Jeroen Schouten - Academia.edu (original) (raw)
Papers by Jeroen Schouten
The Lancet. Infectious diseases, Jan 2, 2016
Antimicrobial stewardship is advocated to improve the quality of antimicrobial use. We did a syst... more Antimicrobial stewardship is advocated to improve the quality of antimicrobial use. We did a systematic review and meta-analysis to assess whether antimicrobial stewardship objectives had any effects in hospitals and long-term care facilities on four predefined patients' outcomes: clinical outcomes, adverse events, costs, and bacterial resistance rates. We identified 14 stewardship objectives and did a separate systematic search for articles relating to each one in Embase, Ovid MEDLINE, and PubMed. Studies were included if they reported data on any of the four predefined outcomes in patients in whom the specific antimicrobial stewardship objective was assessed and compared the findings in patients in whom the objective was or was not met. We used a random-effects model to calculate relative risk reductions with relative risks and 95% CIs. We identified 145 unique studies with data on nine stewardship objectives. Overall, the quality of evidence was generally low and heterogeneit...
Clinical pharmacokinetics, Jan 9, 2015
Caspofungin is an echinocandin antifungal agent used as first-line therapy for the treatment of i... more Caspofungin is an echinocandin antifungal agent used as first-line therapy for the treatment of invasive candidiasis. The maintenance dose is adapted to body weight (BW) or liver function (Child-Pugh score B or C). We aimed to study the pharmacokinetics of caspofungin and assess pharmacokinetic target attainment for various dosing strategies. Caspofungin pharmacokinetic data from 21 intensive care unit (ICU) patients was available. A population pharmacokinetic model was developed. Various dosing regimens (loading dose/maintenance dose) were simulated: licensed regimens (I) 70/50 mg (for BW <80 kg) or 70/70 mg (for BW >80 kg); and (II) 70/35 mg (for Child-Pugh score B); and adapted regimens (III) 100/50 mg (for Child-Pugh score B); (IV) 100/70 mg; and (V) 100/100 mg. Target attainment based on a preclinical pharmacokinetic target for Candida albicans was assessed for relevant minimal inhibitory concentrations (MICs). A two-compartment model best fitted the data. Clearance was 0...
Antimicrobial Agents and Chemotherapy, 2015
count: 250 words / Word count: 3.111 words 23 ABSTRACT (250/250 words) 30 Purpose: Micafungin is ... more count: 250 words / Word count: 3.111 words 23 ABSTRACT (250/250 words) 30 Purpose: Micafungin is considered an important agent for the treatment of invasive fungal infections in the 31 Intensive Care Unit (ICU). Little is known on the pharmacokinetics of micafungin. We investigated micafungin 32 pharmacokinetics (PK) in ICU patients and set out to explore parameters of influence on micafungin plasma 33 concentrations.
The Netherlands journal of medicine, 2012
The Dutch Working Party on Antibiotic Policy (SWAB) and the Dutch Association of Chest Physicians... more The Dutch Working Party on Antibiotic Policy (SWAB) and the Dutch Association of Chest Physicians (NVALT) convened a joint committee to develop evidence-based guidelines on the diagnosis and treatment of community acquired pneumonia (CAP). The guidelines are intended for adult patients with CAP who present at the hospital and are treated as outpatients as well as for hospitalised patients up to 72 hours after admission. Areas covered include current patterns of epidemiology and antibiotic resistance of causative agents of CAP in the Netherlands, the possibility to predict the causative agent of CAP on the basis of clinical data at first presentation, risk factors associated with specific pathogens, the importance of the severity of disease upon presentation for choice of initial treatment, the role of rapid diagnostic tests in treatment decisions, the optimal initial empiric treatment and treatment when a specific pathogen has been identified, the timeframe in which the first dose o...
Stroke; a journal of cerebral circulation, 2007
The Netherlands journal of medicine, 2007
Clinical indicators give an indication of the quality of the patient care delivered. They must co... more Clinical indicators give an indication of the quality of the patient care delivered. They must comply with highquality standards and should be constructed in a careful and transparent manner. Indicators must be relevant to the important aspects of quality of care. There should be adequate research evidence that the recommendations from which they are derived are related to clinical effectiveness, safety and efficiency. They should measure the quality in a valid and reliable manner with little inter- and intra-observer variability so that they are suitable for comparisons between professionals, practices, and institutions. Indicators are selected from research data with consideration for optimal patient care (preferably an evidence-based guideline), supplemented by expert opinion. In the selection procedure, the feasibility, such as their measurability and improvability, is important beside validity and reliability. A clinical indicator should be defined exactly and expressed as a qu...
