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Riezk A, Wilson RC, Cass AEG, Holmes AH, Rawson TM. A low-volume LC/MS method for highly sensitive monitoring of phenoxymethylpenicillin, benzylpenicillin, and probenecid in human serum. Anal Methods 2024; 16:558-565. [PMID: 38189092 PMCID: PMC10809906 DOI: 10.1039/d3ay01816d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/27/2023] [Indexed: 01/09/2024]
Abstract
Background: The optimization of antimicrobial dosing plays a crucial role in improving the likelihood of achieving therapeutic success while reducing the risks associated with toxicity and antimicrobial resistance. Probenecid has shown significant potential in enhancing the serum exposure of phenoxymethylpenicillin, thereby allowing for lower doses of phenoxymethylpenicillin to achieve similar pharmacokinetic/pharmacodynamic (PK/PD) targets. We developed a triple quadrupole liquid chromatography mass spectrometry (TQ LC/MS) analysis of, phenoxymethylpenicillin, benzylpenicillin and probenecid using benzylpenicillin-d7 and probenecid-d14 as IS in single low-volumes of human serum, with improved limit of quantification to support therapeutic drug monitoring. Methods: Sample clean-up was performed by protein precipitation using acetonitrile. Reverse phase chromatography was performed using TQ LC/MS. The mobile phase consisted of 55% methanol in water + 0.1% formic acid, with a flow rate of 0.4 mL min-1. Antibiotic stability was assessed at different temperatures. Results: Chromatographic separation was achieved within 2 minutes, allowing simultaneous measurement of phenoxymethylpenicillin, benzylpenicillin and probenecid in a single 15 μL blood sample. Validation indicated linearity over the range 0.0015-10 mg L-1, with accuracy of 96-102% and a LLOQ of 0.01 mg L-1. All drugs demonstrated good stability under different storage conditions. Conclusion: The developed method is simple, rapid, accurate and clinically applicable for the quantification of phenoxymethylpenicillin, benzylpenicillin and probenecid in tandem.
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Affiliation(s)
- Alaa Riezk
- 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
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Richard C Wilson
- 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
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
- David Price Evans Infectious Diseases & Global Health Group, The University of Liverpool, Liverpool, L7 8TX, UK
| | - Anthony E G Cass
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
- Department of Chemistry, Molecular Sciences Research Hub, Imperial College, London, UK
| | - Alison H 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
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
- David Price Evans Infectious Diseases & Global Health Group, The University of Liverpool, Liverpool, L7 8TX, UK
| | - Timothy M 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
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
- David Price Evans Infectious Diseases & Global Health Group, The University of Liverpool, Liverpool, L7 8TX, UK
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Bolton WJ, Wilson R, Gilchrist M, Georgiou P, Holmes A, Rawson TM. Personalising intravenous to oral antibiotic switch decision making through fair interpretable machine learning. Nat Commun 2024; 15:506. [PMID: 38218885 PMCID: PMC10787786 DOI: 10.1038/s41467-024-44740-2] [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: 05/05/2023] [Accepted: 01/02/2024] [Indexed: 01/15/2024] Open
Abstract
Antimicrobial resistance (AMR) and healthcare associated infections pose a significant threat globally. One key prevention strategy is to follow antimicrobial stewardship practices, in particular, to maximise targeted oral therapy and reduce the use of indwelling vascular devices for intravenous (IV) administration. Appreciating when an individual patient can switch from IV to oral antibiotic treatment is often non-trivial and not standardised. To tackle this problem we created a machine learning model to predict when a patient could switch based on routinely collected clinical parameters. 10,362 unique intensive care unit stays were extracted and two informative feature sets identified. Our best model achieved a mean AUROC of 0.80 (SD 0.01) on the hold-out set while not being biased to individuals protected characteristics. Interpretability methodologies were employed to create clinically useful visual explanations. In summary, our model provides individualised, fair, and interpretable predictions for when a patient could switch from IV-to-oral antibiotic treatment. Prospectively evaluation of safety and efficacy is needed before such technology can be applied clinically.
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Affiliation(s)
- William J Bolton
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK.
- AI4Health Centre for Doctoral Training, Imperial College London, London, UK.
- Department of Computing, Imperial College London, London, UK.
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.
| | - Richard Wilson
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Faculty of Health & Life Sciences, University of Liverpool, Liverpool, UK
| | - Mark Gilchrist
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Pantelis Georgiou
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Centre for Bio-inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, London, UK
| | - Alison Holmes
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Faculty of Health & Life Sciences, University of Liverpool, Liverpool, UK
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Timothy M Rawson
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
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Satta G, Rawson TM, Moore LS. Coronavirus disease 2019 (COVID-19) impact on central-line-associated bloodstream infections (CLABSI): a systematic review. Infect Prev Pract 2023; 5:100313. [PMID: 37920796 PMCID: PMC10618700 DOI: 10.1016/j.infpip.2023.100313] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/02/2023] [Indexed: 11/04/2023] Open
Abstract
Introduction Central line-associated bloodstream infections (CLABSI) are an important clinical and public health issue, impacted by the purported increase in healthcare-associated infections (including CLABSI) during the COVID-19 pandemic. This review evaluates the impact of COVID-19 on CLABSI at a global level, to determine risk factors, effective preventive measures and microbiological epidemiology. Methods A systematic literature review was performed using a PECO framework, with COVID-19 infection as the exposure measure and CLABSI rates as the main outcome of interest, pre- and during the pandemic. Results Overall, most studies (17 of N=21) found a significant increase in CLABSI incidence/rates during the pandemic. Four studies showed a reduction (N=1) or no increase (N=3). High workload, redeployment, and 'overwhelmed' healthcare staff were recurrent risk-factor themes, likely to have negatively influenced basic infection control practices, including compliance with hand hygiene and line care bundles. Microbiological epidemiology was also impacted, with an increase in enterococcal infections and other pathogens. Conclusion The COVID-19 pandemic significantly impacted CLABSI incidence/rates. Observations from the different studies highlight significant gaps in healthcare associated infections (HCAI) knowledge and practice during the pandemic, and the importance of identifying preventive measures effective in reducing CLABSI, essential to health system resilience for future pandemics. Central to this are changes to CLABSI surveillance, as reporting is not mandatory in many healthcare systems. An audit tool combined with regular assessments of the compliance with infection control measures and line care bundles also remains an essential step in the prevention of CLABSI.
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Affiliation(s)
- Giovanni Satta
- Department of Infection, University College London Hospitals NHS Foundation Trust, London, UK
| | - Timothy M. Rawson
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
| | - Luke S.P. Moore
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, London, UK
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Moore LSP, Villegas MV, Wenzler E, Rawson TM, Oladele RO, Doi Y, Apisarnthanarak A. Rapid Diagnostic Test Value and Implementation in Antimicrobial Stewardship Across Low-to-Middle and High-Income Countries: A Mixed-Methods Review. Infect Dis Ther 2023:10.1007/s40121-023-00815-z. [PMID: 37261612 DOI: 10.1007/s40121-023-00815-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/20/2023] [Indexed: 06/02/2023] Open
Abstract
Despite technological advancements in infectious disease rapid diagnostic tests (RDTs) and use to direct therapy at the per-patient level, RDT utilisation in antimicrobial stewardship programmes (ASPs) is variable across low-to-middle income and high-income countries. Key insights from a panel of seven infectious disease experts from Colombia, Japan, Nigeria, Thailand, the UK, and the USA, combined with evidence from a literature review, were used to assess the value of RDTs in ASPs. From this, a value framework is proposed which aims to define the benefits of RDT use in ASPs, separate from per-patient benefits. Expert insights highlight that, to realise the value of RDTs within ASPs, effective implementation is key; actionable advice for choosing an RDT is proposed. Experts advocate the inclusion of RDTs in the World Health Organization Model List of essential in vitro diagnostics and in iterative development of national action plans.
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Affiliation(s)
- Luke S P Moore
- Clinical Infection Department, Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
- Imperial College Healthcare NHS Trust, North West London Pathology, London, UK.
- NIHR Health Protection Research Unit in Healthcare Associated Infections & Antimicrobial Resistance, Imperial College London, London, UK.
| | - Maria Virginia Villegas
- Grupo de Resistencia Antimicrobiana y Epidemiología Hospitalaria, Universidad El Bosque, Bogotá, Colombia
- Molecular Genetics and Antimicrobial Resistance Unit, International Center for Microbial Genomics, Universidad El Bosque, Bogotá, Colombia
| | - Eric Wenzler
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Timothy M Rawson
- NIHR Health Protection Research Unit in Healthcare Associated Infections & Antimicrobial Resistance, Imperial College London, London, UK
- Centre for Antimicrobial Optimisation, Imperial College London, London, UK
| | - Rita O Oladele
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Yohei Doi
- Department of Infectious Diseases, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
- Department of Microbiology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anucha Apisarnthanarak
- Research Group in Infectious Diseases Epidemiology and Prevention, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
- Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
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Vasikasin V, Panuvatvanich B, Rawson TM, Holmes AH, Nasomsong W. Towards optimizing carbapenem selection in stewardship strategies: a prospective propensity score-matched study of ertapenem versus class 2 carbapenems for empirical treatment of third-generation cephalosporin-resistant Enterobacterales bacteraemia. J Antimicrob Chemother 2023:7186566. [PMID: 37252945 DOI: 10.1093/jac/dkad165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/11/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Third-generation cephalosporin-resistant Enterobacterales (3GCRE) are increasing in prevalence, leading to greater carbapenem consumption. Selecting ertapenem has been proposed as a strategy to reduce carbapenem resistance development. However, there are limited data for the efficacy of empirical ertapenem for 3GCRE bacteraemia. OBJECTIVES To compare the efficacy of empirical ertapenem and class 2 carbapenems for the treatment of 3GCRE bacteraemia. METHODS A prospective non-inferiority observational cohort study was performed from May 2019 to December 2021. Adult patients with monomicrobial 3GCRE bacteraemia receiving carbapenems within 24 h were included at two hospitals in Thailand. Propensity scores were used to control for confounding, and sensitivity analyses were performed in several subgroups. The primary outcome was 30 day mortality. This study is registered with clinicaltrials.gov (NCT03925402). RESULTS Empirical carbapenems were prescribed in 427/1032 (41%) patients with 3GCRE bacteraemia, of whom 221 received ertapenem and 206 received class 2 carbapenems. One-to-one propensity score matching resulted in 94 pairs. Escherichia coli was identified in 151 (80%) of cases. All patients had underlying comorbidities. Septic shock and respiratory failure were the presenting syndromes in 46 (24%) and 33 (18%) patients, respectively. The overall 30 day mortality rate was 26/188 (13.8%). Ertapenem was non-inferior to class 2 carbapenems in 30 day mortality (12.8% versus 14.9%; mean difference -0.02; 95% CI: -0.12 to 0.08). Sensitivity analyses were consistent regardless of aetiological pathogens, septic shock, source of infection, nosocomial acquisition, lactate levels or albumin levels. CONCLUSIONS Ertapenem may be of comparable efficacy to class 2 carbapenems in the empirical treatment of 3GCRE bacteraemia.
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Affiliation(s)
- Vasin Vasikasin
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK
- Department of Internal Medicine, Phramongkutklao Hospital, 315 Ratchavithi Rd, Ratchadhevi, Bangkok, 10400, Thailand
| | - Bawornnan Panuvatvanich
- Department of Internal Medicine, Phramongkutklao Hospital, 315 Ratchavithi Rd, Ratchadhevi, Bangkok, 10400, Thailand
| | - Timothy M Rawson
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK
| | - Alison H Holmes
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, L69 7TX, UK
| | - Worapong Nasomsong
- Department of Internal Medicine, Phramongkutklao Hospital, 315 Ratchavithi Rd, Ratchadhevi, Bangkok, 10400, Thailand
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6
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Vasikasin V, Rawson TM, Holmes AH, Otter J. Can precision antibiotic prescribing help prevent the spread of carbapenem-resistant organisms in the hospital setting? JAC Antimicrob Resist 2023; 5:dlad036. [PMID: 37008824 PMCID: PMC10050941 DOI: 10.1093/jacamr/dlad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023] Open
Abstract
The emergence of carbapenem-resistant organisms (CROs) is a significant global threat. Reduction of carbapenem consumption can decrease CROs. In the global endemic era of ESBL-producing bacteria, carbapenems are considered the treatment of choice, leading to challenge in limiting carbapenem use. This review describes the role of precision prescribing for prevention of CROs. This involves improving antibiotic selection, dosing and shortening duration. The effect of different antibiotics, dosing and duration on CRO development are explored. Available options for precision prescribing, gaps in the scientific evidence, and areas for future research are also presented.
