Política de antibióticos. Comisión de Infecciones y uso de antimicrobianos / The antibiotic policy. The Infection Committee and antimicrobial use

La política de antibióticos es el conjunto de estrategias y actividades llevadas a cabo para organizar el tratamiento antimicrobiano en el hospital, y conseguir resultados en salud para los pacientes. Los principios básicos que deben dirigirla son la medicina basada en la evidencia, la epidemiología local y la libertad de prescripción de los facultativos. En la actualidad, la política de antibióticos es más necesaria que nunca por razones clínicas, epidemiológicas y económicas. La Comisión de Infecciones es la responsable de la política de antibióticos en los hospitales. Sus funciones, como órgano asesor de la dirección médica, son el análisis de la epidemiología de las infecciones del centro, las medidas para su prevención y control, la mejora del uso apropiado de los antimicrobianos, la formación y la producción de conocimientos. Conseguir los objetivos clínicos, ecológicos y económicos de la política de antibióticos no es tarea fácil. Poner de acuerdo a cientos de profesionales en torno a las recomendaciones sobre indicaciones, posología y duración del tratamiento antibiótico basadas en las mejores evidencias científicas y en las guías locales, es complejo, pero se puede hacer. Para ello es clave que la Comisión de Infecciones desarrolle el PROA a través de un equipo multidisciplinar y con liderazgo profesional, y que cuente con el apoyo institucional que asegure que el buen uso de los antimicrobianos es un objetivo prioritario del centro, y por lo tanto de cada uno de los servicios implicados, y que el equipo de PROA dispone de los recursos necesarios (AU)

The antibiotic policy is the set of strategies and activities undertaken to organize the antimicrobial treatment in the hospital, and achieve health outcomes for patients. The basic principles are to be direct evidence-based medicine, local epidemiology and freedom for prescribing physicians. Anantibiotic policy is now more necessary than ever for clinical, epidemiological and economic reasons. The Infection Committee is responsible for the antibiotics policy in hospitals. Its functions as an advisory body to the medical directorate are the analysis of the epidemiology of the infections in the center, measures for its prevention and control, improving the appropriate use of antimicrobials, training, and knowledge production. To achieve clinical, environmental and economic policy objectives of antibiotics is not easy. The agreement of hundreds of professionals for recommendations on indications, dosage and duration of antibiotic treatment, based on the best scientific evidence and local guides is complex, but it can be done. The key to this is that the Infection Committee develops antimicrobial stewardship through a multidisciplinary team and professional leadership, and has the institutional support to ensure that the proper use of antimicrobials is a priority for the center, and therefore of each of the services involved, and that the team has the resources for antimicrobial stewardship (AU)

[The antibiotic policy. The Infection Committee and antimicrobial use]. / Política de antibióticos. Comisión de Infecciones y uso de antimicrobianos.

The antibiotic policy is the set of strategies and activities undertaken to organize the antimicrobial treatment in the hospital, and achieve health outcomes for patients. The basic principles are to be direct evidence-based medicine, local epidemiology and freedom for prescribing physicians. An antibiotic policy is now more necessary than ever for clinical, epidemiological and economic reasons. The Infection Committee is responsible for the antibiotics policy in hospitals. Its functions as an advisory body to the medical directorate are the analysis of the epidemiology of the infections in the center, measures for its prevention and control, improving the appropriate use of antimicrobials, training, and knowledge production. To achieve clinical, environmental and economic policy objectives of antibiotics is not easy. The agreement of hundreds of professionals for recommendations on indications, dosage and duration of antibiotic treatment, based on the best scientific evidence and local guides is complex, but it can be done. The key to this is that the Infection Committee develops antimicrobial stewardship through a multidisciplinary team and professional leadership, and has the institutional support to ensure that the proper use of antimicrobials is a priority for the center, and therefore of each of the services involved, and that the team has the resources for antimicrobial stewardship.

Cost-effectiveness analysis comparing two approaches for empirical antifungal therapy in hematological patients with persistent febrile neutropenia.

New approaches of empirical antifungal therapy (EAT) in selected hematological patients with persistent febrile neutropenia (PFN) have been proposed in recent years, but their cost-effectiveness has not been studied. The aim of this study was to compare the cost-effectiveness of two different approaches of EAT in hematological patients with PFN: the diagnosis-driven antifungal therapy (DDAT) approach versus the standard approach of EAT. A decision tree to assess the cost-effectiveness of both approaches was developed. Outcome probabilities and treatment pathways were extrapolated from two studies: a prospective cohort study following the DDAT approach and a randomized clinical trial following the standard approach. Uncertainty was undertaken through sensitivity analyses and Monte Carlo simulation. The average effectiveness and economic advantages in the DDAT approach compared to the standard approach were 2.6% and €5,879 (33%) per PFN episode, respectively. The DDAT was the dominant approach in the 99.5% of the simulations performed with average cost-effectiveness per PFN episode of €32,671 versus €52,479 in the EAT approach. The results were robust over a wide range of variables. The DDAT approach is more cost-effective than the EAT approach in the management of PFN in hematological patients.

[Evaluation of pharmacodynamic target attainment with vancomycin treatment of bacteremia due to Staphylococcus aureus methicillin resistant]. / Evaluación farmacocinética y farmacodinámica del tratamiento con vancomicina en la bacteriemia por Staphylococcusaureus resistente a meticilina.

