2019-12-09    |    浏览次数:3680次    |    来源:京港感染论坛



A microbiologist consultant should attend daily ICU rounds


(Antibiotics are widely used in the intensive care unit (ICU); with approximately half of the patients diagnosed with an infection, this is not surprising [1]. In parallel, we are witnessing an increase in the incidence of infections caused by multidrug resistant (MDR) infections, in which  exposure to antibiotics is a contributing factor [2].)

医院范围内的抗生素管理计划(antibiotic stewardship programs,ASP)已经实施,以减少抗生素暴露并改善患者预后。在涉及不同专业的多学科合作中,应用不同的干预措施可以帮助处方医生更好地作出抗生素决策。它可能包括提供指南、处方限制、审查和反馈[3]。

(Hospital-wide antibiotic stewardship programs (ASP) have been developed to reduce antibiotic exposure and improve patient outcomes. In a multidisciplinary approach involving different specialties, different interventions are used to assist prescribers in better antibiotic decision-making. This may include the provision of guidelines, formulary restrictions, review and feedback[3].)


(ASP meetings are widely used in the ICU [4] but the frequency, duration and its participants vary from daily  meetings with the complete team discussing each patient to once-weekly meetings with part of the team to discuss the difficult to treat patients.)


(Despite the presence of the microbiologist in ICU is frequently advocated [5], and studies have reported on improved antimicrobial practices after establishing a more closer interaction between clinicians and microbiologists in before-after studies in single-center studies [6], no study has formally demonstrated the superiority of a strategy with a microbiologist in daily rounds compared to different types of “liaisons” in ICU, nor in other settings. Furthermore, the systematic review by Lane et al. [7], which explored facilitators and barriers for patients care round in ICU, did not identify the “microbiologist” (but the pharmacist instead!) as leading character in multidisciplinary team rounds.)


(Still, extensive knowledge on susceptibility patterns, local ecology, the importance of previous infections and colonization with MDR pathogens are among the core competencies of clinical microbiologists deemed essential for appropriate management of antimicrobial therapy in the ICU (Table 1).)


(Since the (often mandatory) introduction of ASPs in hospital, an increasing burden has been placed upon Antimicrobial Management Team members, who have often extended their work without being provided additional workforce or funding. This is especially true for microbiologists who now need to combine more clinical outreach work with laboratory practice. As daily/weekly meetings and continuous out-of-hours service are requested by ever more departments, the workload for the microbiologist is increasing. In an era where physician burnout is more prevalent than ever before, this should not be underestimated.)

通过Vosviewer软件对于Web of Science 网站检索关键词“Microbiologist consultant”(微生物学咨询)所得的聚类分析图,提示研究热点及发展方向(余跃天制图并释义)。


(Even if daily presence of a microbiologist may be considered valuable by intensivists [5], the time efficiency of such meetings is obviously questionable: not all patients have an infectious problem or have antibiotics and—once the topic of infections is discussed—intensivists may linger on indefinitely about nutrition, weaning or any other non-infection-related (but equally important) problem during which the microbiologist is clearly wasting time. Moreover, other members of the ASP team present at the meeting may also be losing valuable time.)


(With the introduction of rapid diagnostics [8], establishing diagnosis of the causative pathogen and susceptibility patterns in a matter of hours rather than days, a daily meeting at a fixed moment seems obsolete and would essentially slow down appropriate antimicrobial decision making. Moreover, modern communication technology and advanced electronic medical records nowadays allow for other means of interaction between the microbiologist and the ICU team [9].)


(So, how can we find a more efficient and less time-consuming way to integrate valuable microbiological advice into modern ICU practice?)


(Based on the experience of the team, the availability of the microbiologist and the needs of the unit at a specific moment in time, a unit-tailored approach can be preferable. In recently started ASP teams, daily meetings with the whole team may be very valuable, but, as experience of the team grows, antibiotic therapy is settled in clear local guidelines, laboratory is 24/7 and a microbiologist is available on call for the most rapid communication process of microbiology results to ICU team-the role of daily meetings may change. In a mature ASP team, meetings should be used to reinforce knowledge and strategies as well as to introduce new concepts or discuss ecology, etc. At that stage, much of the antimicrobial prescriptions are covered by guidelines and standard practices which are now very familiar to the bedside team.)


(We remain convinced that face-to-face contact is essential for implementation of good antimicrobial stewardship. While day-to-day immediate feedback using  modern information technology solutions is now feasible and effective, we must keep seeing the microbiologist in our ICU in person on a regular basis (but not necessarily daily during ICU rounds) to (Table 1):)


(Learn about our prescribing patterns related to (changing) resistance patterns in our ICU unit.)


(Learn about new developments in (rapid) diagnostics and their effect in relevant antimicrobial stewardship principles in ICU.)


(Assist in interpretation of results or in reducing unnecessary testing.)