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Affiliation(s)
- Vasin Vasikasin
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK
- Department of Internal Medicine, Phramongkutklao Hospital, 315 Ratchavithi Rd., Ratchadhevi, Bangkok, 10400, Thailand
| | - Timothy M Rawson
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK
| | - Alison H Holmes
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, L69 7TX, UK
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Riezk A, Wilson RC, Rawson TM, Vasikasin V, Arkel P, Ferris TJ, Haigh LD, Cass AEG, Holmes AH. A rapid, simple, high-performance liquid chromatography method for the clinical measurement of beta-lactam antibiotics in serum and interstitial fluid. Anal Methods 2023; 15:829-836. [PMID: 36727437 DOI: 10.1039/d2ay01276f] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Background: enhanced methods of therapeutic drug monitoring are required to support the individualisation of antibiotic dosing based on pharmacokinetics (PK) parameters. PK studies can be hampered by limited total serum volume, especially in neonates, or by sensitivity in the case of critically ill patients. We aimed to develop a liquid chromatography-mass spectrometry (LC/MS) analysis of benzylpenicillin, phenoxymethylpenicillin and amoxicillin in single low volumes of human serum and interstitial fluid (ISF) samples, with an improved limit of detection (LOD) and limit of quantification (LOQ), compared with previously published assays. Methods: sample clean-up was performed by protein precipitation using acetonitrile. Reverse phase chromatography was performed using triple quadrupole LC/MS. The mobile phase consisted of 55% methanol in water + 0.1% formic acid, with a flow rate of 0.4 mL min-1. Antibiotics stability was assessed at different temperatures. Results: chromatographic separation was achieved within 3 minutes for all analytes. Three common penicillins can now be measured in a single low-volume blood and ISF sample (15 μL) for the first time. Validation has demonstrated the method to be linear over the range 0.0015-10 mg L-1, with an accuracy of 93-104% and high sensitivity, with LOD ≈ 0.003 mg L-1 and LOQ ≈ 0.01 mg L-1 for all three analytes, which is critical for use in dose optimisation/individualisation. All evaluated penicillins indicated good stability at room temperature over 4 h, at (4 °C) over 24 h and at -80 °C for 6 months. Conclusion: the developed method is simple, rapid, accurate and clinically applicable for the quantification of three penicillin classes.
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Affiliation(s)
- Alaa Riezk
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Richard C Wilson
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Timothy M Rawson
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Vasin Vasikasin
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Paul Arkel
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Trevor J Ferris
- Department of Chemistry, Molecular Sciences Research Hub, Imperial College, London, UK
| | - Lisa D Haigh
- Department of Chemistry, Molecular Sciences Research Hub, Imperial College, London, UK
| | - Anthony E G Cass
- Department of Chemistry, Molecular Sciences Research Hub, Imperial College, London, UK
| | - Alison H Holmes
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London, W12 0NN, UK.
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Riezk A, Vasikasin V, Wilson RC, Rawson TM, McLeod JG, Dhillon R, Duckers J, Cass AEG, Holmes AH. Triple quadrupole LC/MS method for the simultaneous quantitative measurement of cefiderocol and meropenem in serum. Anal Methods 2023; 15:746-751. [PMID: 36655876 DOI: 10.1039/d2ay01459a] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Background: therapeutic drug monitoring is a crucial aspect of the management of hospitalized patients. The correct dosage of antibiotics is imperative to ensure their adequate exposure specially in critically ill patients. The aim of this study is to establish and validate a robust and fast liquid chromatography-tandem mass spectrometry (LC/MS) method for the simultaneous quantification of two important antibiotics in critically ill patients, cefiderocol and meropenem in human plasma. Methods: sample clean-up was performed by protein precipitation using acetonitrile. Reverse phase chromatography was performed using triple quadrupole LC/MS. The mobile phase was consisted of 55% methanol in water +0.1% formic acid, with flow rate of 0.4 ml min-1. Antibiotics stability was assessed at different temperatures. Serum protein binding was assessed using ultrafiltration devices. Results: chromatographic separation was achieved within 1.5 minutes for all analytes. Validation has demonstrated the method to be linear over the range 0.0025-50 mg L-1 for cefiderocol and 0.00028-50 mg L-1 for meropenem, with accuracy of 94-101% and highly sensitive, with LLOQ ≈ 0.02 mg L-1 and 0.003 mg L-1 for cefiderocol and meropenem, respectively. Both cefiderocol and meropenem showed a good stability at room temperature over 6 h, and at (4 °C) over 24 h. Cefiderocol and meropenem demonstrated a protein binding of 49-60% and 98%, respectively in human plasma. Conclusion: the developed method is simple, rapid, accurate and clinically applicable for the quantification of cefiderocol and meropenem.
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Affiliation(s)
- Alaa Riezk
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Hammersmith Campus, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Vasin Vasikasin
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Hammersmith Campus, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Richard C Wilson
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Hammersmith Campus, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Timothy M Rawson
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Hammersmith Campus, Du Cane Road, Acton, London, W12 0NN, UK.
| | - James G McLeod
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Hammersmith Campus, Du Cane Road, Acton, London, W12 0NN, UK.
| | - Rishi Dhillon
- Public Health Wales Microbiology, University Hospital of Wales, Heath Park Cardiff, UK
| | - Jamie Duckers
- Public Health Wales Microbiology, University Hospital of Wales, Heath Park Cardiff, UK
| | - Anthony E G Cass
- Department of Chemistry, Molecular Sciences Research Hub, Imperial College, London, UK
| | - Alison H Holmes
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Hammersmith Campus, Du Cane Road, Acton, London, W12 0NN, UK.
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Rawson TM, Antcliffe DB, Wilson RC, Abdolrasouli A, Moore LSP. Management of Bacterial and Fungal Infections in the ICU: Diagnosis, Treatment, and Prevention Recommendations. Infect Drug Resist 2023; 16:2709-2726. [PMID: 37168515 PMCID: PMC10166098 DOI: 10.2147/idr.s390946] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/22/2023] [Indexed: 05/13/2023] Open
Abstract
Bacterial and fungal infections are common issues for patients in the intensive care unit (ICU). Large, multinational point prevalence surveys have identified that up to 50% of ICU patients have a diagnosis of bacterial or fungal infection at any one time. Infection in the ICU is associated with its own challenges. Causative organisms often harbour intrinsic and acquired mechanisms of drug-resistance, making empiric and targeted antimicrobial selection challenging. Infection in the ICU is associated with worse clinical outcomes for patients. We review the epidemiology of bacterial and fungal infection in the ICU. We discuss risk factors for acquisition, approaches to diagnosis and management, and common strategies for the prevention of infection.
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Affiliation(s)
- Timothy M Rawson
- Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Hospital, London, UK
- Centre for Antimicrobial Optimisation, Imperial College London, Imperial College London, London, UK
- David Price Evan’s Group in Infectious Diseases and Global Health, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
- Correspondence: Timothy M Rawson, Health Protection Research Unit in Healthcare Associated Infections & Antimicrobial Resistance, Hammersmith Hospital, Du Cane Road, London, W12 0NN, United Kingdom, Email
| | - David B Antcliffe
- Centre for Antimicrobial Optimisation, Imperial College London, Imperial College London, London, UK
- Division Anaesthesia, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Richard C Wilson
- Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Hospital, London, UK
- Centre for Antimicrobial Optimisation, Imperial College London, Imperial College London, London, UK
- David Price Evan’s Group in Infectious Diseases and Global Health, Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, UK
| | | | - Luke S P Moore
- Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Hospital, London, UK
- Chelsea & Westminster NHS Foundation Trust, London, UK
- North West London Pathology, Imperial College Healthcare NHS Trust, London, UK
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Mistry R, Rawson TM, Troise O, Mughal N, Moore LSP, Hughes S. Haematological and hepatic adverse effects of ceftriaxone in ambulatory care: a dual-centre retrospective observational analysis of standard vs high dose. BMC Infect Dis 2022; 22:959. [PMID: 36566229 PMCID: PMC9789631 DOI: 10.1186/s12879-022-07925-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/06/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoint criteria for methicillin-susceptible Staphylococcus aureus (MSSA) treatment with ceftriaxone are based upon high dose (4 g/day) rather than standard dose (2 g/day) posology. This is particularly relevant for invasive infections, and for patients managed via Outpatient Parenteral Antimicrobial Therapy (OPAT), but may result in increased drug toxicity. We quantified the incidence of neutropenia, thrombocytopenia and raised liver enzymes between standard and high dose ceftriaxone in adult patients. METHOD Adult outpatients prescribed ≥ 7 days of ceftriaxone therapy were identified, and clinical, pharmacological, and laboratory parameters extracted from electronic health records between May 2021 and December 2021. Incidence and median time to haematological and hepto-toxicity were analysed. Univariate odds ratios were calculated for neutrophil count and ALT levels with 95% confidence level and Chi squared/Fisher's exact test used to identify statistical significance. RESULTS Incidence of neutropenia was comparable between both groups; 8/47 (17%) in the 2 g group vs 6/39 (15.4%) in the 4 g group (OR 0.89 (95% CI 0.26-2.63), p > 0.999). Median time to neutropenia was 12 and 17 days in the 2 g and 4 g groups respectively. Thrombocytopenia was observed in 0/47 in the 2 g group compared with 3/39 (7.7%) in the 4 g group (p 0.089). Median time to thrombocytopenia was 7 days in the 4 g group. Elevated liver enzymes did not clearly correlate with ceftriaxone dosing; present in 5/47 (10.6%) and 2/39 (5.1%) for 2 g and 4 g respectively (OR 0.45 (95% CI 0.87-2.36), p 0.448). Treatment cessation due to any adverse effect was similar between both groups 2/47 (4.3%) for 2 g and 3/39 (7.7%) for 4 g (OR 1.86 (95% CI 0.36-10.92), p 0.655). CONCLUSIONS Increased adverse effects with 4 g (over 2 g) daily dosing of ceftriaxone was not observed in an OPAT population. However absolute development of haematological and liver dyscrasias was appreciable-monitoring of liver function and full blood count in patients receiving prolonged ceftriaxone is indicated irrespective of dosing.
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Affiliation(s)
- Rakhee Mistry
- grid.428062.a0000 0004 0497 2835Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK
| | - Timothy M. Rawson
- grid.428062.a0000 0004 0497 2835Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK ,North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF UK
| | - Oliver Troise
- grid.428062.a0000 0004 0497 2835Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK
| | - Nabeela Mughal
- grid.428062.a0000 0004 0497 2835Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK ,North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF UK ,grid.7445.20000 0001 2113 8111National 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 S. P. Moore
- grid.428062.a0000 0004 0497 2835Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK ,North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF UK ,grid.7445.20000 0001 2113 8111National 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
| | - Stephen Hughes
- grid.428062.a0000 0004 0497 2835Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH UK
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11
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Bolton WJ, Rawson TM, Hernandez B, Wilson R, Antcliffe D, Georgiou P, Holmes AH. Machine learning and synthetic outcome estimation for individualised antimicrobial cessation. Front Digit Health 2022; 4:997219. [PMID: 36479189 PMCID: PMC9719971 DOI: 10.3389/fdgth.2022.997219] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/27/2022] [Indexed: 08/18/2023] Open
Abstract
The decision on when it is appropriate to stop antimicrobial treatment in an individual patient is complex and under-researched. Ceasing too early can drive treatment failure, while excessive treatment risks adverse events. Under- and over-treatment can promote the development of antimicrobial resistance (AMR). We extracted routinely collected electronic health record data from the MIMIC-IV database for 18,988 patients (22,845 unique stays) who received intravenous antibiotic treatment during an intensive care unit (ICU) admission. A model was developed that utilises a recurrent neural network autoencoder and a synthetic control-based approach to estimate patients' ICU length of stay (LOS) and mortality outcomes for any given day, under the alternative scenarios of if they were to stop vs. continue antibiotic treatment. Control days where our model should reproduce labels demonstrated minimal difference for both stopping and continuing scenarios indicating estimations are reliable (LOS results of 0.24 and 0.42 days mean delta, 1.93 and 3.76 root mean squared error, respectively). Meanwhile, impact days where we assess the potential effect of the unobserved scenario showed that stopping antibiotic therapy earlier had a statistically significant shorter LOS (mean reduction 2.71 days, p -value <0.01). No impact on mortality was observed. In summary, we have developed a model to reliably estimate patient outcomes under the contrasting scenarios of stopping or continuing antibiotic treatment. Retrospective results are in line with previous clinical studies that demonstrate shorter antibiotic treatment durations are often non-inferior. With additional development into a clinical decision support system, this could be used to support individualised antimicrobial cessation decision-making, reduce the excessive use of antibiotics, and address the problem of AMR.
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Affiliation(s)
- William J. Bolton
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
- AI4Health Centre for Doctoral Training, Imperial College London, London, United Kingdom
- Department of Computing, Imperial College London, London, United Kingdom
| | - Timothy M. Rawson
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - Bernard Hernandez
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
- Centre for Bio-inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, London, United Kingdom
| | - Richard Wilson
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - David Antcliffe
- Department of Critical Care, Imperial College Healthcare NHS Trust, London, United Kingdom
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Pantelis Georgiou
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
- Centre for Bio-inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, London, United Kingdom
| | - Alison H. Holmes
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
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12
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Bolton WJ, Badea C, Georgiou P, Holmes A, Rawson TM. Developing moral AI to support decision-making about antimicrobial use. NAT MACH INTELL 2022. [DOI: 10.1038/s42256-022-00558-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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Herrero P, Wilson RC, Armiger R, Roberts JA, Holmes A, Georgiou P, Rawson TM. Closed-loop control of continuous piperacillin delivery: An in silico study. Front Bioeng Biotechnol 2022; 10:1015389. [DOI: 10.3389/fbioe.2022.1015389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background and objective: Sub-therapeutic dosing of piperacillin-tazobactam in critically-ill patients is associated with poor clinical outcomes and may promote the emergence of drug-resistant infections. In this paper, an in silico investigation of whether closed-loop control can improve pharmacokinetic-pharmacodynamic (PK-PD) target attainment is described.Method: An in silico platform was developed using PK data from 20 critically-ill patients receiving piperacillin-tazobactam where serum and tissue interstitial fluid (ISF) PK were defined. Intra-day variability on renal clearance, ISF sensor error, and infusion constraints were taken into account. Proportional-integral-derivative (PID) control was selected for drug delivery modulation. Dose adjustment was made based on ISF sensor data with a 30-min sampling period, targeting a serum piperacillin concentration between 32 and 64 mg/L. A single tuning parameter set was employed across the virtual population. The PID controller was compared to standard therapy, including bolus and continuous infusion of piperacillin-tazobactam.Results: Despite significant inter-subject and simulated intra-day PK variability and sensor error, PID demonstrated a significant improvement in target attainment compared to traditional bolus and continuous infusion approaches.Conclusion: A PID controller driven by ISF drug concentration measurements has the potential to precisely deliver piperacillin-tazobactam in critically-ill patients undergoing treatment for sepsis.
