Matthew Dryden

Antibiotic stewardship and early discharge from hospital: impact of a structured approach to antimicrobial management

OBJECTIVESnTo assess the impact of an infection team review of patients receiving antibiotics in six hospitals across the UK and to establish the suitability of these patients for continued care in the community.nnnMETHODSnAn evaluation audit tool was used to assess all patients on antibiotic treatment on acute wards on a given day. Clinical and antibiotic use data were collected by an infection team (doctor, nurse and antibiotic pharmacist). Assessments were made of the requirement for continuing antibiotic treatment, route and duration [including intravenous (iv)/oral switch] and of the suitability of the patients for discharge from hospital and their requirement for community support.nnnRESULTSnOf 1356 patients reviewed, 429 (32%) were on systemic antibiotics, comprising 165 (38%) on ivu200a±u200aoral antibiotics and 264 (62%) on oral antibiotics alone. Ninety-nine (23%) patients (including 26 on iv antibiotics) had their antibiotics stopped immediately on clinical grounds. The other 330 (77%) patients (including 139 on iv antibiotics) needed to continue antibiotics, although 47 (34%) could be switched to oral. Eighty-nine (21%) patients were considered eligible for discharge, comprising 10 who would have required outpatient parenteral antibiotic therapy (OPAT), 55 who were suitable for oral outpatient treatment and 24 who had their antibiotics stopped.nnnCONCLUSIONSnInfection team review had a significant impact on antimicrobial use, facilitating iv to oral switch and a reduction in the volume of antibiotic use, possibly reducing the risk of healthcare-associated complications and infections. It identified many patients who could potentially have been managed in the community with appropriate resources, saving 481 bed-days. The health economics are reported in a companion paper.

A European survey of antibiotic management of methicillin-resistant Staphylococcus aureus infection: current clinical opinion and practice

Although the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) varies across Europe, healthcare-associated MRSA infections are common in many countries. Despite several national guidelines, the approach to treatment of MRSA infections varies across the continent, and there are multiple areas of management uncertainty for which there is little clinical evidence to guide practice. A faculty, convened to explore some of these areas, devised a survey that was used to compare the perspectives of infection specialists from across Europe on the management of MRSA infections with those of the faculty specialists. The survey instrument, a web-based questionnaire, was sent to 3840 registered delegates of the 19th European Congress of Clinical Microbiology and Infectious Diseases, held in April 2009. Of the 501 (13%) respondents to the survey, 84% were infection/microbiology specialists and 80% were from Europe. This article reports the survey results from European respondents, and shows a broad range of opinion and practice on a variety of issues pertaining to the management of minor and serious MRSA infections, such as pneumonia, bacteraemia, and skin and soft tissue infections. The issues include changing epidemiology, when and when not to treat, choice of treatment, and duration and route of treatment. The survey identified areas where practice can be improved and where further research is needed, and also identified areas of pan-European consensus of opinion that could be applied to European guidelines for the management of MRSA infection.

European perspective and update on the management of complicated skin and soft tissue infections due to methicillin-resistant Staphylococcus aureus after more than 10 years of experience with linezolid

Complicated skin and soft tissue infections (cSSTIs) are a diverse group of infections, with a range of presentations and microbiological causes. Hospitalization is common for patients with a cSSTI, which is treated by drainage of the affected area and with antibiotics. Host factors such as co-morbidities, and microbial factors, in particular drug resistance, complicate the management of these infections. Methicillin-resistant Staphylococcus aureus (MRSA) is an important cSSTI pathogen in Europe, and its involvement can be associated with poor patient outcomes. European guidelines recommend vancomycin, teicoplanin, linezolid, daptomycin, tigecycline or ceftaroline for treatment of MRSA cSSTIs. Of primary importance when treating cSSTIs is the agents clinical efficacy against the causative pathogens, as well as its bioavailability in the skin and associated structures. Linezolid is well-suited for the treatment of MRSA cSSTIs; it achieves high penetration into skin and soft tissues with 100% oral bioavailability, and therefore enables an intravenous to oral switch and outpatient treatment. When eligible patients are offered oral therapy the associated length of hospital stay and overall costs can be reduced. Linezolid has demonstrated clinical efficacy and favourable outcomes in patients for the treatment of MRSA cSSTIs including the treatment of lower extremity infections. Furthermore, efficacy has been documented in key defined populations, such as individuals with renal impairment and the obese. The safety profile of linezolid is well-documented, making this antibacterial a viable choice for the treatment of MRSA cSSTIs.

Reduction in antibiotic use through procalcitonin testing in patients in the medical admission unit or intensive care unit with suspicion of infection

We report an evaluation of the utility of serum procalcitonin (PCT) measurement as an additional diagnostic tool to support initiating or withholding antibiotics in clinical situations where there is a clinical suspicion of infection but the diagnosis is uncertain. During a six-month period, 99xa0patients on the medical admission unit (MAU) with suspected infection, and 42xa0patients on the intensive care unit (ICU) with clinical signs or physiological parameters suggesting possible new infection, had serum PCT concentration measured with the result available within 90min of the request. The test was initiated by the microbiology/infection team during clinical consultations to support the antibiotic decision. On the basis of low PCT values, antibiotics were withheld in MAU on 52xa0occasions and in ICU on 42xa0occasions. Patients were followed up prospectively for a week. There was neither progression of bacterial infection requiring antibiotics, nor complications or infection-related mortality in any patients who were denied antibiotics on either MAU or ICU. Without the PCT value it is likely that all of these patients would have received empirical antibiotics. Reduction in unnecessary antibiotic usage was made without any adverse effects on these patients and there was a clear reduction in antibiotic prescribing with cost reduction implications. PCT has the potential to become a valuable tool in antibiotic management.

