Caroline Landelle

Clinical impact of unsolicited post-prescription antibiotic review in surgical and medical wards: a randomized controlled trial

This study aimed to determine the clinical course of patients and the quality of antibiotic use using a systematic and unsolicited post-prescription antibiotic review. Seven hundred and fifty-three adult patients receiving antibiotic therapy for 3-5 days were randomized to receive either a post-prescription review by the infectious disease physician (IDP), followed by a recommendation to the attending physician to modify the prescription when appropriate, or no systematic review of the prescription. In the intervention group, 63.3% of prescriptions prompted IDP recommendations, which were mostly followed by ward physicians (90.3%). Early antibiotic modifications were more frequent in the intervention group (57.1% vs. 25.7%, p <0.0001), including stopping therapy, shortening duration and de-escalating broad-spectrum antibiotics. IDP intervention led to a significant reduction of the median [IQR] duration of antibiotic therapy (6 [4-9] vs. 7 days [5-9], p <0.0001). In-hospital mortality, ICU admission and new course of antibiotic therapy rates did not differ between the two groups. Fewer patients in the intervention group were readmitted for relapsing infection (3.4% vs. 7.9%, p 0.01). There was a trend for a shorter length of hospital stay in patients suffering from community-acquired infections in the intervention group (5 days [3-10] vs. 6 days [3-14], p 0.06). This study provides clinical evidence that a post-prescription antibiotic review followed by unsolicited IDP advice is effective in reducing antibiotic exposure of patients and increasing the quality of antibiotic use, and may reduce hospital stay and relapsing infection rates, with no adverse effects on other patient outcomes.

Is patient isolation the single most important measure to prevent the spread of multidrug-resistant pathogens?

Isolation or cohorting of infected patients is an old concept. Its purpose is to prevent the transmission of microorganisms from infected or colonized patients to other patients, hospital visitors, and health care workers, who may subsequently transmit them to other patients or become infected or colonized themselves. Because the process of isolating patients is expensive, time-consuming, often uncomfortable for patients and may impede care, it should be implemented only when necessary. Conversely, failure to isolate a patient with multidrug-resistant microorganisms may lead to adverse outcomes, and may ultimately be expensive when one considers the direct costs of an outbreak investigation and the indirect costs of lost productivity. In this review, we argue that contact precautions are essential to control the spread of epidemic and endemic multidrug-resistant microorganisms, and discuss limitations of some available data.

Reassessment of intravenous antibiotic therapy using a reminder or direct counselling

OBJECTIVES Encouraging reassessment of intravenous antibiotic therapy at days 3-4 is an important step in the management of patients and may be done by delivering a questionnaire or through systematic infectious disease physician (IDP) advice to prescribers. PATIENTS AND METHODS In this before-and-after study, prescriptions of 13 selected intravenous antibiotics from surgical or medical wards were screened from a computer-generated listing and prospectively included. Three strategies were compared over three consecutive 8 week periods: conventional management by the attending physician (control group); distribution of a questionnaire to the physician (questionnaire group); or distribution of the questionnaire followed by IDP advice (Q-IDP group). The primary outcome was the percentage of modifications of antibiotic therapy at day 4, including withdrawal of therapy, de-escalation, oral switch or reducing the planned duration of therapy. RESULTS Overall, 402 prescriptions were included. At day 4, 48.9% and 54.5% of prescriptions were modified in the control and questionnaire groups, respectively (P = 0.35). In contrast, more prescriptions (66.2%) were modified in the Q-IDP group as compared with the control group (P = 0.004). Stopping therapy in the absence of apparent bacterial infection occurred significantly more often in the Q-IDP group than in the control (P < 0.0001) or questionnaire groups (P = 0.002). CONCLUSIONS This study shows a modest impact of only distributing a questionnaire aimed at reminding physicians to reassess therapy, whereas systematic IDP intervention improves the modification rate.

Protracted Outbreak of Multidrug-Resistant Acinetobacter baumannii after Intercontinental Transfer of Colonized Patients

OBJECTIVE To describe the course and management of a protracted outbreak after intercontinental transfer of 2 patients colonized with multidrug-resistant Acinetobacter baumannii (MDRAB). DESIGN An 18-month outbreak investigation. SETTING An 860-bed university hospital in France. PATIENTS Case patients (ie, carriers) were those colonized or infected with an MDRAB isolate. METHODS During the epidemic period, all intensive care unit (ICU) patients and contacts of carriers who were transferred to wards were screened for MDRAB carriage. Contact precautions, environmental screening, and auditing of healthcare worker (HCW) practices were implemented; rooms were cleaned with hydrogen peroxide mist disinfection. One ICU, in which most of the cases occurred, was closed on 4 occasions for thorough cleaning and disinfection. RESULTS The 2 index case patients were identified as 2 patients who carried the same MDRAB strain and who were admitted to the hospital after repatriation from Tahiti 5 months apart. During an 18-month period, a total of 84 secondary cases occurred. Reintroduction of MDRAB into the ICUs occurred from patients previously colonized or from healthcare personnel. Termination of the outbreak was only achieved when all carriers from wards or the ICU were cohorted to an isolation unit with dedicated healthcare personnel. CONCLUSIONS Intercontinental transfer of carriers of MDRAB can result in extensive outbreaks and serious disruption of the hospitals organization. Transmission from carriers most likely occurred via the hands of HCWs, poor cleaning protocols, airborne spread, and contaminated water from sink traps. This protracted outbreak was controlled only after implementation of an extensive control program and eventual cohorting of all carriers in an isolation unit with dedicated healthcare personnel.

