scholarly journals 1555. Evaluation of Local Pathogens and Management of Diabetic Foot Infections

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S778-S778
Author(s):  
Jessica L Seadler ◽  
Natalie Tucker ◽  
Beth Cady ◽  
Praveen Mullangi
Keyword(s):  
Antibiotic Therapy ◽  
Broad Spectrum ◽  
Diabetic Foot ◽  
Antimicrobial Agents ◽  
Specific Treatment ◽  
Retrospective Chart Review ◽  
Primary Objective ◽  
Empiric Antibiotic Therapy ◽  
Diabetic Foot Infections ◽  
Empiric Antibiotic

Abstract Background Diabetic foot infections (DFI) are a potentially devastating complication for patients with diabetes. When treating these patients, there is a need for selection of highly effective antibiotics coupled with a need to avoid excessive use of broad-spectrum antimicrobial agents that could lead to adverse patient outcomes. At this institution, it has been observed that there is a lack of compliance with consensus guideline recommendations for the choice of empiric antibiotic therapy for DFI, leading to overuse of broad-spectrum antibiotics. Methods A retrospective chart review was performed for hospitalized patients over 18 years of age that received antibiotics for DFI during the period of August 1, 2018 to July 31, 2019. Patients were excluded if they were continuing outpatient antibiotics for an existing DFI, were being treated with antibiotics for a concurrent infection, or were pregnant. The primary objective was the rate of guideline-compliant empiric antibiotic regimens as broken down by infection severity. Secondary objectives included the duration of antibiotic therapy per patient, and rates of empiric methicillin-resistant Staphylococcus aureus (MRSA) and P. aeruginosa coverage. Results A total of 114 patients were included in the analysis. A majority of patients had an infection of moderate severity (65.8%), followed by 19.3% with severe infections, and 14.9% with mild infections. In the total population, only 26.3% of patients received empiric antibiotic regimens that were guideline-compliant. A large percentage of patients received empiric anti-MRSA antibiotics (95.6%) and empiric anti-pseudomonal agents (89.5%). Use of these broad-spectrum agents did not differ by infection severity. Ninety-nine (86.8%) patients had a site culture collected. S. aureus was the most commonly isolated organism and there was a low rate of P. aeruginosa (10.1%). Conclusion There is room for improvement in the management of DFI at this institution. A specific area that has been identified is the overuse of empiric anti-pseudomonal agents in patients without risk factors for P. aeruginosa. The results of this study will be evaluated alongside consensus guidelines and used to create institution-specific treatment guidance that providers can employ to optimize the management of DFI. Disclosures All Authors: No reported disclosures

2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infectionsa

2013 ◽  
Vol 103 (1) ◽  
pp. 2-7 ◽  
Author(s):  
Benjamin A. Lipsky ◽  
Anthony R. Berendt ◽  
Paul B. Cornia ◽  
James C. Pile ◽  
Edgar J. G. Peters ◽  
...  
Keyword(s):  
Antibiotic Therapy ◽  
Diabetic Foot ◽  
Empiric Antibiotic Therapy ◽  
Diabetic Patients ◽  
Bone Culture ◽  
Healthcare Organizations ◽  
Surgical Interventions ◽  
Diabetic Foot Infections ◽  
Empiric Antibiotic ◽  
Severe Infections

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Reduction in Inadequate Empiric Antibiotic Therapy for Ventilator-Associated Pneumonia: Impact of a Unit-Specific Treatment Pathway

2008 ◽  
Vol 74 (6) ◽  
pp. 516-523 ◽  
Author(s):  
Louis J. Magnotti ◽  
Thomas J. Schroeppel ◽  
Timothy C. Fabian ◽  
L. Paige Clement ◽  
Joseph M. Swanson ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Antibiotic Therapy ◽  
Injury Severity ◽  
Specific Treatment ◽  
Empiric Antibiotic Therapy ◽  
Trauma Patients ◽  
Ventilator Associated Pneumonia ◽  
Empiric Antibiotic ◽  
Specific Pathway

