Antimicrobial Stewardship Opportunities in Critically Ill Patients with Gram-Negative Lower Respiratory Tract Infections: A Multicenter Cross-Sectional Analysis

Springer Science and Business Media LLC - Tập 7 - Trang 135-146 - 2017
Kimberly C. Claeys1, Evan J. Zasowski2, Trang D. Trinh2, Abdalhamid M. Lagnf2, Susan L. Davis2, Michael J. Rybak2
1University of Maryland School of Pharmacy, Baltimore, USA
2Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, USA

Tóm tắt

Lower respiratory tract infections (LRTIs) are a major cause of morbidity and death. Because of changes in how LRTIs are defined coupled with the increasing prevalence of drug resistance, there is a gap in knowledge regarding the current burden of antimicrobial use for Centers for Disease Control and Prevention (CDC)-defined LRTIs. We describe the infection characteristics, antibiotic consumption, and clinical and economic outcomes of patients with Gram-negative (GN) LRTIs treated in intensive care units (ICUs). This was a retrospective, observational, cross-sectional study of adult patients treated in ICUs at two large academic medical centers in metropolitan Detroit, Michigan, from October 2013 to October 2015. To meet the inclusion criteria, patients must have had CDC-defined LRTI caused by a GN pathogen during ICU stay. Microbiological assessment of available Pseudomonas aeruginosa isolates included minimum inhibitory concentrations for key antimicrobial agents. Four hundred and seventy-two patients, primarily from the community (346, 73.3%), were treated in medical ICUs (272, 57.6%). Clinically defined pneumonia was common (264, 55.9%). Six hundred and nineteen GN organisms were identified from index respiratory cultures: P. aeruginosa was common (224, 36.2%), with 21.6% of these isolates being multidrug resistant. Cefepime (213, 45.1%) and piperacillin/tazobactam (174, 36.8%) were the most frequent empiric GN therapies. Empiric GN therapy was inappropriate in 44.6% of cases. Lack of in vitro susceptibility (80.1%) was the most common reason for inappropriateness. Patients with inappropriate empiric GN therapy had longer overall stay, which translated to a median total cost of care of $79,800 (interquartile range $48,775 to $129,600) versus $68,000 (interquartile range $38,400 to $116,175), p = 0.013. Clinical failure (31.5% vs 30.0%, p = 0.912) and in-hospital all-cause mortality (26.4% vs 25.9%, p = 0.814) were not different. Drug-resistant pathogens were frequently found and empiric GN therapy was inappropriate in nearly 50% of cases. Inappropriate therapy led to increased lengths of stay and was associated with higher costs of care.

Tài liệu tham khảo

Hall MJ, DeFrances CJ, Williams SN, et al. National Hospital Discharge Survey: 2007 summary. Natl Health Stat Rep. 2010;29:24.

Craven DE, Kunches LM, Kilinsky V, et al. Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis. 1986;133(5):792–6.

Craven DE, Driks MR. Nosocomial pneumonia in the intubated patient. Semin Respir Infect. 1987;2(1):20–33.

Jimenez P, Torres A, Rodriguez-Roisin R, et al. Incidence and etiology of pneumonia acquired during mechanical ventilation. Crit Care Med. 1989;17(9):882–5.

Rello J, Quintana E, Ausina V, et al. Incidence, etiology, and outcome of nosocomial pneumonia in mechanically ventilated patients. Chest. 1991;100(2):439–44.

Craven DE, Steger KA. Nosocomial pneumonia in mechanically ventilated adult patients: epidemiology and prevention in 1996. Semin Respir Infect. 1996;11(1):32–53.

George DL. Epidemiology of nosocomial ventilator-associated pneumonia. Infect Control Hosp Epidemiol. 1993;14(3):163–9.

Safdar N, Dezfulian C, Collard HR, et al. Clinical and economic consequences of ventilator-associated pneumonia: a systematic review. Crit Care Med. 2005;33(10):2184–93.