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14
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Arkell P, Wilson R, Watkins K, Antcliffe DB, Gilchrist M, Wilson M, Rawson TM, Holmes A. Application of therapeutic drug monitoring to the treatment of bacterial central nervous system infection: a scoping review. J Antimicrob Chemother 2022; 77:3408-3413. [PMID: 36227686 DOI: 10.1093/jac/dkac332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Bacterial central nervous system (CNS) infection is challenging to treat and carries high risk of recurrence, morbidity, and mortality. Low CNS penetration of antibiotics may contribute to poor clinical outcomes from bacterial CNS infections. The current application of therapeutic drug monitoring (TDM) to management of bacterial CNS infection was reviewed. METHODS Studies were included if they described adults treated for a suspected/confirmed bacterial CNS infection and had antibiotic drug concentration(s) determined that affected individual treatment. RESULTS One-hundred-and-thirty-six citations were retrieved. Seventeen manuscripts were included describing management of 68 patients. TDM for vancomycin (58/68) and the beta-lactams (29/68) was most common. Timing of clinical sampling varied widely between studies and across different antibiotics. Methods for setting individual PK-PD targets, determining parameters and making treatment changes varied widely and were sometimes unclear. DISCUSSION Despite increasing observational data showing low CNS penetration of various antibiotics, there are few clinical studies describing practical implementation of TDM in management of CNS infection. Lack of consensus around clinically relevant CSF PK-PD targets and protocols for dose-adjustment may contribute. Standardised investigation of TDM as a tool to improve treatment is required, especially as innovative drug concentration-sensing and PK-PD modelling technologies are emerging. Data generated at different centres offering TDM should be open access and aggregated to enrich understanding and optimize application.
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Affiliation(s)
- Paul Arkell
- Department of Infectious Disease, Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, UK
| | - Richard Wilson
- Department of Infectious Disease, Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, UK.,Department of Infectious Disease, National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, UK.,Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L69 3BX, UK.,Department of Pharmacy, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Killian Watkins
- Department of Infectious Disease, Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, UK
| | - David B Antcliffe
- Department of Infectious Disease, Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, UK.,Department of Anaesthesia and Critical Care, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, UK.,Division of Anaesthesia, Pain and Critical Care Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Mark Gilchrist
- Department of Infectious Disease, Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, UK.,Department of Infectious Disease, National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, UK.,Department of Pharmacy, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Mark Wilson
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - Timothy M Rawson
- Department of Infectious Disease, Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, UK.,Department of Infectious Disease, National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, UK
| | - Alison Holmes
- Department of Infectious Disease, Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, UK.,Department of Infectious Disease, National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, UK.,Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L69 3BX, UK
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15
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Rawson TM, Eigo T, Wilson R, Husson F, Dhillon R, Seddon O, Holmes A, Gilchrist M. Exploring patient acceptance of research within complex oral and IV outpatient parenteral antimicrobial therapy (COpAT) networks. JAC Antimicrob Resist 2022; 4:dlac087. [PMID: 36003076 PMCID: PMC9397122 DOI: 10.1093/jacamr/dlac087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Timothy M 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
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London , Du Cane Road , London, W12 0NN, UK
| | - Theresa Eigo
- Imperial College Healthcare NHS Trust, Hammersmith Hospital , Du Cane Road , London W12 0HS, UK
| | - Richard Wilson
- 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
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London , Du Cane Road , London, W12 0NN, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital , Du Cane Road , London W12 0HS, UK
| | - Fran Husson
- 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
| | - Rishi Dhillon
- Public Health Wales Microbiology, University Hospital Wales , Heath Park , Cardiff, CF14 4XW, UK
| | - Owen Seddon
- Public Health Wales Microbiology, University Hospital Wales , Heath Park , Cardiff, CF14 4XW, UK
| | - Alison 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
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London , Du Cane Road , London, W12 0NN, UK
| | - Mark Gilchrist
- 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
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London , 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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16
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Wilson RC, Arkell P, Riezk A, Gilchrist M, Wheeler G, Hope W, Holmes AH, Rawson TM. Addition of probenecid to oral β-lactam antibiotics: a systematic review and meta-analysis. J Antimicrob Chemother 2022; 77:2364-2372. [PMID: 35726853 DOI: 10.1093/jac/dkac200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/29/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To explore the literature comparing the pharmacokinetic and clinical outcomes from adding probenecid to oral β-lactams. METHODS Medline and EMBASE were searched from inception to December 2021 for all English language studies comparing the addition of probenecid (intervention) with an oral β-lactam [flucloxacillin, penicillin V, amoxicillin (± clavulanate), cefalexin, cefuroxime axetil] alone (comparator). ROBINS-I and ROB-2 tools were used. Data on antibiotic therapy, infection diagnosis, primary and secondary outcomes relating to pharmacokinetics and clinical outcomes, plus adverse events were extracted and reported descriptively. For a subset of studies comparing treatment failure between probenecid and control groups, meta-analysis was performed. RESULTS Overall, 18/295 (6%) screened abstracts were included. Populations, methodology and outcome data were heterogeneous. Common populations included healthy volunteers (9/18; 50%) and those with gonococcal infection (6/18; 33%). Most studies were crossover trials (11/18; 61%) or parallel-arm randomized trials (4/18; 22%). Where pharmacokinetic analyses were performed, addition of probenecid to oral β-lactams increased total AUC (7/7; 100%), Cmax (5/8; 63%) and serum t½ (6/8; 75%). Probenecid improved PTA (2/2; 100%). Meta-analysis of 3105 (2258 intervention, 847 control) patients treated for gonococcal disease demonstrated a relative risk of treatment failure in the random-effects model of 0.33 (95% CI 0.20-0.55; I2 = 7%), favouring probenecid. CONCLUSIONS Probenecid-boosted β-lactam therapy is associated with improved outcomes in gonococcal disease. Pharmacokinetic data suggest that probenecid-boosted oral β-lactam therapy may have a broader application, but appropriately powered mechanistic and efficacy studies are required.
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Affiliation(s)
- Richard C Wilson
- National Institute for Health and Care Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, UK.,Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London W12 0NN, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Paul Arkell
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London W12 0NN, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Alaa Riezk
- Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London W12 0NN, UK
| | - Mark Gilchrist
- National Institute for Health and Care Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, UK.,Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London W12 0NN, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Graham Wheeler
- Imperial Clinical Trials Unit, Imperial College London, Stadium House, Wood Lane, London W12 7RH, UK
| | - William Hope
- Centre for Excellence in Infectious Diseases Research (CEIDR), University of Liverpool, Liverpool L7 8TX, UK
| | - Alison H Holmes
- National Institute for Health and Care Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, UK.,Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London W12 0NN, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Timothy M Rawson
- National Institute for Health and Care Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, UK.,Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, Du Cane Road, Acton, London W12 0NN, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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17
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Mehta R, Chekmeneva E, Jackson H, Sands C, Mills E, Arancon D, Li HK, Arkell P, Rawson TM, Hammond R, Amran M, Haber A, Cooke GS, Noursadeghi M, Kaforou M, Lewis MR, Takats Z, Sriskandan S. Antiviral metabolite 3'-deoxy-3',4'-didehydro-cytidine is detectable in serum and identifies acute viral infections including COVID-19. Med 2022; 3:204-215.e6. [PMID: 35128501 PMCID: PMC8801973 DOI: 10.1016/j.medj.2022.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/14/2021] [Accepted: 01/21/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND There is a critical need for rapid viral infection diagnostics to enable prompt case identification in pandemic settings and support targeted antimicrobial prescribing. METHODS Using untargeted high-resolution liquid chromatography coupled with mass spectrometry, we compared the admission serum metabolome of emergency department patients with viral infections (including COVID-19), bacterial infections, inflammatory conditions, and healthy controls. Sera from an independent cohort of emergency department patients admitted with viral or bacterial infections underwent profiling to validate findings. Associations between whole-blood gene expression and the identified metabolite of interest were examined. FINDINGS 3'-Deoxy-3',4'-didehydro-cytidine (ddhC), a free base of the only known human antiviral small molecule ddhC-triphosphate (ddhCTP), was detected for the first time in serum. When comparing 60 viral with 101 non-viral cases in the discovery cohort, ddhC was the most significantly differentially abundant metabolite, generating an area under the receiver operating characteristic curve (AUC) of 0.954 (95% CI: 0.923-0.986). In the validation cohort, ddhC was again the most significantly differentially abundant metabolite when comparing 40 viral with 40 bacterial cases, generating an AUC of 0.81 (95% CI 0.708-0.915). Transcripts of viperin and CMPK2, enzymes responsible for ddhCTP synthesis, were among the five genes most highly correlated with ddhC abundance. CONCLUSIONS The antiviral precursor molecule ddhC is detectable in serum and an accurate marker for acute viral infection. Interferon-inducible genes viperin and CMPK2 are implicated in ddhC production in vivo. These findings highlight a future diagnostic role for ddhC in viral diagnosis, pandemic preparedness, and acute infection management. FUNDING NIHR Imperial BRC; UKRI.
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Affiliation(s)
- Ravi Mehta
- Department of Infectious Disease, Imperial College London, London W12 0NN, UK
| | - Elena Chekmeneva
- National Phenome Centre, Imperial College London, London SW7 2AZ, UK
- Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London SW7 2AZ, UK
| | - Heather Jackson
- Department of Infectious Disease, Imperial College London, London W12 0NN, UK
| | - Caroline Sands
- National Phenome Centre, Imperial College London, London SW7 2AZ, UK
- Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London SW7 2AZ, UK
| | - Ewurabena Mills
- Department of Infectious Disease, Imperial College London, London W12 0NN, UK
| | | | - Ho Kwong Li
- Department of Infectious Disease, Imperial College London, London W12 0NN, UK
- MRC Centre for Molecular Bacteriology & Infection, Imperial College London, London SW7 2AZ, UK
| | - Paul Arkell
- Department of Infectious Disease, Imperial College London, London W12 0NN, UK
- Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Timothy M. Rawson
- Department of Infectious Disease, Imperial College London, London W12 0NN, UK
- Imperial College Healthcare NHS Trust, London W12 0HS, UK
- Division of Infection & Immunity, University College London, London WC1 E6BT, UK
| | - Robert Hammond
- Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Maisarah Amran
- Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Anna Haber
- Imperial College Healthcare NHS Trust, London W12 0HS, UK
| | - Graham S. Cooke
- Department of Infectious Disease, Imperial College London, London W12 0NN, UK
| | - Mahdad Noursadeghi
- Division of Infection & Immunity, University College London, London WC1 E6BT, UK
| | - Myrsini Kaforou
- Department of Infectious Disease, Imperial College London, London W12 0NN, UK
| | - Matthew R. Lewis
- National Phenome Centre, Imperial College London, London SW7 2AZ, UK
- Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London SW7 2AZ, UK
| | - Zoltan Takats
- National Phenome Centre, Imperial College London, London SW7 2AZ, UK
- Division of Systems Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London SW7 2AZ, UK
| | - Shiranee Sriskandan
- Department of Infectious Disease, Imperial College London, London W12 0NN, UK
- MRC Centre for Molecular Bacteriology & Infection, Imperial College London, London SW7 2AZ, UK
- NIHR Health Protection Research Unit in Healthcare-associated Infection & Antimicrobial Resistance, Imperial College London, London W12 0NN, UK
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18
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Rawson TM, Fatania N, Abdolrasouli A. UK standards for microbiology investigations of ear infection (SMI B1) are inadequate for the recovery of fungal pathogens and laboratory diagnosis of otomycosis: a real‐life prospective evaluation. Mycoses 2022; 65:490-495. [DOI: 10.1111/myc.13423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Timothy M. Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance Imperial College London London United Kingdom
- Centre for Antimicrobial Optimisation Imperial College London London United Kingdom
- Department of Infectious Diseases Imperial College London London United Kingdom
| | - Nita Fatania
- Department of Medical Microbiology Charing Cross Hospital London United Kingdom
| | - Alireza Abdolrasouli
- Department of Infectious Diseases Imperial College London London United Kingdom
- Department of Medical Microbiology King’s College Hospital London United Kingdom
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19
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Rawson TM, Wilson RC, Moore LSP, Macgowan AP, Lovering AM, Bayliss M, Kyriakides M, Gilchrist M, Roberts JA, Hope WW, Holmes AH. Exploring the Pharmacokinetics of Phenoxymethylpenicillin (Penicillin-V) in Adults: A Healthy Volunteer Study. Open Forum Infect Dis 2021; 8:ofab573. [PMID: 34934774 PMCID: PMC8684501 DOI: 10.1093/ofid/ofab573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/11/2021] [Indexed: 12/05/2022] Open
Abstract
This healthy volunteer study aimed to explore phenoxymethylpenicillin (penicillin-V) pharmacokinetics (PK) to support the planning of large dosing studies in adults. Volunteers were dosed with penicillin-V at steady state. Total and unbound penicillin-V serum concentrations were determined, and a base population PK model was fitted to the data.
