Infectious disease consultation and microbiologic surveillance for intensive care unit trauma patients: a pilot study

Friends Not Foes: Optimizing Collaboration with Subspecialists

Pediatric orthopedic patients can be complex to manage. As orthopedists plan for possible surgical interventions, consultation with pediatric subspecialists will be necessary. This article discusses the considerations an orthopedist should make when deciding on the timing and the appropriateness of consultation-both preoperatively and perioperatively. Consultation before surgical intervention will especially be useful if the subspecialist will be collaborating in the management of the condition postoperatively (whether inpatient or outpatient). Clear and early consultation in both written and verbal format will facilitate quality and expedite the patient's care.

Establishment of an interdisciplinary board for bone and joint infections

PURPOSE

The incidence of bone and joint infections is increasing while their treatment remains a challenge. Although guidelines and recommendations exist, evidence is often lacking and treatment complicated by complex clinical presentations and therapeutic options. Interdisciplinary boards shown to improve management of other diseases, seem potentially helpful. We describe the establishment of an osteomyelitis board to show the existing demand for such a platform.

METHODS

All patients discussed in the board for bone and joint infections between October 2014 and September 2020 were included in this retrospective study. Data were extracted from patient records and analyzed descriptively.

RESULTS

A total of 851 requests related to 563 patients were discussed in the board during the study period. After a run-in period of 3 years, a stable number of cases (> 170/year) were discussed, submitted by nearly all hospital departments (22 of 25). Recommendations were mainly related to antibiotic treatment (43%) and to diagnostics (24%). Periprosthetic joint infections were the most frequent entity (33%), followed by native vertebral osteomyelitis and other osteomyelitis. In 3% of requests, suspected infection could be excluded, in 7% further diagnostics were recommended to confirm or rule out infection.

CONCLUSIONS

A multidisciplinary board for bone and joint infections was successfully established, potentially serving as a template for further boards. Recommendations were mainly related to antibiotic treatment and further diagnostics, highlighting the need for interdisciplinary discussion to individualize and optimize treatment plans based on guidelines. Further research in needed to evaluate impact on morbidity, mortality and costs.

Infectious disease services: a survey from four university hospitals in Germany

PURPOSE

Involvement of infectious disease (ID) specialists in the care of hospitalized patients with infections through consultation services improves the quality of care and the outcome of patients. This survey aimed to describe activities and utilization of ID consultations at four German tertiary care hospitals.

METHODS

A 1-month (March 2016) retrospective cross-sectional study at four university hospitals (Freiburg, Jena, Cologne and Regensburg) was performed. Only ID consultations with written documentation and bedside patient evaluation were included. Consultations were analyzed with regard to requesting departments, infections, case severity, and diagnostic and therapeutic recommendations.

RESULTS

In the study period, 638 ID consultations were performed in 479 patients-corresponding to 3-4 consultations per 100 inpatient cases. Patients were characterized by a high disease complexity-the mean case mix index in patients with consultation was 10.1 compared to 1.6 for all patients. ID consultations were requested by many different specialties, with approximately half of the requests coming from surgical disciplines. ID consultations resulted in revised diagnoses in 34% of the cases, provided recommendations for additional diagnostic procedures in 66%, and for modifications of antimicrobial regimens in 70% of the cases.

CONCLUSIONS

Infectious disease consultations were requested for patients with severe and complicated diseases and resulted in recommendations that highly impacted the diagnostic work-up and therapeutic management of patients. The results of this survey may help to estimate requirements for establishment of such services in Germany.

Place des référents en antibiothérapie en réanimation

Dans les hôpitaux français, les référents antibiotiques ont comme principale mission d’assurer une activité de conseil sur le bon usage des antibiotiques sur avis sollicités ou à partir d’alertes générées par la microbiologie ou la pharmacie. À première vue, leurs contributions semblent donc importantes en réanimation, où près d’un patient sur deux reçoit une antibiothérapie pendant son séjour. Plusieurs études ont montré que les avis des infectiologues permettaient d’améliorer la qualité de l’antibiothérapie prescrite et de réduire l’exposition des patients aux antibiotiques. Cependant, les bénéfices de ces interventions sur l’évolution clinique des patients ou sur l’écologie bactérienne sont plus difficiles à démontrer. L’activité des référents antibiotiques doit s’intégrer dans un programme multidisciplinaire de bon usage des antibiotiques, intégrant d’autres intervenants et en premier lieu les réanimateurs, avec lesquels une collaboration étroite est fondamentale pour la réussite de ce programme.

The Value That Infectious Diseases Physicians Bring to the Healthcare System

While a career in infectious diseases (ID) has always been challenging and exciting, recognition of the value that ID physicians provide to the healthcare system as a whole, over and above the value they provide to individual patients, has been poor in this system. In response to this disparity, the Infectious Diseases Society of America Clinical Affairs Committee has long endeavored to quantify the value of ID physicians to the system, which is challenging in part because of the many avenues through which they influence healthcare. We discuss data showing that ID physicians improve clinical outcomes, positively impact transitions of care, and direct system-level improvements through infection prevention and antimicrobial stewardship. We identify areas where value-based care provides additional future opportunities for ID physicians. A Clinical Affairs Committee-sponsored study of ID physicians' positive impact on patient outcomes shows that few medical specialties are better positioned to positively impact the Triple Aim approach-better health, better care, and lower per capita cost-that is the principle tenet of healthcare system reform.

