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Willems J, Heyndrickx A, Schelstraete P, Gadeyne B, De Cock P, Vandendriessche S, Depuydt P. The use of information technology to improve interdisciplinary communication during infectious diseases ward rounds on the paediatric intensive care unit. Sci Rep 2024; 14:1657. [PMID: 38238516 PMCID: PMC10796760 DOI: 10.1038/s41598-024-51986-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/11/2024] [Indexed: 01/22/2024] Open
Abstract
Prospective audit with feedback during infectious diseases ward rounds (IDWR) is a common antimicrobial stewardship (AMS) practice on the Paediatric Intensive Care Unit (PICU). These interdisciplinary meetings rely on the quality of handover, with high risk of omission of information. We developed an electronic platform integrating infection-related patient data (COSARAPed). In the mixed PICU of a Belgian tertiary hospital we conducted an observational prospective cohort study comparing patient handovers during IDWRs using the COSARAPed-platform to those with access only to conventional resources. The quality of handover was investigated directly by assessment if the narrative was in accordance with Situation-Background-Assessment-Recommendation principles and if adequate demonstration of diagnostic information occurred, and also indirectly by registration if this was only achieved after intervention by the non-presenting AMS team members. We also recorded all AMS-recommendations. During a 6-month study period, 24 IDWRs and 82 patient presentations were assessed. We could only find a statistically significant advantage in favor of COSARAPed by indirect evaluation. We registered 92 AMS-recommendations, mainly resulting in reduced antibiotic pressure. We concluded that the IDWR is an appropriate platform for AMS on the PICU and that the utilisation of COSARAPed may enhance the quality of patient handover.
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Affiliation(s)
- Jef Willems
- Department of Critical Care, Paediatric Intensive Care Unit, Ghent University Hospital, 1K12-D, Corneel Heymanslaan 10, 9000, Ghent, Belgium.
| | | | - Petra Schelstraete
- Department of Paediatrics, Paediatric Pneumology and Infectious Diseases, Ghent University Hospital, Ghent, Belgium
| | - Bram Gadeyne
- Department of Critical Care, Intensive Care Unit, Ghent University Hospital, Ghent, Belgium
| | - Pieter De Cock
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
- Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - Stien Vandendriessche
- Department of Laboratory Medicine, Medical Microbiology, Ghent University Hospital, Ghent, Belgium
| | - Pieter Depuydt
- Department of Critical Care, Intensive Care Unit, Ghent University Hospital, Ghent, Belgium
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Delanghe JR, Himpe J, Boelens J, Benoit D, Gadeyne B, Speeckaert MM, Verbeke F. C-reactive protein interacts with amphotericin B liposomes and its potential clinical consequences. Clin Chem Lab Med 2023; 61:1065-1068. [PMID: 36691951 DOI: 10.1515/cclm-2022-1213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/13/2023] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Amphotericin B (AmB) is the gold standard for treating invasive fungal infections. New liposomal-containing AmB formulations have been developed to improve efficacy and tolerability. Serum/plasma C-reactive protein (CRP) values are widely used for monitoring infections and inflammation. CRP shows a high affinity to phosphocholine and it aggregates structures bearing this ligand, e.g. phosphocholine-containing liposomes. Therefore, we studied the interaction between CRP and phosphocholine-containing liposomal AmB preparations in vivo and in vitro. METHODS CRP was prepared by affinity chromatography. Liposomal AmB (L-AmB, AmBisome®) was spiked (final concentrations of L-AmB: 150 mg/L) to CRP-containing serum (final CRP concentration: 300 mg/L). Following the addition of L-AmB, complex formation was monitored turbidimetrically. The size of CRP-L-AmB complexes was assessed using gel filtration. CRP was monitored in patients receiving either L-Amb or AmB lipid complex (ABLC). RESULTS Following addition of L-AmB to CRP-containing plasma, turbidimetry showed an increase in absorbance. These results were confirmed by gel permeation chromatography. Similarly, in vivo effects were observed following intravenous administration of AmBisome®: a decline in CRP values was observed. In patients receiving L-Amb, decline of CRP concentration was faster than in patients receiving ABLC. CONCLUSIONS In vitro experiments are suggestive of a complexation between CRP and liposomes in plasma. Interpretation of CRP values following administration of AmBisome® might be impaired due to this complexation. In vivo formation of complexes between liposomes and CRP might contribute, or even lead, to intravascular microembolisation. Similar effects have been described following the administration of Intralipid® and other phosphocholine-containing liposomes.