OBJECTIVE: The objective of the study is to evaluate the ability of standard vancomycin dosing strategies actually recommended to attain the pharmacodynamic target of an area under the curve of vancomycin serum concentration versus time from 0 to 24 hours (AUC(24h)) to minimum inhibitory concentration (MIC) ratio greater than 400:1 for patients with a suspected or documented methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia by individual analysis and Monte Carlo simulation. MATERIAL AND METHODS: The study included all patients admitted with suspected or proven MRSA infection during the years 2007-2008, and who were initially treated with vancomycin at a dose of 30 mg/kg/ day, and underwent pharmacokinetic monitoring. The area under the curve of vancomycin serum concentration versus time from 0 to 24 hours (AUC(24h)) was calculated as daily dose/ clearance total (D(24h)/CL). Additionally, we studied 45 isolates of MRSA obtained from blood cultures in the period 2007-2008. The MIC to vancomycin was determined using Epsilon-test®. The PK-PD parameter calculated was AUC(24h)/MIC. Microsoft Excel was used to perform a 10.000 subject Monte Carlo simulation. An AUC(24h)/MIC > or =400 was assumed as the target attainment. RESULTS: In the individual study, the percentage of patients with AUC(24h)/ MIC(50/90) > or = 400 was 50%. The probability (%) of attaining AUC(24h)/MIC ratio values > or = 400 by Monte Carlo simulation was of 66%. The vancomycin MIC value from which the scenario would have to wait a suboptimal treatment (target < 90%) was >1 mg/ L. DISCUSSION: This study shows that in the population studied to achieve a vancomycin AUC(24h)/MIC > or =400 is not always attained with the standard dose. Therefore, one would expect a high probability of suboptimal vancomycin AUC(24h)/MIC ratios for patients infected with organisms with vancomycin MICs of >1 mg/ L treated with doses of 30 mg/ kg/ day.

Evaluación farmacocinética y farmacodinámica del tratamiento con vancomicina en la bacteriemia por Staphylococcus aureus resistente a meticilina / Evaluation of pharmacodynamic target attainment with vancomycin treatment of bacteremia due to Staphylococcus aureus methicillin resistant

Objetivo: Evaluar la capacidad de la actual estrategia dedosificación de vancomicina de obtener un objetivo farmacocinético/farmacodinámico (FC/FD) de área bajo la curva CMImayor de 400 en pacientes con sospecha o bacteriemia documentadapor Staphylococcus aureus resistente a meticilina(SARM) mediante análisis individual de los pacientes y simulaciónde Monte Carlo.Material y métodos: El estudio incluyó a todos los pacientesingresados con sospecha o bacteriemia documentada porSARM durante los años 2007-2008 y que inicialmente fuerontratados con una dosis de vancomicina de 30 mg/kg/día y quefueron sometidos a seguimiento farmacocinético.El área bajo la curva de la concentración sérica de vancomicinafrente al tiempo de 0 a 24 horas (ABC24h) se calculó comola dosis diaria / aclaramiento total (D24h/CL). Además, se estudiaron45 cepas de SARM obtenidas de hemocultivospertenecientes a pacientes individuales. El CMI a vancomicinafue determinada por Epsilon-test®. Además se realizó una simulaciónde Monte Carlo sobre 10.000 individuos, un ABC24h/CMI >=400 se asumió como objetivo.Resultados: en el estudio individual, el porcentaje de pacientescon ABC24h/CMI50/90 >=400 fue del 50%. La probabilidad(%) de alcanzar ABC24h/CMI >= 400 por simulación Monte Carloen la población estudiada fue de 66%. El valor de CMI a vancomicinaa partir del cual se podría inferir un escenario subóptimode tratamiento (objetivo <90%) fue de > 1 mg/L.Discusión: Este estudio muestra que en la población estudiadaconseguir un cociente ABC24h/CMI >= 400 para vancomicinano es siempre posible con la dosis estándar especialmenteen pacientes infectados con microorganismos con CMI a vancomicina> 1 mg/L y que son tratados con dosis de vancomicinade 30 mg/kg/día(AU)

Objective: The objective of the study is to evaluatethe ability of standard vancomycin dosing strategiesactually recommended to attain the pharmacodynamictarget of an area under the curve of vancomycin serumconcentration versus time from 0 to 24 hours (AUC24h)to minimum inhibitory concentration (MIC) ratio greaterthan 400:1 for patients with a suspected or documentedmethicillin-resistant Staphylococcus aureus(MRSA) bacteraemia by individual analysis and MonteCarlo simulation.Material and methods: The study included all patientsadmitted with suspected or proven MRSA infectionduring the years 2007-2008, and who were initiallytreated with vancomycin at a dose of 30mg/kg/day, and underwent pharmacokinetic monitoring.The area under the curve of vancomycin serumconcentration versus time from 0 to 24 hours (AUC24h)was calculated as daily dose/clearance total (D24h/CL).Additionally, we studied 45 isolates of MRSA obtainedfrom blood cultures in the period 2007-2008. The MICto vancomycin was determined using Epsilon-test®.The PK-PD parameter calculated was AUC24h/MIC. MicrosoftExcel was used to perform a 10.000 subjectMonte Carlo simulation. An AUC24h/MIC ≥ 400 was assumedas the target attainment. Results: In the individual study, the percentage of patientswith AUC24h/MIC50/90 >= 400 was 50%. The probability(%) of attaining AUC24h/MIC ratio values >= 400 by MonteCarlo simulation was of 66%. The vancomycin MIC valuefrom which the scenario would have to wait a suboptimaltreatment (target <90%) was >1 mg/L.Discussion: This study shows that in the populationstudied to achieve a vancomycin AUC24h/MIC >= 400 isnot always attained with the standard dose. Therefore,one would expect a high probability of suboptimal vancomycinAUC24h/MIC ratios for patients infected with organismswith vancomycin MICs of >1 mg/L treated withdoses of 30 mg/kg/day(AU)