Antimicrobial selection policies in the ICU

2016 ◽  
Author(s):  
David L. Paterson ◽  
Yoshiro Hayashi
Keyword(s):  
Antibiotic Therapy ◽  
Bacterial Identification ◽  
Antibiotic Resistant ◽  
Antibiotic Selection ◽  
Use Of Technology ◽  
Drug Choice ◽  
Empiric Antibiotic ◽  
Prolonged Antibiotic Therapy ◽  
Antibiotic Dosing ◽  
Selection Of

Antibiotic selection is a crucial drug choice in critically-ill patients. Optimization of empiric antibiotic choice can be gained by knowledge of the site of infection and the probable causative organisms at that site. This should be linked with knowledge of the local epidemiology of antibiotic resistance in the actual intensive care unit housing the patient. Initial empiric antimicrobial choice may need to be broad in order to cover potential antibiotic-resistant pathogens. However, it is important to be prudent in antibiotic strategy since the selection of multiple-resistant organisms by excessively broad or prolonged antibiotic therapy may affect not just the patient undergoing antibiotic therapy, but also other future patients. Selection of appropriate antibiotic regimens can be facilitated by the use of technology such as MALDI-TOF for rapid bacterial identification. Consultation with infectious disease physicians or specialist pharmacists may also be warranted in order to optimize antibiotic dosing, duration of infusion and frequency of administration, so as to meet pharmacodynamics targets linked to improved patient outcome.

scholarly journals 194. Description of Positive Blood Culture Results not Identified by Verigene Informs Empiric Antibiotic Selection

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S116-S117
Author(s):  
Connor Deri ◽  
Whitney Nesbitt ◽  
George Nelson ◽  
Jessica Keefe
Keyword(s):  
Antibiotic Therapy ◽  
Resistance Mechanism ◽  
Bloodstream Infections ◽  
Blood Cultures ◽  
Aerobic Bacteria ◽  
Gram Positive ◽  
Antibiotic Selection ◽  
Gram Negative ◽  
Empiric Antibiotic ◽  
Gram Negative Organisms

Abstract Background Bloodstream infections are a leading cause of mortality amongst hospitalized patients. Optimizing time to pathogen identification and receipt of appropriate antibiotic therapy significantly decreases mortality, morbidity, and length of hospitalization. Rapid diagnostic tests, such as Verigene, assist in the early identification of bacteria and resistance determinants from positive blood cultures; however, Verigene assays are limited to the detection of 13 gram-positive and 9 gram-negative bacteria. Methods The purpose of this study was to describe gram-negative and gram-positive aerobic bacteria identified from positive blood cultures with no Verigene target detected and to use the susceptibilities to create an antibiogram to assist in empiric antibiotic selection. A total of 2325 positive blood cultures resulted between January 2017 and October 2018 underwent Verigene testing. Results Of the 2325 isolates, 383 (16.5%), had no Verigene organism or resistance mechanism detected. Of these, there were 239 (62.4%) gram-positive isolates, 141 (36.8%) gram-negative isolates, and 3 yeast isolates with 96 unique organisms. Seventy-six (19.8%) of the organisms identified by standard culture, but not Verigene testing, are included on Verigene panel. We analyzed nine common antibiotics active against gram-negative organisms to determine percent susceptibilities against the isolated aerobic pathogens: amikacin (92.1%), cefepime (93.5%), ceftazidime (94.0%), ceftriaxone (79.7%), ciprofloxacin (88.5%), gentamicin (91.9%), levofloxacin (86.9%), piperacillin–tazobactam (83.8%), and tobramycin (85.5%). Additionally, four antibiotics active against gram-positive organisms were analyzed for gram-positive susceptibilities: cefotaxime (91.8%), ceftriaxone (98.1%), levofloxacin (82.5%), and vancomycin (91.8%). Conclusion The results of this study provide clinicians with antibiotic susceptibilities against organisms that were not identified through Verigene to better guide timely and appropriate antibiotic therapy against gram-negative and gram-positive aerobic bacteria. Disclosures All authors: No reported disclosures.

scholarly journals Population-Level Burden of Delayed or In Vitro Discordant Empiric Antibiotics Among Bacteremic Patients at US Hospitals

