- Leeds Institute for Health Sciences, University of Leeds, Clarendon Way, Leeds, UK.
- NIHR Leeds In Vitro Diagnostics Co-operative (MIC), Leeds, UK.
| | - A Joy Allen
- Access and Innovation, Roche Diagnostics UK and Ireland, Burgess Hill, UK
| | - James Karichu
- Global Access & Policy, Roche Diagnostics Solutions, Pleasanton, California, USA
| | - Louis P Garrison
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, USA
| | - Brigitta U Monz
- Global Access & Policy, Roche Diagnostics International AG, Forrenstrasse 2, 6343, Rotkreuz, Switzerland
| |
Collapse
|
3
|
Jordan J, Tume L, Clarke M, McAuley D, McDowell C, McIlmurray L, Morris K, Peters M, Walsh T, Blackwood B. Delivery of a novel intervention to facilitate liberation from mechanical ventilation in paediatric intensive care: A process evaluation. PLoS One 2023; 18:e0293063. [PMID: 38011103 PMCID: PMC10681213 DOI: 10.1371/journal.pone.0293063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/04/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Prolonged mechanical ventilation increases the risk of mortality and morbidity. Optimising sedation and early testing for possible liberation from invasive mechanical ventilation (IMV) has been shown to reduce time on the ventilator. Alongside a multicentre trial of sedation and ventilation weaning, we conducted a mixed method process evaluation to understand how the intervention content and delivery was linked to trial outcomes. METHODS 10,495 children admitted to 18 paediatric intensive care units (ICUs) in the United Kingdom participated in a stepped-wedge, cluster randomised controlled trial, with 1955 clinical staff trained to deliver the intervention. The intervention comprised assessment and optimisation of sedation levels, and bedside screening of respiratory parameters to indicate readiness for a spontaneous breathing trial prior to liberation from ventilation. 193 clinical staff were interviewed towards the end of the trial. Interview data were thematically analysed, and quantitative adherence data were analysed using descriptive statistics. RESULTS The intervention led to a reduced duration of IMV (adjusted median difference- 7.1 hours, 95% CI -9.6 to -5.3, p = 0.01). Overall intervention adherence was 75% (range 59-85%). Ease and flexibility of the intervention promoted it use; designated responsibilities, explicit pathways of decision-making and a shared language for communication fostered proactivity and consistency towards extubation. Delivery of the intervention was hindered by established hospital and unit organisational and patient care routines, clinician preference and absence of clinical leadership. CONCLUSIONS The SANDWICH trial showed a significant, although small, reduction in duration of IMV. Findings suggest that greater direction in decision-making pathways, robust embedment of new practice in unit routine, and capitalising on the skills of Advanced Nurse Practitioners and physiotherapists would have contributed to greater intervention effect. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN16998143.
Collapse
Affiliation(s)
- Joanne Jordan
- School of Health, Wellbeing and Social Care, Open University, Milton Keynes, England
| | - Lyvonne Tume
- Faculty of Heath, Social Care & Medicine, Edge Hill University, Ormskirk, England
- PICU, Alder Hey Children’s NHS Trust, Liverpool, England
| | - Mike Clarke
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, Northern Ireland
| | - Danny McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Northern Ireland
| | - Cliona McDowell
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, Northern Ireland
| | - Lisa McIlmurray
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Northern Ireland
| | - Kevin Morris
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, England
- Institute of Applied Health Research, University of Birmingham, Birmingham, England
| | - Mark Peters
- Great Ormond Street Institute of Child Health, NIHR Biomedical Research Centre, University College London, London, England
- Great Ormond Street Hospital, London, England
| | - Timothy Walsh
- Institute of Population Health Sciences, University of Edinburgh, Edinburgh, Scotland
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Northern Ireland
| |
Collapse
|
4
|
Singh S, Nurek M, Mason S, Moore LS, Mughal N, Vizcaychipi MP. WHY STOP? A prospective observational vignette-based study to determine the cognitive-behavioural effects of rapid diagnostic PCR-based point-of-care test results on antibiotic cessation in ICU infections. BMJ Open 2023; 13:e073577. [PMID: 37989388 PMCID: PMC10668237 DOI: 10.1136/bmjopen-2023-073577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 10/19/2023] [Indexed: 11/23/2023] Open
Abstract
OBJECTIVES Point-of-care tests (POCTs) for infection offer accurate rapid diagnostics but do not consistently improve antibiotic stewardship (ASP) of suspected ventilator-associated pneumonia. We aimed to measure the effect of a negative PCR-POCT result on intensive care unit (ICU) clinicians' antibiotic decisions and the additional effects of patient trajectory and cognitive-behavioural factors (clinician intuition, dis/interest in POCT, risk averseness). DESIGN Observational cohort simulation study. SETTING ICU. PARTICIPANTS 70 ICU consultants/trainees working in UK-based teaching hospitals. METHODS Clinicians saw four case vignettes describing patients who had completed a course of antibiotics for respiratory infection. Vignettes comprised clinical and biological data (ie, white cell count, C reactive protein), varied to create four trajectories: clinico-biological improvement (the 'improvement' case), clinico-biological worsening ('worsening'), clinical improvement/biological worsening ('discordant clin better'), clinical worsening/biological improvement ('discordant clin worse'). Based on this, clinicians made an initial antibiotics decision (stop/continue) and rated confidence (6-point Likert scale). A PCR-based POCT was then offered, which clinicians could accept or decline. All clinicians (including those who declined) were shown the result, which was negative. Clinicians updated their antibiotics decision and confidence. MEASURES Antibiotics decisions and confidence were compared pre-POCT versus post-POCT, per vignette. RESULTS A negative POCT result increased the proportion of stop decisions (54% pre-POCT vs 70% post-POCT, χ2(1)=25.82, p<0.001, w=0.32) in all vignettes except improvement (already high), most notably in discordant clin worse (49% pre-POCT vs 74% post-POCT). In a linear regression, factors that significantly reduced clinicians' inclination to stop antibiotics were a worsening trajectory (b=-0.73 (-1.33, -0.14), p=0.015), initial confidence in continuing (b=0.66 (0.56, 0.76), p<0.001) and involuntary receipt of POCT results (clinicians who accepted the POCT were more inclined to stop than clinicians who declined it, b=1.30 (0.58, 2.02), p<0.001). Clinician risk averseness was not found to influence antibiotic decisions (b=-0.01 (-0.12, 0.10), p=0.872). CONCLUSIONS A negative PCR-POCT result can encourage antibiotic cessation in ICU, notably in cases of clinical worsening (where the inclination might otherwise be to continue). This effect may be reduced by high clinician confidence to continue and/or disinterest in POCT, perhaps due to low trust/perceived utility. Such cognitive-behavioural and trajectorial factors warrant greater consideration in future ASP study design.
Collapse
Affiliation(s)
- Suveer Singh
- Faculty of Medicine, Imperial College London, London, UK
- Respiratory and Intensive Care Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Martine Nurek
- Surgery and Cancer, Imperial College London, London, UK
| | - Sonia Mason
- Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Luke Sp Moore
- Imperial College London, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nabeela Mughal
- Imperial College London, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Marcela P Vizcaychipi
- APMIC, Imperial College London, London, UK
- Magill Department of Anaesthesia and Intensive Care Medicine, Chelsea and Westminster Healthcare NHS Trust, London, UK
| |
Collapse
|
5
|
Mangioni D, Panigada M, Palomba E, Bobbio C, Chatenoud L, Alagna L, Fumagalli J, Gori A, Grancini A, Guzzardella A, Lombardi A, Matinato C, Meli A, Muscatello A, Porretti L, Tomasello M, Trombetta E, Valenti L, Bandera A, Grasselli G. Incidence, microbiological and immunological characteristics of ventilator-associated pneumonia assessed by bronchoalveolar lavage and endotracheal aspirate in a prospective cohort of COVID-19 patients: CoV-AP study. Crit Care 2023; 27:369. [PMID: 37749631 PMCID: PMC10521470 DOI: 10.1186/s13054-023-04658-5] [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: 07/28/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND No univocal recommendation exists for microbiological diagnosis of ventilator-associated pneumonia (VAP). Sampling of either proximal or distal respiratory tract likely impacts on the broad range of VAP incidence between cohorts. Immune biomarkers to rule-in/rule-out VAP diagnosis, although promising, have not yet been validated. COVID-19-induced ARDS made VAP recognition even more challenging, often leading to overdiagnosis and overtreatment. We evaluated the impact of different respiratory samples and laboratory techniques on VAP incidence and microbiological findings in COVID-19 patients. METHODS Prospective single-centre cohort study conducted among COVID-19 mechanically ventilated patients in Policlinico Hospital (Milan, Italy) from January 2021 to May 2022. Microbiological confirmation of suspected VAP (sVAP) was based on concomitant endotracheal aspirates (ETA) and bronchoalveolar lavage (BAL). Conventional and fast microbiology (FILMARRAY® Pneumonia Panel plus, BALFAPPP) as well as immunological markers (immune cells and inflammatory cytokines) was analysed. RESULTS Seventy-nine patients were included. Exposure to antibiotics and steroid therapy before ICU admission occurred in 51/79 (64.6%) and 60/79 (65.9%) patients, respectively. Median duration of MV at VAP suspicion was 6 (5-9) days. Incidence rate of microbiologically confirmed VAP was 33.1 (95% CI 22.1-44.0) and 20.1 (95% CI 12.5-27.7) according to ETA and BAL, respectively. Concordance between ETA and BAL was observed in 35/49 (71.4%) cases, concordance between BALFAPPP and BAL in 39/49 (79.6%) cases. With BAL as reference standard, ETA showed 88.9% (95% CI 70.8-97.7) sensitivity and 50.0% (95% CI 28.2-71.8) specificity (Cohen's Kappa 0.40, 95% CI 0.16-0.65). BALFAPPP showed 95.0% (95% CI 75.1-99.9) sensitivity and 69% (95% CI 49.2-84.7) specificity (Cohen's Kappa 0.60, 95% CI 0.39-0.81). BAL IL-1β differed significantly between VAP (135 (IQR 11-450) pg/ml) and no-VAP (10 (IQR 2.9-105) pg/ml) patients (P = 0.03). CONCLUSIONS In COVID-19 ICU patients, differences in microbial sampling at VAP suspicion could lead to high variability in VAP incidence and microbiological findings. Concordance between ETA and BAL was mainly limited by over 20% of ETA positive and BAL negative samples, while BALFAPPP showed high sensitivity but limited specificity when evaluating in-panel targets only. These factors should be considered when comparing results of cohorts with different sampling. BAL IL-1β showed potential in discriminating microbiologically confirmed VAP. CLINICAL TRIAL REGISTRATION NCT04766983, registered on February 23, 2021.
Collapse
Affiliation(s)
- Davide Mangioni
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Mauro Panigada
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Emanuele Palomba
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy.
| | - Chiara Bobbio
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Laura Alagna
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jacopo Fumagalli
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Anna Grancini
- Microbiology Laboratory, Clinical Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Lombardi
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Caterina Matinato
- Microbiology Laboratory, Clinical Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Meli
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Muscatello
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Porretti
- Flow Cytometry and Cell Sorting Laboratory, Clinical Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mara Tomasello
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Elena Trombetta
- Flow Cytometry and Cell Sorting Laboratory, Clinical Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Precision Medicine, Biological Resource Center Unit, Department of Transfusion Medicine, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Bandera
- Infectious Diseases Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milano, Milan, Italy
- Department of Anaesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
6
|
Ahuja N, Mishra A, Gupta R, Ray S. Biomarkers in sepsis-looking for the Holy Grail or chasing a mirage! World J Crit Care Med 2023; 12:188-203. [PMID: 37745257 PMCID: PMC10515097 DOI: 10.5492/wjccm.v12.i4.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/12/2023] [Accepted: 06/12/2023] [Indexed: 09/05/2023] Open
Abstract
Sepsis is defined as a life-threatening organ dysfunction caused by the dysregulated host response to infection. It is a complex syndrome and is characterized by physiologic, pathologic and biochemical abnormalities in response to an infection. Diagnosis of sepsis is based on history, physical examination and other investigations (including biomarkers) which may help to increase the certainty of diagnosis. Biomarkers have been evaluated in the past for many diseases and have been evaluated for sepsis as well. Biomarkers may find a possible role in diagnosis, prognostication, therapeutic monitoring and anti-microbial stewardship in sepsis. Since the pathophysiology of sepsis is quite complex and is incompletely understood, a single biomarker that may be robust enough to provide all information has not been found as of yet. However, many biomarkers have been studied and some of them have applications at the bedside and guide clinical decision-making. We evaluated the PubMed database to search for sepsis biomarkers for diagnosis, prognosis and possible role in antibiotic escalation and de-escalation. Clinical trials, meta-analyses, systematic reviews and randomized controlled trials were included. Commonly studied biomarkers such as procalcitonin, Soluble urokinase-type plasminogen activator (Supar), presepsin, soluble triggering receptor expressed on myeloid cells 1, interleukin 6, C-reactive protein, etc., have been described for their possible applications as biomarkers in septic patients. The sepsis biomarkers are still an area of active research with newer evidence adding to the knowledge base continuously. For patients presenting with sepsis, early diagnosis and prompt resuscitation and early administration of anti-microbials (preferably within 1 h) and source control are desired goals. Biomarkers may help us in the diagnosis, prognosis and therapeutic monitoring of septic patients. The marker redefining our view on sepsis is yet a mirage that clinicians and researchers continue to chase.