Empiric antibiotic therapy is routinely initiated for patients with presumed ventilator-associated pneumonia (VAP). Reported mortality rates for inadequate empiric antibiotic therapy (IEAT) for VAP range from 45 to 91 per cent. The purpose of this study was to determine the effect of a unit-specific pathway for the empiric management of VAP on reducing IEAT episodes and improving outcomes in trauma patients. Patients admitted with VAP over 36-months were identified and stratified by gender, age, severity of shock, and injury severity. Outcomes included number of IEAT episodes, ventilator days, intensive care unit days, hospital days, and mortality. Three hundred and ninety-three patients with 668 VAP episodes were identified. There were 144 (22%) IEAT episodes: significantly reduced compared with our previous study (39%) ( P < 0.001). Patients were classified by number of IEAT episodes: 0 (n = 271), 1 (n = 98) and ≥ 2 (n = 24). Mortality was 12 per cent, 13 per cent, and 38 per cent ( P < 0.001), respectively. Multivariable logistic regression identified multiple IEAT episodes as an independent predictor of mortality (odds ratio = 4.7; 95% confidence interval: 1.684–13.162). Multiple IEAT episodes were also associated with prolonged mechanical ventilation and intensive care unit stay ( P < 0.001). Trauma patients with multiple IEAT episodes for VAP have increased morbidity and mortality. Adherence to a unit-specific pathway for the empiric management of VAP reduces multiple IEAT episodes. By limiting IEAT episodes, resource utilization and hospital mortality are significantly decreased.

scholarly journals 191. Appropriateness of Empiric Antibiotics for Enterobacteriaceae Bacteremia

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S115-S115
Author(s):  
Brandon J Smith ◽  
Abigail Kois ◽  
Nathan Gartland ◽  
Joseph Tholany ◽  
Ricardo Arbulu
Keyword(s):  
Antibiotic Therapy ◽  
Bacterial Resistance ◽  
Retrospective Chart Review ◽  
Standard Of Care ◽  
Academic Community ◽  
Empiric Antibiotic Therapy ◽  
In Vitro Susceptibility ◽  
Empiric Antibiotics ◽  
Empiric Antibiotic

Abstract Background Appropriate empiric antibiotic therapy is associated with decreased mortality and recurrence in patients with Enterobacteriaceae bacteremia (EB). Increasing bacterial resistance adds an additional layer to this complex clinical scenario. Swift utilization of appropriate antibiotics is crucial for improved patient outcomes. However, prolonged and excessively broad antibiotic coverage is not without its own complications. Our study aimed to review the appropriateness of empiric antibiotics for EB. Methods A retrospective chart review of all patients >18 years of age who were admitted to a single academic community hospital during 2018 EB anytime throughout their hospitalization. The primary endpoint was the appropriateness of empiric antibiotic therapy, defined as receiving active therapy prior to the return of antimicrobial sensitivities that were susceptible to the empiric agents used. Appropriateness was further adjusted for standard of care (SOC) practices. Specifically, despite in vitro susceptibility of piperacillin/tazobactam and cefepime, carbapenem therapy is preferred for ESBL infections. Results Our study identified 178 patients with EB. Most common organisms included E.coli (64.6%), K. pneumoniae (11.8%) and P. mirabilis (7.3%). Resistance patterns included 1 CRE (0.57%) and 17 ESBL (9.7%) isolates. Most common sources of infection included urinary (63.5%) and intraabdominal (13.5%). Based on the sensitivity reports of tested isolates, 83.7% of patients received appropriate empiric antibiotics. After adjustment for SOC, 11.8% of ESBL patients (2/17) and 0% of CRE (0/1) patients received appropriate therapy. Comparatively 89.0% of patients without ESBL or CRE (137/154) received appropriate care (P < 0.0001). Conclusion The results of this study demonstrate that across our patient population, over 80% of patients received appropriate empiric antibiotics for EB; however, this percentage was dramatically lower for patients with ESBL or CRE infections. This highlights room for improved rapid diagnosis and identification of risk factors predisposing to resistant organisms thereby decreasing the time to appropriate antibiotic therapy. Disclosures All authors: No reported disclosures.