![Research paper thumbnail of [Optimizing the antibiotics policy in The Netherlands. VIII. Revised SWAB guidelines for antimicrobial therapy in adults with community-acquired pneumonia]](https://attachments.academia-assets.com/44790967/thumbnails/1.jpg)
](Nederlands tijdschrift voor geneeskunde, Jan 5, 2005
The Dutch Working Party on Antibiotic Policy (SWAB) has revised the 1998 guideline for community-... more The Dutch Working Party on Antibiotic Policy (SWAB) has revised the 1998 guideline for community-acquired pneumonia (CAP) in light of changing resistance patterns for common pathogens and new developments in epidemiology, diagnostic testing and treatment strategies. The current guideline is applicable to both primary and inpatient care, and has been developed by delegates of all professional organisations involved in the treatment of CAP, following recommendations for evidence-based guideline development. Assessment of a patient's 'severity of illness' at presentation is considered important when choosing an optimal empirical antibiotic regimen for CAP. Severely-ill patients should be treated with antibiotics covering the most important expected pathogens, including Legionella. Assessment of the severity of illness may be facilitated by the use of validated scoring systems like the pneumonia severity index and the 'confusion, urea, respiratory-rate, blood-pressure, 6...
The Netherlands journal of medicine, 2005
The Dutch Working Party on Antibiotic Policy (SWAB) develops evidence-based guidelines, aimed at ... more The Dutch Working Party on Antibiotic Policy (SWAB) develops evidence-based guidelines, aimed at optimalisation of antibiotic use and limitation of the spread of antimicrobial resistance. A revision of the SWAB guideline for the treatment of community-acquired pneumonia (CAP), published in 1998, was considered necessary because of changes in resistance patterns and new insights into the epidemiology, diagnostics and treatment of CAP. In contrast to the former version, this guideline is transmural and has been drawn up according to the recommendations for evidence-based guideline development by a multidisciplinary committee consisting of experts from all relevant professional societies. The 'severity of disease' exhibited by the patient with pneumonia on admission is considered important for the choice of the optimum empirical treatment strategy. Severely ill patients are treated empirically with a drug directed against multiple potential pathogens, including Legionella spp. ...
The Netherlands journal of medicine, 2005
Control measures for the use of antibiotics are essential because of the potential harmful conseq... more Control measures for the use of antibiotics are essential because of the potential harmful consequences of side effects. Various methods have been developed to help curb undesirable antibiotic prescription. We performed a survey in Dutch secondary care hospitals (response rate 73%) to make an inventory of these measures and elucidate possible shortcomings. Almost every hospital was using an antibiotic formulary (97%), sometimes supported by extra restrictions in antibiotic choice (55%). Local practice guidelines (95%) were commonly present, but effective implementation, for example using intranet applications, could be improved (21%). National guidelines had received little attention in the composition process of local guidelines (19%). Other measures such as educational programmes for specialists (11%) and feedback on antibiotic prescription (52%) remained largely underused, although their effective implementation may optimise antibiotic prescription in hospitals.
Journal of Antimicrobial Chemotherapy, 2014
Caspofungin is used for treatment of invasive fungal infections. As the pharmacokinetics (PK) of ... more Caspofungin is used for treatment of invasive fungal infections. As the pharmacokinetics (PK) of antimicrobial agents in critically ill patients can be highly variable, we set out to explore caspofungin PK in ICU patients. ICU patients receiving caspofungin were eligible. Patients received a loading dose of 70 mg followed by 50 mg daily (70 mg if body weight &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;80 kg); they were evaluable upon completion of the first PK curve at day 3. Additionally, daily trough samples were taken and a second PK curve was recorded at day 7. PK analysis was performed using a standard two-stage approach. Twenty-one patients were evaluable. Median (range) age and body weight were 71 (45-80) years and 75 (50-99) kg. PK sampling on day 3 (n = 21) resulted in the following median (IQR) parameters: AUC0-24 88.7 (72.2-97.5) mg·h/L; Cmin 2.15 (1.40-2.48) mg/L; Cmax 7.51 (6.05-8.17) mg/L; V 7.72 (6.12-9.01) L; and CL 0.57 (0.54-0.77) L/h. PK sampling on day 7 (n = 13) resulted in AUC0-24 107.2 (90.4-125.3) mg·h/L, Cmin 2.55 (1.82-3.08) mg/L, Cmax 8.65 (7.16-9.34) mg/L, V 7.03 (5.51-7.73) L and CL 0.54 (0.44-0.60) L/h. We did not identify any covariates significantly affecting caspofungin PK in ICU patients (e.g. body weight, albumin, liver function). Caspofungin was well tolerated and no unexpected side effects were observed. Caspofungin PK in ICU patients showed limited intraindividual and moderate interindividual variability, and caspofungin was well tolerated. A standard two-stage approach did not reveal significant covariates. Our study showed similar caspofungin PK parameters in ICU patients compared with non-critically ill patients.