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Affiliation(s)
- Joris R Delanghe
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Jonas Himpe
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Jerina Boelens
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Dominique Benoit
- Department of Internal Medicine, Ghent University Hospital, Ghent, Belgium
| | - Bram Gadeyne
- Department of Development of Healthcare Applications, Ghent University Hospital, Ghent, Belgium
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Fierens J, De Bus L, Colpaert K, Boelens J, Gadeyne B, Decruyenaere J, Van Braeckel E, Depuydt P. Antimicrobial prescription in severe COVID-19 and CAP: a matched case-control study. Acta Clin Belg 2021; 77:837-844. [PMID: 34709997 DOI: 10.1080/17843286.2021.1996068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND In severe coronavirus diseases 2019 (COVID-19), a high and potentially excessive use of antimicrobials for suspected bacterial co-infection and intensive care unit (ICU)-acquired infections has been repeatedly reported. OBJECTIVES To compare an ICU cohort of community-acquired pneumonia (CAP) with a cohort of severe COVID-19 pertaining to co-infections, ICU-acquired infections and associated antimicrobial consumption. METHODS We retrospectively compared a cohort of CAP patients with a cohort of COVID-19 patients matched according to organ failure, ICU length of stay (LOS) and ventilation days. Patient data such as demographics, infection focus, probability and severity, ICU severity scores and ICU and in-hospital mortality, days of antimicrobial therapy (DOT) and number of antimicrobial prescriptions, using an incremental scale, were registered and analysed. The total number of cultures (sputum, urinary, blood cultures) was collected and corrected for ICU LOS. FINDINGS CAP patients (n = 148) were matched to COVID-19 patients (n = 74). Significantly less sputum cultures (68.2% versus 18.9%, P < 0.05) and bronchoalveolar lavages (BAL) (73.7% versus 36.5%, P < 0.05) were performed in COVID-19 patients. Six (8.1%) COVID-19 patients were diagnosed with a co-infection. Respectively, 58 of 148 (39.2%) CAP and 38 of 74 (51.4%) COVID-19 patients (P = 0.09) developed ICU-acquired infections. Antimicrobial distribution, both in the number of prescriptions and DOT, was similar in both cohorts. CONCLUSIONS We found a low rate of microbiologically confirmed bacterial co-infection and a high rate of ICU-acquired infections in COVID-19 patients. Infection probabilities, antimicrobial prescriptions and DOT were comparable with a matched CAP cohort.
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Affiliation(s)
- J. Fierens
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - L. De Bus
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - K. Colpaert
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - J. Boelens
- Department of Laboratory Medicine and Department of Diagnostic Sciences, Ghent University Hospital and Ghent University, Ghent, Belgium
| | - B. Gadeyne
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - J. Decruyenaere
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - E. Van Braeckel
- Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - P. Depuydt
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
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Dhaese SAM, Colin P, Willems H, Heffernan A, Gadeyne B, Van Vooren S, Depuydt P, Hoste E, Stove V, Verstraete AG, Lipman J, Roberts JA, De Waele JJ. Saturable elimination of piperacillin in critically ill patients: implications for continuous infusion. Int J Antimicrob Agents 2019; 54:741-749. [PMID: 31479741 DOI: 10.1016/j.ijantimicag.2019.08.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/29/2019] [Accepted: 08/24/2019] [Indexed: 12/24/2022]
Abstract
The study aimed to evaluate saturation of piperacillin elimination in critically ill adult patients. Seventeen critically ill adult patients received continuous and intermittent infusion of piperacillin/tazobactam. Piperacillin plasma concentrations (n = 217) were analysed using population pharmacokinetic (PopPK) modelling. Post-hoc simulations were performed to evaluate the type I error rate associated with the study. Unseen data were used to validate the final model. The mean error (ME) and root mean square error (RMSE) were calculated as a measure of bias and imprecision, respectively. A PopPK model with parallel linear and non-linear elimination best fitted the data. The median and 95% confidence interval (CI) for the model parameters drug clearance (CL), volume of central compartment (V), volume of peripheral compartment (Vp) and intercompartmental clearance (Q) were 9 (7.69-11) L/h, 6.18 (4.93-11.2) L, 11.17 (7.26-12) L and 15.61 (12.66-23.8) L/h, respectively. The Michaelis-Menten constant (Km) and the maximum elimination rate for Michaelis-Menten elimination (Vmax) were estimated without population variability in the model to avoid overfitting and inflation of the type I error rate. The population estimates for Km and Vmax were 37.09 mg/L and 353.57 mg/h, respectively. The bias (ME) was -20.8 (95% CI -26.2 to -15.4) mg/L, whilst imprecision (RMSE) was 49.2 (95% CI 41.2-56) mg/L. In conclusion, piperacillin elimination is (partially) saturable. Moreover, the population estimate for Km lies within the therapeutic window and therefore saturation of elimination should be accounted for when defining optimum dosing regimens for piperacillin in critically ill patients.
