Embed Size (px)
Citation preview
Quality management of bloodstream infections today
Setting standards
L. Eduardo López Cortés
Seville, Spain
Hospital UniversitarioVirgen Macarena, Seville
ESCMID eLibrary
by a
uthor
Conflicts of interest
None for this talk
Research grants REIPI, Instituto de Salud Carlos III, Spanish Ministry of Economy
ESCMID eLibrary
by a
uthor
Overview
1. Relevancy of the issue
2. QCI in bacteremia: why are they necessary?
3. Successful examples: S. aureus, Candida spp.
4. Proposed QCI:
Blood cultures indicators
ID advice
Empirical therapy indicators
Follow-up BC
Source searching
De-escalation
Therapy duration
Clinical indicatorsESCMID eLibrary
by a
uthor
Population-based surveillance for all community-onset BSI
Calgary, 2000-2004
4,467 episodes Overall annual incidence of
82/100,000 people
Mortality rate of 13%
ESCMID eLibrary
by a
uthor
Consequences of bacteremia
Increased patient morbidity and mortality:
Prolonged hospital stay
Excessive drug costs
Selection of resistant organisms
Rodríguez-Baño J, et al. CMI 2010; 16:1408-13ESCMID eLibrary
by a
uthor
Quality of care indicators (QCI)
It would be necessary to standardize their clinical management to improve prognosis and reduce associated mortality
But...There is a lack of information (almost nothing in the last 10 years…)
Why doesn´t it exist ?
Bacteremia is not a type of infection per se
Is the consequence of multiple and heterogeneous types of infections very complex task to standardize
Successful examples with impact on mortality:
S. aureus bacteremia
Candidemia
Catheter related BSI ESCMID eLibrary
by a
uthor
5 QCI for candidemia (nonneutropenic)
1. Follow-up BC
2. Ophthalmological evaluation to exclude endophthalmitis
3. Targeted therapy: Transition from echinocandin fluconazole
4. Removal of intravenous catheter
5. Duration of therapy: 2 weeks after documented clearance of Candida (in patients without metastatic complications)
Pappas PG, et al. CID 2009; 48:503-35ESCMID eLibrary
by a
uthor
Systematic review to identify evidence-based QCI for SAB management
Multicentre, before-after study Intervention: structured, written
recommendation by IDs based on those QCI
Outcomes: Adherence to QCI and mortality
López-Cortés LE, et al. CID 2013; 57:1225-33ESCMID eLibrary
by a
uthor
QCI for S. aureus bacteremia
López-Cortés LE, et al. CID 2013; 57:1225-33ESCMID eLibrary
by a
uthor
Proposed QCI for bacteremia
Blood culture procedure
ESCMID eLibrary
by a
uthor
Blood cultures evaluation
1. Nº of BC / 100 admissions OR 100 rooms
2. Nº of (+) BC / 100 admissions OR 100 patients-days
3. Nº of BC AND (+) BC in ER / 100 ER admissions
4. Nº of contaminated BC / total BC less than 3%?
5. Nº of BC with CNS isolation / total + BC
Bacteremia work group. Unidad Clínica Intercentros Virgen Macarena y Virgen del Rocío
10-30 min.
ESCMID eLibrary
by a
uthor
Proposed QCI for bacteremia
ID evaluation
ESCMID eLibrary
by a
uthor
Voguel M, et al. J Infect 2016; 72(1):19-28ESCMID eLibrary
by a
uthor
Micro and ID evaluation
1. Number of early reported preliminary results (with management advice) by ID
consultant / 100 (+) BC
2. Nº cases with active ID consultation offered /100 BC
3. Nº of BSI classified by acquisition and source / 100 (+) BC
4. Nº of nosocomial BSI / 1,000 patient-days
Rodríguez-Baño J, et al. Expert Rev Anti Infect Ther 2010; 8:815-29. ESCMID eLibrary
by a
uthor
Proposed QCI for bacteremia
Empirical therapy
ESCMID eLibrary
by a
uthor
Empirical therapy
A crucial decision, above all in patients with SS & septic shock
Aspects to take into account:
Severity of illness
Medical records: surgery/other procedures, endovascular and prosthetic devices, etc.