Hot topics in the diagnosis and management of skin and soft-tissue infections.

Eighteen hot topics regarding the diagnosis and management of skin and soft-tissue infections (SSTIs) were selected and reviewed by members of the SSTI Working Group of the International Society of Chemotherapy (ISC). Despite the large amount of literature available on the issue selected, there are still many unknowns with regard to many of them and further studies are required to answer these challenging issues that face clinicians on a daily basis.

Reactive oxygen: a novel antimicrobial mechanism for targeting biofilm-associated infection

Reactive oxygen species (ROS) is a novel therapeutic strategy for topical or local application to wounds, mucosa or internal structures where there may be heavy bacterial bioburden with biofilm and chronic inflammation. Bacterial biofilms are a significant problem in clinical settings owing to their increased tolerance towards conventionally prescribed antibiotics and their propensity for selection of further antibacterial resistance. There is therefore a pressing need for the development of alternative therapeutic strategies that can improve antibiotic efficacy towards biofilms. ROS has been successful in treating chronic wounds and in clearing multidrug-resistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA), and carbapenemase-producing isolates from wounds and vascular line sites. There is significant antifungal activity of ROS against planktonic and biofilm forms. Nebulised ROS has been evaluated in limited subjects to assess reductions in bioburden in chronically colonised respiratory tracts. The antibiofilm activity of ROS could have great implications for the treatment of a variety of persistent respiratory conditions. Use of ROS on internal prosthetic devices shows promise. A variety of novel delivery mechanisms are being developed to apply ROS activity to different anatomical sites.

Hot topics in reactive oxygen therapy: antimicrobial and immunological mechanisms, safety, and clinical applications

Reactive oxygen species (ROS), when combined with various delivery mechanisms, has the potential to become a powerful novel therapeutic agent against difficult-to-treat infections, especially those involving biofilm. It is important in the context of the global antibiotic resistance crisis. ROS is rapidly active in vitro against all Gram-positive and Gram-negative bacteria tested. ROS also has antifungal and antiviral properties. ROS prevents the formation of biofilms caused by a range of bacterial species in wounds and respiratory epithelium. ROS has been successfully used in infection prevention, eradication of multiresistant organisms, prevention of surgical site infection, and intravascular line care. This antimicrobial mechanism has great potential for the control of bioburden and biofilm at many sites, thus providing an alternative to systemic antibiotics on epithelial/mucosal surfaces, for wound and cavity infection, chronic respiratory infections and possibly recurrent urinary infections as well as local delivery to deeper structures and prosthetic devices. Its simplicity and stability lend itself to use in developing economies as well.

Prosthetic joints: shining lights on challenging blind spots

Fifteen hot topics on joint replacement (JR) and prosthetic joint infection (PJI) with controversies and contentious areas were selected and reviewed by members of the Bone and Joint Working Group of the International Society of Chemotherapy (ISC) with co-opted orthopaedic and infection specialist colleagues. A manuscript was prepared, following an in-depth review of the current literature, with the aim of providing an insight into these complex issues and, when applicable, provide personal views from authors’ own experience. There remain many unanswered questions in regards to these and other areas of arthroplasty and more studies are required in some of these fields.

Clostridium difficile multidisciplinary team root cause analysis: impact on clinical care and circumvention of financial penalties posed by clinical commissioning groups, but at what cost?:

Background: In Hampshire Hospitals NHS Foundation Trust, in addition to an on-the-spot investigation into hospital-onset Clostridium difficile infection (CDI) by the infection prevention team, a multidisciplinary team root cause analysis (MDT-RCA) forum has been developed. The MDT-RCA aims to deliver a more thorough investigation into individual cases and the recommendation of cases to the clinical commissioning groups (CCG) appeals panel against potential financial penalties (£10,000 per breached case). We mainly aimed to investigate the financial impact of MDT-RCAs to the Trust. Methodology: Over two years, 84 cases of hospital-onset CDI cases were reviewed by the MDT-RCA forum. Results: Among this cohort, no additional learning outcomes were identified by the MDT-RCAs over those that were found by on-the-spot investigations. In total, 543 staff members attended the MDT-RCAs at a potential cost to the Trust of £23,795.74–£51,670.10. The Trust appealed against financial penalties for 27 cases and 14 were successful, i.e. £140,000 would have been avoided had targets been breached by 14 cases. However, targets were only breached by two cases, meaning only £20,000 in fines was avoided. Deducting this from the total costs of the MDT-RCA meant the Trust lost £3,795.74–£31,670.10. Conclusion: Over the two years reviewed, the MDT-RCA proved to be costly to the Trust, with no additional learning or quality improvement measures identified.

Hot topics in necrotising skin and soft tissue infections

Please cite this article as: Kordo Saeed , Silvano Esposito , Ian Gould , Tiziana Ascione , Matteo Bassetti , Eric Bonnet , Emilio Bouza , Monica Chan , Joshua S Davis , Giuseppe De Simone , Matthew Dryden , Thomas Gottlieb , Karolin Hijazi , David C Lye , Pasquale Pagliano , Christina Petridou , Elda Righi , John Segreti , Serhet Unal , Ata Nevzat Yalcin , Hot topics in necrotising skin and soft tissue infections, International Journal of Antimicrobial Agents (2018), doi: 10.1016/j.ijantimicag.2018.02.012