International Journal of Nursing Studies, 2014
Quality and Safety in Health Care, 2007
Background: Physician adherence to key recommendations of guidelines for community-acquired pneum... more Background: Physician adherence to key recommendations of guidelines for community-acquired pneumonia (CAP) is often not optimal. A better understanding of factors influencing optimal performance is needed to plan effective change. Methods: The authors used semistructured interviews with care providers in three Dutch medium-sized hospitals to qualitatively study and understand barriers to appropriate antibiotic use in patients with CAP. They discussed recommendations about the prescription of empirical antibiotic therapy that adheres to the guidelines, timely administration of antibiotics, adjusting antibiotic dosage to accommodate decreased renal function, switching and streamlining therapy, and blood and sputum culturing. The authors then classified the barriers each recommendation faced into categories using a conceptual framework (Cabana). Results: Eighteen interviews were performed with residents and specialists in pulmonology and internal medicine, with medical microbiologists and a clinical pharmacist. Two additional multidisciplinary small group interviews which included nurses were performed. Each guideline recommendation elicited a different type of barrier. Regarding the choice of guideline-adherent empirical therapy, treating physicians said that they worried about patient outcome when prescribing narrow-spectrum antibiotic therapy. Regarding the timeliness of antibiotic administration, barriers such as conflicting guidelines and organisational factors (for example, delayed laboratory results, antibiotics not directly available, lack of time) were reported. Not streamlining therapy after culture results became available was thought to be due to the physicians' attitude of ''never change a winning team''. Conclusions: Efforts to improve the use of antibiotics for patients with CAP should consider the range of barriers that care providers face. Each recommendation meets its own barriers. Interventions to improve adherence should be tailored to these factors.
Journal of Antimicrobial Chemotherapy, 2005
Objectives: To develop effective and targeted interventions to improve care for patients with com... more Objectives: To develop effective and targeted interventions to improve care for patients with communityacquired pneumonia (CAP), insight is needed into the factors that influence the quality of antibiotic use. Therefore, we measured the performance of nine quality indicators and studied determinants of variation in the quality of antibiotic use.
Journal of Antimicrobial Chemotherapy, 2014
Objectives: In blood culture-proven pneumococcal infections, streamlining empirical therapy to mo... more Objectives: In blood culture-proven pneumococcal infections, streamlining empirical therapy to monotherapy with a penicillin is preferred in order to reduce the use of broad-spectrum antibiotics. However, adherence to this international recommendation is poor, and curiously it is unclear whether antibiotic streamlining may be harmful to individual patients. We investigated whether streamlining in bacteraemic pneumococcal infections is associated with mortality.
Critical Care, 2012
Introduction: To evaluate whether alkaline phosphatase (AP) treatment improves renal function in ... more Introduction: To evaluate whether alkaline phosphatase (AP) treatment improves renal function in sepsis-induced acute kidney injury (AKI), a prospective, double-blind, randomized, placebo-controlled study in critically ill patients with severe sepsis or septic shock with evidence of AKI was performed.
Clinical Toxicology, 2012
Context . Acute intoxications are frequently seen in Dutch hospitals. Based on single-centre stud... more Context . Acute intoxications are frequently seen in Dutch hospitals. Based on single-centre studies and the fact that there are no clear guidelines, we hypothesised that hospital admission of acute intoxications may vary. Furthermore, decontamination treatment of poisonings may differ between hospitals, as earlier studies showed that adherence to international guidelines concerning decontamination may be poor. Objective . We aim to identify possible variations in Dutch hospital admission and decontamination treatment of patients with acute intoxications. Materials and methods . Data on acute intoxications was retrospectively collected from patient records from the emergency departments of six Dutch hospitals. All patients older than 14 years who presented between 1 January 2008 and 31 December 2008 were included in the study. Results . The percentage of suicide attempts differed signifi cantly between the hospitals (25 -73%, p Ͻ 0.0001) as equally the percentage of intoxications with drugs of abuse (18 -61%, p Ͻ 0.0001). Marked differences in admission rates were found (27 -78%, p Ͻ 0.0001) and these differences remained even when intoxications because of suicide attempts and drugs of abuse were analysed separately (admission rate of 52 -87%, p Ͻ 0.0001 and 8 -71%, p Ͻ 0.0001 respectively). Reported consultation with the National Poisons Information Centre differed between hospitals (range 0% to 80 -100%). No statistical differences were found between hospitals for the use of activated charcoal (16.1 -42.5%, p = 0.037). Gastric lavage was used infrequently in all hospitals. (6.6 -16.7%, p = 0.614). Discussion and conclusion . The admission rate of patients with an acute intoxication varies considerably, especially in the case of intoxications with drugs of abuse. Consultations with the National Poisons Information Centre differed between the six hospitals. Rates of decontamination did not vary, which may indicate adherence to guidelines by the American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists. National guidelines or admission algorithms may reduce variations in poisoning management and make the care for these patients more effi cient.
