Therapeutic Drug Monitoring of Antibiotics in the Elderly: A Narrative Review

The future approach for the management of acute bacterial skin and skin structure infections

PURPOSE OF REVIEW

To discuss the new available options for the treatment of acute bacterial skin and skin structure infections (ABSSSIs) and how to implement in the clinical practice innovative approaches for their management.

RECENT FINDINGS

The availability of long-acting antibiotics, including dalbavancin and oritavancin, changed the approach to patients with ABSSSI. Direct discharge from the emergency department and early discharge from the hospital should be considered in patients with ABSSSI. Despite limited data about different bactericidal properties, the choice between dalbavancin and oritavacin is usually based on patients' characteristics and comorbidities. Delafloxacin and omadacycline are other options and have the advantage to be available for both intravenous and oral formulations, allowing a sequential therapy and switch from intravenous to oral treatment in clinically stable patients. Further studies should elucidate the profile of patients who may beneficiate from these drugs.

SUMMARY

Early discharge from the hospital should be considered in patients with ABSSSI at a high risk of methicillin-resistant Staphylococcus aureus and in vulnerable patients for which hospitalization may have detrimental consequences. In elderly individuals, patients with diabetes mellitus, oncological people who need for continuing their healthcare pathway, this approach may reduce complications and costs related to hospitalization.

Gram-positive infections in special populations. Expert view on the role of dalbavancin

INTRODUCTION

This review considers special populations as those patients for whom Gram-positive infections are particularly challenging to treat. We examine the potential benefits of dalbavancin in these patients.

AREAS COVERED

We focus on patients with renal impairment, hepatic failure or obesity, and, also, pediatric patients, elderly patients and socially vulnerable individuals. Five independent experts conducted exhaustive literature searches on PubMed. Papers were selected for inclusion according to their relevance to the topic. For each special population, we outline the most significant characteristics for infection management, describing the challenges of the most frequent Gram-positive infections, and reviewing the potential role of dalbavancin.

EXPERT OPINION

Dalbavancin may be a valid alternative to overcome the difficulties of infection management in these populations. We hope our insights will prove useful for patient-centered care. A long half-life, evidence-based efficacy and good safety profile make dalbavancin an adequate option, particularly for patients for whom oral treatment or continued IV access may be challenging, or those for whom hospital stay is more impactful. [Figure: see text].

Current role of ceftobiprole in the treatment of hospital-acquired and community-acquired pneumonia: expert opinion based on literature and real-life experiences

INTRODUCTION

Community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP) are major global health challenges, with high morbidity and mortality rates. The increasing prevalence of multidrug-resistant (MDR) bacteria may diminish the effectiveness of standard empirical antibiotics, highlighting the need for broader-spectrum agents that target also MDR organisms.

AREAS COVERED

This review summarizes findings from a PubMed search on the use of ceftobiprole in CAP and HAP. It highlights key features of ceftobiprole, including its mechanism of action and broad spectrum of activity against multiple MDR pathogens. Clinical data from randomized controlled trials and real-world studies underscore its non-inferiority to standard treatments, with favorable safety profile and high clinical cure rates even in challenging cases.

EXPERT OPINION

Ceftobiprole represents a valid option for the patients with CAP and HAP. Its main advantages include its broad spectrum of activity, making it a valuable therapeutic choice for treating polymicrobial infections, and its favorable safety profile, which makes it a good candidate in elderly patients with multiple comorbidities and polypharmacy. Caution is advised in patients at high risk of ESBL-producing organisms or MDR Pseudomonas aeruginosa infections, where combination therapy is recommended. Moreover, therapeutic drug monitoring is recommended to improve outcomes, particularly in complex clinical conditions.

Nursing home nurses' opinions on the potential evolution of their role in antibiotic stewardship: A French national cross-sectional survey

AIMS

To assess French nursing home nurses' opinions on the potential evolution of their antibiotic stewardship role, facilitators and barriers, and nurses' characteristics associated with their opinion toward new roles regarding antibiotic prescribing.

DESIGN

We conducted a cross-sectional study in French nursing homes with ≥20 beds and for which an email address was available in a national database managed by the French government between May and June 2022.

METHODS

A self-administered internet-based questionnaire of 43 closed-ended Likert items was sent to directors of eligible nursing homes by email asking them to forward the link to the questionnaire to the nurses and head nurses of their institution. Data analysis included descriptive statistics and χ2 tests.

RESULTS

7215 nursing homes were sent the online questionnaire; 1090 participants completed it partially or totally and 923 fully filled in the questionnaire. A majority of nurses supported strengthening and expanding their antibiotic stewardship role. Regarding new roles, over 70% agreed that nurses could collect urine samples to perform a urine culture on their own initiative, prescribe microbiological laboratory tests, and change the drug formulation or the administration route of the antibiotic prescribed by the general practitioner. One-third declared that they could initiate antibiotics for some infections and/or change the empirical antibiotic treatment prescribed by the general practitioner. Nurses from public nursing homes with connection to a hospital (27.5% vs. >35% for other status) and with recent experience in nursing homes (31% for <5 years of practice vs. 41% for 10 years or more) were less likely to agree to prescribe antibiotics.

CONCLUSIONS

This quantitative questionnaire survey identified potential new nurses' roles in antibiotic stewardship that seem to be acceptable and feasible for participants. These new nurses' roles need to be explored in future experimentations before considering implementation.

