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Garnfeldt VM, Vincent JL, Gruson D, Garay OU, Vansieleghem S, Iniguez L, Lefevre A. The budget impact of procalcitonin-guided antibiotic stewardship compared to standard of care for patients with suspected sepsis admitted to the intensive care unit in Belgium. PLoS One 2023; 18:e0293544. [PMID: 37903106 PMCID: PMC10615283 DOI: 10.1371/journal.pone.0293544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/15/2023] [Indexed: 11/01/2023] Open
Abstract
In Belgium, antibiotic resistance leads to approximately 530 deaths with a €24 million financial burden annually. This study estimated the impact of procalcitonin-guided antibiotic stewardship programs to reduce antibiotic consumption versus standard of care in patients with suspected sepsis. A decision analytic tree modelled health and budget outcomes of procalcitonin-guided antibiotic stewardship programs for patients admitted to the intensive care unit (ICU). A literature search, a survey with local clinical experts, and national database searches were conducted to obtain model input parameters. The main outcomes were total budget impact per patient, reduction in number of antibiotic resistance cases, and cost per antibiotic day avoided. To evaluate the impact of parameter uncertainty on the source data, a deterministic sensitivity analysis was performed. A scenario analysis was conducted to investigate budget impact when including parameters for reduction in length of ICU stay and mechanical ventilation duration, in addition to base-case parameters. Based on model predictions, procalcitonin-guided antibiotic stewardship programs could reduce the number of antibiotic days by 66,868, resulting in €1.98 million savings towards antibiotic treatment in current clinical practice. Antibiotic resistance cases could decrease by 7.7% (6.1% vs 9.2%) in the procalcitonin-guided setting compared with standard of care. The base-case budget impact suggests an investment of €1.90 per patient. The sensitivity analysis showed uncertainty, as the main drivers can alter potential cost savings. The scenario analysis indicated a saving of €1,405 per patient, with a reduction of 1.5 days in the ICU (14.8 days vs 12.8 days), and a reduction of 22.7% (18.1-27.2%) in mechanical ventilation duration. The associated sensitivity analysis was shown to be robust in all parameters. Procalcitonin-guided antibiotic stewardship programs are associated with clinical benefits that positively influence antimicrobial resistance in Belgium. A small investment per patient to implement procalcitonin testing may lead to considerable cost savings.
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Affiliation(s)
- Victoria Madeleine Garnfeldt
- Department of Health Science and Technology, Aalborg University, Gistrup, Denmark
- Government, Access & Patient Affairs, Roche Diagnostics Belgium, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme, University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Damien Gruson
- Department of Clinical Biochemistry, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | | | - Leonardo Iniguez
- Marketing and Medical Excellence, Roche Diagnostics Belgium, Brussels, Belgium
| | - Alexander Lefevre
- Government, Access & Patient Affairs, Roche Diagnostics Belgium, Brussels, Belgium
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Scheithauer S, Karasimos B, Manamayil D, Häfner H, Lewalter K, Mischke K, Heintz B, Tacke F, Brücken D, Lüring C, Heidenhain C, Tewarie L, Hilgers RD, Lemmen SW. A prospective cluster trial to increase antibiotic prescription quality in seven non-ICU wards. GMS HYGIENE AND INFECTION CONTROL 2023; 18:Doc14. [PMID: 37405250 PMCID: PMC10316282 DOI: 10.3205/dgkh000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Aim To evaluate general shortcomings and faculty-specific pitfalls as well as to improve antibiotic prescription quality (ABQ) in non-ICU wards, we performed a prospective cluster trial. Methods An infectious-disease (ID) consulting service performed a prospective investigation consisting of three 12-week phases with point prevalence evaluation conducted once per week (=36 evaluations in total) at seven non-ICU wards, followed by assessment of sustainability (weeks 37-48). Baseline evaluation (phase 1) defined multifaceted interventions by identifying the main shortcomings. Then, to distinguish intervention from time effects, the interventions were performed in four wards, and the 3 remaining wards served as controls; after assessing effects (phase 2), the same interventions were performed in the remaining wards to test the generalizability of the interventions (phase 3). The prolonged responses after all interventions were then analyzed in phase 4. ABQ was evaluated by at least two ID specialists who assessed the indication for therapy, the adherence to the hospital guidelines for empirical therapy, and the overall antibiotic prescription quality. Results In phase 1, 406 of 659 (62%) patients cases were adequately treated with antibiotics; the main reason for inappropriate prescription was the lack of an indication (107/253; 42%). The antibiotic prescription quality (ABQ) significantly increased, reaching 86% in all wards after the focused interventions (502/584; nDf=3, ddf=1,697, F=6.9, p=0.0001). In phase 2 the effect was only seen in wards that already participated in interventions (248/347; 71%). No improvement was seen in wards that received interventions only after phase 2 (189/295; 64%). A given indication significantly increased from about 80% to more than 90% (p<.0001). No carryover effects were observed. Discussion ABQ can be improved significantly by intervention bundles with apparent sustainable effects.
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Affiliation(s)
- Simone Scheithauer
- Department of Infection Control and Infectious Diseases, University Medical Center Göttingen (UMG), Georg-August University Göttingen, Germany
| | - Britta Karasimos
- Clinic for Orthopedics and Trauma Surgery, Hospital Düren, Düren, Germany
| | - David Manamayil
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| | - Helga Häfner
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| | - Karl Lewalter
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| | - Karl Mischke
- Medical Clinic 1, Leopoldina Hospital Schweinfurt, Schweinfurt, Germany
| | - Bernhard Heintz
- Clinic for Nephrology, University Hospital Aachen, Aachen, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte (CCM)/Campus Virchow-Klinikum (CVK, Charité – University Medical Center Berlin, Berlin, Germany
| | - David Brücken
- Clinic for Traumatology, University Hospital Aachen, Aachen, Germany
| | | | - Christoph Heidenhain
- Clinic for Visceral Surgery, AGAPLESION MARKUS Krankenhaus Frankfurt, Frankfurt/Main, Germany
| | | | | | - Sebastian W. Lemmen
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
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Ghosh S, Salhotra R, Singh A, Lyall A, Arora G, Kumar N, Chawla A, Gupta M. New Antibiotic Prescription Pattern in Critically Ill Patients ("Ant-critic"): Prospective Observational Study from an Indian Intensive Care Unit. Indian J Crit Care Med 2022; 26:1275-1284. [PMID: 36755637 PMCID: PMC9886023 DOI: 10.5005/jp-journals-10071-24366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction This study aimed to address the issue of antibiotic prescription processes in an Indian Intensive care unit (ICUs). Materials and methods In a prospective longitudinal study, all adult patients admitted in the ICU for 24 hours or above between 01 June 2020 and 31 July 2021 were screened for any new antibiotic prescription throughout their ICU stay. All new antibiotic prescriptions were assessed for baseline variables at prescription, any modifications during the course, and the outcome of antibiotic prescription. Results A total of 1014 patients fulfilled entry criteria; 59.2 and 7.2% of days they were on a therapeutic and prophylactic antibiotic(s). Patients, who were prescribed therapeutic antibiotic(s), had worse ICU outcomes. A total of 49.5% of patients (502 of 1,014) received a total of 552 new antibiotic prescriptions during their ICU stay. About 92.13% of these prescriptions were empirical and blood or other specimens were sent for culture in 78.81 and 60.04% of instances. A total of 31.7% of episodes were microbiologically proven and were more likely to be prescribed by an ICU consultant. A total of 169 modifications were done in 142 prescription episodes; 73 of them after sensitivity results. Thus, the overall rate of de-escalation was 13.95%. Apart from the negative culture result (36.05%), an important reason for a relatively low rate of de-escalation was the absence of sampling (12.32%). Longer ICU stay before antibiotic prescription, underlying chronic liver disease (CLD), worse organ dysfunction, and septic shock were independently associated with unfavorable treatment outcomes. No such independent association was observed between antibiotic appropriateness and patient outcome. Conclusion Future antibiotic stewardship strategies should address issues of high empirical prescription and poor microbiological sampling hindering the de-escalation process. How to cite this article Ghosh S, Salhotra R, Singh A, Lyall A, Arora G, Kumar N, et al. New Antibiotic Prescription Pattern in Critically Ill Patients ("Ant-critic"): Prospective Observational Study from an Indian Intensive Care Unit. Indian J Crit Care Med 2022;26(12):1275-1284.
