Development of an Electronic Definition for De-escalation of Antibiotics in Hospitalized Patients

Abstract Background Antimicrobial stewardship programs (ASPs) promote the principle of de-escalation: moving from broad- to narrow-spectrum agents and stopping antibiotics when no longer indicated. A standard, objective definition of de-escalation applied to electronic data could be useful for ASP assessments. Methods We derived an electronic definition of antibiotic de-escalation and performed a retrospective study among 5 hospitals. Antibiotics were ranked into 4 categories: narrow-spectrum, broad-spectrum, extended-spectrum, and agents targeted for protection. Eligible adult patients were cared for on inpatient units, had antibiotic therapy for at least 2 days, and were hospitalized for at least 3 days after starting antibiotics. Number of antibiotics and rank were assessed at 2 time points: day of antibiotic initiation and either day of discharge or day 5. De-escalation was defined as reduction in either the number of antibiotics or rank. Escalation was an increase in either number or rank. Unchanged was either no change or discordant directions of change. We summarized outcomes among hospitals, units, and diagnoses. Results Among 39 226 eligible admissions, de-escalation occurred in 14 138 (36%), escalation in 5129 (13%), and antibiotics were unchanged in 19 959 (51%). De-escalation varied among hospitals (median, 37%; range, 31–39%, P < .001). Diagnoses with lower de-escalation rates included intra-abdominal (23%) and skin and soft tissue (28%) infections. Critical care had higher rates of both de-escalation and escalation compared with wards. Conclusions Our electronic de-escalation metric demonstrated variation among hospitals, units, and diagnoses. This metric may be useful for assessing stewardship opportunities and impact.

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Can antibiotic De-escalation Be Measured Without Chart Review? A Proposed Electronic Definition

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx162.070 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S28-S29 ◽

Cited By ~ 1

Author(s):

Rebekah W Moehring ◽

Xinru Ren ◽

Deverick J Anderson ◽

Angelina Davis ◽

April Dyer ◽

...

Keyword(s):

Antibiotic Therapy ◽

Antimicrobial Stewardship ◽

Medication Administration ◽

Upper Respiratory Tract ◽

Narrow Spectrum ◽

Icd 10 ◽

Upper Respiratory ◽

Definition Of ◽

Intra Abdominal Infection ◽

Inpatient Units

Abstract Background Antimicrobial stewardship programs promote de-escalation: moving from broad to narrow spectrum agents and/or stopping antibiotics as more clinical data return. A standard definition of de-escalation objectively applied to electronic data could provide a means to assess stewardship improvement opportunities. Methods We performed a retrospective cohort study of de-escalation events among five hospitals from the Duke Health System and the Duke Antimicrobial Stewardship Outreach Network using 2016 electronic medication administration record data. Antibiotics were ranked into four categories: narrow spectrum (e.g., cefazolin), broad spectrum, extended spectrum, and agents typically targeted for protection (e.g., meropenem). Included patients were cared for on inpatient units, had antibiotic therapy for at least 2 days, and had at least 3 days of hospitalization after starting antibiotics. De-escalation was defined as reduction in either the number of antibiotics or rank measured at two time points: day 1 of initiation of antibiotic therapy and day 5 (or day of discharge if occurring on day 3 or 4). Escalation was an increase in either number or rank of agents. Unchanged was either no change or discordant directions of change in number and rank. For all categories, the outcome was percent among qualifying admissions. Descriptive statistics were used to describe de-escalation among hospitals, unit type, and ICD-10 diagnoses. Results Among 39,226 included admissions, de-escalation occurred in 14,138 (36%), escalation in 5,129 (13%), and antibiotics were unchanged in 19,959 (51%) (Figure). Percent de-escalation was significantly different among hospitals (median 37%, range 31–39%, P < .001). Infectious diagnoses with lower rates of de-escalation included intra-abdominal infection (23%), skin and soft-tissue infection (28%), and ENT/upper respiratory tract infection (19%). Intensive care units had higher rates of both de-escalation and escalation (43% and 16%) when compared with non-ICU wards (35% and 13%, P < .001). Conclusion We provided an objective, electronic definition of de-escalation and demonstrated variation among hospitals, units, and diagnoses. This metric may be useful for assessing stewardship opportunities. Disclosures All authors: No reported disclosures.

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How Does Antimicrobial Stewardship Affect Inappropriate Antibiotic Therapy in Urological Patients?

Antibiotics ◽

10.3390/antibiotics9020063 ◽

2020 ◽

Vol 9 (2) ◽

pp. 63 ◽

Cited By ~ 3

Author(s):

Atsushi Uda ◽

Katsumi Shigemura ◽

Koichi Kitagawa ◽

Kayo Osawa ◽

Kenichiro Onuma ◽

...

