“Guidelines for proper use of prophylactic antimicrobial for surgery” published in 2016 recommends the selection, dose interval and dosage of prophylactic antimicrobial according to patient characteristics for each surgical procedure. In our hospital, prophylactic antimicrobial had been set by the clinical path, but the adjustment of interval and dosage according to renal function or weight had been left to surgeons. Since January 2018, the ward pharmacists have started the electronic patient record–based prescription suggestion in collaboration with surgeons and operating room nurses for the purpose of improving the appropriate use of prophylactic antimicrobial. Appropriate use ratio of prophylactic antimicrobial before/after the intervention was significantly improved. The ratio was the following: all groups: 62.0％/87.4％ (P＜0.001), renal impairment group: 34.0％/86.3％(P＜0.001), overweight group: 20％/92.3％(P=0.001). It has been shown that the ward pharmacist’s intervention improved the appropriate use ratio of dose interval and dosage of prophylactic antimicrobial. Our intervention may lead to reduction in the incidence of surgical site infection and prevention of adverse events by antimicrobial.
We implemented “Prospective audit and Feedback” as core strategy of ASP. We evaluated the effectiveness of surgical infection treatment for all bacteremia and Bacteroides, which are frequently the cause of surgical infections. As a result, the rate of two sets of blood culture increased and the in–hospital mortality rate of bacteremia was significantly improved (34.9％→23.1％: P＝0.04). In Bacteroides bacteremia, AST activity decreased the frequency of carbapenem agents used in empirical treatment and increased TAZ/PIPC. In addition, the de–escalation rate in definitive therapy increased (9.7％→34.8％: P=0.04). No obvious change in susceptibility to Bacteroides was observed. The prognosis of bacteremia tended to be improved. From the above, it was shown that the AST activities in our hospital is effective in the treatment of surgical infectious diseases.
The spread of drug–resistant bacteria has become a problem worldwide. In Japan, the National Action Plan on Antimicrobial Resistance (AMR) 2016〜2020 including the performance indicators about the reduction of the resistance rate and the amount of antibacterial drugs was created in 2016. In surgery, emergency department or intensive care unit, several multidrug resistant pathogens have become a problem, however, a large number of antibacterial drugs are used for prevention of postoperative infections and severe infections such as sepsis. The enhancement of activities centered on the infection control team and antimicrobial stewardship team is required for antimicrobial stewardship.
To save severely septic patients and simultaneously prevent the emergence of resistant bacteria, antibiotics should be administered empirically and then de–escalated promptly, after bacterial susceptibility is confirmed. De–escalation therapy for septic shock is a safe strategy associated with lower mortality; however, its incidence is not high in Intensive Care Units (ICU). From 76 patients admitted to our ICU with a diagnosis of sepsis, most of surgical patients were infected with community–acquired agents including digestive infections. Broad–spectrum antibiotics were used empirically in ＞90％ patients; approximately 20％ surgical patients received more than one drug. The adequate rate of empirical therapy was about 95％. Antibiotic de–escalation therapy was performed in 50％ of cases receiving broad–spectrum antibiotics. There were various reasons behind the hesitancy to apply de–escalation therapy to severely ill patients: unknown causative agent, no visible improvement of pathological conditions, presence of multiple infection foci, and immunosuppression. In order to promote the proper use of antibiotics in ICU, in addition to a strong cooperation between clinicians, antimicrobial stewardship team, and ICU–dedicated pharmacists, critically ill patients’ treatment should be carried out rationally in accordance with the basic treatment logic for infectious diseases, and in parallel a rapid bacteria diagnostic method should be applied.
Antimicrobial dosing for critically ill patients that is derived from other patient groups is likely to be suboptimal because of significant antibiotic pharmacokinetic changes, particularly in terms of drug volume of distribution and clearance. Organ support techniques including continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO) increase the pharmacokinetic variability. This article topics the recently published antibiotic pharmacokinetic data associated with infectious disease, those receiving CRRT and ECMO. In the content of such variable pharmacokinetics, a guideline approach to dosing remains elusive because of insufficient available data and, therefore, antimicrobial stewardship including TDM should be considered advantageous where possible.
A 76–year–old man was referred to our hospital with a complaint of high fever. Abdominal ultrasonography showed a low echoic lesion in the liver. We diagnosed his condition as a liver abscess, and percutaneous transhepatic abscess drainage was immediately performed. Klebsiella pneumoniae was detected in the patient’s abscess fluid culture, blood and spinal fluid. The patient was suspected of having meningitis. Abdominal enhanced computed tomography revealed multiple liver abscesses, and we performed additional abscess drainage. During the course of his illness, he developed a cervical abscess, and incisional drainage was performed. To identify the origin of the liver abscesses, a full gastrointestinal study was conducted, and revealed gastric cancer and rectal cancer. A total of 168 days after the first admission, laparoscopic distal gastrectomy and low anterior resection were performed. He did not have recurrence of the liver abscesses or liver metastases of gastric cancer or rectal cancer 25 months after the operation. In an effort to identify the cause of liver abscesses, gastrointestinal examination should be performed. Thus, our report describes a case in which the patient had multiple infections including liver abscesses, bacteremia, meningitis, and a cervical abscess before surgery for gastric cancer and rectal cancer.