- Antimicrobial Stewardship Bundles for the Treatment of Uncomplicated Gram-Negative Bacteremia
- Bundles Strike Again: Non-VAP HAP Prevention
Did you miss the previous edition of Journal Club? You can find it and other past installments in the IDSA News archives. For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, M.D., FIDSA, in each issue of Clinical Infectious Diseases.
Reviewed by Razan El Ramahi, M.B.B.S.
Antimicrobial stewardship program interventions targeting the treatment of bloodstream infections improve outcomes such as time to effective therapy, appropriate de-escalation, length of stay, and mortality. For uncomplicated Gram-negative bacteremia, recent data indicate that shorter duration of antimicrobial therapy and switching from intravenous to oral agents after clinical stability produce clinical outcomes similar to previous practices. The expansion of ASP interventions to target these measures is an opportunity to facilitate their uptake while potentially reducing the cost of care and side effects associated with longer antibiotic courses.
In a study published by Erickson et al. in Open Forum Infectious Diseases, the authors report outcomes associated with ASP bundle interventions in this context. The study included two retrospective cohorts of adult patients admitted with Gram-negative bacteremia from pre-ASP (11/2014 to 10/2015; n = 51) and post-ASP (10/2017 to 9/2018; n = 86) periods. The post-ASP intervention included encouraging intravenous-to-oral switch, discouraging repeat blood cultures without an indication for prolonged therapy, and promoting 7-day treatment durations. The median duration of therapy was shorter in the post-ASP group (10 days, range 10-14) compared to the pre-ASP group (14 days, range 10-16), P < 0.001. Intravenous-to-oral switch occurred earlier in the post-ASP cohort (day 4, range 3-5) compared to the pre-ASP cohort (day 5, range 4-6), P = 0.046. Hospital readmission rates at 30 days were higher in the pre-ASP group (39.2% vs 23.3%, P = 0.047). There was no significant different in 30-day mortality, and recurrence of bacteremia between the pre-ASP and post-ASP cohorts (0% vs 2.3%, P = 0.273, and 0% vs 2.3%, P = 0.273, respectively). The estimated cost per case decreased by 27 percent, pre-ASP to post-ASP (P = 0.19).
This study adds to the body of evidence favoring the use of ASP interventions to affect changes consistent with updated evidence while improving patient outcomes and reducing health care costs.
Reviewed by Nirav Patel, M.D.
One consistent theme in infection prevention is the use of several small interventions, that when coupled together in a consistent manner, help reduce infections. Much of the research on the prevention of hospital-acquired pneumonia (HAP) has centered around ventilator-associated pneumonia (VAP) and using a bundled intervention approach to reduce VAP rates. While true VAPs are associated with high morbidity and mortality rates, the overall incidence of VAP is much lower than HAP, and thus a bundle approach to reduce non-ventilator-associated hospital-acquired pneumonias makes clinical and epidemiological sense.
Lacerna and collaborators conducted a longitudinal observational study, recently reported in Infection Control & Hospital Epidemiology, across 21 Kaiser Permanente hospitals in northern California, with seven interventions: mobilization, upright feeding, swallowing evaluation, sedation restriction, elevation of the head of bed, oral care, and feeding tube care. These interventions were built into the electronic health record and implemented per protocol for all admissions.
The authors were able to demonstrate substantial and sustained improvements in their primary endpoints, specifically a decrease in HAP rate from 5.92 per 1,000 admissions to 1.79 per 1,000 admissions from 2012-2018, and a decrease in HAP mortality from 1.05 to 0.34 per 1,000 admissions. Days of therapy for broad-spectrum antibiotics and use of benzodiazepines also decreased significantly. However, once HAP was established there was no substantial change in mortality, 18% in 2012 and 19% in 2016, suggesting that the mortality improvements were all from a reduction in risk for the development of HAP.
This is a powerful study demonstrating the impact of several small interventions that when deployed broadly and consistently, reduced the incidence of HAP across a large system of hospitals. Furthermore, the interventions were performed in a real-world setting, were common sense in nature, and with minimal risk to the patient. Other organizations should consider using these approaches to maximize patient safety and outcomes.