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Rinaldi M, Gatti M, Tonetti T, Nocera D, Ambretti S, Berlingeri A, Nigrisoli G, Pierucci E, Siniscalchi A, Pea F, Viale P, Giannella M. Impact of a multidisciplinary management team on clinical outcome in ICU patients affected by Gram-negative bloodstream infections: a pre-post quasi-experimental study. Ann Intensive Care 2024; 14:36. [PMID: 38448761 PMCID: PMC10917714 DOI: 10.1186/s13613-024-01271-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Bloodstream infections (BSIs) by Gram-negative pathogens play a major role in intensive care patients, both in terms of prevalence and severity, especially if multi-drug resistant pathogens are involved. Early appropriate antibiotic therapy is therefore a cornerstone in the management of these patients, and growing evidence shows that implementation of a multidisciplinary team may improve patients' outcomes. Our aim was to evaluate the clinical and microbiological impact of the application of a multidisciplinary team on critically ill patients. METHODS Pre-post study enrolling critically ill patients with Gram negative bloodstream infection in intensive care unit. In the pre-intervention phase (from January until December 2018) patients were managed with infectious disease consultation on demand, in the post-intervention phase (from January until December 2022) patients were managed with a daily evaluation by a multidisciplinary team composed of intensivist, infectious disease physician, clinical pharmacologist and microbiologist. RESULTS Overall, 135 patients were enrolled during the study period, of them 67 (49.6%) in the pre-intervention phase and 68 (50.4%) in the post-intervention phase. Median age was 67 (58-75) years, sex male was 31.9%. Septic shock, the need for continuous renal replacement therapy and mechanical ventilation at BSI onset were similar in both groups, no difference of multidrug-resistant organisms (MDRO) prevalence was observed. In the post-phase, empirical administration of carbapenems decreased significantly (40.3% vs. 62.7%, p = 0.02) with an increase of appropriate empirical therapy (86.9% vs. 55.2%, p < 0.001) and a decrease of overall antibiotic treatment (12 vs. 16 days, p < 0.001). Despite no differences in delta SOFA and all-cause 30-day mortality, a significant decrease in microbiological failure (10.3% vs. 29.9%, p = 0.005) and a new-onset 30-day MDRO colonization (8.3% vs. 36.6%, p < 0.001) in the post-phase was reported. At multivariable analysis adjusted for main covariates, the institution of a multidisciplinary management team (MMT) was found to be protective both for new MDRO colonization [OR 0.17, 95%CI(0.05-0.67)] and microbiological failure [OR 0.37, 95%CI (0.14-0.98)]. CONCLUSIONS The institution of a MMT allowed for an optimization of antimicrobial treatments, reflecting to a significant decrease in new MDRO colonization and microbiological failure among critically ill patients.
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Affiliation(s)
- Matteo Rinaldi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti, 9, Bologna, 40138, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti, 9, Bologna, 40138, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Tommaso Tonetti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti, 9, Bologna, 40138, Italy.
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | - Domenico Nocera
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti, 9, Bologna, 40138, Italy
| | - Simone Ambretti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti, 9, Bologna, 40138, Italy
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, 40138, Italy
| | - Andrea Berlingeri
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti, 9, Bologna, 40138, Italy
- Microbiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, 40138, Italy
| | - Giacomo Nigrisoli
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti, 9, Bologna, 40138, Italy
| | - Elisabetta Pierucci
- Anesthesiology and General Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Siniscalchi
- Anesthesia and Intensive Care Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, 40138, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti, 9, Bologna, 40138, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti, 9, Bologna, 40138, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maddalena Giannella
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti, 9, Bologna, 40138, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Gupta A, Siddiqui F, Saxena B, Purwar S, Saigal S, Sharma JP, Kumar S. A prospective study evaluating the effect of a "Diagnostic Stewardship Care-Bundle" for automated blood culture diagnostics. J Glob Antimicrob Resist 2023; 35:360-368. [PMID: 38035932 DOI: 10.1016/j.jgar.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVES We prospectively implemented a diagnostic stewardship care-bundle checklist, 'Sepsis-48 DSB', with the aim of reducing intervening duration of key steps of automated blood culture diagnostics (aBCD). METHODS Sepsis-48 DSB was implemented for automated blood culture bottles (BCBs) received from adult intensive care units (AICUs) during the intervention period (P2; July 2020-June 2021) and intervening durations were compared with those during the retrospective, pre-intervention period (P1; March-June 2020). During both periods, provisional blood culture reports (pBCR) were issued wherein direct microbial identification (dID) was performed in BCBs with Gram-negatives by directly inoculating conventional biochemical tests and direct antimicrobial susceptibility testing (dAST) using EUCAST RAST method. The results were compared with the standard of care (SoC) method (i.e. full incubation followed by identification and AST by VITEKⓇ-2 Compact). RESULTS During P2, significant reductions in loading time (LT; median: 63.5 vs. 32 minutes, P < 0.001), time to dID+dAST performance (TTD; 186 vs. 115 minutes, P = 0.0018) and an increase in compliance to bundle targets (LT ≤45: 44% vs. 66%, P = 0.006 and TTD ≤120: 34% vs. 51.7%, P = 0.03) were observed. Using dID+dAST method, results were read 694 minutes earlier than SoC method. Of 176 pBCR, 165 (94%) were concordant with SoC in microbial identification of species. Categorical agreement for any drug-bug combination was 92.7% (1079/1164) and corresponding major, very major, and minor error rates were 8.8% (19/216), 4.9% (45/921), and 1.8% (21/1164), respectively. CONCLUSION The 'diagnostic stewardship care-bundle' strategy was successfully implemented with considerable diagnostic accuracy leading to significant reductions in duration of targeted steps of aBCD.
