Franky Buyle

Daily cost of antimicrobial therapy in patients with Intensive Care Unit-acquired, laboratory-confirmed bloodstream infection

This study analysed daily antimicrobial costs of Intensive Care Unit (ICU)-acquired, laboratory-confirmed bloodstream infection (BSI) per patient admitted to the ICU of a university hospital, based on prospectively collected data over a 4-year period (2003-2006). Costs were calculated based on the price of the agent(s) initiated on the first day of appropriate treatment and according to: (i) focus of infection; (ii) pathogen; and (iii) antimicrobial agent. The study included 310 adult patients who developed 446 BSI episodes. Mean overall daily antimicrobial cost was euro114.25. Daily antimicrobial cost was most expensive for BSIs with unknown focus (euro137.70), followed by catheter-related (euro122.73), pulmonary (euro112.80), abdominal (euro98.00), wound (euro89.21), urinary (euro87.85) and other inciting focuses (euro81.59). Coagulase-negative staphylococci were the most prevalent pathogens isolated. Treatment of BSIs caused by Candida spp. was the most costly. The daily antimicrobial costs per infected patient with multidrug-resistant BSI was ca. 50% higher compared with those without (euro165.09 vs. euro82.67; P<0.001). Among the total of 852 prescriptions, beta-lactam antibiotics accounted for approximately one-third of the overall daily cost of antimicrobial agents. The antibiotic cost associated with ICU-acquired, laboratory-confirmed BSI is significant and should be reduced by implementing infection control measures and preventive strategies.

Epidemiology of infection in critically ill patients with acute renal failure

Objectives: Critically ill patients with infection are at increased risk for developing acute renal failure (ARF), and ARF is associated with an increased risk for infection. Both conditions are associated with prolonged length of stay (LOS) and worse outcome; however, little data exist on the epidemiology of infection in this specific cohort. Therefore, we investigated the occurrence of infection in a cohort of critically ill patients with ARF treated with renal replacement therapy (RRT). In addition, we assessed whether this infection worsened outcome. Design: Retrospective cohort study. Setting: General intensive care unit (ICU) in an academic tertiary care center comprising a 22-bed surgical ICU, eight-bed cardiac surgery ICU, 14-bed medical ICU, and six-bed burn center. Patients: Six hundred forty-seven consecutive critically ill patients with ARF treated with RRT, admitted between 2000 and 2004. Interventions: None. Measurements and Main Results: total of 519 (80.2%), 193 (29.8%), 66 (10.2%), and ten (1.5%) patients developed one, two, three, and four episodes of infection, respectively. Of 788 episodes of infection observed, 364 (46.2%) occurred before, 318 (40.3%) during, and 106 (13.4%) after discontinuation of RRT. Pneumonia (54.3%) was most frequent, followed by intra-abdominal (11.9%) and urinary tract infections (9.7%). Infections were caused by Gram-negative organisms in 33.7%, Gram-positive organisms in 21.6%, and yeasts in 9.8%. Patients with infection had higher mortality (p = 0.04) and longer ICU and hospital LOS. They needed more vasoactive therapy and spent more time on mechanical ventilation and RRT (all p < 0.001) than patients without infection. After adjustment for potential confounders, Acute Physiology and Chronic Health Evaluation II score, age, mechanical ventilation, and vasoactive therapy were associated with worse outcome, but infection was not. Conclusions: Infection occurred in four fifths of critically ill patients with ARF treated with RRT and was in an unadjusted analysis associated with longer LOS and higher mortality. After correction for other covariates, infection was no longer associated with in-hospital mortality.

Infection risk related to the use of medicinal leeches

ObjectiveTo assess the incidence of postoperative wound infections related to treatment with medicinal leeches at Ghent University Hospital.MethodA 2-year retrospective analysis of bacteriologic culture results of soft tissue infections in patients treated with medicinal leeches.ResultsCultures of suspected wound infections were taken and susceptibility testing of isolates was performed on 17 of 47 patients (36.2%). Aeromonas was frequently isolated (18.5%).ConclusionsA high incidence of infection during and after application of medicinal leeches, despite their external decontamination, necessitates an antibiotic prophylaxis. In particular Aeromonas must be covered, as soft tissue infections with these bacteria can give serious complications. The prophylactic antibiotic should cover the most frequent isolated species taking into account the importance of Aeromonas and the susceptibility pattern. Based on the results, fluoroquinolones seem to be a good choice. The authors believe that practical recommendations to hospital pharmacists on prophylaxis during Hirudo medicinalis treatment, might enhance the safety of it’s use by reducing the number of infections.

