Initiation Of Antimicrobial Therapy Research Articles

THE USE OF EMPIRICAL ANTIBIOTICS IN THE CRITICAL CARE UNIT

Antimicrobial therapy plays a crucial role in managing infections in critically ill patients, yet its indiscriminate use can lead to adverse outcomes. Here, we propose a systematic approach for guiding empirical antimicrobial therapy in intensive care unit (ICU) patients with suspected infections. Diagnostic evaluation, including imaging, laboratory tests, and physical examination, is essential to assess the necessity of antimicrobial treatment. Despite advances, no gold standard biomarker for differentiating infection from inflammation necessitates thorough diagnostic assessment. Prompt microbiological sampling is crucial for accurate diagnosis and tailored treatment. Emergency initiation of antimicrobial therapy is recommended for conditions like sepsis and septic shock, emphasizing the need for timely intervention. Pathogen profiling and consideration of multidrug resistance risk factors are essential for selecting appropriate empirical therapy. Customized evaluation based on patient characteristics and regional trends is paramount for optimal antibiotic selection. Pharmacokinetic and pharmacodynamic parameters should guide dosing to ensure adequate antibacterial levels while minimizing adverse effects. Future research should focus on AI-powered decision-making systems, optimal timelines for starting or postponing therapy, and the environmental impacts of antibiotic use to enhance patient outcomes and reduce antimicrobial resistance.

Cost-avoidance associated with implementation of an overnight emergency medicine pharmacist at a Level I Trauma, Comprehensive Stroke Center

AimTo investigate the cost-avoidance associated with implementation of an overnight emergency medicine pharmacist (EMP) through documented clinical interventions. DesignRetrospective evaluation of prospectively tracked interventions in a single Level I Trauma, Comprehensive Stroke Center, from November 25, 2020 through March 12, 2021 during expanded emergency medicine service hours (2300–0700). InterventionsOne of 45 clinical patient-care recommendations associated with cost-avoidance were available to be selected and documented by the EMP; more than one intervention was allowed per patient, though one clinical intervention could not be counted as multiple items. Documented services were associated with monetary cost avoidance based upon available literature assessing pharmacy clinical interventions. Differences in time from imaging to systemic thrombolytics and percentage of patients meeting door-to-alteplase benchmarks were compared with and without the availability of EMPs. ResultsOvernight EMPs documented 820 interventions during 107 overnight shifts with a cost avoidance of $612,974. The most common interventions were bedside monitoring (n = 127; $50,694), drug information consultation (97; $11,269), and antimicrobial therapy initiation and streamlining (95; $60,101). When categorizing interventions, 378 (46%; $292,484) were input as hands-on care, 216 (26%; $94,899) as individualization of patient care, 135 (17%; $25,897) as administrative and supportive tasks, 84 (10%; $121,746) as adverse drug event prevention, and 7 (1%; $77,964) as resource utilization. All patients (n = 6) with an acute ischemic stroke during the evaluation period received systemic thrombolytics ≤45 min in the presence of EMPs compared with 50% receiving thrombolytics ≤45 min without EMPs. ConclusionsExpanded overnight coverage by EMPs provided clinical bedside pharmacotherapy expertise to critically ill patients otherwise not available prior to study implementation. Clinical interventions were associated with substantial cost-avoidance.

Neumonía adquirida en la comunidad: epidemiología, diagnóstico, escalas pronósticas de gravedad y nuevas opciones terapéuticas

This narrative review article explores the current scientific knowledge on the definition, epidemiology, diagnostic criteria, microbiology, treatment, and prevention of severe community-acquired pneumonia (SCAP) in immunocompetent adults. At present, despite major scientific advances in diagnostic evaluation, clinical management, antimicrobial therapy, and prevention, severe community-acquired pneumonia remains a major cause of morbidity and mortality, as well as having a major economic impact in terms of increased healthcare expenditure worldwide. This pathology is considered one of the leading causes of sepsis/septic shock, with an extremely high overall mortality rate, which justifies all the effort in early diagnosis, proper management, and prompt initiation of antimicrobial therapy. Including biomarkers (isolated or in combination) associated with applying diagnostic criteria and prognostic severity scales in clinical practice helps identify patients with severe community-acquired pneumonia, defines immediate admission to the intensive care unit, and, thus, minimizes the adverse outcomes of this serious pathology.