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Affiliation(s)
- Timothy M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.,Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, London, UK
| | - Richard C Wilson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.,Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, London, UK
| | - Luke S P Moore
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.,Chelsea & Westminster NHS Foundation Trust, London, UK.,Central London Community Healthcare NHS Trust, London, UK
| | - Alasdair P Macgowan
- Department of Infection Sciences, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Andrew M Lovering
- Department of Infection Sciences, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Mark Bayliss
- Department of Infection Sciences, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Mathew Kyriakides
- Department of Infection Sciences, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Mark Gilchrist
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.,Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, London, UK
| | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre and Centre for Translational Pharmacodynamics, The University of Queensland, Brisbane, Australia
| | - William W Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Alison H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.,Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Hospital, London, UK
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20
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Al-Hindawi A, Abdulaal A, Rawson TM, Alqahtani SA, Mughal N, Moore LSP. COVID-19 Prognostic Models: A Pro-con Debate for Machine Learning vs. Traditional Statistics. Front Digit Health 2021; 3:637944. [PMID: 35005694 PMCID: PMC8734592 DOI: 10.3389/fdgth.2021.637944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 11/15/2021] [Indexed: 01/08/2023] Open
Abstract
The SARS-CoV-2 virus, which causes the COVID-19 pandemic, has had an unprecedented impact on healthcare requiring multidisciplinary innovation and novel thinking to minimize impact and improve outcomes. Wide-ranging disciplines have collaborated including diverse clinicians (radiology, microbiology, and critical care), who are working increasingly closely with data-science. This has been leveraged through the democratization of data-science with the increasing availability of easy to access open datasets, tutorials, programming languages, and hardware which makes it significantly easier to create mathematical models. To address the COVID-19 pandemic, such data-science has enabled modeling of the impact of the virus on the population and individuals for diagnostic, prognostic, and epidemiological ends. This has led to two large systematic reviews on this topic that have highlighted the two different ways in which this feat has been attempted: one using classical statistics and the other using more novel machine learning techniques. In this review, we debate the relative strengths and weaknesses of each method toward the specific task of predicting COVID-19 outcomes.
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Affiliation(s)
- Ahmed Al-Hindawi
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | - Ahmed Abdulaal
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Timothy M. Rawson
- Health Protection Research Unit for Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
- Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
| | - Saleh A. Alqahtani
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Johns Hopkins University, Baltimore, MD, United States
| | - Nabeela Mughal
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
- Faculty of Medicine, Imperial College London, London, United Kingdom
- North West London Pathology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Luke S. P. Moore
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
- Faculty of Medicine, Imperial College London, London, United Kingdom
- North West London Pathology, Imperial College Healthcare NHS Trust, London, United Kingdom
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21
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Hernandez B, Herrero-Viñas P, Rawson TM, Moore LSP, Holmes AH, Georgiou P. Resistance Trend Estimation Using Regression Analysis to Enhance Antimicrobial Surveillance: A Multi-Centre Study in London 2009-2016. Antibiotics (Basel) 2021; 10:1267. [PMID: 34680846 PMCID: PMC8533047 DOI: 10.3390/antibiotics10101267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 12/31/2022] Open
Abstract
In the last years, there has been an increase of antimicrobial resistance rates around the world with the misuse and overuse of antimicrobials as one of the main leading drivers. In response to this threat, a variety of initiatives have arisen to promote the efficient use of antimicrobials. These initiatives rely on antimicrobial surveillance systems to promote appropriate prescription practices and are provided by national or global health care institutions with limited consideration of the variations within hospitals. As a consequence, physicians' adherence to these generic guidelines is still limited. To fill this gap, this work presents an automated approach to performing local antimicrobial surveillance from microbiology data. Moreover, in addition to the commonly reported resistance rates, this work estimates secular resistance trends through regression analysis to provide a single value that effectively communicates the resistance trend to a wider audience. The methods considered for trend estimation were ordinary least squares regression, weighted least squares regression with weights inversely proportional to the number of microbiology records available and autoregressive integrated moving average. Among these, weighted least squares regression was found to be the most robust against changes in the granularity of the time series and presented the best performance. To validate the results, three case studies have been thoroughly compared with the existing literature: (i) Escherichia coli in urine cultures; (ii) Escherichia coli in blood cultures; and (iii) Staphylococcus aureus in wound cultures. The benefits of providing local rather than general antimicrobial surveillance data of a higher quality is two fold. Firstly, it has the potential to stimulate engagement among physicians to strengthen their knowledge and awareness on antimicrobial resistance which might encourage prescribers to change their prescription habits more willingly. Moreover, it provides fundamental knowledge to the wide range of stakeholders to revise and potentially tailor existing guidelines to the specific needs of each hospital.
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Affiliation(s)
- Bernard Hernandez
- Centre for Bio-Inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, London SW7 2AZ, UK; (P.H.-V.); (P.G.)
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, London W12 0NN, UK; (T.M.R.); (A.H.H.)
| | - Pau Herrero-Viñas
- Centre for Bio-Inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, London SW7 2AZ, UK; (P.H.-V.); (P.G.)
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, London W12 0NN, UK; (T.M.R.); (A.H.H.)
| | - Timothy M. Rawson
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, London W12 0NN, UK; (T.M.R.); (A.H.H.)
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK
| | - Luke S. P. Moore
- Chelsea and Westminster NHS Foundation Trust, London SW10 9NH, UK;
| | - Alison H. Holmes
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, London W12 0NN, UK; (T.M.R.); (A.H.H.)
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, UK
| | - Pantelis Georgiou
- Centre for Bio-Inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, London SW7 2AZ, UK; (P.H.-V.); (P.G.)
- Centre for Antimicrobial Optimisation (CAMO), Imperial College London, London W12 0NN, UK; (T.M.R.); (A.H.H.)
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22
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Zhu NJ, Rawson TM, Mookerjee S, Price JR, Davies F, Otter J, Aylin P, Hope R, Gilchrist M, Shersing Y, Holmes A. Changing Patterns of Bloodstream Infections in the Community and Acute Care Across 2 Coronavirus Disease 2019 Epidemic Waves: A Retrospective Analysis Using Data Linkage. Clin Infect Dis 2021; 75:e1082-e1091. [PMID: 34596212 PMCID: PMC9402624 DOI: 10.1093/cid/ciab869] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND We examined community- and hospital-acquired bloodstream infections (BSIs) in coronavirus disease 2019 (COVID-19) and non-COVID-19 patients across 2 epidemic waves. METHODS We analyzed blood cultures of patients presenting to a London hospital group between January 2020 and February 2021. We reported BSI incidence, changes in sampling, case mix, healthcare capacity, and COVID-19 variants. RESULTS We identified 1047 BSIs from 34 044 blood cultures, including 653 (62.4%) community-acquired and 394 (37.6%) hospital-acquired. Important pattern changes were seen. Community-acquired Escherichia coli BSIs remained below prepandemic level during COVID-19 waves, but peaked following lockdown easing in May 2020, deviating from the historical trend of peaking in August. The hospital-acquired BSI rate was 100.4 per 100 000 patient-days across the pandemic, increasing to 132.3 during the first wave and 190.9 during the second, with significant increase in elective inpatients. Patients with a hospital-acquired BSI, including those without COVID-19, experienced 20.2 excess days of hospital stay and 26.7% higher mortality, higher than reported in prepandemic literature. In intensive care, the BSI rate was 421.0 per 100 000 intensive care unit patient-days during the second wave, compared to 101.3 pre-COVID-19. The BSI incidence in those infected with the severe acute respiratory syndrome coronavirus 2 Alpha variant was similar to that seen with earlier variants. CONCLUSIONS The pandemic have impacted the patterns of community- and hospital-acquired BSIs, in COVID-19 and non-COVID-19 patients. Factors driving the patterns are complex. Infection surveillance needs to consider key aspects of pandemic response and changes in healthcare practice.
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Affiliation(s)
- Nina J Zhu
- Correspondence: N. J. Zhu, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Hospital, Du Cane Road, London, W12 0NN, UK ()
| | - Timothy M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom,Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom,Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
| | - Siddharth Mookerjee
- Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom
| | - James R Price
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom,Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom
| | - Frances Davies
- Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom
| | - Jonathan Otter
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom,Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom
| | - Paul Aylin
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom,Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdomand
| | - Russell Hope
- Division of Healthcare Associated Infection and Antimicrobial Resistance, Public Health England, London, United Kingdom
| | - Mark Gilchrist
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom,Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom,Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
| | - Yeeshika Shersing
- Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom
| | - Alison Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom,Imperial College Healthcare National Health Service Trust, Imperial College London, London, United Kingdom,Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom
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23
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Ming DK, Myall AC, Hernandez B, Weiße AY, Peach RL, Barahona M, Rawson TM, Holmes AH. Correction to: Informing antimicrobial management in the context of COVID-19: understanding the longitudinal dynamics of C-reactive protein and procalcitonin. BMC Infect Dis 2021; 21:988. [PMID: 34548046 PMCID: PMC8454290 DOI: 10.1186/s12879-021-06696-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Damien K Ming
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London, W12 0NN, UK. .,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.
| | - Ashleigh C Myall
- 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.,Department of Mathematics, Imperial College London, London, UK
| | - Bernard Hernandez
- 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
| | - Andrea Y Weiße
- School of Informatics, University of Edinburgh, Scotland, UK.,School of Biological Science, University of Edinburgh, Scotland, UK
| | - Robert L Peach
- Department of Neurology, University Hospital of Würzburg, 97080, Würzburg, Germany.,Department of Mathematics, Imperial College London, London, UK
| | | | - Timothy M Rawson
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London, W12 0NN, UK.,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
| | - Alison H Holmes
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London, W12 0NN, UK.,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
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24
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Ming DK, Myall AC, Hernandez B, Weiße AY, Peach RL, Barahona M, Rawson TM, Holmes AH. Informing antimicrobial management in the context of COVID-19: understanding the longitudinal dynamics of C-reactive protein and procalcitonin. BMC Infect Dis 2021; 21:932. [PMID: 34496795 PMCID: PMC8424157 DOI: 10.1186/s12879-021-06621-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 08/26/2021] [Indexed: 01/08/2023] Open
Abstract
Background To characterise the longitudinal dynamics of C-reactive protein (CRP) and Procalcitonin (PCT) in a cohort of hospitalised patients with COVID-19 and support antimicrobial decision-making. Methods Longitudinal CRP and PCT concentrations and trajectories of 237 hospitalised patients with COVID-19 were modelled. The dataset comprised of 2,021 data points for CRP and 284 points for PCT. Pairwise comparisons were performed between: (i) those with or without significant bacterial growth from cultures, and (ii) those who survived or died in hospital. Results CRP concentrations were higher over time in COVID-19 patients with positive microbiology (day 9: 236 vs 123 mg/L, p < 0.0001) and in those who died (day 8: 226 vs 152 mg/L, p < 0.0001) but only after day 7 of COVID-related symptom onset. Failure for CRP to reduce in the first week of hospital admission was associated with significantly higher odds of death. PCT concentrations were higher in patients with COVID-19 and positive microbiology or in those who died, although these differences were not statistically significant. Conclusions Both the absolute CRP concentration and the trajectory during the first week of hospital admission are important factors predicting microbiology culture positivity and outcome in patients hospitalised with COVID-19. Further work is needed to describe the role of PCT for co-infection. Understanding relationships of these biomarkers can support development of risk models and inform optimal antimicrobial strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06621-7.
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Affiliation(s)
- Damien K Ming
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London, W12 0NN, UK. .,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.
| | - Ashleigh C Myall
- 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.,Department of Mathematics, Imperial College London, London, UK
| | - Bernard Hernandez
- 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
| | - Andrea Y Weiße
- School of Informatics, University of Edinburgh, Scotland, UK.,School of Biological Science, University of Edinburgh, Scotland, UK
| | - Robert L Peach
- Department of Neurology, University Hospital of Würzburg, 97080, Würzburg, Germany.,Department of Mathematics, Imperial College London, London, UK
| | | | - Timothy M Rawson
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London, W12 0NN, UK.,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
| | - Alison H Holmes
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London, W12 0NN, UK.,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
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25
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Rawson TM. Antimicrobial stewardship during the COVID-19 pandemic. Int J Antimicrob Agents 2021. [PMCID: PMC8460239 DOI: 10.1016/j.ijantimicag.2021.106420.23] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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26
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Charani E, McKee M, Ahmad R, Balasegaram M, Bonaconsa C, Merrett GB, Busse R, Carter V, Castro-Sanchez E, Franklin BD, Georgiou P, Hill-Cawthorne K, Hope W, Imanaka Y, Kambugu A, Leather AJM, Mbamalu O, McLeod M, Mendelson M, Mpundu M, Rawson TM, Ricciardi W, Rodriguez-Manzano J, Singh S, Tsioutis C, Uchea C, Zhu N, Holmes AH. Optimising antimicrobial use in humans - review of current evidence and an interdisciplinary consensus on key priorities for research. Lancet Reg Health Eur 2021; 7:100161. [PMID: 34557847 PMCID: PMC8454847 DOI: 10.1016/j.lanepe.2021.100161] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Addressing the silent pandemic of antimicrobial resistance (AMR) is a focus of the 2021 G7 meeting. A major driver of AMR and poor clinical outcomes is suboptimal antimicrobial use. Current research in AMR is inequitably focused on new drug development. To achieve antimicrobial security we need to balance AMR research efforts between development of new agents and strategies to preserve the efficacy and maximise effectiveness of existing agents. Combining a review of current evidence and multistage engagement with diverse international stakeholders (including those in healthcare, public health, research, patient advocacy and policy) we identified research priorities for optimising antimicrobial use in humans across four broad themes: policy and strategic planning; medicines management and prescribing systems; technology to optimise prescribing; and context, culture and behaviours. Sustainable progress depends on: developing economic and contextually appropriate interventions; facilitating better use of data and prescribing systems across healthcare settings; supporting appropriate and scalable technological innovation. Implementing this strategy for AMR research on the optimisation of antimicrobial use in humans could contribute to equitable global health security.
