Antimicrobial use in the ICU: Indications and accuracy-an observational trial (original) (raw)
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Focus on antimicrobial use in the era of increasing antimicrobial resistance in ICU
Intensive Care Medicine, 2016
Antibiotic stewardship in the spectrum of resistance bacteria fight Antimicrobial resistance in microorganisms increased inexorably driven by antimicrobial exposure in healthcare, agriculture, and the environment. Onward transmission is affected by standards of infection control, sanitation, access to clean water, access to quality-assured antimicrobials and diagnostic tests, travel, and migration [1, 2]. The intensive care unit (ICU) represents the best bacterial resistance amplifier. Indeed, the most critically ill patients with invasive procedures are treated with broad-spectrum antimicrobials in an environment with a huge number of healthcare workers and an extremely high risk of transmission from patient to patient. Strategies to reduce curative antibiotic therapy to the bare essential are therefore needed and should include an immediate diagnostic process before starting early probabilistic antimicrobial therapy in case of severe sepsis or septic shock. The strategies proposed by a French multidisciplinary panel of experts using GRADE methods are detailed in this journal (67 recommendations) [3]. The key messages are that all antibiotic usage promotes antibiotic resistance. Adequate high dose is essential to cure patients but treatment should spare carbapenems in community-acquired infections. Combination therapy is suggested for patients with septic shock and neutropenia or in patients at high risk of multidrug-resistant bacterias. Antibiotics should be reassessed after 48-72 h and deescalated. Duration of therapy should be reduced. In contrast, in the absence of severe sepsis, waiting for objective data to diagnose infection before treatment with antimicrobial drugs for suspected ICU-acquired infections does
Critical Care, 2018
Background: Preparing an antibiotic stewardship program requires detailed information on overall antibiotic use, prescription indication and ecology. However, longitudinal data of this kind are scarce. Computerization of the patient chart has offered the potential to collect complete data of high resolution. To gain insight in our global antibiotic use, we aimed to explore antibiotic prescription in our intensive care unit (ICU) from various angles over a prolonged time period. Methods: We studied all adult patients admitted to Ghent University Hospital ICU from 1 January 2013 until 31 December 2016. Antibiotic prescription data were prospectively merged with diagnostic (suspected focus, severity and probability of infection at the time of prescription, or prophylaxis) and microbiology data by ICU physicians during daily workflow through dedicated software. Definite focus of infection and probability of infection (classified as high/moderate/low) were reassessed by dedicated ICU physicians at patient discharge. Results: During the study period, 8763 patients were admitted and overall antibiotic consumption amounted to 1232 days of therapy (DOT)/1000 patient days. Antibacterial DOT (84% of total DOT) were linked with infection in 80%; the predominant foci were the respiratory tract (49%) and the abdomen (19%). A microbial cause was identified in 56% (3169/5686). Moderate/low probability infections accounted for 42% of antibacterial DOT prescribed for respiratory tract infections; for abdominal infections, this figure was 15%. The median treatment duration of moderate/low probability respiratory infections was 4 days (IQR 3-7). Antifungal DOT (16% of total DOT) were linked with infection in 47% of total antifungal DOT. Antifungal prophylaxis was primarily administered in the surgical ICU (76%), with a median duration of 4 DOT (IQR 2-9). Conclusions: By prospectively combining antibiotic, microbiology and clinical data we were able to construct a longitudinal, multifaceted dataset on antibiotic use and infection diagnosis. A complete overview of this kind may allow the identification of antibiotic prescription patterns that require future antibiotic stewardship attention.
Impact of healthcare-associated infection and antimicrobial therapy in intensive care
Journal of Pharmaceutical Health Services Research, 2010
Objectives To characterise antimicrobial use in patients with and without laboratoryconfirmed healthcare-associated infections (HAIs), to contribute additionally to a study of HAI impact in two intensive care units (ICUs). Methods From January until June 2008, a prospective observational non-randomised study was conducted in two ICUs. HAI was defined as a positive culture collected 48 h after ICU admission, so only laboratory-confirmed infections were included. Antimicrobial therapy was included for HAI-detection criteria to eliminate cases of contamination or/and colonisation. All data were collected from the hospital online clinical database and analysed using proper statistical software. Key findings Of the 213 patients included, 93 were found to have at least one HAI. The main sites of infection were the respiratory tract, bloodstream and urinary tract. Among the 234 HAIs detected the most frequently isolated microorganisms were Candida albicans, methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa. Piperacillin/ tazobactam, meropenem, vancomycin and ceftriaxone were the most prescribed antimicrobials, including in the group of patients without laboratory-confirmed HAIs. The HAI group had a prolonged length of stay and antimicrobial treatment, and higher antimicrobial treatment costs (P < 0.001). Conclusions The prescription pattern of antimicrobial drugs was strongly influenced by the microorganisms causing the HAIs. The occurrence of HAIs had a great clinical and economic impact in these ICUs, and antimicrobial therapy in patients with HAIs cost three times more, associated with a doubled length of stay. Nevertheless, patients without HAIs also showed significant prevention costs.