Group A ß-hemolytic streptococcal pharyngitis: An updated review.

Group A ß-hemolytic streptococcus (GABHS) is the leading bacterial cause of acute pharyngitis in children and adolescents worldwide. This article aims to familiarize clinicians with the clinical manifestations, evaluation, diagnosis, and management of GABHS pharyngitis. A search was conducted in December 2022 in PubMed Clinical Queries using the key term "group A β-hemolytic streptococcal pharyngitis". This review covers mainly literature published in the previous ten years. Children with GABHS pharyngitis typically present with an abrupt onset of fever, intense pain in the throat, pain on swallowing, an inflamed pharynx, enlarged and erythematous tonsils, a red and swollen uvula, enlarged tender anterior cervical lymph nodes. As clinical manifestations may not be specific, even experienced clinicians may have difficulties diagnosing GABHS pharyngitis solely based on epidemiologic or clinical grounds alone. Patients suspected of having GABHS pharyngitis should be confirmed by microbiologic testing (e.g., culture, rapid antigen detection test, molecular point-of-care test) of a throat swab specimen prior to the initiation of antimicrobial therapy. Microbiologic testing is generally unnecessary in patients with pharyngitis whose clinical and epidemiologic findings do not suggest GABHS. Clinical score systems such as the Centor score and McIssac score have been developed to help clinicians decide which patients should undergo diagnostic testing and reduce the unnecessary use of antimicrobials. Antimicrobial therapy should be initiated without delay once the diagnosis is confirmed. Oral penicillin V and amoxicillin remain the drugs of choice. For patients who have a non-anaphylactic allergy to penicillin, oral cephalosporin is an acceptable alternative. For patients with a history of immediate, anaphylactic-type hypersensitivity to penicillin, oral clindamycin, clarithromycin, and azithromycin are acceptable alternatives. Early diagnosis and antimicrobial treatment are recommended to prevent suppurative complications (e.g., cervical lymphadenitis, peritonsillar abscess) and non-suppurative complications (particularly rheumatic fever) as well as to reduce the severity of symptoms, to shorten the duration of the illness and to reduce disease transmission.

Point-of-care measurement of C-reactive protein promotes de-escalation of treatment decisions and strengthens the perceived clinical confidence of physicians in out-of-hours outpatient emergency medical services

ObjectivesOut-of-hours outpatient emergency medical services (OEMS) provide healthcare for patients with non-life-threatening conditions in need for urgent care when outpatient practices are closed. We studied the use of point-of-care-testing of...