REPORTING METHOD

The study adhered to relevant EQUATOR guidelines and followed the STROBE reporting guidelines.

PATIENT OR PUBLIC CONTRIBUTION

A self-administered internet-based questionnaire was sent to directors of eligible nursing homes by email asking them to forward the link to the questionnaire to the nurses and head nurses of their institution. Nurses and head nurses who were interested and willing could complete the questionnaire online partially or fully.

TRIAL AND PROTOCOL REGISTRATION

This study is not a clinical trial and is not eligible for trial registration. We used another suitable study registration site, the Center for Open Science.

Self-isolation of an Italian long-term care facility during COVID-19 pandemic: A comparison study on care-related infectious episodes

The aim of this retrospective cohort study is to understand if and how much the preventive self-isolation approach might have been a valid model to avoid care-related infection, not only from COVID-19 but also from other non-viral infectious diseases. From March to May 2020, the healthcare and management staff of the Villa Santa Maria long-term care facilities, located in the village of Montenero di Bisaccia (Campobasso, Molise, Italy), decided to carry out a preventive self-isolation plan to safeguard the residents from SARS-CoV-2. The impact on other infectious diseases was evaluated by analyzing the antibiotic therapies prescription trend among the inpatients. Our data showed that although self-isolation protected residents and caregivers from SARS-CoV-2, it can also be associated with mobility reduction, leading to an increase in bedridden pathologies, namely, pressure ulcers and pressure sores. The simultaneous isolation of residents and caregivers in the same location significantly reduced any outside influence as a cause of possible infections.

Pharmacokinetics of Antibacterial Agents in the Elderly: The Body of Evidence

Infections are important factors contributing to the morbidity and mortality among elderly patients. High rates of consumption of antimicrobial agents by the elderly may result in increased risk of toxic reactions, deteriorating functions of various organs and systems and leading to the prolongation of hospital stay, admission to the intensive care unit, disability, and lethal outcome. Both safety and efficacy of antibiotics are determined by the values of their plasma concentrations, widely affected by physiologic and pathologic age-related changes specific for the elderly population. Drug absorption, distribution, metabolism, and excretion are altered in different extents depending on functional and morphological changes in the cardiovascular system, gastrointestinal tract, liver, and kidneys. Water and fat content, skeletal muscle mass, nutritional status, use of concomitant drugs are other determinants of pharmacokinetics changes observed in the elderly. The choice of a proper dosing regimen is essential to provide effective and safe antibiotic therapy in terms of attainment of certain pharmacodynamic targets. The objective of this review is to perform a structure of evidence on the age-related changes contributing to the alteration of pharmacokinetic parameters in the elderly.

Antibiotic Misuse Behaviours of Older People: Confirmation of the Factor Structure of the Antibiotic Use Questionnaire

Antibacterial resistance (AR) is responsible for steadily rising numbers of untreatable bacterial infections, most prevalently found in the older adult (OA) population due to age-related physical and cognitive deterioration, more frequent and long-lasting hospital visits, and reduced immunity. There are currently no established measures of antibiotic use behaviours for older adults, and theory-informed approaches to identifying the drivers of antibiotic use in older adults are lacking in the literature. The objective of this study was to identify predictors of antibiotic use and misuse in older adults using the Antibiotic Use Questionnaire (AUQ), a measure informed by the factors of the Theory of Planned Behaviour (TPB): attitudes and beliefs, social norms, perceived behavioural control, behaviour, and a covariate-knowledge. A measure of social desirability was included, and participants scoring highly were excluded to control for social desirability bias. Confirmatory Factor Analyses and regression analyses were conducted to test the hypotheses in a cross-sectional, anonymous survey. A total of 211 participants completed the survey, 47 of which were excluded due to incompletion and high social desirability scores (≥5). Results of the factor analysis confirmed that some (but not all) factors from previous research in the general population were confirmed in the OA sample. No factors were found to be significant predictors of antibiotic use behaviour. Several suggestions for the variance in results from that of the first study are suggested, including challenges with meeting requirement for statistical power. The paper concludes that further research is required to determine the validity of the AUQ in an older adult population.

When and How to Use MIC in Clinical Practice?

Bacterial resistance to antibiotics continues to be a global public health problem. The choice of the most effective antibiotic and the use of an adapted dose in the initial phase of the infection are essential to limit the emergence of resistance. This will depend on (i) the isolated bacteria and its resistance profile, (ii) the pharmacodynamic (PD) profile of the antibiotic used and its level of toxicity, (iii) the site of infection, and (iv) the pharmacokinetic (PK) profile of the patient. In order to take account of both parameters to optimize the administered treatment, a minimal inhibitory concentration (MIC) determination associated with therapeutic drug monitoring (TDM) and their combined interpretation are required. The objective of this narrative review is thus to suggest microbiological, pharmacological, and/or clinical situations for which this approach could be useful. Regarding the microbiological aspect, such as the detection of antibiotic resistance and its level, the preservation of broad-spectrum β-lactams is particularly discussed. PK-PD profiles are relevant for difficult-to-reach infections and specific populations such as intensive care patients, cystic fibrosis patients, obese, or elderly patients. Finally, MIC and TDM are tools available to clinicians, who should not hesitate to use them to manage their patients.