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Affiliation(s)
- Ayush Gupta
- Department of Microbiology, All India Institute of Medical Science (AIIMS), Bhopal, India.
| | - Farha Siddiqui
- Department of Microbiology, All India Institute of Medical Science (AIIMS), Bhopal, India
| | - Bhoomika Saxena
- Department of Microbiology, All India Institute of Medical Science (AIIMS), Bhopal, India
| | - Shashank Purwar
- Department of Microbiology, All India Institute of Medical Science (AIIMS), Bhopal, India
| | - Saurabh Saigal
- Department of Critical Care and Anesthesiology, All India Institute of Medical Science, (AIIMS), Bhopal, India
| | - Jai Prakash Sharma
- Department of Critical Care and Anesthesiology, All India Institute of Medical Science, (AIIMS), Bhopal, India
| | - Sanjeev Kumar
- Department of Community and Family Medicine, All India Institute of Medical Science, (AIIMS), Bhopal, India
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Tobudic S, Bahrs C, Schneider L, Paulussen E, Bartonickova L, Hagel S, Starzengruber P, Burgmann H, Pletz MW. Early treatment response to piperacillin/tazobactam in patients with bloodstream infections caused by non-ESBL ampicillin/sulbactam-resistant Escherichia coli: a binational cohort study. Infection 2023; 51:1749-1758. [PMID: 37462895 PMCID: PMC10665230 DOI: 10.1007/s15010-023-02074-z] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/04/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE This study aimed to compare treatment outcomes for bloodstream infections (BSI) caused by a piperacillin/tazobactam (PIP/TAZ)-susceptible E. coli among three patient groups: BSI caused by ampicillin/sulbactam (AMP/SLB)-resistant isolates treated with PIP/TAZ, BSI caused by AMP/SLB-sensitive isolates treated with PIP/TAZ, and BSI caused by AMP/SLB-resistant isolates treated with another monotherapy. METHODS This retrospective study was conducted in two academic centres in Europe. Adult patients with E. coli BSI were screened from 2014 to 2020. Inclusion criteria were non-ESBL BSI and initial monotherapy for ≥ 72 h. To reduce the expected bias between the patient groups, propensity score matching was performed. The primary outcome was early treatment response after 72 h and required absence of SOFA score increase in ICU/IMC patients, as well as resolution of fever, leukocytosis, and bacteraemia. RESULTS Of the 1707 patients screened, 315 (18.5%) were included in the final analysis. Urinary tract infection was the most common source of BSI (54.9%). Monotherapies other than PIP/TAZ were cephalosporins (48.6%), carbapenems (34.3%), and quinolones (17.1%). Enhanced early treatment response rate was detected (p = 0.04) in patients with BSI caused by AMP/SLB-resistant isolates treated with another monotherapy (74.3%) compared to those treated with PIP/TAZ (57.1%), and was mainly driven by the use of cephalosporins and quinolones (p ≤ 0.03). Clinical success, 28-day mortality, and rate of relapsing BSI did not significantly differ between the groups. CONCLUSIONS Our study suggests that initial use of PIP/TAZ may be associated with reduced early treatment response in E. coli BSI caused by AMP/SLB-resistant isolates compared to alternative monotherapies.
