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Wang EY, Girotto JE. Approaches to Reduce Use and Duration of Anti-MRSA Agents for Antimicrobial Stewardship Programs: A Review of Recent Literature. J Pharm Pract 2024; 37:448-466. [PMID: 36194825 DOI: 10.1177/08971900221130893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Antimicrobial stewardship programs (ASPs) have the potential to effectively deescalate unnecessary methicillin-resistant Staphylococcus aureus (MRSA) coverage. This review summarizes literature published from 2014 through 2021 describing contemporary ASP methods and their resulting effectiveness at reducing anti-MRSA agent use (ie vancomycin, linezolid, daptomycin, ceftaroline, and clindamycin). This review of the literature examined the following strategies, which had reports of success in either decreasing the use or duration of anti-MRSA agents: prospective review and feedback, antibiotic timeouts, health system or department protocol changes, polymerase chain reaction (PCR) and rapid testing of patient samples. Most of the current literature continue to support most ASP interventions including antibiotic timeouts, pathways, and molecular testing including MRSA nasal PCRs and rapid diagnostic testing can be successful at reducing unnecessary anti-MRSA use.
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Affiliation(s)
- Ethan Y Wang
- Department of Pharmacy Practice, University of Connecticut, School of Pharmacy, Storrs, CT, USA
| | - Jennifer E Girotto
- Department of Pharmacy Practice, University of Connecticut, School of Pharmacy, Storrs, CT, USA
- Department of Pediatrics, Antimicrobial Stewardship Program Connecticut Children's, Hartford, CT, USA
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Gupta AK, Mann A, Polla Ravi S, Wang T. Navigating fungal infections and antifungal stewardship: drug resistance, susceptibility testing, therapeutic drug monitoring and future directions. Ital J Dermatol Venerol 2024; 159:105-117. [PMID: 38088126 DOI: 10.23736/s2784-8671.23.07694-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/24/2024]
Abstract
Antifungal stewardship refers to the rational use of antifungal agents. Historically, in some instances, the misuse or overuse of antifungal agents has predisposed patients to an elevated risk of systemic side-effects and treatment resistance, as well as increased healthcare costs. Superficial mycoses, such as onychomycosis, are sometimes treated without any diagnostic testing and is associated with a high likelihood of self-diagnosis and self-treatment, potentially leading to the emergence of resistance against commonly used antifungals like terbinafine. Practitioners need to ensure that a proper clinical diagnosis is backed up by appropriate testing. This may include the traditional light microscopy and culture; additionally, molecular techniques (such as polymerase chain reaction, terbinafine gene mutational analysis) and antifungal susceptibility testing are considerations as appropriate. The choice of antifungal agent should be guided by what is the standard of care in the location where the clinician practices as well as more broadly state and national prescription patterns. Recently, reports of treatment resistance concerning both superficial and deep fungal infections have added another layer of difficulty to clinical practice. This review aims to explore the phenomenon of antifungal drug resistance, and highlights the importance of adopting antifungal stewardship programs. We provide an overview of treatment resistance and mechanisms of resistance reported thus far in dermatophytes. Challenges of performing antifungal susceptibility testing and therapeutic drug monitoring are discussed, as well as principles, recommendations and future directions of antifungal stewardship programs.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, Canada -
- Mediprobe Research Inc, London, ON, Canada -
| | | | | | - Tong Wang
- Mediprobe Research Inc, London, ON, Canada
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3
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Channon-Wells S, Hérin C, Elbeshlawi I, Gray J, Patel S, Paulus S. The use of routinely collected electronic prescribing data to benchmark intravenous antibiotic use between two tertiary paediatric haematology-oncology inpatient units: a retrospective study. JAC Antimicrob Resist 2024; 6:dlad142. [PMID: 38161969 PMCID: PMC10753649 DOI: 10.1093/jacamr/dlad142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 12/05/2023] [Indexed: 01/03/2024] Open
Abstract
