Interventions to improve antibiotic prescribing practices for hospital inpatients

Analysis of knowledge and attitude surveys to identify barriers and enablers of appropriate antimicrobial prescribing in three Australian tertiary hospitals

BACKGROUND

Antimicrobial stewardship programmes aim to optimise use of antibiotics and are now mandatory in all Australian hospitals.

AIM

We aimed to identify barriers to and enablers of appropriate antimicrobial prescribing among hospital doctors.

METHODS

Two paper-based and one web-based surveys were administered at three Australian university teaching hospitals from March 2010 to May 2011. The 18-item questionnaire recorded doctors’ level of experience, their knowledge regarding the use of common antimicrobials and their attitudes regarding antimicrobial prescribing. Local survey modifications allowed inclusion of specific questions on: infections in intensive care unit patients, clinical microbiology and use of local guidelines.

RESULTS

The respondents (n = 272) were comprised of 96 (35%) registrars, 67 (25%)residents, 57 (21%) interns and 47 (17%) consultant hospital doctors. Forty-one per cent were working in a medical specialty. Identified barriers included: gaps in antimicrobial prescribing knowledge (especially among interns), a lack of awareness about which antimicrobials were restricted and a reliance on senior colleagues to make antimicrobial prescribing decisions. Enablers of optimal prescribing included: an acknowledgement of the need for assistance in prescribing and reported readiness to consult national prescribing guidelines. These results were used to help guide and prioritise interventions to improve prescribing practices.

CONCLUSION

A transferable knowledge and attitudes survey tool can be used to highlight barriers and facilitators to optimal hospital antimicrobial prescribing in order to inform tailored antimicrobial stewardship interventions.

Use of a Computer Decision Support System and Antimicrobial Therapy Appropriateness

Objective.

To determine whether antimicrobial (AM) courses ordered with an antimicrobial computer decision support system (CDSS) were more likely to be appropriate than courses ordered without the CDSS.

Design.

Retrospective cohort study. Blinded expert reviewers judged whether AM courses were appropriate, considering drug selection, route, dose, and duration.

Setting.

A 279-bed university-affiliated Department of Veterans Affairs (VA) hospital.

Patients.

A 500-patient random sample of inpatients who received a therapeutic AM course between October 2007 and September 2008.

Intervention.

An optional CDSS, available at the point of order entry in the VA computerized patient record system.

Results.

CDSS courses were significantly more likely to be appropriate (111/254, 44%) compared with non-CDSS courses (81/246, 33%, P = .013). Courses were more likely to be appropriate when the initial provider diagnosis of the condition being treated was correct (168/273, 62%) than when it was incorrect, uncertain, or a sign or symptom rather than a disease (24/227, 11%, P< .001). In multivariable analysis, CDSS-ordered courses were more likely to be appropriate than non-CDSS-ordered courses (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.13–2.98). Courses were also more likely to be judged appropriate when the initial provider diagnosis of the condition being treated was correct than when it was incorrect, uncertain, or a sign or symptom rather than a disease (OR, 3.56; 95% CI, 1.4-9.0).

Conclusions.

Use of the CDSS was associated with more appropriate AM use. To achieve greater improvements, strategies are needed to improve provider diagnoses of syndromes that are infectious or possibly infectious.

Educational interventions to improve prescription and dispensing of antibiotics: a systematic review

Background

Excessive and inappropriate antibiotic use contributes to growing antibiotic resistance, an important public-health problem. Strategies must be developed to improve antibiotic-prescribing. Our purpose is to review of educational programs aimed at improving antibiotic-prescribing by physicians and/or antibiotic-dispensing by pharmacists, in both primary-care and hospital settings.

Methods

We conducted a critical systematic search and review of the relevant literature on educational programs aimed at improving antibiotic prescribing and dispensing practice in primary-care and hospital settings, published in January 2001 through December 2011.

Results

We identified 78 studies for analysis, 47 in primary-care and 31 in hospital settings. The studies differed widely in design but mostly reported positive results. Outcomes measured in the reviewed studies were adherence to guidelines, total of antibiotics prescribed, or both, attitudes and behavior related to antibiotic prescribing and quality of pharmacy practice related to antibiotics. Twenty-nine studies (62%) in primary care and twenty-four (78%) in hospital setting reported positive results for all measured outcomes; fourteen studies (30%) in primary care and six (20%) in hospital setting reported positive results for some outcomes and results that were not statistically influenced by the intervention for others; only four studies in primary care and one study in hospital setting failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics prescribed, after educational interventions, were observed, respectively, in 46% and 41% of all the reviewed studies. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively.

Conclusion

The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1276) contains supplementary material, which is available to authorized users.