Initial empirical antibacterial therapy of ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) is the most frequently occurring nosocomial infection, accounting for considerable morbidity and mortality. Diagnosis can be difficult, creating important therapeutic challenges for intensivists. Early therapy is important in maximizing outcomes, but inappropriate antibacterial treatment has its own risks. A balance needs to be struck between the necessary therapeutic benefits and the negative effects (selection of resistant pathogens, costs, and adverse effects) of antibacterials. Several studies have indicated, in various groups of critically ill patients including those with VAP, that starting treatment with an ineffective antibacterial can increase hospital and intensive care unit length of stay and mortality. When the responsible microorganisms cannot be defined, it may be better to start treatment with a broad-spectrum antibacterial regimen, taking into account individual patient factors and local bacteriology patterns, including antibacterial resistance. As soon as the nature of the pathogen has been defined, the antibacterial agent(s) should be modified accordingly, with the primary aim to reduce the antibacterial spectrum. The optimal duration of therapy is controversial and probably best tailored to the individual patient depending on clinical response and resolution of the factors used to diagnose VAP in that patient. Consultation with an infectious disease specialist may facilitate these therapeutic decisions. With the high morbidity and mortality associated with VAP, prevention is an important issue. General measures include adequate hand hygiene. Physicians must be aware of the risk factors for VAP and of accepted and effective strategies of prevention.

Infectious diseases consultations can make the difference: a brief review and a plea for more infectious diseases specialists in Germany

Trained infectious diseases (ID) specialists are an integral part of inpatient and outpatient care in many countries, however, these specialized services are established only in selected tertiary care hospitals in Germany. This review summarises studies that addressed the impact of ID consultation services on patient care and outcome. Extensive data for a clinical benefit is available in the context of Staphylococcus aureus bacteremia (SAB), in which in-hospital or 30-day mortality was significantly reduced by 40-50 % in patients evaluated and treated in cooperation with ID consultants. This effect was associated with improved adherence to quality-of-care standards. Moreover, newer studies show a reduced length of hospital stay due to ID consultations, especially if patients are evaluated early in the course of their hospital stay. Of note, informal consultations do not seem to be equivalent to a formal ID consultation with bedside patient evaluation. Studies in other patient groups (solid organ transplant recipients or intensive care unit patients) or in the context of other infections (infective endocarditis, pneumonia, other bloodstream infections) also revealed positive effects of ID consultations. Higher rates of appropriate empirical and targeted antimicrobial treatments and de-escalation strategies due to successful pathogen identification were documented. These modifications resulted in lower treatment costs and decreased antimicrobial resistance development. Although there are methodological limitations in single studies, we consider the consistent and reproducible positive effects of ID consultations shown in studies in different countries and health care systems as convincing evidence for improved quality-of-care and treatment outcomes in patients with infectious diseases. Thus, we strongly recommend efforts to establish significantly more ID consultation services in hospitals in Germany.

[Impact of an infectious diseases consultation service on the quality of care and the survival of patients with infectious diseases]

While trained infectious diseases (ID) specialists are regularly involved in inpatient and outpatient care in the United States and Canada, these specialized services are only rarely established in Germany. This article aims to summarize the findings of numerous studies that investigated the impact of ID consultation services on patient care and outcome in patients suffering from infectious diseases. The strongest evidence for a clinical benefit is found in the context of Staphylococcus aureus bacteremia (SAB), where in-hospital- and day-30 mortality was significantly and consistently reduced by about 40% in patients that were evaluated and treated in cooperation with an ID physician. Furthermore, studies revealed that this effect was associated with an improved adherence to standards of care. Newer studies show a reduced length of hospital stay due to ID consultations, especially if patients are evaluated early in the course of their hospital stay. Of note, informal or curbside consultations do not seem to be equivalent to a formal ID consultation with bedside patient evaluation. Studies in other patient groups (solid organ transplant recipients or intensive care unit patients) or in the context of other infections (infective endocarditis, pneumonia, other bloodstream infections) also revealed positive effects of ID consultations. Higher rates of appropriate empirical and targeted antimicrobial treatments and de-escalation strategies due to successful pathogen identification were documented. These modifications resulted in lower treatment costs and decreased antimicrobial resistance development. Although there are methodological limitations in single studies, we consider the consistent and reproducible positive effects of ID consultations shown in studies in different countries and health care systems as convincing evidence for the improved quality of care and treatment outcomes in patients with infectious diseases. Thus, strong consideration should be given to establish ID consultation services in small and medium sized hospitals as well.

