Dataset Information

Safety of antimicrobial de-escalation for culture-negative severe pneumonia.

ABSTRACT:

Purpose

This study investigated the outcomes of antimicrobial de-escalation (ADE) based on mortality and the incidence of multi-drug resistant (MDR) pathogen occurrence in patients with culture-negative pneumonia presenting with sepsis and septic shock.

Materials and methods

We retrospectively analyzed patients diagnosed with severe pneumonia requiring intensive care unit (ICU) admission and possessing negative microbiological culture results at a tertiary referral hospital in South Korea from March 2008 to July 2018.

Results

We identified 107 patients with culture-negative pneumonia. The Acute Physiologic and Chronic Health Evaluation (APACHE) II and Sepsis-related Organ Failure Assessment (SOFA) mean scores were 20.3?±?8.6 and 9.6?±?3.3, respectively. Among the patients, 40 (37.4%) underwent ADE. The APACHE II, SOFA, and follow-up SOFA scores did not differ significantly between the groups, and no differences were found in ICU mortality and MDR pathogen occurrence (27.5% vs 41.8%, P?=?.137 and 15.0% vs 16.9% P?=?.794, respectively).

Conclusions

We observed similar ICU mortality and MDR pathogen occurrence in patients with culture-negative pneumonia presenting with sepsis/shock regardless of whether they received ADE. Additionally, ADE lowered the antimicrobial burden.

SUBMITTER: Byoung Soo K

PROVIDER: S-EPMC7126337 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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Publications

Safety of antimicrobial de-escalation for culture-negative severe pneumonia.

Byoung Soo Kwon K Sang Ho Choi C Younsuck Koh K Jin-Won Huh H Sang-Bum Hong H Chae-Man Lim L

Journal of critical care 20190628

<h4>Purpose</h4>This study investigated the outcomes of antimicrobial de-escalation (ADE) based on mortality and the incidence of multi-drug resistant (MDR) pathogen occurrence in patients with culture-negative pneumonia presenting with sepsis and septic shock.<h4>Materials and methods</h4>We retrospectively analyzed patients diagnosed with severe pneumonia requiring intensive care unit (ICU) admission and possessing negative microbiological culture results at a tertiary referral hospital in Sou ...[more]

PMID: 31319347

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Project description:BACKGROUND:Antibiotics are commonly administered to hospitalized patients with infiltrates for possible bacterial pneumonia, often leading to unnecessary treatment and increasing the risk for resistance emergence. Therefore, we performed a study to determine if an enhanced antibiotic de-escalation practice could improve antibiotic utilization in mechanically ventilated patients with suspected pneumonia cared for in an academic closed intensive care unit (ICU). METHODS:This was a prospective cross-over trial comparing routine antibiotic management (RAM) and enhanced antimicrobial de-escalation (EAD) performed within two medical ICUs (total 34 beds) at Barnes-Jewish Hospital, an academic referral center. Patients in the EAD group had their antibiotic orders and microbiology results reviewed daily by a dedicated team comprised of a second-year critical care fellow, an ICU attending physician and an ICU pharmacist. Antibiotic de-escalation recommendations were made when appropriate based on microbiologic test results and clinical response to therapy. RESULTS:There were 283 patients evaluable, with suspected pneumonia requiring mechanical ventilation: 139 (49.1%) patients in the RAM group and 144 (50.9%) in the EAD group. Early treatment failure based on clinical deterioration occurred in 33 (23.7%) and 40 (27.8%) patients, respectively (P?=?0.438). In the remaining patients, antimicrobial de-escalation occurred in 70 (66.0%) and 70 (67.3%), respectively (P?=?0.845). There was no difference between groups in total antibiotic days ((median (interquartile range)) 7.0 days (4.0, 9.0) versus 7.0 days (4.0, 8.8) (P?=?0.616)); hospital mortality (25.2% versus 35.4% (P?=?0.061)); or hospital duration (12.0 days (6.0, 20.0) versus 11.0 days (6.0, 22.0) (P?=?0.918). CONCLUSIONS:The addition of an EAD program to a high-intensity daytime staffing model already practicing a high-level of antibiotic stewardship in an academic ICU was not associated with greater antibiotic de-escalation or a reduction in the overall duration of antibiotic therapy. TRIAL REGISTRATION:ClinicalTrials.gov, NCT02685930 . Registered on 26 January 2016.