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Affiliation(s)
- Esmita Charani
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, South Africa
| | - Martin McKee
- London School of Hygiene and Tropical Medicine, London, UK
| | - Raheelah Ahmad
- School of Health Sciences City, University of London, UK
| | - Manica Balasegaram
- The Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | - Candice Bonaconsa
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, South Africa
| | | | | | - Vanessa Carter
- Stanford University Medicine X e-Patient Scholars Program 2017, Health Communication and Social Media South Africa, Africa CDC Civil Society Champion for AMR
| | - Enrique Castro-Sanchez
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
| | - Bryony D Franklin
- University College London School of Pharmacy, London, UK
- Imperial College Healthcare NHS Trust, Centre for Medication Safety and Service Quality, Pharmacy Department, London, UK
| | - Pantelis Georgiou
- Department of Electrical and Electronic Engineering, Faculty of Engineering, Imperial College London, London, UK
| | - Kerri Hill-Cawthorne
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
| | - William Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, UK
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Andrew Kambugu
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrew JM Leather
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Oluchi Mbamalu
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, South Africa
| | - M McLeod
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
- Imperial College Healthcare NHS Trust, Centre for Medication Safety and Service Quality, Pharmacy Department, London, UK
| | - Marc Mendelson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, University of Cape Town, South Africa
| | | | - Timothy M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
- Department of Bioengineering, Imperial College London, London, UK
| | | | - Jesus Rodriguez-Manzano
- Department of Electrical and Electronic Engineering, Faculty of Engineering, Imperial College London, London, UK
- Department of Infectious Diseases, Faculty of Medicine, Imperial College London, London
| | - Sanjeev Singh
- Department of Infection Control and Epidemiology, Amrita Institute of Medical Science, Amrita Vishwa Vidyapeetham, Kochi (Kerala), India
| | - Constantinos Tsioutis
- Department of Internal Medicine and Infection Prevention and Control, School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - Chibuzor Uchea
- Drug-Resistant Infections Priority Programme,Wellcome Trust, London, UK
| | - Nina Zhu
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
| | - Alison H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, UK
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27
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Denny S, Rawson TM, Hart P, Satta G, Abdulaal A, Hughes S, Gilchrist M, Mughal N, Moore LSP. Bacteraemia variation during the COVID-19 pandemic; a multi-centre UK secondary care ecological analysis. BMC Infect Dis 2021; 21:556. [PMID: 34116643 PMCID: PMC8195453 DOI: 10.1186/s12879-021-06159-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 05/10/2021] [Indexed: 11/29/2022] Open
Abstract
Background We investigated for change in blood stream infections (BSI) with Enterobacterales, coagulase negative staphylococci (CoNS), Streptococcus pneumoniae, and Staphylococcus aureus during the first UK wave of SARS-CoV-2 across five London hospitals. Methods A retrospective multicentre ecological analysis was undertaken evaluating all blood cultures taken from adults from 01 April 2017 to 30 April 2020 across five acute hospitals in London. Linear trend analysis and ARIMA models allowing for seasonality were used to look for significant variation. Results One hundred nineteen thousand five hundred eighty-four blood cultures were included. At the height of the UK SARS-CoV-2 first wave in April 2020, Enterobacterales bacteraemias were at an historic low across two London trusts (63/3814, 1.65%), whilst all CoNS BSI were at an historic high (173/3814, 4.25%). This differed significantly for both Enterobacterales (p = 0.013), CoNS central line associated BSIs (CLABSI) (p < 0.01) and CoNS non-CLABSI (p < 0.01), when compared with prior periods, even allowing for seasonal variation. S. pneumoniae (p = 0.631) and S. aureus (p = 0.617) BSI did not vary significant throughout the study period. Conclusions Significantly fewer than expected Enterobacterales BSI occurred during the UK peak of the COVID-19 pandemic; identifying potential causes, including potential unintended consequences of national self-isolation public health messaging, is essential. High rates of CoNS BSI, with evidence of increased CLABSI, but also likely contamination associated with increased use of personal protective equipment, may result in inappropriate antimicrobial use and indicates a clear area for intervention during further waves. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06159-8.
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Affiliation(s)
- Sarah Denny
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Timothy M Rawson
- Imperial College Healthcare NHS Trust, Praed Street, London, W2 1NY, UK.,Department of Infectious Diseases, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | | | - Giovanni Satta
- Imperial College Healthcare NHS Trust, Praed Street, London, W2 1NY, UK.,North West London Pathology, Fulham Palace Road, London, W6 8RF, UK
| | - Ahmed Abdulaal
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Stephen Hughes
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK
| | - Mark Gilchrist
- Imperial College Healthcare NHS Trust, Praed Street, London, W2 1NY, UK
| | - Nabeela Mughal
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.,Department of Infectious Diseases, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK.,North West London Pathology, Fulham Palace Road, London, W6 8RF, UK
| | - Luke S P Moore
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK. .,Department of Infectious Diseases, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK. .,North West London Pathology, Fulham Palace Road, London, W6 8RF, UK.
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28
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Rawson TM, Moore LSP, Zhu N, Ranganathan N, Skolimowska K, Gilchrist M, Satta G, Cooke G, Holmes A. Reply to Dudoignon et al. Clin Infect Dis 2021; 72:906-908. [PMID: 32544234 DOI: 10.1093/cid/ciaa767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Timothy M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, United Kingdom.,Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Campus, London, United Kingdom.,Department of Infectious Diseases, Imperial College London, South Kensington Campus, South Kensington, United Kingdom
| | - Luke S P Moore
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom.,Chelsea and Westminster NHS Foundation Trust, London, United Kingdom
| | - Nina Zhu
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Nishanthy Ranganathan
- Department of Infectious Diseases, Imperial College London, South Kensington Campus, South Kensington, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Keira Skolimowska
- Department of Infectious Diseases, Imperial College London, South Kensington Campus, South Kensington, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Mark Gilchrist
- Department of Infectious Diseases, Imperial College London, South Kensington Campus, South Kensington, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Giovanni Satta
- Department of Infectious Diseases, Imperial College London, South Kensington Campus, South Kensington, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Graham Cooke
- Department of Infectious Diseases, Imperial College London, South Kensington Campus, South Kensington, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Alison Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, United Kingdom.,Centre for Antimicrobial Optimisation, Imperial College London, Hammersmith Campus, London, United Kingdom.,Department of Infectious Diseases, Imperial College London, South Kensington Campus, South Kensington, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
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Rawson TM, Hernandez B, Wilson RC, Ming D, Herrero P, Ranganathan N, Skolimowska K, Gilchrist M, Satta G, Georgiou P, Holmes AH. Supervised machine learning to support the diagnosis of bacterial infection in the context of COVID-19. JAC Antimicrob Resist 2021; 3:dlab002. [PMID: 34192255 PMCID: PMC7928888 DOI: 10.1093/jacamr/dlab002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/04/2021] [Indexed: 11/28/2022] Open
Abstract
Background Bacterial infection has been challenging to diagnose in patients with COVID-19. We developed and evaluated supervised machine learning algorithms to support the diagnosis of secondary bacterial infection in hospitalized patients during the COVID-19 pandemic. Methods Inpatient data at three London hospitals for the first COVD-19 wave in March and April 2020 were extracted. Demographic, blood test and microbiology data for individuals with and without SARS-CoV-2-positive PCR were obtained. A Gaussian Naive Bayes, Support Vector Machine (SVM) and Artificial Neural Network were trained and compared using the area under the receiver operating characteristic curve (AUCROC). The best performing algorithm (SVM with 21 blood test variables) was prospectively piloted in July 2020. AUCROC was calculated for the prediction of a positive microbiological sample within 48 h of admission. Results A total of 15 599 daily blood profiles for 1186 individual patients were identified to train the algorithms; 771/1186 (65%) individuals were SARS-CoV-2 PCR positive. Clinically significant microbiology results were present for 166/1186 (14%) patients during admission. An SVM algorithm trained with 21 routine blood test variables and over 8000 individual profiles had the best performance. AUCROC was 0.913, sensitivity 0.801 and specificity 0.890. Prospective testing on 54 patients on admission (28/54, 52% SARS-CoV-2 PCR positive) demonstrated an AUCROC of 0.960 (95% CI: 0.90–1.00). Conclusions An SVM using 21 routine blood test variables had excellent performance at inferring the likelihood of positive microbiology. Further prospective evaluation of the algorithms ability to support decision making for the diagnosis of bacterial infection in COVID-19 cohorts is underway.
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Affiliation(s)
- Timothy M 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.,Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London W12 0NN, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Bernard Hernandez
- Centre for Bio-inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Richard C Wilson
- 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.,Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London W12 0NN, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Damien Ming
- 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.,Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London W12 0NN, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Pau Herrero
- Centre for Bio-inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Nisha Ranganathan
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Keira Skolimowska
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Mark Gilchrist
- 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
| | - Giovanni Satta
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Pantelis Georgiou
- Centre for Bio-inspired Technology, Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Alison H 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.,Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, 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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30
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Rawson TM, Moore LSP, Zhu N, Ranganathan N, Skolimowska K, Gilchrist M, Satta G, Cooke G, Holmes A. Bacterial and Fungal Coinfection in Individuals With Coronavirus: A Rapid Review To Support COVID-19 Antimicrobial Prescribing. Clin Infect Dis 2020; 71:2459-2468. [PMID: 32358954 PMCID: PMC7197596 DOI: 10.1093/cid/ciaa530] [Citation(s) in RCA: 676] [Impact Index Per Article: 169.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/30/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND To explore and describe the current literature surrounding bacterial/fungal coinfection in patients with coronavirus infection. METHODS MEDLINE, EMBASE, and Web of Science were searched using broad-based search criteria relating to coronavirus and bacterial coinfection. Articles presenting clinical data for patients with coronavirus infection (defined as SARS-1, MERS, SARS-CoV-2, and other coronavirus) and bacterial/fungal coinfection reported in English, Mandarin, or Italian were included. Data describing bacterial/fungal coinfections, treatments, and outcomes were extracted. Secondary analysis of studies reporting antimicrobial prescribing in SARS-CoV-2 even in absence of coinfection was performed. RESULTS 1007 abstracts were identified. Eighteen full texts reporting bacterial/fungal coinfection were included. Most studies did not identify or report bacterial/fungal coinfection (85/140; 61%). Nine of 18 (50%) studies reported on COVID-19, 5/18 (28%) on SARS-1, 1/18 (6%) on MERS, and 3/18 (17%) on other coronaviruses. For COVID-19, 62/806 (8%) patients were reported as experiencing bacterial/fungal coinfection during hospital admission. Secondary analysis demonstrated wide use of broad-spectrum antibacterials, despite a paucity of evidence for bacterial coinfection. On secondary analysis, 1450/2010 (72%) of patients reported received antimicrobial therapy. No antimicrobial stewardship interventions were described. For non-COVID-19 cases, bacterial/fungal coinfection was reported in 89/815 (11%) of patients. Broad-spectrum antibiotic use was reported. CONCLUSIONS Despite frequent prescription of broad-spectrum empirical antimicrobials in patients with coronavirus-associated respiratory infections, there is a paucity of data to support the association with respiratory bacterial/fungal coinfection. Generation of prospective evidence to support development of antimicrobial policy and appropriate stewardship interventions specific for the COVID-19 pandemic is urgently required.