Are multifaceted interventions more effective than single-component interventions in changing health-care professionals' behaviours? An overview of systematic reviews

Background

One of the greatest challenges in healthcare is how to best translate research evidence into clinical practice, which includes how to change health-care professionals’ behaviours. A commonly held view is that multifaceted interventions are more effective than single-component interventions. The purpose of this study was to conduct an overview of systematic reviews to evaluate the effectiveness of multifaceted interventions in comparison to single-component interventions in changing health-care professionals’ behaviour in clinical settings.

Methods

The Rx for Change database, which consists of quality-appraised systematic reviews of interventions to change health-care professional behaviour, was used to identify systematic reviews for the overview. Dual, independent screening and data extraction was conducted. Included reviews used three different approaches (of varying methodological robustness) to evaluate the effectiveness of multifaceted interventions: (1) effect size/dose-response statistical analyses, (2) direct (non-statistical) comparisons of multifaceted to single interventions and (3) indirect comparisons of multifaceted to single interventions.

Results

Twenty-five reviews were included in the overview. Three reviews provided effect size/dose-response statistical analyses of the effectiveness of multifaceted interventions; no statistical evidence of a relationship between the number of intervention components and the effect size was found. Eight reviews reported direct (non-statistical) comparisons of multifaceted to single-component interventions; four of these reviews found multifaceted interventions to be generally effective compared to single interventions, while the remaining four reviews found that multifaceted interventions had either mixed effects or were generally ineffective compared to single interventions. Twenty-three reviews indirectly compared the effectiveness of multifaceted to single interventions; nine of which also reported either a statistical (dose-response) analysis (N = 2) or a non-statistical direct comparison (N = 7). The majority (N = 15) of reviews reporting indirect comparisons of multifaceted to single interventions showed similar effectiveness for multifaceted and single interventions when compared to controls. Of the remaining eight reviews, six found single interventions to be generally effective while multifaceted had mixed effectiveness.

Conclusion

This overview of systematic reviews offers no compelling evidence that multifaceted interventions are more effective than single-component interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0152-6) contains supplementary material, which is available to authorized users.

Antimicrobial stewardship-qualitative and quantitative outcomes: the role of measurement

Overuse and misuse of antibiotics have contributed to the growing problem of antimicrobial resistance and serious side effects including Clostridium difficile infection. The Centers for Disease Control and Prevention estimates that more than 2 million people are infected by multidrug-resistant organisms every year. They propose that promoting antimicrobial stewardship programs (ASP) is an essential component to combat this growing threat. One of the major barriers in implementing effective ASP is the availability of reliable measures which reflect intervention effectiveness. Measuring ASP can be divided into four categories: antimicrobial consumption, process measures, outcome measures, and financial. This article reviews the strengths and weaknesses of the current measures.

Quality indicators on the use of antimicrobials in critically ill patients

Quality indicators have been applied to many areas of health care in recent years, including intensive care. However, they have not been specifically developed and validated for antimicrobial use in critically ill patients. Antimicrobials play a key role in intensive care units not only in the prognosis of each individual patient, but also in the development of resistance and changes in the flora in this setting. Evaluating the use of these agents is complex in the intensive care unit, however, because the indications vary greatly and antimicrobial treatment is often changed during admission. We designed and developed specific quality indicators regarding the use of antimicrobials in critically ill patients admitted to the intensive care unit. These indicators are proposed as a tool for application in intensive care units to detect problems in the use of antimicrobials. Future trials are needed, however, to validate these indicators in a large population over time.

Antibiotic stewardship in the intensive care unit

The rapid emergence and dissemination of antimicrobial-resistant microorganisms in ICUs worldwide constitute a problem of crisis dimensions. The root causes of this problem are multifactorial, but the core issues are clear. The emergence of antibiotic resistance is highly correlated with selective pressure resulting from inappropriate use of these drugs. Appropriate antibiotic stewardship in ICUs includes not only rapid identification and optimal treatment of bacterial infections in these critically ill patients, based on pharmacokinetic-pharmacodynamic characteristics, but also improving our ability to avoid administering unnecessary broad-spectrum antibiotics, shortening the duration of their administration, and reducing the numbers of patients receiving undue antibiotic therapy. Either we will be able to implement such a policy or we and our patients will face an uncontrollable surge of very difficult-to-treat pathogens.

Time from onset of SIRS to antibiotic administration and outcomes after subarachnoid hemorrhage

INTRODUCTION

The interval from presentation with systemic inflammatory response syndrome (SIRS) to the start of antibiotic administration affects mortality in patients with sepsis. However, patients with subarachnoid hemorrhage (SAH) often develop SIRS directly from their brain injury, making it a less useful indicator of infection. We therefore hypothesized that SIRS would not be a suitable trigger for antibiotics in this population.

METHODS

We examined the time from the development of SIRS until antibiotic initiation and its relationship to long-term neurological outcomes in patients with nontraumatic SAH. Patients' baseline characteristics, time of antibiotic administration, and hospital course were collected from retrospective chart review. The primary outcome, 6-month functional status, was prospectively determined using blinded, structured interviews incorporating the modified Rankin Scale (mRS).