Clinical Infectious Diseases, 2007
Limited data exist on the most effective approach to increase the quality of antibiotic use for l... more Limited data exist on the most effective approach to increase the quality of antibiotic use for lower respiratory tract infections at hospitals. One thousand nine hundred six patients with community-acquired pneumonia or an exacerbation of chronic obstructive pulmonary disease (acute exacerbation of chronic bronchitis) were included in a cluster-randomized, controlled trial at 6 medium-to-large Dutch hospitals. A multifaceted guideline-implementation strategy that was tailored to baseline performance and considered the barriers in the target group was used. Principal outcome measures were (1) guideline-adherent antibiotic prescription, (2) adaptation of dose and dose interval of antibiotics according to renal function, (3) switches in therapy, (4) streamlining of therapy, and (5) Gram staining and culture of sputum samples. Secondary process outcomes were applicable to community-acquired pneumonia (e.g., timely administration of antibiotics) or acute exacerbation of chronic bronchitis (e.g., not prescribing macrolides). The rate of guideline-adherent antibiotic prescription increased from 50.3% to 64.3% in the intervention hospitals (odds ratio [OR], 2.63; 95% confidence interval [CI], 1.57-4.42; P=.0008). The rate of adaptation of antibiotic dose according to renal function increased from 79.4% to 95.1% in the intervention hospitals (OR, 7.32; 95% CI, 2.09-25.7; P=.02). The switch from intravenous to oral therapy improved more in the control hospitals (from 53.3% to 71.9%) than in the intervention hospitals (from 74% to 83.6%). The change from broad-spectrum empirical therapy to pathogen-directed therapy improved by 5.7% in the intervention hospitals (P = not significant). Fewer sputum samples were obtained from both the intervention group (rate of sputum samples obtained decreased from 55.8% to 53.1%) and the control group (rate of sputum samples obtained decreased from 49.6% to 42.7%). Timely administration of antibiotics for community-acquired pneumonia increased significantly in the intervention group (from 55.2% to 62.9%; OR, 2.49; 95% CI, 1.11-5.57; P=.026). With regard to some important aspects, tailoring interventions to change antibiotic use improved the quality of treatment for patients hospitalized with lower respiratory tract infection.
Clinical Infectious Diseases, 2005
To assess and improve the quality of antibiotic use in patients with community-acquired pneumonia... more To assess and improve the quality of antibiotic use in patients with community-acquired pneumonia (CAP) and acute exacerbation of chronic bronchitis or chronic obstructive pulmonary disease (AECB), a valid set of quality indicators is required. This set should also be applicable in practice. Guidelines and literature were reviewed to derive potential indicators for quality of antibiotic use in treating hospitalized patients with lower respiratory tract infection (LRTI). To assess the evidence base of each indicator, a literature review was performed. Grade A recommendations were considered valid. For grade B-D recommendations, an expert panel performed a consensus procedure on the indicator&amp;#39;s relevance to patient health, reduction of antimicrobial resistance, and cost containment. To test applicability in practice, feasibility, opportunity for improvement, reliability, and case-mix stability were determined for a data set of 899 hospitalized patients with LRTI. None of the potential indicators from guidelines and literature were supported by grade A evidence. Nineteen indicators were selected by consensus procedure (12 indicators for CAP and 7 indicators for AECB). Lack of feasibility and of opportunity for improvement led to the exclusion of 4 indicators. A final set of 15 indicators was defined (9 indicators for CAP and 6 indicators for AECB). A valid set of quality indicators for antibiotic use in hospitalized patients with LRTI was developed by combining evidence and expert opinion in a carefully planned procedure. Subjecting indicators to an applicability test is essential before using them in quality-improvement projects. In our demonstration setting, 4 of the 19 indicators were inapplicable in practice.
Clinical Infectious Diseases, 2008
Appropriateness of antibiotic treatment of urinary tract infection (UTI) is important. The aim of... more Appropriateness of antibiotic treatment of urinary tract infection (UTI) is important. The aim of this study was to develop a set of valid, reliable, and applicable indicators to assess the quality of antibiotic use in the treatment of hospitalized patients with complicated UTI. A multidisciplinary panel of 13 experts reviewed and prioritized recommendations extracted from a recently developed evidence-based national guideline for the treatment of complicated UTI. The content validity was assessed in 2 consecutive rounds with an in-between discussion meeting. Next, we tested the feasibility, interobserver reliability, opportunity for improvement, and case-mix stability of the potential indicators for a data set of 341 inpatients and outpatients with complicated UTIs who were treated at the urology or internal medicine departments at 4 hospitals. The panel selected and prioritized 13 indicators. Four and 9 indicators were performed satisfactorily in the urology and internal medicine departments, as follows: performance of urine culture, prescription of treatment in accordance with guidelines, tailoring of treatment on the basis of culture results, and a switch to oral treatment when possible in the urology and internal medicine departments; and selective use of fluoroquinolones, administration of treatment for at least 10 days, prescription of treatment for men in accordance with guidelines, replacement of catheters in patients with UTI, and adaptation of the dosage on the basis of renal function in the internal medicine department. A systemic evidence- and consensus-based approach was used to develop a set of valid quality indicators. Tests of the applicability of these indicators in practice in different settings is essential before they are used in quality-improvement strategies.
