Optimal duration of antimicrobial therapy for uncomplicated Gram-negative bloodstream infections

Infection ◽  
2017 ◽  
Vol 45 (5) ◽  
pp. 613-620 ◽  
Author(s):  
Avery N. Nelson ◽  
Julie Ann Justo ◽  
P. Brandon Bookstaver ◽  
Joseph Kohn ◽  
Helmut Albrecht ◽  
...  
Keyword(s):  
Antimicrobial Therapy ◽  
Bloodstream Infections ◽  
Gram Negative ◽  
Optimal Duration

scholarly journals Optimal Duration of Antimicrobial Therapy for Bloodstream Infections Due to Gram-Negative Bacilli

2016 ◽  
Vol 3 (suppl_1) ◽  
Author(s):  
Avery Nelson ◽  
Julie Ann Justo ◽  
P. Brandon Bookstaver ◽  
Joseph Kohn ◽  
Helmut Albrecht ◽  
...  
Keyword(s):  
Antimicrobial Therapy ◽  
Bloodstream Infections ◽  
Gram Negative ◽  
Optimal Duration

scholarly journals Cumulative Effect of an Antimicrobial Stewardship and Rapid Diagnostic Testing Bundle on Early Streamlining of Antimicrobial Therapy in Gram-Negative Bloodstream Infections

2017 ◽  
Vol 61 (9) ◽  
Author(s):  
P. B. Bookstaver ◽  
E. B. Nimmich ◽  
T. J. Smith ◽  
J. A. Justo ◽  
J. Kohn ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Phase 1 ◽  
Bloodstream Infections ◽  
Antimicrobial Stewardship Program ◽  
Phase 2 ◽  
Beta Lactams ◽  
Gram Negative ◽  
Stewardship Program ◽  
Tof Ms

ABSTRACT The use of rapid diagnostic tests (RDTs) enhances antimicrobial stewardship program (ASP) interventions in optimization of antimicrobial therapy. This quasi-experimental cohort study evaluated the combined impact of an ASP/RDT bundle on the appropriateness of empirical antimicrobial therapy (EAT) and time to de-escalation of broad-spectrum antimicrobial agents (BSAA) in Gram-negative bloodstream infections (GNBSI). The ASP/RDT bundle consisted of system-wide GNBSI treatment guidelines, prospective stewardship monitoring, and sequential introduction of two RDTs, matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) and the FilmArray blood culture identification (BCID) panel. The preintervention period was January 2010 through December 2013, and the postintervention period followed from January 2014 through June 2015. The postintervention period was conducted in two phases; phase 1 followed the introduction of MALDI-TOF MS, and phase 2 followed the introduction of the FilmArray BCID panel. The interventions resulted in significantly improved appropriateness of EAT (95% versus 91%; P = 0.02). Significant reductions in median time to de-escalation from combination antimicrobial therapy (2.8 versus 1.5 days), antipseudomonal beta-lactams (4.0 versus 2.5 days), and carbapenems (4.0 versus 2.5 days) were observed in the postintervention compared to the preintervention period (P < 0.001 for all). The reduction in median time to de-escalation from combination therapy (1.0 versus 2.0 days; P = 0.03) and antipseudomonal beta-lactams (2.2 versus 2.7 days; P = 0.04) was further augmented during phase 2 compared to phase 1 of the postintervention period. Implementation of an antimicrobial stewardship program and RDT intervention bundle in a multihospital health care system is associated with improved appropriateness of EAT for GNBSI and decreased utilization of BSAA through early de-escalation.

scholarly journals 1043. Evaluation of Early Clinical Failure Criteria for Gram-Negative Bloodstream Infections

2018 ◽  
Vol 5 (suppl_1) ◽  
pp. S311-S312
Author(s):  
Hana Rac ◽  
Alyssa Gould ◽  
P Brandon Bookstaver ◽  
Julie Ann Justo ◽  
Joseph Kohn ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Antimicrobial Therapy ◽  
Bloodstream Infections ◽  
Failure Criteria ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Clinical Failure ◽  
Gram Negative ◽  
Additional Criterion ◽  
Prolonged Hospitalization