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Affiliation(s)
- S A M Dhaese
- Ghent University Hospital, Department of Critical Care Medicine, C. Heymanslaan 10, 9000 Ghent, Belgium.
| | - P Colin
- University of Groningen, University Medical Center Groningen, Department of Anesthesiology, Groningen, The Netherlands; Ghent University, Laboratory of Medical Biochemistry and Clinical Analysis, Ghent, Belgium
| | - H Willems
- Ghent University Hospital, Department of Critical Care Medicine, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - A Heffernan
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; School of Medicine, Griffith University, Southport, QLD, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - B Gadeyne
- Ghent University Hospital, Department of Critical Care Medicine, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - S Van Vooren
- Ghent University, Department of Diagnostic Sciences, Ghent, Belgium
| | - P Depuydt
- Ghent University Hospital, Department of Critical Care Medicine, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - E Hoste
- Ghent University Hospital, Department of Critical Care Medicine, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - V Stove
- Ghent University, Department of Diagnostic Sciences, Ghent, Belgium; Ghent University Hospital, Department of Laboratory Medicine, Ghent, Belgium
| | - A G Verstraete
- Ghent University, Department of Diagnostic Sciences, Ghent, Belgium; Ghent University Hospital, Department of Laboratory Medicine, Ghent, Belgium
| | - J Lipman
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; Royal Brisbane and Women's Hospital, Department of Intensive Care Medicine, Brisbane, QLD, Australia; CHU Nîmes, Department of Anesthesiology and Critical Care, Nîmes, France
| | - J A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia; Royal Brisbane and Women's Hospital, Department of Intensive Care Medicine, Brisbane, QLD, Australia; Royal Brisbane and Women's Hospital, Department of Pharmacy, Brisbane, QLD, Australia
| | - J J De Waele
- Ghent University Hospital, Department of Critical Care Medicine, C. Heymanslaan 10, 9000 Ghent, Belgium
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De Bus L, Gadeyne B, Steen J, Boelens J, Claeys G, Benoit D, De Waele J, Decruyenaere J, Depuydt P. A complete and multifaceted overview of antibiotic use and infection diagnosis in the intensive care unit: results from a prospective four-year registration. Crit Care 2018; 22:241. [PMID: 30268142 PMCID: PMC6162888 DOI: 10.1186/s13054-018-2178-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/05/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Preparing an antibiotic stewardship program requires detailed information on overall antibiotic use, prescription indication and ecology. However, longitudinal data of this kind are scarce. Computerization of the patient chart has offered the potential to collect complete data of high resolution. To gain insight in our global antibiotic use, we aimed to explore antibiotic prescription in our intensive care unit (ICU) from various angles over a prolonged time period. METHODS We studied all adult patients admitted to Ghent University Hospital ICU from 1 January 2013 until 31 December 2016. Antibiotic prescription data were prospectively merged with diagnostic (suspected focus, severity and probability of infection at the time of prescription, or prophylaxis) and microbiology data by ICU physicians during daily workflow through dedicated software. Definite focus of infection and probability of infection (classified as high/moderate/low) were reassessed by dedicated ICU physicians at patient discharge. RESULTS During the study period, 8763 patients were admitted and overall antibiotic consumption amounted to 1232 days of therapy (DOT)/1000 patient days. Antibacterial DOT (84% of total DOT) were linked with infection in 80%; the predominant foci were the respiratory tract (49%) and the abdomen (19%). A microbial cause was identified in 56% (3169/5686). Moderate/low probability infections accounted for 42% of antibacterial DOT prescribed for respiratory tract infections; for abdominal infections, this figure was 15%. The median treatment duration of moderate/low probability respiratory infections was 4 days (IQR 3-7). Antifungal DOT (16% of total DOT) were linked with infection in 47% of total antifungal DOT. Antifungal prophylaxis was primarily administered in the surgical ICU (76%), with a median duration of 4 DOT (IQR 2-9). CONCLUSIONS By prospectively combining antibiotic, microbiology and clinical data we were able to construct a longitudinal, multifaceted dataset on antibiotic use and infection diagnosis. A complete overview of this kind may allow the identification of antibiotic prescription patterns that require future antibiotic stewardship attention.
