The World Health Organization (WHO) proposed a global priority pathogen list (PPL) of multidrug resistant (MDR) bacteria. Our current objective was to provide global expert ranking of the most serious multi-drug resistant (MDR) bacteria present at intensive care units (ICU) that have become a threat in clinical practice. Methods: A proposal addressing a pathogens priority list (PPL) for ICU, arising from the WHO Global PPL was developed. Based on the supporting data, the pathogens were grouped in three priority tiers: Critical, high and medium. A multi-criteria decision analyses (MCDA) was used to identify the priority tiers. Results: After MCDA analysis, mortality, treatability and cost of therapy were of highest concern (scores of 19/20, 19/20 and 15/20, respectively) while dealing with PPL, followed by healthcare burden and resistance prevalence. Carbapenen-resistant (CR) Acinetobacter baumannii, Carbapenemaseexpressing Klebsiella pneumoniae (KPC) and MDR Pseudomonas aeruginosa were identified as critical organisms. High risk organisms were represented by CR Pseudomonas aeruginosa, Methicillinresistant Staphylococcus aureus, and Extended Spectrum Beta lactamase(ESBL) Enterobacteriaceae. Finally, ESBL Serratia marcescens, Vancomycin-resistant Enterococci and TMP-SMX resistant Stenotrophomonas maltophilia were identified as medium priority. Conclusions: We conclude that education, investigation, funding and development of new antimicrobials for ICU organisms should focus on Carbapenem-resistant Gram negative organisms.
2017 ESCMID practice guidelines reported safety concerns and weak evidence of benefit supporting use of aerosolized antibiotics in mechanically ventilated patients. Our primary goal was to assess current patterns of aerosolized antibiotic prescription in mechanically ventilated patients. A sequential global survey was performed prior to the release of the ESCMID guidelines, from the 1st of February to the 30th of April 2017, using an electronic platform. Responses were analyzed comparing geographical regions. A total of 410 units responded, with 261 (177 from Europe) being eligible for the full survey. 26.8% of units reported not using aerosolized antibiotics. The two major indications amongst prescribing units were ventilator-associated pneumonia and ventilator-associated tracheobronchitis (74.3% and 49.4%, respectively). 63.6% of units indicated prescription solely in response to multi-drug resistant organisms. In comparison with a survey undertaken in 2014, there was a significant reduction in use of aerosolized antibiotics for prophylaxis (50.6% vs 7.7%, p < 0.05) and colonization (52.9% vs 25.3%, p < 0.05). The large majority of units (91.7%) reported only prescribing in patients with positive pulmonary cultures. Asia appeared to be an outlier, with 53.3% of units reporting empirical use. The most commonly used device was the jet nebulizer. The most commonly prescribed drugs were colistin methanesulfonate (57.6%), colistin base (41.9%) and amikacin (31.4%), although there was considerable heterogeneity across geographical areas. A significant gap exists between ESCMID clinical practice recommendations and the use of aerosolized antibiotics in clinical practice. Our findings indicate an urgent need for high-quality education to bring practice into line with evidence-based guidelines.
Invasive fungal infections are a common life-threatening disease and a major cause of morbidity, particularly in patients with malignancies, and Candida spp. is the most common isolated fungi in bloodstream. Candidemia is the focus of this review, which covers an approach to diagnosis and treatment, with an emphasis on patients with malignancies. Acute leukemia, lymphoma, or myelodysplastic syndrome are the most common hematological malignancies associated with candidemia, while among solid tumors, gastrointestinal cancer has the majority of fungemia cases. Epidemiologic trends show there is a discrepancy between malignancies, where there is an important prevalence of non-albicans Candida in hematological malignancy patients. Diagnosis is challenging, and a high index of suspicion is required to select at-risk patients for early empiric therapy with the goal of reducing mortality. There is an increased effort to improve understanding of individualized approaches to the patient based on precision medicine and to improve diagnosis in the future. The basis of treatment is prompt therapy with echinocandins and target therapy based on susceptibility and minimum inhibitory concentrations (MICs).
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