RESULTS

Sixty-six of 70 patients with SAH during the study period had 6-month follow-up and were included in this analysis. SIRS developed in 57 patients (86%, 95% CI 78-95%). In ordinal logistic regression models controlling for age and illness severity, the time from SIRS onset until antibiotic initiation was not associated with 6-month mRS scores (OR per hour, 0.994; 95% CI 0.987-1.001).

CONCLUSIONS

In this cohort of patients with SAH, time from SIRS onset until antibiotic administration was not related to functional outcomes. Our results indicate that SIRS is nonspecific in patients with SAH, and support the safety of withholding antibiotics in those who lack additional evidence of infection or hemodynamic deterioration.

Clostridium difficile infection in the elderly

Clostridium difficile-associated illness is an increasingly prevalent and morbid condition. The elderly population is at a disproportionate risk of developing symptomatic disease and associated complications, including progression to severe or fulminant disease, and development of recurrent infections. This article analyzes the factors that influence C difficile disease propensity and severity, with particular attention directed toward features relevant to the rapidly aging population.

Antibiotic prescribing in various clinical departments in a tertiary care teaching hospital in northern India

BACKGROUND

Antibiotic resistance is not only a problem for the individual patient; it also reduces the effectiveness of established treatment and has become a major threat to public health by increasing the complexity and cost of treatment and reducing the probability of a successful outcome.

AIM

A prospective cross sectional study was carried out with the aim of identifying prescription pattern of antibiotics in a tertiary care teaching hospital in Northern India.

MATERIALS AND METHODS

A total of 300 prescriptions were collected, collated and analysed from the indoor patients of MG hospital, Jaipur, India from the department of Medicine, Surgery and Orthopaedics. The prescribing and dispensing details of antibiotics from each prescription were recorded in the tabular form as mentioned in Data Acquisition form. Comparison of antibiotic prescribing practices among all the three departments was made by using Percentage method.

RESULTS

Majority of prescriptions (51%) with single drug was prescribed in Medicine department, followed by 16% in surgery and only 2% in Orthopaedics. Prescriptions with 3 drugs were prescribed mostly in Orthopaedics (66%) followed by 46% in Surgery and 10% in Medicine. 51% prescriptions in Orthopaedics department were of Ceftriaxone+ Sulbactam+ Amikacin. Thirty four percent prescriptions in Medicine department were of Ceftriaxone. 18% prescriptions in Surgery department were of Ceftriaxone+ Sulbactam+ Tobramycin.

CONCLUSION

This study clearly highlights the practice of Poly-Pharmacy and injudicious usage of antibiotics in hospital settings. The Government of India is planning to revise the antibiotic policy issued in 2011 and put a ban on over the counter availability of third generation antibiotics. General public awareness and sensitization of doctors and revision of clinical drug policy is the need of the hour to bring the changes at all possible level for the longterm and better clinical outcome in medical practice.

Evaluation of an intervention to improve blood culture practices: a cluster randomised trial

This study aimed to evaluate an intervention to improve blood culture practices. A cluster randomised trial in two parallel groups was performed at the Grenoble University Hospital, France. In October 2009, the results of a practices audit and the guidelines for the optimal use of blood cultures were disseminated to clinical departments. We compared two types of information dissemination: simple presentation or presentation associated with an infectious diseases (ID) specialist intervention. The principal endpoint was blood culture performance measured by the rate of patients having one positive blood culture and the rate of positive blood cultures. The cases of 130 patients in the "ID" group and 119 patients in the "simple presentation" group were audited during the second audit in April 2010. The rate of patients with one positive blood culture increased in both groups (13.62 % vs 9.89 % for the ID group, p = 0.002, 15.90 % vs 13.47 % for the simple presentation group, p = 0.009). The rate of positive blood cultures improved in both groups (6.68 % vs 5.96 % for the ID group, p = 0.003, 6.52 % vs 6.21 % for the simple presentation group, p = 0.017). The blood culture indication was significantly less often specified in the request form in the simple presentation group, while it remained stable in the ID group (p = 0.04). The rate of positive blood cultures and the rate of patients having one positive blood culture improved in both groups. The ID specialist intervention did not have more of an impact on practices than a simple presentation of audit feedback and guidelines.

A cross-sectional survey of antimicrobial stewardship strategies in UK hospitals

WHAT IS KNOWN AND OBJECTIVE

Antimicrobial stewardship programmes describe strategies to optimize antimicrobial prescribing and utilization, minimize resistance and improve patient outcomes. Strategies in hospitals are usually implemented by multidisciplinary antimicrobial teams (AMTs). The objective of this study was to describe the profile and activities of AMTs within hospitals in the United Kingdom (UK).