Prospective multicentre feasibility study of a quality of care indicator for intravenous to oral switch therapy with highly bioavailable antibiotics

BACKGROUND Enhanced oral (po) bioavailability of antimicrobial drugs allows conversion to po therapy once a patient meets defined clinical criteria. This can reduce length of hospital stay, healthcare costs and risk of complications related to intravenous (iv) access. We developed a quality indicator for assessing the appropriate iv-to-po switch of bioavailable antibiotics and evaluated its feasibility and clinical relevance across acute healthcare systems. METHODS The study was designed as a multicentre, multinational observational audit. The indicator was the proportion of inappropriate iv treatments at any point in time in adult patients treated with fluoroquinolones, clindamycin, linezolid or metronidazole. Treatments were prospectively evaluated by a trained physician or clinical pharmacist using predefined clinical criteria. The feasibility of the indicator was evaluated by measuring data availability, data collection workload and sensitivity to improvement RESULTS Data were collected over a 3 month period in five university hospitals in Austria, Belgium and Germany and iv treatment was assessed in 211 patients. The indicator was measurable in 99.1% of cases. By intention-to-treat analysis, 37.0% (95% CI 30.5-43.9) of treatments were inappropriate, ranging from 17.5% to 53.8% across hospitals. The median time needed for case assessment and documentation was 29 min. CONCLUSIONS This quality indicator was found to be generally feasible in hospitals across three European countries, and informative about the local need for clinical quality improvement.

Development and validation of potential structure indicators for evaluating antimicrobial stewardship programmes in European hospitals.

This study describes the development of structure indicators for hospital antimicrobial stewardship programmes and pilot validation across European hospitals. A multi-disciplinary panel from four European countries developed structure indicators in three steps: identification and listing of indicators, remote ranking of indicators using multi-criteria scoring, selection of indicators in a face-to-face consensus meeting. Additionally, the top-ten indicators were identified as a minimal set of key indicators. A survey was sent to the directors of antimicrobial stewardship programmes in European hospitals. The yes/no answers for the indicators were transformed into numbers in order to calculate the total scores. A list of 58 indicators was selected and categorised into the following topics: antimicrobial stewardship services (12 items), tools (16 items), human resources and mandate (6 items), health care personnel development (4 items), basic diagnostic capabilities (6 items), microbiological rapid tests (2 items), evaluation of microbiological drug resistance data (3 items), antibiotic consumption control (5 items) and drug use monitoring (4 items). The indicator scores, reported by 11 pilot hospitals from five European countries, ranged from 32 to 50 (maximum score = 58) and from 5 to 10 points (maximum score = 10) for, respectively, the complete and the top-ten list. An international panel selected 58 potential structure indicators, among which was a minimal set of ten key structure indicators, that could be useful for assessment of the comprehensiveness and resource-intensity of antimicrobial stewardship programmes. There was significant heterogeneity among participating centres with regard to their score for structural components of effective antimicrobial stewardship.

Importance of Infusion Volume and Pump Characteristics in Extended Administration of β-Lactam Antibiotics

The introduction of a new protocol at Ghent University Hospital (Ghent, Belgium) for the extended administration of piperacillin-tazobactam (TZP) and meropenem drew attention to a potential pitfall that is well-known in daily clinical practice but often neglected, i.e., the contribution of infusion line dead space to the incomplete administration of the drug. The Antibiotic Policy Working Party at the institution implemented an extended 3-h protocol for TZP and meropenem administration in both intensive care units (ICU) and regular wards. The protocol specified that TZP is to be infused as a loading dose of 4.5 g over 30 min, followed by a 3-h infusion of 4.5 g every 6 h, with dosage adjustments according to renal function. For meropenem, a 1-g loading dose over 30 min is to be followed by a 3-h infusion of 1 g every 8 h. Dose regimens are based upon the Belgian version of the Sanford guide (5). Extended administration was chosen since recent research has highlighted the possible benefits (1-4). For the extended administration of both antibiotics, a smaller volume of 50 ml of 0.9% saline was used, compared to the standard 100-ml solutions used previously. The reduction in volume enabled the protocol to be used hospital-wide, including for patients with fluid restrictions. This implementation involved a switch to a new volumetric pump system (Alaris GP volumetric pump and GP 59-type infusion set). It was observed that every replacement of the infusion line resulted in a 40% loss of the prescribed antibiotic dose if the infusion line was not cleared with a compatible solution after the antibiotic infusion. On the other hand, nonreplacement of the infusion line dead space increased the risk of infusion of the degraded product, in particular in view of the issue of stability of meropenem in solution, as the residual volume was infused in the first 75 min of the subsequent 3-h infusion. Indeed, the package leaflet of the Alaris system states that a priming volume of 24 ml is required, which unfortunately was not considered before implementation of the protocol. Dead-space volume replacement is a critical issue (6) that needs to be addressed when the dead space exceeds 10% of the infused volume. The problem described is not dependent on the drug or infusion duration. The detection of this potential problem resulted in a prompt adaptation of the protocol with the requirement of higher solution volumes for non-ICU patients (at least 250 ml) and the use of the more expensive pressurized pumps, where the infusion dead space is less than 1 ml, for ICU patients and patients with fluid restrictions. In parallel, tests are running with a volumetric pump set that enables users to consider the line space at the end of the infusion and deliver the overfill. We wish to draw the attention on the importance of infusion volume and pump characteristics. We hence encourage the inclusion of this information into study method sections in publications on extended infusions.