Critical Care Medicine and Infectious Diseases: An Emerging Combined Subspecialty in the United States

The recent rise in unfilled training positions among infectious diseases (ID) fellowship programs nationwide indicates that ID is declining as a career choice among internal medicine residency graduates. Supplementing ID training with training in critical care medicine (CCM) might be a way to regenerate interest in the specialty. Hands-on patient care and higher salaries are obvious attractions. High infection prevalence and antibiotic resistance in intensive care units, expanding immunosuppressed host populations, and public health crises such as the recent Ebola outbreak underscore the potential synergy of CCM-ID training. Most intensivists receive training in pulmonary medicine and only 1% of current board-certified intensivists are trained in ID. While still small, this cohort of CCM-ID certified physicians has continued to rise over the last 2 decades. ID and CCM program leadership nationwide must recognize these trends and the merits of the CCM-ID combination to facilitate creation of formal dual-training opportunities.

Antibiotic stewardship programmes in intensive care units: Why, how, and where are they leading us

Antibiotic usage and increasing antimicrobial resistance (AMR) mount significant challenges to patient safety and management of the critically ill on intensive care units (ICU). Antibiotic stewardship programmes (ASPs) aim to optimise appropriate antibiotic treatment whilst minimising antibiotic resistance. Different models of ASP in intensive care setting, include “standard” control of antibiotic prescribing such as “de-escalation strategies”through to interventional approaches utilising biomarker-guided antibiotic prescribing. A systematic review of outcomes related studies for ASPs in an ICU setting was conducted. Forty three studies were identified from MEDLINE between 1996 and 2014. Of 34 non-protocolised studies, [1 randomised control trial (RCT), 22 observational and 11 case series], 29 (85%) were positive with respect to one or more outcome: These were the key outcome of reduced antibiotic use, or ICU length of stay, antibiotic resistance, or prescribing cost burden. Limitations of non-standard antibiotic initiation triggers, patient and antibiotic selection bias or baseline demographic variance were identified. All 9 protocolised studies were RCTs, of which 8 were procalcitonin (PCT) guided antibiotic stop/start interventions. Five studies addressed antibiotic escalation, 3 de-escalation and 1 addressed both. Six studies reported positive outcomes for reduced antibiotic use, ICU length of stay or antibiotic resistance. PCT based ASPs are effective as antibiotic-stop (de-escalation) triggers, but not as an escalation trigger alone. PCT has also been effective in reducing antibiotic usage without worsening morbidity or mortality in ventilator associated pulmonary infection. No study has demonstrated survival benefit of ASP. Ongoing challenges to infectious disease management, reported by the World Health Organisation global report 2014, are high AMR to newer antibiotics, and regional knowledge gaps in AMR surveillance. Improved AMR surveillance data, identifying core aspects of successful ASPs that are transferable, and further well-conducted trials will be necessary if ASPs are to be an effective platform for delivering desired patient outcomes and safety through best antibiotic policy.

Contribution of antimicrobial stewardship programs to reduction of antimicrobial therapy costs in community hospital with 429 Beds --before-after comparative two-year trial in Japan

Objectives

Do antimicrobial stewardship programs (ASPs) contribute to reduction of antimicrobial therapy costs in Japanese community hospitals? To answer this health economic question, a before-after comparative two-year trial in a community hospital in the country was designed.

Methods

The study was conducted at National Hospital Organization Tochigi Medical Center, a community hospital with 429 beds. We compared six-month period before-ASP (January 2010 to June 2010) and 24-month period after ASP (July 2010 to June 2012) in primary and secondary outcome measures. Three medical doctors, three pharmacists and two microbiology technologists participate in the ASPs. The team then provided recommendations based on the supplemental elements to primary physicians who prescribed injectable antimicrobials. Prospective audit with intervention and feedback was applied in the core strategy while dose optimization, de-escalation and recommendations for alternate agents and blood cultures were applied in the supplemental elements. The primary outcome was measured by the antimicrobial therapy costs (USD per 1,000 patient-days), while the secondary outcomes included the amount of antimicrobials used (defined daily doses per 1,000 patient-days), sensitivity rates (%) of Pseudomonas aeruginosa (P. aeruginosa) to Meropenem (MEPM), Ciprofloxacin (CPFX) and Amikacin (AMK), length of stay (days) and detection rates (per 1,000 patient-day) of methicillin-resistant Staphylococcus aureus (MRSA) and extended spectrum beta-lactamase-producing organisms (ESBLs) through blood cultures.

Results

In the study, recommendations were made for 465 cases out of 1,427 cases subject to the core strategy, and recommendations for 251 cases (54.0%) were accepted. After ASP, the antimicrobial therapy costs decreased by 25.8% (P = 0.005) from those before ASP. Among the secondary outcomes, significant changes were observed in the amount of aminoglycosides used, which decreased by 80.0% (P < 0.001) and the detection rate of MRSA, which decreased by 48.3% (P < 0.001).

Conclusions

The study suggested the possibility that ASPs contributed to the reduction of the antimicrobial therapy costs in a community hospital with 429 beds.

The burden of infection in severely injured trauma patients and the relationship with admission shock severity

BACKGROUND

Infection following severe injury is common and has a major impact on patient outcomes. The relationship between patient, injury, and physiologic characteristics with subsequent infections is not clearly defined. The objective of this study was to characterize the drivers and burden of all-cause infection in critical care trauma patients.

METHODS

A prospective cohort study of severely injured adult patients admitted to critical care was conducted. Data were collected prospectively on patient and injury characteristics, baseline physiology, coagulation profiles, and blood product use. Patients were followed up daily for infectious episodes and other adverse outcomes while in the hospital.