Nosocomial infection after septic shock among intensive care unit patients.

OBJECTIVES To measure the incidence of nosocomial infection (NI) among patients with septic shock according to the place of septic shock acquisition and to evaluate the increase in the risk of pulmonary infection associated with septic shock. DESIGN Prospective cohort study. SETTING Two intensive care units (ICUs) of a French university hospital. PATIENTS AND METHODS The study included a total of 209 septic shock patients during the period December 1, 2001 through April 30, 2005. The place of septic shock acquisition for 108 patients was the community; for 87, the hospital; and for 14, the ICU. To evaluate the impact of septic shock on the development of pulmonary infection, a competitive and adjusted hazard ratio (aHR) model was applied to nontrauma ICU patients. RESULTS Among the 209 study patients, 48 (23%) experienced 66 NIs after septic shock. There was no significant difference in the NI attack rates according to place of acquisition: for the community acquisition group, 24 cases per 100 patients (95% confidence interval [CI], 16-32); for the hospital acquisition group, 20 cases per 100 patients (95% CI, 11-28); and for the ICU acquisition group, 36 cases per 100 patients (95% CI, 11-61) (P = .3). For nontrauma ICU patients, the presence of community-acquired septic shock was found to be independently associated with a higher incidence of pulmonary infection, compared with the absence of septic shock (aHR, 2.12 [95% CI, 1.08-4.16]; P = .03). CONCLUSIONS The risk of NI did not differ by the place of septic shock acquisition. The risk of pulmonary infection was higher for ICU patients with community-acquired septic shock who were admitted for underlying nontrauma disease. Studies are needed to investigate the pathogenic mechanisms that facilitate pulmonary infection in this population, taking into account exposure to invasive devices and immunosuppression after the initial phase of septic shock.

Administration of antibiotic agents before intraoperative sampling in orthopedic infections alters culture results

UNLABELLED Many physicians and surgeons think that prescribing antibiotics before intraoperative sampling does not alter the microbiological results. METHODS Case-control study of adult patients hospitalized with orthopedic infections. RESULTS Among 2740 episodes of orthopedic infections, 1167 (43%) had received antibiotic therapy before surgical sampling. Among these, 220 (19%) grew no pathogens while the proportion of culture-negative results in the 2573 who had no preoperative antibiotic therapy was only 6%. By multivariate analyses, pre-operative antibiotic exposure was associated with significantly more culture-negative results (odds ratio 2.8, 95% confidence interval 2.1-3.7), more non-fermenting rods and skin commensals (odds ratio 2.8 and 3.0, respectively). Even a single pre-operative dose of antibiotic was significantly associated with subsequent culture-negative results (19/93 vs. 297/2350; χ²-test, p = 0.01) and skin commensals (17/74 vs. 274/2350; p = 0.01) compared to episodes without preceding prophylaxis. CONCLUSIONS Prior antibiotic use, including single-dose prophylactic administrations, is three-fold associated with culture-negative results, non-fermenting rods and resistant skin commensals.

Randomized, placebo-controlled, double-blind clinical trial to evaluate the efficacy of polyhexanide for topical decolonization of MRSA carriers

OBJECTIVES The objective of this study was to evaluate the efficacy of polyhexanide (Prontoderm(®)) in eliminating MRSA carriage. METHODS In a 1900 bed teaching hospital, MRSA-colonized patients were randomized into a double-blind, placebo-controlled superiority trial between January 2011 and July 2014. Patients were treated with either polyhexanide or placebo applied to the anterior nares (thrice daily) and skin (once daily) for 10 days. The primary outcome was MRSA decolonization at day 28 (D28) after the end of treatment assessed by ITT responder and PP analyses (microbiological follow-up ± 7 days and topical treatment ≥ 5 days). Secondary outcomes included safety, emergence of resistance and MRSA genotype changes. Registered trial number ISRCTN02288276. RESULTS Of 2590 patients screened, 146 (polyhexanide group, 71; placebo group, 75) were included. ITT analysis showed that 24/71 (33.8%) patients in the polyhexanide group versus 22/75 (29.3%) in the placebo group were MRSA-free at D28 (risk difference, 4.5%; 95% CI, -10.6% to 19.5%; P = 0.56). PP analysis confirmed the results with 19/53 (35.8%) decolonized polyhexanide-treated patients versus 17/56 (30.4%) in the placebo arm (risk difference, 5.5%; 95% CI, -12.2% to 23%; P = 0.54). Nine serious adverse events occurred in the polyhexanide group versus 12 in the placebo group; none was attributable to study medication. Emergence of polyhexanide resistance or cross-resistance between polyhexanide and chlorhexidine was not observed. No case of exogenous recolonization by a genotypically different MRSA strain was documented. CONCLUSIONS This study suggests that under real-life conditions, a single polyhexanide decolonization course is not effective in eradicating MRSA carriage.