Background High-quality systematic data on antimicrobial use in UK inpatient paediatric haematology-oncology services are lacking, despite this population being at high risk from antimicrobial exposure and resistance. Objectives We conducted a retrospective study to demonstrate how routinely collected electronic prescribing data can address this issue. Patients and methods This retrospective study describes and compares IV antibiotic consumption between two UK paediatric haematology-oncology inpatient units, between 2018 and 2022. Both sites provide similar services and receive proactive antimicrobial stewardship input. Data were extracted from each site's antimicrobial surveillance system, which report monthly days of therapy (DOT) per 100 patient-days (PD). Consumption was reported for specific and total antibiotics. Trends were modelled using linear regression and autoregressive moving average models. Results Total IV antibiotic consumption at each site was similar. Median monthly DOT per 100 PD were 25.9 (IQR: 22.1-34.0) and 29.4 (24.2-34.9). Total antibiotic use declined at both sites, with estimated annual yearly reductions of 3.52 DOT per 100 PD (95% CI: 0.46-6.59) and 2.57 (1.30-3.85). Absolute consumption was similar for carbapenems, piperacillin/tazobactam and aminoglycosides, whilst ceftriaxone and teicoplanin demonstrated approximately 3-fold relative differences in median monthly consumption. Meropenem, piperacillin/tazobactam, teicoplanin, vancomycin and gentamicin all demonstrated statistically significant reductions in use over time at either one or both sites, although this was most marked for piperacillin/tazobactam and vancomycin. Conclusions Routinely collected electronic prescribing data can aid benchmarking of antibiotic use in paediatric haematology-oncology inpatients, highlighting areas to target stewardship strategies, and evaluating their impact. This approach should be rolled out nationally, and to other high-risk groups.
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Affiliation(s)
- Samuel Channon-Wells
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Infectious Disease, Imperial College London, London, UK
- School of Medicine, St Mary’s Hospital, Praed Street London W2 1NY, UK
| | - Caroline Hérin
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ismail Elbeshlawi
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Juliet Gray
- Department of Paediatric Infectious Diseases and Immunology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK
- Centre for Cancer Immunology, University of Southampton and Department of Paediatric Oncology, University Hospital Southampton NHS Foundation Trust, Southampton SO17 1BJ, UK
| | - Sanjay Patel
- Department of Paediatric Infectious Diseases and Immunology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK
| | - Stephane Paulus
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Ferguson JK, Chiu S, Oldmeadow C, Deane J, Munnoch S, Fraser N. VRE acquisition in hospital and its association with hospital antimicrobial usage -a non-linear analysis of an extended time series. Infect Dis Health 2023; 28:151-158. [PMID: 36803829 DOI: 10.1016/j.idh.2023.01.003] [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: 07/27/2022] [Revised: 01/12/2023] [Accepted: 01/15/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Vancomycin resistant enterococci (VRE) have become endemic pathogens in many Australian hospitals causing significant morbidity. There are few observational studies that have evaluated the effect of antibiotic usage on VRE acquisition. This study examined VRE acquisition and its association with antimicrobial use. The setting was a NSW tertiary hospital with 800 beds over a 63 month period up to March 2020, straddling piperacillin-tazobactam (PT) shortages that occurred from in September 2017. METHODS The primary outcome was monthly inpatient hospital onset Vancomycin-resistant Enterococci (VRE) acquisitions. Multivariate adaptive regression splines (MARS) were used to estimate hypothetical thresholds, where antimicrobial use above threshold is associated with increased incidence of hospital onset VRE acquisition. Specific antimicrobials and categorised usage (broad, less broad and narrow spectrum) were modelled. RESULTS There were 846 hospital onset VRE detections over the study period. Hospital onset vanB and vanA VRE acquisitions fell significantly by 64% and 36% respectively after the PT shortage. MARS modelling indicated that PT usage was the only antibiotic found to exhibit a meaningful threshold. PT usage greater than 17.4 defined daily doses/1000 occupied bed-days (95%C I: 13.4, 20.5) was associated with higher onset of hospital VRE. CONCLUSIONS This paper highlights the large, sustained impact that reduced broad spectrum antimicrobial use had on VRE acquisition and showed that PT use in particular was a major driver with a relatively low threshold. It raises the question as to whether hospitals should be determining local antimicrobial usage targets based on direct evidence from local data analysed with non-linear methods.