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Affiliation(s)
- Selma Tobudic
- Division of Infectious Diseases, Department of Internal Medicine I, Medical University Vienna, Vienna, Austria
| | - Christina Bahrs
- Division of Infectious Diseases, Department of Internal Medicine I, Medical University Vienna, Vienna, Austria.
- Institute of Infectious Diseases and Infection Control, Jena University Hospital/Friedrich-Schiller-University, Am Klinikum 1, 07747, Jena, Germany.
| | - Lisa Schneider
- Division of Infectious Diseases, Department of Internal Medicine I, Medical University Vienna, Vienna, Austria
| | - Emilia Paulussen
- Institute of Infectious Diseases and Infection Control, Jena University Hospital/Friedrich-Schiller-University, Am Klinikum 1, 07747, Jena, Germany
| | - Lucie Bartonickova
- Institute of Medical Microbiology, Jena University Hospital/Friedrich-Schiller-University, Jena, Germany
| | - Stefan Hagel
- Institute of Infectious Diseases and Infection Control, Jena University Hospital/Friedrich-Schiller-University, Am Klinikum 1, 07747, Jena, Germany
| | - Peter Starzengruber
- Division of Clinical Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Heinz Burgmann
- Division of Infectious Diseases, Department of Internal Medicine I, Medical University Vienna, Vienna, Austria
| | - Mathias W Pletz
- Division of Infectious Diseases, Department of Internal Medicine I, Medical University Vienna, Vienna, Austria
- Center for Sepsis Care and Control, Jena University Hospital/Friedrich-Schiller-University, Jena, Germany
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Gupta A, Siddiqui F, Saxena B, Purwar S, Saigal S, Sharma JP, Kumar S. A prospective study evaluating the effect of a 'Diagnostic Stewardship Care-Bundle' for automated blood culture diagnostics. J Glob Antimicrob Resist 2023; 34:119-126. [PMID: 37437843 DOI: 10.1016/j.jgar.2023.07.001] [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: 04/03/2023] [Revised: 06/15/2023] [Accepted: 07/02/2023] [Indexed: 07/14/2023] Open
Abstract
OBJECTIVES We prospectively implemented a diagnostic stewardship care-bundle checklist, 'Sepsis-48 DSB', with the aim of reducing intervening duration of key steps of automated blood culture diagnostics (aBCD). METHODS Sepsis-48 DSB was implemented for automated blood culture bottles (BCBs) received from adult intensive care units (AICUs) during the intervention period (P2; July 2020-June 2021) and intervening durations were compared with those during the retrospective, pre-intervention period (P1; March-June 2020). During both periods, provisional blood culture reports (pBCR) were issued wherein direct microbial identification (dID) was performed in BCBs with Gram-negatives by directly inoculating conventional biochemical tests and direct antimicrobial susceptibility testing (dAST) using EUCAST RAST method. The results were compared with the standard of care (SoC) method (i.e. full incubation followed by identification and AST by VITEKⓇ-2 Compact). RESULTS During P2, significant reductions in loading time (LT) [median: 63.5 vs. 32 minutes, P < 0.001], time to dID+dAST performance (TTD) [186 vs. 115 minutes, P = 0.0018] and an increase in compliance to bundle targets [LT ≤45: 44% vs. 66%, P = 0.006 and TTD ≤120: 34% vs. 51.7%, P = 0.03] were observed. Using dID+dAST method, results were read 694 minutes earlier than SoC method. Of 176 pBCR, 165 (94%) were concordant with SoC in microbial identification of species. Categorical agreement for any drug-bug combination was 92.7% (1079/1164) and corresponding major, very major, and minor error rates were 8.8% (19/216), 4.9% (45/921), and 1.8% (21/1164), respectively. CONCLUSION The 'diagnostic stewardship care-bundle' strategy was successfully implemented with considerable diagnostic accuracy leading to significant reductions in duration of targeted steps of aBCD.
