Citation Information :
Agarwal J, Singh V, Das A, Sen M. Reversing the Trend of Antimicrobial Resistance in ICU: Role of Antimicrobial and Diagnostic Stewardship. Indian J Crit Care Med 2021; 25 (6):635-641.
Background: Increasing antimicrobial resistance (AMR) among common bacteria combined with the slow development of new antibiotics has posed a challenge to clinicians.
Aim and objective: To demonstrate whether antimicrobial and diagnostic stewardship program (ASP and DSP)-related interventions improve antibiotic susceptibilities among common bacteria causing bloodstream infections (BSI) in patients admitted to the intensive care unit (ICU) and whether these resulted in changes in the volume of antimicrobial consumption.
Materials and methods: We compared the susceptibility patterns of gram-negative bacteria (GNB) and gram-positive cocci (GPC) causing BSI and changes in the volume of antibiotics prescribed for the same before and after 2017 by a retrospective analysis.
Results: Postintervention, there was increased susceptibility of all GNBs to aminoglycosides; Escherichia coli and Klebsiella spp. to beta-lactambeta-lactamase inhibitors (BLBLI) combinations; and Klebsiella spp. and Pseudomonas spp. to carbapenems. Acinetobacter spp., Klebsiella spp., and Pseudomonas spp. showed improved susceptibility to doxycycline, whereas E. coli and Klebsiella spp. showed significantly improved susceptibility to fluoroquinolones. Among GPCs, there was increased susceptibility of Staphylococcus aureus (levofloxacin, clindamycin, and aminoglycoside), coagulase-negative S. aureus (CoNS) (chloramphenicol, levofloxacin, clindamycin, and aminoglycoside), and enterococci (chloramphenicol, levofloxacin, and clindamycin). There was a significant reduction in usage of antimicrobials for the treatment of GPCs (linezolid, doxycycline, chloramphenicol, levofloxacin, BLBLI, macrolide, and cephalosporin) and GNBs (levofloxacin, cephalosporin, carbapenem, and colistin), which caused BSI.
Conclusion: The present study illustrated that combined ASP and DSP interventions successfully reversed the resistance pattern of organisms causing BSI and resulted in a reduction in antibiotic utilization.
Pickens CI, Wunderink RG. Principles and practice of antibiotic stewardship in the ICU. Chest 2019;156(1):163–171. DOI: 10.1016/j.chest.2019.01.013.
Infectious Diseases Society of America. Antimicrobial stewardship: promoting antimicrobial stewardship in human medicine. Available from: https://www.idsociety.org/policy–advocacy/antimicrobial-resistance/antimicrobial-stewardship/.
Evans RS, Pestotnik SL, Classen DC, Clemmer TP, Weaver LK, Orme JF Jr, et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 1998;338(4):232–238. DOI: 10.1056/NEJM199801223380406.
Timbrook TT, Hurst JM, Bosso JA. Impact of an antimicrobial stewardship program on antimicrobial utilization, bacterial susceptibilities, and financial expenditures at an academic medical center. Hosp Pharm 2016;51(9):703–711. DOI: 10.1310/hpj5109-703.
Yong MK, Buising KL, Cheng AC, Thursky KA. Improved susceptibility of Gram-negative bacteria in an intensive care unit following implementation of a computerized antibiotic decision support system. J Antimicrob Chemother 2010;65(5):1062–1069. DOI: 10.1093/jac/dkq058.
Gregory JR, Suleyman S. A review of the opportunities and Shortcomings of Antibiotic stewardship. U.S. Pharmacist 2018;43(4):HS-7–HS-12.
O’Sullivan CE. Antimicrobial stewardship failure: time for a new model. J Antimicrob Chemother 2020;75(5):1087–1090. DOI: 10.1093/jac/dkaa006.
Nathwani D, Varghese D, Stephens J, Ansari W. Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review. Antimicrob Resist Infect Control 2019;8(1). DOI: 10.1186/s13756-019-0471-0.
Messacar K, Parker SK, Todd JK, Dominguez SR. Implementation of rapid molecular infectious disease diagnostics: the role of diagnostic and antimicrobial stewardship. J Clin Microbiol 2017;55(3):715–723. DOI: 10.1128/JCM.02264-16.
Timsit JF, Ruppé E, Barbier F, Tabah A, Bassetti M. Bloodstream infections in critically ill patients: an expert statement. Intensive Care Med 2020;46(2):266–284. DOI: 10.1007/s00134-020-05950-6.
Marschall J, Mermel L, Fakih M, Hadaway L, Kallen A, O’Grady N, et al. Strategies to prevent central line–associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35(7):753–771. DOI: 10.1086/676533.
Collee FG, Miles RS, Watt B. Tests for the identification of bacteria. In: Collee JG, Fraser AG, Marmion BP, Simmons A, editors. Mackie & McCartney practical medical microbiology, 14th ed. London: Churchill Livingstone; 1996. p. 131–150.
Miles RS, Amyes SGB. Laboratory control of antimicrobial therapy. In: Collee JG, Fraser AG, Marmion BP, Simmons A, editors. Mackie & McCartney practical medical microbiology, 14th ed. London: Churchill Livingstone; 1996. p. 151–178. Clinical and Laboratory Standards Institute.