RESULTS

Three hundred patients (Injury Severity Score [ISS] >15) were recruited. In 48 hours or less, 29 patients (10%) died, leaving a cohort of 271. One hundred forty-one patients (52%) developed at least one infection. Three hundred four infections were diagnosed overall. Infection and noninfection groups were matched for age, sex, mechanism, and ISS. Infection rates were greater with any degree of admission shock and threefold higher in the most severely shocked cohort (p < 0.01). In multivariate analysis, base deficit (odds ratio [OR], 1.78, 95% confidence interval [CI], 1.48-1.94; p < 0.001) and lactate (OR, 1.36; 95% CI, 1.10-1.69; p = 0.05) were independently associated with the development of infection. Outcomes were significantly worse for the patients with infection. In multivariate logistic regression, infection was the only factor independently associated with multiple-organ failure (p < 0.001; OR, 15.4; 95% CI, 8.2-28.9; r = 0.402), ventilator-free days (p < 0.001; β, -4.48; 95% CI, -6.7 to -2.1; r = 0.245), critical care length of stay (p < 0.001; β, 13.2; 95% CI, 10.0-16.4; r = 0.466), and hospital length of stay (p < 0.001; β, 31.1; 95% CI, 24.0-38.2; r = 0.492).

CONCLUSION

Infectious complications are a burden for severely injured patients and occur early in the critical care stay. Severity of admission shock was predictive of infection and represents an opportunity for interventions to improve infectious outcomes. The incidence of infection may also have utility as an end point for clinical trials in trauma hemorrhage given the relationship with patient-experienced outcomes.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level II.

A national network of infectious diseases experts

OBJECTIVES

The aim of this study was to consider the implementation of a network of infectious diseases (ID) experts to optimize the antibiotic prescriptions of community and hospital practitioners.

METHODS

An observational prospective study was conducted among ID experts in the Pays-de-la-Loire Region to evaluate the number of calls and to determine the practitioner's reasons for soliciting ID expertise. For each phone consultation, four criteria were recorded during 5 days: origin of the call (internal/external), kind of question (diagnostic/therapeutic) time spent for the advice provided, type of advice.

RESULTS

A total of 386 phone consultations for 20 infectious disease specialists were recorded during the study period (5 days); 81% were internal to the hospital, 7.7% from another hospital, and 11.3% from private practice, 56.3% of the questions concerned a therapeutic strategy, 21% a diagnostic advice, and 22.6% concerned both diagnosis and therapy. Two third of the questions were answered within 10minutes. In 68.7% of cases, the ID specialist answered immediately, 19.8% of calls required following-up the patient, 6% led to refer the patient to an ID consultation, and 5.5% to hospitalization.

CONCLUSION

The survey results stress the important need for such ID expertise, both in hospitals and in ambulatory medicine. Collaboration of ID specialists in a regional network would allow an easy and permanent access to antibiotic therapy advice for prescribers. This network would improve the quality and safety of care.

Infectious diseases specialty intervention is associated with decreased mortality and lower healthcare costs

BACKGROUND

Previous studies, largely based on chart reviews with small sample sizes, have demonstrated that infectious diseases (ID) specialists positively impact patient outcomes. We investigated how ID specialists impact mortality, utilization, and costs using a large claims dataset.

METHODS

We used administrative fee-for-service Medicare claims to identify beneficiaries hospitalized from 2008 to 2009 with at least 1 of 11 infections. There were 101 991 stays with and 170 336 stays without ID interventions. Cohorts were propensity score matched for patient demographics, comorbidities, and hospital characteristics. Regression models compared ID versus non-ID intervention and early versus late ID intervention. Risk-adjusted outcomes included hospital and intensive care unit (ICU) length of stay (LOS), mortality, readmissions, hospital charges, and Medicare payments.

RESULTS

The ID intervention cohort demonstrated significantly lower mortality (odds ratio [OR], 0.87; 95% confidence interval [CI], .83 to .91) and readmissions (OR, 0.96; 95% CI, .93 to .99) than the non-ID intervention cohort. Medicare charges and payments were not significantly different; the ID intervention cohort ICU LOS was 3.7% shorter (95% CI, -5.5% to -1.9%). Patients receiving ID intervention within 2 days of admission had significantly lower 30-day mortality and readmission, hospital and ICU length of stay, and Medicare charges and payments compared with patients receiving later ID interventions.

CONCLUSIONS

ID interventions are associated with improved patient outcomes. Early ID interventions are also associated with reduced costs for Medicare beneficiaries with select infections.

Strategic Alliance Between the Infectious Diseases Specialist and Intensive Care Unit Physician for Change in Antibiotic Use

There is a general consensus that antimicrobial use in intensive care units (ICU) is greater than that in general wards. By implementing a strategy of systematic infectious disease consultations in agreement with the ICU chief, we have modified the antibiotic prescription habits of the ICU physician. A reduction was observed in the use of selected antibiotics (third-generation cephalosporins, vancomycin, carbapenems and piperacillin-tazobactam), with a significant reduction in the length of hospital stay for ICU patients and lower antibiotic costs without negative impact on patient mortality. Leadership by the infectious diseases consultant in combination with commitment by ICU physicians is a simple and effective method to change antibiotic prescription habits in the ICU.