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Affiliation(s)
- J K Ferguson
- John Hunter Hospital, Newcastle, NSW, Australia; University of Newcastle, NSW, Australia.
| | - S Chiu
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - C Oldmeadow
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - J Deane
- Infection Prevention Service, Hunter New England Health Service, NSW, Australia
| | - S Munnoch
- Infection Prevention Service, Hunter New England Health Service, NSW, Australia
| | - N Fraser
- Hunter New England Population Health Unit, NSW, Australia
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Antimicrobial Stewardship Interventions in Pediatric Oncology: A Systematic Review. J Clin Med 2022; 11:jcm11154545. [PMID: 35956160 PMCID: PMC9369733 DOI: 10.3390/jcm11154545] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 12/28/2022] Open
Abstract
Antimicrobial stewardship programs represent efficacious measures for reducing antibiotic overuse and improving outcomes in different settings. Specific data on pediatric oncology are lacking. We conducted a systematic review on the PubMed and Trip databases according to the PRISMA guidelines, searching for reports regarding antimicrobial stewardship in pediatric oncology and hematology patients. The aim of the study was to summarize the present literature regarding the implementation of antimicrobial stewardship programs or initiatives in this particular population, and provide insights for future investigations. Nine papers were included in the qualitative analysis: three regarding antifungal interventions, five regarding antibacterial interventions, and one regarding both antifungal and antibacterial stewardship interventions. Variable strategies were reported among the included studies. Different parameters were used to evaluate the impact of these interventions, including days of therapy per 1000-patient-days, infections with resistant strains, safety analysis, and costs. We generally observed a reduction in the prescription of broad-spectrum antibiotics and an improved appropriateness, with reduced antibiotic-related side effects and no difference in infection-related mortality. Antibiotic stewardship programs or interventions are effective in reducing antibiotic consumption and improving outcomes in pediatric oncology hematology settings, although stewardship strategies differ substantially in different institutions. A standardized approach needs to be implemented in future studies in order to better elucidate the impact of stewardship programs in this category of patients.
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Wattier RL, Esbenshade AJ. From "More is Better" to "Less is More": A Commentary on Antimicrobial Use in Pediatric Oncology. J Pediatric Infect Dis Soc 2022; 11:229-238. [PMID: 35099542 DOI: 10.1093/jpids/piab111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/09/2021] [Indexed: 11/14/2022]
Abstract
Reducing avoidable antimicrobial exposure to pediatric patients with cancer is achievable and necessary to promote optimal short- and long-term outcomes. Multiple evidence-based practices are already well established but should be more consistently implemented. Important opportunities exist to further improve the evidence to guide selective antimicrobial use in pediatric oncology.
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Affiliation(s)
- Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California San Francisco, San Francisco, California, USA
| | - Adam J Esbenshade
- Department of Pediatrics, Division of Hematology/Oncology, Vanderbilt University, Nashville, Tennessee, USA
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Chiotos K, Fitzgerald JC, Hayes M, Dashefsky H, Metjian TA, Woods-Hill C, Biedron L, Stinson H, Ku BC, Robbins Tighe S, Weiss SL, Balamuth F, Schriver E, Gerber JS. Improving Vancomycin Stewardship in Critically Ill Children. Pediatrics 2022; 149:185402. [PMID: 35362066 PMCID: PMC9647566 DOI: 10.1542/peds.2021-052165] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Inappropriate vancomycin use is common in children's hospitals. We report a quality improvement (QI) intervention to reduce vancomycin use in our tertiary care PICU. METHODS We retrospectively quantified the prevalence of infections caused by organisms requiring vancomycin therapy, including methicillin-resistant Staphylococcus aureus (MRSA), among patients with suspected bacterial infections. Guided by these data, we performed 3 QI interventions over a 3-year period, including (1) stakeholder education, (2) generation of a consensus-based guideline for empiric vancomycin use, and (3) implementation of this guideline through clinical decision support. Vancomycin use in days of therapy (DOT) per 1000 patient days was measured by using statistical process control charts. Balancing measures included frequency of bacteremia due to an organism requiring vancomycin not covered with empiric therapy, 30-day mortality, and cardiovascular, respiratory, and renal organ dysfunction. RESULTS Among 1276 episodes of suspected bacterial infection, a total of 19 cases of bacteremia (1.5%) due to organisms requiring vancomycin therapy were identified, including 6 MRSA bacteremias (0.5%). During the 3-year QI project, overall vancomycin DOT per 1000 patient days in the PICU decreased from a baseline mean of 182 DOT per 1000 patient days to 109 DOT per 1000 patient days (a 40% reduction). All balancing measures were unchanged, and all cases of MRSA bacteremia were treated empirically with vancomycin. CONCLUSION Our interventions reduced overall vancomycin use in the PICU without evidence of harm. Provider education and consensus building surrounding indications for empiric vancomycin use were key strategies.