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Affiliation(s)
- Supradip Ghosh
- Department of Critical Care Medicine, Fortis Escorts Hospital, Faridabad, Haryana, India,Supradip Ghosh, Department of Critical Care Medicine, Fortis Escorts Hospital, Faridabad, Haryana, India, Phone: +91 9818590021, e-mail:
| | - Ripenmeet Salhotra
- Department of Critical Care Medicine, Amrita Hospital, Faridabad, Haryana, India
| | - Amandeep Singh
- Department of Critical Care Medicine, Fortis Escorts Hospital, Faridabad, Haryana, India
| | - Aditya Lyall
- Department of Critical Care Medicine, Fortis Escorts Hospital, Faridabad, Haryana, India
| | - Garima Arora
- Department of Critical Care Medicine, Werribee Mercy Hospital, Werribee, Victoria, Australia
| | - Niranjan Kumar
- Department of Critical Care Medicine, Mediversal Multi Superspeciality Hospital, Kankarbagh, Patna, Bihar, India
| | - Aayush Chawla
- Department of Critical Care Medicine, Amrita Hospital, Faridabad, Haryana, India
| | - Meenakshi Gupta
- Department of Critical Care Medicine, Fortis Escorts Hospital, Faridabad, Haryana, India
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Tufa TB, Mackenzie CR, Orth HM, Wienemann T, Nordmann T, Abdissa S, Hurissa Z, Schönfeld A, Bosselmann M, Häussinger D, Pfeffer K, Luedde T, Fuchs A, Feldt T. Prevalence and characterization of antimicrobial resistance among gram-negative bacteria isolated from febrile hospitalized patients in central Ethiopia. Antimicrob Resist Infect Control 2022; 11:8. [PMID: 35033191 PMCID: PMC8761287 DOI: 10.1186/s13756-022-01053-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 01/03/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Infectious diseases are among the leading causes of death in many low-income countries, such as Ethiopia. Without reliable local data concerning causative pathogens and antimicrobial resistance, empiric treatment is suboptimal. The objective of this study was to characterize gram-negative bacteria (GNB) as pathogens and their resistance pattern in hospitalized patients with infections in central Ethiopia. METHODS Patients ≥ 1 year of age with fever admitted to the Asella Referral and Teaching Hospital from April 2016 to June 2018 were included. Blood and other appropriate clinical specimens were collected and cultured on appropriate media. Antibiotic susceptibility testing (AST) was performed using the Kirby-Bauer method and VITEK® 2. Species identification and detection of resistance genes were conducted using MALDI-ToF MS (VITEK® MS) and PCR, respectively. RESULTS Among the 684 study participants, 54.2% were male, and the median age was 22.0 (IQR: 14-35) years. Blood cultures were positive in 5.4% (n = 37) of cases. Among other clinical samples, 60.6% (20/33), 20.8% (5/24), and 37.5% (3/8) of swabs/pus, urine and other body fluid cultures, respectively, were positive. Among 66 pathogenic isolates, 57.6% (n = 38) were GNB, 39.4% (n = 26) were gram-positive, and 3.0% (n = 2) were Candida species. Among the isolated GNB, 42.1% (16/38) were Escherichia coli, 23.7% (9/38) Klebsiella pneumoniae and 10.5% (4/38) Pseudomonas aeruginosa. In total, 27/38 gram-negative isolates were available for further analysis. Resistance rates were as follows: ampicillin/sulbactam, 92.6% (n = 25); cefotaxime, 88.9% (n = 24); ceftazidime, 74.1% (n = 20); cefepime, 74.1% (n = 20); gentamicin, 55.6% (n = 15); piperacillin/tazobactam, 48.1% (n = 13); meropenem, 7.4% (n = 2); and amikacin, 3.7% (n = 1). The blaNDM-1 gene was detected in one K. pneumoniae and one Acinetobacter baumannii isolate, which carried an additional blaOXA-51 gene. The ESBL enzymes were detected in 81.5% (n = 22) of isolates as follows: TEM, 77.2% (n = 17); CTX-M-1 group, 68.2% (n = 15); SHV group, 27.3% (n = 6); and CTX-M-9 group, 9.1% (n = 2). Based on the in vitro antimicrobial susceptibility results, empiric treatment initiated in 13 of 18 (72.2%) patients was likely ineffective. CONCLUSION We report a high prevalence of ESBL-producing bacteria (81.5%) and carbapenem resistance (7.4%), with more than half of GNB carrying two or more ESBL enzymes resulting in suboptimal empiric antibiotic therapy. These findings indicate a need for local and national antimicrobial resistance surveillance and the strengthening of antimicrobial stewardship programs.
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Affiliation(s)
- Tafese Beyene Tufa
- College of Health Sciences, Arsi University, P.O. Box 04, Asella, Ethiopia. .,Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty of Heinrich Heine University, Moorenstr. 5, 40225, Duesseldorf, Germany. .,Hirsch Institute of Tropical Medicine, P.O. Box 04, Asella, Ethiopia. .,Institute of Medical Microbiology and Hospital Hygiene, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Universitätsstr. 1, 40225, Duesseldorf, Germany.
