Impact of a Multistep Bundles Intervention in the Management and Outcome of Gram-Negative Bloodstream Infections: A Single-Center “Proof-of-Concept” Study

Abstract

Background This is a “proof-of-concept” study aiming to evaluate the impact of a multi-step bundles intervention in the management and outcome of patients with Gram-negative bloodstream infections (GN-BSIs). Methods This was a single-center, quasi-experimental design study. In the pre-phase (January 2019 to May 2020), patients were retrospectively enrolled. During the post-phase (June 2020 to September 2021), all patients were prospectively enrolled in a non-mandatory three steps bundles intervention arm including: i) step one: imaging to detect deep foci of infection, follow-up blood cultures and procalcitonin monitoring; ii) step two: early targeted antibiotic treatment and surgical source control; iii) step three: discontinuation of antibiotics within 7-10 days in case of uncomplicated BSI. Patients were followed up to 28-days from BSI onset. The primary outcome was 28-day mortality. Results A total of 271 patients were enrolled: 127 and 144 in the pre- vs post-phase, respectively. Full application of step one (67% vs 42%; p < .001), step two (83% vs 72%, p = .031), and step three (54% vs 2%, p < .001) increased in the pre-phase. Overall, the intervention reduced the 28-day mortality (22% vs 35% respectively, p = .016) and the median duration of total (11 vs 15 days, p < .001) and targeted (8 vs 12 days, p = .001) antibiotic therapy. Finally, the multivariate Cox regression confirmed the independent protective effect of the adherence to step one (aHR = 0.36, 95%CI = 0.20-0.63) and step two (aHR = 0.48, 95%CI = 0.29-0.81) on risk of 28-day mortality. Conclusions Clinical management and outcome of patients with GN-BSIs may be improved by providing a pre-established multi-step bundles intervention.

Impact of a Pro-Active Infectious Disease Consultation on the Management of a Multidrug-Resistant Organisms Outbreak in a COVID-19 Hospital: A Three-Months Quasi-Experimental Study

“…The results of these antibiotic stewardship strategies in terms of mortality risk reduction in our population are in line with the current literature [ 28 ]: inappropriate use of antibiotics can cause antibiotic resistance up to emergency levels, multiple adverse events, further secondary infections, and in turn, deaths. Accordingly, this work supports the importance of providing stewardship interventions, also in the context of the COVID-19 pandemic [ 29 , 30 ].…”

Cefiderocol Versus Colistin for the Treatment of Carbapenem-Resistant Acinetobacter baumannii Complex Bloodstream Infections: A Retrospective, Propensity-Score Adjusted, Monocentric Cohort Study

“…Additional risk factors for mortality emerging from this study were older age, septic shock, and delayed appropriate antimicrobial therapy, as frequently reported by other studies conducted on gram-negative bacterial BSI [ 2 , 9 – 11 , 19 , 20 ]. Importantly, to improve the outcome of BSIs, many additional factors are determinant: for instance, a multi-step bundle approach to manage gram-negative bacterial BSI may be beneficial, improving the identification of deep sites of infections and rate of early targeted antimicrobial therapy and allowing rapid discontinuation of antibiotics in cases of uncomplicated BSIs, preventing adverse events [ 21 ].…”

“…CRAB-BSI occurred with septic shock, acute lung failure, and acute kidney failure in 36%, 42%, and 31% of patients, respectively. At presentation, the median SOFA score was 5 (2-6), and 30 (25%) patients had a PITT bacteriemia score [ 4. All CRAB isolates were sensitive to colistin [median (q1-q3) MIC = 0.5 (0.5-1) mg/l] and to cefiderocol [median (q1-q3) disk diffusion diameter 20 (18)(19)(20)(21)(22) mm], except two strains which were resistant to cefiderocol at baseline. Of note, all the strains were resistant to aminoglycosides, carbapenems, fluoroquinolones, and ampicillin/sulbactam; finally, tigecycline sensitivity (MIC B 2 mg/l) was documented in 11 (9%) cases.…”

Stenotrophomonas maltophilia Infections: A Systematic Review and Meta-Analysis of Comparative Efficacy of Available Treatments, with Critical Assessment of Novel Therapeutic Options

“…Indeed, in a recent study, the benefit of a multi-step bundles approach aimed at managing BSIs by Gram-negative bacteria as a "clinical syndrome" was demonstrated; mortality was reduced by improving the identification of deep sites of infections, the rate of early targeted antimicrobial therapy, and the rapid discontinuation of antibiotics in cases of uncomplicated BSIs [71]. These bundles should also be used in cases of SM infections; in fact, as occurred in the study conducted by Sarzynski and co-workers [44], patients in the levofloxacin group showed a reduced mortality probably because they were more likely to receive an early effective empirical therapy (10% versus 0.9%).…”