表1 ICU中微生物学专业人员参与的领域概况


























(Conversely, microbiologists must be exposed regularly to the clinical complexities in ICU to improve their integrative consultation skills and regular interaction with intensivists will facilitate this.)


(We advocate the adoption of an alternative scheduling of appointments with clinical microbiologists and other ASP team members as below:)


(Once weekly clinical round in which difficulty-to-treat patients are discussed with the microbiologist.)


(Once per 3-6 months feedback session with data on adherence to appropriate prescribing (using relevant quality indicators for antimicrobial prescribing in ICU such as guideline adherence, appropriate duration and PK-PD) and an oversight of hospital-wide emergence of MDR pathogens.)


(More frequent (and even daily) meetings during outbreaks or epidemics requiring close collaboration and with need for intensified infection control measures.)


(In conclusion, the importance of a microbiologist with his/her knowledge based in the management of ICU infections is undisputed. However, in this era of modern communication tools, physical presence of a microbiologist at a daily face-to-face ward round may not be needed once an ICU antimicrobial stewardship program is fully established. We support the use of continuous digital microbiological support and established ICU adapted guidelines on one hand and a more flexible face-to-face approach when dedicated advice is really needed. 24/7 availability of an (on call) microbiologist to validate rapid diagnostic testing is essential to allow for fast change of therapy. We do believe that structural (not daily but weekly or monthly) meetings are warranted to keep both parties aligned.)


  • 一方面,欧洲(作者是荷兰、意大利、比利时)的ICU与微生物学的互动,深入而丰富,远远超过了我们的想象。和循证医学临床实践指南一样,我们还在未证之先,他们已经是既证之后。也好吧,我们一面建构一面解构,骨感的现实成就我们复合的理念,“瞻前顾后”交辉我们渴望的眼眸!

  • 一方面,能够看到欧洲临床医生对微生物学无缝嵌入的思考、尊敬、现实、弹性……医学既是技术,也是理念,更是团队合作互相成就,也是与时俱进消长融通!合作与圆融才是人类的本质。马克思谓:人是一切社会关系的总和。而医生纳入了微生物学观念,恰是完成了医学修炼的一阶、一节,可作一结、一嗟!

  • 一方面,弱弱地说,题目是余医生铁定。我不敢用“顾问”一词。(●’◡’●)


1. Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, Moreno R, Lipman J, Gomersall C, Sakr Y, Reinhart K, EPIC-II Group of Investigators (2009) International study of the prevalence and outcomes of infection in intensive care units. JAMA 302:23232329. https://doi.org/10.1001/jama.2009.1754

2. Timsit JF, Bassetti M, Cremer O, Daikos G, de Waele J, Kallil A, Kipnis E, Kollef M, Laupland K, Paiva JA, Rodríguez-Baño J, Ruppé É, Salluh J, Taccone FS, Weiss E, Barbier F (2019) Rationalizing antimicrobial therapy in the ICU: a narrative review. Intensive Care Med 45:172189. https://doi.org/10.1007/s00134-019-05520-5

3. Charani E, Cooke J, Holmes A (2010) Antibiotic stewardship programmeswhats missing. J Antimicrob Chemother 65:22752277. https://doi.org/10.1093/jac/dkq357

4. Kollef MH, Bassetti M, Francois B, Burnham J, Dimopoulos G, GarnachoMontero J, Lipman J, Luyt CE, Nicolau DP, Postma MJ, Torres A, Welte T, Wunderink RG (2017) The intensive care medicine research agenda on multidrug-resistant bacteria, antibiotics, and stewardship. Intensive Care Med 43:11871197. https://doi.org/10.1007/s00134-017-4682-7

5. Wilson L, Dempsey G (2007) Medical microbiology ward rounds in critical care. Crit Care 11:P75. https://doi.org/10.1186/cc5235

6. Arena F, Scolletta S, Marchetti L, Galano A, Maglioni E, Giani T, Corsi E, Lombardi S, Biagioli B, Rossolini GM (2015) Impact of a clinical microbiology-intensive care consulting program in a cardiothoracic intensive care unit. Am J Infect Control 43:10181021. https://doi.org/10.1016/j.ajic.2015.04.200

7. Lane D, Ferri M, Lemaire J, McLaughlin K, Stelfox HT (2013) A systematic review of evidence-informed practices for patient care rounds in the ICU. Crit Care Med 41:20152029. https://doi.org/10.1097/CCM.0b013e31828a435f

8. Decousser JW, Poirel L, Nordmann P (2017) Recent advances in biochemical and molecular diagnostics for the rapid detection of antibiotic-resistant Enterobacteriaceae: a focus on β-lactam resistance. Expert Rev Mol Diagn 17:327350. https://doi.org/10.1080/14737159.2017.1289087

9. Curtis CE, Al Bahar F, Marriott JF (2017) The effectiveness of computerised decision support on antibiotic use in hospitals: a systematic review. PLoS One 12:e0183062. https://doi.org/10.1371/journal.pone.0183062