Collapse
Affiliation(s)
- Neelmani Ahuja
- Department of Critical Care Medicine, Holy Family Hospital, Delhi 110025, India
| | - Anjali Mishra
- Department of Critical Care Medicine, Holy Family Hospital, Delhi 110025, India
| | - Ruchi Gupta
- Department of Critical Care Medicine, Holy Family Hospital, Delhi 110025, India
| | - Sumit Ray
- Department of Critical Care Medicine, Holy Family Hospital, Delhi 110025, India
| |
Collapse
|
7
|
Adjei A, Kukula V, Narh CT, Odopey S, Arthur E, Odonkor G, Mensah MM, Olliaro P, Horgan P, Dittrich S, Moore CE, Salami O, Awini E, Nkeramahame J, Williams J, Baiden R. Impact of Point-of-Care Rapid Diagnostic Tests on Antibiotic Prescription Among Patients Aged <18 Years in Primary Healthcare Settings in 2 Peri-Urban Districts in Ghana: Randomized Controlled Trial Results. Clin Infect Dis 2023; 77:S145-S155. [PMID: 37490745 PMCID: PMC10368405 DOI: 10.1093/cid/ciad328] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Inappropriate antibiotic prescriptions are a known driver of antimicrobial resistance in settings with limited diagnostic capacity. This study aimed to assess the impact of diagnostic algorithms incorporating rapid diagnostic tests on clinical outcomes and antibiotic prescriptions compared with standard-of-care practices, of acute febrile illness cases at outpatient clinics in Shai-Osudoku and Prampram districts in Ghana. METHODS This was an open-label, centrally randomized controlled trial in 4 health facilities. Participants aged 6 months to <18 years of both sexes with acute febrile illness were randomized to receive a package of interventions to guide antibiotic prescriptions or standard care. Clinical outcomes were assessed on day 7. RESULTS In total, 1512 patients were randomized to either the intervention (n = 761) or control (n = 751) group. Majority were children aged <5 years (1154 of 1512, 76.3%) and male (809 of 1512, 53.5%). There was 11% relative risk reduction of antibiotic prescription in intervention group (RR, 0.89; 95% CI, .79 to 1.01); 14% in children aged <5 years (RR, 0.86; 95% CI, .75 to .98), 15% in nonmalaria patients (RR, 0.85; 95% CI, .75 to .96), and 16% in patients with respiratory symptoms (RR, 0.84; 95% CI, .73 to .96). Almost all participants had favorable outcomes (759 of 761, 99.7% vs 747 of 751, 99.4%). CONCLUSIONS In low- and middle-income countries, the combination of point-of-care diagnostics, diagnostic algorithms, and communication training can be used at the primary healthcare level to reduce antibiotic prescriptions among children with acute febrile illness, patients with nonmalarial fevers, and respiratory symptoms. CLINICAL TRIALS REGISTRATION NCT04081051.
Collapse
Affiliation(s)
- Alexander Adjei
- Department of Epidemiology, Dodowa Health Research Centre, Dodowa, Ghana
| | - Vida Kukula
- Department of Epidemiology, Dodowa Health Research Centre, Dodowa, Ghana
| | - Clement Tetteh Narh
- Department of Epidemiology, Dodowa Health Research Centre, Dodowa, Ghana
- Department of Epidemiology and Biostatistics, Fred N. Binka School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Selase Odopey
- Department of Epidemiology, Dodowa Health Research Centre, Dodowa, Ghana
| | - Emmanuel Arthur
- Department of Epidemiology, Dodowa Health Research Centre, Dodowa, Ghana
| | - Gabriel Odonkor
- Department of Epidemiology, Dodowa Health Research Centre, Dodowa, Ghana
| | | | - Piero Olliaro
- Department of Medical Affairs, FIND, Geneva, Switzerland
- International Severe Acute Respiratory and Emerging Infection Consortium, Pandemic Sciences Institute, University of Oxford, Oxford, United Kingdom
| | - Philip Horgan
- Department of Medical Affairs, FIND, Geneva, Switzerland
- Nuffield Department of Medicine, Big Data Institute, University of Oxford, Oxford, United Kingdom
- Evidence & Impact Oxford, Oxford, United Kingdom
| | - Sabine Dittrich
- Department of Medical Affairs, FIND, Geneva, Switzerland
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- Deggendorf Institute of Technology, European Campus Rottal Inn, Pfarrkirchen, Germany
| | - Catrin E Moore
- Nuffield Department of Medicine, Big Data Institute, University of Oxford, Oxford, United Kingdom
- Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, St. George's University of London, London, United Kingdom
| | - Olawale Salami
- Department of Medical Affairs, FIND, Geneva, Switzerland
| | - Elizabeth Awini
- Department of Epidemiology, Dodowa Health Research Centre, Dodowa, Ghana
| | | | - John Williams
- Department of Epidemiology, Dodowa Health Research Centre, Dodowa, Ghana
| | - Rita Baiden
- Department of Epidemiology, Dodowa Health Research Centre, Dodowa, Ghana
| |
Collapse
|
8
|
Clark JA, Conway Morris A, Kanaris C, Inwald D, Butt W, Osowicki J, Schlapbach LJ, Curran MD, White D, Daubney E, Agrawal S, Navapurkar V, Török ME, Baker S, Pathan N. A qualitative investigation of paediatric intensive care staff attitudes towards the diagnosis of lower respiratory tract infection in the molecular diagnostics era. INTENSIVE CARE MEDICINE. PAEDIATRIC AND NEONATAL 2023; 1:10. [PMID: 37425493 PMCID: PMC10329081 DOI: 10.1007/s44253-023-00008-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/09/2023] [Indexed: 07/11/2023]
Abstract
Background In the past decade, molecular diagnostic syndromic arrays incorporating a range of bacterial and viral pathogens have been described. It is unclear how paediatric intensive care unit (PICU) staff diagnose lower respiratory tract infection (LRTI) and integrate diagnostic array results into antimicrobial decision-making. Methods An online survey with eleven questions was distributed throughout paediatric intensive care societies in the UK, continental Europe and Australasia with a total of 755 members. Participants were asked to rate the clinical factors and investigations they used when prescribing for LRTI. Semi-structured interviews were undertaken with staff who participated in a single-centre observational study of a 52-pathogen diagnostic array. Results Seventy-two survey responses were received; most responses were from senior doctors. Whilst diagnostic arrays were used less frequently than routine investigations (i.e. microbiological culture), they were of comparable perceived utility when making antimicrobial decisions. Prescribers reported that for arrays to be clinically impactful, they would need to deliver results within 6 h for stable patients and within 1 h for unstable patients to inform their immediate decision to prescribe antimicrobials. From 16 staff interviews, we identified that arrays were helpful for the diagnosis and screening of bacterial LRTI. Staff reported it could be challenging to interpret results in some cases due to the high sensitivity of the test. Therefore, results were considered within the context of the patient and discussed within the multidisciplinary team. Conclusions Diagnostic arrays were considered of comparable value to microbiological investigations by PICU prescribers. Our findings support the need for further clinical and economic evaluation of diagnostic arrays in a randomised control trial. Trial registration Clinicaltrials.gov, NCT04233268. Registered on 18 January 2020. Supplementary Information The online version contains supplementary material available at 10.1007/s44253-023-00008-z.
Collapse
Affiliation(s)
- John A. Clark
- Department of Paediatrics, University of Cambridge, Level 8, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew Conway Morris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Division of Immunology, Department of Pathology, University of Cambridge, Cambridge, UK
| | - Constantinos Kanaris
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Blizard Institute, Queen Mary University of London, London, UK
| | - David Inwald
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Warwick Butt
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Joshua Osowicki
- Infectious Diseases Unit, Department of General Medicine, Royal Children’s Hospital Melbourne, Parkville, Australia
| | - Luregn J. Schlapbach
- Department of Intensive Care and Neonatology and Children’s Research Center, University Children’s Hospital Zürich, Zurich, Switzerland
| | - Martin D. Curran
- United Kingdom Health Security Agency, Clinical Microbiology and Public Health Laboratory, Cambridge, UK
| | - Deborah White
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Esther Daubney
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Shruti Agrawal
- Department of Paediatrics, University of Cambridge, Level 8, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Vilas Navapurkar
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M. Estée Török
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Infectious Diseases, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Level 8, Addenbrooke’s Hospital, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
9
|
Essmann L, Wirz Y, Gregoriano C, Schuetz P. One biomarker does not fit all: tailoring anti-infective therapy through utilization of procalcitonin and other specific biomarkers. Expert Rev Mol Diagn 2023; 23:739-752. [PMID: 37505928 DOI: 10.1080/14737159.2023.2242782] [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: 05/05/2023] [Revised: 07/05/2023] [Accepted: 07/27/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Considering the ongoing increase in antibiotic resistance, the importance of judicious use of antibiotics through reduction of exposure is crucial. Adding procalcitonin (PCT) and other biomarkers to pathogen-specific tests may help to further improve antibiotic therapy algorithms and advance antibiotic stewardship programs to achieve these goals. AREAS COVERED In recent years, several trials have investigated the inclusion of biomarkers such as PCT into clinical decision-making algorithms. For adult patients, findings demonstrated improvements in the individualization of antibiotic treatment, particularly for patients with respiratory tract infections and sepsis. While most trials were performed in hospitals with central laboratories, point-of-care testing might further advance the field by providing a cost-effective and rapid diagnostic tool in upcoming years. Furthermore, novel biomarkers including CD-64, presepsin, Pancreatic stone and sTREM-1, have all shown promising results for increased accuracy of sepsis diagnosis. Availability of these markers however is currently still limited and there is insufficient evidence for their routine use in clinical care. EXPERT OPINION In addition to new host-response markers, combining such biomarkers with pathogen-directed diagnostics present a promising strategy to increase algorithm accuracy in differentiating between bacterial and viral infections. Recent advances in microbiologic testing using PCR or nucleic amplification tests may further improve the diagnostic yield and promote more targeted pathogen-specific antibiotic therapy.
Collapse
Affiliation(s)
- Lennart Essmann
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - Yannick Wirz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Philipp Schuetz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| |
Collapse
|
10
|
Jeffrey M, Denny KJ, Lipman J, Conway Morris A. Differentiating infection, colonisation, and sterile inflammation in critical illness: the emerging role of host-response profiling. Intensive Care Med 2023; 49:760-771. [PMID: 37344680 DOI: 10.1007/s00134-023-07108-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/22/2023] [Indexed: 06/23/2023]
Abstract
Infection results when a pathogen produces host tissue damage and elicits an immune response. Critically ill patients experience immune activation secondary to both sterile and infectious insults, with overlapping clinical phenotypes and underlying immunological mechanisms. Patients also undergo a shift in microbiota with the emergence of pathogen-dominant microbiomes. Whilst the combination of inflammation and microbial shift has long challenged intensivists in the identification of true infection, the advent of highly sensitive molecular diagnostics has further confounded the diagnostic dilemma as the number of microbial detections increases. Given the key role of the host immune response in the development and definition of infection, profiling the host response offers the potential to help unravel the conundrum of distinguishing colonisation and sterile inflammation from true infection. This narrative review provides an overview of current approaches to distinguishing colonisation from infection using routinely available techniques and proposes matrices to support decision-making in this setting. In searching for new tools to better discriminate these states, the review turns to the understanding of the underlying pathobiology of the host response to infection. It then reviews the techniques available to assess this response in a clinically applicable context. It will cover techniques including profiling of transcriptome, protein expression, and immune functional assays, detailing the current state of knowledge in diagnostics along with the challenges and opportunities. The ultimate infection diagnostic tool will likely combine an assessment of both host immune response and sensitive pathogen detection to improve patient management and facilitate antimicrobial stewardship.
Collapse
Affiliation(s)
- Mark Jeffrey
- John V Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Division of Anaesthesia, Department of Medicine, Level 4, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK
| | - Kerina J Denny
- Department of Intensive Care, Gold Coast University Hospital, Southport, QLD, Australia
- School of Medicine, University of Queensland, Herston, Brisbane, Australia
| | - Jeffrey Lipman
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Jamieson Trauma Institute and Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Nimes University Hospital, University of Montpellier, Nimes, France
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
- Division of Anaesthesia, Department of Medicine, Level 4, Addenbrooke's Hospital, University of Cambridge, Hills Road, Cambridge, CB2 0QQ, UK.
- Division of Immunology, Department of Pathology, University of Cambridge, Cambridge, UK.
| |
Collapse
|
11
|
Moore LSP, Villegas MV, Wenzler E, Rawson TM, Oladele RO, Doi Y, Apisarnthanarak A. Rapid Diagnostic Test Value and Implementation in Antimicrobial Stewardship Across Low-to-Middle and High-Income Countries: A Mixed-Methods Review. Infect Dis Ther 2023:10.1007/s40121-023-00815-z. [PMID: 37261612 DOI: 10.1007/s40121-023-00815-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/20/2023] [Indexed: 06/02/2023] Open
Abstract
Despite technological advancements in infectious disease rapid diagnostic tests (RDTs) and use to direct therapy at the per-patient level, RDT utilisation in antimicrobial stewardship programmes (ASPs) is variable across low-to-middle income and high-income countries. Key insights from a panel of seven infectious disease experts from Colombia, Japan, Nigeria, Thailand, the UK, and the USA, combined with evidence from a literature review, were used to assess the value of RDTs in ASPs. From this, a value framework is proposed which aims to define the benefits of RDT use in ASPs, separate from per-patient benefits. Expert insights highlight that, to realise the value of RDTs within ASPs, effective implementation is key; actionable advice for choosing an RDT is proposed. Experts advocate the inclusion of RDTs in the World Health Organization Model List of essential in vitro diagnostics and in iterative development of national action plans.
Collapse
Affiliation(s)
- Luke S P Moore
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
- Imperial College Healthcare NHS Trust, North West London Pathology, London, UK.
