The 2018 Lebanese Society of Infectious Diseases and Clinical Microbiology Guidelines for the use of antimicrobial therapy in complicated intra-abdominal infections in the era of antimicrobial resistance

Abstract

Background The Lebanese Society of Infectious Diseases and Clinical Microbiology (LSIDCM) is involved in antimicrobial stewardship. In an attempt at guiding clinicians across Lebanon in regards to the proper use of antimicrobial agents, members of this society are in the process of preparing national guidelines for common infectious diseases, among which are the guidelines for empiric and targeted antimicrobial therapy of complicated intra-abdominal infections (cIAI). The aims of these guidelines are optimizing patient care based on evidence-based literature and local antimicrobial susceptibility data, together with limiting the inappropriate use of antimicrobials thus decreasing the emergence of antimicrobial resistance (AMR) and curtailing on other adverse outcomes. Methods Recommendations in these guidelines are adapted from other international guidelines but modeled based on locally derived susceptibility data and on the availability of pharmaceutical and other resources. Results These guidelines propose antimicrobial therapy of cIAI in adults based on risk factors, site of acquisition of infection, and clinical severity of illness. We recommend using antibiotic therapy targeting third-generation cephalosporin (3GC)-resistant gram negative organisms, with carbapenem sparing as much as possible, for community-acquired infections when the following risk factors exist: prior (within 90 days) exposure to antibiotics, immunocompromised state, recent history of hospitalization or of surgery and invasive procedure all within the preceding 90 days. We also recommend antimicrobial de-escalation strategy after culture results. Prompt and adequate antimicrobial therapy for cIAI reduces morbidity and mortality; however, the duration of therapy should be limited to no more than 4 days when adequate source control is achieved and the patient is clinically stable. The management of acute pancreatitis is conservative, with a role for antibiotic therapy only in specific situations and after microbiological diagnosis. The use of broad-spectrum antimicrobial agents including systemic antifungals and newly approved antibiotics is preferably restricted to infectious diseases specialists. Conclusion These guidelines represent a major step towards initiating a Lebanese national antimicrobial stewardship program. The LSIDCM emphasizes on development of a national AMR surveillance network, in addition to a national antibiogram for cIAI stratified based on the setting (community, hospital, unit-based) that should be frequently updated.

Assessing the Quality of Clinical Practice Guidelines in the Middle East and North Africa (MENA) Region: A Systematic Review

“…Characteristics of CPGsHaddad et al107 The 2018 Lebanese Society of Infectious Diseases and Clinical Microbiology Guidelines for the use of antimicrobial therapy in complicated intra-abdominal infections in the era of antimicrobial resistance.…”

The effect of an antibiotic stewardship program on tigecycline use in a Tertiary Care Hospital, an intervention study

“…Shifting the types of infections treated with tigecycline was one of the main priorities of the ASP. The empiric use of tigecycline as a mono- or combination therapy to reduce carbapenem use in non-severely ill patients with cSSTI and cIAI who were at risk for infection with MDR bacteria was supported by national and international guidelines, multicenter studies, and expert opinions [ 16 , 27 – 32 ].…”

“…For instance, recently updated international guidelines indicate that the optimal duration of antibiotic therapy is 3–5 days in cIAI cases where patients undergo an adequate source-control procedure [ 28 , 29 ]. The duration can be extended to 7 days depending on the presence of concomitant bacteremia, rate of fever resolution and other signs of infection, and the presence of comorbidities [ 27 , 38 ]. For other infections like acute bacterial cSSTI, the latest IDSA guidelines suggest 7 to 10 days of therapy with individualization based on clinical response and factors like comorbidities, etiology, and appropriateness of drug or dosages [ 39 ].…”

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“…Lack of adherence to antibiotic use guidelines has already been documented in Lebanon [28,29] The above information on antibiotic use and misuse begs for national campaigns for antibiotic stewardship including guidelines and education A 2016 study of Lebanese hospitals showed that only 7% knew what the term antimicrobial stewardship meant, although around 65% reported having some type of antibiotic control program in the hospital and only 50% had an outcome measure in place [30]. However, in recent years, The Lebanese Society of Infectious Diseases has published several articles guiding the treatment of specific diseases such as UTIs and complicated intraabdominal infections [31,32]. .Moreover, the Alliance for the Prudent Use of Antibiotics (APUA) has a Lebanese chapter that has been active especially in antibiotic stewardship education [33], braving the first steps to promoting antibiotic stewardship programs in the country; steps that other nations with a similar pattern of antibiotic use should also follow.…”