Reducing Broad-Spectrum Antimicrobial Use in Extracorporeal Membrane Oxygenation: Reduce AMMO Study

Abstract

Background The use of extracorporeal membrane oxygenation (ECMO) in critically ill adults is increasing. There are currently no guidelines for antimicrobial prophylaxis. We analyzed 7 years of prophylactic antimicrobial use across three time series for patients on ECMO at our institution in the development, improvement, and streamlining of our ECMO antimicrobial prophylaxis protocol. Study design and Methods In this quasi-experimental interrupted time series analysis, we evaluated the impact of an initial ECMO antimicrobial prophylaxis protocol, implemented in 2014, on antimicrobial use and NHSN reportable infection rates. Then, following a revision and streamlining of the protocol in November 2018, we re-evaluated the same metrics. Results Our study population included 338 ICU patients who received ECMO between July 2011 and November 2019. After implementation of the first version of the protocol we did not observe significant changes in antimicrobial use or infection rates in these patients; however, following revision and streamlining of the protocol, we demonstrated a significant reduction in broad spectrum antimicrobial use for prophylaxis in patients on ECMO without any evidence of a compensatory increase in infection rates. Conclusion Our final protocol significantly reduces broad spectrum antimicrobial use for prophylaxis in patients on ECMO. We propose a standard antimicrobial prophylaxis regimen for patients on ECMO based on current evidence and our experience.

Analysis of Nosocomial Infection and Risk Factors in Patients with ECMO Treatment

“…Therefore, it is extremely important to understand the related nosocomial infection after ECMO to prevent nosocomial infection occurrence. In the present study, 16 cases developed the nosocomial infection after ECMO, with an infection rate of 28.57%, which is similar to the previous studies reporting that the infection incidence during ECMO is 20.5%-35.0%, 10 , 12 , 17 while our result is lower than the nosocomial infection rate of 40.62% evidenced by Wang et al 18…”

“…In our clinical practice, the decision of experts from multiple departments including infectious diseases, microbiology, infectious disease control, critical care, respiratory, pharmacy and others have been collected to make the strategies of medication, infection prevention and infection control. Aditya et al 12 evaluated the impact of an initial ECMO antimicrobial prophylaxis protocol (antimicrobials with a broader spectrum of activity) on antimicrobial use and NHSN reportable infection rates, the results showed that this multidisciplinary team-based approach to antimicrobial stewardship can significantly reduce antimicrobial prophylaxis and overuse in ECMO patients without increased risk of nosocomial infection. Therefore, it is extremely important to understand the related nosocomial infection after ECMO to prevent nosocomial infection occurrence.…”

“…However, there are no appropriate guidelines and prognostic factors for antimicrobial prophylaxis in patients with ECMO. 12 , 13 To make the effective protocol of antibiotic application, it is crucial to figure out the profiling of nosocomial infections and risk factors.…”

Hospital expenses of nosocomial infection associated with extracorporeal membrane oxygenation in China: a retrospective cohort study

“…It is not hard to explain that medical institutions often keep track of patients with nosocomial infections, which involves the increase in these costs. Study have found that ECMO patients are at high risk of hospitalization in the future, and a multidisciplinary team-based antimicrobial stewardship approach can significantly reduce the prophylaxis and overuse of antimicrobial in ECMO patients without increased risk of nosocomial infection (15,31). The ELSO ID TASK FORCE Recommendation Summary also suggests that cautious, aggressive use of antifungal prophylaxis in patients deemed to be at particularly high risk (32).…”

“…This technology usually exposes patients to a variety of complications, so patients often have to pay high costs (12,13). With the discovery that antimicrobial prophylaxis in patients on ECMO could reduce nosocomial infection and showed lower mortality, some studies have found that antimicrobial prophylaxis and overuse have gradually emerged, so whether it is a cost-effective intervention is still undiscovered (14,15). Because of the extra cost of ECMOrelated nosocomial infection, it may bring more economic burden to the health system.…”