- NIHR Health Protection Research Unit in Healthcare Associated Infections & Antimicrobial Resistance, Imperial College London, London, UK.
| | - Maria Virginia Villegas
- Grupo de Resistencia Antimicrobiana y Epidemiología Hospitalaria, Universidad El Bosque, Bogotá, Colombia
- Molecular Genetics and Antimicrobial Resistance Unit, International Center for Microbial Genomics, Universidad El Bosque, Bogotá, Colombia
| | - Eric Wenzler
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Timothy M Rawson
- NIHR Health Protection Research Unit in Healthcare Associated Infections & Antimicrobial Resistance, Imperial College London, London, UK
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
| | - Rita O Oladele
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Yohei Doi
- Department of Infectious Diseases, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
- Department of Microbiology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anucha Apisarnthanarak
- Research Group in Infectious Diseases Epidemiology and Prevention, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| |
Collapse
|
12
|
Verghis R, Blackwood B, McDowell C, Toner P, Hadfield D, Gordon AC, Clarke M, McAuley D. Heterogeneity of surrogate outcome measures used in critical care studies: A systematic review. Clin Trials 2023; 20:307-318. [PMID: 36946422 PMCID: PMC10617004 DOI: 10.1177/17407745231151842] [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] [Indexed: 03/23/2023]
Abstract
BACKGROUND The choice of outcome measure is a critical decision in the design of any clinical trial, but many Phase III clinical trials in critical care fail to detect a difference between the interventions being compared. This may be because the surrogate outcomes used to show beneficial effects in early phase trials (which informed the design of the subsequent Phase III trials) are not valid guides to the differences between the interventions for the main outcomes of the Phase III trials. We undertook a systematic review (1) to generate a list of outcome measures used in critical care trials, (2) to determine the variability in the outcome reporting in the respiratory subgroup and (3) to create a smaller list of potential early phase endpoints in the respiratory subgroup. METHODS Data related to outcomes were extracted from studies published in the six top-ranked critical care journals between 2010 and 2020. Outcomes were classified into subcategories and categories. A subset of early phase endpoints relevant to the respiratory subgroup was selected for further investigation. The variability of the outcomes and the variability in reporting was investigated. RESULTS A total of 6905 references were retrieved and a total of 294 separate outcomes were identified from 58 studies. The outcomes were then classified into 11 categories and 66 subcategories. A subset of 22 outcomes relevant for the respiratory group were identified as potential early phase outcomes. The summary statistics, time points and definitions show the outcomes are analysed and reported in different ways. CONCLUSION The outcome measures were defined, analysed and reported in a variety of ways. This creates difficulties for synthesising data in systematic reviews and planning definitive trials. This review once again highlights an urgent need for standardisation and validation of surrogate outcomes reported in critical care trials. Future work should aim to validate and develop a core outcome set for surrogate outcomes in critical care trials.
Collapse
Affiliation(s)
- Rejina Verghis
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Bronagh Blackwood
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | | | - Philip Toner
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Daniel Hadfield
- Critical Care Unit, King’s College Hospital NHS Foundation Trust, London, UK
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Mike Clarke
- Centre of Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | - Daniel McAuley
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| |
Collapse
|
13
|
Mikacenic C, Fussner LA, Bell J, Burnham EL, Chlan LL, Cook SK, Dickson RP, Almonor F, Luo F, Madan K, Morales-Nebreda L, Mould KJ, Simpson AJ, Singer BD, Stapleton RD, Wendt CH, Files DC. Research Bronchoscopies in Critically Ill Research Participants: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:621-631. [PMID: 37125997 PMCID: PMC10174130 DOI: 10.1513/annalsats.202302-106st] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Bronchoscopy for research purposes is a valuable tool to understand lung-specific biology in human participants. Despite published reports and active research protocols using this procedure in critically ill patients, no recent document encapsulates the important safety considerations and downstream applications of this procedure in this setting. The objectives were to identify safe practices for patient selection and protection of hospital staff, provide recommendations for sample procurement to standardize studies, and give guidance on sample preparation for novel research technologies. Seventeen international experts in the management of critically ill patients, bronchoscopy in clinical and research settings, and experience in patient-oriented clinical or translational research convened for a workshop. Review of relevant literature, expert presentations, and discussion generated the findings presented herein. The committee concludes that research bronchoscopy with bronchoalveolar lavage in critically ill patients on mechanical ventilation is valuable and safe in appropriately selected patients. This report includes recommendations on standardization of this procedure and prioritizes the reporting of sample management to produce more reproducible results between laboratories. This document serves as a resource to the community of researchers who endeavor to include bronchoscopy as part of their research protocols and highlights key considerations for the inclusion and safety of research participants.
Collapse
|
14
|
Daghmouri MA, Dudoignon E, Chaouch MA, Baekgaard J, Bougle A, Leone M, Deniau B, Depret F. Comparison of a short versus long-course antibiotic therapy for ventilator-associated pneumonia: a systematic review and meta-analysis of randomized controlled trials. EClinicalMedicine 2023; 58:101880. [PMID: 36911269 PMCID: PMC9995933 DOI: 10.1016/j.eclinm.2023.101880] [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] [Received: 12/19/2022] [Revised: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND For ventilator-associated pneumonia (VAP), the safety of short-course versus long-course antibiotic therapy is still debated, especially regarding documented VAP due to non-fermenting Gram-negative bacilli (NF-GNB). The aim of this meta-analysis was to assess the rates of recurrence and relapse of VAP in patients receiving short-course (≤8 days) and long-course (≥10-15 days) of antibiotic therapy. METHODS The protocol for this study was registered in the PROSPERO database (ID: CRD42022365138). We performed an electronic search of the relevant literature and limited our search to data published from 2000 until September 1, 2022. We searched for randomized controlled trials (RCTs) in the United States National Library of Medicine, Cochrane Database of Systematic Reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, National Institutes of Health PubMed/MEDLINE, web of science and Google Scholar databases. The primary endpoint was the recurrence and relapses of VAP, secondary endpoints were 28-day mortality, mechanical ventilation duration, number of extra-pulmonary infections and length of ICU stay. FINDINGS We identified five relevant studies involving 1069 patients (530 patients in the short-course group and 539 patients in the long-course group). The meta-analysis did not reveal any significant difference between short and long-course antibiotic therapy for recurrence and relapses of VAP (odd ratio "OR" = 1.48, 95% confidence intervals (CI) [0.96, 2.28], p = 0.08 and OR = 1.45, 95% CI [0.94, 2.22], p = 0.09, respectively), including those due to NF-GNB (OR = 1.90, 95% CI [0.93, 3.33], p = 0.05 and OR = 1.76, 95% CI [0.93, 3.33], p = 0.08, respectively). No difference was found for 28 days-mortality (OR = 1.24, 95% CI [0.92, 1.67], p = 0.16), mechanical ventilation duration, number of extra-pulmonary infections and length of ICU stay. However, short-course therapy significantly increased the number of antibiotic-free days. INTERPRETATION Our meta-analysis showed that short-course antibiotic therapy did not result in increased number of recurence and relapses of VAP, suggesting that short-course should be preferred to reduce the exposure to antibiotics. FUNDING None.
Collapse
Affiliation(s)
- Mohamed Aziz Daghmouri
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis-Lariboisière, AP-HP, Paris, France
- Corresponding author. Hôpital Saint Louis, 1 Avenue Claude Vellefaux, Paris 75010, France.
| | - Emmanuel Dudoignon
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis-Lariboisière, AP-HP, Paris, France
- INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
| | - Mohamed Ali Chaouch
- Department of Visceral Surgery, University Hospital of Fattouma Bourguiba, Monastir, Tunisia
| | - Josefine Baekgaard
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis-Lariboisière, AP-HP, Paris, France
| | - Adrien Bougle
- Department of Anesthesiology and Critical Care Medicine, Cardiology Institute, Sorbonne University, GRC 29, AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Marc Leone
- Service d'anesthésie et de Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
- Centre for CardioVascular and Nutrition Research (C2VN), Inserm 1263, Inrae 1260, Aix Marseille University, Marseille, France
| | - Benjamin Deniau
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis-Lariboisière, AP-HP, Paris, France
- INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
- Department of Visceral Surgery, University Hospital of Fattouma Bourguiba, Monastir, Tunisia
| | - François Depret
- Department of Anesthesiology, Critical Care and Burn Unit, University Hospital Saint-Louis-Lariboisière, AP-HP, Paris, France
- INSERM UMR-S 942, Cardiovascular Markers in Stress Condition (MASCOT), Université de Paris Cité, Paris, France
- Université de Paris Cité, Paris, France
| |
Collapse
|
15
|
Conway Morris A, Hellyer TP. Sniffing out pneumonia in the ICU. Anaesthesia 2023; 78:684-687. [PMID: 36947845 DOI: 10.1111/anae.16005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2023] [Indexed: 03/24/2023]
Affiliation(s)
- A Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, UK
- Division of Immunology, Department of Pathology, University of Cambridge, UK
- John V Farman Intensive Care Unit, Addenbrooke's Hospital, Cambridge, UK
| | - T P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
- Critical Care Department, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| |
Collapse
|
16
|
Mixed-methods process evaluation of a respiratory-culture diagnostic stewardship intervention. Infect Control Hosp Epidemiol 2023; 44:191-199. [PMID: 36594433 DOI: 10.1017/ice.2022.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To conduct a process evaluation of a respiratory culture diagnostic stewardship intervention. DESIGN Mixed-methods study. SETTING Tertiary-care pediatric intensive care unit (PICU). PARTICIPANTS Critical care, infectious diseases, and pulmonary attending physicians and fellows; PICU nurse practitioners and hospitalist physicians; pediatric residents; and PICU nurses and respiratory therapists. METHODS This mixed-methods study was conducted concurrently with a diagnostic stewardship intervention to reduce the inappropriate collection of respiratory cultures in mechanically ventilated children. We quantified baseline respiratory culture utilization and indications for ordering using quantitative methods. Semistructured interviews informed by these data and the Consolidated Framework for Implementation Research (CFIR) were then performed, recorded, transcribed, and coded to identify salient themes. Finally, themes identified in these interviews were used to create a cross-sectional survey. RESULTS The number of cultures collected per day of service varied between attending physicians (range, 2.2-27 cultures per 100 days). In total, 14 interviews were performed, and 87 clinicians completed the survey (response rate, 47%) and 77 nurses or respiratory therapists completed the survey (response rate, 17%). Clinicians varied in their stated practices regarding culture ordering, and these differences both clustered by specialty and were associated with perceived utility of the respiratory culture. Furthermore, group "default" practices, fear, and hierarchy were drivers of culture orders. Barriers to standardization included fear of a missed diagnosis and tension between practice standardization and individual decision making. CONCLUSIONS We identified significant variation in utilization and perceptions of respiratory cultures as well as several key barriers to implementation of this diagnostic test stewardship intervention.
Collapse
|
17
|
Salas M, Gossell-Williams M, Yalamanchili P, Dhingra S, Malikova MA, Aimer O, Junaid T. The Use of Biomarkers in Pharmacovigilance: A Systematic Review of the Literature. Biomark Insights 2023; 18:11772719231164528. [PMID: 37077840 PMCID: PMC10108426 DOI: 10.1177/11772719231164528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/02/2023] [Indexed: 04/21/2023] Open
Abstract
Background The use of biomarkers varies from disease etiognosis and diagnosis to signal detection, risk prediction, and management. Biomarker use has expanded in recent years, however, there are limited reviews on the use of biomarkers in pharmacovigilance and specifically in the monitoring and management of adverse drug reactions (ADRs). Objective The objective of this manuscript is to identify the multiple uses of biomarkers in pharmacovigilance irrespective of the therapeutic area. Design This is a systematic review of the literature. Data Sources and Methods Embase and MEDLINE database searches were conducted for literature published between 2010-March 19, 2021. Scientific articles that described the potential use of biomarkers in pharmacovigilance in sufficient detail were reviewed. Papers that did not fulfill the United States Food and Drug Administration (US FDA) definition of a biomarker were excluded, which is based on the International Conference on Harmonisation (ICH)-E16 guidance. Results Twenty-seven articles were identified for evaluation. Most articles involved predictive biomarkers (41%), followed by safety biomarkers (38%), pharmacodynamic/response biomarkers (14%), and diagnostic biomarkers (7%). Some articles described biomarkers that applied to multiple categories. Conclusion Various categories of biomarkers including safety, predictive, pharmacodynamic/response, and diagnostic biomarkers are being investigated for potential use in pharmacovigilance. The most frequent potential uses of biomarkers in pharmacovigilance in the literature were the prediction of the severity of an ADR, mortality, response, safety, and toxicity. The safety biomarkers identified were used to evaluate patient safety during dose escalation, identify patients who may benefit from further biomarker testing during treatment, and monitor ADRs.
Collapse
Affiliation(s)
- Maribel Salas
- Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
- Center for Real-world Effectiveness and Safety of Therapeutics (CREST), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Priyanka Yalamanchili
- Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
- Rutgers Institute for Pharmaceutical Industry Fellowships, Piscataway, NJ, USA
- Priyanka Yalamanchili, Daiichi Sankyo, Inc., 211 Mount Airy Rd, Basking Ridge, NJ 07920-2311, USA.
| | - Sameer Dhingra
- Department of Pharmacy Practice, National Institute of Pharmaceutical Education and Research (NIPER), Hajipur, India
| | - Marina A Malikova
- School of Medicine, Boston University, Boston, MA, USA
- Department of Surgery, Boston Medical Center, Boston, MA, USA
| | | | | |
Collapse
|
18
|
Gadsby NJ, Musher DM. The Microbial Etiology of Community-Acquired Pneumonia in Adults: from Classical Bacteriology to Host Transcriptional Signatures. Clin Microbiol Rev 2022; 35:e0001522. [PMID: 36165783 PMCID: PMC9769922 DOI: 10.1128/cmr.00015-22] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
All modern advances notwithstanding, pneumonia remains a common infection with substantial morbidity and mortality. Understanding of the etiology of pneumonia continues to evolve as new techniques enable identification of already known organisms and as new organisms emerge. We now review the etiology of pneumonia (at present often called "community-acquired pneumonia") beginning with classic bacteriologic techniques, which identified Streptococcus pneumoniae as the overwhelmingly common cause, to more modern bacteriologic studies, which emphasize Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis, Enterobacteriaceae, Pseudomonas, and normal respiratory flora. Urine antigen detection is useful in identifying Legionella and pneumococcus. The low yield of bacteria in recent studies is due to the failure to obtain valid sputum samples before antibiotics are administered. The use of high-quality sputum specimens enables identification of recognized ("typical") bacterial pathogens as well as a role for commensal bacteria ("normal respiratory flora"). Nucleic acid amplification technology for viruses has revolutionized diagnosis, showing the importance of viral pneumonia leading to hospitalization with or without coinfecting bacterial organisms. Quantitative PCR study of sputum is in its early stages of application, but regular detection of high counts of bacterial DNA from organisms that are not seen on Gram stain or grown in quantitative culture presents a therapeutic dilemma. This finding may reflect the host microbiome of the respiratory tract, in which case treatment may not need to be given for them. Finally, host transcriptional signatures might enable clinicians to distinguish between viral and bacterial pneumonia, an important practical consideration.