2020 ◽  
Vol 41 (S1) ◽  
pp. s44-s45
Author(s):  
Sameer Kadri ◽  
Yi Ling Lai ◽  
Sarah Warner ◽  
Jeffrey R. Strich ◽  
Ahmed Babiker ◽  
...  
Keyword(s):  
Septic Shock ◽  
Antibiotic Therapy ◽  
Population Level ◽  
Empiric Antibiotic Therapy ◽  
Teaching Hospitals ◽  
Antibiotic Resistant ◽  
Empiric Antibiotic ◽  
Resistance Patterns ◽  
To Receive

Background: Delayed or in vitro inactive empiric antibiotic therapy may be detrimental to survival in patients with bloodstream infections (BSIs). Understanding the landscape of delayed or discordant empiric antibiotic therapy (DDEAT) across different patient, pathogen, and hospital types, as well as by their baseline resistance milieu, may enable providers, antimicrobial stewardship programs, and policy makers to optimize empiric prescribing. Methods: Inpatients with clinically suspected serious infection (based on sampling of blood cultures and receiving systemic antibiotic therapy on the same or next day) found to have BSI were identified in the Cerner Healthfacts EHR database. Patients were considered to have received DDEAT when, on culture sampling day, they received either no antibiotic(s) or none that displayed in vitro activity against the pathogenic bloodstream isolate. Antibiotic-resistant phenotypes were defined by in vitro resistance to taxon-specific prototype antibiotics (eg, methicillin/oxacillin resistance in S. aureus) and were used to estimate baseline resistance prevalence encountered by the hospital. The probability of DDEAT was examined by bacterial taxon, by time of BSI onset, and by presence versus absence of antibiotic-resistance phenotypes, sepsis or septic shock, hospital type, and baseline resistance. Results: Of 26,036 assessable patients with a BSI at 131 US hospitals between 2005 and 2014, 14,658 (56%) had sepsis, 3,623 (14%) had septic shock, 5,084 (20%) had antibiotic-resistant phenotypes, and 8,593 (33%) received DDEAT. Also, 4,428 (52%) recipients of DDEAT received no antibiotics on culture sampling day, whereas the remaining 4,165 (48%) received in vitro discordant therapy. DDEAT occurred most often in S. maltophilia (87%) and E. faecium (80%) BSIs; however, 75% of DDEAT cases and 76% of deaths among recipients of DDEAT collectively occurred among patients with S. aureus and Enterobacteriales BSIs. For every 8 bacteremic patients presenting with septic shock, 1 patient did not receive any antibiotics on culture day (Fig. 1A). Patients with BSIs of hospital (vs community) onset were twice as likely to receive no antibiotics on culture day, whereas those with bloodstream pathogens displaying antibiotic-resistant (vs susceptible) phenotypes were 3 times as likely to receive in vitro discordant therapy (Fig. 1B). The median proportion of DDEAT ranged between 25% (14, 37%) in eight <300-bed teaching hospitals in the lowest baseline resistance quartile and 40% (31, 50%) at five ≥300-bed teaching hospitals in the third baseline resistance quartile (Fig. 2). Conclusions: Delayed or in vitro discordant empiric antibiotic therapy is common among patients with BSI in US hospitals regardless of hospital size, teaching status, or local resistance patterns. Prompt empiric antibiotic therapy in septic shock and hospital-onset BSI needs more support. Reliable detection of S. aureus and Enterobacteriales bloodstream pathogens and their resistance patterns earlier with rapid point-of-care diagnostics may mitigate the population-level impact of DDEAT in BSI.Funding: This study was funded in part by the National Institutes of Health Clinical Center, National Institutes of Allergy and Infectious Diseases, National Cancer Institute (NCI contract no. HHSN261200800001E) and the Agency for Healthcare Research and Quality.Disclosures: None

scholarly journals Influence of Antibiotic Susceptibility Testing on Antibiotic Choice in Hospital-Acquired and Ventilator-Associated Pneumonia

