Inappropriate and unnecessary antibiotic prescriptions are common in the outpatient setting and as patients transition from inpatient to outpatient care. This review is designed to discuss effective strategies aimed to improve appropriate antibiotic use during transitions of care and in the outpatient setting for high-priority syndrome areas including acute respiratory infections (ARI), urinary tract infections (UTI), skin and soft tissue infections (SSTI), and bone and joint infections (BJI).
Recent Findings
Unlike inpatient stewardship programs, outpatient stewardship practices are currently not standardized across many healthcare systems. Since starting an outpatient ASP can be overwhelming, many programs opt to start by focusing on a smaller subset of high-priority locations or syndromes where antibiotics may be inappropriately prescribed. Numerous studies have identified effective antimicrobial stewardship strategies that can be incorporated on transitions of care and in the outpatient setting; however, a multimodal approach combining several stewardship strategies is often cited as the most effective approach. Available syndrome-specific interventions include opportunities at time of diagnosis, order entry, and post-prescription which may be tailored to meet individual program needs.
Summary
Outpatient ASP interventions targeted at diagnostic stewardship, adjustments to duration of therapy, optimization of agent selection, and avoidance of intravenous therapy remain high-priority target areas to prevent inappropriate antibiotic use.
{"title":"Antibiotic Use at Hospital Discharge and Outpatient Antimicrobial Stewardship","authors":"Mandee Noval, Colleen Burgoyne, Jacinta Chin, Kathryn Dzintars, Aileen Jimenez, Angela Perhac, Jessa Brenon","doi":"10.1007/s11908-023-00824-6","DOIUrl":"https://doi.org/10.1007/s11908-023-00824-6","url":null,"abstract":"<h3 data-test=\"abstract-sub-heading\">Purpose of Review</h3><p>Inappropriate and unnecessary antibiotic prescriptions are common in the outpatient setting and as patients transition from inpatient to outpatient care. This review is designed to discuss effective strategies aimed to improve appropriate antibiotic use during transitions of care and in the outpatient setting for high-priority syndrome areas including acute respiratory infections (ARI), urinary tract infections (UTI), skin and soft tissue infections (SSTI), and bone and joint infections (BJI).</p><h3 data-test=\"abstract-sub-heading\">Recent Findings</h3><p>Unlike inpatient stewardship programs, outpatient stewardship practices are currently not standardized across many healthcare systems. Since starting an outpatient ASP can be overwhelming, many programs opt to start by focusing on a smaller subset of high-priority locations or syndromes where antibiotics may be inappropriately prescribed. Numerous studies have identified effective antimicrobial stewardship strategies that can be incorporated on transitions of care and in the outpatient setting; however, a multimodal approach combining several stewardship strategies is often cited as the most effective approach. Available syndrome-specific interventions include opportunities at time of diagnosis, order entry, and post-prescription which may be tailored to meet individual program needs.</p><h3 data-test=\"abstract-sub-heading\">Summary</h3><p>Outpatient ASP interventions targeted at diagnostic stewardship, adjustments to duration of therapy, optimization of agent selection, and avoidance of intravenous therapy remain high-priority target areas to prevent inappropriate antibiotic use.</p>","PeriodicalId":48839,"journal":{"name":"Current Infectious Disease Reports","volume":"18 1","pages":""},"PeriodicalIF":3.1,"publicationDate":"2023-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138534643","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-04DOI: 10.1007/s11908-023-00820-w
Tucker John Guy Smith, Peter Daniels, Barry Rittmann
{"title":"Complex Outpatient Antimicrobial Therapy: Alternative Management Strategies and Outcomes","authors":"Tucker John Guy Smith, Peter Daniels, Barry Rittmann","doi":"10.1007/s11908-023-00820-w","DOIUrl":"https://doi.org/10.1007/s11908-023-00820-w","url":null,"abstract":"","PeriodicalId":48839,"journal":{"name":"Current Infectious Disease Reports","volume":"12 2","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135774059","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-01DOI: 10.1007/s11908-023-00821-9
Jade B. Flinn, Amy D. Britton, Jennifer Garland, Jennifer Cuzzolina, Paul D. Biddinger, Vikramjit Mukherjee, Jonathan D. Grein
{"title":"Rebuilding for Tomorrow’s Outbreak: The State of Special Pathogen Preparedness in the USA in the Wake of COVID-19","authors":"Jade B. Flinn, Amy D. Britton, Jennifer Garland, Jennifer Cuzzolina, Paul D. Biddinger, Vikramjit Mukherjee, Jonathan D. Grein","doi":"10.1007/s11908-023-00821-9","DOIUrl":"https://doi.org/10.1007/s11908-023-00821-9","url":null,"abstract":"","PeriodicalId":48839,"journal":{"name":"Current Infectious Disease Reports","volume":"263 5","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135273483","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-31DOI: 10.1007/s11908-023-00823-7