Keyword(s):

Infectious Disease ◽

Disease Management ◽

Antibiotic Therapy ◽

Antimicrobial Stewardship ◽

Broad Spectrum ◽

Retrospective Review ◽

Antibiotic Use ◽

University Hospital ◽

Annual Changes ◽

Inappropriate Medications

Antimicrobial stewardship teams (ASTs) have been well-accepted in recent years; however, their clinical outcomes have not been fully investigated in urological patients. The purpose of this study was to evaluate the outcomes of intervention via a retrospective review of urological patients, as discussed in the AST meetings, who were treated with broad-spectrum antibiotics between 2014 and 2018 at the Department of Urology, Kobe University Hospital in Japan. Interventions were discussed in AST meetings for patients identified by pharmacists as having received inappropriate antibiotic therapy. The annual changes in numbers of inappropriate medications and culture submissions over five years at the urology department were statistically analyzed. Among 1,033 patients audited by pharmacists, inappropriate antibiotic therapy was found in 118 cases (11.4%). The numbers of inappropriate antibiotic use cases and of interventions for indefinite infections had significantly decreased during the study period (p = 0.012 and p = 0.033, respectively). However, the number of blood and drainage culture submissions had significantly increased (p = 0.009 and p = 0.035, respectively). Our findings suggest that urologists have probably become more familiar with infectious disease management through AST intervention, leading to a decrease in inappropriate antibiotic use and an increase in culture submissions.

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Fournier Syndrome-Surgical and Intensive Care Treatment

10.53902/mrprs.2021.01.000507 ◽

2021 ◽

Vol 1 (2) ◽

Author(s):

Paoliello V

Keyword(s):

Intensive Care ◽

Soft Tissue ◽

Antibiotic Therapy ◽

Broad Spectrum ◽

Normal Skin ◽

Acute Infection ◽

Intensive Care Treatment ◽

Broad Spectrum Antibiotic ◽

Gram Negative ◽

Complementary Actions

Fournier’s Gangrene, also referred to as necrotising fasciitis, Mellene Syndrome or Fournier Syndrome (FS), is a soft-tissue acute infection of the perinium with secondary necrotising cellulitis caused by anaerobic germs or gram-negative bacilli or both. This infection may develop in apparently normal skin, affects the tegumentary and fascial planes but it affects the muscle - aponeurotic plane very rarely dissecting the necrotic tissues, as it rapidly moves towards sepsis, with multiple failure of the organs and death. Treatment consists of agressive surgical debridement, broad spectrum antibiotic therapy, hyperbaric oxiygen therapy (OHB) and other complementary actions.

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Procalcitonin-guided protocol use and impact on intensive care unit and antibiotic management: a pilot study

Revista Brasileira de Farmácia Hospitalar e Serviços de Saúde ◽

10.30968/rbfhss.2021.122.0563 ◽

2021 ◽

Vol 12 (2) ◽

pp. 563

Author(s):

Danillo E. OLIVEIRA ◽

Eudes G. CUNHA ◽

Diana M. GUERRA ◽

Valéria S. BEZERRA

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Retrospective Study ◽

Antibiotic Therapy ◽

Hospital Costs ◽

Protocol Adherence ◽

Unified Health System ◽

Antibiotic Management ◽

Therapy Cost

Objective: To assess the procalcitonin protocol use and its impact on antibiotic therapy management of critically ill patients in the intensive care unit (ICU). Method: An observational descriptive and retrospective study conducted in an adult ICU with 28 beds from the Brazilian Unified Health System (SUS). Results: This present study observed a 78% (90/116) of PCT protocol adherence in the studied ICU. We observed a reduction in days of antibiotic treatment (DOT) going from 14 to 8,5 treatment-day duration (5.49 ± 2.2 days), impacting the overall antibiotic therapy cost for a decrease of 40.91%. Conclusion: The study revealed that PCT use was associated with substantial benefits, reducing hospital costs and days of exposure to antibiotic therapy applied to patients affected by infectious diseases in critical care settings.

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Antibiotics in Necrotizing Soft Tissue Infections

Antibiotics ◽

10.3390/antibiotics10091104 ◽

2021 ◽

Vol 10 (9) ◽

pp. 1104

Author(s):

Tomas Urbina ◽

Keyvan Razazi ◽

Clément Ourghanlian ◽

Paul-Louis Woerther ◽

Olivier Chosidow ◽

...