Collapse
Affiliation(s)
- Naomi J. Gadsby
- Department of Laboratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Daniel M. Musher
- Michael E. DeBakey Veterans Administration Medical Center, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
19
|
Navapurkar V, Bartholdson Scott J, Maes M, Hellyer TP, Higginson E, Forrest S, Pereira-Dias J, Parmar S, Heasman-Hunt E, Polgarova P, Brown J, Titti L, Smith WPW, Scott J, Rostron A, Routledge M, Sapsford D, Török ME, McMullan R, Enoch DA, Wong V, Curran MD, Brown NM, Simpson AJ, Herre J, Dougan G, Conway Morris A. Development and implementation of a customised rapid syndromic diagnostic test for severe pneumonia. Wellcome Open Res 2022; 6:256. [PMID: 36337362 PMCID: PMC9617073 DOI: 10.12688/wellcomeopenres.17099.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 02/02/2023] Open
Abstract
Background: The diagnosis of pneumonia has been hampered by a reliance on bacterial cultures which take several days to return a result, and are frequently negative. In critically ill patients this leads to the use of empiric, broad-spectrum antimicrobials and compromises good antimicrobial stewardship. The objective of this study was to establish the performance of a syndromic molecular diagnostic approach, using a custom TaqMan array card (TAC) covering 52 respiratory pathogens, and assess its impact on antimicrobial prescribing. Methods: The TAC was validated against a retrospective multi-centre cohort of broncho-alveolar lavage samples. The TAC was assessed prospectively in patients undergoing investigation for suspected pneumonia, with a comparator cohort formed of patients investigated when the TAC laboratory team were unavailable. Co-primary outcomes were sensitivity compared to conventional microbiology and, for the prospective study, time to result. Metagenomic sequencing was performed to validate findings in prospective samples. Antibiotic free days (AFD) were compared between the study cohort and comparator group. Results: 128 stored samples were tested, with sensitivity of 97% (95% confidence interval (CI) 88-100%). Prospectively, 95 patients were tested by TAC, with 71 forming the comparator group. TAC returned results 51 hours (interquartile range 41-69 hours) faster than culture and with sensitivity of 92% (95% CI 83-98%) compared to conventional microbiology. 94% of organisms identified by sequencing were detected by TAC. There was a significant difference in the distribution of AFDs with more AFDs in the TAC group (p=0.02). TAC group were more likely to experience antimicrobial de-escalation (odds ratio 2.9 (95%1.5-5.5)). Conclusions: Implementation of a syndromic molecular diagnostic approach to pneumonia led to faster results, with high sensitivity and impact on antibiotic prescribing.
Collapse
Affiliation(s)
- Vilas Navapurkar
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Josefin Bartholdson Scott
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Ellen Higginson
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Joana Pereira-Dias
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Surendra Parmar
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Emma Heasman-Hunt
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Petra Polgarova
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Joanne Brown
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Lissamma Titti
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - William PW Smith
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Anthony Rostron
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Matthew Routledge
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - David Sapsford
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - M. Estée Török
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK,Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
| | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Vanessa Wong
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | | | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Nicholas M Brown
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - A John Simpson
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Jurgen Herre
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK,
| |
Collapse
|
20
|
Navapurkar V, Bartholdson Scott J, Maes M, Hellyer TP, Higginson E, Forrest S, Pereira-Dias J, Parmar S, Heasman-Hunt E, Polgarova P, Brown J, Titti L, Smith WPW, Scott J, Rostron A, Routledge M, Sapsford D, Török ME, McMullan R, Enoch DA, Wong V, Curran MD, Brown NM, Simpson AJ, Herre J, Dougan G, Conway Morris A. Development and implementation of a customised rapid syndromic diagnostic test for severe pneumonia. Wellcome Open Res 2022; 6:256. [PMID: 36337362 PMCID: PMC9617073 DOI: 10.12688/wellcomeopenres.17099.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2022] [Indexed: 02/02/2023] Open
Abstract
Background: The diagnosis of pneumonia has been hampered by a reliance on bacterial cultures which take several days to return a result, and are frequently negative. In critically ill patients this leads to the use of empiric, broad-spectrum antimicrobials and compromises good antimicrobial stewardship. The objective of this study was to establish the performance of a syndromic molecular diagnostic approach, using a custom TaqMan array card (TAC) covering 52 respiratory pathogens, and assess its impact on antimicrobial prescribing. Methods: The TAC was validated against a retrospective multi-centre cohort of broncho-alveolar lavage samples. The TAC was assessed prospectively in patients undergoing investigation for suspected pneumonia, with a comparator cohort formed of patients investigated when the TAC laboratory team were unavailable. Co-primary outcomes were sensitivity compared to conventional microbiology and, for the prospective study, time to result. Metagenomic sequencing was performed to validate findings in prospective samples. Antibiotic free days (AFD) were compared between the study cohort and comparator group. Results: 128 stored samples were tested, with sensitivity of 97% (95% confidence interval (CI) 88-100%). Prospectively, 95 patients were tested by TAC, with 71 forming the comparator group. TAC returned results 51 hours (interquartile range 41-69 hours) faster than culture and with sensitivity of 92% (95% CI 83-98%) compared to conventional microbiology. 94% of organisms identified by sequencing were detected by TAC. There was a significant difference in the distribution of AFDs with more AFDs in the TAC group (p=0.02). TAC group were more likely to experience antimicrobial de-escalation (odds ratio 2.9 (95%1.5-5.5)). Conclusions: Implementation of a syndromic molecular diagnostic approach to pneumonia led to faster results, with high sensitivity and impact on antibiotic prescribing.
Collapse
Affiliation(s)
- Vilas Navapurkar
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Josefin Bartholdson Scott
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Ellen Higginson
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Joana Pereira-Dias
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Surendra Parmar
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Emma Heasman-Hunt
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Petra Polgarova
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Joanne Brown
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Lissamma Titti
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - William PW Smith
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Anthony Rostron
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Matthew Routledge
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - David Sapsford
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - M. Estée Török
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK,Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
| | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Vanessa Wong
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | | | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Nicholas M Brown
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - A John Simpson
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Jurgen Herre
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK,
| |
Collapse
|
21
|
Navapurkar V, Bartholdson Scott J, Maes M, Hellyer TP, Higginson E, Forrest S, Pereira-Dias J, Parmar S, Heasman-Hunt E, Polgarova P, Brown J, Titti L, Smith WPW, Scott J, Rostron A, Routledge M, Sapsford D, Török ME, McMullan R, Enoch DA, Wong V, Curran MD, Brown NM, Simpson AJ, Herre J, Dougan G, Conway Morris A. Development and implementation of a customised rapid syndromic diagnostic test for severe pneumonia. Wellcome Open Res 2022; 6:256. [PMID: 36337362 PMCID: PMC9617073 DOI: 10.12688/wellcomeopenres.17099.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2021] [Indexed: 02/02/2023] Open
Abstract
Background: The diagnosis of pneumonia has been hampered by a reliance on bacterial cultures which take several days to return a result, and are frequently negative. In critically ill patients this leads to the use of empiric, broad-spectrum antimicrobials and compromises good antimicrobial stewardship. The objective of this study was to establish the performance of a syndromic molecular diagnostic approach, using a custom TaqMan array card (TAC) covering 52 respiratory pathogens, and assess its impact on antimicrobial prescribing. Methods: The TAC was validated against a retrospective multi-centre cohort of broncho-alveolar lavage samples. The TAC was assessed prospectively in patients undergoing investigation for suspected pneumonia, with a comparator cohort formed of patients investigated when the TAC laboratory team were unavailable. Co-primary outcomes were sensitivity compared to conventional microbiology and, for the prospective study, time to result. Metagenomic sequencing was performed to validate findings in prospective samples. Antibiotic free days (AFD) were compared between the study cohort and comparator group. Results: 128 stored samples were tested, with sensitivity of 97% (95% confidence interval (CI) 88-100%). Prospectively, 95 patients were tested by TAC, with 71 forming the comparator group. TAC returned results 51 hours (interquartile range 41-69 hours) faster than culture and with sensitivity of 92% (95% CI 83-98%) compared to conventional microbiology. 94% of organisms identified by sequencing were detected by TAC. There was a significant difference in the distribution of AFDs with more AFDs in the TAC group (p=0.02). TAC group were more likely to experience antimicrobial de-escalation (odds ratio 2.9 (95%1.5-5.5)). Conclusions: Implementation of a syndromic molecular diagnostic approach to pneumonia led to faster results, with high sensitivity and impact on antibiotic prescribing.
Collapse
Affiliation(s)
- Vilas Navapurkar
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Josefin Bartholdson Scott
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Mailis Maes
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Ellen Higginson
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Sally Forrest
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Joana Pereira-Dias
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Surendra Parmar
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Emma Heasman-Hunt
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Petra Polgarova
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Joanne Brown
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Lissamma Titti
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - William PW Smith
- School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
| | - Jonathan Scott
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Anthony Rostron
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK
| | - Matthew Routledge
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - David Sapsford
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - M. Estée Török
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK,Microbiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, BT9 7BL, UK
| | - David A Enoch
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Vanessa Wong
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | | | - Martin D Curran
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Nicholas M Brown
- Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - A John Simpson
- Translational and Clinical Research Institute, University of Newcastle, Newcastle upon Tyne, NE2 4HH, UK,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Jurgen Herre
- Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Gordon Dougan
- Cambridge Institute of Therapeutic Immunology & Infectious Disease, University of Cambridge, Cambridge, CB2 0AW, UK
| | - Andrew Conway Morris
- John V Farman Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK,Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK,
| |
Collapse
|
22
|
Poole S, Tanner AR, Naidu VV, Borca F, Phan H, Saeed K, Grocott MPW, Dushianthan A, Moyses H, Clark TW. Molecular point-of-care testing for lower respiratory tract pathogens improves safe antibiotic de-escalation in patients with pneumonia in the ICU: results of a randomised controlled trial. J Infect 2022; 85:625-633. [PMID: 36096312 DOI: 10.1016/j.jinf.2022.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/01/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Effective treatment of pneumonia requires timely administration of appropriate antimicrobials but standard diagnostic tests take around 48 hours to generate results. Highly accurate, rapid molecular tests have been developed for identifying organisms in lower respiratory tract samples, however their impact on antibiotic use is unknown. The aim of this study was to assess the impact of syndromic molecular point-of-care testing compared to conventional diagnostic testing, on antibiotic use. METHODS In this pragmatic, randomised controlled trial, we enrolled critically ill adults with pneumonia. Patients were assigned (1:1) to molecular testing of samples at the point-of-care or routine clinical care. The primary outcome was the proportion of patients who received results-directed antimicrobial therapy. RESULTS 200 patients were randomly assigned to point-of-care testing (n=100) or the control group (n=100). 85 patients had community acquired pneumonia (42 in the mPOCT group and 43 in the control group), 69 hospital acquired pneumonia (30 in mPOCT and 39 in control) and 46 ventilator associated pneumonia (28 in mPOCT and 18 in control). The median [IQR] time to results was 1.7 [1.6-1.9] hours for point-of-care testing and 66.7 [56.7-88.5] hours for standard diagnostics (difference of -65.0 hours, 95%CI -68.0 to -62.0; p<0.0001). 71 (71%) patients in the point-of-care testing arm had pathogens detected compared to 51 (51%) in the control arm (difference of 20%, 95%CI 7 to 33; p=0.004). 80 (80%) of patients in the point-of-care group received results-directed therapy, compared with 29 (29%) of 99 in the control group (difference of 51%, 95%CI 39-63; p<0.0001). Time to results-directed therapy was 2.3 [1.8-7.2] hours in the mPOCT group and 46.1 [23.0-51.5] hours in the control group (difference of -43.8 hours, 95% CI -48.9 to -38.6; p<0.0001). 42 (42%) patients in mPOCT group had antibiotics de-escalated compared with 8 (8%) of 98 in the control group (difference of 34%, 95%CI 23-45; p<0.0001). Time to de-escalation was 4.8 [2.4-13.0] hours in the mPOCT group compared with 46.5 [26.3-48.6] hours in the control group (difference of -41.4 hours, 95%CI -53 to -29.7; p<0.0001). There was no major difference in antibiotic duration or in clinical or safety outcomes between the two groups. CONCLUSIONS Use of molecular point-of-care testing in patients with pneumonia returned results more rapidly and identified more pathogens than conventional testing. This was associated with improvements in appropriate antimicrobial use and appeared safe.
Collapse
Affiliation(s)
- Stephen Poole
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - Alex R Tanner
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Vasanth V Naidu
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Florina Borca
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Clinical Informatics Research Unit, University of Southampton, Southampton, UK
| | - Hang Phan
- Clinical Informatics Research Unit, University of Southampton, Southampton, UK
| | - Kordo Saeed
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK; School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Michael P W Grocott
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ahilanandan Dushianthan
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Helen Moyses
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Tristan W Clark
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK; School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; NIHR Post-Doctoral Fellowship Programme, UK
| |
Collapse
|
23
|
Serra Mitjà P, Centeno C, Garcia-Olivé I, Antuori A, Casadellà M, Tazi R, Armestar F, Fernández E, Andreo F, Rosell A. Bronchoscopy in Critically Ill COVID-19 Patients: Findings, Microbiological Profile, and Coinfection. J Bronchology Interv Pulmonol 2022; 29:186-190. [PMID: 35730778 DOI: 10.1097/lbr.0000000000000807] [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: 03/12/2021] [Accepted: 08/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bronchoscopy is a widely use technique in critically ill patients. Nosocomial coinfections are a cause of morbidity and mortality in intensive care units. OBJECTIVES Our aim was to describe bronchoscopy findings and analyze microbiological profile and probably coinfection through bronchial aspirate (BA) samples in patients with coronavirus disease 2019 pneumonia requiring intensive care unit admission. METHODS Retrospective observational study analyzing the BA samples collected from intubated patients with coronavirus disease 2019 in a referral Hospital (Spain). RESULTS One hundred fifty-five consecutive BA samples were collected from 75 patients. Ninety (58%) were positive cultures for different microorganisms, 11 (7.1%) were polymicrobial, and 37 (23.7%) contained resistant microorganisms. There was a statistically significant association between increased days of orotracheal intubation and positive BA (18.9 vs. 10.9 d, P<0.01), polymicrobial infection (22.11 vs. 13.54, P<0.01) and isolation of resistant microorganisms (18.88 vs. 10.94, P<0.01). In 88% of the cases a new antibiotic or change in antibiotic treatment was made. CONCLUSION Bronchoscopy in critically ill patient was safe and could be useful to manage these patients and conduct the microbiological study, that seems to be higher and different than in nonepidemic periods. The longer the intubation period, the greater the probability of coinfection, isolation of resistant microorganisms and polymicrobial infection.