[The referral of infectious diseases is a key activity for infectious diseases departments and units, as well as for the hospital]

Infectious diseases referrals (IDR) is a core activity of infectious diseases departments, and is certainly the one with the greatest potential impact on the hospital due to their cross-sectional nature, and with the emergence of a bacterial resistance and antimicrobial crisis. However, there is no standard model for IDR, no official training, and evaluation is merely descriptive. Paradoxically IDR are at risk in a health system that demands more quality and efficiency. The aim of this review is to assess what is known about IDR, its definition, key features, objectives, method, and the evaluation of results, and to suggest improvements to this key activity for the infectious diseases departments and the hospital.

Formal infectious diseases consultation is associated with decreased mortality in Staphylococcus aureus bacteraemia

To determine the impact of infectious diseases consultation (IDC) in Staphylococcus aureus bacteraemia. All MRSA bacteraemia and a random subset of MSSA bacteraemia were retrospectively analysed. Out of 599 SAB episodes, 162 (27%) were followed by an IDC. Patients with IDC were younger and more frequently intravenous drug users, but fewer resided in a long-term care facility or were indigenous. Hospital length of stay was longer (29.5 vs 17 days, p < 0.001), and endocarditis (19.1% vs 7.3%, p < 0.001) and metastatic seeding (22.2% vs 10.1%, p < 0.001) were more frequent in the IDC group; however, SAPS II scores were lower in the IDC group (27 vs 37, p < 0.001). ICU admission rates in the two groups were similar. The isolate tested susceptible to empirical therapy more frequently in the IDC group (88.9% vs 78.0%, p = 0.003). Seven-day (3.1 vs 16.5%), 30-day (8.0% vs 27.0%) and 1-year mortality (22.2% vs 44.9%) were all lower in the IDC group (all p < 0.001). Multivariate analysis showed that effective initial therapy was the only variable associated with the protective effect of IDC. In patients with SAB, all-cause mortality was significantly lower in patients who had an IDC, because of the higher proportion of patients receiving effective initial antibiotics.

Positive blood culture in hospital: notification methods and impact of recommendations by an infectious disease specialist

OBJECTIVE

The study's objective was to describe the notification methods of positive blood cultures and analyse the impact of recommendations made by an infectious disease specialist on the appropriateness of antibiotherapy.

METHOD

We included all patients with positive blood cultures, from 12 different hospitals (including six with mobile infectious disease teams: MIDT) during a seven-day period. Medical records were retrospectively analysed to determine the delivered antibiotic treatment and the notification method of positive blood culture. We considered that the antibiotic treatment was appropriate if the antibiotic was effective on the isolated bacterium, whatever its spectrum. We assessed the impact of recommendations on appropriateness of antibiotherapy.

RESULTS

One hundred and eighty-six patients were included. 44% (n=86) were considered as contamination cases. In true infections (n=104), Staphylococcus aureus and enterobacteria accounted for 51% of isolated bacteria. The Medical Unit was notified of blood culture positivity the day of positivity in 98% of cases (n=182). Antibiotic recommendations were given on the same day in 71% of cases. The antibiotic treatment was appropriate if recommendations were given in 92% of bacteremia, and only in 79% in without any recommendations (P=0.1).

CONCLUSION

Antibiotic treatment seems to be more appropriate when antibiotic recommendations are given. This suggests that the MIDT has a key role in improving antibiotic prescriptions, whether for effectiveness, cost, or bacterial ecology.

Impact of an assisted reassessment of antibiotic therapies on the quality of prescriptions in an intensive care unit

OBJECTIVES

The study's objective was to assess the impact of a professional multifaceted intervention designed to improve the quality of inpatient empirical therapeutic antibiotic courses at the time of their reassessment, i.e. 24 to 96 hours after treatment initiation.

DESIGN

We conducted a 5-month prospective pre- and post-intervention study in a medical Intensive Care Unit (ICU) in a teaching hospital, using time-series analysis. The intervention was a multifaceted professional intervention combining systematic 3-weekly visits of an infectious diseases specialist to discuss all antibiotic therapies, interactive teaching courses, and daily contact with a microbiologist.

RESULTS

Eighty-one antibiotic prescriptions were assessed, 37 before and 44 after the intervention. The prevalence of adequate antibiotic prescriptions was high and not statistically different before and after the intervention (73% vs. 80%, P=0.31), both for sudden change (P=0.67) and linear trend (P=0.055), using interrupted time-series analysis. The intervention triggered a more frequent reassessment of the diagnosis between day 2 and day 4 (11% vs. 32%, P=0.02) and slightly improved the adaptation of antibiotic therapies to positive microbiology (25% before vs. 50% after, P=0.18).

CONCLUSIONS

Our multifaceted intervention may have improved the quality of antibiotic therapies around day 3 of prescription, but the difference did not reach statistical significance, possibly because of a ceiling effect.

Impact of antimicrobial stewardship in critical care: a systematic review

OBJECTIVES

To evaluate the current state of evidence for antimicrobial stewardship interventions in the critical care unit.

