Improving urinary tract infection treatment through a multifaceted antimicrobial stewardship intervention in the emergency department

BACKGROUND

Urinary tract infection (UTI) is frequently encountered in the emergency department (ED). We assessed an antibiotic stewardship intervention tailored for the ED. The primary objective was improving overall adherence to agent choice and treatment duration. The secondary objective was a decrease in fluoroquinolone prescription.

METHODS

This pre-post study included patients discharged from the ED with a UTI diagnosis. The intensive intervention period lasted three months and involved dissemination of guidelines, short lectures, incorporation of order sets into electronic ED charts and weekly personal audit and feedback. The following 11-month phase was a booster period consisting of monthly text messages of the treatment protocol. Assessment of adherence to the protocol was compared between the three-month pre-intervention period and the last two months of the intensive intervention period, as well as with the last two months of the booster period.

RESULTS

A total of 177 patients were included in the pre-intervention period, 156 in the intervention period, and 94 in the late follow-up assessing the booster period. Median age was 49 (18-94) years, 78.2% were female, 84.8% had cystitis. During the intervention period, protocol adherence with antibiotic selection and duration increased from 41% to 84% (p < 0.001). Adherence remained high in the late follow-up period (73.4% vs. 41%, p < 0.001). Fluoroquinolone use decreased from 19.1% pre-intervention, to 5% in the intervention and 7.4% in the late follow-up periods (p < 0.001).

CONCLUSIONS

An antibiotic stewardship intervention in a busy ED resulted in adherence to treatment protocols, including a decrease in fluoroquinolone use. A monthly reminder preserved most of the effect for a year.

Use of electronic pharmacy transaction data and website development to assess antibiotic use in nursing homes

BACKGROUND

In 2017, the Centers for Medicare and Medicaid Services required all long-term care facilities, including nursing homes, to have an antibiotic stewardship program. Many nursing homes lack the resources, expertise, or infrastructure to track and analyze antibiotic use measures. Here, we demonstrate that pharmacy invoices are a viable source of data to track and report antibiotic use in nursing homes.

METHODS

The dispensing pharmacy working with several nursing homes in the same healthcare corporation provided pharmacy invoices from 2014 to 2016 as files formatted as comma separated values. We aggregated these files by aligning elements into a consistent set of variables and assessed the completeness of data from each nursing home over time. Data cleaning involved removing rows that did not describe systemic medications, de-duplication, consolidating prescription refills, and removing prescriptions for insulin and opioids, which are medications that were not administered at a regular dose or schedule. After merging this cleaned invoice data to nursing home census data including bed days of care and publicly available data characterizing bed allocation for each nursing home, we used the resulting database to describe several antibiotic use metrics and generated an interactive website to permit further analysis.

RESULTS

The resultant database permitted assessment of the following antibiotic use metrics: days of antibiotic therapy, length of antibiotic therapy, rate of antibiotic starts, and the antibiotic spectrum index. Further, we created a template for summarizing data within a facility and comparing across facilities. https://sunahsong.shinyapps.io/USNursingHomes/ .

CONCLUSIONS

Lack of resources and infrastructure contributes to challenges facing nursing homes as they develop antibiotic stewardship programs. Our experience with using pharmacy invoice data may serve as a useful approach for nursing homes to track and report antibiotic use.

Decreasing antibiotic over-use by implementation of an antibiotic stewardship programme in preterm neonates in resource limited settings - a quality improvement initiative

BACKGROUND

Antibiotics play a critical role in neonatal sepsis but excessive use is associated with adverse outcomes and the current prescribing rates of antibiotics are unacceptably high.

AIM

To reduce antibiotic over-use in preterm neonates by implementing an antibiotic stewardship programme using a quality improvement (QI) initiative.

METHODS

This study was conducted at a neonatal intensive care unit in a resource-limited setting. The reasons for antibiotic over-use were analysed and an antibiotic stewardship programme was implemented by using a QI initiative. The duration of the QI was a 1-month baseline phase followed by 3 months of implementation which was undertaken in the form of Plan-Do-Study-Act (P-D-S-A) cycles. The sustainment phase was observed for 2 months. All neonates admitted to the preterm unit were included. The outcome measure was the antibiotic usage expressed as days of therapy (DOT)/1000 patient days.

RESULTS

In the baseline phase, DOT/1000 patient days was 1464 which fell to 706, 511, and 442 DOT/1000 patient days, respectively, over 3 months, resulting in a 65% reduction in antibiotic usage. This was achieved by a combination of efforts directed towards defining the conditions for no antibiotics, revising existing antibiotic policy, stopping orders at 48 hours, de-escalation to the narrowest spectrum antibiotic, stopping prophylactic antifungal agents and limited use of broad-spectrum antibiotics. The results were achieved without an increase in culture-positive sepsis or mortality.