METHOD

All hospitals within the UK (n = 836) were included, and a prepiloted questionnaire was mailed to the 'Director of Pharmacy'. Non-respondents were mailed up to two reminder questionnaires at two-weekly intervals. Main outcome measures are as follows: existence and remit of the AMTs; availability of antimicrobial-prescribing policies, aims, scope and methods of dissemination; and monitoring and feedback provided on antimicrobial policy adherence.

RESULTS

Response rate was 33% (n = 273). Completed questionnaires analysed were n = 226. Eighty-two (n = 186) of respondents indicated the presence of an AMT within the hospital, with 95% of these (n = 177) reporting an antimicrobial pharmacist as part of the team. All AMTs (n = 186) were involved in development of an antimicrobial policy and almost all (99% n = 184) promoted adherence and restricting use of specific antimicrobials (97% n = 180). Ninety-eight per cent of respondents (n = 222) reported the availability of a local antimicrobial-prescribing policy within the hospital with this disseminated mainly through the hospital intranet (98% n = 217). Adherence to policy was measured mainly through audits measuring the appropriateness of antimicrobial use against the local policy (76% n = 169). Hospitals in England (P = 0·010), tertiary care hospitals (P = 0·021) and bed capacity >500 (P < 0·001) were more likely to have an AMT, as were hospitals with an accident and emergency department (P < 0·001), an infectious diseases unit (P = 0·019) and a microbiology department (P < 0·001). Audits to measure policy adherence were more likely (P < 0·001) if an AMT was present. The only variable retained in bivariate logistic regression was the presence of a microbiology unit, with an odds ratio of 14·1 (95% CI 6·02-33·33, P < 0·001).

WHAT IS NEW AND CONCLUSIONS

Although most respondents reported an antimicrobial-prescribing policy, less had an AMT. Despite recent government and regional initiatives, further improvements in antimicrobial stewardship are still required.

Clinician-led improvement in cancer care (CLICC)--testing a multifaceted implementation strategy to increase evidence-based prostate cancer care: phased randomised controlled trial--study protocol

BACKGROUND

Clinical practice guidelines have been widely developed and disseminated with the aim of improving healthcare processes and patient outcomes but the uptake of evidence-based practice remains haphazard. There is a need to develop effective implementation methods to achieve large-scale adoption of proven innovations and recommended care. Clinical networks are increasingly being viewed as a vehicle through which evidence-based care can be embedded into healthcare systems using a collegial approach to agree on and implement a range of strategies within hospitals. In Australia, the provision of evidence-based care for men with prostate cancer has been identified as a high priority. Clinical audits have shown that fewer than 10% of patients in New South Wales (NSW) Australia at high risk of recurrence after radical prostatectomy receive guideline recommended radiation treatment following surgery. This trial will test a clinical network-based intervention to improve uptake of guideline recommended care for men with high-risk prostate cancer.

METHODS/DESIGN

In Phase I, a phased randomised cluster trial will test a multifaceted intervention that harnesses the NSW Agency for Clinical Innovation (ACI) Urology Clinical Network to increase evidence-based care for men with high-risk prostate cancer following surgery. The intervention will be introduced in nine NSW hospitals over 10 months using a stepped wedge design. Outcome data (referral to radiation oncology for discussion of adjuvant radiotherapy in line with guideline recommended care or referral to a clinical trial of adjuvant versus salvage radiotherapy) will be collected through review of patient medical records. In Phase II, mixed methods will be used to identify mechanisms of provider and organisational change. Clinicians' knowledge and attitudes will be assessed through surveys. Process outcome measures will be assessed through document review. Semi-structured interviews will be conducted to elucidate mechanisms of change.

DISCUSSION

The study will be one of the first randomised controlled trials to test the effectiveness of clinical networks to lead changes in clinical practice in hospitals treating patients with high-risk cancer. It will additionally provide direction regarding implementation strategies that can be effectively employed to encourage widespread adoption of clinical practice guidelines.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910.

Understanding and changing human behaviour--antibiotic mainstreaming as an approach to facilitate modification of provider and consumer behaviour

This paper addresses: 1) Situations where human behaviour is involved in relation to antibiotics, focusing on providers and consumers; 2) Theories about human behaviour and factors influencing behaviour in relation to antibiotics; 3) How behaviour in relation to antibiotics can change; and, 4) Antibiotic mainstreaming as an approach to facilitate changes in human behaviour as regards antibiotics. Influencing human behaviour in relation to antibiotics is a complex process which includes factors like knowledge, attitudes, social norms, socio-economic conditions, peer pressure, experiences, and bio-physical and socio-behavioural environment. Further, key concepts are often perceived in different ways by different individuals. While designing and implementing projects or programmes for behavioural change with respect to antibiotics for professionals or consumers it is helpful to consider theories or models of behaviour change, e.g. the 'stages of change model', including pre-contemplation, contemplation, preparation, action, and maintenance. People in different stages of change are susceptible to different behaviour modification strategies. Application of marketing principles to 'global good', so-called 'social marketing', to improve 'welfare of the individual and society' is gaining increased attention in public health. In conclusion, just providing correct knowledge is not sufficient although it is a pre-requisite for behaviour modification in the desired direction. We can never change the behaviour of any other human, but we can facilitate for others to change their own behaviour. One possibility is to implement 'antibiotic mainstreaming' as a potentially effective way for behaviour modification, i.e. to address consequences for maintaining effective antibiotics in all activities and decisions in society.

Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews

BACKGROUND

Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use.

OBJECTIVES

To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence.

METHODS

SEARCH METHODS

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012.

SELECTION CRITERIA

We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview.

DATA COLLECTION AND ANALYSIS

We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses.

MAIN RESULTS

We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity.

AUTHORS' CONCLUSIONS

This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.

Feasibility and impact of an intensified antibiotic stewardship programme targeting cephalosporin and fluoroquinolone use in a tertiary care university medical center

BACKGROUND

Restricted use of third-generation cephalosporins and fluoroquinolones has been linked to a reduced incidence of hospital-acquired infections with multidrug-resistant bacteria. We implemented an intensified antibiotic stewardship (ABS) programme in the medical service of a university hospital center aiming at a reduction by at least 30% in the use of these two drug classes.

METHODS

The ABS programme was focused on the 300-bed medical service. Prescription of third-generation cephalosporins was discouraged, whereas the use of penicillins was encouraged. Monthly drug use density was measured in WHO-ATC defined and locally recommended daily doses (DDD and RDD) per 100 patient days, to evaluate trends before (01/2008 to 10/2011) and after starting the intervention (1/2012 to 3/2013). The effect was analysed using interrupted time-series analysis with six non-intervention departments as controls.

RESULTS

Following initiation of the ABS intervention, overall antibiotic use in the medical service declined (p < 0.001). There was a significant intervention-related decrease in the use of cephalosporins and fluoroquinolones (p < 0.001) outperforming the decreasing baseline trend. Trend changes observed in some of the control departments were smaller, and the difference between trend changes in the medical service and those in control departments were highly significant for overall use and cephalosporin use reductions (p < 0.001) as well as for the increasing use of penicillins (p < 0.001). Mean use density levels (in RDD per 100 patient days) dropped for cephalosporins from 16.3 to 10.3 (-37%) and for fluoroquinolones from 17.7 to 10.1 (-43%), respectively. During the same period, the use of penicillins increased (15.4 to 18.2; 18%). The changes in expenditures for antibiotics in the medical service compared to control services minus programme costs indicated initial net cost savings likely to be associated with the programme.

CONCLUSION

An intensified ABS programme targeting cephalosporin und fluoroquinolone use in the setting of a large academic hospital is feasible and effective. The intervention may serve as a model for other services and hospitals with a similar structure and baseline situation.

Sensitivity and specificity of procalcitonin to determine etiology of diarrhea in children younger than 5 years

AIM

The aim of this study is to assess the sensitivity and specificity of procalcitonin to determine bacterial etiology of diarrhea.

THE EXAMINEES AND METHODS

For this purpose we conducted the study comprising 115 children aged 1 to 60 months admitted at the Department of Pediatric Gastroenterology, Pediatric Clinic, divided in three groups based on etiology of the diarrhea that has been confirmed with respective tests during the hospitalization. Each group has equal number of patients - 35. The first group was confirmed to have bacterial diarrhea, the second viral diarrhea and the third extra intestinal diarrhea. The determination of procalcitonin has been established with the ELFA methods of producer B.R.A.H.M.S Diagnostica GmbH, Berlin, (Germany).

RESULTS

From the total number of 1130 patient with acute diarrhea procalcitonin was assessed in 105. 67 (63.8%) of these patient were male. More than one third (38.14%) of the children in our study were younger then 12 months. Approximately the same was the number of children 13-24 months (33 patients or 31.43%) and 25-60 months (32 patients or 30.43%). The mean value of PRC in children with viral diarrhea was 0.13±0.5 ng/mL in children with bacterial diarrhea was 5.3±4.9 ng/m Land in children with extra intestinal diarrhea was 1.7±2.8 ng/mL. When measured using ANOVA and Turkey HSD tests, results have shown the statistical significance when comparing viral with bacterial and extra intestinal diarrhea but were statistically insignificant when comparing bacterial and extra intestinal diarrhea.

CONCLUSION

Procalcitonin is an important but not conclusive marker of bacterial etiology of acute diarrhea in children younger than 5 years.