Hugonnet S, Eggimann P, Borst F, et al. Impact of ventilator-associated pneumonia on resource utilization and patient outcome infection control and hospital epidemiology. Infect Control Hosp Epidemiol. 2004;25(12):1090–6.

Klompas M. Complications of mechanical ventilation — the CDC’s new surveillance paradigm. N Engl J Med. 2013;368(16):1472–5.

Dudeck MA, Horan TC, Peterson KD, et al. National Healthcare Safety Network (NHSN) report, data summary for 2010, device-associated module. Am J Infect Control. 2011;39(10):798–816.

Hussein K, Sprecher H, Mashiach T, et al. Carbapenem resistance among Klebsiella pneumoniae isolates: risk factors, molecular characteristics, and susceptibility patterns. Infect Control Hosp Epidemiol. 2009;30(7):666–71.

Won SY, Munoz-Price LS, Lolans K, et al. Emergence and rapid regional spread of Klebsiella pneumoniae carbapenemase-producing Enterobacteriaceae. Clin Infect Dis. 2011;53(6):532–40.

Patel N, Harrington S, Dihmess A, et al. Clinical epidemiology of carbapenem-intermediate or -resistant Enterobacteriaceae. J Antimicrob Chemother. 2011;66(7):1600–8.

Sader HS, et al. Pseudomonas aeruginosa Antimicrobial Susceptibility Results from Four Years (2012 to 2015) of the International Network for Optimal Resistance Monitoring Program in the United States. Antimicrob Agents Chemother. 2016;60(8):4743–9.

Chia JH, Su LH, Lee MH, et al. Development of high-level carbapenem resistance in Klebsiella pneumoniae among patients with prolonged hospitalization and carbapenem exposure. Microbial Drug Resist. 2010;16(4):317–25.

Centers for Disease Control and Prevention (CDC). November 2015 Update-CRE Toolkit; 2012. https://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf. Accessed Feb 2017.

Fraser A, Paul M, Almanasreh N, et al. Benefit of appropriate empirical antibiotic treatment: thirty-day mortality and duration of hospital stay. Am J Med. 2006;119(11):970–6.

Kollef MH, Sherman G, Ward S, et al. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999;115(2):462–74.

Alvarez-Lerma F, ICU-Acquired Pneumonia Study Group. Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. Intensive Care Med. 1996;22(5):387–94.

Centers for Disease Control and Prevention. CDC/NHSN surveillance definitions for specific types of infections. 2013. http://www.cdc.gov/nhsn/pdfs/pscmanual/17pscnosinfdef_current.pdf Accessed 9 Oct 2016.

Karvouniaris M, Makris D, Manoulakas E, et al. Ventilator-associated tracheobronchitis increases the length of intensive care unit stay. Infect Control Hosp Epidemiol. 2013;34(8):800–8.

Magiorakos AP, Srinivasan A, Carey RB, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect. 2012;18(3):268–81.

Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing; twenty-third informational supplement. CLSI document M100–S23. Wayne, (PA): Clinical and Laboratory Standards Institute; 2013.

American Hospital Association. AHA Annual Survey Database. 2015. https://www.ahadataviewer.com/book-cd-products/AHA-Survey/. Accessed 15 Dec 2016.

American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171(4):388–416.

Boucher HW, Talbot GH, Bradley JS, et al. Bad bugs, no drugs: no ESKAPE! An update from the Infectious Diseases Society of America. Clin Infect Dis. 2009;48(1):1–12.

Food and Drug Administration Center for Drug Evaluation and Research. Guidance for industry—hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia: developing drugs for treatment. 2014. http://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm234907.pdf. Accessed 12 Feb 2017.

Wyrwich KW, Yu H, Sato R, et al. Community-acquired pneumonia: symptoms and burden of illness at diagnosis among US adults aged 50 years and older. Patient. 2013;6(2):125–34.

Kollef MH, Hamilton CW, Ernst FR. Economic impact of ventilator-associated pneumonia in a large matched cohort. Infect Control Hosp Epidemiol. 2012;33(3):250–6.