scholarly journals Timing of antibiotic therapy in the ICU

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Marin H. Kollef ◽  
Andrew F. Shorr ◽  
Matteo Bassetti ◽  
Jean-Francois Timsit ◽  
Scott T. Micek ◽  
...  
Keyword(s):  
Antibiotic Therapy ◽  
Broad Spectrum ◽  
Drug Exposure ◽  
Empiric Antibiotic Therapy ◽  
Antibiotic Administration ◽  
In Vitro Susceptibility ◽  
Empiric Antibiotic ◽  
Life Threatening ◽  
Sepsis And Septic Shock

AbstractSevere or life threatening infections are common among patients in the intensive care unit (ICU). Most infections in the ICU are bacterial or fungal in origin and require antimicrobial therapy for clinical resolution. Antibiotics are the cornerstone of therapy for infected critically ill patients. However, antibiotics are often not optimally administered resulting in less favorable patient outcomes including greater mortality. The timing of antibiotics in patients with life threatening infections including sepsis and septic shock is now recognized as one of the most important determinants of survival for this population. Individuals who have a delay in the administration of antibiotic therapy for serious infections can have a doubling or more in their mortality. Additionally, the timing of an appropriate antibiotic regimen, one that is active against the offending pathogens based on in vitro susceptibility, also influences survival. Thus not only is early empiric antibiotic administration important but the selection of those agents is crucial as well. The duration of antibiotic infusions, especially for β-lactams, can also influence antibiotic efficacy by increasing antimicrobial drug exposure for the offending pathogen. However, due to mounting antibiotic resistance, aggressive antimicrobial de-escalation based on microbiology results is necessary to counterbalance the pressures of early broad-spectrum antibiotic therapy. In this review, we examine time related variables impacting antibiotic optimization as it relates to the treatment of life threatening infections in the ICU. In addition to highlighting the importance of antibiotic timing in the ICU we hope to provide an approach to antimicrobials that also minimizes the unnecessary use of these agents. Such approaches will increasingly be linked to advances in molecular microbiology testing and artificial intelligence/machine learning. Such advances should help identify patients needing empiric antibiotic therapy at an earlier time point as well as the specific antibiotics required in order to avoid unnecessary administration of broad-spectrum antibiotics.

scholarly journals Toe ulcers and early diagnosis of osteomyelitis in diabetic patients

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0041
Author(s):  
Maria Gala Santini Araujo ◽  
Pablo Sotelano ◽  
Nelly Carrasco ◽  
Ana Parise ◽  
Daniel Villena
Keyword(s):  
Antibiotic Therapy ◽  
Diabetic Foot ◽  
Bone Biopsy ◽  
Healing Time ◽  
Empiric Antibiotic Therapy ◽  
Foot Ulcers ◽  
Diabetic Patients ◽  
Inclusion Criteria ◽  
Bone Edema ◽  
Empiric Antibiotic