Abstract Background Early identification of patients at high risk of morbidity and mortality following Gram-negative bloodstream infections (GN-BSI) based on initial clinical course may prompt adjustments to optimize diagnostic and treatment plans. This retrospective cohort study aims to develop early clinical failure criteria (ECFC) to predict unfavorable outcomes in patients with GN-BSI. Methods Adults with community-onset GN-BSI who survived hospitalization for at least 96 hours at Palmetto Health hospitals in Columbia, SC, USA from January 1, 2010 to June 30, 2015 were identified. Multivariate logistic regression was used to examine association between clinical variables within 72–96 hours of BSI and unfavorable outcomes (28-day mortality or hospital length of stay &gt;14 days). Results Among 766 patients with GN-BSI, 225 (29%) had unfavorable outcomes. After adjustments for Charlson Comorbidity Index and appropriateness of empirical antimicrobial therapy in multivariate model, predictors of unfavorable outcomes included systolic blood pressure &lt;100 mmHg or vasopressor use (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.1–2.5), heart rate &gt;100/minute (aOR 1.7, 95% CI 1.1–2.5), respiratory rate ≥22/minute or mechanical ventilation (aOR 2.1, 95% CI 1.4–3.3), altered mental status (aOR 4.5, 95% CI 2.8–7.1), and peripheral WBC count &gt;12 × 103/mm3 (aOR 2.7, 95% CI 1.8–4.1) at 72–96 hours from index BSI. Area under receiver operating characteristic curve of ECFC model in predicting unfavorable outcomes was 0.77 (0.84 and 0.71 in predicting 28-day mortality and prolonged hospitalization separately, respectively). Predicted 28-day mortality increased from 1% in patients with no ECFC to 3%, 7%, 16%, 32%, and 54% in presence of each additional criterion (P &lt; 0.001). Predicted hospital length of stay was 7.5 days in patients without any ECFC and increased by 4.0 days (95% CI 3.1–4.9, P &lt; 0.001) in presence of each additional criterion. Conclusion Risk of 28-day mortality or prolonged hospitalization can be estimated within 72–96 hours of GN-BSI using ECFC. These criteria may have utility in future clinical research in assessing response to antimicrobial therapy based on a standard evidence-based definition of early clinical failure. Disclosures P. B. Bookstaver, CutisPharma: Scientific Advisor, &lt;$1,000. Melinta Therapeutics: Speaker’s Bureau, &lt;$1,000.

scholarly journals Development of Institutional Guidelines for Management of Gram-Negative Bloodstream Infections: Incorporating Local Evidence

2017 ◽  
Vol 52 (10) ◽  
pp. 691-697 ◽  
Author(s):  
Elizabeth B. Nimmich ◽  
P. Brandon Bookstaver ◽  
Joseph Kohn ◽  
Julie Ann Justo ◽  
Katie L. Hammer ◽  
...  
Keyword(s):  
Health Care ◽  
Critically Ill ◽  
Antimicrobial Therapy ◽  
Critically Ill Patients ◽  
Severity Of Illness ◽  
Bloodstream Infections ◽  
Evidence Based ◽  
Gram Negative ◽  
Empirical Antimicrobial Therapy ◽  
Hospital Acquired