DIRECT ANTIMICROBIAL SUSCEPTIBILITY TESTING OF GRAM NEGATIVE BACILLI FROM POSITIVE BLOOD CULTURES

Conventional blood culture and susceptibility pattern takes around 48 hours after blood culture bottles turns positive on Bact/ALERT system. Rapid initiation of antimicrobial therapy is required in management of sepsis patients to reduce its adverse effects on mortality and morbidity. Objective of this study was to execute rapid and accurate direct antimicrobial susceptibility testing (DST) of gram negative bacilli on positive blood culture bottles by the disk diffusion method and compare the results with those of standard antimicrobial susceptibility testing (AST). This prospective study was performed at the Saveetha Institute of Medical and Technical Science, Sriperumbudur, with mono-bacterial gram negative bacilli. 100-gram negative bacilli (GNB) samples were agged from positive blood cultures with duration of 3 months. Both DST and AST results were interpreted, and the isolates were identied by vitek2. On 100 GNB isolates, the most common organism was Escherichia coli, followed by Klebsiella pneumoniae (27%), Pseudomonas aeruginosa (11%), Acinetobacter baumanii (8%), Salmonella typhi (7%), Enterobacter cloacae (3%), Acinetobacter lwof(3%) and Serratia marsacens. The DST and AST correlations were found to be in 99% categorical agreement, with 1% minor error, 0% major error, and 0% very major error. The concentration of bacterial inoculums impacts the results between DST and AST. DST reduces the crucial time from 24 to 48 hours for patients with bloodstream infections treated with empirical antibiotic therapy, which may or may not be resistant. DST initiates early antibiotic therapy that is susceptible to treating a bloodstream infection or sepsis. Aims and Objective: To evaluate categorical agreement of antimicrobials between DST and AST from positive blood culture bottles by Kirby-Bauer disk diffusion method. Materials and methods: A prospective study was conducted in tertiary care hospital, with sample size of 100 gram negative bacilli from positive blood culture bottles in patients suspected with blood stream infections during the period from October 2022 to December 2022. RESULTS: Out of 100 gram negative bacilli , Escherichia coli (37%) was the most common isolate, followed by Klebsiella pneumonia (27%), Pseudomonass aeroginosa (11%), Acinetobacter baumanii (8%), Salmonella typhi (7%), Enterobacter clocae (3%), Acinetobacter lw of(3%) and Serratia marsacens (2%). Conclusion: During this study, there was 99% categorical agreement between DST and AST. Earlier treatment with antimicrobials can reduce the mortality and morbidity in bacteraemia patients

Vision health perspectives on Breaking Bad: Ophthalmic sequelae of methamphetamine use disorder.

Methamphetamine use has become a rampant public health issue that not only causes devastating consequences to the user but also poses a burden to surrounding communities. A spectrum of ophthalmic sequelae is associated with methamphetamine use and includes episcleritis, scleritis, corneal ulceration, panophthalmitis, endophthalmitis, retinal vasculitis, and retinopathy. In many instances, prompt recognition of the condition and associated infectious process and early initiation of antimicrobial therapy are crucial steps to preventing vision loss. In this review, we summarize the reported ocular complications that may result from methamphetamine use in addition to several postulated mechanisms regarding the ocular toxicity of methamphetamine. The increasing prevalence of methamphetamine use as a public health threat highlights the need for continued investigation of this ophthalmologic issue.

Fighting Antimicrobial Resistance in Neonatal Intensive Care Units: Rational Use of Antibiotics in Neonatal Sepsis

Antibiotics are the most frequently prescribed drugs in neonatal intensive care units (NICUs) due to the severity of complications accompanying neonatal sepsis. However, antimicrobial drugs are often used inappropriately due to the difficulties in diagnosing sepsis in the neonatal population. The reckless use of antibiotics leads to the development of resistant strains, rendering multidrug-resistant pathogens a serious problem in NICUs and a global threat to public health. The aim of this narrative review is to provide a brief overview of neonatal sepsis and an update on the data regarding indications for antimicrobial therapy initiation, current guidance in the empirical antimicrobial selection and duration of therapy, and indications for early discontinuation.

1323. Laboratory Abnormalities in Children Undergoing Outpatient Therapy for Staphylococcus aureus Acute Hematogenous Osteomyelitis: Should We Worry?