| | - Colin R Mackenzie
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Universitätsstr. 1, 40225, Duesseldorf, Germany
| | - Hans Martin Orth
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty of Heinrich Heine University, Moorenstr. 5, 40225, Duesseldorf, Germany.,Hirsch Institute of Tropical Medicine, P.O. Box 04, Asella, Ethiopia
| | - Tobias Wienemann
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Universitätsstr. 1, 40225, Duesseldorf, Germany
| | - Tamara Nordmann
- Division Tropical Medicine, Department of Medicine, University Medical Center Hamburg-Eppendorf, Bernhard-Nacht-Straße 74, 20359, Hamburg, Germany
| | - Sileshi Abdissa
- College of Health Sciences, Arsi University, P.O. Box 04, Asella, Ethiopia.,Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty of Heinrich Heine University, Moorenstr. 5, 40225, Duesseldorf, Germany.,Hirsch Institute of Tropical Medicine, P.O. Box 04, Asella, Ethiopia.,Institute of Medical Microbiology and Hospital Hygiene, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Universitätsstr. 1, 40225, Duesseldorf, Germany
| | - Zewdu Hurissa
- College of Health Sciences, Arsi University, P.O. Box 04, Asella, Ethiopia
| | - Andreas Schönfeld
- Department of Infectious Diseases, Essen University Hospital, Essen, Germany
| | | | - Dieter Häussinger
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty of Heinrich Heine University, Moorenstr. 5, 40225, Duesseldorf, Germany.,Hirsch Institute of Tropical Medicine, P.O. Box 04, Asella, Ethiopia
| | - Klaus Pfeffer
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine University, Universitätsstr. 1, 40225, Duesseldorf, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty of Heinrich Heine University, Moorenstr. 5, 40225, Duesseldorf, Germany.,Hirsch Institute of Tropical Medicine, P.O. Box 04, Asella, Ethiopia
| | - Andre Fuchs
- Hirsch Institute of Tropical Medicine, P.O. Box 04, Asella, Ethiopia.,Internal Medicine III - Gastroenterology and Infectious Diseases, University Hospital of Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Torsten Feldt
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty of Heinrich Heine University, Moorenstr. 5, 40225, Duesseldorf, Germany.,Hirsch Institute of Tropical Medicine, P.O. Box 04, Asella, Ethiopia
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Montravers P, Kantor E, Constantin JM, Lefrant JY, Lescot T, Nesseler N, Paugam C, Jabaudon M, Dupont H. Epidemiology and prognosis of anti-infective therapy in the ICU setting during acute pancreatitis: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:393. [PMID: 31805988 PMCID: PMC6896276 DOI: 10.1186/s13054-019-2681-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 11/21/2019] [Indexed: 02/06/2023]
Abstract
Background Recent international guidelines for acute pancreatitis (AP) recommend limiting anti-infective therapy (AIT) to cases of suspected necrotizing AP or nosocomial extrapancreatic infection. Limited data are available concerning empirical and documented AIT prescribing practices in patients admitted to the intensive care unit (ICU) for the management of AP. Methods Using a multicentre, retrospective (2009–2014), observational database of ICU patients admitted for AP, our primary objective was to assess the incidence of AIT prescribing practices during the first 30 days following admission. Secondary objectives were to assess the independent impact of centre characteristics on the incidence of AIT and to identify factors associated with crude hospital mortality in a logistic regression model. Results In this cohort of 860 patients, 359 (42%) received AIT on admission. Before day 30, 340/359 (95%) AIT patients and 226/501 (45%) AIT-free patients on admission received additional AIT, mainly for intra-abdominal and lung infections. A large heterogeneity was observed between centres in terms of the incidence of infections, therapeutic management including AIT and prognosis. Administration of AIT on admission or until day 30 was not associated with an increased mortality rate. Patients receiving AIT on admission had increased rates of complications (septic shock, intra-abdominal and pulmonary infections), therapeutic (surgical, percutaneous, endoscopic) interventions and increased length of ICU stay compared to AIT-free patients. Patients receiving delayed AIT after admission and until day 30 had increased rates of complications (respiratory distress syndrome, intra-abdominal and pulmonary infections), therapeutic interventions and increased length of ICU stay compared to those receiving AIT on admission. Risk factors for hospital mortality assessed on admission were age (adjusted odds ratio [95% confidence interval] 1.03 [1.02–1.05]; p < 0.0001), Balthazar score E (2.26 [1.43–3.56]; p < 0.0001), oliguria/anuria (2.18 [1.82–4.33]; p < 0.0001), vasoactive support (2.83 [1.73–4.62]; p < 0.0001) and mechanical ventilation (1.90 [1.15–3.14]; p = 0.011), but not AIT (0.63 [0.40–1.01]; p = 0.057). Conclusions High proportions of ICU patients admitted for AP receive AIT, both on admission and during their ICU stay. A large heterogeneity was observed between centres in terms of incidence of infections, AIT prescribing practices, therapeutic management and outcome. AIT reflects the initial severity and complications of AP, but is not a risk factor for death.
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Affiliation(s)
- Philippe Montravers
- Département d'Anesthésie-Réanimation, CHU Bichat-Claude Bernard, HUPNVS, APHP, 48 rue Henri Huchard, F-75018, Paris, France. .,Université de Paris, Paris, France. .,INSERM UMR 1152 - Université de Paris, Paris, France.
| | - Elie Kantor
- Département d'Anesthésie-Réanimation, CHU Bichat-Claude Bernard, HUPNVS, APHP, 48 rue Henri Huchard, F-75018, Paris, France.,Université de Paris, Paris, France
| | - Jean-Michel Constantin
- Département de Médecine Post-opératoire, CHU Clermont-Ferrand, Clermont-Ferrand, France.,Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Jean-Yves Lefrant
- Division of Anaesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, and EA 2992, Université Montpellier, Nîmes, France
| | - Thomas Lescot
- Department of Anaesthesia and Critical Care, Saint-Antoine University Hospital, Assistance Publique-Hôpitaux de Paris, and Sorbonne Universités, UPMC Univ Paris 06, Paris, France
| | - Nicolas Nesseler
- Surgical Intensive Care Unit, Hôpital Pontchaillou, and Inserm U 991, Université de Rennes 1, Rennes, France
| | - Catherine Paugam
- Université de Paris, Paris, France.,Department of Anaesthesiology and Critical Care Medicine, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Jabaudon
- Département de Médecine Post-opératoire, CHU Clermont-Ferrand, Clermont-Ferrand, France.,Université Clermont Auvergne, CNRS UMR 6293, INSERM U1103, GReD, Clermont-Ferrand, France
| | - Hervé Dupont
- Medical and Surgical ICU, Amiens University Hospital and INSERM U1088, University of Picardy Jules Verne, Amiens, France
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Usefulness of Gram stain examination of peritoneal fluid in postoperative peritonitis to guide empirical antibiotherapy. Eur J Trauma Emerg Surg 2019; 46:1335-1340. [PMID: 31143982 DOI: 10.1007/s00068-019-01161-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/22/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE In postoperative peritonitis, Gram stain examination (GSE) of peritoneal fluid has been proposed as a guide for the prescription of glycopeptides and antifungal therapy in empirical antibiotherapy. No data support this approach for Gram-positive cocci. We aimed to evaluate the performance of GSE in predicting the results of the culture of peritoneal fluid. METHODS In this retrospective single-center study, concordance between GSE and culture of peritoneal fluid was assessed for different types of microorganisms. Factors associated with concordance of the two tests were evaluated in the subpopulation of Gram-positive cocci peritonitis. RESULTS Among the 152 episodes, the GSE was negative in 57 cases. The negative predictive value and the positive predictive value were 41% and 87% for Gram-positive cocci (GPC), 31% and 86% for Gram-negative bacilli, and 78% and 94% for fungi. GSE is not a reliable guide for the choice of empirical antibiotherapy and cannot reliably rule out the presence of GPC at culture. If we aim to achieve a high rate of adequacy, the systematic use of glycopeptide in the empirical antibiotherapy may be considered. CONCLUSION GSE shows poor performance to predict the results of culture of peritoneal fluid in postoperative peritonitis. Avoiding covering resistant GPC cannot be based on the result of GSE.