IP Innovative Publication Pvt. Ltd, 2017
Background: To study the bacteriological profile of infections in patients admitted to ICU and to determine the antibiotic susceptibility patterns of the bacterial isolates. This study was done as Prospective study of 2 months period with a study population of patients admitted to Intensive care unit of a tertiary care hospital. Materials and Methods: Selection criteria for this study was with an inclusion criteria of patients admitted to ICU for various reasons and developing infection within 48 hours of admission and the exclusion criteria was patients admitted to ICU and not developing infection and patients admitted to ICU with an already existing infection. All the samples were processed as per standard microbiology guidelines. Results: Gram negative bacilli were predominant with 73.35% as compared to Gram positive cocci of 9.97% of the total aerobic bacteria grown from various samples of patients admitted in Intensive care unit. Escherichia coli were more common with 26.67% of the total bacteria isolated. This was followed by Acinetobacter species 16.67%, Pseudomonas aeruginosa 16.67%, Klebsiella pneumoniae 6.67% and Enterobacter species6.67%. Among the Gram positive cocci, Staphylococcus aureus was more commonly isolated with 16.67% followed by Enterococcus species 6.67% and Streptococcus species 3.30%. Antibiotic resistance was observed by most bacteria to Penicillins, third generation Cephalosporins, Fluoroquinolones like Ciprofloxacin, Cotrimoxazole. Conclusion: Multi-drug resistance is a major hurdle in treating patients admitted to ICU setting in a hospital. Regular surveillance of antibiotic susceptibility patterns is very important for setting orders to guide the clinician in choosing empirical or directed therapy of infected patients.
Predictors of antibiotic utilization among intensive care unit patients
Journal of Chemotherapy, 2020
Increased antibiotic utilization in hospital is linked to higher total treatment costs, together with increased length of stay, surgery and emergency admission. The aim of our retrospective cohort study was to investigate predictors of antibiotic utilization per single patient from an intensive care unit (ICU) of a tertiary care, university hospital in Serbia. Average utilization of antibiotics per patient was 23.9 ± 20.4 defined daily doses (DDDs). Diagnosis of systemic infection increased antibiotics utilization per patient for 10.0 DDDs, positive blood culture for 5.4 DDDs, isolation of Pseudomonas spp. for 19.5 DDDs, isolation of Acinetobacter spp. for 6.3 DDDs and injury for 7.3 DDDs per patient. Each new day of hospitalization and each additional drug prescribed increased utilization for further 0.3 DDDs and 1.2 DDDs, respectively. Appropriate and limited use of antibiotics in ICU is of key importance for preserving their effectiveness and decrease of bacterial resistance.
Indian Journal of Pharmacy Practice, 2020
Introduction: Appropriate use of antimicrobials is the best possible way to safeguard the effectiveness of existing antimicrobials and to reduce the development of antimicrobial resistance. Objective: This study aims to evaluate and compare the utilization pattern of antimicrobial drugs in intensive care units (ICUs) and wards of a private tertiary care hospital. Materials and Methods: This is an observational prospective study carried out in ICUs and wards of private tertiary care hospital. In-patients receiving at least one antimicrobial agent were included in the study while patients with incomplete information were excluded out of the study. Utilization pattern of antimicrobial drugs was analyzed using RPM plus indicators recommended by World Health Organization. Student's t-test was used to determine statistical difference between continuous variables of ICUs and wards. Results: The number of patients studied in ICUs and wards was 405 and 561, respectively. In ICUs, the average number of medications prescribed was 13.49±1.41, of which average number of AMDs was 2.49±1.61. While in wards, the average number of medication was 10.51±5.17, of which average number of AMDs was 1.91±1.27. Overall 75% antimicrobials were administered by parenteral route. Conclusion: The findings of this study indicate that there is scope of improvement in extent of use of parenteral antimicrobial therapy.
Indications for antibiotic use in ICU patients: a one-year prospective surveillance
Journal of Antimicrobial Chemotherapy, 1997
. Bronchoscopic techniques were used to diagnose pneumonia. In practice, BPI must be treated, but a proportion of antibiotics prescribed for non-BPI may be unnecessary. The subdivision in BPI and non-BPI may help to identify these cases. In all, 515 patients were admitted to ICU and 36% of these had at least one infection. Of all infections, 53% were ICU-acquired and 99% of these occurred in intubated patients. Antibiotics were prescribed in 61% of admissions. Of all antibiotics prescribed for therapy, 49% were for respiratory tract infections, 19% for abdominal infections and 13% for sepsis eci. Categorized by indication, 59% of all antibiotic prescriptions were for BPI, 28% for non-BPI and 13% for prophylaxis. A theoretical reduction of 25% in the number of non-BPI prescriptions would result only in a 7% decrease of total antibiotic use. We conclude that almost all antibiotics prescribed were for intubated patients and for BPI. Respiratory infections were the single most common infection and accounted for 49% of all antibiotics used. Therefore, in our setting, prevention of respiratory tract infections is probably the most effective mode to reduce antibiotic use.
Advances in Therapy
The high prevalence of infectious diseases in the intensive care unit (ICU) and consequently elevated pressure for immediate and effective treatment have led to increased antimicrobial therapy consumption and misuse. Moreover, the emerging global threat of antimicrobial resistance and lack of novel antimicrobials justify the implementation of judicious antimicrobial stewardship programs (ASP) in the ICU. However, even though the importance of ASP is generally accepted, its implementation in the ICU is far from optimal and current evidence regarding strategies such as de-escalation remains controversial. The limitations of clinical guidance for antimicrobial therapy initiation and discontinuation have led to multiple studies for the evaluation of more objective tools, such as biomarkers as adjuncts for ASP. C-reactive protein and procalcitonin can be adequate for clinical use in acute infectious diseases, the latter being the most studied for ASP purposes. Although promising, current evidence highlights challenges in biomarker application and interpretation. Furthermore, the physiological alterations in the critically ill render pharmacokinetics and pharmacodynamics crucial parameters for adequate antimicrobial therapy use. Individual pharmacokinetic and pharmacodynamic targets can reduce antimicrobial therapy misuse and risk of antimicrobial resistance.