Abstract Background Recent PIDS practice guidelines for acute hematogenous osteomyelitis (AHO) advocate for regular laboratory monitoring for adverse drug events. Data are limited however with respect to the frequency or clinical impact of antibiotic-related laboratory abnormalities (ARLA) in pediatric AHO. We reviewed the experience with ARLA in children undergoing treatment for S. aureus AHO. Methods Cases of S. aureus AHO in children were reviewed from 2011-2020. Eligible cases were those 1) discharged to complete therapy at home (IV or oral), 2) with baseline complete blood count (CBC), creatinine and AST/ALT obtained during the hospitalization and 3) at least one CBC, creatinine, and/or AST/ALT measurement in the outpatient setting while receiving AHO therapy. Neutropenia, thrombocytopenia and AST/ALT elevation were defined using the NIH DAIDS pediatric toxicity grading system; acute kidney injury (AKI) was defined using pRIFLE. Results 207 subjects met inclusion criteria. Outpatient CBC was obtained in 187 subjects, creatinine in 121 and AST/ALT in 63. Patients with and without ARLA were similar with respect to age and demographics. Neutropenia developed in 12 (6.4%) and thrombocytopenia in 5 (2.7%) at a median of 23 and 18 days of therapy, respectively (Figures 1). Outpatient hematologic abnormalities were more common among subjects with MRSA, history of inpatient ARLA and those receiving certain antibiotics, specifically vancomycin (Figures 2, 3). There was no clear relationship with hematologic abnormalities and vancomycin daily dose. Neutropenia prompted modification of therapy in 1 case. No infections or bleeding events were attributable to ARLA. Three cases of outpatient AKI occurred (2.1% [vancomycin, n=1; cefazolin, n=2]); one subject had therapy discontinued. Outpatient AST/ALT elevation occurred in six (9.5%), none of which were symptomatic. Patients with AST/ALT elevation were disproportionately treated with cefazolin (p=0.006). Panel A. The number of patients experiencing antibiotic-related laboratory abnormalities (ARLA). Panel B. Box plots depicting the timing of ARLA relative to initiation of antimicrobial therapy. Conclusion ARLAs, particularly neutropenia, are common in patients receiving outpatient therapy for AHO after 2-3 weeks of therapy. However, the majority of ARLA are mild and do not result in symptoms or modification of therapy. Further study is necessary to appreciate how these findings might be applicable to all cause osteomyelitis. Disclosures Jonathon C. McNeil, MD, Agency for Healthcare Research and Quality: Grant/Research Support|Allergan: Provided reagents for unrelated research|Nabriva: Site investigator for multicenter clinical trial Sheldon L. Kaplan, MD, MeMed: Grant/Research Support|Pfizer: Grant/Research Support.

Clinical and bacteriological profile of neonatal sepsis: a prospective hospital-based study in a tertiary care hospital in eastern zone of West Bengal

Background: Neonatal sepsis remains a leading cause of morbidity and mortality among neonates and clinical manifestations are non-specific. Delayed identification and inappropriate treatment remain as key factors causing high neonatal mortality. Increasing emergence of multidrug-resistant organisms reduces antibiotic options. Hence there is a need for institutional guidelines based on local microbial prevalence and their antibiotic susceptibility patterns.Methods: Blood cultures were collected from all suspected cases prior to the initiation of antimicrobial therapy. Neonatal sepsis with positive blood culture cases is included in the study.Results: Among 170 neonate blood culture was positive in 41 neonates (preterm - 71% and term neonate - 29%). Early onset neonatal sepsis (EONS) constituted 61% and Late onset neonatal sepsis (LONS) constituted 39%. Respiratory distress, hypoglycaemia, seizures, lethargy were more common presentations in EONS while cellulitis, sclerema, septic arthritis, loose stool, vomiting, blood in stool, hyperthermia and recurrent apnoea were more common presentations in LONS. Gram positive organisms constituted 51.2%, gram negative organisms were 46.3%, fungi were 9.8% of total pathogens. Among gram positive cons (43.9%) was most common while amongst gram negative Klebsiella (22%) was most common. Candida peliculosa was the most commonly isolated fungus. Cons, staphylococcus and enterococcus were seen to be 100% sensitive to linezolid. Enterococcus also showed 100% sensitivity to vancomycin, teicoplanin and tigecycline. Gram-positive bacteria showed the highest sensitivity to linezolid and vancomycin. Acinetobacter baumanii showed 80% sensitivity to gentamicin, 60% sensitivity to tigecycline and colistin. E. coli showed 66% sensitivity to tigecycline.Conclusions: We were able to analyze common causative pathogens, associated risk factors, and the antibiotic susceptibility pattern of neonatal sepsis.