Collapse
Affiliation(s)
- Pere Serra Mitjà
- Pneumology Unit
- Germans Trias and Pujol Research Institute (IGTP)
- CibeRes, Cyber Respiratory Diseases, Bunyola, Spain
| | - Carmen Centeno
- Pneumology Unit
- Germans Trias and Pujol Research Institute (IGTP)
- CibeRes, Cyber Respiratory Diseases, Bunyola, Spain
| | - Ignasi Garcia-Olivé
- Pneumology Unit
- Germans Trias and Pujol Research Institute (IGTP)
- CibeRes, Cyber Respiratory Diseases, Bunyola, Spain
| | | | | | - Rachid Tazi
- Pneumology Unit
- Germans Trias and Pujol Research Institute (IGTP)
- CibeRes, Cyber Respiratory Diseases, Bunyola, Spain
| | - Fernando Armestar
- Servei de Medicina Intensiva
- Department of Medicine, Autonomous University of Barcelona, Barcelona
| | - Ester Fernández
- Thoracic Surgery Unit, Germans Trias i Pujol University Hospital
- Department of Medicine, Autonomous University of Barcelona, Barcelona
| | - Felipe Andreo
- Pneumology Unit
- Germans Trias and Pujol Research Institute (IGTP)
- Department of Medicine, Autonomous University of Barcelona, Barcelona
- CibeRes, Cyber Respiratory Diseases, Bunyola, Spain
| | - Antoni Rosell
- Pneumology Unit
- Germans Trias and Pujol Research Institute (IGTP)
- Department of Medicine, Autonomous University of Barcelona, Barcelona
- CibeRes, Cyber Respiratory Diseases, Bunyola, Spain
| |
Collapse
|
24
|
Fanning J, Panigada M, Li Bassi G. Nosocomial Pneumonia in the Mechanically Ventilated Patient. Semin Respir Crit Care Med 2022; 43:426-439. [PMID: 35714627 DOI: 10.1055/s-0042-1749448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Ventilator-associated pneumonia (VAP) is a common complication occurring in critically ill patients who are mechanically ventilated and is the leading cause of nosocomial infection-related death. Etiologic agents for VAP widely differ based on the population of intensive care unit patients, duration of hospital stay, and prior antimicrobial therapy. VAP due to multidrug-resistant pathogens is associated with the highest morbidity and mortality, likely due to delays in appropriate antimicrobial treatment. International guidelines are currently available to guide diagnostic and therapeutic strategies. VAP can be prevented through various pharmacological and non-pharmacological interventions, which are more effective when grouped as bundles. When VAP is clinically suspected, diagnostic strategies should include early collection of respiratory samples to guide antimicrobial therapy. Empirical treatment should be based on the most likely etiologic microorganisms and antibiotics likely to be active against these microorganisms. Response to therapy should be reassessed after 3 to 5 days and antimicrobials adjusted or de-escalated to reduce the burden of the disease. Finally, considering that drug resistance is increasing worldwide, several novel antibiotics are being tested to efficiently treat VAP in the coming decades.
Collapse
Affiliation(s)
- Jonathon Fanning
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, Royal Brisbane and Women's Hospital, Queensland, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Nuffield Department of Population Health, Oxford University, United Kingdom
| | - Mauro Panigada
- Department of Anaesthesiology, Intensive Care and EmergencyFondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, St Andrew's War Memorial Hospital, Queensland, Australia.,Queensland University of Technology, Brisbane, Australia.,Intensive Care Unit, The Wesley Hospital, Auchenflower, Queensland, Australia.,Wesley Medical Research, The Wesley Hospital, Auchenflower, Australia
| |
Collapse
|
25
|
Watkins RR. Antibiotic stewardship in the era of precision medicine. JAC Antimicrob Resist 2022; 4:dlac066. [PMID: 35733911 PMCID: PMC9209748 DOI: 10.1093/jacamr/dlac066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Antimicrobial resistance (AMR) continues to spread at an alarming rate worldwide. Novel approaches are needed to mitigate its deleterious impact on antibiotic efficacy. Antibiotic stewardship aims to promote the appropriate use of antibiotics through evidence-based interventions. One paradigm is precision medicine, a medical model in which decisions, practices, interventions, and therapies are adapted to the individual patient based on their predicted response or risk of disease. Precision medicine approaches hold promise as a way to improve outcomes for patients with myriad illnesses, including infections such as bacteraemia and pneumonia. This review describes the latest advances in precision medicine as they pertain to antibiotic stewardship, with an emphasis on hospital-based antibiotic stewardship programmes. The impact of the COVID-19 pandemic on AMR and antibiotic stewardship, gaps in the scientific evidence, and areas for further research are also discussed.
Collapse
Affiliation(s)
- Richard R Watkins
- Department of Medicine, Northeast Ohio Medical University , Rootstown, OH , USA
| |
Collapse
|
26
|
Sun YC, Wang CY, Wang HL, Yuan Y, Lu JH, Zhong L. Probiotic in the prevention of ventilator-associated pneumonia in critically ill patients: evidence from meta-analysis and trial sequential analysis of randomized clinical trials. BMC Pulm Med 2022; 22:168. [PMID: 35484547 PMCID: PMC9052689 DOI: 10.1186/s12890-022-01965-5] [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: 12/16/2021] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Probiotic might have a role in the prevention of ventilator-associated pneumonia (VAP) among mechanically ventilated patients, but the efficacy and safety remained inconsistent. The aim of this systematic review and meta-analysis was to evaluate the efficacy and safety of probiotic (prebiotic, synbiotic) versus placebo in preventing VAP in critically ill patients undergoing mechanical ventilation. METHODS PubMed, Embase and the Cochrane library databases were searched to 10 October 2021 without language restriction for randomized or semi-randomized controlled trials evaluating probiotic (prebiotic, synbiotic) vs. placebo in prevention of VAP in critically ill mechanically ventilated patients. The pooled relative risk (RR) along with 95% confidence intervals (CI) were combined using a random-effects model. Furthermore, the trial sequential analysis (TSA) and subgroup analyses were performed. Statistical significance was regarded as P < 0.05. RESULTS Twenty-three trials involving 5543 patients were eligible for this meta-analysis. The combined RR of decreasing the risk of VAP by probiotic was 0.67 (0.56, 0.81) for all eligible studies, 0.69 (n = 5136; 95% CI = 0.57 to 0.84; P < 0.01) for adults studies and 0.55 (n = 407; 95%CI = 0.31 to 0.99; P = 0.046) for neonates/children studies. Additionally, the above-mentioned positive finding in 20 adults studies was verified by the results of TSA, subgroup analyses and cumulative meta-analysis. Ample evidences demonstrated a 31% decrease in RR of incidence of VAP was noted when prophylactic probiotic therapy was administrated among adult patients. Finally, there were no effects on the ICU/hospital/28-/90-day mortality, bacteremia, CRBSI, diarrhea, ICU-acquired infections, infectious complications, pneumonia, UTI and wound infection between two groups (P > 0.05 for all). CONCLUSIONS Based on the results of our study, the current evidences suggested that prophylactic administration of probiotic might be utilized as a preventive method for VAP in neonates/children and adults patients who required mechanical ventilation. However, further large, high-quality RCTs are warranted to assess the efficacy and safety of probiotic treatment in critically ill patients, especially for the neonates/children studies and the long-term consequences of this therapy.
Collapse
Affiliation(s)
- Yue-Chen Sun
- Department of Emergency, Huzhou Central Hospital, Affiliated Central Hospital HuZhou University, Huzhou, 313000, Zhejiang Province, China
| | - Chen-Yi Wang
- Department of Intensive Care Unit, Ningbo Yinzhou No. 2 Hospital, Ningbo, 315000, Zhejiang Province, China
| | - Hai-Li Wang
- Department of Obstetrics and Gynecology, Huzhou Central Hospital, Affiliated Central Hospital HuZhou University, Huzhou, 313000, Zhejiang Province, China
| | - Yao Yuan
- Department of Intensive Care Unit, Ningbo Yinzhou No. 2 Hospital, Ningbo, 315000, Zhejiang Province, China
| | - Jian-Hong Lu
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Central Hospital HuZhou University, No. 1558, North Sanhuan Road, Huzhou, 313000, Zhejiang Province, China
| | - Lei Zhong
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Central Hospital HuZhou University, No. 1558, North Sanhuan Road, Huzhou, 313000, Zhejiang Province, China.
| |
Collapse
|
27
|
Yoshimura J, Yamakawa K, Ohta Y, Nakamura K, Hashimoto H, Kawada M, Takahashi H, Yamagiwa T, Kodate A, Miyamoto K, Fujimi S, Morimoto T. Effect of Gram Stain-Guided Initial Antibiotic Therapy on Clinical Response in Patients With Ventilator-Associated Pneumonia: The GRACE-VAP Randomized Clinical Trial. JAMA Netw Open 2022; 5:e226136. [PMID: 35394515 PMCID: PMC8994124 DOI: 10.1001/jamanetworkopen.2022.6136] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE Gram staining should provide immediate information for detecting causative pathogens. However, the effect of Gram staining on restricting the initial antibiotic choice has not been investigated in intensive care units (ICUs). OBJECTIVE To compare the clinical response to Gram stain-guided restrictive antibiotic therapy vs guideline-based broad-spectrum antibiotic treatment in patients with ventilator-associated pneumonia (VAP). DESIGN, SETTING, AND PARTICIPANTS This multicenter, open-label, noninferiority randomized clinical trial (Gram Stain-Guided Antibiotics Choice for VAP) was conducted in the ICUs of 12 tertiary referral hospitals in Japan from April 1, 2018, through May 31, 2020. Patients aged 15 years or older with a VAP diagnosis and a modified Clinical Pulmonary Infection Score of 5 or higher were included. The primary analysis was based on the per-protocol analysis population. INTERVENTIONS Patients were randomized to Gram stain-guided antibiotic therapy or guideline-based antibiotic therapy (based on the 2016 Infectious Disease Society of America and American Thoracic Society clinical practice guidelines for VAP). MAIN OUTCOMES AND MEASURES The primary outcome was the clinical response rate; clinical response was defined as completion of antibiotic therapy within 14 days, improvement or lack of progression of baseline radiographic findings, resolution of signs and symptoms of pneumonia, and lack of antibiotic agent readministration, with a noninferiority margin of 20%. Secondary outcomes were the proportions of antipseudomonal agents and anti-methicillin-resistant Staphylococcus aureus (MRSA) agents as initial antibiotic therapies; 28-day mortality, ICU-free days, ventilator-free days; and adverse events. RESULTS In total, 206 patients (median [IQR] age, 69 [54-78] years; 141 men [68.4%]) were randomized to the Gram stain-guided group (n = 103) or guideline-based group (n = 103). Clinical response occurred in 79 patients (76.7%) in the Gram stain-guided group and 74 patients (71.8%) in the guideline-based group (risk difference, 0.05; 95% CI, -0.07 to 0.17; P < .001 for noninferiority). Reduced use of antipseudomonal agents (30.1%; 95% CI, 21.5%-39.9%; P < .001) and anti-MRSA agents (38.8%; 95% CI, 29.4%-48.9%; P < .001) was observed in the Gram stain-guided group vs guideline-based group. The 28-day cumulative incidence of mortality was 13.6% (n = 14) in the Gram stain-guided group vs 17.5% (n = 18) in the guideline-based group (P = .39). Escalation of antibiotics according to culture results was performed in 7 patients (6.8%) in the Gram stain-guided group and 1 patient (1.0%) in the guideline-based group (P = .03). There were no significant differences between the groups in ICU-free days, ventilator-free days, and adverse events. CONCLUSIONS AND RELEVANCE Results of this trial showed that Gram stain-guided treatment was noninferior to guideline-based treatment and significantly reduced the use of broad-spectrum antibiotics in patients with VAP. Gram staining can potentially ameliorate the multidrug-resistant organisms in the critical care setting. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03506113.
Collapse
Affiliation(s)
- Jumpei Yoshimura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi, Osaka, Japan
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi, Osaka, Japan
- Department of Emergency Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Yoshinori Ohta
- Education and Training Center for Students and Professionals in Healthcare, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Masahiro Kawada
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Hiroki Takahashi
- Department of Emergency and Critical Care Medicine, Kansai Medical University Hospital, Hirakata, Osaka, Japan
| | - Takeshi Yamagiwa
- Department of Emergency Medicine, Ebina General Hospital, Ebina, Kanagawa, Japan
| | - Akira Kodate
- Department of Emergency and Critical Care Medicine, Sapporo City General Hospital, Chuoh, Sapporo, Hokkaido, Japan
| | - Kyohei Miyamoto
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, Wakayama, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi, Osaka, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| |
Collapse
|
28
|
Kyriazopoulou E, Giamarellos-Bourboulis EJ. Antimicrobial Stewardship Using Biomarkers: Accumulating Evidence for the Critically Ill. Antibiotics (Basel) 2022; 11:antibiotics11030367. [PMID: 35326830 PMCID: PMC8944654 DOI: 10.3390/antibiotics11030367] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 12/28/2022] Open
Abstract
This review aims to summarize current progress in the management of critically ill, using biomarkers as guidance for antimicrobial treatment with a focus on antimicrobial stewardship. Accumulated evidence from randomized clinical trials (RCTs) and observational studies in adults for the biomarker-guided antimicrobial treatment of critically ill (mainly sepsis and COVID-19 patients) has been extensively searched and is provided. Procalcitonin (PCT) is the best studied biomarker; in the majority of randomized clinical trials an algorithm of discontinuation of antibiotics with decreasing PCT over serial measurements has been proven safe and effective to reduce length of antimicrobial treatment, antibiotic-associated adverse events and long-term infectious complications like infections by multidrug-resistant organisms and Clostridioides difficile. Other biomarkers, such as C-reactive protein and presepsin, are already being tested as guidance for shorter antimicrobial treatment, but more research is needed. Current evidence suggests that biomarkers, mainly procalcitonin, should be implemented in antimicrobial stewardship programs even in the COVID-19 era, when, although bacterial coinfection rate is low, antimicrobial overconsumption remains high.