CONCLUSIONS

Implementation of a tailored antibiotic stewardship programme through a QI initiative was effective and safe in reducing antibiotic use in preterm neonates in a resource-limited setting.

ABBREVIATIONS

AIIMS, All India Institute of Medical Sciences; DOT, days of therapy; HIC, high-income countries; ICMR, Indian Council of Medical Research; LMIC, low- to middle-income countries; LOS, late-onset sepsis; NICU, neonatal intensive care unit; NNF, National Neonatology Forum; P-D-S-A, plan-do-study-act; QI, quality improvement; SNCU, Special newborn care unit.

Antibiotic stewardship program in Pakistan: a multicenter qualitative study exploring medical doctors' knowledge, perception and practices

Background

The emerging threat of antibiotic resistance is growing exponentially and antibiotic stewardship programs are cornerstone to fight against this global threat. The study aimed to explore the knowledge, perspectives and practices of physicians regarding various aspects of antibiotic stewardship program including antibiotic stewardship activities, rational use of antibiotics, antibiotic resistance, prescribing practices and factors associated with these practices.

Methods

In this qualitative study, a total of 17 semi-structured, in-depth interviews with doctors of three tertiary care public sector hospitals in Bahawalpur and Rahim Yar Khan were conducted. The convenient sampling method was adopted to collect the data and the saturation point criterion was applied to determine the sample size. Thematic analysis approach was used to draw conclusions from the data.

Results

The analysis of data yielded five themes, 12 subthemes and 26 categories. The themes included, (i) perception about antibiotic use and antibiotic stewardship, (ii) antibiotic prescription practices, (iii) antibiotic resistance, (iv) limited strategies adopted by hospital administration to ensure quality and safe distribution of antibiotics, (v) implementation of antibiotic stewardship program: barriers, suggestion and future benefits. Doctors had misconceptions about the rational use of antibiotics. The perception regarding antibiotic stewardship programs was poor. Moreover, very few activities related to ASP existed. The participants gave many suggestions for successful implementation of ASP in order to reduce the burden of antibiotic resistance, including development of guidelines for the use of antibiotics, strict legislation regarding use of antibiotics, active participation of healthcare professionals and awareness program among general public about the use of antibiotics.

Conclusion

This study concluded that poor knowledge of doctors regarding ASP, non-existence of antibiogram of hospital and lack of rules for the safe use of antibiotics were the main driving factors associated with irrational antibiotic prescription practices and development of AR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06043-5.

Antibiotic audit in medicine intensive care unit of tertiary care centre: A must do exercise

PURPOSE

Antimicrobial resistance (AMR) is a serious threat to the humanity now a days. To prevent it, the first step is to know about our antibiotic practices. Audit is the first step in continuous quality improvement which intend to go ahead. Antibiotic stewardship involves appropriate antibiotic (empirical or definitive) at correct time in correct doses and frequency for appropriate duration.

METHOD

We conducted a retrospective study in intensive care unit at our tertiary care center of Bihar, India. Our aim was to know about empirical antibiotic we are prescribing in suspected sepsis patients and their rationality too. National treatment guidelines for infectious disease released by National Centre for Disease Control (NCDC) was taken as standard of care. We recorded demographic profile, SOFA (Sequential Organ Failure Assessment), APACHE II (Acute Physiology and Chronic Health Evaluation), antibiotic prescribed, final etiology of infection, and outcome of the patient and total ICU stay.

RESULT

We found that combination of two antibiotics were given in majority of patients (53%) and the third generation cephalosporin was the most commonly prescribed antibiotic. In our audit, rational combinations according to the antibiotic policies were given in 73.7% of patients. Appropriate doses of antibiotics were given in 89.5% of patients.

CONCLUSION

Audit is a mandatory exercise to provide quality care in the health care system.

Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration

OBJECTIVE

Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones.

DESIGN

Quasi-experimental, pre- and post-intervention study.

SETTING AND PARTICIPANTS

Six NHs in Monroe County, NY.

METHODS

A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time.

RESULTS

Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042).

CONCLUSIONS AND IMPLICATIONS

A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.