Kinetics of serum C-reactive protein and procalcitonin levels and their connection to outcomes in community-acquired sepsis

Introduction and objective: Community-acquired sepsis is a life-threatening systemic reaction to infection starting 72 hours within hospital admittance. Data concerning kinetics of serum C-reactive protein (CRP) and procalcitonin (PCT) levels during disease progression are sparse. Our aim was to analyze kinetics of CRP and PCT among adults with community-acquired sepsis. Methods: We analyzed data of consecutive patients hospitalized with community-acquired sepsis at our centre during 2016. Sepsis was defined according to ACCP/SCCM criteria, community-acquisition was ascertained by a priori exclusion criteria. CRP and PCT values of days 1–14 were collected. Primary outcomes were in-hospital all-cause mortality, intensive care unit admission, secondary outcomes were septic source and the causative microorganism. Absolute (ΔabsCRP, ΔabsPCT) and relative (Δ%CRP, Δ%PCT) differences were calculated between values at the time of diagnosis and control values within 24 hours of empirical antimicrobial therapy initiation. Results: 193 patients were included. In-hospital all-cause mortality was 13.9%, intensive care unit admittance was 25.9%. Patients who died had significantly smaller median Δ%PCT decrements (–7.7 ± 127.9% vs. –45.7 ± 88.8%, p = 0.01), compared to survivors. During hospital stay, daily absolute values of PCT on days 2–14, while those of CRP on days 5–14 were significantly higher among patients who died. Patients admitted to the intensive care unit also had smaller median Δ%PCT decrements (–19.6 ± 72.5% vs. –49.8 ± 100.8%, p = 0.01), compared to non-admitted patients. Calculated parameters did not show significant correlations with septic focus or causative microorganisms. Discussion, conclusion: Our findings suggest that specific fluctuations of CRP and PCT are observable, and Δ%PCT might be a favourable parameter for outcome prediction among adults with community-acquired sepsis.

Antimicrobial therapy of community-acquired pneumonia during stewardship efforts and a coronavirus pandemic: an observational study

BackgroundCommunity-acquired pneumonia (CAP) is the most frequent infection diagnosis in hospitals. Antimicrobial therapy for CAP is depicted in clinical practice guidelines, but adherence data and effect of antibiotic stewardship measures are lacking.MethodsA dedicated antibiotic team pointed out CAP as a potential target for antimicrobial stewardship (AMS) measures at a 1.000-bed, tertiary care, teaching university hospital in Norway from March until May for the years 2016 throughout 2021. The aim of the AMS program was to increase diagnostic and antimicrobial therapy adherence to national clinical practice guideline recommendations through multiple and continuous AMS efforts. Descriptive statistics were retrospectively used to delineate antimicrobial therapy for CAP. The primary outcomes were proportions that received narrow-spectrum beta-lactams, and broad-spectrum antimicrobial therapy.Results1.112 CAP episodes were identified. The annual proportion that received narrow-spectrum beta-lactams increased from 56.1 to 74.4% (p = 0.045). Correspondingly, the annual proportion that received broad-spectrum antimicrobial therapy decreased from 34.1 to 17.1% (p = 0.002). Trends were affected by the coronavirus pandemic. Mortality and 30-day readmission rates remained unchanged. De-escalation strategies were frequently unutilized, and overall therapy duration exceeded clinical practice guideline recommendations substantially. Microbiologically confirmed CAP episodes increased from 33.7 to 56.2% during the study period.ConclusionCAP is a suitable model condition that is sensitive to AMS measures. A continuous focus on improved microbiological diagnostics and antimicrobial therapy initiation is efficient in increasing adherence to guideline recommendations. There is an unmet need for better antimicrobial de-escalation strategies.

Intensivists' perceptions and attitudes towards infectious diseases management in the ICU: An international survey.