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Affiliation(s)
- Liesbet De Bus
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
| | - Bram Gadeyne
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Johan Steen
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Jerina Boelens
- Department of Laboratory Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Geert Claeys
- Department of Laboratory Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Dominique Benoit
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Jan De Waele
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Johan Decruyenaere
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Pieter Depuydt
- Department of Critical Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.,Heymans Institute of Pharmacology, Ghent University, C. Heymanslaan 10, 9000, Ghent, Belgium
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Druwé P, Monsieurs KG, Piers R, Gagg J, Nakahara S, Alpert EA, van Schuppen H, Élő G, Truhlář A, Huybrechts SA, Mpotos N, Joly LM, Xanthos T, Roessler M, Paal P, Cocchi MN, BjØrshol C, Pauliková M, Nurmi J, Salmeron PP, Owczuk R, Svavarsdóttir H, Deasy C, Cimpoesu D, Ioannides M, Fuenzalida PA, Kurland L, Raffay V, Pachys G, Gadeyne B, Steen J, Vansteelandt S, De Paepe P, Benoit DD. Perception of inappropriate cardiopulmonary resuscitation by clinicians working in emergency departments and ambulance services: The REAPPROPRIATE international, multi-centre, cross sectional survey. Resuscitation 2018; 132:112-119. [PMID: 30218746 DOI: 10.1016/j.resuscitation.2018.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/16/2018] [Accepted: 09/09/2018] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Cardiopulmonary resuscitation (CPR) is often started irrespective of comorbidity or cause of arrest. We aimed to determine the prevalence of perception of inappropriate CPR of the last cardiac arrest encountered by clinicians working in emergency departments and out-of-hospital, factors associated with perception, and its relation to patient outcome. METHODS A cross-sectional survey was conducted in 288 centres in 24 countries. Factors associated with perception of CPR and outcome were analyzed by Cochran-Mantel-Haenszel tests and conditional logistic models. RESULTS Of the 4018 participating clinicians, 3150 (78.4%) perceived their last CPR attempt as appropriate, 548 (13.6%) were uncertain about its appropriateness and 320 (8.0%) perceived inappropriateness; survival to hospital discharge was 370/2412 (15.3%), 8/481 (1.7%) and 8/294 (2.7%) respectively. After adjusting for country, team and clinician's characteristics, the prevalence of perception of inappropriate CPR was higher for a non-shockable initial rhythm (OR 3.76 [2.13-6.64]; P < .0001), a non-witnessed arrest (2.68 [1.89-3.79]; P < .0001), in older patients (2.94 [2.18-3.96]; P < .0001, for patients >79 years) and in case of a "poor" first physical impression of the patient (3.45 [2.36-5.05]; P < .0001). In accordance, non-shockable and non-witnessed arrests were both associated with lower survival to hospital discharge (0.33 [0.26-0.41]; P < 0.0001 and 0.25 [0.15-0.41]; P < 0.0001, respectively), as were older patient age (0.25 [0.14-0.44]; P < 0.0001 for patients >79 years) and a "poor" first physical impression (0.26 [0.19-0.35]; P < 0.0001). CONCLUSIONS The perception of inappropriate CPR increased when objective indicators of poor prognosis were present and was associated with a low survival to hospital discharge. Factoring clinical judgment into the decision to (not) attempt CPR may reduce harm inflicted by excessive resuscitation attempts.