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Ambaras Khan R, Aziz Z. Antibiotic de-escalation in patients with pneumonia in the intensive care unit: A systematic review and meta-analysis. Int J Clin Pract 2018; 72:e13245. [PMID: 30144239 DOI: 10.1111/ijcp.13245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 07/16/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES OF THE REVIEW Antibiotic de-escalation is part of an antibiotic stewardship strategy to achieve adequate therapy for infections while avoiding the prolonged use of broad-spectrum antibiotics. However, there is a paucity of clinical evidence on the clinical impact of this strategy in pneumonia patients in the intensive care unit (ICU). This review aimed to evaluate the impact of antibiotic de-escalation therapy for adult patients diagnosed with pneumonia in the ICU. METHODS USED TO CONDUCT THE REVIEW This review was conducted in accordance with the Meta-analysis of Observational Studies in Epidemiology (MOOSE) recommendation. Electronic databases including MEDLINE, CINAHL, PubMed, Embase, Cochrane Databases and Cochrane Central Register of Controlled Trials were searched up to March 2017 for relevant trials. The methodological quality of included trials was assessed by using a modified version of the Newcastle-Ottawa Quality Assessment Scale for Case-Control and Cohort Studies. A meta-analysis was conducted using the random-effect model to combine the rate of mortality and length of stay outcomes. FINDINGS OF THE REVIEW Nine observational trials involving 2128 patients were considered eligible for inclusion. Although based on low quality evidence, there was a statistically significant difference in favour of the impact of de-escalation on hospital stay but not mortality (MD -5.96 days; 95% CI -8.39 to -3.52). INTERPRETATIONS AND IMPLICATIONS OF THE FINDINGS This review highlights the need for more rigorous studies to be carried out before a firm conclusion on the benefit of de-escalation therapy is supported.
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Affiliation(s)
- Rahela Ambaras Khan
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Zoriah Aziz
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Brooks D, Polubothu P, Young D, Booth MG, Smith A. Sepsis caused by bloodstream infection in patients in the intensive care unit: the impact of inactive empiric antimicrobial therapy on outcome. J Hosp Infect 2017; 98:369-374. [PMID: 28993134 DOI: 10.1016/j.jhin.2017.09.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/29/2017] [Accepted: 09/29/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Sepsis is one of the leading causes of death in the UK. AIMS To identify the rate of inactive antimicrobial therapy (AMT) in the intensive care unit (ICU) and whether inactive AMT has an effect on in-hospital mortality, ICU mortality, 90-day mortality and length of hospital stay. A further aim was to identify risk factors for receiving inactive AMT. METHODS This was a retrospective observational study conducted at Glasgow Royal Infirmary ICU between January 2010 and December 2013. In total, 12,000 blood cultures were taken over this time period, of which 127 were deemed clinically significant. Multi-variate logistic regression was used to identify risk factors independently associated with mortality. Univariate analysis followed by multi-variate analysis was performed to identify risk factors for receiving inactive AMT. RESULTS The rate of inactive AMT was 47% (N = 60). Multi-variate analysis showed that receiving antibiotics within the first 24h of ICU admission led to reduced mortality [relative risk 1.70, 95% confidence interval (CI) 1.19-2.44]. Furthermore, it showed that severity of illness (as defined by SIRS criteria sepsis vs septic shock) increased mortality [odds ratio (OR) 9.87, 95% CI 1.73-55.5]. However, inactive AMT did not increase mortality (OR 1.07, 95% CI 0.47-2.41) or length of hospital stay (53.2 vs 69.1 days, P = 0.348). Fungal bloodstream infection was found to be a risk factor for receiving inactive AMT (OR 5.10, 95% CI 1.29-20.14). CONCLUSION Mortality from sepsis is influenced by multiple factors. This study was unable to demonstrate that inactive AMT had an effect on mortality in sepsis.
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Affiliation(s)
- D Brooks
- School of Medicine, Glasgow University, Glasgow, UK.
| | - P Polubothu
- Clinical Microbiology, Glasgow Royal Infirmary, Glasgow, UK
| | - D Young
- Clinical Microbiology, Glasgow Royal Infirmary, Glasgow, UK
| | - M G Booth
- Intensive Care Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - A Smith
- School of Medicine, Glasgow University, Glasgow, UK
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Montravers P, Tashk P, Tran Dinh A. Unmet needs in the management of intra-abdominal infections. Expert Rev Anti Infect Ther 2017; 15:839-850. [PMID: 28841096 DOI: 10.1080/14787210.2017.1372750] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Intra-abdominal infections remain a leading cause of death, morbidity and resource use in surgical wards and intensive care units. The growing complexity of their management has led to new paradigms and unresolved issues in anti-infective therapy described in the current review. Areas covered: We analyzed the literature, recent guidelines, and expert opinions published over the last decade. Expert commentary: Prospective randomized trials are difficult to perform and observational studies or database analyses should be encouraged. Epidemiologic and microbiologic reports should be promoted, especially in developing/resource-limited countries and in specific subpopulations such as children, older people and patients with underlying diseases. The diagnostic process, including imaging procedures, could be improved. The value of biomarkers for diagnosis, monitoring and discontinuation of therapy should be clarified and improved. New microbiologic techniques are needed to speed up the diagnostic process and to improve the adequacy of anti-infective therapy. Very little progress has been made in the detection of clinical failures. Many aspects of anti-infective management, both for bacteria and fungi, remain unresolved, such as the high inoculum, the type of microorganisms to be treated, the timing of therapy, the value of de-escalation, drug monitoring and duration of therapy. New antibiotics are expected.
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Affiliation(s)
- Philippe Montravers
- a Paris Diderot Sorbonne Cite University, and Anesthesiology and Critical Care Medicine , Bichat-Claude Bernard University Hospital, HUPNSV, AP-HP , Paris , France.,b INSERM UMR 1152 , Paris , France
| | - Parvine Tashk
- a Paris Diderot Sorbonne Cite University, and Anesthesiology and Critical Care Medicine , Bichat-Claude Bernard University Hospital, HUPNSV, AP-HP , Paris , France
| | - Alexy Tran Dinh
- a Paris Diderot Sorbonne Cite University, and Anesthesiology and Critical Care Medicine , Bichat-Claude Bernard University Hospital, HUPNSV, AP-HP , Paris , France.,c INSERM UMR 1148 , Paris , France
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10
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Mazuski JE, Tessier JM, May AK, Sawyer RG, Nadler EP, Rosengart MR, Chang PK, O'Neill PJ, Mollen KP, Huston JM, Diaz JJ, Prince JM. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt) 2017; 18:1-76. [PMID: 28085573 DOI: 10.1089/sur.2016.261] [Citation(s) in RCA: 306] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.