Relative faecal abundance of extended-spectrum β-lactamase-producing Enterobacterales and its impact on infections among intensive care unit patients: a pilot study

This pilot prospective study assessed the association between the faecal relative abundance of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE) and the occurrence of ESBL-PE related infections. Twenty-four patients were included. The median ESBL relative abundance was 32.4%. The mean ESBL-PE relative abundance (ESBL-PE-RA) was more than five-fold higher in patients exposed during the last three months to antibiotics (P = 0.002). Furthermore, the mean ESBL relative abundance was more than two-fold higher in patients colonized with non-E. coli strains (P = 0.044). The mean ESBL-PE-RA was more than 10-fold higher for the concordant patients than for the discordant patients (59.1% vs 4.9%; P < 0.001).

Reducing antibiotic prescriptions in children is not associated with higher rate of complications

Acute otitis media (AOM) and sore throat are common reasons for antibiotic prescription in children. Starting from 2007, evidence-based guidelines and other multifaceted improvement activities (ProBA project) were implemented in Emilia-Romagna, a northern Italian region. Antibiotic prescription rate in the region decreased with time (37% relative reduction from 2005 to 2019). Within the ProBA project, this retrospective observational study, including all hospitals of the region, aims to assess if lower rate of antibiotic prescription was associated with an increased rate of acute mastoiditis and acute rheumatic fever (ARF). Hospital admission rates for acute mastoiditis and ARF from 2005 to 2019 were calculated using ICD-9 codes. Hospital intervention rates for myringotomy, incision of mastoid, and mastoidectomy were also assessed. A comparison with antibiotic prescription rate in the pediatric population was performed. Data were gathered using administrative databases and trends were calculated using Poisson regression. During the study period, rate of mastoiditis and similar diagnosis declined from 54.1 to 33.6 per 100.000 (β coefficient = - 0.047, p value < 0.001) and rate of surgical treatment from 134.6 to 89.6 per 100.000 (β coefficient = - 0.036, p value < 0.001), whereas rate of ARF remained stable at around 4.4-4.8 per 100.000 (β coefficient = - 0.009, p value = 0.472).Conclusion: ProBA project implementation-recommending 5 days of amoxicillin for AOM when needed and 6 days of amoxicillin when streptococcal pharyngitis is detected-was associated with a reduced antibiotic use without an increase of complications. What is Known: • Acute otitis media (AOM) and streptococcal pharyngitis are common pediatric infections and frequent cause of antibiotics prescription. • Fear of rare complications like mastoiditis and acute rheumatic fever can hinder health professionals' compliance with evidence-based guideline. What is New: • Guidelines recommending a short course of antibiotics for AOM and streptococcal pharyngitis are associated with reduced antibiotic prescriptions and no increase of complications. • Analysis based on administrative databases is useful for monitoring projects and supporting health professionals in complying with guidelines.

Rates of bacterial co-infections and antimicrobial use in COVID-19 patients: a retrospective cohort study in light of antibiotic stewardship

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide. Bacterial co-infections are associated with unfavourable outcomes in respiratory viral infections; however, microbiological and antibiotic data related to COVID-19 are sparse. Adequate use of antibiotics in line with antibiotic stewardship (ABS) principles is warranted during the pandemic. We performed a retrospective study of clinical and microbiological characteristics of 140 COVID-19 patients admitted between February and April 2020 to a German University hospital, with a focus on bacterial co-infections and antimicrobial therapy. The final date of follow-up was 6 May 2020. Clinical data of 140 COVID-19 patients were recorded: The median age was 63.5 (range 17-99) years; 64% were males. According to the implemented local ABS guidelines, the most commonly used antibiotic regimen was ampicillin/sulbactam (41.5%) with a median duration of 6 (range 1-13) days. Urinary antigen tests for Legionella pneumophila and Streptococcus peumoniae were negative in all cases. In critically ill patients admitted to intensive care units (n = 50), co-infections with Enterobacterales (34.0%) and Aspergillus fumigatus (18.0%) were detected. Blood cultures collected at admission showed a diagnostic yield of 4.2%. Bacterial and fungal co-infections are rare in COVID-19 patients and are mainly prevalent in critically ill patients. Further studies are needed to assess the impact of antimicrobial therapy on therapeutic outcome in COVID-19 patients to prevent antimicrobial overuse. ABS guidelines could help in optimising the management of COVID-19. Investigation of microbial patterns of infectious complications in critically ill COVID-19 patients is also required.