Jessica K. Ortwine, Wenjing Wei, Norman S. Mang, Brenton C. Hall, Helen Ding
{"title":"One Small Step (Down) for Antibiotics, One Giant Leap for Outpatient Therapy: The Role of Oral Antibiotics in Serious Bacterial Infections","authors":"Jessica K. Ortwine, Wenjing Wei, Norman S. Mang, Brenton C. Hall, Helen Ding","doi":"10.1007/s11908-023-00823-7","DOIUrl":"https://doi.org/10.1007/s11908-023-00823-7","url":null,"abstract":"","PeriodicalId":48839,"journal":{"name":"Current Infectious Disease Reports","volume":"41 2","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135870857","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-31DOI: 10.1007/s11908-023-00818-4
Abdullah Tarik Aslan, Budi Permana, Patrick N. A. Harris, Kuban D. Naidoo, Michael A. Pienaar, Adam D. Irwin
Abstract Purpose of Review To describe existing applications of artificial intelligence (AI) in sepsis management and the opportunities and challenges associated with its implementation in the paediatric intensive care unit. Recent Findings Over the last decade, significant advances have occurred in the use of AI techniques, particularly in relation to medical image analysis. Increasingly, these techniques are being applied to a broad array of datasets. The availability of both structured and unstructured data from electronic health records, omics data and digital technologies (for example, portable sensors) is rapidly extending the range of applications for AI. These techniques offer the exciting potential to improve the recognition of sepsis and to help us understand the pathophysiological pathways and therapeutic targets of sepsis. Summary Although AI has great potential to improve sepsis management in children, significant challenges need to be overcome before it can be successfully implemented to change healthcare delivery.
{"title":"The Opportunities and Challenges for Artificial Intelligence to Improve Sepsis Outcomes in the Paediatric Intensive Care Unit","authors":"Abdullah Tarik Aslan, Budi Permana, Patrick N. A. Harris, Kuban D. Naidoo, Michael A. Pienaar, Adam D. Irwin","doi":"10.1007/s11908-023-00818-4","DOIUrl":"https://doi.org/10.1007/s11908-023-00818-4","url":null,"abstract":"Abstract Purpose of Review To describe existing applications of artificial intelligence (AI) in sepsis management and the opportunities and challenges associated with its implementation in the paediatric intensive care unit. Recent Findings Over the last decade, significant advances have occurred in the use of AI techniques, particularly in relation to medical image analysis. Increasingly, these techniques are being applied to a broad array of datasets. The availability of both structured and unstructured data from electronic health records, omics data and digital technologies (for example, portable sensors) is rapidly extending the range of applications for AI. These techniques offer the exciting potential to improve the recognition of sepsis and to help us understand the pathophysiological pathways and therapeutic targets of sepsis. Summary Although AI has great potential to improve sepsis management in children, significant challenges need to be overcome before it can be successfully implemented to change healthcare delivery.","PeriodicalId":48839,"journal":{"name":"Current Infectious Disease Reports","volume":"27 5","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135871689","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-27DOI: 10.1007/s11908-023-00822-8
Caitlin Sande, Zoë J. Boston, Lindsay R. Kalan, Meghan B. Brennan
Abstract Purpose of Review In 2019, the International Working Group on the Diabetic Foot voiced six concerns regarding the use of molecular microbiology techniques for routine diagnosis of infection complicating diabetic foot ulcers. The purpose of this review is to evaluate contemporary evidence addressing each of these concerns and describe promising avenues for continued development of molecular microbiology assays. Recent Findings Since 2019, the feasibility of conducting metagenomic and metatranscriptomic studies on diabetic foot ulcer samples has been shown. However, these preliminary studies used small samples with concerns for selection bias. We await larger-scale, longitudinal studies, potentially using the recently formed Diabetic Foot Consortium, to identify microbiome profiles associated with infection and patient outcomes. How these results would translate into a clinical diagnostic requires further clarification. Summary High-throughput molecular microbiology techniques are not yet ready for clinical adoption as first-line diagnostics. However, moving from amplicon sequencing to metagenomic and metatranscriptomic studies has the potential to significantly accelerate development of assays that might meaningfully impact patient care.
