Use Of Antibiotics In Intensive Care Unit Research Articles

1792. Different Patterns of Antibiotic Use in Different Administrative Categories: An Overview of 10 years (2009/2018) of a Statewide Surveillance Program in Sao Paulo, Brazil

Abstract Background To describe intensive care unit (ICU) antibiotic use in different administrative categories based on data reported to the Nosocomial Surveillance System of the State Health Department (SHD) in the State of Sao Paulo. Methods This ecological study describes at an aggregated level the antibiotic use in adult ICU reported to São Paulo SHD, from 2009 to 2018. ICUs were categorized by hospital administrative category (private, public, and philanthropic). Public hospitals were subdivided into two administrative sub-categories as Social Health Organization (SHO), which administration is private but public funded, or direct public administration (DPA). Resistance phenotype incidence and antibiotic use correlation was calculated for meticilin-resistant Staphylococcus aureus (MRSA) and glycopeptide use, third generation cephalosporin (3GC)-resistant Enterobacterales and carbapenem use, carbapenem-resistant gram-negative bacilli (CR-GNB) and polymyxins use. Results The average number of hospitals reporting annual data on antibiotic use was 386. A total of 17.490.966 patient-days were included. Total antibiotic use in ICUs increased from 588.16 in 2009 to 943.12 DDD/1000pd in 2018 (p< 0,01). The DDD (defined daily dose) of antibiotic was higher in public hospitals (mean 889.11 DDD/1000pd), than in the private hospitals (mean 849.07 DDD/1000pd) and in the philanthropic hospitals (mean 48 785.12 DDD/1000pd) (p< 0.05). Positive correlations were detected between glycopeptide use and MRSA incidence, polymyxins use and CR-GNB incidence. A weak negative correlation between carbapenems use and 3GC-resistante Enterobacterales incidence were found. Figure I:Antimicrobial use by therapeutic class between 2009 and 2018 in DDD / 1000 patient-daysTable I:Antibiotic use by therapeutic class by administrative type in DDD/1000 patients-dayTable II:Antibiotic use in public hospital by subgroup between 2009 and 2018 in DDD/1000 patients-day Conclusion We found higher use of antibiotics in public hospitals than in private and philanthropic. Differences in antibiotic use were observed among SHO e DPA public hospitals. These data provide important information for formulating hypotheses and public health strategies to improve antimicrobial prescription. Disclosures All Authors: No reported disclosures.

Drug Utilization Evaluation of Antibiotics in Intensive Care Units of a Referral Teaching Hospital

Background: Drug Utilization Evaluation (DUE) studies are designed to assess drug usage appropriateness. This study aimed to evaluate the drug utilization of antibiotics in the intensive care units (ICUs) of a referral teaching hospital.
 Methods: Patients hospitalized in ICU who received antibiotics were enrolled in this crosssectional study. Patients’ medical charts were reviewed and data including indication of antibiotics, dosing, dose adjustment, and culture sensitivity test were recorded in a predesigned data collection form. Related guidelines and references were used for judgement about the correctness of these parameters.
 Results: Among 182 evaluated antibiotic prescriptions, 75.8% of the cases were prescribed empirically that for 31.88% of them microbial culture and sensitivity test were requested. Indication was appropriate in 51.6%. Fifteen patients needed antibiotic dose adjustment that was performed just for 4 patients. Doses of antibiotics were correct in 58.5% of cases. Meropenem (15.9%), Metronidazole (15.9%), and vancomycin (11.5%) were the most frequently prescribed antibiotics.
 Conclusion: Use of antibiotics in ICUs of our hospital is associated with high rate of errors especially in the aspects of medical indication and dosage. J

Assessing the Prescription Pattern of Antimicrobial Agents in Intensive Care Unit at Tertiary Care Hospital