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Affiliation(s)
- John E Mazuski
- 1 Department of Surgery, Washington University School of Medicine , Saint Louis, Missouri
| | | | - Addison K May
- 3 Department of Surgery, Vanderbilt University , Nashville, Tennessee
| | - Robert G Sawyer
- 4 Department of Surgery, University of Virginia , Charlottesville, Virginia
| | - Evan P Nadler
- 5 Division of Pediatric Surgery, Children's National Medical Center , Washington, DC
| | - Matthew R Rosengart
- 6 Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Phillip K Chang
- 7 Department of Surgery, University of Kentucky , Lexington, Kentucky
| | | | - Kevin P Mollen
- 9 Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jared M Huston
- 10 Department of Surgery, Hofstra Northwell School of Medicine , Hempstead, New York
| | - Jose J Diaz
- 11 Department of Surgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jose M Prince
- 12 Departments of Surgery and Pediatrics, Hofstra-Northwell School of Medicine , Hempstead, New York
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11
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Sartelli M, Catena F, Abu-Zidan FM, Ansaloni L, Biffl WL, Boermeester MA, Ceresoli M, Chiara O, Coccolini F, De Waele JJ, Di Saverio S, Eckmann C, Fraga GP, Giannella M, Girardis M, Griffiths EA, Kashuk J, Kirkpatrick AW, Khokha V, Kluger Y, Labricciosa FM, Leppaniemi A, Maier RV, May AK, Malangoni M, Martin-Loeches I, Mazuski J, Montravers P, Peitzman A, Pereira BM, Reis T, Sakakushev B, Sganga G, Soreide K, Sugrue M, Ulrych J, Vincent JL, Viale P, Moore EE. Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference. World J Emerg Surg 2017; 12:22. [PMID: 28484510 PMCID: PMC5418731 DOI: 10.1186/s13017-017-0132-7] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 04/25/2017] [Indexed: 12/18/2022] Open
Abstract
This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.
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Affiliation(s)
| | - Fausto Catena
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Walter L Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, HI USA
| | | | - Marco Ceresoli
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Osvaldo Chiara
- Emergency Department, Trauma Center, Niguarda Hospital, Milan, Italy
| | - Federico Coccolini
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | | | - Christian Eckmann
- Department of General, Visceral, and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Hannover, Germany
| | - Gustavo P Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Ewen A Griffiths
- General and Upper GI Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Jeffry Kashuk
- Department of Surgery, Assia Medical Group, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Andrew W Kirkpatrick
- Departments of Surgery, Critical Care Medicine, and the Regional Trauma Service, Foothills Medical Centre, Calgary, AB Canada
| | - Vladimir Khokha
- Department of Emergency Surgery, Mozyr City Hospital, Mozyr, Belarus
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Francesco M Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, UNIVPM, Ancona, Italy
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Ronald V Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Addison K May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN USA
| | | | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Wellcome Trust-HRB Clinical Research, Department of Clinical Medicine, Trinity Centre for Health Sciences, St James's University Hospital, Dublin, Ireland
| | - John Mazuski
- Department of Surgery, School of Medicine, Washington University in Saint Louis, St. Louis, MO USA
| | - Philippe Montravers
- Département d'Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | - Andrew Peitzman
- Department of Surgery, UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Bruno M Pereira
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Tarcisio Reis
- Emergency post-operative Department, Otavio De Freitas Hospital and Osvaldo Cruz Hospital Recife, Recife, Brazil
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Gabriele Sganga
- Department of Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Michael Sugrue
- Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, Ireland
| | - Jan Ulrych
- 1st Department of Surgery, Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Praha, Czech Republic
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Ernest E Moore
- Department of Surgery, University of Colorado, Denver, CO USA
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12
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de With K, Allerberger F, Amann S, Apfalter P, Brodt HR, Eckmanns T, Fellhauer M, Geiss HK, Janata O, Krause R, Lemmen S, Meyer E, Mittermayer H, Porsche U, Presterl E, Reuter S, Sinha B, Strauß R, Wechsler-Fördös A, Wenisch C, Kern WV. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2017; 44:395-439. [PMID: 27066980 PMCID: PMC4889644 DOI: 10.1007/s15010-016-0885-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. Materials and methods A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. Conclusion The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.
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Affiliation(s)
- K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - F Allerberger
- Division Public Health, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - S Amann
- Hospital Pharmacy, Munich Municipal Hospital, Munich, Germany
| | - P Apfalter
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - H-R Brodt
- Department of Infectious Disease Medical Clinic II, Goethe-University Frankfurt, Frankfurt, Germany
| | - T Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - M Fellhauer
- Hospital Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - H K Geiss
- Department of Hospital Epidemiology and Infectiology, Sana Kliniken AG, Ismaning, Germany
| | - O Janata
- Department for Hygiene and Infection Control, Danube Hospital, Vienna, Austria
| | - R Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
| | - S Lemmen
- Division of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany
| | - E Meyer
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Berlin, Germany
| | - H Mittermayer
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - U Porsche
- Department for Clinical Pharmacy and Drug Information, Landesapotheke, Landeskliniken Salzburg (SALK), Salzburg, Austria
| | - E Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - S Reuter
- Clinic for General Internal Medicine, Infectious Diseases, Pneumology and Osteology, Klinikum Leverkusen, Leverkusen, Germany
| | - B Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Strauß
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Erlangen, Germany
| | - A Wechsler-Fördös
- Department of Antibiotics and Infection Control, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Wenisch
- Medical Department of Infection and Tropical Medicine, Kaiser Franz Josef Hospital, Vienna, Austria
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, Freiburg University Medical Center, Freiburg, Germany
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13
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Gutiérrez-Pizarraya A, Leone M, Garnacho-Montero J, Martin C, Martin-Loeches I. Collaborative approach of individual participant data of prospective studies of de-escalation in non-immunosuppressed critically ill patients with sepsis. Expert Rev Clin Pharmacol 2017; 10:457-465. [PMID: 28266901 DOI: 10.1080/17512433.2017.1293520] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is a concern to conduct de-escalation in very sick patients. AIMS To determine if de-escalation is feasible in ICU settings. METHODS We performed a metaanalysis of published studies conducted comparing de-escalation (defined by withdrawal of at least one antimicrobial empirically prescribed, switch to a new antimicrobial with narrower spectrum and withdrawal of at least one antimicrobial plus change of another drug to a new one with narrower spectrum) in non-immunocompromised patients with sepsis admitted to ICU. RESULTS Eight hundred and seventeen patients with severe sepsis or septic shock were evaluated. De-escalation was applied in 274 patients (33.5%). We found no differences in hospital long of stay between de-escalation group compared to those who did not receive it. We also found significant lower hospital mortality in de-escalation group as compared with no modification group in front of the others (25.9 vs. 43.1%; p < 0.001). Taking into account the etiology of infection, in both gram negative and gram positives microorganisms, de-escalation strategy was assessed as a good prognosis factor for mortality in the adjusted multivariate analysis (OR 0.41; 95% CI 0.22-0.74 and OR 0.33; 95% CI 0.15-0.70 respectively) whereas SOFA score along with age were found as a factors independently associated with a worse clinical outcome (OR 1.23; 95% CI 1.12-1.35 and OR 1.02; 95% CI 1.01-1.04 respectively). CONCLUSIONS In our study there was an independent association of de-escalation and decrease mortality rate.