What are the challenges for antibiotic stewardship at the community level? An analysis of the drivers of antibiotic provision by informal healthcare providers in rural India

In many low- and middle-income countries, providers without formal training are an important source of antibiotics, but may provide these inappropriately, contributing to the rising burden of drug resistant infections. Informal providers (IPs) who practise allopathic medicine are part of India's pluralistic health system legacy. They outnumber formal providers but operate in a policy environment of unclear legitimacy, creating unique challenges for antibiotic stewardship. Using a systems approach we analysed the multiple intrinsic (provider specific) and extrinsic (community, health and regulatory system and pharmaceutical industry) drivers of antibiotic provision by IPs in rural West Bengal, to inform the design of community stewardship interventions. We surveyed 291 IPs in randomly selected village clusters in two contrasting districts and conducted in-depth interviews with 30 IPs and 17 key informants including pharmaceutical sales representatives, managers and wholesalers/retailers; medically qualified private and public doctors and health and regulatory officials. Eight focus group discussions were conducted with community members. We found a mosaic or bricolage of informal practices conducted by IPs, qualified doctors and industry stakeholders that sustained private enterprise and supplemented the weak public health sector. IPs' intrinsic drivers included misconceptions about the therapeutic necessity of antibiotics, and direct and indirect economic benefits, though antibiotics were not the most profitable category of drug sales. Private doctors were a key source of IPs' learning, often in exchange for referrals. IPs constituted a substantial market for local and global pharmaceutical companies that adopted aggressive business strategies to exploit less-saturated rural markets. Paradoxically, the top-down nature of regulations produced a regulatory impasse wherein regulators were reluctant to enforce heavy sanctions for illegal sales, fearing an adverse impact on rural healthcare, but could not implement enabling strategies to improve antibiotic provision due to legal barriers. We discuss the implications for a multi-stakeholder antibiotic stewardship strategy in this setting.

A cluster randomized stepped-wedge trial to de-implement unnecessary post-operative antibiotics in children: the optimizing perioperative antibiotic in children (OPerAtiC) trial

BACKGROUND

Antibiotic-resistant infections have become a public health crisis that is driven by the inappropriate use of antibiotics. In the USA, antibiotic stewardship programs (ASP) have been established and are required by regulatory agencies to help combat the problem of antibiotic resistance. Post-operative antibiotic use in surgical cases deemed low-risk for infection is an area with significant overuse of antibiotics in children. Consensus among leading public health organizations has led to guidelines eliminating post-operative antibiotics in low-risk surgeries. However, the best strategies to de-implement these inappropriate antibiotics in this setting are unknown.

METHODS/DESIGN

A 3-year stepped wedge cluster randomized trial will be conducted at nine US Children's Hospitals to assess the impact of two de-implementation strategies, order set change and facilitation training, on inappropriate post-operative antibiotic prescribing in low risk (i.e., clean and clean-contaminated) surgical cases. The facilitation training will amplify order set changes and will involve a 2-day workshop with antibiotic stewardship teams. This training will be led by an implementation scientist expert (VRM) and a pediatric infectious diseases physician with antibiotic stewardship expertise (JGN). The primary clinical outcome will be the percentage of surgical cases receiving unnecessary post-operative antibiotics. Secondary clinical outcomes will include the rate of surgical site infections and the rate of Clostridioides difficile infections, a common negative consequence of antibiotic use. Monthly semi-structured interviews at each hospital will assess the implementation process of the two strategies. The primary implementation outcome is penetration, which will be defined as the number of order sets changed or developed by each hospital during the study. Additional implementation outcomes will include the ASP team members' assessment of the acceptability, appropriateness, and feasibility of each strategy while they are being implemented.

DISCUSSION

This study will provide important information on the impact of two potential strategies to de-implement unnecessary post-operative antibiotic use in children while assessing important clinical outcomes. As more unnecessary medical practices are identified, de-implementation strategies, including facilitation, need to be rigorously evaluated. Along with this study, other rigorously designed studies evaluating additional strategies are needed to further advance the burgeoning field of de-implementation.

TRIAL REGISTRATION

NCT04366440. Registered April 28, 2020, https://clinicaltrials.gov/ct2/show/NCT04366440 .

Impact of rapid multiplex PCR on management of antibiotic therapy in COVID-19-positive patients hospitalized in intensive care unit

Because the diagnosis of co/superinfection in COVID-19 patients is challenging, empirical antibiotic therapy is frequently initiated until microbiological analysis results. We evaluated the performance and the impact of the BioFire® FilmArray® Pneumonia plus Panel on 112 respiratory samples from 67 COVID-19 ICU patients suspected of co/superinfections. Globally, the sensitivity and specificity of the test were 89.3% and 99.1%, respectively. Positive tests led to antibiotic initiation or adaptation in 15% of episodes and de-escalation in 4%. When negative, 28% of episodes remained antibiotic-free (14% no initiation, 14% withdrawal). Rapid multiplex PCRs can help to improve antibiotic stewardship by administering appropriate antibiotics earlier and avoiding unnecessary prescriptions.