Dixit A, Kumar N, Kumar S, Trigun V. Antimicrobial resistance: progress in the decade since emergence of New Delhi metallo-β-lactamase in India. Indian J Community Med 2019;44(1):4–8. DOI: 10.4103/ijcm.IJCM_217_18.
Ghafur A, Nagvekar V, Thilakavathy S, Chandra K, Gopalakrishnan R, Vidyalakshmi P, et al. “Save Antibiotics, Save lives”: an Indian success story of infection control through persuasive diplomacy. Antimicrob Resist Infect Control 2012;1(1):29. DOI: 10.1186/2047-2994-1-29.
Rupali P, Palanikumar P, Shanthamurthy D, Peter JV, Kandasamy S, Zacchaeus NGP, et al. Impact of an antimicrobial stewardship intervention in India: evaluation of post-prescription review and feedback as a method of promoting optimal antimicrobial use in the intensive care units of a tertiary-care hospital. Infect Control Hosp Epidemiol 2019;40(5):512–519. DOI: 10.1017/ice.2019.29.
Patel, P. Minding the gap: rethinking implementation of antimicrobial stewardship in India. Infect Control Hosp Epidemiol 2019;40(5):520. DOI: 10.1017/ice.2019.62.
Singh S, Menon VP, Mohamed ZU, Kumar VA, Nampoothiri V, Sudhir S, et al. Implementation and impact of an antimicrobial stewardship program at a tertiary care center in South India. Open Forum Infect Dis 2019;6(4):ofy290. DOI: 10.1093/ofid/ofy290p.
Jawhari B, Keenan L, Zakus D, Ludwick D, Isaac A, Saleh A, et al. Barriers and facilitators to Electronic Medical Record (EMR) use in an urban slum. Int J Med Inform 2016;94:246–254. DOI: 10.1016/j.ijmedinf.2016.07.015.
Baubie K, Shaughnessy C, Kostiuk L, Varsha Joseph M, Safdar N, Singh SK, et al. Evaluating antibiotic stewardship in a tertiary care hospital in Kerala, India: a qualitative interview study. BMJ Open 2019;9(5):e026193. DOI: 10.1136/bmjopen-2018-026193.
Rimawi RH, Mazer MA, Siraj DS, et al. Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome. Crit Care Med 2013;41(9):2099–2107. DOI: 10.1097/CCM.0b013e31828e9863.
Adrie C, Garrouste-Orgeas M, Ibn Essaied W, Schwebel C, Darmon M, Mourvillier B, et al. Attributable mortality of ICU-acquired bloodstream infections: impact of the source, causative micro-organism, resistance profile and antimicrobial therapy. J Infect 2017;74(2):131–141. DOI: 10.1016/j.jinf.2016.11.001.
Bassetti M, Righi E, Carnelutti A. Bloodstream infections in the Intensive Care Unit. Virulence 2016;7(3):267–279. DOI: 10.1080/21505594.2015.1134072.
Bharadwaj R, Bal A, Kapila K, Mave V, Gupta A. Blood stream infections. BioMed Res Int 2014;2014. Article ID 515273. DOI: 10.1155/2014/515273.
Khurana S, Bhardwaj N, Kumari M, Malhotra R, Mathur P. Prevalence, etiology, and antibiotic resistance profiles of bacterial bloodstream infections in a tertiary care hospital in Northern India: a 4-year study. J Lab Physicians 2018;10(4):426–431. DOI: 10.4103/JLP.JLP_78_18
Nordmann P, Poirel L. Epidemiology and diagnostics of carbapenem resistance in gram-negative bacteria. Clin Infect Dis 2019;69(Suppl. 7):S521. DOI: 10.1093/cid/ciz824.
Alizadeh N, Ahangarzadeh Rezaee M, Samadi Kafil H, Hasani A, Soroush Barhaghi MH, Milani M, et al. Evaluation of resistance mechanisms in carbapenem-resistant enterobacteriaceae. Infect Drug Resist 2020;13:1377–1385. DOI: 10.2147/IDR.S244357.
Falagas ME, Kasiakou SK. Colistin: the revival of polymyxins for the management of multidrug-resist- ant gram-negative bacterial infections. Clin Infect Dis 2005;40(9):1333–1341. DOI: 10.1086/429323.
El-Sayed Ahmed MAE, Zhong LL, Shen C, Yang Y, Doi Y, Tian GB. Colistin and its role in the Era of antibiotic resistance: an extended review (2000–2019). Emerg Microbes Infect 2020;9(1):868–885. DOI: 10.1080/22221751.2020.1754133.
Kale P, Dhawan B. The changing face of community-acquired methicillin-resistant Staphylococcus aureus. Indian J Med Microbiol 2016;34(3):275–285. DOI: 10.4103/0255-0857.188313.
Bondarenka CM, Bosso JA. Successful implementation of an antimicrobial stewardship program at an academic medical center. Hosp Pharm 2017;52(7):508–513. DOI: 10.1177/0018578717721535.
Patel R, Fang FC. Diagnostic stewardship: opportunity for a laboratory-infectious diseases partnership. Clin Infect Dis 2018;67(5):799–801. DOI: 10.1093/cid/ciy077.