A multidisciplinary intervention to reduce infections of ESBL- and AmpC-producing, gram-negative bacteria at a University Hospital

In response to a considerable increase in the infections caused by ESBL/AmpC-producing Klebsiella pneumonia in 2008, a multidisciplinary intervention, with a main focus on antimicrobial stewardship, was carried out at one university hospital. Four other hospitals were used as controls. Stringent guidelines for antimicrobial treatment and prophylaxis were disseminated throughout the intervention hospital; cephalosporins were restricted for prophylaxis use only, fluoroquinolones for empiric use in septic shock only, and carbapenems were selected for penicillin-allergic patients, infections due to ESBL/AmpC-producing and other resistant bacteria, in addition to their use in severe sepsis/septic shock. Piperacillin-tazobactam ± gentamicin was recommended for empiric treatments of most febrile conditions. The intervention also included education and guidance on infection control, as well as various other surveillances. Two year follow-up data on the incidence rates of patients with selected bacterial infections, outcomes, and antibiotic consumption were assessed, employing before-and-after analysis and segmented regression analysis of interrupted time series, using the other hospitals as controls. The intervention led to a sustained change in antimicrobial consumption, and the incidence of patients infected with ESBL-producing K. pneumoniae decreased significantly (p<0.001). The incidences of other hospital-associated infections also declined (p’s<0.02), but piperacillin-tazobactam-resistant Pseudomonas aeruginosa and Enterococcus faecium infections increased (p’s<0.033). In wards with high antimicrobial consumption, the patient gut carrier rate of ESBL-producing bacteria significantly decreased (p = 0.023). The unadjusted, all-cause 30-day mortality rates of K. pneumoniae and E. coli were unchanged over the four-year period, with similar results in all five hospitals. Although not statistically significant, the 30-day mortality rate of patients with ESBL-producing K. pneumoniae decreased, from 35% in 2008–2009, to 17% in 2010–2011. The two-year follow-up data indicated that this multidisciplinary intervention led to a statistically significant decrease in the incidence of ESBL/AmpC-resistant K. pneumoniae infections, as well as in the incidences of other typical hospital-associated bacterial infections.

Changing use of surgical antibiotic prophylaxis in Thika Hospital, Kenya: a quality improvement intervention with an interrupted time series design

Introduction

In low-income countries, Surgical Site Infection (SSI) is a common form of hospital-acquired infection. Antibiotic prophylaxis is an effective method of preventing these infections, if given immediately before the start of surgery. Although several studies in Africa have compared pre-operative versus post-operative prophylaxis, there are no studies describing the implementation of policies to improve prescribing of surgical antibiotic prophylaxis in African hospitals.

Methods

We conducted SSI surveillance at a typical Government hospital in Kenya over a 16 month period between August 2010 and December 2011, using standard definitions of SSI and the extent of contamination of surgical wounds. As an intervention, we developed a hospital policy that advised pre-operative antibiotic prophylaxis and discouraged extended post-operative antibiotics use. We measured process, outcome and balancing effects of this intervention in using an interrupted time series design.

Results

From a starting point of near-exclusive post-operative antibiotic use, after policy introduction in February 2011 there was rapid adoption of the use of pre-operative antibiotic prophylaxis (60% of operations at 1 week; 98% at 6 weeks) and a substantial decrease in the use of post-operative antibiotics (40% of operations at 1 week; 10% at 6 weeks) in Clean and Clean-Contaminated surgery. There was no immediate step-change in risk of SSI, but overall, there appeared to be a moderate reduction in the risk of superficial SSI across all levels of wound contamination. There were marked reductions in the costs associated with antibiotic use, the number of intravenous injections performed and nursing time spent administering these.

Conclusion

Implementation of a locally developed policy regarding surgical antibiotic prophylaxis is an achievable quality improvement target for hospitals in low-income countries, and can lead to substantial benefits for individual patients and the institution.

A modified method for measuring antibiotic use in healthcare settings: implications for antibiotic stewardship and benchmarking

OBJECTIVES

To determine whether adjusting the denominator of the common hospital antibiotic use measurement unit (defined daily doses/100 bed-days) by including age-adjusted comorbidity score (100 bed-days/age-adjusted comorbidity score) would result in more accurate and meaningful assessment of hospital antibiotic use.

METHODS

The association between the monthly sum of age-adjusted comorbidity and monthly antibiotic use was measured using time-series analysis (January 2008 to June 2012). For the purposes of conducting internal benchmarking, two antibiotic usage datasets were constructed, i.e. 2004-07 (first study period) and 2008-11 (second study period). Monthly antibiotic use was normalized per 100 bed-days and per 100 bed-days/age-adjusted comorbidity score.

RESULTS

Results showed that antibiotic use had significant positive relationships with the sum of age-adjusted comorbidity score (P = 0.0004). The results also showed that there was a negative relationship between antibiotic use and (i) alcohol-based hand rub use (P = 0.0370) and (ii) clinical pharmacist activity (P = 0.0031). Normalizing antibiotic use per 100 bed-days contributed to a comparative usage rate of 1.31, i.e. the average antibiotic use during the second period was 31% higher than during the first period. However, normalizing antibiotic use per 100 bed-days per age-adjusted comorbidity score resulted in a comparative usage rate of 0.98, i.e. the average antibiotic use was 2% lower in the second study period. Importantly, the latter comparative usage rate is independent of differences in patient density and case mix characteristics between the two studied populations.

