A global priority list of the TOp TEn resistant Microorganisms (TOTEM) study at intensive care: a prioritization exercise based on multi-criteria decision analysis

  • Jordi RelloEmail author
  • Vandana Kalwaje Eshwara
  • Leo Lagunes
  • Joana Alves
  • Richard G. Wunderink
  • Andrew Conway-Morris
  • Jose Nicolas Rojas
  • Emine Alp
  • Zhongheng Zhang
Original Article


The World Health Organization (WHO) proposed a global priority pathogen list (PPL) of multidrug-resistant (MDR) bacteria. Our current objective was to provide global expert ranking of the most serious MDR bacteria present at intensive care units (ICU) that have become a threat in clinical practice. A proposal addressing a PPL for ICU, arising from the WHO Global PPL, was developed. Based on the supporting data, the pathogens were grouped in three priority tiers: critical, high, and medium. A multi-criteria decision analysis (MCDA) was used to identify the priority tiers. After MCDA, mortality, treatability, and cost of therapy were of highest concern (scores of 19/20, 19/20, and 15/20, respectively) while dealing with PPL, followed by healthcare burden and resistance prevalence. Carbapenem-resistant (CR) Acinetobacter baumannii, carbapenemase-expressing Klebsiella pneumoniae (KPC), and MDR Pseudomonas aeruginosa were identified as critical organisms. High-risk organisms were represented by CR Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and extended-spectrum beta-lactamase (ESBL) Enterobacteriaceae. Finally, ESBL Serratia marcescens, vancomycin-resistant Enterococci, and TMP-SMX-resistant Stenotrophomonas maltophilia were identified as medium priority. We conclude that education, investigation, funding, and development of new antimicrobials for ICU organisms should focus on carbapenem-resistant Gram-negative organisms.


Multidrug-resistant bacteria Infection control Colonization Prevention Research Antimicrobials Intensive care Sepsis 



We appreciate comments in the design from Nieves Larrosa, Barcelona, Spain. The study was developed in part from the Observership Programme, ESCMID, Basel, Switzerland (Vandana KE).


The study was funded in part by Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain, and Observership Programme from ESCMID, Basel, Switzerland.

Compliance with ethical standards

Competing interests

Dr. Rello served in the speaker’s bureau or consultant for Pfizer, Anchoagen, ROCHE. The remaining authors have no conflicts of interest to declare.

Ethical approval

Not required.

Supplementary material

10096_2018_3428_MOESM1_ESM.docx (14 kb)
Online Resource 1 (DOCX 13.9 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Jordi Rello
    • 1
    • 2
    Email author
  • Vandana Kalwaje Eshwara
    • 3
  • Leo Lagunes
    • 2
    • 4
  • Joana Alves
    • 5
  • Richard G. Wunderink
    • 6
  • Andrew Conway-Morris
    • 7
  • Jose Nicolas Rojas
    • 8
  • Emine Alp
    • 9
  • Zhongheng Zhang
    • 10
  1. 1.CIBER de Enfermedades Respiratorias, CIBERESBarcelonaSpain
  2. 2.Vall d’Hebron Institut of Research (VHIR)BarcelonaSpain
  3. 3.Department of Microbiology, Kasturba Medical CollegeManipal Academy of Higher EducationManipalIndia
  4. 4.Intensive CareSan Luis PotosiMexico
  5. 5.Infectious DiseasesSão João Hospital CenterPortoPortugal
  6. 6.Pulmonary & Critical CareNorthwestern University Feinberg School of MedicineChicagoUSA
  7. 7.Division of Anaesthesia, Department of MedicineUniversity of CambridgeCambridgeUK
  8. 8.Intensive Care DepartmentClinica Santa FeBogotaColombia
  9. 9.Department of Infectious Diseases and Clinical Microbiology, Infection Control CommitteeErciyes UniversityKayseriTurkey
  10. 10.Department of emergency medicine, Sir Run-Run Shaw HospitalZhejiang University School of MedicineHangzhouChina

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