METHODS

We performed a systematic search of OVID MEDLINE, Embase and Cochrane electronic databases from 1996-2010. Studies were included if they involved any experimental intervention to improve antimicrobial utilization in the critical care setting.

RESULTS

Thirty-eight studies met the inclusion criteria, of which 24 met our quality inclusion criteria. The quality of research was poor, with only 3 randomized controlled trials, 3 interrupted time series and 18 (75%) uncontrolled before-and-after studies. We identified six intervention types: studies of antibiotic restriction or pre-approval (six studies); formal infectious diseases physician consultation (five); implementation of guidelines or protocols for de-escalation (two); guidelines for antibiotic prophylaxis or treatment in intensive care (two); formal reassessment of antibiotics on a pre-specified day of therapy (three); and implementation of computer-assisted decision support (six). Stewardship interventions were associated with reductions in antimicrobial utilization (11%-38% defined daily doses/1000 patient-days), lower total antimicrobial costs (US$ 5-10/patient-day), shorter average duration of antibiotic therapy, less inappropriate use and fewer antibiotic adverse events. Stewardship interventions beyond 6 months were associated with reductions in antimicrobial resistance rates, although this differed by drug-pathogen combination. Antibiotic stewardship was not associated with increases in nosocomial infection rates, length of stay or mortality.

CONCLUSIONS

More rigorous research is needed, but available evidence suggests that antimicrobial stewardship is associated with improved antimicrobial utilization in the intensive care unit, with corresponding improvements in antimicrobial resistance and adverse events, and without compromise of short-term clinical outcomes.

Prescription of antibiotics in intensive care units in Latin America: an observational study

A one-day point prevalence study to investigate the patterns of antibiotic use was undertaken in 43 latin American (LA) intensive care units. Of 510 patients admitted, 231 received antibiotic treatment on the day of the study (45%); in 125 cases (54%) due to nosocomial-acquired infections. The most frequent infection reported was nosocomial pneumonia (43%). Only in 122 patients (53%) were cultures performed before starting antibiotic treatment. 33% of the isolated microorganisms were enterobacteriaceae (40% extended-spectrum beta-lactamase-producing), 23% methicillin-resistant Staphylococcus aureus and 17% carbapenems-resistant non-fermentative Gram-negatives. The antibiotics most frequently prescribed were carbapenems (99/231, 43%); alone (60/99, 60%) or in combination with vancomycin (39/99, 40%). "Restricted" antibiotics (carbapenems, vancomycin, piperacillin-tazobactam, broad-spectrum cephalosporins, tigecycline, polymixins and linezolid) were most frequently indicated in severely ill patients (APACHE II score at admission >15, p=0.0007 and, SOFA score at the beginning of the antibiotic treatment >3, p=0.0000). Only 36% of antibiotic treatments were cultured-directed.Our findings help explain the high rates of multidrug-resistant pathogens in LA settings (i.e. ESBL-producing Gram-negatives) and the severity of the registered patients illnesses.

Infectious diseases consultation lowers mortality from Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia (SAB) is a lethal and increasingly common infection in hospitalized patients. We assessed the impact of infectious diseases consultation (IDC) on clinical management and hospital mortality of SAB in 240 hospitalized patients in a retrospective cohort study. Patients who received IDC were older than those who did not (57.9 vs. 51.7 yr; p = 0.05), and were more likely to have a health care-associated infection (63% vs. 45%; p < 0.01). In patients who received IDC, there was a higher prevalence of severe complications of SAB such as central nervous system involvement (5% vs. 0%, p = 0.01), endocarditis (20% vs. 2%; p < 0.01), or osteomyelitis (15.6% vs. 3.4%; p < 0.01). Patients who received IDC had closer blood culture follow-up and better antibiotic selection, and were more likely to have pus or prosthetic material removed. Hospital mortality from SAB was lower in patients who received IDC than in those who did not (13.9% vs. 23.7%; p = 0.05). In multivariate survival analysis, IDC was associated with substantially lower hazard of hospital mortality during SAB (hazard 0.46; p = 0.03). This mortality benefit accrued predominantly in patients with methicillin-resistant SAB (hazard 0.3; p < 0.01), and in patients who did not require ICU admission (hazard 0.15; p = 0.01). In conclusion, IDC is associated with reduced mortality in patients with staphylococcal bacteremia.

Role of the infectious diseases specialist consultant on the appropriateness of antimicrobial therapy prescription in an intensive care unit

BACKGROUND

Use of routine microbiologic surveillance, antibiotic practice guidelines, and infectious diseases (ID) specialist consultation might contribute to achieve an early diagnosis and an appropriate antibiotic treatment of infections, particularly in an intensive care unit (ICU) setting.

METHODS

We conducted a prospective cohort study in an ICU over a period of 4 years (2001-2004). We studied all patients with a possible or definite diagnosis of infection who received antimicrobial treatment, analyzing the appropriateness of antimicrobial therapy prescription before (P1) and after (P2) the implementation (January 1, 2003) of a systematic ID specialist consultation program.

