De-escalation and discontinuation strategies in high-risk neutropenic patients: an interrupted time series analyses of antimicrobial consumption and impact on outcome.

Febrile neutropenia (FN) is the main reason for antibiotic prescription in hematology wards where, on the other hand, antibiotic stewardship (AS) is poorly explored. The objectives of the present study were to evaluate (1) the impact of an AS intervention on antibiotic consumption and (2) the applicability and acceptance rate of the intervention and its clinical impact. A persuasive AS intervention based on European Conference on Infection in Leukaemia (ECIL) guidelines for FN was implemented in a high-risk hematology ward in a tertiary referral public university hospital. This included the creation and diffusion of flow charts on de-escalation and discontinuation of antibiotics for FN, and the introduction in the team of a doctor dedicated to the implementation of flow charts and to antibiotic prescription revision. All consecutive patients receiving antibiotics during hospitalization were included. A segmented linear regression model was performed for the evaluation of antibiotic consumption, taking into account 1-year pre-intervention period and 6-month intervention period. Overall, 137 consecutive antibiotic prescriptions were re-evaluated, 100 prescriptions were for FN. A significant reduction of the level of carbapenem consumption was observed during the intervention period (level change (estimate coefficient ± standard error) = - 135.28 ± 59.49; p = 0.04). Applicability and acceptability of flow charts were high. No differences in terms of intensive care unit transfers, bacteremia incidence, and mortality were found. A persuasive AS intervention in hematology significantly reduced carbapenem consumption without affecting outcome and was well accepted. This should encourage further applications of ECIL guidelines for FN.

Costs associated with implementation of a strict policy for controlling spread of highly resistant microorganisms in France.

OBJECTIVE: To assess costs associated with implementation of a strict 'search and isolate' strategy for controlling highly drug-resistant organisms (HDRO). DESIGN: Review of data from 2-year prospective surveillance (01/2012 to 12/2013) of HDRO. SETTING: Three university hospitals located in northern Paris. METHODS: Episodes were defined as single cases or outbreaks of glycopeptide-resistant enterococci (GRE) or carbapenemase-producing Enterobacteriacae (CPE) colonisation. Costs were related to staff reinforcement, costs of screening cultures, contact precautions and interruption of new admissions. Univariate analysis, along with simple and multiple linear regression analyses, was conducted to determine variables associated with cost of HDRO management. RESULTS: Overall, 41 consecutive episodes were included, 28 single cases and 13 outbreaks. The cost (mean ± SD) associated with management of a single case identified within and/or 48 h after admission was €4443 ± 11,552 and €11,445 ± 15,743, respectively (p<0.01). In an outbreak, the total cost varied from €14,864 ± 17,734 for an episode with one secondary case (€7432 ± 8867 per case) to €136,525 ± 151,231 (€12,845 ± 5129 per case) when more than one secondary case occurred. In episodes of single cases, contact precautions and microbiological analyses represented 51% and 30% of overall cost, respectively. In outbreaks, cost related to interruption of new admissions represented 77-94% of total costs, and had the greatest financial impact (R(2)=0.98, p<0.01). CONCLUSIONS: In HDRO episodes occurring at three university hospitals, interruption of new admissions constituted the most costly measure in an outbreak situation.

New procedure to reduce the time and cost of broncho-pulmonary specimen management using the Previ Isola® automated inoculation system.

The microbiological diagnosis of respiratory tract infections requires serial manual dilutions of the clinical specimen before agar plate inoculation, disrupting the workflow in bacteriology clinical laboratories. Automated plating instrument systems have been designed to increase the speed, reproducibility and safety of this inoculating step; nevertheless, data concerning respiratory specimens are lacking. We tested a specific procedure that uses the Previ Isola® (bioMérieux, Craponne, France) to inoculate with broncho-pulmonary specimens (BPS). A total of 350 BPS from a university-affiliated hospital were managed in parallel using the manual reference and the automated methods (expectoration: 75; broncho-alveolar lavage: 68; tracheal aspiration: 17; protected distal sample: 190). A specific enumeration reading grid, a pre-liquefaction step and a fluidity test, performed before the inoculation, were designed for the automated method. The qualitative (i.e., the number of specimens yielding a bacterial count greater than the clinical threshold) and quantitative (i.e., the discrepancy within a 0.5 log value) concordances were 100% and 98.2%, respectively. The slimmest subgroup of expectorations could not be managed by the automated method (8%, 6/75). The technical time and cost savings (i.e., number of consumed plates) reached 50%. Additional studies are required for specific populations, such as cystic fibrosis specimens and associated bacterial variants. An automated decapper should be implemented to increase the biosafety of the process. The PREVI Isola® adapted procedure is a time- and cost-saving method for broncho-pulmonary specimen processing.