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Affiliation(s)
- Ayush Gupta
- Department of Microbiology, All India Institute of Medical Science (AIIMS), Bhopal, India.
| | - Farha Siddiqui
- Department of Microbiology, All India Institute of Medical Science (AIIMS), Bhopal, India
| | - Bhoomika Saxena
- Department of Microbiology, All India Institute of Medical Science (AIIMS), Bhopal, India
| | - Shashank Purwar
- Department of Microbiology, All India Institute of Medical Science (AIIMS), Bhopal, India
| | - Saurabh Saigal
- Department of Critical Care and Anesthesiology, All India Institute of Medical Science, (AIIMS), Bhopal, India
| | - Jai Prakash Sharma
- Department of Critical Care and Anesthesiology, All India Institute of Medical Science, (AIIMS), Bhopal, India
| | - Sanjeev Kumar
- Department of Community and Family Medicine, All India Institute of Medical Science, (AIIMS), Bhopal, India
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Mponponsuo K, Brown KA, Fridman DJ, Johnstone J, Langford BJ, Lee SM, MacFadden DR, Patel SN, Schwartz KL, Daneman N. Highly versus less bioavailable oral antibiotics in the treatment of gram-negative bloodstream infections: a propensity-matched cohort analysis. Clin Microbiol Infect 2023; 29:490-497. [PMID: 36216237 DOI: 10.1016/j.cmi.2022.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 06/30/2022] [Revised: 09/28/2022] [Accepted: 10/03/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In this study, we evaluated the clinical outcomes associated with the use of highly bioavailable oral antibiotics (fluoroquinolones and trimethoprim-sulfamethoxazole) compared with the less-bioavailable oral antibiotics (β-lactams) in gram-negative bloodstream infections (BSIs). METHODS Among hospitalized older adult patients in Ontario, Canada, discharged home on oral treatment for gram-negative BSI between 1 January 2017 and 31 December 2019, we used a matched cohort design to compare outcomes among those receiving highly versus less-bioavailable agents; hard-matching 1:1 on sex, BSI pathogen (Escherichia coli vs. non-E. coli), and infection source (urinary vs. non-urinary/unknown source) along with a propensity score, incorporating specific pathogen, patient, and infection characteristics. The primary outcome was the composite of 90-day all-cause mortality, recurrent BSI with the same pathogen (genus and species), and re-admission to any Ontario hospital. RESULTS A total of 2012 patients were included in the study (1006 in each bioavailability category). Those who received highly (compared with less) bioavailable antibiotics at discharge had lower rates of the composite outcome (171/1006 [17.0%] vs. 216/1006 [21.5%]), adjusted odds ratio being 0.74 (95% CI, 0.60-0.92). Recurrent BSI at 90 days was the main driver for the composite outcome occurring in 64 (5.4%) and 107 (9.4%) patients of the highly and less-bioavailable groups, respectively (p < 0.001) (adjusted odds ratio, 0.56; 95% CI, 0.40-0.78). DISCUSSION Use of highly (compared with less) bioavailable antibiotics at discharge was associated with significantly better clinical outcomes among patients with gram-negative BSIs.
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Affiliation(s)
- Kwadwo Mponponsuo
- Institute for Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada.
| | - Kevin A Brown
- Public Health Ontario, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Daniel J Fridman
- Institute for Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Jennie Johnstone
- Infection Prevention and Control, Sinai Health and Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Bradley J Langford
- Public Health Ontario, Hotel Dieu Shaver Health and Rehabilitation Center, Toronto, Ontario, Canada
| | - Samantha M Lee
- Institute for Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Samir N Patel
- Public Health Ontario, University of Toronto Department of Laboratory Medicine and Pathobiology, Toronto, Ontario, Canada
| | - Kevin L Schwartz
- Public Health Ontario, Institute for Clinical Evaluative Sciences, Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.