Prevention of hospital-acquired pneumonia in non-ventilated adult patients: a narrative review

BackgroundPneumonia is one of the leading hospital-acquired infections worldwide and has an important impact. Although preventive measures for ventilator-associated pneumonia (VAP) are well known, less is known about appropriate measures for prevention of hospital-acquired pneumonia (HAP).AimThe purpose of this narrative review is to provide an overview of the current standards for preventing HAP in non-ventilated adult patients.MethodsA search of the literature up to May 2015 was conducted using Medline for guidelines published by national professional societies or professional medical associations. In addition, a comprehensive search for the following preventive measures was performed: hand hygiene, oral care, bed position, mobilization, diagnosis and treatment of dysphagia, aspiration prevention, viral infections and stress bleeding prophylaxis.FindingsRegarding international guidelines, several measures were recommended for VAP, whilst no specific recommendations for HAP prevention in non-ventilated patients are available. There is reasonable evidence available that oral care is associated with a reduction in HAP. Early mobilization interventions, swift diagnosis and treatment of dysphagia, and multimodal programmes for the prevention of nosocomial influenza cross-infection, have a positive impact on HAP reduction. The impact of bed position and stress bleeding prophylaxis remains uncertain. Systematic antibiotic prophylaxis for HAP prevention should be avoided.ConclusionScant literature and little guidance is available for the prevention of HAP among non-ventilated adult patients. In addition, the criteria used for the diagnosis of HAP and the populations targeted in the studies selected are heterogeneous. Oral care was the most studied measure and was commonly associated with a decrease in HAP rate, although a broad range of interventions are proposed. No robust evidence is available for other measures. Further high-quality studies are required to evaluate the impact of specific measures on HAP prevention in non-ventilated adult patients.

Delayed increase of S100A9 messenger RNA predicts hospital-acquired infection after septic shock.

Objective:Septic shock remains a serious disease with high mortality and increased risk of hospital-acquired infection. The prediction of outcome is of the utmost importance for selecting patients for therapeutic strategies aiming to modify the immune response. The aim of this study was to assess the capability of S100A9 messenger RNA in whole blood from patients with septic shock to predict survival and the occurrence of hospital-acquired infection. Design:Cohort study. Setting:Two intensive care units in a university hospital. Subjects:The study included patients with septic shock (n = 166) and healthy volunteers (n = 44). Interventions:None. Measurements and Main Results:For the patients with septic shock patients, overall mortality was 38% and the mean Simplified Acute Physiologic Scale II on shock onset was 52. Using quantitative reverse transcriptase–polymerase chain reactions, we found that median S100A9 messenger RNA was significantly lower in healthy volunteers than in patients with septic shock (p < .0001) between days 1 and 3 after onset of the septic shock and not significantly different between nonsurvivor and survivor patients (p = .1278). However, median S100A9 messenger RNA measured on days 7–10 was significantly higher in patients who were about to contract hospital-acquired infections compared with those who were not (p = .009). In the multivariate analysis, the S100A9 marker increased the probability of contracting hospital-acquired infections with an odds ratio of 1.12 per unit (p = .0054). Conclusions:S100A9 messenger RNA is increased in septic shock and its delayed overexpression is associated with the occurrence of secondary hospital-acquired infection. This biomarker may be of major interest in identifying patients with increased risk of hospital-acquired infection who could benefit from targeted therapy aimed at restoring their immune functions.

Infection control measures to decrease the burden of antimicrobial resistance in the critical care setting

Purpose of reviewThe prevalence of multidrug-resistant organisms (MDROs) in ICUs is increasing worldwide. This review assesses the role of infection control measures, excluding antibiotic stewardship programs, in reducing the burden of resistance in ICUs. Recent findingsThe knowledge base about the effect of increased hand hygiene compliance in reducing the burden of methicillin-resistant Staphylococcus aureus in ICUs has been improved. Universal decolonization with chlorhexidine body washing was associated with significant reduction in MDRO prevalence, but vigilance for emerging chlorhexidine resistance is required. A significant reduction of resistance for Gram-negative bacilli has been demonstrated with the use of selective decontamination, but further clinical trials are necessary before definitive conclusions can be drawn regarding long-term risk/benefit ratios. SummaryIn the recent years, several high-quality clinical studies have assessed the ability of various infection control measures in reducing the burden of antimicrobial resistance. Significant progress has been made in identifying interventions effective in preventing transmission of MDROs in ICUs, in particular, decolonization. However, it still remains impossible to determine the exact and relative importance of different infection control measures. Any approach must ultimately be tailored to the local epidemiology of the targeted ICU.