2020 ◽  
Vol 41 (S1) ◽  
pp. s520-s521
Author(s):  
Taissa Zappernick ◽  
Robbie Christian ◽  
Sharanie Sims ◽  
Brigid Wilson ◽  
Federico Perez ◽  
...  
Keyword(s):  
Antibiotic Therapy ◽  
Antibiotic Susceptibility ◽  
Susceptibility Testing ◽  
Empiric Antibiotic Therapy ◽  
Ventilator Associated Pneumonia ◽  
Antibiotic Susceptibility Testing ◽  
Bacterial Identification ◽  
Respiratory Sample ◽  
Empiric Antibiotic ◽  
Hospital Acquired

Background: The survival of patients with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) is largely determined by the timely administration of effective antibiotic therapy. Guidelines for the treatment HAP and VAP recommend empiric treatment with broad-spectrum antibiotics and tailoring of antibiotic therapy once results of microbiological testing are available. Objective: We examined the influence of bacterial identification and antibiotic susceptibility testing on antibiotic therapy for patients with HAP or VAP. Methods: We used the US Veterans’ Health Administration (VHA) database to identify a retrospective cohort of patients diagnosed with HAP or VAP between fiscal year 2015 and 2018. We further analyzed patients who were started on empiric antibiotic therapy, for whom microbiological test results from a respiratory sample were available within 7 days and who were alive within 48 hours of sample collection. We used the antibiotic spectrum index (ASI) to compare antibiotics prescribed the day before and the day after availability of bacterial identification and antibiotic susceptibility testing results. Results: We identified 4,669 cases of HAP and VAP in 4,555 VHA patients. The median time from respiratory sample receipt in the laboratory to final result of bacterial identification and antibiotic susceptibility testing was 2.22 days (IQR, 1.31–3.38 days). The most common pathogen was Staphylococcus aureus (n = 994), with methicillin resistance in 58% of those isolates tested. The next most common pathogen was Pseudomonas spp (n = 946 isolates). The susceptibility of antipseudomonal antibiotics, when tested, was as follows: 64% to carbapenems, 74% to cephalosporins, 75% to β-lactam/β-lactamase inhibitors, 69% to fluoroquinolones, and 95% to amikacin. Lactose-fermenting gram-negative bacteria (296 Escherichia coli and 360 Klebsiella pneumoniae) were also common. Among the 3,094 cases who received empiric antibiotic therapy, 607 (20%) had antibiotics stopped the day after antibiotic susceptibility results became available, 920 (30%) had a decrease in ASI, 1,075 (35%) had no change in ASI, and 492 (16%) had an increase in ASI (Fig. 1). Among the 1,098 patients who were not started on empiric antibiotic therapy, only 154 (14%) were started on antibiotic therapy the day after antibiotic susceptibility results became available. Conclusions: Changes in antibiotic therapy occurred in at least two-thirds of cases the day after bacterial identification and antibiotic susceptibility results became available. These results highlight how respiratory cultures can inform the treatment and improve antibiotic stewardship for patients with HAP/VAP.Funding: This study was supported by Accelerate Diagnostics.Disclosures: None

Effect of sample collection methodology on nasal culture results in cats

2009 ◽  
Vol 11 (8) ◽  
pp. 645-649 ◽  
Author(s):  
Lynelle R. Johnson ◽  
Philip H. Kass
Keyword(s):  
Antibiotic Therapy ◽  
Sampling Method ◽  
Empiric Antibiotic Therapy ◽  
Mycoplasma Species ◽  
Antibacterial Resistance ◽  
Sample Collection ◽  
Antibiotic Selection ◽  
Nasal Disease ◽  
Empiric Antibiotic ◽  
Aerobic And Anaerobic

Empiric antibiotic therapy is often employed to treat feline chronic rhinosinusitis (CRS), however, collection of samples for culture should result in improved antibiotic selection and development of less antibacterial resistance. This study evaluated the effect of sampling method on culture results in 44 cats and found that aerobic and anaerobic cultures were positive significantly more often from nasal flush samples than from tissue biopsy samples. Frequency of positive Mycoplasma species culture did not differ between the two sampling methodologies, although results were discordant in eight sample pairs. Mycoplasma species were cultured from flush samples only in three cats and from biopsy samples only in five cats. These results suggest that a nasal flush sample is adequate for determining the presence of bacterial organisms in feline nasal disease, however, failure to culture Mycoplasma species from a nasal flush must be interpreted with caution.