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Affiliation(s)
- Patrick Druwé
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium.
| | | | - Ruth Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - James Gagg
- Department of Emergency Medicine, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | | | | | - Hans van Schuppen
- Department of Anesthesiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gábor Élő
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Kralove Region and University Hospital Hradec Kralove, Czech Republic
| | - Sofie A Huybrechts
- Department of Emergency Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Nicolas Mpotos
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Luc-Marie Joly
- Department of Emergency Medicine, Rouen University Hospital, Rouen, France
| | - Theodoros Xanthos
- European University, Nicosia, Cyprus, Hellenic Society of Cardiopulmonary Resuscitation, Athens, Greece
| | - Markus Roessler
- Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen, Germany
| | - Peter Paal
- Department of Anesthesiology and Critical Care Medicine, University Hospital Innsbruck, Austria
| | - Michael N Cocchi
- Harvard Medical School, Department of Emergency Medicine and Department of Anesthesia, Critical Care and Pain Medicine, Division of Critical Care, Beth Israel Deaconess Medical Center, USA
| | - Conrad BjØrshol
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, The Regional Centre for Emergency Medical Research and Development (RAKOS), Department of Clinical Medicine, University of Bergen, Norway
| | - Monika Pauliková
- Department of Anesthesiology and Intensive Care, East Slovak Institute of Oncology, Košice, Slovakia
| | - Jouni Nurmi
- Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | | | - Radoslaw Owczuk
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Gdansk, Poland
| | | | - Conor Deasy
- Department of Emergency Medicine, Cork University Hospital, Cork, Republic of Ireland
| | - Diana Cimpoesu
- University of Medicine and Pharmacy Gr.T. Popa and Emergency County Hospital Sf. Spiridon, Iasi, Romania
| | | | | | - Lisa Kurland
- Department of Medical Sciences, Örebro University and Department of Clinical Research and Education, Karolinska Institute, Stockholm, Sweden
| | - Violetta Raffay
- Municipal Institute for Emergency Medicine, Novi Sad, Serbia
| | - Gal Pachys
- Emergency Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Bram Gadeyne
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Johan Steen
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Stijn Vansteelandt
- Department of Applied Mathematics, Computer Science and Statistics, Faculty of Sciences, Ghent University, Ghent, Belgium; Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter De Paepe
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
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Benoit DD, Jensen HI, Malmgren J, Metaxa V, Reyners AK, Darmon M, Rusinova K, Talmor D, Meert AP, Cancelliere L, Zubek L, Maia P, Michalsen A, Vanheule S, Kompanje EJO, Decruyenaere J, Vandenberghe S, Vansteelandt S, Gadeyne B, Van den Bulcke B, Azoulay E, Piers RD. Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA. Intensive Care Med 2018; 44:1039-1049. [PMID: 29808345 PMCID: PMC6061457 DOI: 10.1007/s00134-018-5231-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 05/14/2018] [Indexed: 01/01/2023]
Abstract
Purpose Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown. Methods In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis. Results Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former. Conclusion Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life. Electronic supplementary material The online version of this article (10.1007/s00134-018-5231-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- D D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
| | - H I Jensen
- Department of Intensive Care Medicine, Vejle Hospital, Vejle, Denmark
- Institute of Regional Research, University of Southern Denmark, Odense C, Denmark
| | - J Malmgren
- Department of Anaesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - V Metaxa
- King's College Hospital, London, UK
| | - A K Reyners
- Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M Darmon
- Hôpital Saint-Louis and University, Paris-7, Paris, France
| | - K Rusinova
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - D Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - A P Meert
- Service des soins intensifs et urgences oncologiques, Institut Jules Bordet, ULB, Brussels, Belgium
| | - L Cancelliere
- SCDU Anestesia e Rianimazione, Azienda and Ospedaliero Universitaria, "Maggiore della Carità", Novara, Italy
| | - L Zubek
- Semmelweis University Budapest, Budapest, Hungary
| | - P Maia
- Intensive Care Department, Hospital S.António, Porto, Portugal
| | | | - S Vanheule
- Department of Psycho-analysis and Clinical Consulting, Faculty of Psychology and Educational Sciences, Ghent University, Ghent, Belgium
| | - E J O Kompanje
- Department of Intensive Care Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J Decruyenaere
- Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - S Vandenberghe
- Department of Applied Mathematics, Computer Science and Statistics, Faculty of Sciences, Ghent University, Ghent, Belgium
| | - S Vansteelandt