Antibiotic stewardship in UK surgical departments: challenges and possible solutions

Antibiotics are one of the most widely used classes of drugs within hospitals in the UK. They have a wide range of uses within all surgical specialties, both as preoperative prophylaxis and for treatment of acute surgical conditions. Antimicrobial resistance has increasingly been seen as a major issue, as the production of new antibiotics has decreased and overall use worldwide has increased. With the COVID-19 pandemic increasing concerns about antimicrobial resistance, there is an ever-increasing need for action. This article examines the particular challenges of antibiotic stewardship in surgical departments within the UK, and outlines possible solutions for improving adherence and reducing the risk of antimicrobial resistance in the future.

Ability of procalcitonin to distinguish between bacterial and nonbacterial infection in severe acute exacerbation of chronic obstructive pulmonary syndrome in the ICU

Background

To assess the ability of procalcitonin (PCT) to distinguish between bacterial and nonbacterial causes of patients with severe acute exacerbation of COPD (AECOPD) admitted to the ICU, we conducted a retrospective analysis of two prospective studies including 375 patients with severe AECOPD with suspected lower respiratory tract infections. PCT levels were sequentially assessed at the time of inclusion, 6 h after and at day 1, using a sensitive immunoassay. The patients were classified according to the presence of a documented bacterial infection (including bacterial and viral coinfection) (BAC + group), or the absence of a documented bacterial infection (i.e., a documented viral infection alone or absence of a documented pathogen) (BAC- group). The accuracy of PCT levels in predicting bacterial infection (BAC + group) vs no bacterial infection (BAC- group) at different time points was evaluated by receiver operating characteristic (ROC) analysis.

Results

Regarding the entire cohort (n = 375), at any time, the PCT levels significantly differed between groups (Kruskal–Wallis test, p < 0.001). A pairwise comparison showed that PCT levels were significantly higher in patients with bacterial infection (n = 94) than in patients without documented pathogens (n = 218) (p < 0.001). No significant difference was observed between patients with bacterial and viral infection (n = 63). For example, the median PCT-H₀ levels were 0.64 ng/ml [0.22–0.87] in the bacterial group vs 0.24 ng/ml [0.15–0.37] in the viral group and 0.16 ng/mL [0.11–0.22] in the group without documented pathogens. With a c-index of 0.64 (95% CI; 0.58–0.71) at H₀, 0.64 [95% CI 0.57–0.70] at H₆ and 0.63 (95% CI; 0.56–0.69) at H₂₄, PCT had a low accuracy for predicting bacterial infection (BAC + group).

Conclusion

Despite higher PCT levels in severe AECOPD caused by bacterial infection, PCT had a poor accuracy to distinguish between bacterial and nonbacterial infection. Procalcitonin might not be sufficient as a standalone marker for initiating antibiotic treatment in this setting.

Risk factors for enterococcal urinary tract infections: a multinational, retrospective cohort study

Complicated urinary tract infection (cUTI) is a frequent cause of morbidity. In this multinational retrospective cohort study, we aimed to demonstrate risk factors for enterococcal UTI. Univariate and multivariate analyses of risk factors for enterococcal infection were performed. Among 791 hospitalized patients with cUTI, enterococci accounted for approximately 10% of cases (78/791). Risk factors for enterococcal UTI in multivariable analysis were male gender, age range of 55-75 years, catheter-associated UTI, and urinary retention. This information may assist treating physicians in their decision-making on prescribing empiric anti-enterococcus treatment to hospitalized patients presenting with cUTI and thus improve clinical outcomes.

The impact of health care provider relationships and communication dynamics on urinary tract infection management and antibiotic utilization for long-term care facility residents treated in the emergency department: A qualitative study

BACKGROUND

For older adults, over diagnosis of urinary tract infections (UTI) is a primary driver of inappropriate antibiotic use. This risk is increased for patients in long-term care facilities (LTCF), especially as they transition back and forth to emergency departments (ED). In this study, we aimed to understand how health care provider communication and relationship dynamics affect LTCF residents treated in the ED to identify barriers to antibiotic stewardship for UTIs.

METHODS

We conducted semi-structured interviews with nurses and physicians from LTCFs and EDs, guided by the Systems Engineering Initiative for Patient Safety framework. Data were systematically coded and underwent iterative, conventional, content analysis.

RESULTS

We interviewed 16 LTCF and 16 ED providers across Wisconsin. ED and LTCF nurses have a critical role in both intrafacility and interfacility communication. Fragmented communication and interprofessional power dynamics were identified barriers to optimal antibiotic prescribing for UTIs. Identified strategies to overcome these issues included using objective diagnostic criteria, development of communication scripts, and nurse-to-nurse education.

