Impact of a multidisciplinary management team on clinical outcome in ICU patients affected by Gram-negative bloodstream infections: a pre-post quasi-experimental study

Abstract

Background Bloodstream infections (BSIs) by Gram-negative pathogens play a major role in intensive care patients, both in terms of prevalence and severity, especially if multi-drug resistant pathogens are involved. Early appropriate antibiotic therapy is therefore a cornerstone in the management of these patients, and growing evidence shows that implementation of a multidisciplinary team may improve patients’ outcomes. Our aim was to evaluate the clinical and microbiological impact of the application of a multidisciplinary team on critically ill patients. Methods Pre-post study enrolling critically ill patients with Gram negative bloodstream infection in intensive care unit. In the pre-intervention phase (from January until December 2018) patients were managed with infectious disease consultation on demand, in the post-intervention phase (from January until December 2022) patients were managed with a daily evaluation by a multidisciplinary team composed of intensivist, infectious disease physician, clinical pharmacologist and microbiologist. Results Overall, 135 patients were enrolled during the study period, of them 67 (49.6%) in the pre-intervention phase and 68 (50.4%) in the post-intervention phase. Median age was 67 (58–75) years, sex male was 31.9%. Septic shock, the need for continuous renal replacement therapy and mechanical ventilation at BSI onset were similar in both groups, no difference of multidrug-resistant organisms (MDRO) prevalence was observed. In the post-phase, empirical administration of carbapenems decreased significantly (40.3% vs. 62.7%, p = 0.02) with an increase of appropriate empirical therapy (86.9% vs. 55.2%, p < 0.001) and a decrease of overall antibiotic treatment (12 vs. 16 days, p < 0.001). Despite no differences in delta SOFA and all-cause 30-day mortality, a significant decrease in microbiological failure (10.3% vs. 29.9%, p = 0.005) and a new-onset 30-day MDRO colonization (8.3% vs. 36.6%, p < 0.001) in the post-phase was reported. At multivariable analysis adjusted for main covariates, the institution of a multidisciplinary management team (MMT) was found to be protective both for new MDRO colonization [OR 0.17, 95%CI(0.05–0.67)] and microbiological failure [OR 0.37, 95%CI (0.14–0.98)]. Conclusions The institution of a MMT allowed for an optimization of antimicrobial treatments, reflecting to a significant decrease in new MDRO colonization and microbiological failure among critically ill patients.

Pharmacokinetic/pharmacodynamic issues for optimizing treatment with beta-lactams of Gram-negative infections in critically ill orthotopic liver transplant recipients: a comprehensive review

“…Previous evidence supported the role of a multidisciplinary management team in improving clinical outcome in different settings involving critically ill patients (Viale et al, 2017;Gatti et al, 2019;Rinaldi et al, 2024). To this regard, a recent pre-post quasi-experimental study assessed the role of a multidisciplinary team composed by the intensivist, the infectious disease consultant, the clinical pharmacologist and the microbiologist on the outcome of 135 critical patients (10.3% OLT recipients) having documented Gram-negative BSIs (Rinaldi et al, 2024). In the postintervention phase, daily evaluation by the multidisciplinary t e a m w a s l i n k e d t o s i g n i fi c a n t d e c r e a s e s o f e i t h e r microbiological failure (10.3% vs. 29.9%; p=0.005) or 30-day new-onset colonization by multidrug-resistant organisms (8.3% vs. 36.6%; p<0.001) (Rinaldi et al, 2024).…”

“…Finally, implementing a coordinated and synchronized multidisciplinary team including the intensive care physician, the surgeon, the infectious disease consultant, the hepatologists, the clinical microbiologist, and the MD clinical pharmacologist could play a major role in the management of critical OLT recipients affected by suspected or documented sepsis (Patel and Huprikar, 2012;Lucey et al, 2023). Previous evidence supported the role of a multidisciplinary management team in improving clinical outcome in different settings involving critically ill patients (Viale et al, 2017;Gatti et al, 2019;Rinaldi et al, 2024). To this regard, a recent pre-post quasi-experimental study assessed the role of a multidisciplinary team composed by the intensivist, the infectious disease consultant, the clinical pharmacologist and the microbiologist on the outcome of 135 critical patients (10.3% OLT recipients) having documented Gram-negative BSIs (Rinaldi et al, 2024).…”

“…To this regard, a recent pre-post quasi-experimental study assessed the role of a multidisciplinary team composed by the intensivist, the infectious disease consultant, the clinical pharmacologist and the microbiologist on the outcome of 135 critical patients (10.3% OLT recipients) having documented Gram-negative BSIs (Rinaldi et al, 2024). In the postintervention phase, daily evaluation by the multidisciplinary t e a m w a s l i n k e d t o s i g n i fi c a n t d e c r e a s e s o f e i t h e r microbiological failure (10.3% vs. 29.9%; p=0.005) or 30-day new-onset colonization by multidrug-resistant organisms (8.3% vs. 36.6%; p<0.001) (Rinaldi et al, 2024). In the scenario of critical OLT recipients, the MD clinical pharmacologist should act in a synchronized way with the other members of the multidisciplinary team, with the aim of ensuring both the optimization of betalactam dosing according to "antimicrobial puzzle" concepts, including the careful assessment of specific OLT-associated pathophysiological alterations, and the promptly attainment of aggressive PK/PD targets by adopting a real-time TDM-guided ECPA program (Figure 2).…”