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Lee IR, Tong SYC, Davis JS, Paterson DL, Syed-Omar SF, Peck KR, Chung DR, Cooke GS, Libau EA, Rahman SNBA, Gandhi MP, Shi L, Zheng S, Chaung J, Tan SY, Kalimuddin S, Archuleta S, Lye DC. Early oral stepdown antibiotic therapy versus continuing intravenous therapy for uncomplicated Gram-negative bacteraemia (the INVEST trial): study protocol for a multicentre, randomised controlled, open-label, phase III, non-inferiority trial. Trials 2022; 23:572. [PMID: 35854360 PMCID: PMC9295110 DOI: 10.1186/s13063-022-06495-3] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/24/2022] [Indexed: 11/17/2022] Open
Abstract
Background The incidence of Gram-negative bacteraemia is rising globally and remains a major cause of morbidity and mortality. The majority of patients with Gram-negative bacteraemia initially receive intravenous (IV) antibiotic therapy. However, it remains unclear whether patients can step down to oral antibiotics after appropriate clinical response has been observed without compromising outcomes. Compared with IV therapy, oral therapy eliminates the risk of catheter-associated adverse events, enhances patient quality of life and reduces healthcare costs. As current management of Gram-negative bacteraemia entails a duration of IV therapy with limited evidence to guide oral conversion, we aim to evaluate the clinical efficacy and economic impact of early stepdown to oral antibiotics. Methods This is an international, multicentre, randomised controlled, open-label, phase III, non-inferiority trial. To be eligible, adult participants must be clinically stable / non-critically ill inpatients with uncomplicated Gram-negative bacteraemia. Randomisation to the intervention or standard arms will be performed with 1:1 allocation ratio. Participants randomised to the intervention arm (within 72 h from index blood culture collection) will be immediately switched to an oral fluoroquinolone or trimethoprim-sulfamethoxazole. Participants randomised to the standard arm will continue to receive IV therapy for at least 24 h post-randomisation before clinical re-assessment and decision-making by the treating doctor. The recommended treatment duration is 7 days of active antibiotics (including empiric therapy), although treatment regimen may be longer than 7 days if clinically indicated. Primary outcome is 30-day all-cause mortality, and the key secondary outcome is health economic evaluation, including estimation of total healthcare cost as well as assessment of patient quality of life and number of quality-adjusted life years saved. Assuming a 30-day mortality of 8% in the standard and intervention arms, with 6% non-inferiority margin, the target sample size is 720 participants which provides 80% power with a one-sided 0.025 α-level after adjustment for 5% drop-out. Discussion A finding of non-inferiority in efficacy of oral fluoroquinolones or trimethoprim-sulfamethoxazole versus IV standard of care antibiotics may hypothetically translate to wider adoption of a more cost-effective treatment strategy with better quality of life outcomes. Trial registration ClinicalTrials.govNCT05199324. Registered 20 January 2022. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06495-3.
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Affiliation(s)
- I Russel Lee
- National Centre for Infectious Diseases, Singapore, Singapore.
| | - Steven Y C Tong
- Department of Infectious Diseases, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Joshua S Davis
- School of Medicine and Public Health, Hunter Medical Research Institute, University of Newcastle, Newcastle, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
| | | | | | | | - Graham S Cooke
- Department of Infectious Diseases, Imperial College London, London, UK
| | | | - Siti-Nabilah B A Rahman
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation, Singapore, Singapore
| | - Mihir P Gandhi
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation, Singapore, Singapore
| | - Luming Shi
- Singapore Clinical Research Institute, Consortium for Clinical Research and Innovation, Singapore, Singapore
| | - Shuwei Zheng
- Department of Infectious Disease, Sengkang General Hospital, Singapore, Singapore
| | - Jenna Chaung
- Division of Infectious Diseases, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Seow Yen Tan
- Department of Infectious Diseases, Changi General Hospital, Singapore, Singapore
| | - Shirin Kalimuddin
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore.,Programme in Emerging Infectious Diseases, Duke-NUS Medical School, Singapore, Singapore
| | - Sophia Archuleta
- Division of Infectious Diseases, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - David C Lye
- National Centre for Infectious Diseases, Singapore, Singapore. .,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore. .,Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore.
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Rossel A, Zandberg KPM, Albrich WC, Huttner A. How representative is a point-of-care randomized trial? Clinical outcomes of patients excluded from a point-of-care randomized controlled trial evaluating antibiotic duration for Gram-negative bacteraemia: a multicentre prospective observational cohort study. Clin Microbiol Infect 2021:S1198-743X(21)00301-3. [PMID: 34116204 DOI: 10.1016/j.cmi.2021.05.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/26/2021] [Accepted: 05/31/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Patients included in randomized controlled trials (RCT) are poorly representative of the general population. We compared outcomes of patients excluded from the PIRATE trial, a point-of-care RCT evaluating antibiotic durations for Gram-negative bacteraemia, with those of enrolled patients. METHODS A prospective observational cohort study, 'EPCO' (Excluded Patients' Clinical Outcomes) included patients excluded from the PIRATE trial. As in PIRATE, whose patients were randomized to 7-day, 14-day, or C-reactive-protein (CRP)-guided antibiotic durations, EPCO's primary outcome was occurrence of clinical success at 30 days. We also compared baseline characteristics, outcome rates and treatment-effect estimates. RESULTS In all, 405 patients were included in EPCO and compared with the 503 PIRATE patients. Reasons for exclusion were mainly medical (317/405; 78%), the most frequent being complicated infection. Excluded patients had more co-morbidities (Charlson median 3 versus 1, p < 0.001). Bacteraemia was more often health-care-associated (26% versus 9%, p < 0.001). The 30-day success rate was significantly lower among EPCO patients (299/396; 76% versus 469/493; 95%, p < 0.001), but the success rate was not significantly different for those excluded for non-medical reasons (68/75; 91%, p 0.09). There was no significant difference in failure rates of EPCO patients according to their treatment duration (difference 7 days versus 14 days: p 0.75; 7 days versus CRP-correspondent: p 1.00; 14 days versus CRP-correspondent: p 1.00). CONCLUSION Although point-of-care-randomized trials are more inclusive and representative than traditional RCTs, they are still likely to select patients with lower failure risk. Shorter antibiotic durations were not associated with failure in either included or excluded patients, supporting the generalizability of the PIRATE trial's findings.