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Affiliation(s)
- Antonio Gutiérrez-Pizarraya
- a Department of Intensive Care Medicine , Instituto de Biomedicina de Sevilla, IBIS/Hospitales Universitarios Virgen Macarena -Virgen del Rocío /CSIC/Universidad de Sevilla , Sevilla , Spain
| | - Marc Leone
- b Service d'anesthésie et de réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille , Aix Marseille Université , Marseille , France
| | - Jose Garnacho-Montero
- c Unidad Clínica de Cuidados Intensivos , Hospital Universitario Virgen Macarena, Instituto Biomedicina , Sevilla , Spain
| | - Claude Martin
- b Service d'anesthésie et de réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille , Aix Marseille Université , Marseille , France
| | - Ignacio Martin-Loeches
- d Trinity College, St James's University Hospital, Trinity Centre for Health Sciences, Multidisciplinary Intensive Care Research Organization (MICRO) , Dublin , Ireland
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Rawson TM, Charani E, Moore LSP, Hernandez B, Castro-Sánchez E, Herrero P, Georgiou P, Holmes AH. Mapping the decision pathways of acute infection management in secondary care among UK medical physicians: a qualitative study. BMC Med 2016; 14:208. [PMID: 27938372 PMCID: PMC5151123 DOI: 10.1186/s12916-016-0751-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/18/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The inappropriate use of antimicrobials drives antimicrobial resistance. We conducted a study to map physician decision-making processes for acute infection management in secondary care to identify potential targets for quality improvement interventions. METHODS Physicians newly qualified to consultant level participated in semi-structured interviews. Interviews were audio recorded and transcribed verbatim for analysis using NVIVO11.0 software. Grounded theory methodology was applied. Analytical categories were created using constant comparison approach to the data and participants were recruited to the study until thematic saturation was reached. RESULTS Twenty physicians were interviewed. The decision pathway for the management of acute infections follows a Bayesian-like step-wise approach, with information processed and systematically added to prior assumptions to guide management. The main emerging themes identified as determinants of the decision-making of individual physicians were (1) perceptions of providing 'optimal' care for the patient with infection by providing rapid and often intravenous therapy; (2) perceptions that stopping/de-escalating therapy was a senior doctor decision with junior trainees not expected to contribute; and (3) expectation of interactions with local guidelines and microbiology service advice. Feedback on review of junior doctor prescribing decisions was often lacking, causing frustration and confusion on appropriate practice within this cohort. CONCLUSION Interventions to improve infection management must incorporate mechanisms to promote distribution of responsibility for decisions made. The disparity between expectations of prescribers to start but not review/stop therapy must be urgently addressed with mechanisms to improve communication and feedback to junior prescribers to facilitate their continued development as prudent antimicrobial prescribers.
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Affiliation(s)
- Timothy Miles Rawson
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.
- Health Protection Research Unit in Healthcare Associated Infections & Antimicrobial Resistance, Hammersmith Hospital, Du Cane Road, London, W12 0NN, UK.
| | - Esmita Charani
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - Luke Stephen Prockter Moore
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Bernard Hernandez
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - Enrique Castro-Sánchez
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - Pau Herrero
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - Pantelis Georgiou
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - Alison Helen Holmes
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
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Montravers P, Augustin P, Grall N, Desmard M, Allou N, Marmuse JP, Guglielminotti J. Characteristics and outcomes of anti-infective de-escalation during health care-associated intra-abdominal infections. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:83. [PMID: 27052675 PMCID: PMC4823898 DOI: 10.1186/s13054-016-1267-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/16/2016] [Indexed: 12/26/2022]
Abstract
Background De-escalation is strongly recommended for antibiotic stewardship. No studies have addressed this issue in the context of health care-associated intra-abdominal infections (HCIAI). We analyzed the factors that could interfere with this process and their clinical consequences in intensive care unit (ICU) patients with HCIAI. Methods All consecutive patients admitted for the management of HCIAI who survived more than 3 days following their diagnosis, who remained in the ICU for more than 3 days, and who did not undergo early reoperation during the first 3 days were analyzed prospectively in an observational, single-center study in a tertiary care university hospital. Results Overall, 311 patients with HCIAI were admitted to the ICU. De-escalation was applied in 110 patients (53 %), and no de-escalation was reported in 96 patients (47 %) (escalation in 65 [32 %] and unchanged regimen in 31 [15 %]). Lower proportions of Enterococcus faecium, nonfermenting Gram-negative bacilli (NFGNB), and multidrug-resistant (MDR) strains were cultured in the de-escalation group. No clinical difference was observed at day 7 between patients who were de-escalated and those who were not. Determinants of de-escalation in multivariate analysis were adequate empiric therapy (OR 9.60, 95 % CI 4.02–22.97) and empiric use of vancomycin (OR 3.39, 95 % CI 1.46–7.87), carbapenems (OR 2.64, 95 % CI 1.01–6.91), and aminoglycosides (OR 2.31 95 % CI 1.08–4.94). The presence of NFGNB (OR 0.28, 95 % CI 0.09–0.89) and the presence of MDR bacteria (OR 0.21, 95 % CI 0.09–0.52) were risk factors for non-de-escalation. De-escalation did not change the overall duration of therapy. The risk factors for death at day 28 were presence of fungi (HR 2.64, 95 % CI 1.34–5.17), Sequential Organ Failure Assessment score on admission (HR 1.29, 95 % CI 1.16–1.42), and age (HR 1.03, 95 % CI 1.01–1.05). The survival rate expressed by a Kaplan-Meier curve was similar between groups (log-rank test p value 0.176). Conclusions De-escalation is a feasible option in patients with polymicrobial infections such as HCIAI, but MDR organisms and NFGNB limit its implementation.
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Affiliation(s)
- Philippe Montravers
- Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France. .,Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.
| | - Pascal Augustin
- Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France
| | - Nathalie Grall
- Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.,INSERM, UMR 1137, Infection, Antimicrobiens, Modélisation, Evolution, Paris, France.,Laboratoire de Microbiologie, AP-HP, CHU Bichat-Claude Bernard, Paris, France
| | - Mathieu Desmard
- Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France.,Service de Réanimation, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Nicolas Allou
- Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France
| | - Jean-Pierre Marmuse
- Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.,Service de Chirurgie Générale, APHP, CHU Bichat-Claude Bernard, Paris, France
| | - Jean Guglielminotti
- Département d'Anesthésie Réanimation, APHP, CHU Bichat-Claude Bernard, Paris, France.,Université Denis Diderot, PRESS Sorbonne Cité, Paris, France.,INSERM, UMR 1137, Infection, Antimicrobiens, Modélisation, Evolution, Paris, France
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16
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Indications and Types of Antibiotic Agents Used in 6 Acute Care Hospitals, 2009-2010: A Pragmatic Retrospective Observational Study. Infect Control Hosp Epidemiol 2015; 37:70-9. [PMID: 26456803 DOI: 10.1017/ice.2015.226] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND To design better antimicrobial stewardship programs, detailed data on the primary drivers and patterns of antibiotic use are needed. OBJECTIVE To characterize the indications for antibiotic therapy, agents used, duration, combinations, and microbiological justification in 6 acute-care US facilities with varied location, size, and type of antimicrobial stewardship programs. DESIGN, PARTICIPANTS, AND SETTING Retrospective medical chart review was performed on a random cross-sectional sample of 1,200 adult inpatients, hospitalized (>24 hrs) in 6 hospitals, and receiving at least 1 antibiotic dose on 4 index dates chosen at equal intervals through a 1-year study period (October 1, 2009-September 30, 2010). METHODS Infectious disease specialists recorded patient demographic characteristics, comorbidities, microbiological and radiological testing, and agents used, dose, duration, and indication for antibiotic prescriptions. RESULTS On the index dates 4,119 (60.5%) of 6,812 inpatients were receiving antibiotics. The random sample of 1,200 case patients was receiving 2,527 antibiotics (average: 2.1 per patient); 540 (21.4%) were prophylactic and 1,987 (78.6%) were therapeutic, of which 372 (18.7%) were pathogen-directed at start. Of the 1,615 empirical starts, 382 (23.7%) were subsequently pathogen-directed and 1,231 (76.2%) remained empirical. Use was primarily for respiratory (27.6% of prescriptions) followed by gastrointestinal (13.1%) infections. Fluoroquinolones, vancomycin, and antipseudomonal penicillins together accounted for 47.1% of therapy-days. CONCLUSIONS Use of broad-spectrum empirical therapy was prevalent in 6 US acute care facilities and in most instances was not subsequently pathogen directed. Fluoroquinolones, vancomycin, and antipseudomonal penicillins were the most frequently used antibiotics, particularly for respiratory indications. Infect. Control Hosp. Epidemiol. 2015;37(1):70-79.