Antibiotic resistance is the major concern in developing countries especially in India, and the prime reason behind it is the irrational prescription of antibiotics. Therefore, assessment of the prescribing pattern of antibiotics in the intensive care unit (ICU) would help to ascertain the rational use of antibiotics in ICU. In a prospective observational study, prescription pattern of patients on antimicrobial agents for any infectious diseases was reviewed and assessed in ICU at a tertiary care hospital for 6 months. All the patients receiving at least one antibiotic except paediatric, pregnant, and lactating patients were included in the study. The prescriptions were also analysed in accordance with the indicators provided by WHO AWARE list. A total of 227 patients were enrolled in the study after obtaining their informed consent form. The majority of patients were in the age group 51 to 65 (33.48%) and males (54.18%). The most common pathological conditions for which patients admitted to ICU were acute gastroenteritis (21.68%), urinary tract infection (13.98), and viral fever (11.19%). Amongst all antimicrobial agents prescribed, cefoperazone along with sulbactam (20.29%) and ceftriaxone (18.84%) was most frequently prescribed followed by metronidazole (9.90%) and levofloxacin (6.76%). Broad-spectrum antibiotics were prescribed in 66% of the total enrolled patients, whereas only 9% of patients underwent a culture sensitivity test. As per the WHO AWARE list, 50% of antimicrobial agents were from the watch category followed by 20% and 17% from the access and reserve category, respectively. The high use of broad-spectrum antibiotics suggests that there is a need for more awareness amongst the health care professionals and communities about the emerging antibiotic resistance problem which is mainly due to over and inappropriate use of antibiotics.

Inapropriate use of antibiotics effective against gram positive microorganisms despite restrictive antibiotic policies in ICUs: a prospective observational study

BackgroundGram-positive spectrum antibiotics such as vancomycin, teicoplanin, daptomycin, and linezolid are frequently used in empirical treatment combinations in critically ill patients. Such inappropriate and unnecessary widespread use, leads to sub-optimal utilisation. However they are covered by the antibiotics restriction programme. This prospective observational study, evaluates gram-positive anti-bacterial utilisations in intensive care units (ICUs) with various evaluation criteria, to determine the frequency of inappropriate usage and the intervention targets required to ensure optimum use.MethodsThis clinical study was conducted prospectively between 01.10.2018 and 01.10.2019 in the medical and surgical ICUs of Gazi University Faculty of Medicine Hospital, Turkey. The total bed capacity was 55. Patients older than 18 years and who were prescribed gram-positive spectrum antibiotics (vancomycin, teicoplanin, linezolid, and daptomycin) were included. Patients under this age or immunosuppressed patients (neutropenic,- HIV-infected patients with hematologic or solid organ malignancies) were not included in the study. During the study period, 200 treatments were evaluated in 169 patients. The demographic and clinical features of the patients were recorded. Besides observations by the clinical staff, the treatments were recorded and evaluated by two infectious diseases specialists and two clinical pharmacists at 24-h intervals from the first day to the last day of treatment.SPSS software for Windows, (version 17, IBM, Armonk, NY) was used to analyse the data. Categorical variables were presented as number and percentage, and non-categorical variables were presented as mean ± standard deviation.ResultsIt was found that inappropriate gram-positive antibiotic use in ICUs was as high as 83% in terms of non-compliance with the selected quality parameters. Multivariate analysis was performed to evaluate the factors associated with inappropriate antibiotic use, increased creatinine levels were found to increase the risk of such use.ConclusionsIn spite of the restricted antibiotics programme, inappropriate antibiotic use in ICUs is quite common. Thus, it is necessary to establish local guidelines in collaboration with different disciplines for the determination and follow-up of de-escalation of such use and optimal treatment doses.

Predictors of antibiotic utilization among intensive care unit patients

Increased antibiotic utilization in hospital is linked to higher total treatment costs, together with increased length of stay, surgery and emergency admission. The aim of our retrospective cohort study was to investigate predictors of antibiotic utilization per single patient from an intensive care unit (ICU) of a tertiary care, university hospital in Serbia. Average utilization of antibiotics per patient was 23.9 ± 20.4 defined daily doses (DDDs). Diagnosis of systemic infection increased antibiotics utilization per patient for 10.0 DDDs, positive blood culture for 5.4 DDDs, isolation of Pseudomonas spp. for 19.5 DDDs, isolation of Acinetobacter spp. for 6.3 DDDs and injury for 7.3 DDDs per patient. Each new day of hospitalization and each additional drug prescribed increased utilization for further 0.3 DDDs and 1.2 DDDs, respectively. Appropriate and limited use of antibiotics in ICU is of key importance for preserving their effectiveness and decrease of bacterial resistance.

