Unit:
Τομέας ΠαθολογίαςLibrary of the School of Health Sciences
Author:
Makina Anna-Armpana
Dissertation committee:
Γεώργιος Δημητριάδης , Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Ευάγγελος Γιαμαρέλλος -Μπουρμπούλης , Καθηγητής, Ιατρική Σχολή,ΕΚΠΑ
Σωτήριος Τσιόδρας , Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Αντώνιος Παπαδόπουλος, Αναπληρωτής Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Αναστασία Αντωνιάδου, Αναπληρώτρια Καθηγήτρια, Ιατρική Σχολή,ΕΚΠΑ
Ράπτης Αθανάσιος, Αναπληρωτής Καθηγητής, Ιατρική Σχολή, ΕΚΠΑ
Πουλάκου Γαρυφαλλιά Αναπληρώτρια Καθηγήτρια, Ιατρική Σχολή, ΕΚΠΑ
Original Title:
Περιορισμός εμπειρικής και στοχευμένης χορήγησης καρβαπενεμών με αντικατάσταση τους απο άλλα δραστικά αντιμικροβιακά σε γ'βάθμιο νοσοκομείο και διερεύνηση μείωσης της αντοχής στις καρβαπενέμες (Προοπτική Μελέτη Παρατήρησης)
Translated title:
Safety of a carbapenem-sparing approach as part of an antibiotic stewardship program,in a setting with increased carbapenem resistance
Summary:
Objective: We sought to implement an Antimicrobial Stewardship Program (ASP) based on carbapenem sparing, in a Greek tertiary hospital with carbapenem-resistance (CR) endemicity. Our objectives were to investigate firstly feasibility and safety, as expressed by patient outcomes and secondly impact of this program in antimicrobial consumption and antimicrobial resistance rates in the hospital.
• Materials and Methods: In a quasi-experimental before-and-after study we compared a 12-month pre-intervention period (October 2012 to September 2013) with a 27-month intervention period (October 2013 to December 2015), in which the Antimicrobial Stewardship Program team (ASPT) provided unsolicited face-to-face consultation for every patient with prescription of meropenem or imipenem. Treating physicians were advised to switch to carbapenem-sparing options for empiric or definite treatment based on risk estimation or microbiological data respectively. Patients switched to carbapenem-sparing regimen comprised Group A and those maintained on a carbapenem-regimen Group B. Patients’ 28 day all-cause mortality, length of stay and duration of antibiotics were measured along with demographics and severity indices. During the study period, quarterly (3-month intervals) antibiotic consumption as well as consumption of carbapenems (imipenem and meropenem), piperacillin/tazobactam, tigecycline, colistin, 3rd generation cephalosporins (ceftriaxone and ceftazidime), aminoglycosides and ciprofloxacin were recorded for the entire hospital and for each department separately as Defined Daily Doses (DDDs)/100 patient-days. Additionally, rates of resistance of key nosocomial Gram-negative pathogens (Klebsiella pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa) were recorded at 6 months intervals and compared between the pre- and post-intervention periods. Resistance rates were defined as the percentage of isolates recovered from any specimen that were resistant to selected class-representative antimicrobials
• Results: Group A enrolled 168 patients and Group B 136 (304 in total), with similar severity (median APACHE II, 19) and rates of septic shock (68% average). Treating physicians’ adherence to the strategy was 71.8%. The majority of Group A received piperacillin-tazobactam based regimens followed by colistin-based regimens. All-cause 28-day mortality of the cohort was 30% with no significant difference between the two groups (26.2% versus 35.3% in group A and B respectively). Age>65years and APACHE II score >12 were associated with significantly increased mortality. Safety was demonstrated also in bacteraemic infections caused by ESBL Enterobacteriaceae or CR-pathogens, among which no difference in mortality was recorded between the two study sub-groups. Group A had significantly longer antibiotic treatment but shorter hospital stay compared to Group B (mean duration, 13.3 vs 10.8 days, respectively, P<0.001; length of stay, median 18 vs 26.5 days respectively, P<0.001). Carbapenem use in the hospital wards was significantly reduced throughout the study period from 32.0 [30.1 – 56.9] in the pre-intervention period to 26.6 [14.3 – 35.8] DDDs/100patient-days (p=0.009). On the other hand, a significant increase was documented in the consumption of other antibiotics from 485.4 [352.1 – 596.5] to 660.0 [641.4 – 822.9] DDDs/100patient-days respectively, (p=0.009). These data did not change when ICU consumption was included. Antimicrobial susceptibility rates of the key pathogens did not change over time. Notably no increase in resistance rates of the antibiotics that counterbalanced carbapenem reduction (piperacillin/tazobactam and colistin) was recorded.
• Conclusion: A Carbapenem-Sparing Program implemented in a Greek hospital with predominance of CR pathogens, was a safe approach for patients with Gram-negative multidrug-resistant infections, indicating that minimizing of carbapenem prescriptions is feasible. Bedside dedicated consultation of the AST ensured acceptance of the strategy. Carbapenem use was significantly decreased compared to the pre-intervention period, however no decrease in resistance rates was noted among the key pathogens.
Main subject category:
Health Sciences
Keywords:
Carbapenem restriction-sparing, Antimicrobial stewardship programm,Carbapenem resistance rates
Number of references:
350