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Affiliation(s)
- Kathleen Chiotos
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Division of Infectious Diseases, Department of Pediatrics,Antimicrobial Stewardship Program,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania,Address correspondence to Kathleen Chiotos, MD, MSCE, 3401 Civic Center Blvd, Wood Building, 6 Floor Room 6029, Philadelphia, PA 19104. E-mail:
| | - Julie C. Fitzgerald
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Hannah Dashefsky
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Charlotte Woods-Hill
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren Biedron
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hannah Stinson
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brandon C. Ku
- Division of Emergency Medicine,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sheila Robbins Tighe
- Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Scott L. Weiss
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fran Balamuth
- Division of Emergency Medicine,Pediatric Sepsis Program, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Jeffrey S. Gerber
- Antimicrobial Stewardship Program,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Sick-Samuels AC, Woods-Hill C. Diagnostic Stewardship in the Pediatric Intensive Care Unit. Infect Dis Clin North Am 2022; 36:203-218. [PMID: 35168711 PMCID: PMC8865365 DOI: 10.1016/j.idc.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the pediatric intensive care unit (PICU), clinicians encounter complex decision making, balancing the need to treat infections promptly against the potential harms of antibiotics. Diagnostic stewardship is an approach to optimize microbiology diagnostic test practices to reduce unnecessary antibiotic treatment. We review the evidence for diagnostic stewardship of blood, endotracheal, and urine cultures in the PICU. Clinicians should consider 3 questions applying diagnostic stewardship: (1) Does the patient have signs or symptoms of an infectious process? (2) What is the optimal diagnostic test available to evaluate for this infection? (3) How should the diagnostic specimen be collected to optimize results?
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Affiliation(s)
- Anna C. Sick-Samuels
- The Johns Hopkins University School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD,The Johns Hopkins Hospital, Department of Hospital Epidemiology and Infection Control, Baltimore, MD
| | - Charlotte Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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9
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Chen TM, Li WH, Wang F, Tan K, Zhu QX, Zhou K, Liu SH, Liu J, Bi J, Deng HL, Chen XX, Li J, Wang YM, Zhao Q, Zhu L, Ma HX, Li Z, Deng JK, Zhu CH, Wu KK, Lin AW, Li SJ, Wang DM, Cai HJ, Zhao SY, Lu XD, Ye L, Dong F, Zhang WS, Yang YH, Liu G. Antibiotics prescription for targeted therapy of pediatric invasive pneumococcal diseases in China: a multicenter retrospective study. BMC Infect Dis 2021; 21:1156. [PMID: 34775956 PMCID: PMC8591947 DOI: 10.1186/s12879-021-06860-8] [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: 03/16/2021] [Accepted: 11/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background Streptococcus pneumoniae (S. pneumoniae) is a major cause of bacterial meningitis, septicemia and pneumonia in children. Inappropriate choice of antibiotic can have important adverse consequences for both the individual and the community. Here, we focused on penicillin/cefotaxime non-susceptibility of S. pneumoniae and evaluated appropriateness of targeted antibiotic therapy for children with IPD (invasive pneumococcal diseases) in China. Methods A multicenter retrospective study was conducted in 14 hospitals from 13 provinces in China. Antibiotics prescription, clinical features and resistance patterns of IPD cases from January 2012 to December 2017 were collected. Appropriateness of targeted antibiotics therapy was assessed. Results 806 IPD cases were collected. The non-susceptibility rates of S. pneumoniae to penicillin and cefotaxime were 40.9% and 20.7% respectively in 492 non-meningitis