Duration of antimicrobial therapy in sepsis
Despite in special situations (for example,
infective endocarditis, Gram-negative meningitis),
prolonged antimicrobial therapy has not been
demonstrated as beneficial. In most cases, it
implies more adverse effects, costs, LOS and
resistance. Zilahi et al in their review of duration
of antibiotic therapy in the ICU, conclude that
shortened antibiotic courses are effective and safe
but do not recommend a ‘one size fits’ all
approach in all situations. 13 In VAP, eight-day
versus five-day courses have demonstrated an
increase in antibiotic-free days and a reduction in
VAP infections by multidrug-resistant
microorganisms without an increase in mortality
and treatment failure, as reviewed by Pugh et al. 14
Chositprasitsakul et al demonstrated that short
(six to ten days) versus long regimes (11–16 days)
for Enterobacteriaceae bacteraemia obtained
comparable outcomes and protection against
multidrug-resistant Gram-negative bacteria. 15
Short-course therapy for invasive meningococcal
disease (four versus seven days) was successful
without disease recurrence. 16
(CDC) identified seven core elements for an
efficacious model:
• leadership commitment
• drug expertise
• action
• accountability
• tracking
• reporting
• education.
Interventions to improve antimicrobial use are
summarised in Table 1. 11 Most teams include
infectious disease physicians or pharmacists
dedicated to this activity, who collaborate with
microbiologists, hospital epidemiologists and the
clinicians responsible for each patient. In sepsis,
intensivists with expertise in severe infections
play a very important role. ASPs use several
strategies such as restrictive prescriptive
authority (limited use is sepsis where antibiotics
are an emergency), prospective review and
feedback, educational programmes, clinical
guidelines, pharmacodynamic dose optimisation
and computer-assisted decision support programs.
But, are ASPs useful? Zhang and Singh conducted
a systematic review of studies related to ASPs in
ICUs and found that 85% of studies were positive
in one or more of these outcomes: decreasing
antibiotic use; ICU LOS; antibiotic resistance or
prescribing costs. 12 To date, many studies have
demonstrated the utility of ASPs to improve
antibiotic prescription and reducing associated
costs, but there are few data demonstrating that
ASPs are effective in reducing antibiotic
resistance.
Antibiotic
stewardship
programmes
have been
created to
support
health care
practitioners
in ensuring
appropriate
antimicrobial
use. Each
hospital should
create a team
according to
their personnel
and budget
21
HHE 2018 | hospitalhealthcare.com
Diagnostic stewardship
One of the barriers to AS defined by Niederman 10
was, in case of negative cultures, the fear of not
treating the causative microorganism. It is well
known that the positivity of microbiological
cultures in ICU is low, as the 51.4% reported in
the EPIC II study. 17 In septic patients, delay to
appropriate antibiotic therapy is an increased
risk of death. 18 When conventional methods
are used, time required to identify causative
microorganisms often exceeds the clinical
decision time and could prevent AS. Novel rapid
identification tools would raise ASPs. New
technology recently developed, such as matrix-
assisted laser desorption ionisation-time of flight
(MALDI-TOF), mass spectometry and PCR-assays
should improve appropriateness of therapy and
favour AS. 19,20 To date, these techniques might
improve patient care and antibiotic
appropriateness but must be carefully interpreted
by clinicians. The process of ordering and
interpreting sophisticated diagnostic tests is
complex and sometimes confounding. It could
result in an excess of false-positive tests.
Routinely, clinicians order tests that frequently
are not adequate according to a patient’s clinical
condition. Diagnostic stewardship is defined by
the Global Antimicrobial Resistance Surveillance
System developed by WHO as follows
“coordinated guidance and interventions to
improve appropriate use of microbiological
diagnostics to guide therapeutic decisions. It
should promote appropriate, timely diagnostic
testing, including specimen collection, and
pathogen identification and accurate, timely
reporting of results to guide patient treatment”. 21
The implementation of diagnostic stewardship
includes different actions such as laboratory
policies to refuse diagnostic tests if not adequate
and educational interventions to train
practitioners to order appropriate tests with
correct sampling. Morgan et al signalled that
a potential harm of diagnostic stewardship is
that by reducing tests, some diagnostics can be
missed, so close clinical monitoring is necessary
to ensure patient safety. 22 Additionally,