Category: Diabetes Introduction/Purpose: Neuropathy and Peripheral arterial disease are the main causes of diabetic foot ulcers. Toes are the most frequent location. Osteomyelitis diagnosis of foot ulcers is still controversial, mainly in ulcers without bone exposure. Although MRI has 90% sensitivity and 85% specificity for osteomyelitis diagnosis, it is not usually used for early detection of bone changes, due to lack of availability and high cost. Bone biopsy puncture is considered the gold standard methodology together with microbiological and histological examinations, but it is not always available in all practices. The purpose of this study was to describe the diagnosis in forefoot ulcers found in diabetic patients using MRI and bone biopsy puncture. Methods: This is a retrospective study, a case series. Clinical records of patients with injuries limited to toes between January 2013 and December 2015 were analyzed. The inclusion criteria were: patients with Diabetes Mellitus (DM) diagnosis and with a grade 1 or 2 digital ulcer according to Wagner’s classification for at least 3 weeks, with visible bone edema in the magnetic resonance (MRI) and those with a bone biopsy performed, and with a minimum follow–up of a year. Patients with diabetic foot ulcers were evaluated by an interdisciplinary team. Laboratory standards were evaluated preoperative and during antibiotic therapy. The surgical bone biopsy was performed by a foot and ankle surgeon with experience in Diabetic foot pathologies. Microbiological and histological study was analyzed. We also recorded the demographic data and identified the patients who had received previous empiric antibiotic therapy. Statistical analysis was performed. Results: Thirty patients out of 93 patients fulfilled inclusion criteria between January 2013 and December 2015. Eleven patients had grade 1 ulcers and 19 grade 2. Twenty-two patients (73.3%) got bone biopsies with positive cultures and 14 (63,3%) had a positive pathological anatomy. Eight patients got negative cultures and pathology. Six patients that did not received empiric antibiotic therapy and 19 patients out of 24 who had received empiric antibiotics had positive cultures. Mean healing time for patients who did not had antibiotics was 4 weeks (3-12) and for the group who received empiric antibiotics was 6 weeks (4-10/) Only 4 patients out of 19 patients with Wagner II ulcers had the toe amputated. Conclusion: A precise diagnosis of the germ was obtained in 73.3% of the patients and a specific antibiotic treatment was completed. Although empiric antibiotic therapy 19 out of 24 patients had positive bone cultures and healing time was longer. Amputation index was 13%, all of them were grade 2 ulcers. There were no major amputations. We consider that in these kind of ulcers that had more than 3 weeks without healing and had no radiographic changes, MRI can show bone edema. Surgical bone biopsy should be done to begin specific antibiotic therapy and improve healing time.

Microbiota and Its Antibiotic Susceptibility in Diabetic Foot Infections: Observations From Polish Nonmetropolitan Hospital, 2015-2016

2020 ◽  
pp. 153473462095368
Author(s):  
Irmina Maria Michalek ◽  
Kryspin Mitura ◽  
Agnieszka Krechowska ◽  
Florentino Luciano Caetano dos Santos
Keyword(s):  
Diabetic Foot ◽  
Antibiotic Susceptibility ◽  
Anaerobic Bacteria ◽  
Empiric Antibiotic Therapy ◽  
Gram Negative ◽  
Diabetic Foot Infection ◽  
Facultatively Anaerobic ◽  
Diabetic Foot Infections ◽  
Empiric Antibiotic ◽  
Surgery Department

In current clinical practice, in case of symptoms-based suspicion of diabetic foot infection, immediate empiric antibiotic therapy is recommended. Prevailing guidelines do not provide region-specific therapy schemes. To validate existing recommendations, there is an urgent need for a report on diabetic foot infection microbiota patterns in Central Europe. This study aimed to describe diabetic foot infections microbiota and its antibiotic susceptibility in Poland. We conducted a single-center descriptive study at the General Surgery Department, Siedlce Hospital, Poland. Data for all patients diagnosed with diabetic foot infection between January 1, 2015, and December 31, 2016, and corresponding antimicrobial susceptibility tests were extracted. A total of 54 patients were included in the study, with a total of 102 microbiological samples. Among 81 positive samples, 77.1% of the isolated bacteria were Gram-negative. A total of 93.4% of the isolates were facultatively anaerobic bacteria. No obligatory anaerobic bacteria and no yeasts were isolated. Facultatively anaerobic, Gram-negative bacteria, mainly Proteus spp and Escherichia coli, were the most common organisms cultured in diabetic foot infections. This study suggests that the currently implemented treatment recommendations might not be adequate in Poland.