Project description:The present study investigated the clinical effect of antibiotic de-escalation therapy in elderly patients with chronic obstructive pulmonary disease (COPD) complicated with severe pneumonia. According to the parity method of hospitalization number, 86 cases were selected and divided into the observation and control group with 43 cases each. Based on empirical antibiotic application, levofloxacin and cephalosporin antibiotics were used in the control group. After treatment for 3 days, the regimen was adjusted to antibiotics active against Gram-positive (G+) and Gram-negative (G-) bacteria such as the third or fourth generation cephalosporin antibiotics, combined with aminoglycoside, or macrolide antibiotics according to their effects. The treatment effects were re-evaluated after 3-7 days. Finally, broad-spectrum antibiotics such as imipenem were chosen or adjusted by bacterial cultures and drug sensitivity results in the control group. Patients in the observation group were treated according to the principle of antibiotic de-escalation therapy. Antibiotics active against G+ and G- bacteria were chosen as the first round of medication. After 3 days, broad-spectrum antibiotics such as imipenem were added to the treatment regimen. After 7 days, the treatment was changed to narrow spectrum antibiotic administration if the disease was in remission, and the antibiotic regimen was adjusted based on bacterial culture and drug sensitivity results. The treatment results were compared. The mechanical ventilation rate, antibiotic courses, number of antibiotics used, and mortality of the observation group were significantly lower than those in the control group (P<0.05). After treatment, lung function improved, partial pressure of oxygen and blood oxygen saturation increased, and partial pressure of carbon dioxide decreased in both groups. The improvement of all of the above parameters were more significant in the observation group (P<0.05). After treatment, the ratio of neutrophils over white blood cells and C-reactive protein levels of the two groups decreased, respiratory failure index (RFI) increased, and the changes were significantly more pronounced in the observation group (P<0.05). In conclusion, following the antibiotic de-escalation principle to treat older patients with COPD complicated with severe pneumonia can reduce the number of antibiotics required, improve lung function and clinical effects, and is safe and effective.

Project description:BACKGROUND:Minimising antimicrobial overuse is needed to limit antimicrobial resistance. There is little evidence on how often microbiological testing informs antimicrobial de-escalation (e.g. stopping, shortening duration, switching to narrower spectrum or intravenous to oral switch) at 48-72 h "review and revise". We performed a patient level analysis of diagnostic microbiology and antimicrobial prescribing to determine the impact of microbiology results on antimicrobial review outcomes. METHODS:Antimicrobial prescribing data were collected for hospitalised adults from across Brighton and Sussex University Hospitals NHS Trust using routine monthly audits of prescribing practice from July 2016 to April 2017. Microbiology testing data for cultures of blood, urine, sputum and cerebrospinal fluid (CSF) were gathered from the hospital pathology database and linked to prescriptions with matching patient identification codes. Antimicrobial prescriptions were grouped into "prescription episodes" (PEs), defined as one or more antimicrobials prescribed to the same patient for the same indication. Medical records were reviewed for all PEs with positive microbiology and a randomised sample of those with negative results to assess the impact of the microbiology result on the antimicrobial prescription(s). RESULTS:After excluding topical and prophylactic prescriptions, data were available for 382 inpatient antimicrobial prescriptions grouped into 276 prescription episodes. 162/276 (59%) had contemporaneous microbiology sent. After filtering likely contaminants, 33/276 (12%) returned relevant positive results, of which 20/33 (61%) had antimicrobials changed from empiric therapy as a result with 6/33 (18%) prompting de-escalation. Positive blood and CSF tended to have greater impact than urine or sputum cultures. 124/276 (45%) PEs returned only negative microbiology, and this was documented in the medical notes less often (9/40, 23%) than positive results (28/33, 85%). Out of 40 reviewed PEs with negative microbiology, we identified just one (~ 3%) in which antimicrobials were unambiguously de-escalated following the negative result. CONCLUSIONS:The majority of diagnostic microbiology tests sent to inform clinical management yielded negative results. However, negative microbiology contributed little to clinical decision making about antimicrobial de-escalation, perhaps reflecting a lack of trust in negative results by treating clinicians. Improving the negative predictive value of currently available diagnostic microbiology could help hospital prescribers in de-escalating antimicrobial therapy.

Dataset Information

Safety of antimicrobial de-escalation for culture-negative severe pneumonia.

Purpose

Materials and methods

Results

Conclusions

Publications

Safety of antimicrobial de-escalation for culture-negative severe pneumonia.

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