Restrepo MI, Anzueto A, Arroliga AC, et al. Economic burden of ventilator-associated pneumonia based on total resource utilization. Infect Control Hosp Epidemiol. 2010;31(5):509–15.

Sader HS, Farrell DJ, Flamm RK, et al. Antimicrobial susceptibility of Gram-negative organisms isolated from patients hospitalised with pneumonia in US and European hospitals: results from the SENTRY Antimicrobial Surveillance Program, 2009–2012. Int J Antimicrob Agents. 2014;43(4):328–34.

Tato M, García-Castillo M, Bofarull AM, et al. In vitro activity of ceftolozane/tazobactam against clinical isolates of Pseudomonas aeruginosa and Enterobacteriaceae recovered in Spanish medical centres: results of the CENIT study. Int J Antimicrob Agents. 2015;46(5):502–10.

Farrell DJ, Sader HS, Flamm RK, et al. Ceftolozane/tazobactam activity tested against Gram-negative bacterial isolates from hospitalised patients with pneumonia in US and European medical centres (2012). Int J Antimicrob Agents. 2014;43(6):533–9.

Martin-Loeches I, Torres A, Rinaudo M, et al. Resistance patterns and outcomes in intensive care unit (ICU)-acquired pneumonia. Validation of European Centre for Disease Prevention and Control (ECDC) and the Centers for Disease Control and Prevention (CDC) classification of multidrug resistant organisms. J Infect. 2015;70(3):213–22.

Adrie C, Garrouste-Orgeas M, Ibn Essaied W, et al. Attributable mortality of ICU-acquired bloodstream infections: impact of the source, causative micro-organism, resistance profile and antimicrobial therapy. J Infect. 2017;74(2):131–41.

Nseir S, Martin-Loeches I, Makris D, et al. Impact of appropriate antimicrobial treatment on transition from ventilator-associated tracheobronchitis to ventilator-associated pneumonia. Crit Care. 2014;18(3):R129.

Chin T, Kushner B, Dersch-Mills D, et al. Antibiotic utilization patterns in patients with ventilator-associated pneumonia: a Canadian context. Can J Infect Dis Med Microbiol 2006;2006:3702625.

Cheng WL, Hsueh PR, Lee CC, et al. Bacteremic pneumonia caused by extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae: appropriateness of empirical treatment matters. J Microbiol Immunol Infect. 2016;49(2):208–15.

Park SY, Park HJ, Moon SM, et al. Impact of adequate empirical combination therapy on mortality from bacteremic Pseudomonas aeruginosa pneumonia. BMC Infect Dis. 2012;12:308.

Joung MK, Kwon KT, Kang CI, et al. Impact of inappropriate antimicrobial therapy on outcome in patients with hospital-acquired pneumonia caused by Acinetobacter baumannii. J Infect. 2010;61(3):212–8.

Stevens V, Dumyati G, Fine LS, et al. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis. 2011;53(1):42–8.

Zilahi G, McMahon MA, Povoa P, et al. Duration of antibiotic therapy in the intensive care unit. J Thorac Dis. 2016;8(12):3774–80.

Chastre J, Wolff M, Fagon JY, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA. 2003;290(19):2588–98.

Pugh R, Grant C, Cooke RP, et al. Short-course versus prolonged-course antibiotic therapy for hospital-acquired pneumonia in critically ill adults. Cochrane Database Syst Rev. 2015;24(8):CD007577.

Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):e61–111.

Klompas M, Berra L. Should ventilator-associated events become a quality indicator for ICUs? Respir Care. 2016;61(6):723–36.

Chang HC, Chen CM, Kung SC, et al. Differences between novel and conventional surveillance paradigms of ventilator-associated pneumonia. Am J Infect Control. 2015;43(2):133–6.

Chalmers JD, Rother C, Salih W, et al. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis. 2014;58(3):330–9.

Kalil AC, Metersky ML, Klompas M, et al. Executive summary: management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63(5):575–82.

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Springer Science and Business Media LLC

Tập 7

135-146

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