The Lancet. Infectious diseases, Jan 2, 2016
Antimicrobial stewardship is advocated to improve the quality of antimicrobial use. We did a syst... more Antimicrobial stewardship is advocated to improve the quality of antimicrobial use. We did a systematic review and meta-analysis to assess whether antimicrobial stewardship objectives had any effects in hospitals and long-term care facilities on four predefined patients' outcomes: clinical outcomes, adverse events, costs, and bacterial resistance rates. We identified 14 stewardship objectives and did a separate systematic search for articles relating to each one in Embase, Ovid MEDLINE, and PubMed. Studies were included if they reported data on any of the four predefined outcomes in patients in whom the specific antimicrobial stewardship objective was assessed and compared the findings in patients in whom the objective was or was not met. We used a random-effects model to calculate relative risk reductions with relative risks and 95% CIs. We identified 145 unique studies with data on nine stewardship objectives. Overall, the quality of evidence was generally low and heterogeneit...
Clinical pharmacokinetics, Jan 9, 2015
Caspofungin is an echinocandin antifungal agent used as first-line therapy for the treatment of i... more Caspofungin is an echinocandin antifungal agent used as first-line therapy for the treatment of invasive candidiasis. The maintenance dose is adapted to body weight (BW) or liver function (Child-Pugh score B or C). We aimed to study the pharmacokinetics of caspofungin and assess pharmacokinetic target attainment for various dosing strategies. Caspofungin pharmacokinetic data from 21 intensive care unit (ICU) patients was available. A population pharmacokinetic model was developed. Various dosing regimens (loading dose/maintenance dose) were simulated: licensed regimens (I) 70/50 mg (for BW <80 kg) or 70/70 mg (for BW >80 kg); and (II) 70/35 mg (for Child-Pugh score B); and adapted regimens (III) 100/50 mg (for Child-Pugh score B); (IV) 100/70 mg; and (V) 100/100 mg. Target attainment based on a preclinical pharmacokinetic target for Candida albicans was assessed for relevant minimal inhibitory concentrations (MICs). A two-compartment model best fitted the data. Clearance was 0...
Antimicrobial Agents and Chemotherapy, 2015
count: 250 words / Word count: 3.111 words 23 ABSTRACT (250/250 words) 30 Purpose: Micafungin is ... more count: 250 words / Word count: 3.111 words 23 ABSTRACT (250/250 words) 30 Purpose: Micafungin is considered an important agent for the treatment of invasive fungal infections in the 31 Intensive Care Unit (ICU). Little is known on the pharmacokinetics of micafungin. We investigated micafungin 32 pharmacokinetics (PK) in ICU patients and set out to explore parameters of influence on micafungin plasma 33 concentrations.
The Netherlands journal of medicine, 2012
The Dutch Working Party on Antibiotic Policy (SWAB) and the Dutch Association of Chest Physicians... more The Dutch Working Party on Antibiotic Policy (SWAB) and the Dutch Association of Chest Physicians (NVALT) convened a joint committee to develop evidence-based guidelines on the diagnosis and treatment of community acquired pneumonia (CAP). The guidelines are intended for adult patients with CAP who present at the hospital and are treated as outpatients as well as for hospitalised patients up to 72 hours after admission. Areas covered include current patterns of epidemiology and antibiotic resistance of causative agents of CAP in the Netherlands, the possibility to predict the causative agent of CAP on the basis of clinical data at first presentation, risk factors associated with specific pathogens, the importance of the severity of disease upon presentation for choice of initial treatment, the role of rapid diagnostic tests in treatment decisions, the optimal initial empiric treatment and treatment when a specific pathogen has been identified, the timeframe in which the first dose o...
Stroke; a journal of cerebral circulation, 2007
The Netherlands journal of medicine, 2007
Clinical indicators give an indication of the quality of the patient care delivered. They must co... more Clinical indicators give an indication of the quality of the patient care delivered. They must comply with highquality standards and should be constructed in a careful and transparent manner. Indicators must be relevant to the important aspects of quality of care. There should be adequate research evidence that the recommendations from which they are derived are related to clinical effectiveness, safety and efficiency. They should measure the quality in a valid and reliable manner with little inter- and intra-observer variability so that they are suitable for comparisons between professionals, practices, and institutions. Indicators are selected from research data with consideration for optimal patient care (preferably an evidence-based guideline), supplemented by expert opinion. In the selection procedure, the feasibility, such as their measurability and improvability, is important beside validity and reliability. A clinical indicator should be defined exactly and expressed as a qu...