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Spaziante M, Giuliano S, Ceccarelli G, Alessandri F, Borrazzo C, Russo A, Venditti M. Gram-negative septic thrombosis in critically ill patients: A retrospective case-control study. Int J Infect Dis 2020; 94:110-115. [PMID: 32126323 DOI: 10.1016/j.ijid.2020.02.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/21/2020] [Accepted: 02/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Data on septic thrombosis caused by Gram-negative bacilli (GN-ST) in intensive care unit (ICU) patients are currently limited. METHODS The aim of this retrospective case-control study (matched 1:3) performed over a 15-month period on ICU patients with bacteraemia, associated (cases) or not (controls) with GN-ST, was to assess 30-day mortality and clinical/microbiological features of GN-ST. RESULTS During the study period, 16 patients with GN-ST and 48 controls were analyzed. Polytrauma was the cause of ICU admission in 12 (75%) cases and 22 (46%) controls (p = 0.019). In no case of septic thrombosis was surgical debridement performed. The site of venous thrombosis was more frequently in the lower limbs, associated with bone fracture in nine out of 12 (75%) cases. The median duration of bacteraemia (22 days vs 1 day; p < 0.001) and time to clinical improvement (15 days vs 4 days; p < 0.001) were significantly longer in cases than in controls. On analysis of the receiver operating characteristics (ROC) curve, bacteraemia >72 h was significantly associated with GN-ST (area under the curve (AUC) 0.95, sensitivity 0.996 and specificity 0.810; p < 0.001). Finally, 30-day mortality was 20% in cases and 67% in controls (p < 0.001). CONCLUSIONS Critically ill patients with GN-ST showed specific clinical features. Despite delayed bacteraemia clearance, targeted antibiotic therapy plus anticoagulation usually provided clinical improvement and a low 30-day mortality rate.
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Affiliation(s)
- Martina Spaziante
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Rome, Italy
| | | | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Rome, Italy
| | - Francesco Alessandri
- Department of Anaesthesia and Intensive Care Medicine, "Sapienza" University of Rome, Rome, Italy
| | - Cristian Borrazzo
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Rome, Italy
| | - Alessandro Russo
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Rome, Italy.
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9
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Hall RG, Yoo E, Faust A, Smith T, Goodman E, Mortensen EM, Raza J, Dehmami F, Alvarez CA. Impact of piperacillin/tazobactam on nephrotoxicity in patients with Gram-negative bacteraemia. Int J Antimicrob Agents 2018; 53:343-346. [PMID: 30415001 DOI: 10.1016/j.ijantimicag.2018.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 09/13/2018] [Revised: 10/30/2018] [Accepted: 11/04/2018] [Indexed: 01/23/2023]
Abstract
Piperacillin/tazobactam (TZP) has been associated with nephrotoxicity in patients receiving vancomycin. Its impact on nephrotoxicity in patients with Gram-negative bacteraemia (GNB) is unclear. This study evaluated the impact of TZP on nephrotoxicity in patients with GNB. This retrospective cohort included patients aged ≥18 years receiving ≥48 h of therapy for bacteraemia due to Escherichia coli, Pseudomonas aeruginosa, Enterobacter, Klebsiella, Acinetobacter or Stenotrophomonas maltophilia from 1/01/2008-8/31/2011. Patients with baseline serum creatinine (SCr) ≥3.5 mg/dL, polymicrobial infection or recurrent bacteraemia were excluded. Nephrotoxicity was defined as a ≥0.5 mg/dL increase in SCr or ≥50% increase from baseline for ≥2 consecutive days. Any variable demonstrating a 10% change in exposure effect was retained in the final model. All variables biologically reasonable causes of nephrotoxicity were also considered for inclusion. The median age of the cohort (n = 292) was 76 years; 38.0% had a cancer diagnosis and ICU residence was common (21.9%). There was no difference in nephrotoxicity incidence based on days of TZP received (0 days, 13.6%; 1-2 days, 14.7%; 3-4 days, 6.9%; ≥5 days, 16.7%; P = 0.71). In multivariable analysis, baseline SCr, total body weight and vasopressor use were independently associated with nephrotoxicity. Duration of TZP was not associated with nephrotoxicity in multivariable analysis (1-2 days, OR = 0.91, 95% CI 0.39-2.12; 3-4 days, OR = 0.48, 95% CI 0.10-2.46; ≥5 days, OR = 0.57, 95% CI 0.11-3.02). In this cohort of GNB patients, duration of TZP was not associated with nephrotoxicity.