Antifungal drugs and rational use of antifungals in treating invasive aspergillosis: the role of the hospital pharmacist

AbstractAim:This review discusses the most common used antifungal agents in the treatment of invasive fungal infections. In addition, guidelines for the treatment of invasive aspergillosis, as used in the Ghent University Hospital, are described. Moreover, the importance of determining the effectiveness of antifungal therapy as well as the potential role of the hospital pharmacist in the management of this infection is highlighted. Methods:A review of the English-language literature was conducted using the MEDLINE database and scientific websites. Search terms including antimycotics, antifungal therapy and invasive aspergillosis were used to refine the search, and preference was given to studies published after 1992. This was completed with recent treatment guidelines. Results:An overview of the most recent advances in antifungal therapy is described. In addition, a flowchart for treatment of invasive aspergillosis (proven, probable or possible) has been developed. Conclusion:Invasive fungal infections will remain a frequent and important complication of modern medicine. Considering the clinical and financial outcome of invasive fungal infections, the role of the hospital pharmacist can be a paramount to the treatment.

Implementation of a multidisciplinary infectious diseases team in a tertiary hospital within an Antimicrobial Stewardship Program

Abstract Background: In January 2011, as part of an antimicrobial stewardship program the Antimicrobial Management Team (AMT) at the Ghent University Hospital initiated a multidisciplinary Infectious Diseases Team (MIT) consisting of infectious diseases physicians, clinical microbiologists, and clinical pharmacists. The aim of this study is to describe the type and acceptance rate of recommendations provided by the MIT. Method: Prospective, observational study in a tertiary care, university teaching hospital with 1062 beds in non-consecutive hospitalized adult patients, excluding intensive care units and paediatrics. Results: The MIT communicated 432 recommendations in 87 days observed. Of the 293 patients for whom a recommendation was made, the median age was 57 years (range: 16–91 years) and 169 (57·7%) were male. Skin or soft tissue infections (14%), respiratory tract infections (13%), infections without known focus (11%), abdominal infections (11%), and bone infections (8%) were most common. Recommendations were made to perform additional clinical investigation(s) [N = 137 (27%)], to adjust the dose of an antimicrobial drug [N = 42 (8%)], to stop an antimicrobial drug [N = 104 (21%)], to switch from a parenteral to an oral drug [N = 39 (8%)] or to initiate an antimicrobial drug [N = 178 (36%)], with an acceptance rate of 73·0%, 83·3%, 81·7%, 76·9%, and 84·0%, respectively. Conclusions: The MIT formulated about five recommendations a day primarily focusing on pharmacotherapy, but also on clinical investigations. In both fields, a high acceptance rate was observed.

The effectiveness of an e-learning course on medication calculation in nursing students: a clustered quasi-experimental study.

AIM To evaluate the effectiveness of an e-learning course compared with a face-to-face lecture on medication calculation. BACKGROUND The current knowledge on medication calculation of nursing students and nurses is insufficient to provide safe care. DESIGN A stratified-clustered quasi-experimental study. METHODS A random selection of nursing schools were allocated to the e-learning course (intervention group) (seven schools; 189 students) or face-to-face lecture (control group) (six schools, 222 students). Students in both groups completed a validated medication calculation test (maximum score: 16) prior to the course (T0), immediately after the course (T1) and 3 months later (T2). A linear mixed model was used for data analysis. RESULTS Medication calculation skills improved significantly more by the face-to-face lecture than e-learning course. Students in both groups significantly improved in medication calculation skills immediately after the course (T1) and 3 months later. The results flattened at T2 with a significant decline in the intervention group between T1 and T2 and a non-significant decline in the control group. Based on a subgroup analysis, improvement in medication calculation skills at T2 could only be observed in vocational-level (sub degree) nursing students receiving a face-to-face course. CONCLUSIONS Both medication calculation courses had a positive effect on medication calculation skills. Students receiving traditional face-to-face lecture improved significantly more than the students receiving the e-learning course.

Clinical pharmacy and pediatrics: why focus on antibiotics?

In recent years, changes in health care financing have necessitated that health care providers delineate and justify both a medical and economic basis for their involvement in patient care [1]. Rational use of antibiotics has been amongst the most targeted issues of different strategies to improve the use of medicines. To this end, both regulatory and financial measures, organizational and professional interventions have been introduced [2]. As with medicine, pharmacy is becoming increasingly specialised, with pharmacists playing key roles in specialised clinical areas. The role of the ‘antibiotic pharmacist’ is expanding [3]. Many reports describe it’s role in an adult population [3, 4]. However, the role of a clinical pharmacist involved in infectiology in a pediatric population is less described.