Point-of-care Procalcitonin Guidance to Reduce Antibiotic Use in Critically Ill Patients: A Randomized Controlled Trial

Introduction: Antibiotic therapy is of great importance in sepsis but prolonged duration can add to the emergence of antibiotic resistance. We aimed to examine whether point-of-care (POC) procalcitonin (PCT) guidance can safely reduce the duration of antibiotic use in infected critically ill patients. Materials and Methods: Eighty adult patients admitted to or acquired sepsis in the intensive care unit (ICU) were enrolled in this randomized controlled trial. Patients were allocated to either POC PCT-guided intervention arm (n=40) or the control arm, in which antibiotic therapy followed local guidelines (n=40). In the PCT-guided arm, antibiotic treatment was discontinued if clinical signs of infection improved and the PCT concentration decreased by >80% of its peak value, or when it reaches a value of <0·5 g/L. Results: The mean duration of antibiotic use for PCT arm was 6.4 (SD 2.3) days compared to 9 (SD 4.3) days in the control arm (p=0.004). In the first 30 days after being assigned to a group, the proportion of patients who received a repeated course of systemic antibiotics was 33% in the PCT arm vs 38.1% in the control arm (p=0.757). Mean length of stay in the ICU was 8.4 (SD 5.3) days in the PCT arm vs 10.4 (SD 12.3) days in the control arm (p=0.404). Mortality at 30 days was 22.5% in the PCT-arm vs 25% in the control arm (p<0.0001). Conclusion: POC PCT guidance stimulates reduction of duration of antibiotic use in ICU, accompanied by a significant decrease in mortality.

Continuous versus intermittent endotracheal cuff pressure control for the prevention of ventilator-associated respiratory infections in Vietnam: study protocol for a randomised controlled trial

BackgroundVentilator-associated respiratory infection (VARI) comprises ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT). Although their diagnostic criteria vary, together these are the most common hospital-acquired infections in intensive care units (ICUs) worldwide, responsible for a large proportion of antibiotic use within ICUs. Evidence-based strategies for the prevention of VARI in resource-limited settings are lacking. Preventing the leakage of oropharyngeal secretions into the lung using continuous endotracheal cuff pressure control is a promising strategy. The aim of this study is to investigate the efficacy of automated, continuous endotracheal cuff pressure control in preventing the development of VARI and reducing antibiotic use in ICUs in Vietnam.Methods/designThis is an open-label randomised controlled multicentre trial. We will enrol 600 adult patients intubated for ≤ 24 h at the time of enrolment. Eligible patients will be stratified according to admission diagnosis (180 tetanus, 420 non-tetanus) and site and will be randomised in a 1:1 ratio to receive either (1) automated, continuous control of endotracheal cuff pressure or (2) intermittent measurement and control of endotracheal cuff pressure using a manual cuff pressure meter. The primary outcome is the occurrence of VARI, defined as either VAP or VAT during the ICU admission up to a maximum of 90 days after randomisation. Patients in both groups who are at risk for VARI will receive a standardised battery of investigations if their treating physician feels a new infection has occurred, the results of which will be used by an endpoint review committee, blinded to the allocated arm and independent of patient care, to determine the primary outcome. All enrolled patients will be followed for mortality and endotracheal tube cuff-related complications at 28 days and 90 days after randomisation. Other secondary outcomes include antibiotic use; days ventilated, in ICU and in hospital; inpatient mortality; costs of antibiotics in ICU; duration of ICU stay; and duration of hospital stay.DiscussionThis study will provide high-quality evidence concerning the use of continuous endotracheal cuff pressure control as a method to reduce VARI, antibiotic use and hospitalisation costs and to shorten stay.Trial registrationClinicalTrials.gov, NCT02966392. Registered on November 9, 2016. Protocol version: 2.0; issue date March 3, 2017.