Nederlands tijdschrift voor geneeskunde, Jan 5, 2005
The Dutch Working Party on Antibiotic Policy (SWAB) has revised the 1998 guideline for community-... more The Dutch Working Party on Antibiotic Policy (SWAB) has revised the 1998 guideline for community-acquired pneumonia (CAP) in light of changing resistance patterns for common pathogens and new developments in epidemiology, diagnostic testing and treatment strategies. The current guideline is applicable to both primary and inpatient care, and has been developed by delegates of all professional organisations involved in the treatment of CAP, following recommendations for evidence-based guideline development. Assessment of a patient's 'severity of illness' at presentation is considered important when choosing an optimal empirical antibiotic regimen for CAP. Severely-ill patients should be treated with antibiotics covering the most important expected pathogens, including Legionella. Assessment of the severity of illness may be facilitated by the use of validated scoring systems like the pneumonia severity index and the 'confusion, urea, respiratory-rate, blood-pressure, 6...
The Netherlands journal of medicine, 2005
The Dutch Working Party on Antibiotic Policy (SWAB) develops evidence-based guidelines, aimed at ... more The Dutch Working Party on Antibiotic Policy (SWAB) develops evidence-based guidelines, aimed at optimalisation of antibiotic use and limitation of the spread of antimicrobial resistance. A revision of the SWAB guideline for the treatment of community-acquired pneumonia (CAP), published in 1998, was considered necessary because of changes in resistance patterns and new insights into the epidemiology, diagnostics and treatment of CAP. In contrast to the former version, this guideline is transmural and has been drawn up according to the recommendations for evidence-based guideline development by a multidisciplinary committee consisting of experts from all relevant professional societies. The 'severity of disease' exhibited by the patient with pneumonia on admission is considered important for the choice of the optimum empirical treatment strategy. Severely ill patients are treated empirically with a drug directed against multiple potential pathogens, including Legionella spp. ...
The Netherlands journal of medicine, 2005
Control measures for the use of antibiotics are essential because of the potential harmful conseq... more Control measures for the use of antibiotics are essential because of the potential harmful consequences of side effects. Various methods have been developed to help curb undesirable antibiotic prescription. We performed a survey in Dutch secondary care hospitals (response rate 73%) to make an inventory of these measures and elucidate possible shortcomings. Almost every hospital was using an antibiotic formulary (97%), sometimes supported by extra restrictions in antibiotic choice (55%). Local practice guidelines (95%) were commonly present, but effective implementation, for example using intranet applications, could be improved (21%). National guidelines had received little attention in the composition process of local guidelines (19%). Other measures such as educational programmes for specialists (11%) and feedback on antibiotic prescription (52%) remained largely underused, although their effective implementation may optimise antibiotic prescription in hospitals.
Journal of Antimicrobial Chemotherapy, 2014
Caspofungin is used for treatment of invasive fungal infections. As the pharmacokinetics (PK) of ... more Caspofungin is used for treatment of invasive fungal infections. As the pharmacokinetics (PK) of antimicrobial agents in critically ill patients can be highly variable, we set out to explore caspofungin PK in ICU patients. ICU patients receiving caspofungin were eligible. Patients received a loading dose of 70 mg followed by 50 mg daily (70 mg if body weight &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;80 kg); they were evaluable upon completion of the first PK curve at day 3. Additionally, daily trough samples were taken and a second PK curve was recorded at day 7. PK analysis was performed using a standard two-stage approach. Twenty-one patients were evaluable. Median (range) age and body weight were 71 (45-80) years and 75 (50-99) kg. PK sampling on day 3 (n = 21) resulted in the following median (IQR) parameters: AUC0-24 88.7 (72.2-97.5) mg·h/L; Cmin 2.15 (1.40-2.48) mg/L; Cmax 7.51 (6.05-8.17) mg/L; V 7.72 (6.12-9.01) L; and CL 0.57 (0.54-0.77) L/h. PK sampling on day 7 (n = 13) resulted in AUC0-24 107.2 (90.4-125.3) mg·h/L, Cmin 2.55 (1.82-3.08) mg/L, Cmax 8.65 (7.16-9.34) mg/L, V 7.03 (5.51-7.73) L and CL 0.54 (0.44-0.60) L/h. We did not identify any covariates significantly affecting caspofungin PK in ICU patients (e.g. body weight, albumin, liver function). Caspofungin was well tolerated and no unexpected side effects were observed. Caspofungin PK in ICU patients showed limited intraindividual and moderate interindividual variability, and caspofungin was well tolerated. A standard two-stage approach did not reveal significant covariates. Our study showed similar caspofungin PK parameters in ICU patients compared with non-critically ill patients.