CONCLUSIONS

The proposed modified antibiotic measure provides an innovative approach to compare variations in antibiotic prescribing while taking account of patient case mix effects.

An evaluation of prescribing practices for community-acquired pneumonia (CAP) in Mongolia

BACKGROUND

Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality in all age groups worldwide. It may be classified as mild/moderate or severe, the latter usually requiring hospitalisation. Although, there are many studies reported in relation to CAP, there is relatively little known about the treatment of CAP and its antibiotic use in Mongolia. The study aim was to evaluate prescribing practices for the treatment of mild/moderate CAP in Mongolia with respect to national prescribing guidelines.

METHODS

Written prescriptions with a written diagnosis of CAP included were collected prospectively and sequentially for ten weeks from a purposefully selected sample of community pharmacies in rural and urban areas of Mongolia. The data collected included the patient's age, gender, medication details, frequency and number of doses prescribed. Evaluation was with respect to the Mongolian Standard Treatment Guidelines (2005, 2008). Statistical differences between groups were tested using the Chi-squared and Fisher's exact tests.

RESULTS

Prescriptions were collected from 22 pharmacies and represented the prescribing practices of 118 doctors. The study enrolled 394 (193 adults and 201 children) patients, with a median age for children of 2.0 years (range: 0.03-12) and adults of 33.0 years (range: 13-92).The most commonly prescribed drugs were aminopenicillins, vitamins, and mucolytics, with the median number of drugs being three per prescription. Inappropriate drug selection was similar for adults (57.7%) and children (56.6%), and the major reason for an overall frequency of inappropriate prescribing for adults was 89.0% and for children 78.0%. Doctors in urban areas prescribed more inappropriate drugs than those in rural areas for both children and adults, p = .0014. The proportion of prescribed injections was 28.4% for adults and 9.0% for children, and for adults was significantly higher in urban areas. The prescribing standard for non-hospitalized patients in Mongolia states that injections should not be prescribed.

CONCLUSIONS

The high level of inappropriate prescribing for mild/moderate CAP highlights the need to develop comprehensive and reliable procedures nationwide to improve prescribing practices in Mongolia.

Development and validation of potential structure indicators for evaluating antimicrobial stewardship programmes in European hospitals

This study describes the development of structure indicators for hospital antimicrobial stewardship programmes and pilot validation across European hospitals. A multi-disciplinary panel from four European countries developed structure indicators in three steps: identification and listing of indicators, remote ranking of indicators using multi-criteria scoring, selection of indicators in a face-to-face consensus meeting. Additionally, the top-ten indicators were identified as a minimal set of key indicators. A survey was sent to the directors of antimicrobial stewardship programmes in European hospitals. The yes/no answers for the indicators were transformed into numbers in order to calculate the total scores. A list of 58 indicators was selected and categorised into the following topics: antimicrobial stewardship services (12 items), tools (16 items), human resources and mandate (6 items), health care personnel development (4 items), basic diagnostic capabilities (6 items), microbiological rapid tests (2 items), evaluation of microbiological drug resistance data (3 items), antibiotic consumption control (5 items) and drug use monitoring (4 items). The indicator scores, reported by 11 pilot hospitals from five European countries, ranged from 32 to 50 (maximum score = 58) and from 5 to 10 points (maximum score = 10) for, respectively, the complete and the top-ten list. An international panel selected 58 potential structure indicators, among which was a minimal set of ten key structure indicators, that could be useful for assessment of the comprehensiveness and resource-intensity of antimicrobial stewardship programmes. There was significant heterogeneity among participating centres with regard to their score for structural components of effective antimicrobial stewardship.

Better drug therapy for the children of Africa: current impediments to success and potential strategies for improvement

A commentary is presented on the urgent need for a comprehensive effort to improve the practice of pediatric therapeutics in Africa. A call for action is addressed to a variety of practitioners internationally, many of whom possess skills that could be fruitfully applied to the improvement of health outcomes for African children. Successful engagement with the many challenges requires the complementary effort of researchers in basic and clinical pharmacology and toxicology, nurses, pharmacists, physicians, clinical pharmacologists, clinical pharmacists, and political leaders and civil servants. While a comprehensive or systematic review of the relevant literature has not been attempted, the authors have highlighted promising initiatives driven by international agencies and academic networks. Two African perspectives are presented to reinforce the prospect of child health gains that can be achieved through consistent pursuit of optimal therapy for conditions such as respiratory infection, diarrhea, malaria, and HIV/AIDS. There is an imperative for development of north-south and south-south partnerships that will amplify current research efforts and mobilize existing knowledge concerning pediatric drugs. The overall goal is a multidisciplinary commitment to making essential medicines available at the right time, the right place, and in the right formulation for African children from infancy to adolescence.