Treatment of lower extremity infections in diabetics

1992 ◽  
Vol 82 (7) ◽  
pp. 361-370 ◽  
Author(s):  
WS Joseph
Keyword(s):  
Lower Extremity ◽  
Antibiotic Therapy ◽  
Medical Literature ◽  
Antibiotic Use ◽  
Classification Systems ◽  
Empiric Antibiotic Therapy ◽  
Surgical Approaches ◽  
Diabetic Foot Infections ◽  
Empiric Antibiotic ◽  
Selection Of

The infected diabetic lower extremity has enjoyed a surge in popularity in the medical literature. There have been numerous papers outlining classification systems for ulcer depth, surgical approaches, and microbiology. Discussions on antibiotic use have usually been directed toward therapy of the "diabetic foot infections" as a group, without regard to differences in severity and location of these infections. These infections can vary from the most superficial of processes to a severe life- and limb-threatening sepsis. The author presents a review of the processes involved in the diabetic lower extremity infection and suggests a classification system for selection of empiric antibiotic therapy based on the severity of the infection.

Persistent Multispecies Actinomyces Mastitis Treated With Repeated Aspiration and Long-Term Oral Antibiotics

2021 ◽  
pp. 000313482110257
Author(s):  
Colin Jenkins ◽  
Anand Ganapathy ◽  
Crystal Fancher ◽  
Kazuhide Matsushima
Keyword(s):  
Antibiotic Therapy ◽  
Rare Condition ◽  
Breast Abscess ◽  
Amoxicillin Clavulanic Acid ◽  
Recurrent Breast ◽  
Causative Bacterium ◽  
Repeated Aspiration ◽  
Prolonged Antibiotic Therapy

Actinomycosis is an infection characterized by abscess formation, draining sinuses, and tissue fibrosis. The causative bacterium is a Gram-positive facultative anaerobe from the genus Actinomyces. Infections classically affect the cervicofacial, thoracic, or pelvic region and often require prolonged antibiotic therapy. Actinomycosis of the breast is a rare condition that may present as a recurrent breast abscess. We present a 33-year-old female with a recurrent breast abscess which grew A. radingae and A. israeli on aspirated fluid cultures. Treatment with surgical aspiration and a 6-week course of oral amoxicillin/clavulanic acid 875 mg twice daily resulted in clinical improvement. Our case demonstrates how recurrent breast abscesses caused by Actinomyces can be difficult to manage. Long-term antibiotic therapy with surgical aspiration and regular follow-up offer the best chance of clinical resolution.

scholarly journals Tetracycline-Resistant Bacteria Selected from Water and Zebrafish after Antibiotic Exposure

2021 ◽  
Vol 18 (6) ◽  
pp. 3218
Author(s):  
Ana Rita Almeida ◽  
Marta Tacão ◽  
Joana Soares ◽  
Inês Domingues ◽  
Isabel Henriques
Keyword(s):  
Statistical Significance ◽  
Recovery Period ◽  
Antibiotic Resistance Genes ◽  
Antibiotic Use ◽  
Resistant Bacteria ◽  
Antibiotic Resistant ◽  
Potential Impact ◽  
Susceptibility Profiles ◽  
Selection Of ◽  
Significant Mortality

The emergence of antibiotic-resistant pathogens due to worldwide antibiotic use is raising concern in several settings, including aquaculture. In this work, the selection of antibiotic-resistant bacteria (ARB) and antibiotic resistance genes (ARGs) was evaluated after exposure of zebrafish to oxytetracycline (OTC) for two months, followed by a recovery period. The selection of ARB in water and fish was determined using selective media. The abundance of tetA genes was estimated through qPCR. Higher prevalence of ARB was measured in all samples exposed to the antibiotic when compared to control samples, although statistical significance was only achieved five days after exposure. Isolates recovered from samples exposed to the antibiotic were affiliated with Pseudomonas and Stenotrophomonas. Various antibiotic susceptibility profiles were detected and 37% of the isolates displayed multidrug resistance (MDR). The selection of the tetA gene was confirmed by qPCR at the highest OTC concentration tested. Two MDR isolates, tested using zebrafish embryos, caused significant mortality, indicating a potential impact on fish health and survival. Overall, our work highlights the potential impact of antibiotic contamination in the selection of potential pathogenic ARB and ARGS.