International Journal of Nursing Studies, 2014
Quality and Safety in Health Care, 2007
Background: Physician adherence to key recommendations of guidelines for community-acquired pneum... more Background: Physician adherence to key recommendations of guidelines for community-acquired pneumonia (CAP) is often not optimal. A better understanding of factors influencing optimal performance is needed to plan effective change. Methods: The authors used semistructured interviews with care providers in three Dutch medium-sized hospitals to qualitatively study and understand barriers to appropriate antibiotic use in patients with CAP. They discussed recommendations about the prescription of empirical antibiotic therapy that adheres to the guidelines, timely administration of antibiotics, adjusting antibiotic dosage to accommodate decreased renal function, switching and streamlining therapy, and blood and sputum culturing. The authors then classified the barriers each recommendation faced into categories using a conceptual framework (Cabana). Results: Eighteen interviews were performed with residents and specialists in pulmonology and internal medicine, with medical microbiologists and a clinical pharmacist. Two additional multidisciplinary small group interviews which included nurses were performed. Each guideline recommendation elicited a different type of barrier. Regarding the choice of guideline-adherent empirical therapy, treating physicians said that they worried about patient outcome when prescribing narrow-spectrum antibiotic therapy. Regarding the timeliness of antibiotic administration, barriers such as conflicting guidelines and organisational factors (for example, delayed laboratory results, antibiotics not directly available, lack of time) were reported. Not streamlining therapy after culture results became available was thought to be due to the physicians' attitude of ''never change a winning team''. Conclusions: Efforts to improve the use of antibiotics for patients with CAP should consider the range of barriers that care providers face. Each recommendation meets its own barriers. Interventions to improve adherence should be tailored to these factors.
Journal of Antimicrobial Chemotherapy, 2005
Objectives: To develop effective and targeted interventions to improve care for patients with com... more Objectives: To develop effective and targeted interventions to improve care for patients with communityacquired pneumonia (CAP), insight is needed into the factors that influence the quality of antibiotic use. Therefore, we measured the performance of nine quality indicators and studied determinants of variation in the quality of antibiotic use.
Journal of Antimicrobial Chemotherapy, 2014
Objectives: In blood culture-proven pneumococcal infections, streamlining empirical therapy to mo... more Objectives: In blood culture-proven pneumococcal infections, streamlining empirical therapy to monotherapy with a penicillin is preferred in order to reduce the use of broad-spectrum antibiotics. However, adherence to this international recommendation is poor, and curiously it is unclear whether antibiotic streamlining may be harmful to individual patients. We investigated whether streamlining in bacteraemic pneumococcal infections is associated with mortality.
Critical Care, 2012
Introduction: To evaluate whether alkaline phosphatase (AP) treatment improves renal function in ... more Introduction: To evaluate whether alkaline phosphatase (AP) treatment improves renal function in sepsis-induced acute kidney injury (AKI), a prospective, double-blind, randomized, placebo-controlled study in critically ill patients with severe sepsis or septic shock with evidence of AKI was performed.
Clinical Toxicology, 2012
Context . Acute intoxications are frequently seen in Dutch hospitals. Based on single-centre stud... more Context . Acute intoxications are frequently seen in Dutch hospitals. Based on single-centre studies and the fact that there are no clear guidelines, we hypothesised that hospital admission of acute intoxications may vary. Furthermore, decontamination treatment of poisonings may differ between hospitals, as earlier studies showed that adherence to international guidelines concerning decontamination may be poor. Objective . We aim to identify possible variations in Dutch hospital admission and decontamination treatment of patients with acute intoxications. Materials and methods . Data on acute intoxications was retrospectively collected from patient records from the emergency departments of six Dutch hospitals. All patients older than 14 years who presented between 1 January 2008 and 31 December 2008 were included in the study. Results . The percentage of suicide attempts differed signifi cantly between the hospitals (25 -73%, p Ͻ 0.0001) as equally the percentage of intoxications with drugs of abuse (18 -61%, p Ͻ 0.0001). Marked differences in admission rates were found (27 -78%, p Ͻ 0.0001) and these differences remained even when intoxications because of suicide attempts and drugs of abuse were analysed separately (admission rate of 52 -87%, p Ͻ 0.0001 and 8 -71%, p Ͻ 0.0001 respectively). Reported consultation with the National Poisons Information Centre differed between hospitals (range 0% to 80 -100%). No statistical differences were found between hospitals for the use of activated charcoal (16.1 -42.5%, p = 0.037). Gastric lavage was used infrequently in all hospitals. (6.6 -16.7%, p = 0.614). Discussion and conclusion . The admission rate of patients with an acute intoxication varies considerably, especially in the case of intoxications with drugs of abuse. Consultations with the National Poisons Information Centre differed between the six hospitals. Rates of decontamination did not vary, which may indicate adherence to guidelines by the American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists. National guidelines or admission algorithms may reduce variations in poisoning management and make the care for these patients more effi cient.