Co-morbidity
Type of acquisition associated with:
More probable etiology
More probable sources
MR risk factors
Previous microbiological isolates
Local epidemiology and more frequent susceptibilities
12 - 24 hours later: Gram stain resultESCMID eLibrary
by a
uthor
Antimicrob Agents Chemoth 2012; 56:472-8
***
*Multivariate logistic regression. **Propensity score. ***Propensity score + logistic regression
***
Prospective multicenter cohort including all BSI episodes (adults) 15 Spanish hospitals, 2006 - 2007. 800 BSI
ESCMID eLibrary
by a
uthor
Proposed QCI for bacteremia
Follow-up blood cultures
ESCMID eLibrary
by a
uthor
Follow-up BC
1. Bacteremia due to S. aureus or Candida spp. (↔ therapy duration and management)
2. Unknown source above all in Streptococcus spp. BSI
Known or suspected endocarditis
3. Presence of fever or other signs of infection > 72 h of adequate therapy
4. Known or suspected site of infection with limited antimicrobial penetration (e.g.: abscess or joint space infections)
5. Presence of prosthetic vascular grafts, intravascular lines, pacemakers, etc.
ESCMID eLibrary
by a
uthor
Proposed QCI for bacteremia
Active source searching
ESCMID eLibrary
by a
uthor
Acquisition & Sources
Rodríguez-Baño J, et al. Expert Rev Anti Infect Ther 2010; 8:815-29. ESCMID eLibrary
by a
uthor
Aetiology & sources
ESCMID eLibrary
by a
uthor
Proposed QCI for bacteremia
De-escalation
ESCMID eLibrary
by a
uthor
But... what is exactly to de-escalate?
Weiss E, et al. Clin Microbiol Infect 2015; 21:649.e1-10
Aim of the study: to provide a consensus definition of DE and to establish a ranking of β-lactam according to both their spectra and their ecological consequences.
28 experts from IC, ID and CM were consulted using questionnaires
ESCMID eLibrary
by a
uthor
Six US hospitals during 2009 and 2010
Primary outcome: modification of antimicrobial regimen on or before the 5th day
4,119 (60%) of 6,812 inpatients received antimicrobials
12.5% of ET were escalated
21.5% were narrowed or discontinued
66,4% were unchanged
Braykov NP, et al. Lancet Infect Dis 2014; 14:1220-7ESCMID eLibrary
by a
uthor
De-escalation
One of the more potentially useful strategies to avoid the overuse of B-S antibiotics.
Based only on expert recommendations and few observational studies many clinicians have doubts about its safety adherence
is much lower than desired
A review of the Cochrane Library:
Silva BN, et al. Cochrane Database Syst Rev 2013ESCMID eLibrary
by a
uthor
Clinical trial “Simplify”
Multicenter (22 centers) Spanish phase III non-inferiority randomized clinical trial.
Inclusion criteria:Hospitalized patients with monomicrobial enterobacteriae BSI of any source
Need to maintain an IV treatment for at least 5 days
Primary outcome: Demonstrate non-inferiority of N-S vs. B-S therapy using an antipseudomonal beta-lactam
Secondary:Clinical response in short (day 5) and long-term (day 30)
Mortality until day 60
Hospital stay and recurrences
Consequences the intestinal colonization by MMRR Gram-negative bacilli
ESCMID eLibrary
by a
uthor
ESCMID eLibrary
by a
uthor
SUSCEPTIBILITY
Ampicillin 2 g IV/6h
TMP/SMX 160/800 mg IV/8 -12h
Cefuroxime 750-1000 mg/8h
Cefotaxime 1-2g IV/8h or ceftriaxone 1 g/12-24h
Amoxicillin/clavulanic 1000/125 mg IV/8h
Ciprofloxacine 400 mg IV/12h
Ertapenem 1g/24h
Piperacillin/tazobactam 4/0.5 g IV/6-8h
Meropenem 1-2 g IV/8h
Imipenem 0.5 g IV/6h - 1g IV/6h
Aztreonam 1-2 g IV/8h
Ceftazidime 1-2 g IV/8h
Cefepime 2 g IV/8-12h.
