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Evaluation of the impact of appropriate antimicrobial use combined with the rapid microbiological results by MALDI-TOF mass spectrometry (MS) in bloodstream infections (BSI) by Gram-negative bacilli


In 2017, the World Health Organization (WHO) published a list of priority bacterial agents resistant to multiple antimicrobials. Especially where there are high incidence rates of resistant microorganisms WHO highlighted the importance of hospitals worldwide implementing and strengthening programs that seek to promote the adequate use of antimicrobials in clinical practice. Such programs are known worldwide as "stewardship" and are focused on offering adequate antimicrobial therapy to the patients, without exposing them to sub-treatment.10The American Societies for Infectious Diseases (IDSA) and Hospital Epidemiology (SHEA), in the last revision of the implementation guide recommended the prospective audit with intervention and feedback by infectious diseases physicians as one of the most important strategies to reduce the inappropriate use of antimicrobials. 11In an era of growing antimicrobial resistance followed by scarce new drugs development, the approach of this project highlights the importance and the urgency of need to optimize antimicrobial therapy as soon as possible to avoid collateral damage of prolonged broad-spectrum antimicrobial therapy.Infections caused by Gram-negative organisms have become a top healthcare priority. The incidence of Gram-negative bacteria producing beta-lactamase extended-spectrum enzymes is estimated to be high at the Instituto Central of Hospital das Clínicas of the University of São Paulo/FMUSP. The introduction of enzyme-producing strains of the carbapenemase class is a problem that has been increasing considerably in ICUs. In 2016, the rate of carbapenem resistance between Acinetobacter baumannii, Klebsiella pneumoniae and Pseudomonas aeruginosa isolated from BSI in ICUs was 77%, 68% and 60%, respectively.A key concept in the field of infectious diseases is organism identification with subsequent antimicrobial susceptibility testing being this information critical when selecting the appropriate antimicrobial therapy.4 The benefits associated with the appropriate use of antimicrobial therapy have demonstrated reduction of costs, mortality rate, less adverse events related to these drugs, decrease hospitalization time, and probably lower risk of development bacterial resistance and consequent emergence of multidrug-resistant (MDR) microorganisms.The delay in the microbiological identification of the infectious agent makes it difficult the determination of therapy when the isolate is widely sensitive, resulting in excessive exposure to the antimicrobial.1 The clinical microbiology laboratory plays an important role because it allows isolating and identifying the pathogens that cause infections and determine their susceptibility to antimicrobials, enabling the adequacy of antimicrobial therapy, almost always empirically prescribed.14With the incorporation of new, rapid and accurate diagnostic technologies by microbiology laboratories, physicians controlling the rational use of antimicrobials can use this information and quickly suit the antimicrobial treatment chosen by the prescribing physician. Integrating results from rapid laboratory methods for organism identification and susceptibility testing with an ASP allows clinicians to de-escalation therapy and enables the timely addition of life-saving treatment for patients with serious infections.13,15 Huang et al. demonstrated that early identification of the pathogen directly from blood culture bottles by MALDI-TOF combined with a antimicrobial stewardship program to drive appropriate use of these drugs reduced mortality from 20.3% to 14.5% in cases of bloodstream infections. Studies have shown benefits with the introduction of this technology in daily laboratory practice, specifically when this accurate and rapid diagnostic tool is accompanied by a rational antimicrobial drug program that alerts prescribing physicians about their results in real time. (AU)

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