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Affiliation(s)
- Ronald G Hall
- Texas Tech University Health Sciences Center, Department of Pharmacy Practice, 5920 Forest Park Road, Suite 400, Dallas, TX 75235, USA; VA North Texas Health Care System, 4500 S. Lancaster Road, Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA; Dose Optimization and Outcomes Research (DOOR) Program, 5920 Forest Park Road, Suite 400, Dallas, TX 75235, USA.
| | - Eunice Yoo
- Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104, USA
| | - Andrew Faust
- Texas Health Presbyterian Dallas, 8200 Walnut Hill Lane, Dallas, TX 75231, USA
| | - Terri Smith
- Texas Health Presbyterian Dallas, 8200 Walnut Hill Lane, Dallas, TX 75231, USA
| | - Edward Goodman
- Texas Health Presbyterian Dallas, 8200 Walnut Hill Lane, Dallas, TX 75231, USA
| | - Eric M Mortensen
- VA North Texas Health Care System, 4500 S. Lancaster Road, Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA; Division of General Internal Medicine, University of Connecticut, 263 Farmington Avenue, Farmington, CT, USA
| | - Jaffar Raza
- Texas Tech University Health Sciences Center, Department of Pharmacy Practice, 5920 Forest Park Road, Suite 400, Dallas, TX 75235, USA
| | - Farbod Dehmami
- Texas Tech University Health Sciences Center, Department of Pharmacy Practice, 5920 Forest Park Road, Suite 400, Dallas, TX 75235, USA
| | - Carlos A Alvarez
- Texas Tech University Health Sciences Center, Department of Pharmacy Practice, 5920 Forest Park Road, Suite 400, Dallas, TX 75235, USA; VA North Texas Health Care System, 4500 S. Lancaster Road, Dallas, TX 75216, USA; University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA
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10
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Lee YM, Moon C, Kim YJ, Lee HJ, Lee MS, Park KH. Clinical impact of delayed catheter removal for patients with central-venous-catheter-related Gram-negative bacteraemia. J Hosp Infect 2018; 99:106-113. [PMID: 29330016 DOI: 10.1016/j.jhin.2018.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 01/04/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gram-negative bacteria are increasingly the cause of catheter-related bloodstream infection (CRBSI), and the prevalence of multi-drug-resistant strains is rising rapidly. This study evaluated the impact of delayed central venous catheter (CVC) removal on clinical outcomes in patients with Gram-negative CRBSI. METHODS Between January 2007 and December 2016, patients with Gram-negative bacteraemia and CVC placement, from two tertiary care hospitals, were included retrospectively. Cases with CVC removal more than three days after onset of bacteraemia or without CVC removal were classified as having delayed CVC removal. RESULTS In total, 112 patients were included. Of these, 78 had CRBSI (43 definite and 35 probable) and 34 had Gram-negative bacteraemia from another source (non-CRBSI). Enterobacteriaceae were less common pathogens in patients with CRBSI than in patients with non-CRBSI (11.5% vs 41.3%; P<0.001). Delayed CVC removal was associated with increased 30-day mortality (40.5% vs 11.8%; P=0.01) in patients with Gram-negative CRBSI; this was not seen in patients with non-CRBSI (25.0% vs 14.3%; P>0.99). Delayed CVC removal [odds ratio (OR) 6.8], multi-drug-resistant (MDR) Gram-negative bacteraemia (OR 6.3) and chronic renal failure (OR 11.1) were associated with 30-day mortality in patients with CRBSI. The protective effect of early CVC removal on mortality was evident in the MDR group (48.3% vs 18.2%; P=0.03), but not in the non-MDR group (11.1% vs 0%; P=0.43). CONCLUSION CVCs should be removed early to improve clinical outcomes in patients with Gram-negative CRBSI, especially in settings where MDR isolates are prevalent.