Experimental N-S arm Control B-S anti-Pseud. arm
Clinical trial “Simplify”
Randomization in the first 24 hours of the availability ofmicro susceptibility
ESCMID eLibrary
by a
uthor
Proposed QCI for bacteremia
Therapy duration
ESCMID eLibrary
by a
uthor
Duration of the therapy
Adequate duration not established in most of the cases
Decision depend on: aetiology, source (controlled or not), clinical evolution, etc.
Mermel LA et al, et al. CID 2009; 49:1-45ESCMID eLibrary
by a
uthor
End-points
Primary end-point: To prove that a 7-day course of antimicrobial treatment is
more eficient than a 14-day course for treating EB bacteremia independtly of the
source.
Secondary end-points:
1.To prove that a 7-day course is as safe as a 14-day course in terms of:
Clinical and microbiological cure.
Adverse reactions to antibiotics and superinfections.
2.To analyze the utility of PCT as a biomarker to decide to stop antibiotics in this setting.
Optimal duration of the antimicrobial treatment for bloodstream infections produced by Enterobacteriaceae.Clinical trial "SHORTEN”
NCT02400268ESCMID eLibrary
by a
uthor
Principal investigator: Dafna Yahav, MD. Rabin Medical Center
Primary end-point: compare short-course antibiotic therapy (<=7 days) versus longer
treatment (>7 days) in gram-negative bacteremia.
Methods: Open Label, parallel assignment. International (Israel and Italy).
Duration of Antibiotics for the Treatment of Gram-negative Bacilli Bacteremia - a Randomized Controlled Trial
NCT01737320ESCMID eLibrary
by a
uthor
Proposed QCI for bacteremia
Clinical indicators
ESCMID eLibrary
by a
uthor
Clinical indicators
1.Periodic evaluation of 14-day crude mortality at least:
E. coli
K. pneumoniae
S. aureus
S. pneumoniae
A. baumannii
P. aeruginosa
2.Periodic evaluation of length of stay in survivor patients
ESCMID eLibrary
by a
uthor
PRO-BAC 2016
Spanish observational cohort for all bacteremia (CA, NA and HCA)
From May 2016 – May 2017
29 tertiary hospital expected 17,000 to 25,000 cases
Main outcomes:
1. Describe clinical management: empirical and targeted therapy, duration, de-escalation, sequential IV to oral, source search and management
2. Study the influence of clinical management on prognosis
3. Describe the different activities carried out by bacteremia teams
ESCMID eLibrary
by a
uthor
Proposed QCI for bacteremia
ESCMID eLibrary
by a
uthor
Proposed QCI
1. Evaluate how blood cultures are taken in your centre
2. Evaluate how is the ID attention in your centre
3. Adequate empirical therapy
4. Carry out follow-up blood cultures (when are indicated)
5. De-escalate based on susceptibility data
6. Adapt the antimicrobial duration
7. Periodic evaluation of 14-day crude mortality
8. Periodic evaluation of length of stay in survivor patients
ESCMID eLibrary
by a
uthor
Final messages
1. QCI for bacteremia are not well described in the literature
2. Establish and follow QCI in bacteremia could help us to standardize clinical
management and improve the prognosis
3. There are some ongoing clinical trials to solve unresolved questions:
De-escalation: Simplify CT
Duration of therapy in EB BSI
4. There is an ongoing observational study (PRO-BAC) to establish QCI in
bacteremia and to describe the activities carried out by bacteremia teams
ESCMID eLibrary
by a
uthor
Acknowledgements
Hospital Macarena Bacteraemia Team
Dr. Jesús Rodríguez Baño
Investigators from Hospital Universitario Virgen Macarena and REIPI
Dr. Jose Molina (PI Shorten)
ESCMID eLibrary
by a
uthor
Bacteremia prevention
Essential key “better than cure”
Be alert to prevent NA and HCA bacteremia (and rest of infections) Urinary catheter
Vascular catheter
Parenteral nutrition
Others
Other ways to prevent infections:
VA pneumonia: raise the head, washed with chlorhexidine, etc
Other invasive procedures: in time and adequate prophilaxis
Pressure ulcers prevention: air mattress, early movilization…
Surgical procedures: in time and adequate prophilaxis, adequate technique
Etc.
Are they necessary TODAY?
ESCMID eLibrary
by a
uthor