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Affiliation(s)
- Timothy M Rawson
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom.,Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom.,Department of Infectious Diseases, Imperial College London, South Kensington, United Kingdom
| | - Luke S P Moore
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom.,Chelsea & Westminster NHS Foundation Trust, London, United Kingdom
| | - Nina Zhu
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - Nishanthy Ranganathan
- Department of Infectious Diseases, Imperial College London, South Kensington, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Keira Skolimowska
- Department of Infectious Diseases, Imperial College London, South Kensington, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Mark Gilchrist
- Department of Infectious Diseases, Imperial College London, South Kensington, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Giovanni Satta
- Department of Infectious Diseases, Imperial College London, South Kensington, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Graham Cooke
- Department of Infectious Diseases, Imperial College London, South Kensington, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Alison Holmes
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom.,Centre for Antimicrobial Optimisation, Imperial College London, London, United Kingdom.,Department of Infectious Diseases, Imperial College London, South Kensington, United Kingdom.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
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31
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Rawson TM, Wilson RC, Holmes A. Understanding the role of bacterial and fungal infection in COVID-19. Clin Microbiol Infect 2020; 27:9-11. [PMID: 32979569 PMCID: PMC7546203 DOI: 10.1016/j.cmi.2020.09.025] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/08/2020] [Accepted: 09/15/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Timothy M 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, United Kingdom; Centre for Antimicrobial Optimization (CAMO), Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, United Kingdom.
| | - Richard C Wilson
- 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, United Kingdom; Centre for Antimicrobial Optimization (CAMO), Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, United Kingdom
| | - Alison 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, United Kingdom; Centre for Antimicrobial Optimization (CAMO), Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, United Kingdom
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Charani E, Ahmad R, Rawson TM, Castro-Sanchèz E, Tarrant C, Holmes AH. The Differences in Antibiotic Decision-making Between Acute Surgical and Acute Medical Teams: An Ethnographic Study of Culture and Team Dynamics. Clin Infect Dis 2020; 69:12-20. [PMID: 30445453 PMCID: PMC6579961 DOI: 10.1093/cid/ciy844] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/28/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Cultural and social determinants influence antibiotic decision-making in hospitals. We investigated and compared cultural determinants of antibiotic decision-making in acute medical and surgical specialties. METHODS An ethnographic observational study of antibiotic decision-making in acute medical and surgical teams at a London teaching hospital was conducted (August 2015-May 2017). Data collection included 500 hours of direct observations, and face-to-face interviews with 23 key informants. A grounded theory approach, aided by Nvivo 11 software, analyzed the emerging themes. An iterative and recursive process of analysis ensured saturation of the themes. The multiple modes of enquiry enabled cross-validation and triangulation of the findings. RESULTS In medicine, accepted norms of the decision-making process are characterized as collectivist (input from pharmacists, infectious disease, and medical microbiology teams), rationalized, and policy-informed, with emphasis on de-escalation of therapy. The gaps in antibiotic decision-making in acute medicine occur chiefly in the transition between the emergency department and inpatient teams, where ownership of the antibiotic prescription is lost. In surgery, team priorities are split between 3 settings: operating room, outpatient clinic, and ward. Senior surgeons are often absent from the ward, leaving junior staff to make complex medical decisions. This results in defensive antibiotic decision-making, leading to prolonged and inappropriate antibiotic use. CONCLUSIONS In medicine, the legacy of infection diagnosis made in the emergency department determines antibiotic decision-making. In surgery, antibiotic decision-making is perceived as a nonsurgical intervention that can be delegated to junior staff or other specialties. Different, bespoke approaches to optimize antibiotic prescribing are therefore needed to address these specific challenges.
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Affiliation(s)
- E Charani
- Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, National Institute for Health Research, Imperial College London
| | - R Ahmad
- Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, National Institute for Health Research, Imperial College London
| | - T M Rawson
- Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, National Institute for Health Research, Imperial College London
| | - E Castro-Sanchèz
- Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, National Institute for Health Research, Imperial College London
| | - C Tarrant
- Department of Health Sciences, University of Leicester, United Kingdom
| | - A H Holmes
- Health Protection Research Unit in Healthcare-Associated Infections and Antimicrobial Resistance, National Institute for Health Research, Imperial College London
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Abstract
Coronavirus disease 2019 may have a complex long-term impact on antimicrobial resistance (AMR). Coordinated strategies at the individual, health-care and policy levels are urgently required to inform necessary actions to reduce the potential longer-term impact on AMR and on access to effective antimicrobials.
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Affiliation(s)
| | - Damien Ming
- Imperial College London, South Kensington, London, UK
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34
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Rawson TM, Moore LSP, Castro-Sanchez E, Charani E, Davies F, Satta G, Ellington MJ, Holmes AH. COVID-19 and the potential long-term impact on antimicrobial resistance. J Antimicrob Chemother 2020; 75:1681-1684. [PMID: 32433765 PMCID: PMC7314000 DOI: 10.1093/jac/dkaa194] [Citation(s) in RCA: 193] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The emergence of the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) has required an unprecedented response to control the spread of the infection and protect the most vulnerable within society. Whilst the pandemic has focused society on the threat of emerging infections and hand hygiene, certain infection control and antimicrobial stewardship policies may have to be relaxed. It is unclear whether the unintended consequences of these changes will have a net-positive or -negative impact on rates of antimicrobial resistance. Whilst the urgent focus must be on controlling this pandemic, sustained efforts to address the longer-term global threat of antimicrobial resistance should not be overlooked.
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Affiliation(s)
- Timothy M 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
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, Du Cane Road, London W12 0NN, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Luke S P 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
- Chelsea & Westminster NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK
| | - Enrique Castro-Sanchez
- 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
| | - 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
- Public Health England, National Infection Service, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Frances Davies
- 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
| | - Giovanni Satta
- 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
| | - Matthew J Ellington
- Public Health England, National Infection Service, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Alison H 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
- Centre for Antimicrobial Optimisation, Hammersmith Hospital, Imperial College London, 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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Rawson TM, Hernandez B, Moore LSP, Blandy O, Herrero P, Gilchrist M, Gordon A, Toumazou C, Sriskandan S, Georgiou P, Holmes AH. Supervised machine learning for the prediction of infection on admission to hospital: a prospective observational cohort study. J Antimicrob Chemother 2020; 74:1108-1115. [PMID: 30590545 DOI: 10.1093/jac/dky514] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 10/11/2018] [Accepted: 11/14/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Infection diagnosis can be challenging, relying on clinical judgement and non-specific markers of infection. We evaluated a supervised machine learning (SML) algorithm for diagnosing bacterial infection using routinely available blood parameters on presentation to hospital. METHODS An SML algorithm was developed to classify cases into infection versus no infection using microbiology records and six available blood parameters (C-reactive protein, white cell count, bilirubin, creatinine, ALT and alkaline phosphatase) from 160203 individuals. A cohort of patients admitted to hospital over a 6 month period had their admission blood parameters prospectively inputted into the SML algorithm. They were prospectively followed up from admission to classify those who fulfilled clinical case criteria for a community-acquired bacterial infection within 72 h of admission using a pre-determined definition. Predictive ability was assessed using receiver operating characteristics (ROC) with cut-off values for optimal sensitivity and specificity explored. RESULTS One hundred and four individuals were included prospectively. The median (range) cohort age was 65 (21-98) years. The majority were female (56/104; 54%). Thirty-six (35%) were diagnosed with infection in the first 72 h of admission. Overall, 44/104 (42%) individuals had microbiological investigations performed. Treatment was prescribed for 33/36 (92%) of infected individuals and 4/68 (6%) of those with no identifiable bacterial infection. Mean (SD) likelihood estimates for those with and without infection were significantly different. The infection group had a likelihood of 0.80 (0.09) and the non-infection group 0.50 (0.29) (P < 0.01; 95% CI: 0.20-0.40). ROC AUC was 0.84 (95% CI: 0.76-0.91). CONCLUSIONS An SML algorithm was able to diagnose infection in individuals presenting to hospital using routinely available blood parameters.
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Affiliation(s)
- T M 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, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, UK
| | - B Hernandez
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, UK
| | - L S P 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, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, UK
| | - O Blandy
- 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, UK
| | - P Herrero
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, UK
| | - M Gilchrist
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, UK
| | - A Gordon
- Section of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, South Kensington Campus, London, UK
| | - C Toumazou
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, UK
| | - S Sriskandan
- 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, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, UK
| | - P Georgiou
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, UK
| | - A H 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, UK.,Imperial College Healthcare NHS Trust, Hammersmith Hospital, Du Cane Road, London, UK
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Peiffer-Smadja N, Rawson TM, Ahmad R, Buchard A, Georgiou P, Lescure FX, Birgand G, Holmes AH. Corrigendum to 'machine learning for clinical decision support in infectious diseases: a narrative review of current applications' clinical microbiology and infection (2020) 584-595. Clin Microbiol Infect 2020; 26:1118. [PMID: 32450256 DOI: 10.1016/j.cmi.2020.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- N Peiffer-Smadja
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK; French Institute for Medical Research (Inserm), Infection Antimicrobials Modelling Evolution (IAME), UMR, 1137, University Paris Diderot, Paris, France.
| | - T M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - R Ahmad
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | | | - P Georgiou
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - F-X Lescure
- French Institute for Medical Research (Inserm), Infection Antimicrobials Modelling Evolution (IAME), UMR, 1137, University Paris Diderot, Paris, France; Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hˆopitaux de Paris, Paris, France
| | - G Birgand
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - A H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
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37
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Rawson TM, Hernandez B, Moore LSP, Herrero P, Charani E, Ming D, Wilson RC, Blandy O, Sriskandan S, Gilchrist M, Toumazou C, Georgiou P, Holmes AH. A Real-world Evaluation of a Case-based Reasoning Algorithm to Support Antimicrobial Prescribing Decisions in Acute Care. Clin Infect Dis 2020; 72:2103-2111. [DOI: 10.1093/cid/ciaa383] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/02/2020] [Indexed: 12/16/2022] Open
Abstract
Abstract
Background
A locally developed case-based reasoning (CBR) algorithm, designed to augment antimicrobial prescribing in secondary care was evaluated.
Methods
Prescribing recommendations made by a CBR algorithm were compared to decisions made by physicians in clinical practice. Comparisons were examined in 2 patient populations: first, in patients with confirmed Escherichia coli blood stream infections (“E. coli patients”), and second in ward-based patients presenting with a range of potential infections (“ward patients”). Prescribing recommendations were compared against the Antimicrobial Spectrum Index (ASI) and the World Health Organization Essential Medicine List Access, Watch, Reserve (AWaRe) classification system. Appropriateness of a prescription was defined as the spectrum of the prescription covering the known or most-likely organism antimicrobial sensitivity profile.
Results
In total, 224 patients (145 E. coli patients and 79 ward patients) were included. Mean (standard deviation) age was 66 (18) years with 108/224 (48%) female sex. The CBR recommendations were appropriate in 202/224 (90%) compared to 186/224 (83%) in practice (odds ratio [OR]: 1.24 95% confidence interval [CI]: .392–3.936; P = .71). CBR recommendations had a smaller ASI compared to practice with a median (range) of 6 (0–13) compared to 8 (0–12) (P < .01). CBR recommendations were more likely to be classified as Access class antimicrobials compared to physicians’ prescriptions at 110/224 (49%) vs. 79/224 (35%) (OR: 1.77; 95% CI: 1.212–2.588; P < .01). Results were similar for E. coli and ward patients on subgroup analysis.
Conclusions
A CBR-driven decision support system provided appropriate recommendations within a narrower spectrum compared to current clinical practice. Future work must investigate the impact of this intervention on prescribing behaviors more broadly and patient outcomes.
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Affiliation(s)
- Timothy M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, United Kingdom
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Bernard Hernandez
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, United Kingdom
| | - Luke S P Moore
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, United Kingdom
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
- Chelsea & Westminster NHS Foundation Trust, London, United Kingdom
| | - Pau Herrero
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, United Kingdom
| | - Esmita Charani
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Damien Ming
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Richard C Wilson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, United Kingdom
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Oliver Blandy
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Shiranee Sriskandan
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Mark Gilchrist
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Christofer Toumazou
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, United Kingdom
| | - Pantelis Georgiou
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London, United Kingdom
| | - Alison H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, United Kingdom
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
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Affiliation(s)
- Timothy M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Raheelah Ahmad
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Christofer Toumazou
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Pantelis Georgiou
- Department of Electrical and Electronic Engineering, Imperial College London, London, UK
| | - Alison H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.
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Peiffer-Smadja N, Rawson TM, Ahmad R, Buchard A, Georgiou P, Lescure FX, Birgand G, Holmes AH. Machine learning for clinical decision support in infectious diseases: a narrative review of current applications. Clin Microbiol Infect 2019; 26:584-595. [PMID: 31539636 DOI: 10.1016/j.cmi.2019.09.009] [Citation(s) in RCA: 159] [Impact Index Per Article: 31.8] [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: 06/27/2019] [Revised: 08/29/2019] [Accepted: 09/09/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Machine learning (ML) is a growing field in medicine. This narrative review describes the current body of literature on ML for clinical decision support in infectious diseases (ID). OBJECTIVES We aim to inform clinicians about the use of ML for diagnosis, classification, outcome prediction and antimicrobial management in ID. SOURCES References for this review were identified through searches of MEDLINE/PubMed, EMBASE, Google Scholar, biorXiv, ACM Digital Library, arXiV and IEEE Xplore Digital Library up to July 2019. CONTENT We found 60 unique ML-clinical decision support systems (ML-CDSS) aiming to assist ID clinicians. Overall, 37 (62%) focused on bacterial infections, 10 (17%) on viral infections, nine (15%) on tuberculosis and four (7%) on any kind of infection. Among them, 20 (33%) addressed the diagnosis of infection, 18 (30%) the prediction, early detection or stratification of sepsis, 13 (22%) the prediction of treatment response, four (7%) the prediction of antibiotic resistance, three (5%) the choice of antibiotic regimen and two (3%) the choice of a combination antiretroviral therapy. The ML-CDSS were developed for intensive care units (n = 24, 40%), ID consultation (n = 15, 25%), medical or surgical wards (n = 13, 20%), emergency department (n = 4, 7%), primary care (n = 3, 5%) and antimicrobial stewardship (n = 1, 2%). Fifty-three ML-CDSS (88%) were developed using data from high-income countries and seven (12%) with data from low- and middle-income countries (LMIC). The evaluation of ML-CDSS was limited to measures of performance (e.g. sensitivity, specificity) for 57 ML-CDSS (95%) and included data in clinical practice for three (5%). IMPLICATIONS Considering comprehensive patient data from socioeconomically diverse healthcare settings, including primary care and LMICs, may improve the ability of ML-CDSS to suggest decisions adapted to various clinical contexts. Currents gaps identified in the evaluation of ML-CDSS must also be addressed in order to know the potential impact of such tools for clinicians and patients.