A nationwide survey of intravenous antimicrobial use in intensive care units in Japan

Although most patients in the intensive care unit (ICU) receive antibiotics, little is known about patterns of antibiotic use in ICUs in Japan. The objective of this study was to evaluate the pattern of antibiotic use in ICUs. A nationwide one-day cross-sectional surveillance of antibiotic use in the ICU was conducted three times between January 2011 and December 2011. All patients aged at least16 years were included. Data from 52 ICUs and 1148 patients were reviewed. There were 1028 prescriptions for intravenous antibiotics. Of 1148 patients, 834 (73%) received at least one intravenous antibiotic, and 575 had at least one known site of infection. Respiratory and intra-abdominal infections were the two most common types. Of 1028 prescriptions, 331 (34%) were for surgical or medical prophylaxis. Excluding prophylaxis, carbapenems were the most commonly prescribed agent. Infectious disease consultations, pre- and post-prescription antimicrobial stewardship, and ICU-dedicated antibiograms were available in 44%, 52%, 77%, and 21% of the ICUs, respectively. In logistic regression analysis adjusting for patient characteristics, treatment in a university hospital (adjusted odds ratio, 1.72; 95% CI, 1.05–2.84; P = 0.033) and an open ICU (adjusted odds ratio, 2.30; 95% CI, 1.02–5.17; P = 0.044) were significantly associated with greater likelihood of carbapenem use. An increase in the number of closed ICUs and more intensive care specialists may reduce carbapenem use in Japanese ICUs. Large-scale epidemiological studies of antimicrobial resistance in the ICU are needed.

Analysis of the distribution characteristics and drug resistance of non-fermenting bacterial infection in intensive care unit from 2009 to 2015

To study the distribution characteristics and drug resistance of non-fermenting bacterial infection in intensive care unit (ICU) at a tertiary hospital during seven consecutive years, and to provide evidence for rational use of antibiotics in ICU. A retrospective analysis was conducted. The related data about non-fermentative bacteria obtained from clinical specimens, collected from lower respiratory tract, blood, urine, bile and other secretions of ICU patients admitted to Binzhou Medical University Hospital from January 2009 to December 2015 were retrospectively analyzed. The distribution characteristics and drug resistance of non-fermentative bacteria, and isolation rate of multiple drug resistance (MDR) strains were analyzed. 2 672 strains of nonfermentative bacteria were isolated during seven consecutive years, accounting for 57.9％ gram negative (G-) bacilli (2 672/4 613),and 35.2％ of all bacteria (2 672/7 587).The top five were Acinetobacter baumannii (38.4％),Pseudomonas aeruginosa (34.6％),Onion burkholderia cepacia (9.9％),Stenotrophomonas maltophilia (6.2％),and Pseudomonas fluorescens (5.6％).Non-fermentative bacteria were mainly isolated from the lower respiratory tract (60.9％).Isolation of the non-fermentative bacteria accounted for over 50％ of G-bacilli during seven consecutive years, and the isolation rate of the top five types of bacteria showed no obvious change, while positive rate of Acinetobacter baumannii showed a tendency to increase (obviously from 26.5％ in 2009 to 50.2％ in 2015),and a lowering trend of positive rate of Onion burkholderia cepacia,Stenotrophomonas maltophilia, and Pseudomonas fluorescens was obvious (from 15.6％,10.6％,13.0％ in 2009 to 5.6％,7.4％,1.4％ in 2015 respectively) was observed. The isolation rate of Pseudomonas aeruginosa was stable (about 30％) during seven consecutive years. The drug susceptibility results showed that the resistant rates of Acinetobacter baumannii against imipenem, meropenem, aminoglycosides and third-generation cephalmsporins were all higher than 70％,while its resistant rate to cefoperazone-sulbactam was relatively lower (40.2％-68.1％)with relatively higher sensitivity rate (23.6％-46.0％).In contrast, the resistant rates of Pseudomonas aeruginosa against antibiotics were low,while the sensitivity rate to fourth-generation cephalmsporins cefepime (58.3％-87.7％)and third-generation cephalmsporins was high (ceftazidime:55.6％-79.3％,piperacillin-tazobactam:62.5％-86.2％,cefoperazone-sulbactam:46.0％-89.8％).From 2009 to 2015,the incidence of MDR strains of Acinetobacter baumannii showed an obvious increasing tendency (from 68.0％ to 84.1％);in contrast, the incidence of MDR strains of Pseudomonas aeruginosa did not show an obviously increase in incidence from 2009 to 2012,on the other hand, it showed a decreasing tendency from a peak 68.6％ in 2012 to 23.5％ in 2015. The isolation rate of non-fermentative bacteria was high and the drug resistance situation was serious. Therefore,it is important to grasp the knowledge regarding distribution characteristics, drug resistance and variation of non-fermentative bacteria in ICU. It is not only beneficial for both rational use of antibiotics, improve efficacy but also helpful in reducing the emergence of drug resistance stains.