Clinical Infectious Diseases, 2007
Limited data exist on the most effective approach to increase the quality of antibiotic use for l... more Limited data exist on the most effective approach to increase the quality of antibiotic use for lower respiratory tract infections at hospitals. One thousand nine hundred six patients with community-acquired pneumonia or an exacerbation of chronic obstructive pulmonary disease (acute exacerbation of chronic bronchitis) were included in a cluster-randomized, controlled trial at 6 medium-to-large Dutch hospitals. A multifaceted guideline-implementation strategy that was tailored to baseline performance and considered the barriers in the target group was used. Principal outcome measures were (1) guideline-adherent antibiotic prescription, (2) adaptation of dose and dose interval of antibiotics according to renal function, (3) switches in therapy, (4) streamlining of therapy, and (5) Gram staining and culture of sputum samples. Secondary process outcomes were applicable to community-acquired pneumonia (e.g., timely administration of antibiotics) or acute exacerbation of chronic bronchitis (e.g., not prescribing macrolides). The rate of guideline-adherent antibiotic prescription increased from 50.3% to 64.3% in the intervention hospitals (odds ratio [OR], 2.63; 95% confidence interval [CI], 1.57-4.42; P=.0008). The rate of adaptation of antibiotic dose according to renal function increased from 79.4% to 95.1% in the intervention hospitals (OR, 7.32; 95% CI, 2.09-25.7; P=.02). The switch from intravenous to oral therapy improved more in the control hospitals (from 53.3% to 71.9%) than in the intervention hospitals (from 74% to 83.6%). The change from broad-spectrum empirical therapy to pathogen-directed therapy improved by 5.7% in the intervention hospitals (P = not significant). Fewer sputum samples were obtained from both the intervention group (rate of sputum samples obtained decreased from 55.8% to 53.1%) and the control group (rate of sputum samples obtained decreased from 49.6% to 42.7%). Timely administration of antibiotics for community-acquired pneumonia increased significantly in the intervention group (from 55.2% to 62.9%; OR, 2.49; 95% CI, 1.11-5.57; P=.026). With regard to some important aspects, tailoring interventions to change antibiotic use improved the quality of treatment for patients hospitalized with lower respiratory tract infection.
Clinical Infectious Diseases, 2005
To assess and improve the quality of antibiotic use in patients with community-acquired pneumonia... more To assess and improve the quality of antibiotic use in patients with community-acquired pneumonia (CAP) and acute exacerbation of chronic bronchitis or chronic obstructive pulmonary disease (AECB), a valid set of quality indicators is required. This set should also be applicable in practice. Guidelines and literature were reviewed to derive potential indicators for quality of antibiotic use in treating hospitalized patients with lower respiratory tract infection (LRTI). To assess the evidence base of each indicator, a literature review was performed. Grade A recommendations were considered valid. For grade B-D recommendations, an expert panel performed a consensus procedure on the indicator&amp;#39;s relevance to patient health, reduction of antimicrobial resistance, and cost containment. To test applicability in practice, feasibility, opportunity for improvement, reliability, and case-mix stability were determined for a data set of 899 hospitalized patients with LRTI. None of the potential indicators from guidelines and literature were supported by grade A evidence. Nineteen indicators were selected by consensus procedure (12 indicators for CAP and 7 indicators for AECB). Lack of feasibility and of opportunity for improvement led to the exclusion of 4 indicators. A final set of 15 indicators was defined (9 indicators for CAP and 6 indicators for AECB). A valid set of quality indicators for antibiotic use in hospitalized patients with LRTI was developed by combining evidence and expert opinion in a carefully planned procedure. Subjecting indicators to an applicability test is essential before using them in quality-improvement projects. In our demonstration setting, 4 of the 19 indicators were inapplicable in practice.
Clinical Infectious Diseases, 2008
Appropriateness of antibiotic treatment of urinary tract infection (UTI) is important. The aim of... more Appropriateness of antibiotic treatment of urinary tract infection (UTI) is important. The aim of this study was to develop a set of valid, reliable, and applicable indicators to assess the quality of antibiotic use in the treatment of hospitalized patients with complicated UTI. A multidisciplinary panel of 13 experts reviewed and prioritized recommendations extracted from a recently developed evidence-based national guideline for the treatment of complicated UTI. The content validity was assessed in 2 consecutive rounds with an in-between discussion meeting. Next, we tested the feasibility, interobserver reliability, opportunity for improvement, and case-mix stability of the potential indicators for a data set of 341 inpatients and outpatients with complicated UTIs who were treated at the urology or internal medicine departments at 4 hospitals. The panel selected and prioritized 13 indicators. Four and 9 indicators were performed satisfactorily in the urology and internal medicine departments, as follows: performance of urine culture, prescription of treatment in accordance with guidelines, tailoring of treatment on the basis of culture results, and a switch to oral treatment when possible in the urology and internal medicine departments; and selective use of fluoroquinolones, administration of treatment for at least 10 days, prescription of treatment for men in accordance with guidelines, replacement of catheters in patients with UTI, and adaptation of the dosage on the basis of renal function in the internal medicine department. A systemic evidence- and consensus-based approach was used to develop a set of valid quality indicators. Tests of the applicability of these indicators in practice in different settings is essential before they are used in quality-improvement strategies.