Exploring infectious diseases (ID) practice in Intensive Care Unit (ICU) to identify gaps and opportunities. Online international survey (PRACT-INF-ICU) endorsed by the ESICM and open from July 30, 2019 to October 19, 2019. International study conducted in 78 countries. Physicians working in ICU. None. Practice variations were assessed according to respondents' countries income class, training, and years of practice. Univariate and multivariate ordinal logistic regression were used to estimate associations between respondents' characteristics and their perceptions regarding adequacy of training. 466 intensivists with a median practice of 10 years (interquartile range, 5-19) completed the survey. A third reported no antimicrobial stewardship program and 40% had no regular microbiological rounds in their ICUs. Intensivists were mostly the decision makers for the initial antimicrobial therapy which in 70% of cases were based on guidelines or protocols. Non-ICU expertise were sought more frequently on reviewing (48/72h, culture adjustment and discontinuation in 32%, 39% and 21% respectively) rather than antimicrobial therapy initiation (16%). Only 42% described ID training as adequate. Multivariate ordinal logistic regression showed that low- to middle-income countries (OR: 0.41, 95% CI: 0.28-0.61), ICU practice ≤10 years (OR: 0.55, 95% CI: 0.39-0.79), and dual training with anaesthesia (OR: 0.52, 95% CI: 0.34-0.79) or medicine (OR: 0.49, 95% CI: 0.32-0.76) were associated with less training satisfaction. ID practice is heterogeneous across ICUs while antimicrobial stewardship program is not universally implemented. From intensivists' perspective, ID training and knowledge need improvement.

Intensivists’ perceptions and attitudes towards infectious diseases management in the ICU: An international survey

ObjectiveExploring infectious diseases (ID) practice in Intensive Care Unit (ICU) to identify gaps and opportunities. DesignOnline international survey (PRACT-INF-ICU) endorsed by the ESICM and open from July 30, 2019 to October 19, 2019. SettingInternational study conducted in 78 countries. ParticipantsPhysicians working in ICU. InterventionsNone. Main variables of interestPractice variations were assessed according to respondents’ countries income class, training, and years of practice. Univariate and multivariate ordinal logistic regression were used to estimate associations between respondents’ characteristics and their perceptions regarding adequacy of training. Results466 intensivists with a median practice of 10 years (interquartile range, 5–19) completed the survey. A third reported no antimicrobial stewardship program and 40% had no regular microbiological rounds in their ICUs. Intensivists were mostly the decision makers for the initial antimicrobial therapy which in 70% of cases were based on guidelines or protocols. Non-ICU expertise were sought more frequently on reviewing (48/72h, culture adjustment and discontinuation in 32%, 39% and 21% respectively) rather than antimicrobial therapy initiation (16%). Only 42% described ID training as adequate. Multivariate ordinal logistic regression showed that low- to middle-income countries (OR: 0.41, 95% CI: 0.28–0.61), ICU practice ≤10 years (OR: 0.55, 95% CI: 0.39–0.79), and dual training with anaesthesia (OR: 0.52, 95% CI: 0.34–0.79) or medicine (OR: 0.49, 95% CI: 0.32–0.76) were associated with less training satisfaction. ConclusionID practice is heterogeneous across ICUs while antimicrobial stewardship program is not universally implemented. From intensivists’ perspective, ID training and knowledge need improvement.

Rapid Detection of Urinary Tract Infection in 10 min by Tracking Multiple Phenotypic Features in a 30 s Large-Volume Scattering Video of Urine Microscopy.

Rapid point-of-care (POC) diagnosis of bacterial infection diseases provides clinical benefits of prompt initiation of antimicrobial therapy and reduction of the overuse/misuse of unnecessary antibiotics for nonbacterial infections. We present here a POC compatible method for rapid bacterial infection detection in 10 min. We use a large-volume solution scattering imaging (LVSi) system with low magnifications (1-2×) to visualize bacteria in clinical samples, thus eliminating the need for culture-based isolation and enrichment. We tracked multiple intrinsic phenotypic features of individual cells in a short video. By clustering these features with a simple machine learning algorithm, we can differentiate Escherichia coli from similar-sized polystyrene beads, distinguish bacteria with different shapes, and distinguish E. coli from urine particles. We applied the method to detect urinary tract infections in 104 patient urine samples with a 30 s LVSi video, and the results showed 92.3% accuracy compared with the clinical culture results. This technology provides opportunities for rapid bacterial infection diagnosis at POC settings.