CONCLUSIONS

Our qualitative approach revealed important insights about how communication and relationship dynamics influence UTI diagnosis and optimal antibiotic stewardship for LTCF residents evaluated in the ED. Future interventions should strengthen communications between settings and across provider types, and address standardization of diagnostic and treatment communication pathways for LTCF residents with suspected infections transitioning between EDs and LTCFs.

Emergency department methicillin-resistant Staphylococcus aureus nare screen effect on pneumonia treatment duration

STUDY OBJECTIVE

The objective of this study was to determine if performing a methicillin-resistant Staphylococcus aureus (MRSA) nasal screen in the emergency department (ED) decreased general medicine patient exposure to anti-MRSA antibiotics for pneumonia.

METHODS

This was a single-center, retrospective study evaluating patients who had a diagnosis of pneumonia and were initiated on anti-MRSA therapy (vancomycin or linezolid) in the ED and subsequently admitted to a general medicine floor. Patients were divided into two groups: 1) did not receive a MRSA nares screen in the ED (No MRSA screen group) or 2) received a MRSA nares screen in the ED (MRSA screen group). The primary outcome was anti-MRSA antibiotic duration. Secondary outcomes included vancomycin level evaluation, hospital survival, and acute kidney injury.

RESULTS

Of the 116 patients included, 37 patients received a MRSA nares screen in the ED and 79 patients did not. Median duration of antibiotic exposure was similar for both groups (No MRSA screen, 30.5 h [interquartile range (IQR) 20.5-52.5] vs. MRSA screen, 24.5 h [IQR 20.6-40.3]; p = 0.28). Of patients who were screened, 35 were negative and 2 were positive. Secondary outcomes were similar.

CONCLUSION

Performing a MRSA nares screen in the ED for patients diagnosed with pneumonia, initiated on anti-MRSA antibiotics, and admitted to a general medicine floor did not decrease duration of anti-MRSA antibiotics. At this time, ED providers do not need to consider a MRSA nasal screen in the ED for patients being admitted to general medicine, although larger studies could be considered.

Incidence, healthcare-seeking behaviours, antibiotic use and natural history of common infection syndromes in England: results from the Bug Watch community cohort study

BACKGROUND

Better information on the typical course and management of acute common infections in the community could inform antibiotic stewardship campaigns. We aimed to investigate the incidence, management, and natural history of a range of infection syndromes (respiratory, gastrointestinal, mouth/dental, skin/soft tissue, urinary tract, and eye).

METHODS

Bug Watch was an online prospective community cohort study of the general population in England (2018-2019) with weekly symptom reporting for 6 months. We combined symptom reports into infection syndromes, calculated incidence rates, described the proportion leading to healthcare-seeking behaviours and antibiotic use, and estimated duration and severity.

RESULTS

The cohort comprised 873 individuals with 23,111 person-weeks follow-up. The mean age was 54 years and 528 (60%) were female. We identified 1422 infection syndromes, comprising 40,590 symptom reports. The incidence of respiratory tract infection syndromes was two per person year; for all other categories it was less than one. 194/1422 (14%) syndromes led to GP (or dentist) consultation and 136/1422 (10%) to antibiotic use. Symptoms usually resolved within a week and the third day was the most severe.

CONCLUSIONS

Most people reported managing their symptoms without medical consultation. Interventions encouraging safe self-management across a range of acute infection syndromes could decrease pressure on primary healthcare services and support targets for reducing antibiotic prescribing.

Point-prevalence survey of outpatient antibiotic prescription at a tertiary medical center in Sri Lanka: opportunities to improve prescribing practices for respiratory illnesses

Background

Inappropriate antibiotic use is linked to the spread of antimicrobial resistance worldwide, but there are limited systemic data on antibiotic utilization in low- and middle-income countries. The purpose of this study was to evaluate the prevalence and patterns of antibiotic prescription in an ambulatory care setting in Sri Lanka.

Methods

This cross-sectional survey was conducted at the Outpatient Department of a public tertiary medical center in Southern Province, Sri Lanka from February to April 2019. Among consecutive outpatients presenting for care, questionnaires were verbally administered to a systematic random sample to capture information about patient demographics, illness characteristics, and visit outcomes. Prescription data were obtained from the outpatient pharmacy’s electronic prescribing system.

Results

Of 409 surveyed patients, 146 (35.7%) were prescribed an antibiotic. The most frequently prescribed agents were amoxicillin (41 patients, 28.1% of antibiotic recipients) and first-generation cephalosporins (38, 26.0%). Respiratory indications were the most common reason for antibiotic use, comprising 69 (47.3%) of all antibiotic prescriptions. Antibiotics were prescribed for 66.1% of patients presenting with cough and 78.8% of those presenting with rhinorrhea or nasal congestion. Among all antibiotic recipients, 6 (4.1%) underwent diagnostic studies.