cases, whereas those were 73.2% and 43.0% respectively in 314 meningitis cases. Carbapenems were used in 21.3% of non-meningitis cases and 42.0% of meningitis cases for targeted therapy. For 390 non-meningitis cases with isolates susceptible to cefotaxime, vancomycin and linezolid were used in 17.9% and 8.7% of cases respectively for targeted therapy. For 179 meningitis cases with isolates susceptible to cefotaxime, vancomycin and linezolid were prescribed in 55.3% and 15.6% of cases respectively. Overall, inappropriate targeted therapies were identified in 361 (44.8%) of 806 IPD cases, including 232 (28.8%) cases with inappropriate use of carbapenems, 169 (21.0%) cases with inappropriate use of vancomycin and 62 (7.7%) cases with inappropriate use of linezolid. Conclusions Antibiotic regimens for IPD definite therapy were often excessive with extensive prescription of carbapenems, vancomycin or linezolid in China. Antimicrobial stewardship programs should be implemented to improve antimicrobial use.
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Affiliation(s)
- Tian-Ming Chen
- Department of Infectious Diseases, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nalishi Road 56#, Xicheng, Beijing, 100045, China
| | - Wen-Hui Li
- Department of Infection, Hebei Children's Hospital, Shijiazhuang, China
| | - Fang Wang
- Infectious Diseases Department, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Kun Tan
- Division of Infectious Diseases, Shenzhen Children's Hospital, Shenzhen, China
| | - Qing-Xiong Zhu
- Department of Infectious Disease, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Kai Zhou
- Department of Infection, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Shi-Hua Liu
- Department of Infectious Disease, Children's Hospital of Jinan, Jinan, China
| | - Jing Liu
- Department of Infection, Hunan Children's Hospital, Changsha, China
| | - Jing Bi
- Infection Division, Baoding Children's Hospital, Baoding, China
| | - Hui-Ling Deng
- Department 2 of infection, Xi'an Children's Hospital, Xi'an, China
| | - Xue-Xia Chen
- Department of Infectious Disease, Hangzhou Children's Hospital, Hangzhou, China
| | - Juan Li
- Department of Infectious Diseases, Urumqi Children's Hospital, Urumqi, China
| | - Yu-Min Wang
- Department of Pediatrics, Maternal and Child Health Care Hospital of Inner Mongolia, Hohhot, China
| | - Qing Zhao
- Department of Infectious Diseases, Children's Hospital of Shanxi, Taiyuan, China
| | - Liang Zhu
- Department of Infectious Diseases, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nalishi Road 56#, Xicheng, Beijing, 100045, China
| | - Hui-Xuan Ma
- Department of Infection, Hebei Children's Hospital, Shijiazhuang, China
| | - Zhi Li
- Infectious Diseases Department, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Ji-Kui Deng
- Division of Infectious Diseases, Shenzhen Children's Hospital, Shenzhen, China
| | - Chun-Hui Zhu
- Department of Infectious Disease, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Kang-Kang Wu
- Department of Infection, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Ai-Wei Lin
- Department of Infectious Disease, Children's Hospital of Jinan, Jinan, China
| | - Shuang-Jie Li
- Department of Hepatology, Hunan Children's Hospital, Changsha, China
| | - Dong-Meng Wang
- Infection Division, Baoding Children's Hospital, Baoding, China
| | - Hui-Jun Cai
- Clinical Laboratory, Xi'an Children's Hospital, Xi'an, China
| | - Shi-Yong Zhao
- Department of Infectious Disease, Hangzhou Children's Hospital, Hangzhou, China
| | - Xu-Dong Lu
- Department of Infectious Diseases, Urumqi Children's Hospital, Urumqi, China
| | - Lan Ye
- Department of Pediatrics, Maternal and Child Health Care Hospital of Inner Mongolia, Hohhot, China
| | - Fang Dong
- Department of Infectious Diseases, Children's Hospital of Shanxi, Taiyuan, China
| | - Wen-Shuang Zhang
- Department of Respiratory Medicine, Tianjin Children's Hospital, Tianjin, China
| | - Yong-Hong Yang
- Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Gang Liu
- Department of Infectious Diseases, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Nalishi Road 56#, Xicheng, Beijing, 100045, China.