Piperacillin-Tazobactam Induced Rapid Severe Thrombocytopenia Without Known Exposure

Thrombocytopenia is one of the commonly encountered laboratory abnormalities in the inpatient setting. The process of excluding life-threatening causes can be daunting and may result in overlooking iatrogenic sources such as medications. Antibiotics are known culprits; however, there are limited reports of rapid and severe onset thrombocytopenia following piperacillin-tazobactam (TZP) that were frequently observed in critically ill or immunocompromised patients with previous exposure to the antibiotic. This case describes a patient being treated for a soft tissue infection with vancomycin and TZP. Initiation of antimicrobial therapy resulted in severe thrombocytopenia and a platelet nadir of approximately 4,000 within 24 hours of the first doses. Thrombocytopenia resolved within three days of TZP withdrawal. To the best of our knowledge, there have not been any cases described of rapid drug-induced thrombocytopenia without previous exposure to the medication. Medications should always be reviewed when evaluating a patient with rapid and severe thrombocytopenia, which can obviate the need for unnecessary invasive or non-invasive treatments.

A Narrative Review on the Approach to Antimicrobial Use in Ventilated Patients with Multidrug Resistant Organisms in Respiratory Samples-To Treat or Not to Treat? That Is the Question.

Multidrug resistant organisms (MDRO) are commonly isolated in respiratory specimens taken from mechanically ventilated patients. The purpose of this narrative review is to discuss the approach to antimicrobial prescription in ventilated patients who have grown a new MDRO isolate in their respiratory specimen. A MEDLINE and PubMed literature search using keywords “multidrug resistant organisms”, “ventilator-associated pneumonia” and “decision making”, “treatment” or “strategy” was used to identify 329 references as background for this review. Lack of universally accepted diagnostic criteria for ventilator-associated pneumonia, or ventilator-associated tracheobronchitis complicates treatment decisions. Consideration of the clinical context including signs of respiratory infection or deterioration in respiratory or other organ function is essential. The higher the quality of respiratory specimens or the presence of bacteremia would suggest the MDRO is a true pathogen, rather than colonization, and warrants antimicrobial therapy. A patient with higher severity of illness has lower safety margins and may require initiation of antimicrobial therapy until an alternative diagnosis is established. A structured approach to the decision to treat with antimicrobial therapy is proposed.

Antimicrobial Stewardship in the ICU.

Increasing rates of infection and multidrug-resistant pathogens, along with a high use of antimicrobial therapy, make the intensive care unit (ICU) an ideal setting for implementing and supporting antimicrobial stewardship efforts. Overuse of antimicrobial agents is common in the ICU, as practitioners are challenged daily with achieving early, appropriate empiric antimicrobial therapy to improve patient outcomes. While early antimicrobial stewardship programs focused on the financial implications of antimicrobial overuse, current goals of stewardship programs align closely with those of critical care providers-to optimize patient outcomes, reduce development of resistance, and minimize adverse outcomes associated with antibiotic overuse and misuse such as acute kidney injury and Clostridioides difficile-associated disease. Significant opportunities exist in the ICU for critical care clinicians to support stewardship practices at the bedside, including thoughtful and restrained initiation of antimicrobial therapy, use of biomarkers in addition to rapid diagnostics, Staphylococcus aureus screening, and traditional microbiologic culture and susceptibilities to guide antibiotic de-escalation, and use of the shortest duration of therapy that is clinically appropriate. Integration of critical care practitioners into the initiatives of antimicrobial stewardship programs is key to their success. This review summarizes key components of antimicrobial stewardship programs and mechanisms for critical care practitioners to share the responsibility for antimicrobial stewardship.

Severe secondary peritonitis: impact of inappropriate initial antimicrobial therapy on prognosis and potential carbapenem-sparing.