Conclusions

A high prevalence of antibiotic prescription was observed, in particular for treatment of respiratory conditions. These data support the need for improved antimicrobial stewardship in the Sri Lankan outpatient setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-05804-6.

Poor compliance with an antibiotic directive-A call for intensified monitoring

BACKGROUND

In April 2017, the Central Denmark Region Antibiotic Stewardship Committee issued a directive to reduce the general use of piperacillin-tazobactam and prescribe narrow-spectrum antibiotics for mild and moderate pneumonia. The directive was distributed to all regional hospital clinicians.

METHODS

Electronic medical records were used to obtain de-identified details of all antibiotics administered (together with diagnosis codes) to all in-hospital patients (pre-directive and post-directive) in the nine regional hospitals. Average moving range statistical process control charts were used to analyze pre-directive and post-directive variation in antibiotic usage patterns.

RESULTS

Upon the distribution of the directive, a period of decline of the overall usage of piperacillin-tazobactam ensued. Rather than benzylpenicillin, as recommended for pneumonia, the initial decline in piperacillin/tazobactam usage was accompanied by increased use of cefuroxime.

CONCLUSIONS

A steward-directed reduction in piperacillin-tazobactam usage was accompanied by less desirable usage of a broad-spectrum alternative. Future antibiotic stewardship initiatives will hopefully benefit from close monitoring and timely feedback to clinicians. A dialogue with clinicians based on near real-time data is predicted to improve antibiotic stewardship actions.

Knowledge, attitude, and practices of health-care providers toward antibiotic prescribing, antibiotic resistance, and multidrug-resistant tuberculosis

Introduction:

Antibiotic resistance (ABR) is a growing public health problem and is a subject of international concern. It poses a serious threat to health and health-care systems in both developed and developing countries. The problem is more confounding with tuberculosis (TB), and drug resistance in TB has threatened the progress made in TB care and control worldwide. The aim of this study was to understand the knowledge, attitude, and practices of health-care providers (HCPs) toward antibiotics, antibiotic prescribing, ABR, and multidrug-resistant TB (MDR-TB).

Materials and Methods:

A total of 125 participants were included in this cross-sectional, questionnaire-based survey conducted in tertiary care teaching hospitals of the Delhi-NCR region. A five-point Likert scale, whose responses ranged from “strongly agree” to “do not know,” was used to record the responses from participants.

Results:

Among the 125 HCPs who participated in the survey, the response rate was 100%. Around 94.4% of the respondents agreed that ABR is an important and a serious public health issue. More than 80% of the respondents strongly agreed that over-the-counter sale and/or dispensing antibiotics without prescription should be controlled. About 86.4% of the participants agreed that MDR-TB is a growing problem and 59.2% strongly agreed that indiscriminate use of anti-TB drugs could be a major causative factor. Almost 85.6% of the participants agreed that a proper diagnosis should be ensured before treating the TB cases.

Conclusions:

HCPs had a good knowledge of antibiotics and the association of its misuse or overuse with increasing ABR. Educational and persuasive measures are certainly needed, but the use of restrictive and organizational measures appears mandatory if the misuse of antibiotics is to be decreased in the near future. A stringent assessment of the impact of implemented measures seems essential to better guide antibiotic stewardship in our country.

Effect of educational intervention on the appropriate use of oral antimicrobials in oral and maxillofacial surgery: a retrospective secondary data analysis

BACKGROUND

In Japan, oral third-generation cephalosporins with broad-spectrum activity are commonly prescribed in the practices of dentistry and oral surgery. However, there are few reports on the appropriate use of antibiotics in the field of oral surgery. This study aimed to evaluate the appropriateness of antibiotic use before and after an educational intervention in the Department of Oral and Maxillofacial Surgery, Kobe University Hospital.

METHODS

The use of oral antibiotics was investigated among inpatients and outpatients before and after an educational intervention conducted by the antimicrobial stewardship team. Additionally, the frequency of surgical site infection after the surgical removal of an impacted third mandibular molar under general anesthesia and the prevalence of adverse effects of the prescribed antibiotics were comparatively evaluated between 2013 and 2018.

RESULTS

After the educational intervention, a remarkable reduction was noted in the prescription of oral third-generation cephalosporins, but increased use of penicillins was noted among outpatients. There was reduced use of macrolides and quinolones in outpatients. Although a similar trend was seen for inpatients, the use of quinolones increased in this population. Despite the change in the pattern of antibiotic prescription, inpatients who underwent mandibular third molar extraction between 2013 and 2018 did not show a significant increase in the prevalence of surgical site infections (6.2% vs. 1.8%, p = .336) and adverse effects of drugs (2.1% vs. 0%, p = .466).