- Department of Applied Mathematics, Computer Science and Statistics, Faculty of Sciences, Ghent University, Ghent, Belgium
- London School of Hygiene and Tropical Medicine, London, UK
| | - B Gadeyne
- Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - B Van den Bulcke
- Department of Intensive Care Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - E Azoulay
- Hôpital Saint-Louis and University, Paris-7, Paris, France
| | - R D Piers
- Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
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De Bus L, Denys W, Catteeuw J, Gadeyne B, Vermeulen K, Boelens J, Claeys G, De Waele JJ, Decruyenaere J, Depuydt PO. Impact of de-escalation of beta-lactam antibiotics on the emergence of antibiotic resistance in ICU patients: a retrospective observational study. Intensive Care Med 2016; 42:1029-39. [PMID: 27025939 DOI: 10.1007/s00134-016-4301-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 02/29/2016] [Indexed: 01/17/2023]
Abstract
PURPOSE Antibiotic de-escalation is promoted to limit prolonged exposure to broad-spectrum antibiotics, but proof that it prevents the emergence of resistance is lacking. We evaluated determinants of antibiotic de-escalation in an attempt to assess whether the latter is associated with a lower emergence of antimicrobial resistance. METHODS Antibiotic treatments, starting with empirical beta-lactam prescriptions, were prospectively documented during 2013 and 2014 in a tertiary intensive care unit (ICU) and categorized as continuation, de-escalation or escalation of the empirical antimicrobial treatment. Determinants of the de-escalation or escalation treatments were identified by multivariate logistic regression; the continuation category was used as the reference group. Using systematically collected diagnostic and surveillance cultures, we estimated the cumulative incidence of antimicrobial resistance following de-escalation or continuation of therapy, with adjustment for ICU discharge and death as competing risks. RESULTS Of 478 anti-pseudomonal antibiotic prescriptions, 42 (9 %) were classified as escalation of the antimicrobial treatment and 121 (25 %) were classified as de-escalation, mainly through replacement of the originally prescribed antibiotics with those having a narrower spectrum. In multivariate analysis, de-escalation was associated with the identification of etiologic pathogens (p < 0.001). The duration of the antibiotic course in the ICU in de-escalated versus continued prescriptions was 8 (range 6-10) versus 5 (range 4-7) days, respectively (p < 0.001). Mortality did not differ between patients in the de-escalation and continuation categories. The cumulative incidence estimates of the emergence of resistance to the initial beta-lactam antibiotic on day 14 were 30.6 and 23.5 % for de-escalation and continuation, respectively (p = 0.22). For the selection of multi-drug resistant pathogens, these values were 23.5 (de-escalation) and 18.6 % (continuation) respectively (p = 0.35). CONCLUSION The emergence of antibiotic-resistant bacteria after exposure to anti-pseudomonal beta-lactam antibiotics was not lower following de-escalation.
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Affiliation(s)
- Liesbet De Bus
- Department of Critical Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Wouter Denys
- Department of Critical Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - Julie Catteeuw
- Department of Critical Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - Bram Gadeyne
- Department of Critical Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - Karel Vermeulen
- Department of Mathematical Modelling, Statistics and Bioinformatics, Ghent University, Ghent, Belgium
| | - Jerina Boelens
- Department of Laboratory Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - Geert Claeys
- Department of Laboratory Medicine, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - Johan Decruyenaere
- Department of Critical Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
| | - Pieter O Depuydt
- Department of Critical Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
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Catteeuw J, De Bus L, Denys W, Gadeyne B, De Waele JJ, Decruyenaere J, Depuydt PO. DE-ESCALATING ANTI-PSEUDOMONAL β-LACTAMS. Intensive Care Med Exp 2015. [PMCID: PMC4798580 DOI: 10.1186/2197-425x-3-s1-a3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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De Bus L, Saerens L, Gadeyne B, Boelens J, Claeys G, De Waele JJ, Benoit DD, Decruyenaere J, Depuydt PO. Development of antibiotic treatment algorithms based on local ecology and respiratory surveillance cultures to restrict the use of broad-spectrum antimicrobial drugs in the treatment of hospital-acquired pneumonia in the intensive care unit: a retrospective analysis. Crit Care 2014; 18:R152. [PMID: 25030270 PMCID: PMC4223549 DOI: 10.1186/cc13990] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 06/23/2014] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Timely administration of appropriate antibiotic therapy has been shown to improve outcome in hospital-acquired pneumonia (HAP). Empirical treatment guidelines tailored to local ecology have been advocated in antibiotic stewardship programs. We