RESULTS

Among the 349 patients enrolled, we observed 205 infections during P1 and 197 during P2. Infections treated with appropriate antimicrobial therapy were 141 (68.8%) in P1 and 165 (83.7%) in P2 (P .0004). Compliance to the local guidelines for empirical antimicrobial therapy increased by 20.4% from P1 to P2 (P < .0001). Patients receiving an appropriate treatment had a significantly shorter duration of antibiotic treatment (P < .0001), mechanical ventilation (P < .0001), ICU stay (P < .0001), and reduced in-hospital mortality (P = .006). Adherence to local antibiotic therapy guidelines improved significantly from P1 (63.4%) to P2 (83.8%) (P < .0001).

CONCLUSION

The introduction of an ID specialist consultation program may improve the appropriateness of the antimicrobial therapy prescription in ICU and the adherence to the local antibiotic therapy guidelines. Furthermore, appropriate antibiotic therapy is associated with a reduction in both ICU and in-hospital mortality.

[Consultations with infectious disease specialists for patients in a teaching hospital: Adherence in 174 cases]

OBJECTIVES

In a teaching hospital where infectious disease specialists were routinely consulted for infections in patients in other departments, we sought to assess adherence to the specialists' recommendations, identify the factors influencing adherence, and measure the proportion of nosocomial infections among these consultations.

METHODS

We collected data from intrahospital consultations with infectious disease specialists over a 4-week period. Afterwards (48 hours later), a physician and pharmacist collected all prescriptions for anti-infectious agents (dose, drug, combinations) and other orders (laboratory tests, radiology examination, isolation) for each patient.

RESULTS

There were 174 infectious disease consultations requested for 143 inpatients during the study period. Anti-infectious agents were prescribed for 52.4% of patients, modified for 22.4%, and stopped for 9.1%; 16.1% neither had nor required such treatment. The rate of adherence to the specialists' recommendations was 84.6% for anti-infectious prescriptions and 77.4% for other orders. The factors associated with adherence were a bedside consultation (p = 0.04) and a recommendation to stop rather than modify anti-infectious treatment (p = 0.02). Roughly 40% of the patients (n = 57) had a nosocomial infection, most often during hospitalization for surgery (53.1% versus 29.1%, p < 0.01). Consultations were requested for 20% of the nosocomial infections observed at Grenoble University Hospital (based on annual prevalence in 2005).

CONCLUSIONS

The specialist's presence at the patient's bedside has an impact on staff adherence to recommendations. These specialists play a vital role in managing nosocomial infections, which account for more than a third of these intrahospital' consultations.

Improved clinical outcome of patients with Candida bloodstream infections through direct consultation by infectious diseases physicians in a Japanese university hospital

OBJECTIVE

To examine whether intervention by infectious diseases physicians (IDPs) in the treatment decisions that emphasize adequate antifungal treatment and early removal of central venous catheter for patients with Candida bloodstream infection (BSI) improves prognosis.

DESIGN

Retrospective cohort study of patients with Candida BSI, comparing the prognosis of patients before and after the start of the intervention.

SETTING

A 1,240-bed, tertiary care university hospital.

PATIENTS

Forty patients with Candida BSI during a 2-year period, from January 2001 to December 2002, were included in the study. Twenty-three patients in the first year after the start of intervention by IDPs (intervention group) were compared with 17 patients in the first year before the start of the IDP intervention (baseline group).

INTERVENTIONS

In January 2002, a total of 5 IDPs at Kyoto University Hospital gave unsolicited recommendations on antifungal treatment and advised all physicians treating inpatients who had Candida BSI to remove the central venous catheter.

RESULTS

No significant difference was seen between the 2 groups in patients' clinical background, species, and fluconazole susceptibility of the causative organisms. The 30-day survival rate was significantly better in the intervention group (18 [78%] of 23 patients) than in the baseline group (7 [44%] of 16 patients; P=.04 by Fisher's exact test). More patients in the intervention group than in the baseline group received appropriate antifungal therapy (81% vs 50%) and had their central venous catheter removed at an appropriate time (95% vs 81%).

CONCLUSION

The introduction of an active system of IDP consultation for every case of Candida BSI in our hospital substantially improved patient outcomes.

Controlling multiple-drug-resistant organisms at the hospital level

Nosocomial infections due to multiple-drug-resistant (MDR) organisms are associated with poor patient outcomes and increased healthcare cost. The natural history of an MDR nosocomial infection can be characterised in four steps. First is the introduction of MDR organisms into the patient's normal flora as a consequence of inappropriate infection control practices. Second is the selection of MDR organisms due, in part, to inappropriate antibiotic therapy. Third is the development of an MDR infection due, in part, to inappropriate invasive techniques. The fourth step occurs when the patient has developed poor clinical outcomes due, in part, to inappropriate antibiotic therapy. At the local hospital level, a multidisciplinary MDR control programme should be developed with the goals to optimise local surveillance of MDR organisms, improve local infection-control practices, and control local antimicrobial use. Without achieving these three goals, hospitals will not be able to control the spread of MDR organisms.

Infectious disease consultations and antibiotic usage in a Turkish university hospital

OBJECTIVES

The aim of this study was to investigate the various features of infectious disease (ID) consultations and the usage of antibiotics in a Turkish university hospital.

METHODS

A total of 395 consultation requests were recorded during a three-year period.