Collapse
Affiliation(s)
- Evdoxia Kyriazopoulou
- 2nd Department of Critical Care Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Evangelos J. Giamarellos-Bourboulis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
- Correspondence: ; Tel.: +30-210-5831994
| |
Collapse
|
29
|
Lockwood I, Walker RM, Latimer S, Chaboyer W, Cooke M, Gillespie BM. Process evaluations undertaken alongside randomised controlled trials in the hospital setting: A scoping review. Contemp Clin Trials Commun 2022; 26:100894. [PMID: 36684693 PMCID: PMC9846456 DOI: 10.1016/j.conctc.2022.100894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 11/09/2021] [Accepted: 01/17/2022] [Indexed: 01/25/2023] Open
Abstract
Background There is increasing recognition of the importance of undertaking process evaluations alongside implementation of health interventions by examining mechanisms of impact and contextual factors. However, a comprehensive synthesis of process evaluations undertaken alongside clinical trials in hospital settings is lacking. We undertook a scoping review to address this gap. Methods This review was guided by the methodological framework for scoping studies. Studies were identified using four databases; Ovid Medline, EBSCO CINAHL, EMBASE and Scopus. Two authors independently screened all titles and available abstracts, with a third author available to adjudicate. Studies were eligible for inclusion if they described a process evaluation undertaken alongside a randomised controlled trial in the hospital setting. Data were abstracted by one author and checked by two others and analysed both descriptively and using inductive content analysis. Results Data were extracted from 30 articles reporting on 15 trials, most of which were cluster randomised trials (c-RTs) (n = 12). The most common data collection methods used in process evaluations were interviews, questionnaires or surveys, and records or logs. Data analysis revealed three themes relative to how authors: use process data to interpret, understand and explain trial outcomes; evaluate responses to the intervention; and consider the implementation context. Conclusions Findings from this review demonstrate the complex nature of intervention implementation in the hospital setting. Overall, there is need for standardised reporting of process evaluations and more explicit descriptions of how authors use frameworks to guide their evaluation.
Collapse
Affiliation(s)
- Ishtar Lockwood
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Australia,School of Nursing and Midwifery, Griffith University, Brisbane and Gold Coast, Australia
| | - Rachel M. Walker
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Australia,School of Nursing and Midwifery, Griffith University, Brisbane and Gold Coast, Australia,Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Sharon Latimer
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Australia,School of Nursing and Midwifery, Griffith University, Brisbane and Gold Coast, Australia,Gold Coast University Hospital, Southport, Queensland, Australia,Corresponding author. Building L05, Room 3.44, Griffith University, Logan, Queensland, 4131, Australia.
| | - Wendy Chaboyer
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Australia,School of Nursing and Midwifery, Griffith University, Brisbane and Gold Coast, Australia
| | - Marie Cooke
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Australia,School of Nursing and Midwifery, Griffith University, Brisbane and Gold Coast, Australia
| | - Brigid M. Gillespie
- NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Australia,School of Nursing and Midwifery, Griffith University, Brisbane and Gold Coast, Australia,Gold Coast University Hospital, Southport, Queensland, Australia
| |
Collapse
|
30
|
Lau TMM, Daniel R, Hughes K, Wootton M, Hood K, Gillespie D. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlac013. [PMID: 35233529 PMCID: PMC8874134 DOI: 10.1093/jacamr/dlac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/21/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Antimicrobial stewardship interventions (ASIs) aim to reduce the emergence of antimicrobial resistance. We sought to systematically evaluate how microbiological outcomes have been handled and analysed in randomized controlled trials (RCTs) evaluating ASIs. Methods We searched PubMed and Embase from 2011–21. Studies were selected if they were RCTs evaluating ASIs. A narrative synthesis approach was taken, identifying whether the study reported any microbiological data (bacterial genus/species; bacterial colony counts; prevalence of bacterial, microbiologically defined infections; and antibiotic susceptibility, measured pre-randomization or post-randomization in one arm only) or outcomes (post-randomization data compared between arms). Studies with or without microbiological data/outcomes were summarized in terms of study characteristics, methods of reporting and analysis of these outcomes. Results We identified 117 studies, with 34 (29.1%) collecting microbiological data and 18 (15.4%) reporting microbiological outcomes. Most studies with microbiological outcomes were conducted in secondary care (12/18, 66.7%) and targeted adult populations (14/18, 77.8%), and the intervention involved biomarker-guided rapid diagnostic testing (7/18, 38.9%). The overall quality of reporting and analysing microbiological outcomes was low and inconsistent. The selected study population in analyses and methods of handling missing data were unclear. Conclusions This review demonstrates that the quality of handling and reporting microbiological outcomes in RCTs of ASIs was low. The lack of consistency and clarity made it difficult to compare the findings across studies, limiting policy- and clinical decision-making. Therefore, there is a clear need for the development of guidance for handling microbiological outcomes in RCTs and adopting appropriate methods to evaluate these data carefully.
Collapse
Affiliation(s)
- Tin Man Mandy Lau
- Centre for Trials Research, Cardiff University, Cardiff, UK
- Corresponding author. E-mail:
| | - Rhian Daniel
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Kathryn Hughes
- PRIME Centre Wales, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, University Hospital of Wales, Cardiff, UK
| | - Kerry Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | |
Collapse
|
31
|
Fatemi Y, Bergl PA. Diagnostic Stewardship: Appropriate Testing and Judicious Treatments. Crit Care Clin 2021; 38:69-87. [PMID: 34794632 DOI: 10.1016/j.ccc.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Diagnostic stewardship encompasses the entire diagnosis-to-treatment paradigm in the intensive care unit (ICU). Initially born of the antimicrobial stewardship movement, contemporary diagnostic stewardship aims to promote timely and appropriate diagnostic testing that directly links to management decisions. In the stewardship framework, excessive diagnostic testing in low probability cases is discouraged due to its tendency to generate false-positive results, which have their own downstream consequences. Though the evidence basis for diagnostic stewardship initiatives in the ICU is nascent and largely limited to retrospective analyses, available literature generally suggests that these initiatives are safe, feasible, and associated with similar patient outcomes. As diagnostic testing of critically ill patients becomes increasingly sophisticated in the ensuing decade, a stewardship mindset will aid bedside clinicians in interpreting and incorporating new diagnostic strategies in the ICU.
Collapse
Affiliation(s)
- Yasaman Fatemi
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Paul A Bergl
- Department of Critical Care, Gundersen Lutheran Medical Center, 1900 South Avenue, Mail Stop LM3-001, La Crosse, WI 54601, USA; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| |
Collapse
|
32
|
Pickens CO, Gao CA, Cuttica MJ, Smith SB, Pesce LL, Grant RA, Kang M, Morales-Nebreda L, Bavishi AA, Arnold JM, Pawlowski A, Qi C, Budinger GRS, Singer BD, Wunderink RG. Bacterial Superinfection Pneumonia in Patients Mechanically Ventilated for COVID-19 Pneumonia. Am J Respir Crit Care Med 2021; 204:921-932. [PMID: 34409924 PMCID: PMC8534629 DOI: 10.1164/rccm.202106-1354oc] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Rationale: Current guidelines recommend patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia receive empirical antibiotics for suspected bacterial superinfection on the basis of weak evidence. Rates of ventilator-associated pneumonia (VAP) in clinical trials of patients with SARS-CoV-2 pneumonia are unexpectedly low. Objectives: We conducted an observational single-center study to determine the prevalence and etiology of bacterial superinfection at the time of initial intubation and the incidence and etiology of subsequent bacterial VAP in patients with severe SARS-CoV-2 pneumonia. Methods: Bronchoscopic BAL fluid samples from all patients with SARS-CoV-2 pneumonia requiring mechanical ventilation were analyzed using quantitative cultures and a multiplex PCR panel. Actual antibiotic use was compared with guideline-recommended therapy. Measurements and Main Results: We analyzed 386 BAL samples from 179 patients with SARS-CoV-2 pneumonia requiring mechanical ventilation. Bacterial superinfection within 48 hours of intubation was detected in 21% of patients. Seventy-two patients (44.4%) developed at least one VAP episode (VAP incidence rate = 45.2/1,000 ventilator days); 15 (20.8%) initial VAPs were caused by difficult-to-treat pathogens. The clinical criteria did not distinguish between patients with or without bacterial superinfection. BAL-based management was associated with significantly reduced antibiotic use compared with guideline recommendations. Conclusions: In patients with SARS-CoV-2 pneumonia requiring mechanical ventilation, bacterial superinfection at the time of intubation occurs in <25% of patients. Guideline-based empirical antibiotic management at the time of intubation results in antibiotic overuse. Bacterial VAP developed in 44% of patients and could not be accurately identified in the absence of microbiologic analysis of BAL fluid.
Collapse
Affiliation(s)
| | - Catherine A Gao
- Division of Pulmonary and Critical Care, Department of Medicine
| | | | - Sean B Smith
- Division of Pulmonary and Critical Care, Department of Medicine
| | | | - Rogan A Grant
- Division of Pulmonary and Critical Care, Department of Medicine
| | - Mengjia Kang
- Division of Pulmonary and Critical Care, Department of Medicine
| | | | - Avni A Bavishi
- Division of Pulmonary and Critical Care, Department of Medicine
| | - Jason M Arnold
- Division of Pulmonary and Critical Care, Department of Medicine
| | | | - Chao Qi
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | | |
Collapse
|
33
|
Scott J, Ruchaud-Sparagano MH, Musgrave K, Roy AI, Wright SE, Perry JD, Conway Morris A, Rostron AJ, Simpson AJ. Phosphoinositide 3-Kinase δ Inhibition Improves Neutrophil Bacterial Killing in Critically Ill Patients at High Risk of Infection. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2021; 207:1776-1784. [PMID: 34497151 DOI: 10.4049/jimmunol.2000603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/20/2021] [Indexed: 11/19/2022]
Abstract
Acquired neutrophil dysfunction frequently develops during critical illness, independently increasing the risk for intensive care unit-acquired infection. PI3Kδ is implicated in driving neutrophil dysfunction and can potentially be targeted pharmacologically. The aims of this study were to determine whether PI3Kδ inhibition reverses dysfunction in neutrophils from critically ill patients and to describe potential mechanisms. Neutrophils were isolated from blood taken from critically ill patients requiring intubation and mechanical ventilation, renal support, or blood pressure support. In separate validation experiments, neutrophil dysfunction was induced pharmacologically in neutrophils from healthy volunteers. Phagocytosis and bacterial killing assays were performed, and activity of RhoA and protein kinase A (PKA) was assessed. Inhibitors of PI3Kδ, 3-phosphoinositide-dependent protein kinase-1 (PDK1), and PKA were used to determine mechanisms of neutrophil dysfunction. Sixty-six patients were recruited. In the 27 patients (40.9%) with impaired neutrophil function, PI3Kδ inhibition consistently improved function and significantly increased bacterial killing. These findings were validated in neutrophils from healthy volunteers with salbutamol-induced dysfunction and extended to demonstrate that PI3Kδ inhibition restored killing of clinical isolates of nine pathogens commonly associated with intensive care unit-acquired infection. PI3Kδ activation was associated with PDK1 activation, which in turn phosphorylated PKA, which drove phosphorylation and inhibition of the key regulator of neutrophil phagocytosis, RhoA. These data indicate that, in a significant proportion of critically ill patients, PI3Kδ inhibition can improve neutrophil function through PDK1- and PKA-dependent processes, suggesting that therapeutic use of PI3Kδ inhibitors warrants investigation in this setting.
Collapse
Affiliation(s)
- Jonathan Scott
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Marie-Hélène Ruchaud-Sparagano
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kathryn Musgrave
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - Stephen E Wright
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - John D Perry
- Microbiology Department, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; and
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Anthony J Rostron
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, United Kingdom
| | - A John Simpson
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom;
| |
Collapse
|
34
|
Póvoa P, Coelho L. Which Biomarkers Can Be Used as Diagnostic Tools for Infection in Suspected Sepsis? Semin Respir Crit Care Med 2021; 42:662-671. [PMID: 34544183 DOI: 10.1055/s-0041-1735148] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The diagnosis of infection in patients with suspected sepsis is frequently difficult to achieve with a reasonable degree of certainty. Currently, the diagnosis of infection still relies on a combination of systemic manifestations, manifestations of organ dysfunction, and microbiological documentation. In addition, the microbiologic confirmation of infection is obtained only after 2 to 3 days of empiric antibiotic therapy. These criteria are far from perfect being at least in part responsible for the overuse and misuse of antibiotics, in the community and in hospital, and probably the main drive for antibiotic resistance. Biomarkers have been studied and used in several clinical settings as surrogate markers of infection to improve their diagnostic accuracy as well as in the assessment of response to antibiotics and in antibiotic stewardship programs. The aim of this review is to provide a clear overview of the current evidence of usefulness of biomarkers in several clinical scenarios, namely, to diagnose infection to prescribe antibiotics, to exclude infection to withhold antibiotics, and to identify the causative pathogen to target antimicrobial treatment. In recent years, new evidence with "old" biomarkers, like C-reactive protein and procalcitonin, as well as new biomarkers and molecular tests, as breathomics or bacterial DNA identification by polymerase chain reaction, increased markedly in different areas adding useful information for clinical decision making at the bedside when adequately used. The recent evidence shows that the information given by biomarkers can support the suspicion of infection and pathogen identification but also, and not less important, can exclude its diagnosis. Although the ideal biomarker has not yet been found, there are various promising biomarkers that represent true evolutions in the diagnosis of infection in patients with suspected sepsis.