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Affiliation(s)
- Y-M Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - C Moon
- Department of Infectious Diseases, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Y J Kim
- Department of Laboratory Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - H J Lee
- Department of Laboratory Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - M S Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Republic of Korea
| | - K-H Park
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Republic of Korea.
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11
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Albur M, Hamilton F, MacGowan AP. Early warning score: a dynamic marker of severity and prognosis in patients with Gram-negative bacteraemia and sepsis. Ann Clin Microbiol Antimicrob 2016; 15:23. [PMID: 27071911 PMCID: PMC4830018 DOI: 10.1186/s12941-016-0139-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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: 01/28/2016] [Accepted: 03/29/2016] [Indexed: 02/07/2023] Open
Abstract
Background Early Warning Score (EWS) is a physiological composite score of six bedside vital parameters, routinely used in UK hospitals. We evaluated the prognostic ability of EWS in Gram-negative bacteraemia causing sepsis. Methods We prospectively evaluated EWS as a marker of severity and prognosis in adult patients with Gram-negative bacteraemia. All adult patients with Gram-negative bacteraemia admitted to our tertiary Teaching hospital of the National Health Service in England were enrolled over 1 year period. The highest daily EWS score was recorded from 7 days before to 14 days after the date of onset of bacteraemia. The primary outcome was 28-day mortality. Main results A total of 245 consecutive adult patients with Gram-negative bacteraemia with sepsis were enrolled. On multivariate analysis, following variables were associated with death for every single unit change (odds ratio in the brackets): higher age (1.05), lower mean arterial pressure (1.03), lower serum bicarbonate (1.08), higher EWS (1.27), higher SOFA score (1.36), hospital-onset of infection (5.43) and need for vasopressor agents (16.4). EWS on day 0, 1, 2, and average 14-day score were significantly higher in patients who died by 28 days from the onset of bacteraemia [95 % CI 0.4–0.6] p < 0.001. A stepwise rise in EWS and failure of improvement in EWS by 2 points 48 h after the onset of bacteraemia were associated with poor outcome. Conclusion EWS is a simple and cost-effective bedside tool for the assessment of severity and prognosis of sepsis caused by Gram-negative bacteraemia. Electronic supplementary material The online version of this article (doi:10.1186/s12941-016-0139-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mahableshwar Albur
- Department of Infectious Diseases and Medical Microbiology, Bristol Centre for Antimicrobial Research and Evaluation, Southmead Hospital, North Bristol NHS Trust-A Teaching Trust of University of Bristol, Westbury-on-Trym, Bristol, BS10 5ND, UK.
| | - Fergus Hamilton
- Department of Acute Medicine and Medical Microbiology, Southmead Hospital, North Bristol NHS Trust-A Teaching Trust of University of Bristol, Westbury-on-Trym, Bristol, BS10 5ND, UK
| | - Alasdair P MacGowan
- Lead Public Health Microbiologist-South West of England, North Bristol NHS Trust, University of Bristol, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5ND, UK
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12
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Coats J, Rae N, Nathwani D. What is the evidence for the duration of antibiotic therapy in Gram-negative bacteraemia caused by urinary tract infection? A systematic review of the literature. J Glob Antimicrob Resist 2013; 1:39-42. [PMID: 27873605 DOI: 10.1016/j.jgar.2013.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 01/25/2013] [Indexed: 11/29/2022] Open
Abstract
The frequency of secondary bacteraemia is variable depending on the site of infection but is often associated with significant morbidity and mortality. The most common source of Gram-negative bacteraemia is urinary tract infection (UTI). Current guidelines on the treatment of UTI provide no clear guidance on whether the presence of bacteraemia influences the duration or choice of therapy. Here we systematically review the current evidence base for the duration of treatment of Gram-negative bacteraemia secondary to UTI. The available evidence is sparse and of variable quality to draw any firm conclusions. However, in the absence of urgently required high-quality studies, current limited evidence appears to indicate that short courses of antibiotics are as effective at obtaining clinical and bacteriological cure as longer courses.
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Affiliation(s)
- Josh Coats
- Infection Unit, Ward 42, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK
| | - Nikolas Rae
- Infection Unit, Ward 42, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK
| | - Dilip Nathwani
- Infection Unit, Ward 42, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK.
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