compared a local ecology based algorithm (LEBA) to a surveillance culture based algorithm (SCBA) in terms of appropriate coverage and spectrum of antimicrobial activity. METHODS We retrospectively assessed 2 hypothetical empirical antibiotic treatment algorithms for HAP on an existing high-quality prospectively collected database in a mixed 36-bed tertiary intensive care unit (ICU). Data on consecutive episodes of microbiologically confirmed HAP were collected over a period of 40 months and divided in a derivation (1 July 2009 to 31 October 2010) and validation (1 November 2010 until 31 October 2012) cohort. On the derivation cohort we constructed a LEBA, based on overall observed bacterial resistance patterns, and a SCBA, which targeted therapy to surveillance culture (SC) in the individual patient. Therapy was directed against pathogens found in respiratory SC collected two to five days before HAP, and in the absence of these, presence or absence of multi-drug resistant (MDR) pathogens in other SC dictated broad-spectrum, respectively narrow spectrum antibiotic therapy. Subsequently, LEBA and SCBA were retrospectively reviewed and compared with actually prescribed antibiotics in the validation cohort. RESULTS The first 100 HAP episodes made up the derivation cohort and the subsequent 113 HAP episodes the validation cohort. Appropriate antibiotic coverage rates by applying LEBA and SCBA were 88.5% and 87.6%, respectively, and did not differ significantly with respect to appropriateness of the actually prescribed initial therapy (84.1%). SCBA proposed more narrow spectrum therapy as compared to LEBA and the actually prescribed antimicrobials (P <0.001). SCBA recommended significantly less combination therapy and carbapenems compared to LEBA (P <0.001). SCBA targeted antibiotics to recent respiratory SC in 38.1% (43 out of 113 episodes) of HAP; in these cases adequacy was 93% (40 out of 43). CONCLUSION Rates of appropriate antimicrobial coverage were identical in LEBA and SCBA. However, in this setting of moderate MDR prevalence, the use of SCBA would result in a significant reduction of the use of broad-spectrum drugs and may be a preferential strategy when implementing antibiotic stewardship programs.
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De Bus L, Diet G, Gadeyne B, Leroux-Roels I, Claeys G, Steurbaut K, Benoit D, De Turck F, Decruyenaere J, Depuydt P. Validity analysis of a unique infection surveillance system in the intensive care unit by analysis of a data warehouse built through a workflow-integrated software application. J Hosp Infect 2014; 87:159-64. [PMID: 24856115 DOI: 10.1016/j.jhin.2014.03.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 03/30/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND An electronic decision support programme was developed within the intensive care unit (ICU) that provides an overview of all infection-related patient data, and allows ICU physicians to add clinical information during patient rounds, resulting in prospective compilation of a database. AIM To assess the validity of computer-assisted surveillance (CAS) of ICU-acquired infection performed by analysis of this database. METHODS CAS was compared with prospective paper-based surveillance (PBS) for ICU-acquired respiratory tract infection (RTI), bloodstream infection (BSI) and urinary tract infection (UTI) over four months at a 36-bed medical and surgical ICU. An independent panel reviewed the data in the case of discrepancy between CAS and PBS. FINDINGS PBS identified 89 ICU-acquired infections (13 BSI, 18 UTI, 58 RTI) and CAS identified 90 ICU-acquired infections (14 BSI, 17 UTI, 59 RTI) in 876 ICU admissions. There was agreement between CAS and PBS on 13 BSI (100 %), 14 UTI (77.8 %) and 42 RTI (72.4 %). Overall, there was agreement on 69 infections (77.5%), resulting in a kappa score of 0.74. Discrepancy between PBS and CAS was the result of capture error in 11 and 14 infections, respectively. Interobserver disagreement on probability (13 RTI) and focus (two RTI, one UTI) occurred for 16 episodes. The time required to collect information using CAS is less than 30% of the time required when using PBS. CONCLUSION CAS for ICU-acquired infection by analysis of a database built through daily workflow is a feasible surveillance method and has good agreement with PBS. Discrepancy between CAS and PBS is largely due to interobserver variability.
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Affiliation(s)
- L De Bus
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium.
| | - G Diet
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - B Gadeyne
- Department of Information Technology, Ghent University - iMinds, Ghent, Belgium
| | - I Leroux-Roels
- Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
| | - G Claeys
- Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
| | - K Steurbaut
- Department of Information Technology, Ghent University - iMinds, Ghent, Belgium
| | - D Benoit
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - F De Turck
- Department of Information Technology, Ghent University - iMinds, Ghent, Belgium
| | - J Decruyenaere
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - P Depuydt
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
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