Collapse
Affiliation(s)
- Pedro Póvoa
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal.,Nova Medical School, Clinical Medicine, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Luis Coelho
- Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal.,Nova Medical School, Clinical Medicine, CHRC, New University of Lisbon, Lisbon, Portugal
| |
Collapse
|
35
|
Pandolfo AM, Horne R, Jani Y, Reader TW, Bidad N, Brealey D, Enne VI, Livermore DM, Gant V, Brett SJ. Intensivists' beliefs about rapid multiplex molecular diagnostic testing and its potential role in improving prescribing decisions and antimicrobial stewardship: a qualitative study. Antimicrob Resist Infect Control 2021; 10:95. [PMID: 34187563 PMCID: PMC8243627 DOI: 10.1186/s13756-021-00961-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/09/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Rapid molecular diagnostic tests to investigate the microbial aetiology of pneumonias may improve treatment and antimicrobial stewardship in intensive care units (ICUs). Clinicians' endorsement and uptake of these tests is crucial to maximise engagement; however, adoption may be impeded if users harbour unaddressed concerns or if device usage is incompatible with local practice. Accordingly, we strove to identify ICU clinicians' beliefs about molecular diagnostic tests for pneumonias before implementation at the point-of-care. METHODS We conducted semi-structured interviews with 35 critical care doctors working in four ICUs in the United Kingdom. A clinical vignette depicting a fictitious patient with signs of pneumonia was used to explore clinicians' beliefs about the importance of molecular diagnostics and their concerns. Data were analysed thematically. RESULTS Clinicians' beliefs about molecular tests could be grouped into two categories: perceived potential of molecular diagnostics to improve antibiotic prescribing (Molecular Diagnostic Necessity) and concerns about how the test results could be implemented into practice (Molecular Diagnostic Concerns). Molecular Diagnostic Necessity stemmed from beliefs that positive results would facilitate targeted antimicrobial therapy; that negative results would signal the absence of a pathogen, and consequently that having the molecular diagnostic results would bolster clinicians' prescribing confidence. Molecular Diagnostic Concerns included unfamiliarity with the device's capabilities, worry that it would detect non-pathogenic bacteria, uncertainty whether it would fail to detect pathogens, and discomfort with withholding antibiotics until receiving molecular test results. CONCLUSIONS Clinicians believed rapid molecular diagnostics for pneumonias were potentially important and were open to using them; however, they harboured concerns about the tests' capabilities and integration into clinical practice. Implementation strategies should bolster users' necessity beliefs while reducing their concerns; this can be accomplished by publicising the tests' purpose and benefits, identifying and addressing clinicians' misconceptions, establishing a trial period for first-hand familiarisation, and emphasising that, with a swift (e.g., 60-90 min) test, antibiotics can be started and refined after molecular diagnostic results become available.
Collapse
Affiliation(s)
- Alyssa M Pandolfo
- Centre for Behavioural Medicine, University College London, British Medical Association House, Tavistock Square, London, WC1H 9JP, UK
| | - Robert Horne
- Centre for Behavioural Medicine, University College London, British Medical Association House, Tavistock Square, London, WC1H 9JP, UK.
| | - Yogini Jani
- UCLH-UCL Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
| | - Tom W Reader
- Department of Psychological and Behavioural Science, London School of Economics and Political Science, London, UK
| | - Natalie Bidad
- Centre for Behavioural Medicine, University College London, British Medical Association House, Tavistock Square, London, WC1H 9JP, UK
| | - David Brealey
- Division of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Virve I Enne
- Division of Infection and Immunity, University College London Faculty of Medical Sciences, London, UK
| | - David M Livermore
- University of East Anglia Norwich Medical School, Norwich, Norfolk, UK
| | - Vanya Gant
- Department of Medical Microbiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Stephen J Brett
- Department of Surgery and Cancer, Imperial College London, London, UK
| |
Collapse
|
36
|
Paulsson M, Thelaus L, Riesbeck K, Qvarfordt I, Smith ME, Lindén A, Linder A. Heparin-binding protein in lower airway samples as a biomarker for pneumonia. Respir Res 2021; 22:174. [PMID: 34103069 PMCID: PMC8185500 DOI: 10.1186/s12931-021-01764-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/27/2021] [Indexed: 02/06/2023] Open
Abstract
Objectives Ventilator-associated pneumonia (VAP) is difficult to diagnose using clinical criteria and no biomarkers have yet been proved to be sufficiently accurate. The use of the neutrophil-derived Heparin-binding protein (HBP) as a biomarker for pneumonia was investigated in this exploratory case–control study in two intensive care units at a tertiary referral hospital. Methods Patients with clinical signs of pneumonia were recruited and bronchoalveolar lavage fluid (BALF) or bronchial wash (BW) samples were collected. Mechanically ventilated and lung healthy subjects were recruited as controls. HBP was measured with enzyme-linked immunosorbent assay. Results BALF was collected from 14 patients with pneumonia and 14 healthy controls. Median HBP in BALF pneumonia samples was 14,690 ng/ml and controls 16.2 ng/ml (p < 0.0001). BW was collected from 10 pneumonia patients and 10 mechanically ventilated controls. Median HBP in BW pneumonia was 9002 ng/ml and controls 7.6 ng/ml (p < 0.0001). Conclusions These data indicate that HBP concentrations is significantly higher in lower airway samples from patients with pneumonia than control subjects and is a potentially useful biomarker for diagnosis of VAP.
Collapse
Affiliation(s)
- Magnus Paulsson
- Department of Infectious Diseases, Skåne University Hospital, Lund, Sweden. .,Division of Infection Medicine, Department of Clinical Sciences, Faculty of Medicine, Lund University, BMC B14, SE221 85, Lund, Sweden. .,Clinical Microbiology, Department of Translational Medicine, Faculty of Medicine, Lund University, Malmö, Sweden.
| | - Louise Thelaus
- Division of Infection Medicine, Department of Clinical Sciences, Faculty of Medicine, Lund University, BMC B14, SE221 85, Lund, Sweden
| | - Kristian Riesbeck
- Clinical Microbiology, Department of Translational Medicine, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Ingemar Qvarfordt
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Margaretha E Smith
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Lindén
- Unit for Lung and Airway Research, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Karolinska Severe COPD Center, Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Adam Linder
- Department of Infectious Diseases, Skåne University Hospital, Lund, Sweden.,Division of Infection Medicine, Department of Clinical Sciences, Faculty of Medicine, Lund University, BMC B14, SE221 85, Lund, Sweden
| |
Collapse
|
37
|
van der Werf TS. Artificial Intelligence to Guide Empirical Antimicrobial Therapy-Ready for Prime Time? Clin Infect Dis 2021; 72:e856-e858. [PMID: 33070180 DOI: 10.1093/cid/ciaa1585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Tjip S van der Werf
- Department of Internal Medicine, Division of Infectious Diseases, University Medical Center Groningen University of Groningen, Groningen, The Netherlands
| |
Collapse
|
38
|
Abstract
Pneumonia is a common acute respiratory infection that affects the alveoli and distal airways; it is a major health problem and associated with high morbidity and short-term and long-term mortality in all age groups worldwide. Pneumonia is broadly divided into community-acquired pneumonia or hospital-acquired pneumonia. A large variety of microorganisms can cause pneumonia, including bacteria, respiratory viruses and fungi, and there are great geographical variations in their prevalence. Pneumonia occurs more commonly in susceptible individuals, including children of <5 years of age and older adults with prior chronic conditions. Development of the disease largely depends on the host immune response, with pathogen characteristics having a less prominent role. Individuals with pneumonia often present with respiratory and systemic symptoms, and diagnosis is based on both clinical presentation and radiological findings. It is crucial to identify the causative pathogens, as delayed and inadequate antimicrobial therapy can lead to poor outcomes. New antibiotic and non-antibiotic therapies, in addition to rapid and accurate diagnostic tests that can detect pathogens and antibiotic resistance will improve the management of pneumonia.
Collapse
|
39
|
Pickens CO, Gao CA, Cuttica M, Smith SB, Pesce L, Grant R, Kang M, Morales-Nebreda L, Bavishi AA, Arnold J, Pawlowski A, Qi C, Budinger GS, Singer BD, Wunderink RG. Bacterial superinfection pneumonia in SARS-CoV-2 respiratory failure. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2021. [PMID: 33469593 DOI: 10.1101/2021.01.12.20248588] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Severe community-acquired pneumonia secondary to SARS-CoV-2 is a leading cause of death. Current guidelines recommend patients with SARS-CoV-2 pneumonia receive empirical antibiotic therapy for suspected bacterial superinfection, but little evidence supports these recommendations. Methods We obtained bronchoscopic bronchoalveolar lavage (BAL) samples from patients with SARS-CoV-2 pneumonia requiring mechanical ventilation. We analyzed BAL samples with multiplex PCR and quantitative culture to determine the prevalence of superinfecting pathogens at the time of intubation and identify episodes of ventilator-associated pneumonia (VAP) over the course of mechanical ventilation. We compared antibiotic use with guideline-recommended care. Results The 179 ventilated patients with severe SARS-CoV-2 pneumonia discharged from our hospital by June 30, 2020 were analyzed. 162 (90.5%) patients had at least one BAL procedure; 133 (74.3%) within 48 hours after intubation and 112 (62.6%) had at least one subsequent BAL during their hospitalization. A superinfecting pathogen was identified within 48 hours of intubation in 28/133 (21%) patients, most commonly methicillin-sensitive Staphylococcus aureus or Streptococcus species (21/28, 75%). BAL-based treatment reduced antibiotic use compared with guideline-recommended care. 72 patients (44.4%) developed at least one VAP episode. Only 15/72 (20.8%) of initial VAPs were attributable to multidrug-resistant pathogens. The incidence rate of VAP was 45.2/1000 ventilator days. Conclusions With use of sensitive diagnostic tools, bacterial superinfection at the time of intubation is infrequent in patients with severe SARS-CoV-2 pneumonia. Treatment based on current guidelines would result in substantial antibiotic overuse. The incidence rate of VAP in ventilated patients with SARS-CoV-2 pneumonia are higher than historically reported.
Collapse
|
40
|
Singh S, Shah PL. Safe and Efficient Practice of Bronchoscopic Sampling from Mechanically Ventilated Patients: A Structured Evaluation of the Ambu Bronchosampler-Ascope 4 Integrated System. Respiration 2021; 100:27-33. [PMID: 33412544 DOI: 10.1159/000511982] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/24/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bronchoscopic sampling of bronchoalveolar fluid (BAL) should be safe and effective. Current sampling practice risks loss of sample to the attached negative flow, aerosolisation, or spillage, due to repeated circuit breaks, when replacing sample containers. Such concerns were highlighted during the recent coronavirus pandemic. OBJECTIVES Evaluation of an alternative integrated sampling solution, with the Ambu Bronchosampler with aScope 4, by an experienced bronchoscopist in ICU. METHODS An observational study of 20 sequential bronchoscopic diagnostic sampling procedures was performed on mechanically ventilated patients with suspected ventilator-associated pneumonia. Mixed methods assessment was done. The predefined outcome measures were (1) ease of set up, (2) ease of specimen collection, (3) ease of protecting specimen from loss or spillage, and (4) overall workflow. The duration of the procedure and the % volume of sample retrieved were recorded. RESULTS The mean (±standard deviation [SD]) time for collecting 1 sample was 2.5 ± 0.8 min. The mean (±SD) specimen yield for instilled miniBAL was 54.2 ± 17.9%. Compared with standard sampling, the set-up was much easier in 18 (90%), or easier in 2 (10%) of procedures, reducing the connection steps. It was much more intuitive to use in 14 (70%), more intuitive in 4 (20%), and no more intuitive to use in 2 (10%). The overall set-up and workflow was much easier in 69% of the 13 intraprocedural connections and easier or as easy in the remaining 31% procedures. All procedures where pre connection was established were much easier (7, 100%). The Ambu Bronchosampler remained upright in all procedures with no loss or spillage of sample. Obtaining a sample was much easier in 60%, easier in 10%, no different in 20%, and worse in 10%. The ability to protect a sample from start to finish compared to standard procedures was much easier in 80%, easier in 15%, and no different in 5% of procedures. Overall workflow was much easier in 14 (70%), easier in 4 (20%), and no different in 2 (10%) of procedures. CONCLUSIONS The Ambu Bronchosampler unit was a reliable, effective, and possibly safer technique for diagnostic sampling in ICU. It may improve safety standards during the coronavirus pandemic. A randomized control trial against the standard sampling technique is warranted.
Collapse
Affiliation(s)
- Suveer Singh
- Royal Brompton Hospital, London, United Kingdom, .,Chelsea & Westminster Hospital, London, United Kingdom, .,Imperial College London, London, United Kingdom,
| | - Pallav L Shah
- Royal Brompton Hospital, London, United Kingdom.,Chelsea & Westminster Hospital, London, United Kingdom.,Imperial College London, London, United Kingdom
| |
Collapse
|
41
|
Karvouniaris M, Pontikis K, Nitsotolis T, Poulakou G. New perspectives in the antibiotic treatment of mechanically ventilated patients with infections from Gram-negatives. Expert Rev Anti Infect Ther 2020; 19:825-844. [PMID: 33270485 DOI: 10.1080/14787210.2021.1859369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Ventilator-associated pneumonia (VAP) is a common and potentially fatal complication of mechanical ventilation that is often caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB). Despite the repurposing of older treatments and the novel antimicrobials, many resistance mechanisms cannot be confronted, and novel therapies are needed.Areas covered: We searched the literature for keywords regarding the treatment of GNB infections in mechanically ventilated patients. This narrative review presents new data on antibiotics and non-antibiotic approaches focusing on Phase 3 trials against clinically significant GNB that cause VAP.Expert opinion: Ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-relebactam stand out as new options for infections by Klebsiella pneumoniae carbapenemase-producing bacteria, whereas ceftolozane-tazobactam adds therapeutic flexibility in Pseudomonas aeruginosa infections with multiple resistance mechanisms. Ceftazidime-avibactam and ceftolozane-tazobactam have relevant literature. Aztreonam-avibactam holds promise for the treatment of infections by metallo-β-lactamase (MBL)-producing organisms. Recently approved cefiderocol possesses an extended antibacterial spectrum, including KPC- and MBL-producers. However, recently published data have toned down optimism about treating VAP caused by carbapenem-resistant Acinetobacter baumannii. For the latter, eravacycline may provide additional hope, pending pertinent data. Non-antibiotic treatments currently being considered as adjunct therapeutic approaches are welcome. Nevertheless, they will hopefully substitute current antimicrobials in the future.