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Klein Klouwenberg PMC, Cremer OL, van Vught LA, Ong DSY, Frencken JF, Schultz MJ, Bonten MJ, van der Poll T. Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:319. [PMID: 26346055 PMCID: PMC4562354 DOI: 10.1186/s13054-015-1035-1] [Citation(s) in RCA: 168] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Accepted: 08/15/2015] [Indexed: 12/18/2022]
Abstract
Introduction A clinical suspicion of infection is mandatory for diagnosing sepsis in patients with a systemic inflammatory response syndrome. Yet, the accuracy of categorizing critically ill patients presenting to the intensive care unit (ICU) as being infected or not is unknown. We therefore assessed the likelihood of infection in patients who were treated for sepsis upon admission to the ICU, and quantified the association between plausibility of infection and mortality. Methods We studied a cohort of critically ill patients admitted with clinically suspected sepsis to two tertiary ICUs in the Netherlands between January 2011 and December 2013. The likelihood of infection was categorized as none, possible, probable or definite by post-hoc assessment. We used multivariable competing risks survival analyses to determine the association of the plausibility of infection with mortality. Results Among 2579 patients treated for sepsis, 13% had a post-hoc infection likelihood of “none”, and an additional 30% of only “possible”. These percentages were largely similar for different suspected sites of infection. In crude analyses, the likelihood of infection was associated with increased length of stay and complications. In multivariable analysis, patients with an unlikely infection had a higher mortality rate compared to patients with a definite infection (subdistribution hazard ratio 1.23; 95% confidence interval 1.03-1.49). Conclusions This study is the first prospective analysis to show that the clinical diagnosis of sepsis upon ICU admission corresponds poorly with the presence of infection on post-hoc assessment. A higher likelihood of infection does not adversely influence outcome in this population. Trial registration ClinicalTrials.gov NCT01905033. Registered 11 July 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-1035-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Peter M C Klein Klouwenberg
- Department of Intensive Care Medicine, University Medical Center Utrecht, Room F06.149, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands. .,Department of Medical Microbiology, University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands. .,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Room F06.149, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Lonneke A van Vught
- Center for Experimental and Molecular Medicine and Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - David S Y Ong
- Department of Intensive Care Medicine, University Medical Center Utrecht, Room F06.149, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands. .,Department of Medical Microbiology, University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands. .,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Jos F Frencken
- Department of Intensive Care Medicine, University Medical Center Utrecht, Room F06.149, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands. .,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
| | - Marc J Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands. .,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85500, 3508, GA, Utrecht, The Netherlands.
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine and Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
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Weiss E, Zahar JR, Lesprit P, Ruppe E, Leone M, Chastre J, Lucet JC, Paugam-Burtz C, Brun-Buisson C, Timsit JF, Brun-Buisson C, Bruneel F, Chastre J, Lasocki S, Leone M, Montravers P, Nseir S, Paugam-Burtz C, Pease S, Timsit JF, Weiss E, Wolff M, Alfandari S, Fantin B, Gachot B, Lesprit P, Lucet JC, Potel G, Pulcini C, Rabaud C, Tattevin P, Armand-Lefevre L, Cavallo JD, Jarlier V, Joint-Lambert O, Robert J, Ruppé E, Woerther PL. Elaboration of a consensual definition of de-escalation allowing a ranking of β-lactams. Clin Microbiol Infect 2015; 21:649.e1-10. [DOI: 10.1016/j.cmi.2015.03.013] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 01/05/2015] [Accepted: 03/05/2015] [Indexed: 01/22/2023]
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Barrett J, Edgeworth J, Wyncoll D. Shortening the course of antibiotic treatment in the intensive care unit. Expert Rev Anti Infect Ther 2015; 13:463-71. [PMID: 25645293 DOI: 10.1586/14787210.2015.1008451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Effective antimicrobial stewardship is an increasingly important concern for healthcare providers globally. Antibiotics are frequently prescribed for patients who develop sepsis in the intensive care unit and traditionally courses are prolonged, with uncertain benefit and probable harm. There is little evidence to support many guidelines recommending between 10 and 14 days, and a number of studies suggest substantially shorter courses of less than 7 days may suffice. Safely reducing course length is likely to depend on a number of preconditions, including thorough eradication of any septic foci; optimization of serum antibiotic concentrations, particularly when there is physiological derangement; and use of novel biomarkers such as procalcitonin. The critical care environment is well suited to this aim as patients are closely monitored. With these measures in place, it is reasonable to believe short antibiotic courses can safely be used for the majority of intensive care infections.
