Tsioutis, Constantinos

2023-04, Tsioutis, Constantinos, Elda Righi, Nico T. Mutters, Xavier Guirao, Maria Dolores del Toro, Christian Eckmann, Alex W. Friedrich, Maddalena Giannella, Jan Kluytmans, Elisabeth Presterl, Eirini Christaki, Elizabeth L.A. Cross, Alessandro Visentin, Gabriele Sganga, Evelina Tacconelli

Scope: The aim of the guidelines is to provide recommendations on perioperative antibiotic prophylaxis (PAP) in adult inpatients who are carriers of multidrug-resistant Gram-negative bacteria (MDR-GNB) before surgery. Methods: These evidence-based guidelines were developed after a systematic review of published studies on PAP targeting the following MDR-GNB: extended-spectrum cephalosporin-resistant Enterobacterales, carbapenem-resistant Enterobacterales (CRE), aminoglycoside-resistant Enterobacterales, fluoroquinolone-resistant Enterobacterales, cotrimoxazole-resistant Stenotrophomonas maltophilia, carbapenem-resistant Acinetobacter baumannii (CRAB), extremely drug-resistant Pseudomonas aeruginosa, colistin-resistant Gram-negative bacteria, and pan-drug-resistant Gram-negative bacteria. The critical outcomes were the occurrence of surgical site infections (SSIs) caused by any bacteria and/or by the colonizing MDR-GNB, and SSI-attributable mortality. Important outcomes included the occurrence of any type of postsurgical infectious complication, all-cause mortality, and adverse events of PAP, including development of resistance to targeted (culture-based) PAP after surgery and incidence of Clostridioides difficile infections. The last search of all databases was performed until April 30, 2022. The level of evidence and strength of each recommendation were defined according to the Grading of Recommendations Assessment, Development and Evaluation approach. Consensus of a multidisciplinary expert panel was reached for the final list of recommendations. Antimicrobial stewardship considerations were included in the recommendation development. Recommendations: The guideline panel reviewed the evidence, per bacteria, of the risk of SSIs in patients colonized with MDR-GNB before surgery and critically appraised the existing studies. Significant knowledge gaps were identified, and most questions were addressed by observational studies. Moderate to high risk of bias was identified in the retrieved studies, and the majority of the recommendations were supported by low level of evidence. The panel conditionally recommends rectal screening and targeted PAP for fluoroquinolone-resistant Enterobacterales before transrectal ultrasound-guided prostate biopsy and for extended-spectrum cephalosporin-resistant Enterobacterales in patients undergoing colorectal surgery and solid organ transplantation. Screening for CRE and CRAB is suggested before transplant surgery after assessment of the local epidemiology. Careful consideration of the laboratory workload and involvement of antimicrobial stewardship teams before implementing the screening procedures or performing changes in PAP are warranted. High-quality prospective studies to assess the impact of PAP among CRE and CRAB carriers performing high-risk surgeries are advocated. Future well-designed clinical trials should assess the effectiveness of targeted PAP, including the monitoring of MDR-GNB colonization through postoperative cultures using European Committee on Antimicrobial Susceptibility Testing clinical breakpoints.

2022-05, Elena Carrara, David S.Y. Ong, Khetam Hussein, Siran Keske, Anders F. Johansson, Elisabeth Presterl, Sarah Tschudin-Sutter, Evelina Tacconelli, Tsioutis, Constantinos

Scope: This guideline addresses the indications for direct testing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in asymptomatic individuals in health care facilities, with the aim to prevent SARS-CoV-2 transmissions in these settings. The benefit of testing asymptomatic individuals to create a safe environment for patients and health care workers must be weighed against potential unintended consequences, including delaying necessary treatments owing to false positive results and lower quality of care owing to strict isolation measures. Methods: A total of nine PICOs (population, intervention, comparison, outcome) on the topic of testing asymptomatic individuals was selected by the panel members. Subsequently, a literature search for existing guidelines and systematic reviews was performed on PubMed, Epistemonikos, and RecMap using relevant filters available in each database. Data on article/recommendation type, setting, target population, intervention, and quality of the evidence were extracted. Credibility of the systematic reviews was evaluated using the AMSTAR tool, and level of agreement with available recommendation was evaluated with the AGREE II score. Because the evidence available from systematic reviews was deemed insufficiently updated to formulate relevant recommendations, an additional search targeting relevant guidance documents from major public health institutions and original studies was performed. Provisional recommendations were discussed via web conferences until agreement was reached, and final recommendations were formulated according to the GRADE approach. Recommendations: Recommendations were formulated regarding systematic testing in asymptomatic individuals upon admission to a health care setting, during hospital stay, before elective procedures, and before scheduled nonsurgical procedures. Moreover, recommendations regarding testing of asymptomatic visitors, personal caregivers, and health care workers in health care facilities were presented. Recommendations also were given on contact tracing in asymptomatic patients or health care workers and the possibility of a negative screening test to shorten the quarantine period. Furthermore, if applicable, recommendations were specified to transmission rate and vaccination coverage.

2019-05-17, Tsioutis, Constantinos, Evelina Tacconelli, Michael Buhl, Hilary Humphreys, Veronika Malek, Elisabeth Presterl, Jesús Rodriguez-Baño, Margreet C Vos, Walter Zingg, Nico T Mutters, Petrikkos, Georgios I.

Objective The main objective of the study was to investigate major differences among European countries in implementing infection prevention and control (IPC) measures and reasons for reduced compliance. Design An online survey including experts in IPC and a gap analysis were conducted to identify major limitations in implementing IPC guidelines. Setting Europe. Main outcome measures Four areas were targeted: (1) healthcare structure, (2) finances, (3) culture and (4) education and awareness. Perceived compliance to IPC measures was classified as low (<50%), medium (50% to 80%) and high (>80%). Countries were classified in three regions: North-Western Europe (NWE), Eastern Europe (EE) and Southern Europe (SE). Results In total, 482 respondents from 34 out of 44 (77.3%) European countries participated. Respondents reported availability of national guidelines to control multidrug-resistant Gram-negatives (MDR-GN) in 20 countries (58.0%). According to participants, compliance with IPC measures ranged from 17.8% (screening at discharge) to 96.0% (contact precautions). Overall, three areas were identified as critical for the compliance rate: (1) number of infection control staff, (2) IPC dedicated educational programmes and (3) number of clinical staff. Analysis of reasons for low compliance showed high heterogeneity among countries: participants from NWE and SE deemed the lack of educational programmes as the most important, while those from EE considered structural reasons, such as insufficient single bed rooms or lacking materials for isolation, as main contributors to the low compliance. Conclusions Although national guidelines to reduce the spread of MDR-GN are reported in the majority of the European countries, low compliance with IPC measures was commonly reported. Reasons for the low compliance are multifactorial and vary from region to region. Cross-country actions to reduce the spread of MDR-GN have to consider structural and cultural differences in countries. Locally calibrated interventions may be fruitful in the future.