Bacterial and fungal infections are common issues for patients in the intensive care unit (ICU). Large, multinational point prevalence surveys have identified that up to 50% of ICU patients have a diagnosis of bacterial or fungal infection at any one time. Infection in the ICU is associated with its own challenges. Causative organisms often harbour intrinsic and acquired mechanisms of drug-resistance, making empiric and targeted antimicrobial selection challenging. Infection in the ICU is associated with worse clinical outcomes for patients. We review the epidemiology of bacterial and fungal infection in the ICU. We discuss risk factors for acquisition, approaches to diagnosis and management, and common strategies for the prevention of infection. 

/pdf/management-of-bacterial-and-fungal-infections-in-the-icu-2o06jqz0.pdf

Management of Bacterial and Fungal Infections in the ICU: Diagnosis, Treatment, and Prevention Recommendations

Abstract Bacterial and fungal infections are common issues for patients in the intensive care unit (ICU). Large, multinational point prevalence surveys have identified that up to 50% of ICU patients have a diagnosis of bacterial or fungal infection at any one time. Infection in the ICU is associated with its own challenges. Causative organisms often harbour intrinsic and acquired mechanisms of drug-resistance, making empiric and targeted antimicrobial selection challenging. Infection in the ICU is associated with worse clinical outcomes for patients. We review the epidemiology of bacterial and fungal infection in the ICU. We discuss risk factors for acquisition, approaches to diagnosis and management, and common strategies for the prevention of infection.

Objetivo: El objetivo fue determinar la concordancia de la identificación y sensibilidad antibiótica directa del hemocultivo positivo para bacilos Gram negativos, con el sistema Vitek 2 frente al procedimiento estándar.Materiales y métodos: Para el procedimiento directo se extrajeron 8 ml de la botella de hemocultivo positivo, se inocularon en un tubo de extracción de sangre con gel separador, se centrifugó por 10 minutos a 1000g, se resuspendió el pellet con 0.5 ml de solución salina estéril y se preparó el inóculo de las tarjetas deidentificación y sensibilidad antibiótica. La concordancia de identificación se evaluó con el índice Kappa, la sensibilidad antibiótica con essential agreement (EA) y categorical agreement (CA).Resultados: El acierto de identificación (%) y el índice kappa(k) para las cinco especies más frecuentes fue : E. coli 98.0% (48/49) k=0.99, K. pneumoniae 100% (33/33) k=1.0, complejo E. cloacae 100% (13/13) k=1.0, A. baumannii 95% (19/20) k=0.97, P. aeruginosa 66.7% (8/12) k=0.79. Los valores essential agreement y, categorical agreementt para 2175 combinaciones bacteria-antibiótico fueron 97.5% y 97.1% respectivamente.Conclusión: El procedimiento directo del hemocultivo positivo muestra buena concordancia para las principales especies de bacilos Gram negativos y permite obtener resultados 16 a 24 horas antes que el procedimiento estándar.

Identificación y sensibilidad antibiótica de bacilos Gram negativos directamente del hemocultivo positivo

Antimicrobial resistance (AMR) in gram-negative bacteria is an escalating public health challenge nationally and globally. Since the beginning of the 2000s, antimicrobial resistance surveillance systems involving diverse stakeholders, including human healthcare, animal health, and agriculture, have been established worldwide under the leadership of the World Health Organization, merging local AMR data and enabling the periodic release of reports on the AMR landscape, both regionally and internationally. As a result, crucial components of an antimicrobial stewardship program have been identified, and implementation has been initiated at the national level. However, considering the dynamic nature of AMR, it becomes apparent that existing guidelines and consensus reports, which offer evidence-based, current literature insights and recommendations, may struggle to keep pace with the requirements of everyday clinical practice. As this group of experts decided to prepare a guidance document tailored for Turkish clinicians, aimed at aiding in the diagnosis and treatment of gram-negative bacterial infections with AMR in hospitalized patients, the Infectious Diseases Society of America (IDSA) published the “2023 Guidance for the Treatment of AMD-Resistant Gram-Negative Infections” in July 2023. This indicates that the developments in the field of AMR cannot be addressed by the guidelines in a timely manner. As Turkish Infectious Diseases and Clinical Microbiology specialists, we aspire for this article to serve as a valuable resource, offering guidance for healthcare practitioners across various medical disciplines who treat patients afflicted by resistant gram-negative infections.