Background: Appropriate empirical antimicrobial therapy is associated with improved outcomes of patients with Gram-negative bloodstream infections (BSI). Objective: Development of evidence-based institutional management guidelines for empirical antimicrobial therapy of Gram-negative BSI. Methods: Hospitalized adults with Gram-negative BSI in 2011-2012 at Palmetto Health hospitals in Columbia, SC, USA, were identified. Logistic regression was used to examine the association between site of infection acquisition and BSI due to Pseudomonas aeruginosa or chromosomally mediated AmpC-producing Enterobacteriaceae (CAE). Antimicrobial susceptibility rates of bloodstream isolates were stratified by site of acquisition and acute severity of illness. Retained antimicrobial regimens had predefined susceptibility rates ≥90% for noncritically ill and ≥95% for critically ill patients. Results: Among 390 patients, health care–associated (odds ratio [OR]: 3.0, 95% confidence interval [CI]: 1.5-6.3] and hospital-acquired sites of acquisition (OR: 3.7, 95% CI: 1.6-8.4) were identified as risk factors for BSI due to P aeruginosa or CAE, compared with community-acquired BSI (referent). Based on stratified bloodstream antibiogram, ceftriaxone met predefined susceptibility criteria for community-acquired BSI in noncritically ill patients (95%). Cefepime and piperacillin-tazobactam monotherapy achieved predefined susceptibility criteria in noncritically ill (95% both) and critically ill patients with health care–associated and hospital-acquired BSI (96% and 97%, respectively) and critically ill patients with community-acquired BSI (100% both). Conclusions: Incorporation of site of acquisition, local antimicrobial susceptibility rates, and acute severity of illness into institutional guidelines provides objective evidence-based approach for optimizing empirical antimicrobial therapy for Gram-negative BSI. The suggested methodology provides a framework for guideline development in other institutions.

scholarly journals Stratification of the Impact of Inappropriate Empirical Antimicrobial Therapy for Gram-Negative Bloodstream Infections by Predicted Prognosis

2014 ◽  
Vol 59 (1) ◽  
pp. 245-250 ◽  
Author(s):  
Sarah E. Cain ◽  
Joseph Kohn ◽  
P. Brandon Bookstaver ◽  
Helmut Albrecht ◽  
Majdi N. Al-Hasan
Keyword(s):  
Regression Model ◽  
Risk Reduction ◽  
Antimicrobial Therapy ◽  
Cox Regression ◽  
Bloodstream Infections ◽  
Initial Presentation ◽  
Number Needed To Treat ◽  
Gram Negative ◽  
Survival Difference ◽  
The Impact

ABSTRACTThe bloodstream infection mortality risk score (BSIMRS) predicts the outcome of patients with Gram-negative bloodstream infections (BSI) with high discrimination. This retrospective cohort study examined the impact of inappropriate antimicrobial therapy on mortality in adult patients with Gram-negative BSI admitted to Palmetto Health Hospitals in Columbia, SC, USA, from 1 January 2011 to 31 December 2012 after stratification by predicted prognosis at initial presentation using BSIMRS. A multivariate Cox regression model was used to identify independent risk factors for 28-day mortality overall and within each predefined BSIMRS category (<5, 5 to 9, and ≥10). Relative risk reduction (RRR), absolute risk reduction (ARR), and number needed to treat (NNT) were calculated from a predictive logistic regression model of mortality. Overall, 390 unique patients with first episodes of Gram-negative BSI were identified. The median age was 66 years, and 229 (59%) were women. There was significant association between inappropriate antimicrobial therapy and mortality in patients with BSIMRS of 5 to 9 (adjusted hazard ratio [aHR], 3.55; 95% confidence intervals [CI], 1.22 to 8.31;P= 0.02) and BSIMRS of ≥10 (aHR, 4.99; 95% CI, 1.09 to 22.87;P= 0.04) but not in those with BSIMRS of <5 (aHR, 3.34; 95% CI, 0.17 to 22.77;P= 0.34). RRR, ARR, and NNT were 0.25, 0.02, and 63 for BSIMRS of <5; 0.56, 0.32, and 3 for BSIMRS of 5 to 9; and 0.39, 0.39, and 3 for BSIMRS of ≥10, respectively. There is a significant benefit from appropriate antimicrobial therapy in patients with Gram-negative BSI with guarded (BSIMRS of 5 to 9) and poor (BSIMRS of ≥10) predicted prognosis. Survival difference remains unclear among those with good predicted prognosis (BSIMRS of <5) at initial presentation.