Prevalence of antimicrobial resistance among gram-negative isolates in an adult intensive care unit at a tertiary care center in Saudi Arabia

BACKGROUND AND OBJECTIVES:Patients in the ICU have encountered an increasing emergence and spread of antibiotic-resistant pathogens. We examined patterns of antimicrobial susceptibility in gram-negative isolates to commonly used drugs in an adult ICU at a tertiary care hospital in Riyadh, Saudi Arabia.METHODS:A retrospective study was carried out of gram-negative isolates from the adult ICU of King Fahad National Guard Hospital (KFNGH) between 2004 and 2009. Organisms were identified and tested by an automated identification and susceptibility system, and the antibiotic susceptibility testing was confirmed by the disk diffusion method.RESULTS:The most frequently isolated organism was Acinetobacter baumannii, followed by Pseudomonas aeruginosa, Escherichia coli, Klebsiella pnemoniae, Stenotrophomonas maltophilia, and Enterobacter. Antibiotic susceptibility patterns significantly declined in many organisms, especially A baumannii, E coli, S marcescens, and Enterobacter. A baumannii susceptibility was significantly decreased to imipenem (55% to 10%), meropenem (33% to 10%), ciprofloxacin (22% to 10%), and amikacin (12% to 6%). E coli susceptibility was markedly decreased (from 75% to 50% or less) to cefuroxime, ceftazidime, cefotaxime, and cefepime. S marcescens susceptibility was markedly decreased to cefotaxime (100% to 32%), ceftazidime (100% to 35%), and cefepime (100% to 66%). Enterobacter susceptibility was markedly decreased to ceftazidime (34% to 5%), cefotaxime (34% to 6%), and pipracillin-tazobactam (51% to 35%). Respiratory samples were the most frequently indicative of multidrug-resistant pathogens (63%), followed by urinary samples (57%).CONCLUSION:Antimicrobial resistance is an emerging problem in the KFNGH ICU, justifying new more stringent antibiotic prescription guidelines. Continuous monitoring of antimicrobial susceptibility and strict adherence to infection prevention guidelines are essential to eliminate major outbreaks in the future.

Antibiotic resistance in intensive care unit areas.

The incidence of nosocomial infections and antimicrobial resistance rates of nosocomial pathogens vary considerably among countries and even among intensive care units (ICUs) within one hospital. Such differences might be partly due to the selection pressure exerted by certain antibiotics, since intensive care patients are given more antimicrobials than any other group of patients. We therefore compared resistance rates of four important nosocomial pathogens (Staphylococcus aureus, E. coli, Klebsiella pneumoniae, Pseudomonas aeruginosa) isolated from patients in general wards and ICUs. There were few trends toward higher resistance of ICU isolates, and most differences were found with Klebsiella pneumoniae. We also tried to relate antibiotic use in ICUs and frequency of antibiotic resistance of five selected nosocomial pathogens. The ampicillin and cephalosporin resistance of E. coli and Klebsiella pneumoniae arose along with an increase in usage of both drugs. Decreasing prescription of cotrimoxazole was not reflected by decrease in resistance of Staphylococcus aureus and Staphylococcus epidermidis. Increasing prescriptions of tetracyclines were followed by an increasing resistance of E. coli, but not of Staphylococci. The oxacillin resistance of Staphylococcus epidermidis almost paralleled the consumption, the opposite was true for Staphylococcus aureus. There seemed to be a rather close relationship between the incidence of resistant Staphylococcus aureus, Staphylococcus epidermidis and Pseudomonas aeruginosa strains and the quantities of gentamicin, tobramycin and azlocillin prescribed. The increase or decrease of prescriptions of certain antimicrobials increased or decreased their resistance rate to the respective drugs of only certain bacterial strains in one ICU, but not in the other. The findings in our hospital cannot necessarily be applied to other hospitals.(ABSTRACT TRUNCATED AT 250 WORDS)