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Affiliation(s)
- N Peiffer-Smadja
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK; French Institute for Medical Research (Inserm), Infection Antimicrobials Modelling Evolution (IAME), UMR 1137, University Paris Diderot, Paris, France.
| | - T M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - R Ahmad
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | | | - P Georgiou
- Department of Electrical and Electronic Engineering, Imperial College, London, UK
| | - F-X Lescure
- French Institute for Medical Research (Inserm), Infection Antimicrobials Modelling Evolution (IAME), UMR 1137, University Paris Diderot, Paris, France; Infectious Diseases Department, Bichat-Claude Bernard Hospital, Assistance-Publique Hôpitaux de Paris, Paris, France
| | - G Birgand
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - A H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
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Charani E, de Barra E, Rawson TM, Gill D, Gilchrist M, Naylor NR, Holmes AH. Antibiotic prescribing in general medical and surgical specialties: a prospective cohort study. Antimicrob Resist Infect Control 2019; 8:151. [PMID: 31528337 PMCID: PMC6743118 DOI: 10.1186/s13756-019-0603-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background Qualitative work has described the differences in prescribing practice across medical and surgical specialties. This study aimed to understand if specialty impacts quantitative measures of prescribing practice. Methods We prospectively analysed the antibiotic prescribing across general medical and surgical teams for acutely admitted patients. Over a 12-month period (June 2016 – May 2017) 659 patients (362 medical, 297 surgical) were followed for the duration of their hospital stay. Antibiotic prescribing across these cohorts was assessed using Chi-squared or Wilcoxon rank-sum, depending on normality of data. The t-test was used to compare age and length of stay. A logistic regression model was used to predict escalation of antibiotic therapy. Results Surgical patients were younger (p < 0.001) with lower Charlson Comorbidity Index scores (p < 0.001). Antibiotics were prescribed for 45% (162/362) medical and 55% (164/297) surgical patients. Microbiological results were available for 26% (42/164) medical and 29% (48/162) surgical patients, of which 55% (23/42) and 48% (23/48) were positive respectively. There was no difference in the spectrum of antibiotics prescribed between surgery and medicine (p = 0.507). In surgery antibiotics were 1) prescribed more frequently (p = 0.001); 2) for longer (p = 0.016); 3) more likely to be escalated (p = 0.004); 4) less likely to be compliant with local policy (p < 0.001) than medicine. Conclusions Across both specialties, microbiology investigation results are not adequately used to diagnose infections and optimise their management. There is significant variation in antibiotic decision-making (including escalation patterns) between general surgical and medical teams. Antibiotic stewardship interventions targeting surgical specialties need to go beyond surgical prophylaxis. It is critical to focus on of review the patients initiated on therapeutic antibiotics in surgical specialties to ensure that escalation and continuation of therapy is justified.
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Affiliation(s)
- E Charani
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
| | - E de Barra
- 2Royal College of Surgeons in Ireland, RCSI Education & Research Centre, Beaumont Hospital, Beaumont, Dublin 9, Ireland
| | - T M Rawson
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
| | - D Gill
- 3Department of Biostatistics and Epidemiology, School of Public Health, Imperial College London, London, W2 1PG UK
| | - M Gilchrist
- Department of Pharmacy, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London, W12 1NY UK
| | - N R Naylor
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
| | - A H Holmes
- 1NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Hammersmith Campus, Imperial College London, 8th Floor Commonwealth Building, Du Cane Road, London, W12 ONN UK
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Lee AE, Niruttan K, Rawson TM, Moore LSP. Antibacterial resistance in ophthalmic infections: a multi-centre analysis across UK care settings. BMC Infect Dis 2019; 19:768. [PMID: 31481023 PMCID: PMC6724305 DOI: 10.1186/s12879-019-4418-0] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bacterial ophthalmic infections are common. Empirical treatment with topical broad-spectrum antibiotics is recommended for severe cases. Antimicrobial resistance (AMR) to agents used for bacterial ophthalmic infections make it increasingly important to consider changing resistance patterns when prescribing, however UK data in this area are lacking. We evaluate the epidemiology and antimicrobial susceptibilities of ophthalmic pathogens across care settings and compare these with local and national antimicrobial prescribing guidelines. METHODS A retrospective, multi-centre observational analysis was undertaken of ophthalmic microbiology isolates between 2009 and 2015 at a centralised North-West London laboratory (incorporating data from primary care and five London teaching hospitals). Data were analysed using descriptive statistics with respect to patient demographics, pathogen distribution (across age-groups and care setting), seasonality, and susceptibility to topical chloramphenicol, moxifloxacin, and fusidic acid. RESULTS Two thousand six hundred eighty-one isolates (n = 2168 patients) were identified. The commonest pathogen in adults was Staphylococcus spp. across primary, secondary, and tertiary care (51.7%; 43.4%; 33.6% respectively) and in children was Haemophilus spp. (34.6%;28.2%;36.6%). AMR was high and increased across care settings for chloramphenicol (11.8%;15.1%;33.8%); moxifloxacin (5.5%;7.6%;25.5%); and fusidic acid (49.6%;53.4%; 58.7%). Pseudomonas spp. was the commonest chloramphenicol-resistant pathogen across all care settings, whilst Haemophilus spp. was the commonest fusidic acid-resistant pathogen across primary and secondary care. More isolates were recorded in spring (31.6%) than any other season, mostly due to a significant rise in Haemophilus spp. CONCLUSIONS We find UK national and local antimicrobial prescribing policies for ophthalmic infections may not be concordant with the organisms and antimicrobial susceptibilities found in clinical samples. We also find variations in microbial incidence related to patient age, clinical setting, and season. Such variations may have further important implications for prescribing practices and modification of antimicrobial guidelines.
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Affiliation(s)
- Alice E Lee
- Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - Kanchana Niruttan
- Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - Timothy M Rawson
- Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - Luke S P Moore
- Imperial College London, South Kensington Campus, London, SW7 2AZ, UK.
- Chelsea and Westminster NHS Foundation Trust, 369 Fulham Rd, Chelsea, London, SW10 9NH, UK.
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London, W6 8RF, UK.
- National Institute for Health Research Health Protection Research Unit (HPRU) in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, Commonwealth Building, Du Cane Road, London, W12 0NN, UK.
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Gowers SAN, Freeman DME, Rawson TM, Rogers ML, Wilson RC, Holmes AH, Cass AE, O’Hare D. Development of a Minimally Invasive Microneedle-Based Sensor for Continuous Monitoring of β-Lactam Antibiotic Concentrations in Vivo. ACS Sens 2019; 4:1072-1080. [PMID: 30950598 DOI: 10.1021/acssensors.9b00288] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [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: 12/12/2022]
Abstract
Antimicrobial resistance poses a global threat to patient health. Improving the use and effectiveness of antimicrobials is critical in addressing this issue. This includes optimizing the dose of antibiotic delivered to each individual. New sensing approaches that track antimicrobial concentration for each patient in real time could allow individualized drug dosing. This work presents a potentiometric microneedle-based biosensor to detect levels of β-lactam antibiotics in vivo in a healthy human volunteer. The biosensor is coated with a pH-sensitive iridium oxide layer, which detects changes in local pH as a result of β-lactam hydrolysis by β-lactamase immobilized on the electrode surface. Development and optimization of the biosensor coatings are presented, giving a limit of detection of 6.8 μM in 10 mM PBS solution. Biosensors were found to be stable for up to 2 weeks at -20 °C and to withstand sterilization. Sensitivity was retained after application for 6 h in vivo. Proof-of-concept results are presented showing that penicillin concentrations measured using the microneedle-based biosensor track those measured using both discrete blood and microdialysis sampling in vivo. These preliminary results show the potential of this microneedle-based biosensor to provide a minimally invasive means to measure real-time β-lactam concentrations in vivo, representing an important first step toward a closed-loop therapeutic drug monitoring system.
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Affiliation(s)
- Sally A. N. Gowers
- Department of Bioengineering, Imperial College London, London SW7 2AZ, United Kingdom
| | - David M. E. Freeman
- Department of Bioengineering, Imperial College London, London SW7 2AZ, United Kingdom
| | - Timothy M. Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, United Kingdom
| | - Michelle L. Rogers
- Department of Bioengineering, Imperial College London, London SW7 2AZ, United Kingdom
| | - Richard C. Wilson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, United Kingdom
| | - Alison H. Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London W12 0NN, United Kingdom
| | - Anthony E. Cass
- Department of Chemistry & Institute of Biomedical Engineering, Imperial College London, London SW7 2AZ, United Kingdom
| | - Danny O’Hare
- Department of Bioengineering, Imperial College London, London SW7 2AZ, United Kingdom
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Boyd SE, Moore LSP, Rawson TM, Hope WW, Holmes AH. Combination therapy for carbapenemase-producing Entero-bacteriaceae: INCREMENT-al effect on resistance remains unclear. Lancet Infect Dis 2018; 17:899-900. [PMID: 28845792 DOI: 10.1016/s1473-3099(17)30450-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Sara E Boyd
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK; Imperial College Healthcare National Health Service Trust, London, UK; Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool L69 3GE, UK.
| | - Luke S P Moore
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK; Chelsea and Westminster National Health Service Foundation Trust, London, UK
| | - Timothy M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK
| | - William W Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool L69 3GE, UK
| | - Alison H Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London W12 0NN, UK; Imperial College Healthcare National Health Service Trust, London, UK
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Abdolrasouli A, Petrou MA, Park H, Rhodes JL, Rawson TM, Moore LSP, Donaldson H, Holmes AH, Fisher MC, Armstrong-James D. Surveillance for Azole-Resistant Aspergillus fumigatus in a Centralized Diagnostic Mycology Service, London, United Kingdom, 1998-2017. Front Microbiol 2018; 9:2234. [PMID: 30294314 PMCID: PMC6158360 DOI: 10.3389/fmicb.2018.02234] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 08/31/2018] [Indexed: 11/13/2022] Open
Abstract
Background/Objectives: Aspergillus fumigatus is the leading cause of invasive aspergillosis. Treatment is hindered by the emergence of resistance to triazole antimycotic agents. Here, we present the prevalence of triazole resistance among clinical isolates at a major centralized medical mycology laboratory in London, United Kingdom, in the period 1998-2017. Methods: A large number (n = 1469) of clinical A. fumigatus isolates from unselected clinical specimens were identified and their susceptibility against three triazoles, amphotericin B and three echinocandin agents was carried out. All isolates were identified phenotypically and antifungal susceptibility testing was carried out by using a standard broth microdilution method. Results: Retrospective surveillance (1998-2011) shows 5/1151 (0.43%) isolates were resistant to at least one of the clinically used triazole antifungal agents. Prospective surveillance (2015-2017) shows 7/356 (2.2%) isolates were resistant to at least one triazole antifungals demonstrating an increase in incidence of triazole-resistant A. fumigatus in our laboratory. Among five isolates collected from 2015 to 2017 and available for molecular testing, three harbored TR34/L98H alteration in the cyp51A gene that are associated with the acquisition of resistance in the non-patient environment. Conclusion: These data show that historically low prevalence of azole resistance may be increasing, warranting further surveillance of susceptible patients.
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Affiliation(s)
- Alireza Abdolrasouli
- Diagnostic Mycology Service, Department of Medical Microbiology, North West London Pathology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
- Fungal Pathogens Laboratory, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Michael A. Petrou
- Diagnostic Mycology Service, Department of Medical Microbiology, North West London Pathology, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Hyun Park
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Johanna L. Rhodes
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, United Kingdom
| | - Timothy M. Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
- Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Luke S. P. Moore
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
- Imperial College Healthcare National Health Service Trust, London, United Kingdom
- Chelsea and Westminster National Health Service Foundation Trust, London, United Kingdom
| | - Hugo Donaldson
- Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Alison H. Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
- Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Matthew C. Fisher
- MRC Centre for Global Infectious Disease Analysis, Imperial College London, London, United Kingdom
| | - Darius Armstrong-James
- Fungal Pathogens Laboratory, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Alividza V, Mariano V, Ahmad R, Charani E, Rawson TM, Holmes AH, Castro-Sánchez E. Investigating the impact of poverty on colonization and infection with drug-resistant organisms in humans: a systematic review. Infect Dis Poverty 2018; 7:76. [PMID: 30115132 PMCID: PMC6097281 DOI: 10.1186/s40249-018-0459-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [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: 01/15/2018] [Accepted: 07/09/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Poverty increases the risk of contracting infectious diseases and therefore exposure to antibiotics. Yet there is lacking evidence on the relationship between income and non-income dimensions of poverty and antimicrobial resistance. Investigating such relationship would strengthen antimicrobial stewardship interventions. METHODS A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Ovid, MEDLINE, EMBASE, Scopus, CINAHL, PsychINFO, EBSCO, HMIC, and Web of Science databases were searched in October 2016. Prospective and retrospective studies reporting on income or non-income dimensions of poverty and their influence on colonisation or infection with antimicrobial-resistant organisms were retrieved. Study quality was assessed with the Integrated quality criteria for review of multiple study designs (ICROMS) tool. RESULTS Nineteen articles were reviewed. Crowding and homelessness were associated with antimicrobial resistance in community and hospital patients. In high-income countries, low income was associated with Streptococcus pneumoniae and Acinetobacter baumannii resistance and a seven-fold higher infection rate. In low-income countries the findings on this relation were contradictory. Lack of education was linked to resistant S. pneumoniae and Escherichia coli. Two papers explored the relation between water and sanitation and antimicrobial resistance in low-income settings. CONCLUSIONS Despite methodological limitations, the results suggest that addressing social determinants of poverty worldwide remains a crucial yet neglected step towards preventing antimicrobial resistance.