Time to Guideline-Based Empiric Antibiotic Therapy in the Treatment of Pneumonia in a Community Hospital

2016 ◽  
Vol 29 (4) ◽  
pp. 386-391 ◽  
Author(s):  
Beth L. Erwin ◽  
Jeffrey A. Kyle ◽  
Leland N. Allen
Keyword(s):  
Antibiotic Therapy ◽  
Guideline Adherence ◽  
Community Hospital ◽  
Retrospective Chart Review ◽  
Empiric Antibiotic Therapy ◽  
Adherence Rate ◽  
Record System ◽  
Empiric Antibiotic ◽  
The Mean ◽  
Mean Time

Purpose: The 2005 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines for hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and health care-associated pneumonia (HCAP) stress the importance of initiating prompt appropriate empiric antibiotic therapy. This study’s purpose was to determine the percentage of patients with HAP, VAP, and HCAP who received guideline-based empiric antibiotic therapy and to determine the average time to receipt of an appropriate empiric regimen. Methods: A retrospective chart review of adults with HAP, VAP, or HCAP was conducted at a community hospital in suburban Birmingham, Alabama. The hospital’s electronic medical record system utilized International Classification of Diseases, Ninth Revision ( ICD-9) codes to identify patients diagnosed with pneumonia. The percentage of patients who received guideline-based empiric antibiotic therapy was calculated. The mean time from suspected diagnosis of pneumonia to initial administration of the final antibiotic within the empiric regimen was calculated for patients who received guideline-based therapy. Results: Ninety-three patients met the inclusion criteria. The overall guideline adherence rate for empiric antibiotic therapy was 31.2%. The mean time to guideline-based therapy in hours:minutes was 7:47 for HAP and 28:16 for HCAP. For HAP and HCAP combined, the mean time to appropriate therapy was 21:55. Conclusion: Guideline adherence rates were lower and time to appropriate empiric therapy was greater for patients with HCAP compared to patients with HAP.

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.

scholarly journals 114. Implementation of an Empiric Organism Specific Guidelines for Gram-negative Bacteremia in conjunction with Rapid Diagnostic Testing

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S71-S71
Author(s):  
Fidelia Bernice ◽  
Edina Avdic ◽  
Kathryn Dzintars ◽  
Aliyah Cruz
Keyword(s):  
Clinical Status ◽  
Compliance Rate ◽  
Diagnostic Testing ◽  
Specific Treatment ◽  
Resistance Mechanisms ◽  
Primary Objective ◽  
Blood Cultures ◽  
Common Reason ◽  
Empiric Antibiotic Therapy ◽  
Gram Negative

Abstract Background The objective of this study was to confirm the validity of institution specific treatment recommendations targeting organisms identified by GenMark Dx® ePlex® blood cultures identification (BCID) Gram-negative panel prior to susceptibility results. Methods We developed and implemented institution specific guidelines for empiric antibiotic therapy for Gram-negative organisms targeted by GenMark Dx® ePlex® BCID. We utilized blood culture antibiograms, existing evidence for the most optimal agent for each pathogen, probable resistance mechanisms and patient clinical status to create these guidelines. From December 16, 2019 through May 31, 2020, infectious diseases pharmacists reviewed all positive blood cultures; assessed compliance with guidelines and intervened as needed. The primary objective was to determine how frequently guideline recommend agents would be ineffective against targeted pathogens based on susceptibilities. Secondary objectives were compliance with guidelines and frequency of therapy escalation or de-escalation. Results GenMark® testing was completed on 222 cultures positive for Gram-negative rods with target organisms identification in 195 (88%) blood cultures. Two hundred and five organisms were identified; most commonly E. coli (40%) and K. pneumoniae (21%).Resistance markers were detected in 30 aerobic blood cultures; 28 CTX-M, and 2 KPC. Our institutional guideline provided appropriate empiric coverage in 93% of bacteremia episodes. The most common reason for ineffective therapy was the presence of resistance mechanisms not detected by GenMark® test (e.g. non-CTX-M extended spectrum beta-lactamases). The compliance rate with the guidelines was 55%; the most common reason for non-compliance was the use of an anti-pseudmonal beta-lactams in neutropenic patients.. The system failed to identify panel organisms in only 5 (2%) of blood cultures. Conclusion The institution-specific guidelines providing empiric coverage for each organism identified by rapid diagnostic tests can aid antimicrobial stewardship efforts to de-escalate therapy while still providing effective coverage in &gt;90% of cases. Disclosures All Authors: No reported disclosures.

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