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Ruhayel SD, Foley DA, Hamilton K, Ferguson P, Kotecha RS, Bowen AC, Yeoh DK. Viridans Group Streptococci in Pediatric Leukemia and Stem Cell Transplant: Review of a Risk-stratified Guideline for Empiric Vancomycin in Febrile Neutropenia. Pediatr Infect Dis J 2021; 40:832-834. [PMID: 34285167 DOI: 10.1097/inf.0000000000003210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Viridans group streptococci (VGS) are an important cause of sepsis in immunosuppressed children. We reviewed the effectiveness of risk-stratified addition of vancomycin to empiric febrile neutropenia therapy among 107 children with leukemia or undergoing an allogeneic transplant. Of 19 VGS bacteremia episodes, 78.9% were susceptible to risk-stratified antibiotics including 100% from high-risk patients. All blood cultures were flagged positive within 24 hours.
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Affiliation(s)
- Sandra D Ruhayel
- From the Department of Paediatric and Adolescent Haematology, Oncology, Blood and Marrow Transplantation, Perth Children's Hospital
| | - David A Foley
- Infectious Diseases Department, Perth Children's Hospital, Perth, Western Australia
| | - Kate Hamilton
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales
| | - Patricia Ferguson
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales
| | - Rishi S Kotecha
- From the Department of Paediatric and Adolescent Haematology, Oncology, Blood and Marrow Transplantation, Perth Children's Hospital
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia
- School of Pharmacy and Biomedical Sciences, Curtin University
| | - Asha C Bowen
- Infectious Diseases Department, Perth Children's Hospital, Perth, Western Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory
| | - Daniel K Yeoh
- Infectious Diseases Department, Perth Children's Hospital, Perth, Western Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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11
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Woods-Hill CZ, Koontz DW, Voskertchian A, Xie A, Shea J, Miller MR, Fackler JC, Milstone AM. Consensus Recommendations for Blood Culture Use in Critically Ill Children Using a Modified Delphi Approach. Pediatr Crit Care Med 2021; 22:774-784. [PMID: 33899804 PMCID: PMC8416691 DOI: 10.1097/pcc.0000000000002749] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Blood cultures are fundamental in evaluating for sepsis, but excessive cultures can lead to false-positive results and unnecessary antibiotics. Our objective was to create consensus recommendations focusing on when to safely avoid blood cultures in PICU patients. DESIGN A panel of 29 multidisciplinary experts engaged in a two-part modified Delphi process. Round 1 consisted of a literature summary and an electronic survey sent to invited participants. In the survey, participants rated a series of recommendations about when to avoid blood cultures on five-point Likert scale. Consensus was achieved for the recommendation(s) if 75% of respondents chose a score of 4 or 5, and these were included in the final recommendations. Any recommendations that did not meet these a priori criteria for consensus were discussed during the in-person expert panel review (Round 2). Round 2 was facilitated by an independent expert in consensus methodology. After a review of the survey results, comments from round 1, and group discussion, the panelists voted on these recommendations in real-time. SETTING Experts' institutions; in-person discussion in Baltimore, MD. SUBJECTS Experts in pediatric critical care, infectious diseases, nephrology, oncology, and laboratory medicine. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 27 original recommendations, 18 met criteria for achieving consensus in Round 1; some were modified for clarity or condensed from multiple into single recommendations during Round 2. The remaining nine recommendations were discussed and modified until consensus was achieved during Round 2, which had 26 real-time voting participants. The final document contains 19 recommendations. CONCLUSIONS Using a modified Delphi process, we created consensus recommendations on when to avoid blood cultures and prevent overuse in the PICU. These recommendations are a critical step in disseminating diagnostic stewardship on a wider scale in critically ill children.