scholarly journals Day at the Races: Comparing BioFire FilmArray Blood Culture ID Panels to Verigene Blood Culture in Gram-negative Bloodstream Infections using DOOR-MAT Analysis

2021 ◽  
Author(s):  
Kimberly C Claeys ◽  
Kathryn Schlaffer ◽  
Richard Smith ◽  
Stephanie Hitchcock ◽  
Yunyun Jiang ◽  
...  
Keyword(s):  
Blood Culture ◽  
Antimicrobial Therapy ◽  
Bloodstream Infections ◽  
Gram Negative ◽  
Antimicrobial Prescribing ◽  
Resistance Detection

Abstract Three RDT platforms (Verigene BC-GN, BioFire® BCID, and BCID 2 (RUO)) were compared using the Desirability of Outcome Ranking Management of Antimicrobial Therapy (DOOR -MAT) to evaluate potential downstream antimicrobial prescribing decisions resulting from the panels different organism and resistance detection. BioFire BCID (RUO) had the best mean DOOR-MAT scores.

scholarly journals 49. Impact of a Rapid Genotypic Platform for Gram-negative Bloodstream Infections, Paired with an Antimicrobial Stewardship Intervention, on Time to Optimal Antimicrobial Therapy

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S145-S145
Author(s):  
Madison Donnelly ◽  
Jennifer Walls ◽  
Katlyn Wood ◽  
Aiman Bandali
Keyword(s):  
Length Of Stay ◽  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Intervention Group ◽  
Bloodstream Infections ◽  
Post Intervention ◽  
Gram Negative ◽  
E Coli ◽  
Optimal Therapy ◽  
The Impact

Abstract Background Gram-negative bacteremia is associated with significant morbidity and mortality. Development of an algorithm for antimicrobial selection, using institution-specific antibiogram data and rapid diagnostics (RDT), achieves timely and appropriate antimicrobial therapy. The objective of this study is to assess the impact of a pharmacy-driven antimicrobial stewardship initiative in conjunction with ePlex® BCID on time to optimal antimicrobial therapy for patients with gram-negative bloodstream infections. Methods This retrospective, observational, single-center study included adult patients with a documented gram-negative bloodstream infection in whom the ePlex® BCID was employed. A pharmacist-driven antimicrobial stewardship intervention was initiated on December 1, 2020; pre-intervention (December 2019 – March 2020) was compared to the post-intervention (December 2020 – February 2020) period. The following organisms were included: Citrobacter spp., Escherichia coli, Klebsiella aerogenes/pneumoniae/oxytoca, Proteus spp, Enterobacter spp., Pseudomonas aeruginosa, and Acinetobacter baumannii. Polymicrobial bloodstream infections or those who had an ePlex® panel performed prior to admission were excluded. The following clinical outcomes were assessed: time to optimal antimicrobial therapy, length of stay (LOS), and inpatient-30-day mortality. Results One hundred and sixty-three met criteria for inclusion; 98 patients in the pre-intervention group and 65 patients in the post-intervention group. The mean Pitt Bacteremia Score was 1 in both groups (p=0.741). The most common organism identified by ePlex® BCID was E. coli (65.3% vs 70.8%; p=0.676). Eight E. Coli isolates were CTX-M positive; no other gene targets were detected. The most common suspected source of bacteremia was genitourinary (72.5% vs 72.3%; p=1.0). Time to optimal therapy was reduced by 29 hours [37 (31 – 55) vs. 8 (4 – 28); p=0.048). Length of stay and mortality was similar between groups. Conclusion Implementation of a rapid blood culture identification panel along with an antimicrobial stewardship intervention significantly reduced time to optimal therapy. Further studies are warranted to confirm these results. Disclosures All Authors: No reported disclosures

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