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Hospitals need to determine individual MDRO profiles to optimize antibiotic use

Pank Jit Sin
04 Aug 2017
 All hospitals should have their own antibiogram for multi-drug resistant organisms (MDRO) as it will be useful in determining treatment options for patients with ventilator-associated or hospital-acquired pneumonia (VAP and HAP), says a local expert.

 

Speaking at the Malaysian Thoracic Society (MTS) Annual Congress 2017, Dato’ Dr Mahiran Mustafa, head of the Department of Medicine, Hospital Raja Perempuan Zainab II, Kelantan, said the establishment of antibiogram, defined as a collection of data in the form of a table summarizing the percent of individual bacterial pathogens susceptible to different antimicrobial agents, enables physicians to make the best decision on which antimicrobial to use in their hospital setting. Antibiograms are most relevant in the intensive care setting, where pneumonia is common, as this allows the prescription of antibiotics that can (most) successfully treat the bacterial infections occurring there. [Clin Infect Dis 2016;63(5):e61-e111]  

MDRO is the direct result of antibiotic treatment and the increasing consumption of antibiotics. The increase is driven by several factors including the increased use of invasive medical treatments; the use of suppressive agents in the treatment of cancer; complex surgical procedures (requiring prophylactic antibiotic use); an ageing population with lowered immunity to infection and also consumption of antibiotics present in the food chain.

Multidrug resistance has implications beyond the walls of the hospital, said Mahiran. Quoting a study from Germany involving 4,376 patients within 3 days of admission, it was found that 9.5 percent were already positive for third-generation cephalosporin-resistant enterobacteriaceae (3GCREB). Of this number, 79.1 percent consisted of Escherichia coli, 8.5 percent were Klebsiella pneumonia, 5.7 percent were Enterobacter spp. and 4.8 percent were Citrobacter spp. Of the number of 3GCREB samples, 41 percent were also resistant to fluoroquinolones and 90.2 percent also exhibited extended-spectrum beta-lactamase production. [J Antimicrob Chemother 2016;71(10):2957-2963]

Even though Mahiran advocates proper antibiotic stewardship, she concurs it can be difficult to diagnose a bacterial infection. For instance, noninfectious inflammation can also result in fever. Alternatively, the fever may be caused by other sites of infection besides the lung. Additionally, many conditions other than nosocomial pneumonia resemble pulmonary infiltrates on chest radiographs. One must not rule out errors in chest x-ray interpretation, which, although uncommon, should definitely be one of the factors to look out for. 

Patients deserve your best
Mahiran posted these questions to the audience: “Is our standard of care up to the standard required to protect our patients’ safety?” She noted that sometimes doctors may overlook or provide substandard care because doctors feel that nobody is scrutinizing them in their practice—“nobody is looking at the way we manage our patients and what antibiotics we give to them. All these information are confidential.”

Consultants need to know their responsibility and their accountability to their patients, Mahiran added. She said: “Many times you look at critically ill patients and you think they are neutropenic or immunosuppressed patients.” However, more often than not, they are critically ill because they’ve been on prolonged antibiotics; on polymicrobials because doctors may add-on antibiotics without determining which are the best types for the patient and in the end the patients are exposed to more harm than good. Hence, the importance of an antibiogram and following proper HAP and VAP guidelines.  

“We also like to do invasive procedures, which may be more prevalent in certain settings,” noted Mahiran. Prolonged hospital stay is another risk factor to consider. Mahiran said: “Please do not prolong or re-admit your patients unnecessarily. The hospital isn’t a five-star hotel for them to stay as long as they like. Hospital beds will expose patients to nosocomial infection.”

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11 Aug 2017
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