Dirençli Gram-Negatif Bakteri İnfeksiyonlarının Yönetiminde Sık Karşılaşılan Sorunlar ve Çözüm Önerileri: Klinik Pratiğe Yönelik Uzman Görüş

Abstract Antimicrobial susceptibility testing (AST) is a core function of the clinical microbiology laboratory and is critical to the management of patients with bloodstream infections (BSIs) to facilitate optimal antibiotic therapy selection. Recent technological advances have resulted in several rapid methods for determining susceptibility direct from positive blood culture that can provide turnaround times in under 8 h, which is considerably shorter than conventional culture-based methods. As diagnostic results do not directly produce a medical intervention, actionability is a primary determinant of the effect these technologies have on antibiotic use and ultimately patient outcomes. Randomized controlled trials and observational studies consistently show that rapid AST significantly reduces time to results and improves antimicrobial therapy for patients with BSI across various methods, patient populations and organisms. To date, the clinical impact of rapid AST has been demonstrated in some observational studies, but randomized controlled trials have not been sufficiently powered to validate many of these findings. This article reviews various metrics that have been described in the literature to measure the impact of rapid AST on actionability, antibiotic exposure and patient outcomes, as well as highlighting how implementation and workflow processes can affect these metrics. 

Evaluating the impact of rapid antimicrobial susceptibility testing for bloodstream infections: a review of actionability, antibiotic use and patient outcome metrics

Abstract Background Antimicrobial susceptibility testing (AST) is often needed prior to antimicrobial optimization for patients with gram-negative bloodstream infections (GN-BSIs). Rapid AST (rAST) in combination with antimicrobial stewardship (AS) may decrease time to administration of narrower antibiotics. Methods This was a prospective, nonblinded, randomized trial evaluating the impact of a phenotypic rAST method vs conventional AST (cAST) in hospitalized patients with GN-BSI and source control. The primary outcome was time to narrowest effective therapy. Results Two hundred seventy-four patients were randomized and 205 underwent analysis (97 cAST, 108 rAST). Median (interquartile range [IQR]) time to susceptibility results was 23 hours shorter in the rAST group (cAST: 62 [59–67] hours vs rAST: 39 [IQR, 35–46] hours; P < .001). Median (IQR) time to narrowest effective therapy was similar between groups (cAST: 73 [44–138] hours vs rAST: 64 [42–92] hours; P = .10). Median (IQR) time to narrowest effective therapy was significantly shorter in a prespecified subgroup of patients not initially on narrowest therapy and during AS working hours (cAST: 93 [56–154] hours vs rAST: 62 [43–164] hours; P = .004). Significant decreases were observed in median (IQR) time to oral therapy (cAST: 126 [76–209] hours vs rAST: 91 [66–154] hours; P = .02) and median (IQR) length of hospital stay (cAST: 7 [4–13] days vs rAST: 5 [4–8] days; P = .04). Conclusions In patients with GN-BSI, rAST did not significantly decrease time to narrowest effective therapy but did decrease time to oral antibiotics and length of hospital stay. Rapid AST using existing microbiology platforms has potential to optimize patient outcomes.

/pdf/impact-of-a-laboratory-developed-phenotypic-rapid-17flcmuj.pdf

Impact of a Laboratory-Developed Phenotypic Rapid Susceptibility Test Directly From Positive Blood Cultures on Time to Narrowest Effective Therapy in Patients With Gram-Negative Bacteremia: A Prospective Randomized Trial

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Impact of a Laboratory-Developed Phenotypic Rapid Susceptibility Test Directly From Positive Blood Cultures on Time to Narrowest Effective Therapy in Patients With Gram-Negative Bacteremia: A Prospective Randomized Trial