Keyword(s):

Soft Tissue ◽

Antibiotic Therapy ◽

Broad Spectrum ◽

Bacterial Infections ◽

Group A Streptococcus ◽

Empirical Therapy ◽

Antibiotic Use ◽

Soft Tissue Infections ◽

Beta Lactam ◽

Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues. Initial urgent management of NSTIs relies on broad-spectrum antibiotic therapy, rapid surgical debridement of all infected tissues and, when present, treatment of associated organ failures in the intensive care unit. Antibiotic therapy for NSTI patients faces several challenges and should (1) carry broad-spectrum activity against gram-positive and gram-negative pathogens because of frequent polymicrobial infections, considering extended coverage for multidrug resistance in selected cases. In practice, a broad-spectrum beta-lactam antibiotic (e.g., piperacillin-tazobactam) is the mainstay of empirical therapy; (2) decrease toxin production, typically using a clindamycin combination, mainly in proven or suspected group A streptococcus infections; and (3) achieve the best possible tissue diffusion with regards to impaired regional perfusion, tissue necrosis, and pharmacokinetic and pharmacodynamic alterations. The best duration of antibiotic treatment has not been well established and is generally comprised between 7 and 15 days. This article reviews the currently available knowledge regarding antibiotic use in NSTIs.

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Acute Pancreatitis Between Practice and Recommendations

Medical Technologies Journal ◽

10.26415/2572-004x-vol4iss3p561-567 ◽

2020 ◽

Vol 4 (3) ◽

pp. 561-567

Author(s):

Boumediene Elhabachi ◽

Abderrahman Blaha ◽

Morsli Doulat ◽

Hassan Cheheb ◽

Soumia Zaouag

Keyword(s):

Acute Pancreatitis ◽

Retrospective Study ◽

Enteral Nutrition ◽

Antibiotic Therapy ◽

Broad Spectrum ◽

General Surgery ◽

Early Phase ◽

Broad Spectrum Antibiotic ◽

The World ◽

Surgery Department

Background:Acute inflammation of the pancreas, acute pancreatitis (AP) shows an increasing incidence in the world as well as in Algeria. However, lethality and mortality are decreasing, mainly due to recommendations from Atlanta, the International Pancreatology Association and the American Pancreatology Association. The purpose of this work was to analyze the management of AP in the general surgery department of the UHC of Sidi Bel Abbes. Method: In a retrospective study, 100 acute pancreatitis cases admitted to general surgery between January 2017 and December 2019 were analyzed. The abdominal scanner was systematic at the admission. The rate of lipasemia, when greater than 3 times the normal one, allowed, in association with the evocative pain, to make the diagnosis. The severity of AP was assessed using the Balthazar score. An MRI was requested when the scanner was inconclusive, to look for an etiology and / or possible complications. 79 (79%) patients received broad-spectrum antibiotic therapy and diet was systematic. Results: We have transmitted the recommendations of scholar societies to the various specialists and the management of AP is currently more unified and more effective. Scanner is no longer systematic in the early phase. Antibiotic therapy is no longer administered without biological evidence. Enteral nutrition is now possible. Conclusion: We were able to reach the goal of reducing hospitalization and scanning requests. A further analysis of 100 other PA files is planned to confirm the obtained results.

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Inpatient Management of Uncomplicated Skin and Soft Tissue Infections in 34 Veterans Affairs Medical Centers: A Medication Use Evaluation

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz554 ◽

2020 ◽

Vol 7 (1) ◽

Author(s):

Jesse D Sutton ◽

Ronald Carico ◽

Muriel Burk ◽

Makoto M Jones ◽

XiangMing Wei ◽

...

Keyword(s):

Soft Tissue ◽

Antimicrobial Stewardship ◽

Broad Spectrum ◽

Medication Use ◽

Antibiotic Use ◽

Veterans Affairs ◽

Soft Tissue Infections ◽

Gram Negative ◽

Medical Centers ◽

Veterans Affairs Medical Centers

Abstract Background Skin and soft tissue infections (SSTIs) are a key antimicrobial stewardship target because they are a common infection in hospitalized patients, and non-guideline-concordant antibiotic use is frequent. To inform antimicrobial stewardship interventions, we evaluated the proportion of veterans hospitalized with SSTIs who received guideline-concordant empiric antibiotics or an appropriate total duration of antibiotics. Methods A retrospective medication use evaluation was performed in 34 Veterans Affairs Medical Centers between 2016 and 2017. Hospitalized patients who received antibiotics for uncomplicated SSTI were included. Exclusion criteria were complicated SSTI, severe immunosuppression, and antibiotics for any non-SSTI indication. Data were collected by manual chart review. The primary outcome was the proportion of patients receiving both guideline-concordant empiric antibiotics and appropriate treatment duration, defined as 5–10 days of antibiotics. Data were analyzed and reported using descriptive statistics. Results Of the 3890 patients manually evaluated for inclusion, 1828 patients met inclusion criteria. There were 1299 nonpurulent (71%) and 529 purulent SSTIs (29%). Overall, 250 patients (14%) received guideline-concordant empiric therapy and an appropriate duration. The most common reason for non-guideline-concordance was receipt of antibiotics targeting methicillin-resistant Staphylococcus aureus (MRSA) in 906 patients (70%) with a nonpurulent SSTI. Additionally, 819 patients (45%) received broad-spectrum Gram-negative coverage, and 860 patients (48%) received an antibiotic duration >10 days. Conclusions We identified 3 common opportunities to improve antibiotic use for patients hospitalized with uncomplicated SSTIs: use of anti-MRSA antibiotics in patients with nonpurulent SSTIs, use of broad-spectrum Gram-negative antibiotics, and prolonged durations of therapy.