Initiation of antimicrobial therapy (IAT) with broad-spectrum antibiotics is usual in Intensive Care Unit (ICU) patients with secondary peritonitis. Carbapenems are widely proposed by recent guidelines contrasting with current antibiotic stewardship policies of carbapenem-sparing. However, prognosis of inappropriate IAT remains unclear in these patients and broad-spectrum antibiotics are probably overused. We aimed to assess the role of inappropriate IAT in ICU patients with secondary peritonitis and the use of carbapenems in our IAT regimens. We performed a retrospective analysis during a six-year period including 131 ICU patients with secondary peritonitis. We collected data concerning comorbidities, source and severity of peritonitis, management of IAT, peritoneal samples and outcome. Forty-one patients presented with community acquired peritonitis (CAP) and 90 with postoperative peritonitis (POP). Thirty-seven (28.2%) patients died during ICU stay. IAT was inappropriate in 35 (26.7%) patients. Inappropriate IAT was not associated with reduced survival with respectively 26 (27%) deaths when IAT was adequate and 11 (31.4%) deaths when IAT was inadequate (P=0.87). Inappropriate IAT was not associated with the need of re-operation and duration of ICU stay. Carbapenems were delivered in 29 patients but were only necessary for eight patients without alternative treatment. In our study, inappropriate IAT was not associated with a worse prognosis and carbapenems were overused. Extensive delivery of carbapenems proposed by recent guidelines could be reconsidered in the management of these patients.

Экофуцин® как профилактика развития кандидозно- бактериального дисбиоза влагалища на фоне применения системной антибактериальной терапии

Aim: to assess the efficacy and safety of Ecofucin® in patients after performing planned gynecologic surgery procedures based on the changes in vaginal microbiota over time amid the use of systemic antimicrobial therapy (AMT). Patients and Methods: this prospective open randomized comparative parallel-group clinical study involved patients without signs of vaginal microbiota dysbiosis — bacterial vaginosis or candidiasis, who were hospitalized for planned surgery procedures. The group 1 patients (n=39) received systemic AMT and Ecofucin® for intravaginal application once a day at the bedtime for 12 days, starting 6 days before the planned surgery and AMT initiation, while the group 2 patients (n=40) received only systemic AMT. The efficacy was assessed a day after the completion of AMT and the use of the tested medication (i.e. on day 13 after the initiation of Ecofucin application) and 30±2 days after the initiation of using the tested drug. Clinical, microbiological and molecular genetic methods were used for the assessment. Results: symptoms common for vaginal microbiota dysbiosis — bacterial vaginosis and candidiasis were reported by 18% and 21% of the group 2 patients at days 13 and 30±2 after the initiation of AMT, while such symptoms were not recorded in any of the group 1 patients (F=0,107, р=0,007). In 100% of the group 1 patients both lactobacilli and bifidobacteria were detected at all endpoints. In group 2, lactobacilli were found at days 13 and 30±2 in 93.8% and 97% of patients, respectively (F=0.035, p=0.2; F=0.017, p=0.458), bifidobacteria — in 84.4% and 81.1% of patients, respectively (F=0.092, р=0.016; F=0.107, р=0,007, respectively). At the baseline, the groups had similar results of the vaginal discharge culture tests. In the group 1 patients, Candida spp. were not identified at any of the endpoints, in group 2 — Candida spp. were found in 22.5% of patients, starting from day 13 (F=0,125, р=0,002). No adverse events were reported. Conclusion: the administration of Ecofucin® vaginal suppositories containing natamycin 100 mg and excipient lactulose is effective for preventing microbiota dysbiosis — bacterial vaginosis and candidiasis in patients receiving antimicrobial therapy. KEYWORDS: vagina, microbiocenosis, antimicrobial therapy, lactobacilli, bifidobacteria, candidiasis, natamycin, lactulose. FOR CITATION: Kuzmin V.N. Ecofucin® for the prevention of vaginal microbiota dysbiosis — bacterial vaginosis and candidiasis amid the use of systemic antimicrobial therapy. Russian Journal of Woman and Child Health. 2022;5(4):292–296 (in Russ.). DOI: 10.32364/2618-8430- 2022-5-4-292-296.