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Smith ZR, Tajchman SK, Dee BM, Bruno JJ, Qiao W, Tverdek FP. Development of a combination antibiogram for Pseudomonas aeruginosa bacteremia in an oncology population. J Oncol Pharm Pract 2015; 22:409-15. [DOI: 10.1177/1078155215586081] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose Development of a combination antibiogram to identify combinations of antibiotics that have the highest likelihood of attaining one active agent in the empiric management of presumed Pseudomonas aeruginosa bacteremia. Methods Patients with cancer and P. aeruginosa bacteremia from January 1 to December 31, 2012 were included in this analysis. The primary outcome was identification of effective combinations of beta-lactam and non-betalactam agents. An effective combination was defined as one which achieved in-vitro activity to greater than or equal to 85% of isolates collected. Furthermore, the addition of the non-beta-lactam agent was required to increase the in-vitro activity by at least 5% over beta-lactam monotherapy. Multiple secondary outcomes were evaluated. Results One hundred and twenty-three P. aeruginosa isolates were included from 99 patients. Single agent beta-lactam sensitivities ranged from 72.4 to 79.7%. Combination regimen sensitivities ranged from 73.5 to 96.7%. All combination regimens that included a beta-lactam plus an aminoglycoside were found to be effective per the study definition. Independent risk factors for MDR P. aeruginosa were receipt of intravenous (IV) antibiotics within 90 days and hospital length of stay (LOS) greater than or equal to five days. Increasing the number of antibiotics received was associated with a decrease in survival to hospital discharge. Conclusions Effective combination regimens included all beta-lactam aminoglycoside regimens. Receipt of IV antibiotics within 90 days and hospital LOS greater than or equal to five days were independent risk factors for MDR isolates.
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Affiliation(s)
- Zachary R Smith
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI, USA
| | - Sharla K Tajchman
- Division of Pharmacy, Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian M Dee
- Division of Pharmacy, Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey J Bruno
- Division of Pharmacy, Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wei Qiao
- Division of Quantitative Sciences, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Frank P Tverdek
- Division of Pharmacy, Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Teo J, Lim TP, Hsu LY, Tan TY, Sasikala S, Hon PY, Kwa AL, Apisarnthanarak A. Extensively drug-resistant Acinetobacter baumannii in a Thai hospital: a molecular epidemiologic analysis and identification of bactericidal Polymyxin B-based combinations. Antimicrob Resist Infect Control 2015; 4:2. [PMID: 25648393 PMCID: PMC4314787 DOI: 10.1186/s13756-015-0043-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 01/09/2015] [Indexed: 11/22/2022] Open
Abstract
Background Limited knowledge of the local molecular epidemiology and the paucity of new effective antibiotics has resulted in an immense challenge in the control and treatment of extensively drug-resistant (XDR) Acinetobacter baumannii infections in Thailand. Antimicrobial combination regimens may be the only feasible treatment option in such cases. We sought to characterize the local molecular epidemiology and assess the bactericidal activity of various antibiotics individually and in combination against XDR A. baumannii in a Thai hospital. Methods All XDR A. baumannii isolates from Thammasat University Hospital were collected between October 2010 and May 2011. Susceptibility testing was conducted according to reference broth dilution methods. Pulse-field gel electrophoresis was used to genotype the isolates. Carbapenemase genes were detected using polymerase chain reaction. In vitro testing of clinically-relevant concentrations of imipenem, meropenem, doripenem, rifampicin and tigecycline alone and in combination with polymyxin B was conducted using multiple combination bactericidal testing. Results Forty-nine polymyxin B-susceptible XDR A. baumannii isolates were identified. blaOXA-23 and blaOXA-51 genes were detected in all isolates. Eight clonally related clusters were identified, resulting in the initiation of several infection control measures. Imipenem, meropenem, doripenem, rifampicin, and tigecycline in combination with PB respectively, exhibited bactericidal killing in 100%, 100%, 98.0%, 100% and 87.8% isolates respectively at 24 hours. Conclusion Molecular epidemiologic analysis can aid the early detection of infection outbreak within the institution, resulting in the rapid containment of the outbreak. Imipenem/meropenem/rifampicin in combination with polymyxin B demonstrated consistent bactericidal effect against 49 blaOXA-23-harbouring XDR A. baumannii clinical isolates, suggesting a role of combination therapy in the treatment of these infections.