scholarly journals Reduced Length of Stay Using Clinical Decision Support Tool (ASAP) for Empiric Antibiotic Selection

2020 ◽  
Vol 41 (S1) ◽  
pp. s368-s368
Author(s):  
Mary Acree ◽  
Kamaljit Singh ◽  
Urmila Ravichandran ◽  
Jennifer Grant ◽  
Gary Fleming ◽  
...  
Keyword(s):  
Decision Support ◽  
Length Of Stay ◽  
Electronic Health Record ◽  
Clinical Decision Support ◽  
Decision Support Tool ◽  
Clinical Decision ◽  
Health Record ◽  
Antibiotic Selection ◽  
Support Tool ◽  
Empiric Antibiotic

Background: Empiric antibiotic selection is challenging and requires knowledge of the local antibiogram, national guidelines and patient-specific factors, such as drug allergy and recent antibiotic exposure. Clinical decision support for empiric antibiotic selection has the potential to improve adherence to guidelines and improve patient outcomes. Methods: At NorthShore University HealthSystem, a 4-hospital, 789 bed system, an automated point-of-care decision support tool referred to as Antimicrobial Stewardship Assistance Program (ASAP) was created for empiric antibiotic selection for 4 infectious syndromes: pneumonia, skin and soft-tissue infections, urinary tract infection, and intra-abdominal infection. The tool input data from the electronic health record, which can be modified by any user. Using an algorithm created with electronic health record data, antibiogram data, and national guidelines, the tool produces an antibiotic recommendation that can be ordered via a link to order entry. If the tool identifies a patient with a high likelihood for a multidrug-resistant infection, a consultation by an infectious diseases specialist is recommended. Utilization of the tool and associated outcomes were evaluated from July 2018 to May 2019. Results: The ASAP tool was executed by 140 unique, noninfectious diseases providers 790 times. The tool was utilized most often for pneumonia (194 tool uses), followed by urinary tract infection (166 tool uses). The most common provider type to use the tool was an internal medicine hospitalist. The tool increased adherence to the recommended antibiotic regimen for each condition. Antibiotic appropriateness was assessed by an infectious diseases physician. Antibiotics were considered appropriate when they were similar to the antibiotic regimen recommended by the ASAP. Inappropriate antibiotics were classified as broad or narrow. When antibiotic coverage was appropriate, hospital length of stay was statistically significantly shorter (4.8 days vs 6.8 days for broad antibiotics vs 7.4 days for narrow antibiotics; P < .01). No significant differences were identified in mortality or readmission. Conclusions: A clinical decision support tool in the electronic health record can improve adherence to recommended empiric antibiotic therapy. Use of appropriate antibiotics recommended by such a tool can reduce hospital length of stay.Funding: NoneDisclosures: None

scholarly journals Optimized genotyping method for identification of bacterial contaminants in pharmaceutical industry

2016 ◽  
Vol 66 (2) ◽  
pp. 289-295
Author(s):  
Borche Stamatoski ◽  
Miroslava Ilievska ◽  
Hristina Babunovska ◽  
Nikola Sekulovski ◽  
Sasho Panov
Keyword(s):  
Pharmaceutical Industry ◽  
Dna Sequencing ◽  
Bacterial Contamination ◽  
Raw Materials ◽  
Pcr Primers ◽  
Rrna Gene ◽  
Bacterial Identification ◽  
Bacterial Contaminants ◽  
Microbiological Control ◽  
Selection Of

AbstractMicrobiological control is of crucial importance in the pharmaceutical industry regarding the possible bacterial contamination of the environment, water, raw materials and finished products. Molecular identification of bacterial contaminants based on DNA sequencing of the hypervariable 16SrRNA gene has been introduced recently. The aim of this study is to investigate the suitability of gene sequencing using our selection of PCR primers and conditions for rapid and accurate bacterial identification in pharmaceutical industry quality control.DNA was extracted from overnight incubated colonies from 10 bacterial ATCC strains, which are common contaminants in the pharmaceutical industry. A region of bacterial 16SrRNA gene was analyzed by bidirectional DNA sequencing. Bacterial identification based on partial sequencing of the 16SrRNA gene is the appropriate method that could be used in the pharmaceutical industry after adequate validations. We have successfully identified all tested bacteria with more than 99 % similarity to the already published sequences.

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