RESULTS

The departments most frequently requesting the consultation services of the ID department were Orthopedics (29.6%), Neurology (18.5%), Cardiology (11.8%) and Internal Medicine (10.4%). The main reasons were for diagnosis of unexplained fever (42.3%) and for antibiotic modification according to culture results (18%). Diagnoses made by the ID consultant were pneumonia (16.7%), urinary tract infections (9.3%), bone and joint prosthesis infections (9.1%) and in 15.7% of the investigated patients, no infectious focus was determined. It was recognized that the use of antibiotics had already been initiated in the great majority of patients (67.1%) before the consultation request. While the current therapy was changed in 57.4% of these patients, antibiotics were not necessary for 9.8%.

CONCLUSIONS

Since the most common diagnoses were respiratory and urinary tract or bone and joint prosthesis infections, the ID specialists should have detailed knowledge of these problems. Usage of antibiotics without ID consultation was prevalent, therefore a continuous educational program is a necessity for healthcare workers in the hospital.

Initial management of candidemia at an academic medical center: Evaluation of the IDSA guidelines

Treatment of candidemia is more complicated because of the changing epidemiology of Candida and introduction of newer antifungal agents. Utilization and benefit of practice guidelines and infectious disease consultation for the management of candidemia has not been previously described in the routine clinical setting. We prospectively studied the impact of the Infectious Disease Society of America (IDSA) guidelines for the management of candidemia and infectious disease consultation on clinical outcomes in 119 patients with candidemia at a tertiary care hospital. Medical records were reviewed to capture data concerning use of antifungal agents, management of central venous catheters, and infectious disease consultation. Initial antifungal therapy was consistent with the IDSA guidelines in 76% of patients. Variation from the guidelines was independently associated with higher mortality (24% versus 57%, P = 0.003). Infectious disease consultation was independently associated with lower mortality (18% versus 39%, P < 0.01). Use of the IDSA guidelines and infectious disease consultation service was found to improve patient outcomes in patients with candidemia at our institution. Further studies should be performed to validate newer guidelines in a clinical setting at other institutions.

The value of an infectious diseases specialist

Infectious diseases (ID) specialists have played a major role in patient care, infection control, and antibiotic management for many years. With the rapidly changing nature of health care, it has become necessary for ID specialists to articulate their value to multiple audiences. This article summarizes the versatile attributes possessed by ID specialists and delineates their value to patients, hospitals, and other integral groups in the health care continuum.

Antibiotic policies and control of resistance

PURPOSE OF THE REVIEW

The current worldwide pandemic of antibiotic resistance shows no signs of abating. It is clear that it is driven mainly by heavy and often inappropriate antibiotic use. Although control measures are widely practised, it is important that we assess their efficacy critically in order to concentrate expensive control efforts where they will be most effective. The past year has seen much activity in this area, with evidence-based assessments of the literature according to strict guidelines, as well as progress in basic science studies of mechanisms of resistance, and their causes and relations to pathogenicity and adaptability.

RECENT FINDINGS

The present review summarizes current developments in the causes of antibiotic resistance, the classification of antibiotic stewardship and control measures, the evidence base for their efficacy, current problems in hospital practice, the adaptability of bacteria, the content of antibiotic policies and anticipated activities.

SUMMARY

The conclusions from the published literature are that much of it that pertains to changing prescribing practices does not stand up to modern evidence-based analysis concepts. Nevertheless, we can learn from experience in changing other areas of medical practice. We must be pragmatic and must not expect to change the world, but rather take it step by step, recognizing barriers and measuring outcomes and quality indicators. Studies into the molecular basis of resistance confirm the superb genetic adaptability of micro-organisms. They will always be several steps ahead of us. Nevertheless, we are learning how to modify our prescribing habits to minimize resistance, not only by using antibiotics less frequently but also by altering dosing schedules in various ways.

Venilator Management and Criical Care Issues Following Cardiothoracic Trauma

Traumatic injury of the cardiac, pulmonary, or vascular systemsmay result in severe critical illness. Not only does the injury itself result in compromise of normal physiology, but initiation of the inflammatory cascade and mismanagement of the ventilator may lead to worsening status, the acute respiratory distress syndrome, and multiple organ dysfunction. Traumatic injury places the patient athigh risk of infection and nutritional compromise. We review basic concepts of mechanical ventilation and ventilator -associated or -induced lung injury. Barotrauma, volutrauma, atelectrauma and biotrauma, and methods for the clinician to prevent them, arediscussed. Airway pressure release ventilation, mandatory minute ventilation and adaptive support ventilation techniques are intro-duced, as is a discussion of the importance of spontaneous breathing during mechanical ventilation. Special attention is paid to a comprehensive approach to respiratory care. Unique modalities such as prone positioning, independent lung ventilation, and extracorporeal support are presented. The importance of adapting the mode or the minimal-injury concepts of mechanical ventilation to specific injuries is presented. Management approaches to these injuries, including ventilator therapy, pain control, surgical techniques, and critical care issues are described. An overview of the issues of infection inherent to trauma, and nutritional matters, including enteral versus parenteral therapy is presented. Immune-enhanced diets and antioxidantdrugs are integral components of the comprehensive approach to the trauma patient suffering critical illness, and pertinent literatureis summarized.