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Affiliation(s)
- Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Danielle W Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Annie Voskertchian
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Judy Shea
- Division of General Internal Medicine, Department of Medicine and Leonard Davis Institute of Health Economics
| | - Marlene R Miller
- Rainbow Babies and Children’s Hospital
- Case Western Reserve University School of Medicine
- Johns Hopkins Bloomberg School of Public Health
| | - James C Fackler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron M Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Stephanos K, Dubbs SB. Pediatric Hematologic and Oncologic Emergencies. Emerg Med Clin North Am 2021; 39:555-571. [PMID: 34215402 DOI: 10.1016/j.emc.2021.04.007] [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: 02/07/2023]
Abstract
Pediatric hematologic and oncologic emergencies are in 3 major categories: complications of hematologic disorders, emergencies associated with the new onset of cancers, and treatment-associated oncologic emergencies. The overall number of these patients remains low; however, the mortality associated with these diseases remains high despite significant advances in management. This article presents a review of the most commonly encountered pediatric hematologic and oncologic complications that emergency physicians and providers need to know.
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Affiliation(s)
- Kathleen Stephanos
- Departments of Emergency Medicine and Pediatrics, University of Rochester School of Medicine, 601 Elmwood Avenue, Box 655, Rochester, NY 14642, USA.
| | - Sarah B Dubbs
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S. Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA. https://twitter.com/sbuidubbs
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13
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Antibiotic-Resistant Infections and Treatment Challenges in the Immunocompromised Host: An Update. Infect Dis Clin North Am 2021; 34:821-847. [PMID: 33131573 DOI: 10.1016/j.idc.2020.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This article reviews antibiotic resistance and treatment of bacterial infections in the growing number of patients who are immunocompromised: solid organ transplant recipients, the neutropenic host, and persons with human immunodeficiency virus and AIDS. Specific mechanisms of resistance in both gram-negative and gram-positive bacteria, as well as newer treatment options are addressed elsewhere and are only briefly discussed in the context of the immunocompromised host.
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14
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Multi-Drug Resistant Organisms Infection Impact on Patients Length of Stay in Respiratory Care Ward. Antibiotics (Basel) 2021; 10:antibiotics10050608. [PMID: 34065381 PMCID: PMC8160736 DOI: 10.3390/antibiotics10050608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/13/2021] [Accepted: 05/17/2021] [Indexed: 11/26/2022] Open
Abstract
This study aimed to investigate the effects of multi-drug-resistant organism (MDRO) infection and other factors on the length of hospital stay (LOS) of patients in the respiratory care ward (RCW) of a regional hospital in Taiwan. In this retrospective study, we collected cases from MDRO-infected patients in the RCW from January 2016 to March 2020. The RCW comprises 13 beds in total. There were 106 infected patients, of which 42 were in the case group (infected with MDROs) and 64 were in the control group (not infected with MDROs). Clinical specimens were inoculated in a selective medium to isolate the pathogenic bacteria by standard procedures. The results showed the main factors affecting the LOS were: patients with MDRO infection, patients discharged from the RCW, and patients who underwent catheterization. The LOS of patients infected with MDROs was significantly longer than that of patients without MDRO infection (β = 0.55, 95% CI = 0.02–1.09), with the case group and the control group being 479.8 ± 546.5 and 307.3 ± 436.2 days, respectively. Infection with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was associated with a longer LOS than other MDRO strains. These findings have important implications for infection control in RCW and in better tracking the health of patients.