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Affiliation(s)
- Jocelyn Teo
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore, 169608 Singapore
| | - Tze-Peng Lim
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore, 169608 Singapore.,Division of Infectious Diseases, Department of Medicine, 1E Kent Ridge Road, NUHS, Yong Loo Lin School of Medicine, National University of Singapore, Tower Block, Level 9, Singapore, 119228 Singapore
| | - Li-Yang Hsu
- Division of Infectious Diseases, Department of Medicine, 1E Kent Ridge Road, NUHS, Yong Loo Lin School of Medicine, National University of Singapore, Tower Block, Level 9, Singapore, 119228 Singapore
| | - Thean-Yen Tan
- Department of Laboratory Medicine, Changi General Hospital, 2 Simei St 3, Singapore, 529889 Singapore
| | - Suranthran Sasikala
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore, 169608 Singapore.,Current address: AStar, Biopolis, 31 Biopolis Way, Singapore, 138668 Singapore
| | - Pei-Yun Hon
- Division of Infectious Diseases, Department of Medicine, 1E Kent Ridge Road, NUHS, Yong Loo Lin School of Medicine, National University of Singapore, Tower Block, Level 9, Singapore, 119228 Singapore.,Current address: Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Andrea L Kwa
- Department of Pharmacy, Singapore General Hospital, Outram Road, Singapore, 169608 Singapore.,Emerging Infectious Diseases, Duke-NUS Graduate Medical School, Singapore, 169857 Singapore
| | - Anucha Apisarnthanarak
- Division of Infectious Diseases, Faculty of Medicine, Thammasat University Hospital, Pathumthani, 12120 Thailand
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Pogue JM, Alaniz C, Carver PL, Pleva M, Newton D, DePestel DD. Role of Unit-Specific Combination Antibiograms for Improving the Selection of Appropriate Empiric Therapy for Gram-Negative Pneumonia. Infect Control Hosp Epidemiol 2015; 32:289-92. [DOI: 10.1086/658665] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
In an effort to improve the selection of appropriate empiric gram-negative therapy for pneumonia, we examined intensive care unit-specific combination antibiograms. These antibiograms were able to predict appropriate empiric gram-negative therapy. Empiric combination therapy based on unit-specific combination antibiograms may aid in the selection of therapy for gram-negative pneumonia.
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Apisarnthanarak A, Bhooanusas N, Yaprasert A, Mundy LM. Carbapenem de-escalation therapy in a resource-limited setting. Infect Control Hosp Epidemiol 2013; 34:1310-3. [PMID: 24225617 DOI: 10.1086/673976] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Pulmonary infection (P=.01) and an infectious diseases consultation (P=.04) were associated with carbapenem de-escalation; pulmonary infection and septic shock were associated with unsuccessful de-escalation. Successful de-escalation was associated with lower mortality (0% vs 23%; P<.001) and shorter duration of carbapenem use (4 vs 10 days; P ≤ .001).
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Gandhi TN, DePestel DD, Collins CD, Nagel J, Washer LL. Managing antimicrobial resistance in intensive care units. Crit Care Med 2010; 38:S315-23. [PMID: 20647789 DOI: 10.1097/ccm.0b013e3181e6a2a4] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The challenges in managing patients with infection in the intensive care unit are increased in an era where there are dwindling antimicrobial choices for multidrug-resistant pathogens. Clinicians in the intensive care unit must balance between choosing appropriate antimicrobial treatment for patients with suspected infection and utilizing antimicrobials in a judicious fashion. Improving antimicrobial utilization is a critical component to reducing antimicrobial resistance. Although providing effective antimicrobial therapy and improving antimicrobial utilization may seem to be competing goals, there are effective strategies to accomplish both. Antimicrobial stewardship programs provide an organized way to implement these strategies and can enhance the intensive care unit physician's success in improving patient outcomes and combating antimicrobial resistance in the intensive care unit.
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Affiliation(s)
- Tejal N Gandhi
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor, MI, USA.
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Christoff J, Tolentino J, Mawdsley E, Matushek S, Pitrak D, Weber SG. Optimizing empirical antimicrobial therapy for infection due to gram-negative pathogens in the intensive care unit: utility of a combination antibiogram. Infect Control Hosp Epidemiol 2010; 31:256-61. [PMID: 20055664 DOI: 10.1086/650446] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine whether the use of dual antimicrobial therapy based on the results of a combination antibiotic susceptibility report (antibiogram) increases the likelihood of selecting adequate empirical coverage in critically ill patients with infection due to potentially resistant gram-negative pathogens. DESIGN Retrospective data analysis. SETTING Urban academic medical center. METHODS An analysis of culture results and susceptibility data from intensive care unit patients determined by the clinical microbiology laboratory was performed. The proportion of 5 common gram-negative pathogens susceptible to monotherapy with 1 of 3 antipseudomonal antibiotics (piperacillin-tazobactam, ceftazidime, or imipenem) was compared with the proportion susceptible to each of these 3 "backbone" agents plus 1 of 4 additional antimicrobial agents used in combination. RESULTS More than 5,000 clinical isolates were examined. When all isolates recovered during the entire study period were included, the addition of any of the second antibiotics studied to each of the 3 backbone agents significantly increased the likelihood of covering the causative pathogen (P < .01 for each). The benefit of combination therapy was variable when results for each of the 5 organisms were examined individually. When temporal trends in susceptibility were examined, the decrease in the proportion of organisms susceptible to monotherapy was statistically significant for both imipenem and ceftazidime (P < .01). CONCLUSIONS Reporting antibiotic susceptibility data in the form of a combination antibiogram may be useful to clinicians who are considering empirical antimicrobial therapy in the intensive care unit.
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Affiliation(s)
- Jennifer Christoff
- Section of Infectious Diseases, University of Chicago Medical Center, Chicago, Illinois 60637, USA.
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