{"title":"Next Steps: Studying Diabetic Foot Infections with Next-Generation Molecular Assays","authors":"Caitlin Sande, Zoë J. Boston, Lindsay R. Kalan, Meghan B. Brennan","doi":"10.1007/s11908-023-00822-8","DOIUrl":"https://doi.org/10.1007/s11908-023-00822-8","url":null,"abstract":"Abstract Purpose of Review In 2019, the International Working Group on the Diabetic Foot voiced six concerns regarding the use of molecular microbiology techniques for routine diagnosis of infection complicating diabetic foot ulcers. The purpose of this review is to evaluate contemporary evidence addressing each of these concerns and describe promising avenues for continued development of molecular microbiology assays. Recent Findings Since 2019, the feasibility of conducting metagenomic and metatranscriptomic studies on diabetic foot ulcer samples has been shown. However, these preliminary studies used small samples with concerns for selection bias. We await larger-scale, longitudinal studies, potentially using the recently formed Diabetic Foot Consortium, to identify microbiome profiles associated with infection and patient outcomes. How these results would translate into a clinical diagnostic requires further clarification. Summary High-throughput molecular microbiology techniques are not yet ready for clinical adoption as first-line diagnostics. However, moving from amplicon sequencing to metagenomic and metatranscriptomic studies has the potential to significantly accelerate development of assays that might meaningfully impact patient care.","PeriodicalId":48839,"journal":{"name":"Current Infectious Disease Reports","volume":"22 2","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136235252","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-27DOI: 10.1007/s11908-023-00819-3
Rachel Weihe, Mitchell C. Birt, Wissam El Atrouni
{"title":"Should We Tap That? Aspirates and Antibiotics: An Update on Septic Bursitis","authors":"Rachel Weihe, Mitchell C. Birt, Wissam El Atrouni","doi":"10.1007/s11908-023-00819-3","DOIUrl":"https://doi.org/10.1007/s11908-023-00819-3","url":null,"abstract":"","PeriodicalId":48839,"journal":{"name":"Current Infectious Disease Reports","volume":"127 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136261494","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-26DOI: 10.1007/s11908-023-00816-6
Laura Baptista, Inês Moura, Catarina Mendes Silva, João Pedro Baptista
Abstract Purpose of Review In this narrative review encompassing relevant scientific publications regarding critically ill patients in the last 5 years, we discuss key questions regarding the concept, pathophysiology, identification, epidemiology, and implications of augmented renal clearance (ARC) in the treatment of sepsis. Recent Findings Mathematical estimates of renal function show low accuracy when evaluating renal function in the intensive care unit, jeopardizing the correct dosing of antimicrobials. The description of ARC in critically ill patients in several, distant geographical areas worldwide reveals that this condition is more frequent than anticipated. Several new risk factors have been recently reported, needing future confirmation. Pathophysiology is still largely unknown; however, intact kidney physiology, inflammatory mediators, and tubular secretion seem to play a role. Several studies have demonstrated the association between ARC and subtherapeutic levels of several β-lactams, vancomycin, and fluconazole. Lately, there have been recommendations of dosage regimen adjustments for patients with ARC, namely, through increases in total daily dose or prolonged infusion for various antimicrobials. Literature is scarce describing the influence of ARC on clinical outcomes of patients receiving antibiotics, and results are contradictory. Summary Growing body of evidence supports that measured creatinine clearance based on time-defined urine output is strongly recommended for the identification of ARC and for reliable evaluation of its prevalence and risk factors. Clinicians should be alert for the need to use off-label dosing of antimicrobials in septic patients showing ARC. Concise recommendations for antibiotic dosage regimens, based on clinical data, are still needed.