CONCLUSIONS

This study suggests that the judicious use of oral antibiotics is possible through conscious and habitual practice of appropriate antibiotic use. However, further investigation is required to develop measures for appropriate use of oral antibiotics.

Prevalence of Bloodstream Infections and their Etiology in COVID-19 Patients Admitted in a Tertiary Care Hospital in Jaipur

Background

World is in grip of coronavirus disease-2019 (COVID-19) pandemic right now. Majority of studies center around its epidemiological and clinical characteristics. Information regarding secondary bacterial infections is limited. This retrospective observational study was done to determine the prevalence and characteristics of bloodstream infections in COVID-19 patients admitted in a tertiary care center in Jaipur.

Materials and methods

All blood cultures received from COVID-19 positive patients admitted in designated COVID care ICUs and wards were included in the study. A predesigned pretested questionnaire was used to collect relevant data. Blood cultures were done using BD BACTEC™ FX40, and identification and antimicrobial susceptibility testing of isolates were done by VITEK® 2 COMPACT.

Results

One thousand five hundred seventy-eight (1578) COVID-19 positive patients were admitted in center during 5-month study period from whom 158 blood cultures were received. Out of these, 15 (9.4%) were positive. Median age of patients with positive blood culture was 54 years and included 10 males and 5 females. Ten (67%) patients needed intensive care in ICU. Significant correlation of blood culture positivity was found with parameters like ICU admission, presence of an indwelling device, underlying comorbidity, raised biochemical markers, and adverse clinical outcome.

Conclusions

Incidence of bloodstream infections is low for COVID-19 patients. Antibiotic prophylaxis needs to be used with caution, and prompt discontinuation should be done based on clinical judgment.

How to cite this article

Rajni E, Garg VK, Bacchani D, Sharma R, Vohra R, Mamoria V, et al. Prevalence of Bloodstream Infections and their Etiology in COVID-19 Patients Admitted in a Tertiary Care Hospital in Jaipur. Indian J Crit Care Med 2021;25(4):369-373.

Reversing the Trend of Antimicrobial Resistance in ICU: Role of Antimicrobial and Diagnostic Stewardship

Background

Increasing antimicrobial resistance (AMR) among common bacteria combined with the slow development of new antibiotics has posed a challenge to clinicians.

Aim and objective

To demonstrate whether antimicrobial and diagnostic stewardship program (ASP and DSP)-related interventions improve antibiotic susceptibilities among common bacteria causing bloodstream infections (BSI) in patients admitted to the intensive care unit (ICU) and whether these resulted in changes in the volume of antimicrobial consumption.

Materials and methods

We compared the susceptibility patterns of gram-negative bacteria (GNB) and gram-positive cocci (GPC) causing BSI and changes in the volume of antibiotics prescribed for the same before and after 2017 by a retrospective analysis.

Results

Postintervention, there was increased susceptibility of all GNBs to aminoglycosides; Escherichia coli and Klebsiella spp. to beta-lactambeta-lactamase inhibitors (BLBLI) combinations; and Klebsiella spp. and Pseudomonas spp. to carbapenems. Acinetobacter spp., Klebsiella spp., and Pseudomonas spp. showed improved susceptibility to doxycycline, whereas E. coli and Klebsiella spp. showed significantly improved susceptibility to fluoroquinolones. Among GPCs, there was increased susceptibility of Staphylococcus aureus (levofloxacin, clindamycin, and aminoglycoside), coagulase-negative S. aureus (CoNS) (chloramphenicol, levofloxacin, clindamycin, and aminoglycoside), and enterococci (chloramphenicol, levofloxacin, and clindamycin). There was a significant reduction in usage of antimicrobials for the treatment of GPCs (linezolid, doxycycline, chloramphenicol, levofloxacin, BLBLI, macrolide, and cephalosporin) and GNBs (levofloxacin, cephalosporin, carbapenem, and colistin), which caused BSI.

Conclusion

The present study illustrated that combined ASP and DSP interventions successfully reversed the resistance pattern of organisms causing BSI and resulted in a reduction in antibiotic utilization.

How to cite this article

Agarwal J, Singh V, Das A, Nath SS, Kumar R, Sen M. Reversing the Trend of Antimicrobial Resistance in ICU: Role of Antimicrobial and Diagnostic Stewardship. Indian J Crit Care Med 2021;25(6):635-641.