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Affiliation(s)
- Jessica Barrett
- Department of Infectious Diseases, Kings College London and Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
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Braykov NP, Morgan DJ, Schweizer ML, Uslan DZ, Kelesidis T, Weisenberg SA, Johannsson B, Young H, Cantey J, Srinivasan A, Perencevich E, Septimus E, Laxminarayan R. Assessment of empirical antibiotic therapy optimisation in six hospitals: an observational cohort study. THE LANCET. INFECTIOUS DISEASES 2014; 14:1220-7. [PMID: 25455989 PMCID: PMC5525058 DOI: 10.1016/s1473-3099(14)70952-1] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Modification of empirical antimicrobials when warranted by culture results or clinical signs is recommended to control antimicrobial overuse and resistance. We aimed to assess the frequency with which patients were started on empirical antimicrobials, characteristics of the empirical regimen and the clinical characteristics of patients at the time of starting antimicrobials, patterns of changes to empirical therapy at different timepoints, and modifiable factors associated with changes to the initial empirical regimen in the first 5 days of therapy. METHODS We did a chart review of adult inpatients receiving one or more antimicrobials in six US hospitals on 4 days during 2009 and 2010. Our primary outcome was the modification of antimicrobial regimen on or before the 5th day of empirical therapy, analysed as a three-category variable. Bivariate analyses were used to establish demographic and clinical variables associated with the outcome. Variables with p values below 0·1 were included in a multivariable generalised linear latent and mixed model with multinomial logit link to adjust for clustering within hospitals and accommodate a non-binary outcome variable. FINDINGS Across the six study sites, 4119 (60%) of 6812 inpatients received antimicrobials. Of 1200 randomly selected patients with active antimicrobials, 730 (61%) met inclusion criteria. At the start of therapy, 220 (30%) patients were afebrile and had normal white blood cell counts. Appropriate cultures were collected from 432 (59%) patients, and 250 (58%) were negative. By the 5th day of therapy, 12·5% of empirical antimicrobials were escalated, 21·5% were narrowed or discontinued, and 66·4% were unchanged. Narrowing or discontinuation was more likely when cultures were collected at the start of therapy (adjusted OR 1·68, 95% CI 1·05-2·70) and no infection was noted on an initial radiological study (1·76, 1·11-2·79). Escalation was associated with multiple infection sites (2·54, 1·34-4·83) and a positive culture (1·99, 1·20-3·29). INTERPRETATION Broad-spectrum empirical therapy is common, even when clinical signs of infection are absent. Fewer than one in three inpatients have their regimens narrowed within 5 days of starting empirical antimicrobials. Improved diagnostic methods and continued education are needed to guide discontinuation of antimicrobials. FUNDING US Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion; Robert Wood Johnson Foundation; US Department of Veterans Administration; US Department of Homeland Security.
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Affiliation(s)
- Nikolay P Braykov
- Center for Disease Dynamics, Economics and Policy, Washington, DC, USA
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marin L Schweizer
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Daniel Z Uslan
- Infectious Diseases, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Theodoros Kelesidis
- Infectious Diseases, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | | | - Birgir Johannsson
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Heather Young
- Infectious Diseases, Denver Health Medical Center, Denver, CO, USA
| | - Joseph Cantey
- Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Eli Perencevich
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA
| | - Edward Septimus
- Clinical Services Group, HCA Inc, Nashville, TN, USA; Texas A&M Health Science Center College of Medicine, Houston, TX, USA
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics and Policy, Washington, DC, USA; Public Health Foundation of India, New Delhi, India; Princeton University, Princeton, NJ, USA.
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De Waele JJ, Bassetti M, Martin-Loeches I. Impact of de-escalation on ICU patients' prognosis. Intensive Care Med 2014; 40:1583-5. [PMID: 25217149 DOI: 10.1007/s00134-014-3488-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 09/04/2014] [Indexed: 12/12/2022]
Affiliation(s)
- Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium,
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Cotta MO, Roberts JA, Tabah A, Lipman J, Vogelaers D, Blot S. Antimicrobial stewardship of β-lactams in intensive care units. Expert Rev Anti Infect Ther 2014; 12:581-95. [DOI: 10.1586/14787210.2014.902308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Trying to win the war against antibiotics resistance. Crit Care Med 2012. [DOI: 10.1097/ccm.0b013e318270e3b4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Levin PD, Idrees S, Sprung CL, Weissman C, Weiss Y, Moses AE, Benenson S. Antimicrobial use in the ICU: indications and accuracy--an observational trial. J Hosp Med 2012; 7:672-8. [PMID: 22865497 DOI: 10.1002/jhm.1964] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2012] [Revised: 05/31/2012] [Accepted: 06/19/2012] [Indexed: 11/05/2022]
Abstract
BACKGROUND In intensive care unit (ICU) patients, signs of infection and inflammation are similar, making diagnosis of bacterial infections difficult. Antimicrobials may therefore be overused, contributing to development of antimicrobial-resistant bacteria. OBJECTIVES To measure the accuracy of clinician decisions to start antimicrobials; to correlate clinician certainty with the presence of infection; and to examine whether physiological variables correlate with clinician certainty. DESIGN Prospective observational study. SETTING AND PATIENTS Patients staying >48 hours in a general ICU of a tertiary care hospital. MEASUREMENTS The ICU clinician's certainty for the presence of infection was recorded when starting antimicrobials. An independent infectious diseases (ID) specialist determined if antimicrobials were required and if infection was present. Clinician antibiotic start decisions were tested for accuracy according to the ID determination for the presence of infection. RESULTS Empirical antimicrobial therapy was justified by the presence of infection on 67/125 (54%) occasions. Clinician certainty for infection correlated well with the presence of defined infection (r(2) = 0.78), however, infection was defined on 6/19 (31%) occasions when ICU clinician certainty was low (≤2), and antimicrobials were prescribed even when clinician certainty was minimal. Antimicrobial course length was similar whether infection was defined or not (11.5 ± 9.2 vs 10.7 ± 9.1 days; P = 0.65). Physiological variables were not associated with clinician certainty of infection. CONCLUSIONS Antimicrobial therapy is probably overused in the ICU, possibly resulting from difficulties in diagnosis and the perceived greater risk of untreated infection when compared to the risks of potentially unnecessary antimicrobial therapy. Efforts to improve antimicrobial-related decision-making should be mandatory.
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Affiliation(s)
- Phillip D Levin
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
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Williams A, Mathai AS, Phillips AS. Antibiotic prescription patterns at admission into a tertiary level intensive care unit in Northern India. J Pharm Bioallied Sci 2012; 3:531-6. [PMID: 22219587 PMCID: PMC3249701 DOI: 10.4103/0975-7406.90108] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Revised: 04/18/2011] [Accepted: 05/15/2011] [Indexed: 01/11/2023] Open
Abstract
Context: An audit of antibiotic prescribing patterns is an important indicator of the quality and standard of clinical practice. Aims: To study the (1) antibiotic prescription and consumption patterns at admission into the intensive care unit (ICU); (2) average costs of antibiotics prescribed; and (3) correlation of antibiotic usage and the costs incurred with age, severity of illness, and diagnosis. Settings and Design: A 13-bedded tertiary level ICU. A prospective, observational audit. Materials and Methods: Two hundred consecutive prescriptions on patients admitted to the ICU from August to October, 2008, were audited. The total number of drugs and antibiotics, the class, dose, route, and cost of antibiotics were noted and the Defined Daily Dose/100 bed-days (DDD/100 bed-days) of the 10 most frequently prescribed antibiotics were calculated. Statistical analysis used: Univariate analysis was performed using Epi Info software (version 8.0). Results: A total of 1246 drugs and 418 antibiotics were prescribed in the 200 patients studied, that is, an average of 6.23 (± SD 2.73) drugs/prescription and 2.09 (± SD 1.27) antibiotics/prescription. Antibiotics were prescribed on 190 patients (95%) at admission. There was a significant correlation between the number of patients prescribed three or more antibiotics and mortality rates (53% nonsurvivors vs. 33.5% survivors (P = 0.015). The average cost of the antibiotics was Rupees 1995.08 (± SD 2099.99) per patient and antibiotics expenditure accounted for 73.2% of the total drug costs. Conclusions: Antibiotics are commonly prescribed to most ICU patients at admission and contribute significantly to the total drug costs. Antibiotic restriction policies and a multidisciplinary effort to reduce usage are urgently required.
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Affiliation(s)
- Aparna Williams
- Departments of Anesthesiology and Critical Care, Christian Medical College, Ludhiana, Punjab, India
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