{"title":"What is New in Augmented Renal Clearance in Septic Patients?","authors":"Laura Baptista, Inês Moura, Catarina Mendes Silva, João Pedro Baptista","doi":"10.1007/s11908-023-00816-6","DOIUrl":"https://doi.org/10.1007/s11908-023-00816-6","url":null,"abstract":"Abstract Purpose of Review In this narrative review encompassing relevant scientific publications regarding critically ill patients in the last 5 years, we discuss key questions regarding the concept, pathophysiology, identification, epidemiology, and implications of augmented renal clearance (ARC) in the treatment of sepsis. Recent Findings Mathematical estimates of renal function show low accuracy when evaluating renal function in the intensive care unit, jeopardizing the correct dosing of antimicrobials. The description of ARC in critically ill patients in several, distant geographical areas worldwide reveals that this condition is more frequent than anticipated. Several new risk factors have been recently reported, needing future confirmation. Pathophysiology is still largely unknown; however, intact kidney physiology, inflammatory mediators, and tubular secretion seem to play a role. Several studies have demonstrated the association between ARC and subtherapeutic levels of several β-lactams, vancomycin, and fluconazole. Lately, there have been recommendations of dosage regimen adjustments for patients with ARC, namely, through increases in total daily dose or prolonged infusion for various antimicrobials. Literature is scarce describing the influence of ARC on clinical outcomes of patients receiving antibiotics, and results are contradictory. Summary Growing body of evidence supports that measured creatinine clearance based on time-defined urine output is strongly recommended for the identification of ARC and for reliable evaluation of its prevalence and risk factors. Clinicians should be alert for the need to use off-label dosing of antimicrobials in septic patients showing ARC. Concise recommendations for antibiotic dosage regimens, based on clinical data, are still needed.","PeriodicalId":48839,"journal":{"name":"Current Infectious Disease Reports","volume":"23 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134909304","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Infection Prevention in Remote or Resource-Limited Settings: Deploying Technology While Preserving the Human Touch","authors":"Rachel Pryor, Yashasvisai Veeramasu, Gonzalo Bearman","doi":"10.1007/s11908-023-00814-8","DOIUrl":"https://doi.org/10.1007/s11908-023-00814-8","url":null,"abstract":"","PeriodicalId":48839,"journal":{"name":"Current Infectious Disease Reports","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135273709","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-14DOI: 10.1007/s11908-023-00817-5
Robin T. Saggers, Lesego M. Mothibi, Adam D. Irwin, Kuban D. Naidoo
Abstract Purpose of Review Antimicrobial resistance continues to increase throughout the world, with the impact on critically ill children in low- and middle-income paediatric intensive care units largely unknown. Recent Findings There has been a global shift indicating a predominance of Gram-negative bacilli among multidrug-resistant isolates. A 4-year review (2019 to 2022) found a progressive and substantial increase in the incidence of carbapenem-resistant Klebsiella pneumoniae (29% to 51%) alongside high levels of carbapenem-resistant Acinetobacter baumannii (93%) within the paediatric intensive care unit at the Chris Hani Baragwanath Academic Hospital in South Africa. The pharmacological treatment of these infections relies heavily on the continued use of carbapenems, often in combination with colistin. Summary The burden of antimicrobial resistance is disproportionately borne, particularly within sub-Saharan Africa and South Asia. The resource-constrained South African public healthcare system, already significantly burdened by both HIV and TB, continues to face several challenges in combating the growth in antimicrobial resistance. Limited access, largely driven by prohibitive costs, to sophisticated laboratory techniques and newer pharmacological agents, leaves the implementation of effective infection prevention and control and antimicrobial stewardship programmes as the most pragmatic options to address the problem.
{"title":"Challenges Facing PICUs in Low- and Middle-Income Countries in the Treatment of Emerging Multidrug-Resistant Organisms: a Review and Perspective from a South African PICU","authors":"Robin T. Saggers, Lesego M. Mothibi, Adam D. Irwin, Kuban D. Naidoo","doi":"10.1007/s11908-023-00817-5","DOIUrl":"https://doi.org/10.1007/s11908-023-00817-5","url":null,"abstract":"Abstract Purpose of Review Antimicrobial resistance continues to increase throughout the world, with the impact on critically ill children in low- and middle-income paediatric intensive care units largely unknown. Recent Findings There has been a global shift indicating a predominance of Gram-negative bacilli among multidrug-resistant isolates. A 4-year review (2019 to 2022) found a progressive and substantial increase in the incidence of carbapenem-resistant Klebsiella pneumoniae (29% to 51%) alongside high levels of carbapenem-resistant Acinetobacter baumannii (93%) within the paediatric intensive care unit at the Chris Hani Baragwanath Academic Hospital in South Africa. The pharmacological treatment of these infections relies heavily on the continued use of carbapenems, often in combination with colistin. Summary The burden of antimicrobial resistance is disproportionately borne, particularly within sub-Saharan Africa and South Asia. The resource-constrained South African public healthcare system, already significantly burdened by both HIV and TB, continues to face several challenges in combating the growth in antimicrobial resistance. Limited access, largely driven by prohibitive costs, to sophisticated laboratory techniques and newer pharmacological agents, leaves the implementation of effective infection prevention and control and antimicrobial stewardship programmes as the most pragmatic options to address the problem.","PeriodicalId":48839,"journal":{"name":"Current Infectious Disease Reports","volume":"125 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135802074","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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