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15
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Savage TJ, Rao S, Joerger J, Ozonoff A, McAdam AJ, Sandora TJ. Predictive Value of Direct Disk Diffusion Testing from Positive Blood Cultures in a Children's Hospital and Its Utility in Antimicrobial Stewardship. J Clin Microbiol 2021; 59:e02445-20. [PMID: 33692138 PMCID: PMC8316030 DOI: 10.1128/jcm.02445-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 03/06/2021] [Indexed: 12/19/2022] Open
Abstract
Accurate and early susceptibility results could reduce overuse of broad-spectrum antibiotics for empirical treatment of bacteremia. Direct disk diffusion testing (dDD) using nonstandardized inocula directly from blood cultures could facilitate earlier narrowing of antibiotics. To determine the predictive value of dDD compared with standardized antimicrobial susceptibility testing (AST), we performed a retrospective cohort study of 582 blood cultures from 495 pediatric patients with bacteremia. Positive and negative predictive value (PPV: number of isolates susceptible by both dDD and AST divided by the total number of isolates susceptible by dDD; NPV: number of isolates not susceptible [either intermediate or resistant] by both dDD and AST divided by the total number of isolates not susceptible by dDD), sensitivity, specificity, and 95% confidence interval were calculated for each bacterium-antibiotic combination. We evaluated the Antibiotic Spectrum Index of prescribed antibiotics to assess change in antibiotic prescribing after availability of Gram stain, dDD, and AST results. dDD results were available a median of 21 h before AST results. dDD had PPVs of ≥96% for most organism-antibiotic pairs, including 100% (CI 96 to 100%) for Staphylococcus aureus with oxacillin and 99% (CI 93 to 100%) for Enterobacterales with ceftriaxone. NPVs of dDD were variable and frequently lower than the PPV. Very major errors and major errors occurred in 31/5,454 (0.6%) and 231/5,454 (4.2%) organism-antibiotic combinations, respectively. Antibiotics were narrowed in 30% of cases after a dDD result and a further 25% of cases after AST result. dDD is highly predictive of susceptibility for many common organism-antibiotic combinations and provides actionable information one day earlier than standard susceptibility approaches. dDD has the potential to facilitate earlier deescalation to narrow-spectrum antibiotic treatment.
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Affiliation(s)
- Timothy J Savage
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Shun Rao
- Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jill Joerger
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Al Ozonoff
- Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander J McAdam
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas J Sandora
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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Morgan JE, Phillips B, Haeusler GM, Chisholm JC. Optimising Antimicrobial Selection and Duration in the Treatment of Febrile Neutropenia in Children. Infect Drug Resist 2021; 14:1283-1293. [PMID: 33833534 PMCID: PMC8019605 DOI: 10.2147/idr.s238567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/11/2021] [Indexed: 12/13/2022] Open
Abstract
Febrile neutropenia (FN) is a frequent complication of cancer treatment in children. Owing to the potential for overwhelming bacterial sepsis, the recognition and management of FN requires rapid implementation of evidenced-based management protocols. Treatment paradigms have progressed from hospitalisation with broad spectrum antibiotics for all patients, through to risk adapted approaches to management. Such risk adapted approaches aim to provide safe care through incorporating antimicrobial stewardship (AMS) principles such as implementation of comprehensive clinical pathways incorporating de-escalation strategies with the imperative to reduce hospital stay and antibiotic exposure where possible in order to improve patient experience, reduce costs and diminish the risk of nosocomial infection. This review summarises the principles of risk stratification in FN, the current key considerations for optimising empiric antimicrobial selection including knowledge of antimicrobial resistance patterns and emerging technologies for rapid diagnosis of specific infections and summarises existing evidence on time to treatment, investigations required and duration of treatment. To aid treating physicians we suggest the key features based on current evidence that should be part of any FN management guideline and highlight areas for future research. The focus is on treatment of bacterial infections although fungal and viral infections are also important in this patient group.
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Affiliation(s)
- Jessica E Morgan
- Centre for Reviews and Dissemination, University of York, Heslington, YO10 5DD, UK.,Department of Paediatric Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, Heslington, YO10 5DD, UK.,Department of Paediatric Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Gabrielle M Haeusler
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, 3010, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, 3010, Australia.,Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, 3168, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, 3052, Australia
| | - Julia C Chisholm
- Royal Marsden Hospital and Institute of Cancer Research, Sutton, SM2 5PT, UK
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