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Affiliation(s)
- Vivian Alividza
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Victor Mariano
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Raheelah Ahmad
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
- Health Group, Management Department, Imperial College Business School, Exhibition Road, London, UK
| | - Esmita Charani
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Timothy M. Rawson
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Alison H. Holmes
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Enrique Castro-Sánchez
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
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Rawson TM, Ming D, Gowers SA, Freeman DM, Herrero P, Georgiou P, Cass AE, O'Hare D, Holmes AH. Public acceptability of computer-controlled antibiotic management: An exploration of automated dosing and opportunities for implementation. J Infect 2018; 78:75-86. [PMID: 30099085 DOI: 10.1016/j.jinf.2018.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 08/06/2018] [Indexed: 12/25/2022]
Abstract
A paucity of data describing citizen perceptions of novel technologies, including those containing unsupervised computer-controlled systems is currently available. We explored citizen perceptions of using a microneedle biosensor and automated dose control system at a university public festival. Groups of citizens (from 2-6 people per group) attended a short demonstration of a microneedle biosensor and automated dosing system versus a traditional phlebotomy approach over a two-day public festival. Individual groups discussed and reached consensus on a number of short questions regarding their perceptions on the acceptability of such technology. Over the two days, 100 groups participated (56/100 day 1 and 44/100 day 2). The majority of individuals reported high acceptability of microneedle technology (median Likert score 9/10), but the majority believed that doctors should decide what dose of antibiotic is delivered (75/100; 75%). Groups concurred with the acceptability of microneedles to reduce blood tests and pain associated with them. However, concerns were reported over unsupervised computer-controlled programmes making decision about antibiotic dosing. This was driven by concerns over computer error and the inability of systems to contextualise decision making to the human and social context. Future work must consider the greater role of citizen engagement in the development of such technologies, to ensure their acceptability upon implementation in clinical practice.
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Affiliation(s)
- Timothy M 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, United Kingdom.
| | - Damien Ming
- 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, United Kingdom
| | - Sally An Gowers
- Department of Bioengineering, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom
| | - David Me Freeman
- Department of Chemistry, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom
| | - Pau Herrero
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom
| | - Pantelis Georgiou
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom
| | - Anthony E Cass
- Department of Chemistry, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom
| | - Danny O'Hare
- Department of Bioengineering, Imperial College London, South Kensington Campus, London SW7 2AZ, United Kingdom
| | - Alison H 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, United Kingdom
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Rawson TM, Sivakumaran P, Lobo R, Mahir G, Rossiter A, Levy J, McGregor AH, Lupton M, Easton G, Gill D. Development of a web-based tool for undergraduate engagement in medical research; the ProjectPal experience. BMC Med Educ 2018; 18:166. [PMID: 30005595 PMCID: PMC6044023 DOI: 10.1186/s12909-018-1272-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 07/02/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND We report the development and evaluation of a web-based tool designed to facilitate student extra-curricular engagement in medical research through project matching students with academic supervisors. UK based university students were surveyed to explore their perceptions of undergraduate research, barriers and facilitators to current engagement. Following this, an online web-based intervention ( www.ProjectPal.org ) was developed to support access of students to research projects and supervisors. A pilot intervention was undertaken across a London-based university in January 2013 to February 2016. In March 2016, anonymised data were extracted from the prospective data log for analysis of website engagement and usage. Supervisors were surveyed to evaluate the website and student outputs. RESULTS Fifty-one students responded to the electronic survey. Twenty-four (47%) reported frustration at a perceived lack of opportunities to carry out extra-curricular academic projects. Major barriers to engaging in undergraduate research reported were difficulties in identifying suitable supervisors (33/51; 65%) and time pressures (36/51; 71%) associated with this. Students reported being opportunistic in their engagement with undergraduate research. Following implementation of the website, 438 students signed up to ProjectPal and the website was accessed 1357 times. Access increased on a yearly basis. Overall, 70 projects were advertised by 35 supervisors. There were 86 applications made by students for these projects. By February 2016, the 70 projects had generated 5 peer-review publications with a further 7 manuscripts under peer-review, 14 national presentations, and 1 national prize. CONCLUSION The use of an online platform to promote undergraduate engagement with extra-curricular research appears to facilitate extra-curricular engagement with research. Further work to understand the impact compared to normal opportunistic practices in enhancing student engagement is now underway.
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Affiliation(s)
- Timothy M. Rawson
- Imperial College London, South Kensington, London, SW7 2AZ UK
- Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0NN UK
| | | | - Rhannon Lobo
- Imperial College London, South Kensington, London, SW7 2AZ UK
| | - Gheed Mahir
- Imperial College London, South Kensington, London, SW7 2AZ UK
| | - Adam Rossiter
- Imperial College London, South Kensington, London, SW7 2AZ UK
| | - Jeremy Levy
- Imperial College London, South Kensington, London, SW7 2AZ UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, W2 1NY UK
| | - Alison H. McGregor
- Imperial College London, South Kensington, London, SW7 2AZ UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, W2 1NY UK
| | - Martin Lupton
- Imperial College London, South Kensington, London, SW7 2AZ UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, W2 1NY UK
| | - Graham Easton
- Imperial College London, South Kensington, London, SW7 2AZ UK
| | - Dipender Gill
- Imperial College London, South Kensington, London, SW7 2AZ UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, W2 1NY UK
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Abbara A, Rawson TM, Karah N, El-Amin W, Hatcher J, Tajaldin B, Dar O, Dewachi O, Abu Sitta G, Uhlin BE, Sparrow A. A summary and appraisal of existing evidence of antimicrobial resistance in the Syrian conflict. Int J Infect Dis 2018; 75:26-33. [PMID: 29936319 DOI: 10.1016/j.ijid.2018.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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: 03/31/2018] [Revised: 06/13/2018] [Accepted: 06/14/2018] [Indexed: 11/30/2022] Open
Abstract
Antimicrobial resistance (AMR) in populations experiencing war has yet to be addressed, despite the abundance of contemporary conflicts and the protracted nature of twenty-first century wars, in combination with growing global concern over conflict-associated bacterial pathogens. The example of the Syrian conflict is used to explore the feasibility of using existing global policies on AMR in conditions of extreme conflict. The available literature on AMR and prescribing behaviour in Syria before and since the onset of the conflict in March 2011 was identified. Overall, there is a paucity of rigorous data before and since the onset of conflict in Syria to contextualize the burden of AMR. However, post onset of the conflict, an increasing number of studies conducted in neighbouring countries and Europe have reported AMR in Syrian refugees. High rates of multidrug resistance, particularly Gram-negative organisms, have been noted amongst Syrian refugees when compared with local populations. Conflict impedes many of the safeguards against AMR, creates new drivers, and exacerbates existing ones. Given the apparently high rates of AMR in Syria, in neighbouring countries hosting refugees, and in European countries providing asylum, this requires the World Health Organization and other global health institutions to address the causes, costs, and future considerations of conflict-related AMR as an issue of global governance.
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Affiliation(s)
- Aula Abbara
- Department of Infection, Imperial College Healthcare NHS Trust, London, UK.
| | - Timothy M Rawson
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK.
| | - Nabil Karah
- Department of Molecular Biology, Laboratory for Molecular Infection Medicine Sweden, and Umeå Centre for Microbial Research, Umeå University, Umeå, Sweden.
| | - Wael El-Amin
- Department of Microbiology, Broomfield Hospital, Chelmsford, Essex, UK.
| | - James Hatcher
- Department of Infection, Imperial College Healthcare NHS Trust, London, UK
| | | | - Osman Dar
- Public Health England, London, UK; Chatham House Centre on Global Health Security, London, UK.
| | - Omar Dewachi
- Conflict and Health Program, American University of Beirut, Lebanon.
| | | | - Bernt Eric Uhlin
- Department of Molecular Biology, Laboratory for Molecular Infection Medicine Sweden, and Umeå Centre for Microbial Research, Umeå University, Umeå, Sweden
| | - Annie Sparrow
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai, New York, USA.
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Rawson TM, Charani E, Moore LSP, Gilchrist M, Georgiou P, Hope W, Holmes AH. Exploring the Use of C-Reactive Protein to Estimate the Pharmacodynamics of Vancomycin. Ther Drug Monit 2018; 40:315-321. [PMID: 29561305 PMCID: PMC6485622 DOI: 10.1097/ftd.0000000000000507] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND C-reactive protein (CRP) pharmacodynamic (PD) models have the potential to provide adjunctive methods for predicting the individual exposure response to antimicrobial therapy. We investigated CRP PD linked to a vancomycin pharmacokinetic (PK) model using routinely collected data from noncritical care adults in secondary care. METHODS Patients receiving intermittent intravenous vancomycin therapy in secondary care were identified. A 2-compartment vancomycin PK model was linked to a previously described PD model describing CRP response. PK and PD parameters were estimated using a Non-Parametric Adaptive Grid technique. Exposure-response relationships were explored with vancomycin area-under-the-concentration-time-curve (AUC) and EC50 (concentration of drug that causes a half maximal effect) using the index, AUC:EC50, fitted to CRP data using a sigmoidal Emax model. RESULTS Twenty-nine individuals were included. Median age was 62 (21-97) years. Fifteen (52%) patients were microbiology confirmed. PK and PD models were adequately fitted (r 0.83 and 0.82, respectively). There was a wide variation observed in individual Bayesian posterior EC50 estimates (6.95-48.55 mg/L), with mean (SD) AUC:EC50 of 31.46 (29.22). AUC:EC50 was fitted to terminal CRP with AUC:EC50 >19 associated with lower CRP value at 96-120 hours of therapy (100 mg/L versus 44 mg/L; P < 0.01). CONCLUSIONS The use of AUC:EC50 has the potential to provide in vivo organism and host response data as an adjunct for in vitro minimum inhibitory concentration data, which is currently used as the gold standard PD index for vancomycin therapy. This index can be estimated using routinely collected clinical data. Future work must investigate the role of AUC:EC50 in a prospective cohort and explore linkage with direct patient outcomes.
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Affiliation(s)
- Timothy M 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. United
Kingdom
| | - 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. United
Kingdom
| | - Luke SP 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. United
Kingdom
- Imperial College Healthcare NHS Trust, Du Cane Road, London.W12 0HS.
United Kingdom
| | - Mark Gilchrist
- Imperial College Healthcare NHS Trust, Du Cane Road, London.W12 0HS.
United Kingdom
| | - Pantelis Georgiou
- Department of Electrical and Electronic Engineering, Imperial
College London, South Kensington Campus, London, SW7 2AZ, United Kingdom
| | - William Hope
- Department of Molecular and Clinical Pharmacology, University of
Liverpool, Liverpool, L69 3GE, United Kingdom
| | - Alison H 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. United
Kingdom
- Imperial College Healthcare NHS Trust, Du Cane Road, London.W12 0HS.
United Kingdom
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50
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Abbara A, Rawson TM, Karah N, El-Amin W, Hatcher J, Tajaldin B, Dar O, Dewachi O, Abu Sitta G, Uhlin BE, Sparrow A. Antimicrobial resistance in the context of the Syrian conflict: Drivers before and after the onset of conflict and key recommendations. Int J Infect Dis 2018; 73:1-6. [PMID: 29793039 DOI: 10.1016/j.ijid.2018.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 03/31/2018] [Revised: 05/13/2018] [Accepted: 05/16/2018] [Indexed: 10/16/2022] Open
Abstract
Current evidence describing antimicrobial resistance (AMR) in the context of the Syrian conflict is of poor quality and sparse in nature. This paper explores and reports the major drivers of AMR that were present in Syria pre-conflict and those that have emerged since its onset in March 2011. Drivers that existed before the conflict included a lack of enforcement of existing legislation to regulate over-the-counter antibiotics and notification of communicable diseases. This contributed to a number of drivers of AMR after the onset of conflict, and these were also compounded by the exodus of trained staff, the increase in overcrowding and unsanitary conditions, the increase in injuries, and economic sanctions limiting the availability of required laboratory medical materials and equipment. Addressing AMR in this context requires pragmatic, multifaceted action at the local, regional, and international levels to detect and manage potentially high rates of multidrug-resistant infections. Priorities are (1) the development of a competent surveillance system for hospital-acquired infections, (2) antimicrobial stewardship, and (3) the creation of cost-effective and implementable infection control policies. However, it is only by addressing the conflict and immediate cessation of the targeting of health facilities that the rehabilitation of the health system, which is key to addressing AMR in this context, can progress.
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Affiliation(s)
- Aula Abbara
- Department of Infection, Imperial College Healthcare NHS Trust, London, UK.
| | - Timothy M Rawson
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK.
| | - Nabil Karah
- Department of Molecular Biology, Laboratory for Molecular Infection Medicine Sweden, and Umeå Centre for Microbial Research, Umeå University, Umeå, Sweden.
| | - Wael El-Amin
- Department of Microbiology, Broomfield Hospital, Chelmsford, Essex, UK.
| | - James Hatcher
- Department of Infection, Imperial College Healthcare NHS Trust, London, UK.
| | | | - Osman Dar
- Public Health England, Chatham House Centre on Global Health Security, London, UK.
| | - Omar Dewachi
- Conflict and Health Program, American University of Beirut, Lebanon.
| | - Ghassan Abu Sitta
- Conflict and Health Program, American University of Beirut, Lebanon.
| | - Bernt Eric Uhlin
- Department of Molecular Biology, Laboratory for Molecular Infection Medicine Sweden, and Umeå Centre for Microbial Research, Umeå University, Umeå, Sweden.
| | - Annie Sparrow
- Department of Population Health Sciences and Policy, Icahn School of Medicine at Mount Sinai, New York, USA.
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