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Comparison of Narrow-Versus Broad-Spectrum Antibiotics in Elderly Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Journal of Pharmacy Practice ◽

10.1177/0897190020938190 ◽

2020 ◽

pp. 089719002093819

Author(s):

Kayla R. Joyner ◽

Autumn Walkerly ◽

Kelsey Seidel ◽

Nicholas Walsh ◽

Neda Damshekan ◽

...

Keyword(s):

Chronic Obstructive Pulmonary Disease ◽

Elderly Patients ◽

Antibiotic Therapy ◽

Pulmonary Disease ◽

Broad Spectrum ◽

Primary Outcome ◽

Chronic Obstructive ◽

Obstructive Pulmonary Disease ◽

Narrow Spectrum ◽

Acute Exacerbations

Background Little evidence is available regarding the choice of empiric antibiotic therapy in elderly patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The primary objective of this study is to compare the outcomes of elderly patients receiving broad- versus narrow-spectrum antibiotics during hospitalization for AECOPD. Design A multicenter, retrospective, cohort analysis was performed. Inpatients 65 years and older with a primary discharge diagnosis of AECOPD who received ≥48 hours of antibiotic therapy were included in the study population. Patients were compared based on the spectrum of their antibiotic therapy. Narrow-spectrum antibiotics included: azithromycin, doxycycline, sulfamethoxazole/trimethoprim, or aminopenicillin. The primary outcome was a composite of mechanical ventilation 48 hours after admission, transfer to the intensive care unit 48 hours after admission, 30-day chronic obstructive pulmonary disease (COPD) readmission, and oxygen saturation less than 90% on room air or increased oxygen requirements from baseline 48 hours after admission. Results Two hundred fifty-three patients were included in this analysis; 127 patients were included in the narrow-spectrum group, and 126 patients were included in the broad-spectrum group. Patient demographics and comorbid conditions were similarly distributed in each group. The incidence of the primary composite outcome occurred in 50 (39.3%) and 60 (47.6%) of patients in the narrow- and broad-spectrum groups, respectively ( P = .19). Conclusions and Relevance No difference was found in the primary outcome in inpatients aged ≥65 years with AECOPD who received empiric broad-spectrum or narrow-spectrum antibiotics.

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Spondylodiscitis in Children: A Retrospective Study and Comparison With Non-vertebral Osteomyelitis

Frontiers in Pediatrics ◽

10.3389/fped.2021.727031 ◽

2021 ◽

Vol 9 ◽

Author(s):

Marco Roversi ◽

Gianluca Mirra ◽

Antonio Musolino ◽

Domenico Barbuti ◽

Laura Lancella ◽

...

Keyword(s):

Back Pain ◽

Retrospective Study ◽

Antibiotic Therapy ◽

Broad Spectrum ◽

Clinical Management ◽

Clinical Remission ◽

Vertebral Osteomyelitis ◽

Site Specific ◽

Early Start ◽

Neurological Signs

Objectives: The aim of this study is to provide new data on pediatrics spondylodiscitis for an optimal clinical management of this site-specific osteomyelitis.Methods: We reported 48 cases of pediatric spondylodiscitis and made three comparisons between: (1) tubercular and non-tubercular cases; (2) patients aged more or less than 5 years; (3) children with spondylodiscitis and 62 controls with non-vertebral osteomyelitis.Results: A higher rate of sequelae was reported in patients with tubercular spondylodiscitis, but no significant differences were noted at the cut-off of 5 years of age. Compared to non-vertebral osteomyelitis, pediatric spondylodiscitis affects younger children of both genders, usually presenting with afebrile back pain, and requiring longer time to admission, hospitalization, and antibiotic therapy.Conclusion: Pediatric spondylodiscitis is an insidious disease with a non-specific presentation in childhood and peculiarities of its own. However, when clinical remission is obtained by an early start of broad-spectrum antibiotics, prolonging the therapy does not improve, nor worsens, the outcome. Surgical management is mandatory in case of vertebral instability and neurological signs but can be avoided when the infection is promptly treated with antibiotic therapy.

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