Collapse
Affiliation(s)
- Marios Karvouniaris
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Konstantinos Pontikis
- ICU First Department of Respiratory Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Thomas Nitsotolis
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Garyphallia Poulakou
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| |
Collapse
|
42
|
Abstract
Pulmonary infection is one of the main complications occurring in patients suffering from acute respiratory distress syndrome (ARDS). Besides traditional risk factors, dysregulation of lung immune defenses and microbiota may play an important role in ARDS patients. Prone positioning does not seem to be associated with a higher risk of pulmonary infection. Although bacteria associated with ventilator-associated pneumonia (VAP) in ARDS patients are similar to those in patients without ARDS, atypical pathogens (Aspergillus, herpes simplex virus and cytomegalovirus) may also be responsible for infection in ARDS patients. Diagnosing pulmonary infection in ARDS patients is challenging, and requires a combination of clinical, biological and microbiological criteria. The role of modern tools (e.g., molecular methods, metagenomic sequencing, etc.) remains to be evaluated in this setting. One of the challenges of antimicrobial treatment is antibiotics diffusion into the lungs. Although targeted delivery of antibiotics using nebulization may be interesting, their place in ARDS patients remains to be explored. The use of extracorporeal membrane oxygenation in the most severe patients is associated with a high rate of infection and raises several challenges, diagnostic issues and pharmacokinetics/pharmacodynamics changes being at the top. Prevention of pulmonary infection is a key issue in ARDS patients, but there is no specific measure for these high-risk patients. Reinforcing preventive measures using bundles seems to be the best option.
Collapse
|
43
|
Guedes F, Boléo-Tomé JP, Rodrigues LV, Bastos HN, Campainha S, de Santis M, Mota L, Bugalho A. Recommendations for interventional pulmonology during COVID-19 outbreak: a consensus statement from the Portuguese Pulmonology Society. Pulmonology 2020; 26:386-397. [PMID: 32868252 PMCID: PMC7405831 DOI: 10.1016/j.pulmoe.2020.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is an emerging infectious disease caused by a novel SARS-CoV-2 pathogen. Its capacity for human-to-human transmission through respiratory droplets, coupled with a high-level of population mobility, has resulted in a rapid dissemination worldwide. Healthcare workers have been particularly exposed to the risk of infection and represent a significant proportion of COVID-19 cases in the worst affected regions of Europe. Like other open airway procedures or aerosol-generating procedures, bronchoscopy poses a significant risk of spreading contaminated droplets, and medical workers must adapt the procedures to ensure safety of both patients and staff. Several recommendation documents were published at the beginning of the pandemic, but as the situation evolves, our thoughts should not only focus on the present, but should also reflect on how we are going to deal with the presence of the virus in the community until there is a vaccine or specific treatment available. It is in this sense that this document aims to guide interventional pulmonology throughout this period, providing a set of recommendations on how to perform bronchoscopy or pleural procedures safely and efficiently.
Collapse
Affiliation(s)
- F Guedes
- Centro Hospitalar do Porto (CHP), Hospital Geral de Santo António (HGSA), Unidade de Broncologia, Serviço de Pneumologia, Porto, Portugal; Departamento de Clínicas Veterinárias, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto (UP), Porto, Portugal; Centro de Estudos de Ciência Animal (CECA), Instituto de Ciências, Tecnologias e Agroambiente (ICETA) da Universidade do Porto, Praça Gomes Teixeira, Apartado 55142, 4051-401, Porto, Portugal.
| | - J P Boléo-Tomé
- Pulmonology Department, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - L V Rodrigues
- Pulmonology Department, Hospital Sousa Martins, Unidade Local de Saúde da Guarda, Guarda, Portugal; Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - H N Bastos
- Department of Pneumology, Centro Hospitalar São João, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal; IBMC/i3S - Instituto de Biologia Molecular e Celular / Instituto de Investigação e Inovação em Saúde, University of Porto, Portugal
| | - S Campainha
- Pulmonology Department, Vila Nova de Gaia-Espinho Hospital Center, Vila Nova de Gaia, Portugal
| | - M de Santis
- Pulmonology Department, Instituto Português de Oncologia (IPO), Coimbra, Portugal
| | - L Mota
- Pulmonology Department, Hospital Pulido Valente, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - A Bugalho
- Pulmonology Department, CUF Infante Santo Hospital and CUF Descobertas Hospital, Lisbon, Portugal; Comprehensive Health Research Centre, Chronic Diseases Research Center (CEDOC), NOVA Medical School, Lisbon, Portugal
| |
Collapse
|
44
|
Loughlin L, Hellyer TP, White PL, McAuley DF, Conway Morris A, Posso RB, Richardson MD, Denning DW, Simpson AJ, McMullan R. Pulmonary Aspergillosis in Patients with Suspected Ventilator-associated Pneumonia in UK ICUs. Am J Respir Crit Care Med 2020; 202:1125-1132. [PMID: 32609533 PMCID: PMC7560800 DOI: 10.1164/rccm.202002-0355oc] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale:Aspergillus infection in patients with suspected ventilator-associated pneumonia remains uncharacterized because of the absence of a disease definition and limited access to sensitive diagnostic tests.Objectives: To estimate the prevalence and outcomes of Aspergillus infection in adults with suspected ventilator-associated pneumonia.Methods: Two prospective UK studies recruited 360 critically ill adults with new or worsening alveolar shadowing on chest X-ray and clinical/hematological parameters supporting suspected ventilator-associated pneumonia. Stored serum and BAL fluid were available from 194 nonneutropenic patients and underwent mycological testing. Patients were categorized as having probable Aspergillus infection using a definition comprising clinical, radiological, and mycological criteria. Mycological criteria included positive histology or microscopy, positive BAL fluid culture, galactomannan optical index of 1 or more in BAL fluid or 0.5 or more in serum.Measurements and Main Results: Of 194 patients evaluated, 24 met the definition of probable Aspergillus infection, giving an estimated prevalence of 12.4% (95% confidence interval, 8.1-17.8). All 24 patients had positive galactomannan in serum (n = 4), BAL fluid (n = 16), or both (n = 4); three patients cultured Aspergillus sp. in BAL fluid. Patients with probable Aspergillus infection had a significantly longer median duration of critical care stay (25.5 vs. 15.5 d, P = 0.02). ICU mortality was numerically higher in this group, although this was not statistically significant (33.3% vs. 22.8%; P = 0.23).Conclusions: The estimated prevalence for probable Aspergillus infection in this geographically dispersed multicenter UK cohort indicates that this condition should be considered when investigating patients with suspected ventilator-associated pneumonia, including patient groups not previously recognized to be at high risk of aspergillosis.
Collapse
Affiliation(s)
- Laura Loughlin
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - P Lewis White
- Public Health Wales, Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Danny F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom; and
| | - Raquel B Posso
- Public Health Wales, Microbiology Cardiff, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Malcolm D Richardson
- UK NHS Mycology Reference Centre, Manchester University NHS Foundation Trust and
| | - David W Denning
- The University of Manchester and Manchester Academic Health Science Centre, National Aspergillosis Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| |
Collapse
|
45
|
Yoshimura J, Hashimoto H, Yamakawa K. Antibiotic stewardship in critically ill patients with suspected ventilator-associated pneumonia. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1329. [PMID: 33209909 PMCID: PMC7661905 DOI: 10.21037/atm-20-2421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jumpei Yoshimura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi, Osaka, Japan
| | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Hitachi, Ibaraki, Japan.,Department of Infectious Diseases, Hitachi General Hospital, Hitachi, Ibaraki, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi, Osaka, Japan
| |
Collapse
|
46
|
de Roquetaillade C, Mansouri S, Chousterman BG. Could host response guide VAP treatment? No answer yet. THE LANCET RESPIRATORY MEDICINE 2020; 8:e37. [PMID: 32380070 DOI: 10.1016/s2213-2600(20)30126-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/11/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Charles de Roquetaillade
- Department of Anesthesiology, Burn and Critical Care Medicine, Assistance publique Hopitaux de Paris, Saint Louis and Lariboisière University Hospitals, 75010 Paris, France; INSERM U942, Paris, France.
| | - Sehmi Mansouri
- Department of Anesthesiology, Burn and Critical Care Medicine, Assistance publique Hopitaux de Paris, Saint Louis and Lariboisière University Hospitals, 75010 Paris, France; INSERM U942, Paris, France
| | - Benjamin Glenn Chousterman
- Department of Anesthesiology, Burn and Critical Care Medicine, Assistance publique Hopitaux de Paris, Saint Louis and Lariboisière University Hospitals, 75010 Paris, France; INSERM U942, Paris, France
| |
Collapse
|
47
|
Hellyer TP, McAuley DF, Walsh TS, Anderson N, Conway Morris A, Singh S, Dark P, Roy AI, Perkins GD, McMullan R, Emerson LM, Blackwood B, Wright SE, Kefala K, O'Kane CM, Baudouin SV, Paterson RL, Rostron AJ, Agus A, Bannard-Smith J, Robin NM, Welters ID, Bassford C, Yates B, Spencer C, Laha SK, Hulme J, Bonner S, Linnett V, Sonksen J, Van Den Broeck T, Boschman G, Keenan DWJ, Scott J, Allen AJ, Phair G, Parker J, Bowett SA, Simpson AJ. More research is required to understand factors influencing antibiotic prescribing in complex conditions like suspected ventilator-associated pneumonia. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:840. [PMID: 32794522 PMCID: PMC7396250 DOI: 10.21037/atm-20-3701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Thomas P Hellyer
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Daniel F McAuley
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Timothy S Walsh
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Niall Anderson
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | | | - Suveer Singh
- Department of Cancer and Surgery, Imperial College, London, UK
| | - Paul Dark
- Manchester National Institute for Health Research Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | | | - Ronan McMullan
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Lydia M Emerson
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Bronagh Blackwood
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Stephen E Wright
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Kallirroi Kefala
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Cecilia M O'Kane
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Simon V Baudouin
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Ross L Paterson
- Intensive Care Unit, Western General Hospital, Edinburgh, UK
| | | | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | | | - Nicole M Robin
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Ingeborg D Welters
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | | | - Bryan Yates
- Intensive Care Unit, Northumbria Specialist Emergency Care Hospital, Cramlington, UK
| | - Craig Spencer
- Intensive Care Unit, Cardiff and Vale University Health Board, Cardiff, UK
| | | | - Jonathan Hulme
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Stephen Bonner
- Intensive Care Unit, James Cook University Hospital, Middlesbrough, UK
| | - Vanessa Linnett
- Intensive Care Unit, Queen Elizabeth Hospital, Gateshead, UK
| | | | | | - Gert Boschman
- Becton Dickinson Life Sciences, Erembodegem, Belgium
| | | | - Jonathan Scott
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - A Joy Allen
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | - Jennie Parker
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Susan A Bowett
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - A John Simpson
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| |
Collapse
|
48
|
Dhesi Z, Enne VI, O'Grady J, Gant V, Livermore DM. Rapid and Point-of-Care Testing in Respiratory Tract Infections: An Antibiotic Guardian? ACS Pharmacol Transl Sci 2020; 3:401-417. [PMID: 32551433 PMCID: PMC7233852 DOI: 10.1021/acsptsci.0c00027] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Indexed: 12/15/2022]
Abstract
![]()
This
is a narrative review on the potential of rapid and point-of-care
microbiological testing in pneumonia patients, focusing particularly
on hospital-acquired and ventilator-associated pneumonia, which have
substantial mortality and diverse microbiology. This work is written
from a United Kingdom perspective, but much of it is generalizable
internationally. In a world where antimicrobial resistance is a major
international threat, the use of rapid molecular diagnostics has great
potential to improve both the management of pneumonia patients and
the stewardship of antibiotics. Rapid tests potentially can distinguish
patients with bacterial versus viral infection and can swiftly identify
bacterial pathogens and their resistances. We seek to answer the question:
“Can such tests be used as an antibiotic guardian?”
Their availability at the bedside rather than in the laboratory should
best ensure that results are swiftly used to optimize patient management
but will raise new challenges, not the least with respect to maintaining
quality control and microbiology/infection control input. A further
challenge lies in assessing the degree of trust that treating clinicians
will place in these molecular diagnostic tests, particularly when
early de-escalation of antibiotic therapy is indicated.
Collapse
Affiliation(s)
- Zaneeta Dhesi
- University College London, Gower Street, London WC1E 6BT, United Kingdom
| | - Virve I Enne
- University College London, Gower Street, London WC1E 6BT, United Kingdom
| | - Justin O'Grady
- Quadram Institute Bioscience, Norwich Research Park, Norwich NR4 7UA, United Kingdom
| | - Vanya Gant
- University College London Hospitals NHS Foundation Trust, London NW1 2PG, United Kingdom
| | - David M Livermore
- University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, United Kingdom
| |
Collapse
|
49
|
Hellyer TP, Simpson AJ. Could host response guide VAP treatment? No answer yet - Authors' reply. THE LANCET RESPIRATORY MEDICINE 2020; 8:e38. [PMID: 32380071 DOI: 10.1016/s2213-2600(20)30133-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/16/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle NE2 4HH, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle NE2 4HH, UK; National Institute for Health Research Newcastle In Vitro Diagnostics Co-operative, Newcastle University, Newcastle, UK; Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK.
| | | |
Collapse
|
50
|
Luo F, Darwiche K, Singh S, Torrego A, Steinfort DP, Gasparini S, Liu D, Zhang W, Fernandez-Bussy S, Herth FJF, Shah PL. Performing Bronchoscopy in Times of the COVID-19 Pandemic: Practice Statement from an International Expert Panel. Respiration 2020; 99:417-422. [PMID: 32344422 PMCID: PMC7251585 DOI: 10.1159/000507898] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/14/2020] [Indexed: 02/05/2023] Open
Abstract
These recommendations for physicians who perform bronchoscopy will help to protect those patients (un)-affected by the current COVID-19 pandemic, minimize the risk of transmission, and maintain clinical care for all patients.
Collapse
Affiliation(s)
- Fengming Luo
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Kaid Darwiche
- Department of Interventional Pneumology, Ruhrlandklinik, University Medicine Essen, Essen, Germany
| | - Suveer Singh
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Chelsea and Westminster Hospital, London, United Kingdom
| | - Alfonso Torrego
- Respiratory Department, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Daniel P Steinfort
- Department Respiratory Medicine, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Stefano Gasparini
- Department of Biomedical Sciences and Public Health, Polytechnic University of Marche Region Azienda Ospedali Riuniti, Ancona, Italy
| | - Dan Liu
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Zhang
- Department of Respiratory and Critical Care Medicine, Shanghai Changhai Hospital, Second Military Medical University, Shanghai, China
| | | | - Felix J F Herth
- Pneumology and Critical Care Medicine, Thoraxklinik University of Heidelberg, Heidelberg, Germany,
- Translational Lung Research Center Heidelberg, Heidelberg, Germany,
| | - Pallav L Shah
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Chelsea and Westminster Hospital, London, United Kingdom
| |
Collapse
|