Impact of a program combining pre-authorization requirement and post-prescription review of carbapenems: an interrupted time-series analysis

The objective of this study was to assess the impact on carbapenems use of a program combining pre-authorization requirement and systematic post-prescription review of carbapenems prescriptions. The program was implemented in a 1,230-bed teaching tertiary hospital. Monthly carbapenems consumption was analyzed using a controlled interrupted time-series method and compared to that of vancomycin before and after implementation of the intervention. Compared to the pre-intervention period (14 monthly points), a significant and sustained decrease of carbapenems consumption [1.66 defined daily doses (DDD)/1,000 patient-days; p = 0.048] was observed during the intervention period (12 monthly points), despite an increasing trend in incidence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) isolates (0.02/1,000 patient-days per month; p = 0.093). As expected, vancomycin consumption was unaffected by the intervention. A total of 337 prescriptions were reviewed in the intervention period; most were microbiologically documented (81.3%; ESBL-PE: 39.2%). Three of four (76.6%) carbapenems prescriptions were modified within a median [interquartile range] of 2 [1; 4] days, either after infectious disease physician (IDP) advice (48.4%) or by ward physicians (28.2%). Most changes included de-escalating (52.2%) or reducing the planned duration (22.2%), which resulted in a median duration of treatment of only 3 [2; 7] days. The median length of stay and mortality rate were not influenced by the intervention. This reasonably practicable antimicrobial stewardship program including controlled delivery and systematic reevaluation of carbapenems prescriptions was able to reduce their use in our hospital, despite a rising ESBL-PE incidence.

The Impact of Appropriate Antibiotic Prescribing on Treatment Evaluation Parameters

The therapeutic impact of inappropriate prescribing of antibiotics is debatable, particularly in situations where infections are treated empirically with multiply prescribed antibiotics. Prescribers may remain under the illusion that such prescriptions are appropriate on the basis of any observed positive treatment outcomes, even though an antibiotic prescribed in such combination therapy may actually be infective against infecting pathogens. This, inevitably, promotes inappropriate antibiotic prescribing. Prescribers may be motivated to make more conscious attempts to prescribe antibiotics appropriately if it is proven that judicious prescribing of antibiotics has positive impacts on treatment outcomes. The objective of this study was to determine the impact of appropriate prescribing of antibiotics on treatment outcomes, days of patient hospitalization and costs related to antibiotic treatment. Observational data on antibiotic treatment were collected for a one-month period from case notes of all inpatients (n=307) and outpatients (n=865) at five government and mission hospitals in Lesotho. Prescriptions were classified into categories of appropriateness based on extents to which antibiotics were prescribed according to principles. Treatment success rates, mean days of hospitalization and costs of antibiotic treatments of inpatients treated with specified prescription categories were determined. Appropriate prescribing of antibiotics for inpatients had positive impacts on treatment outcomes, patients' days of hospitalization for infections and costs of antibiotic treatments. In outpatient settings, appropriate prescribing of antibiotics failed to show any significant impact on costs of antibiotics. Appropriate prescribing of antibiotics had a positive impact on patients' recovery and costs of antibiotic treatments in inpatient settings.

Impact of an enhanced antibiotic stewardship on reducing methicillin-resistant Staphylococcus aureus in primary and secondary healthcare settings

The objective of this study was to evaluate the impact of restricting high-risk antibiotics on methicillin-resistant Staphylococcus aureus (MRSA) incidence rates in a hospital setting. A secondary objective was to assess the impact of reducing fluoroquinolone use in the primary-care setting on MRSA incidence in the community. This was an interventional, retrospective, ecological investigation in both hospital and community (January 2006 to June 2010). Segmented regression analysis of interrupted time-series was employed to evaluate the intervention. The restriction of high-risk antibiotics was associated with a significant change in hospital MRSA incidence trend (coefficient=-0·00561, P=0·0057). Analysis showed that the intervention relating to reducing fluoroquinolone use in the community was associated with a significant trend change in MRSA incidence in community (coefficient=-0·00004, P=0·0299). The reduction in high-risk antibiotic use and fluoroquinolone use contributed to both a reduction in incidence rates of MRSA in hospital and community (primary-care) settings.

Causes, consequences, and perspectives in the variations of intestinal density of colonization of multidrug-resistant enterobacteria

The intestinal microbiota is a complex environment that hosts 10¹³ to 10¹⁴ bacteria. Among these bacteria stand multidrug-resistant enterobacteria (MDRE), which intestinal densities can substantially vary, especially according to antibiotic exposure. The intestinal density of MDRE and their relative abundance (i.e., the proportion between the density of MDRE and the density of total enterobacteria) could play a major role in the infection process or patient-to-patient transmission. This review discusses the recent advances in understanding (i) what causes variations in the density or relative abundance of intestinal colonization, (ii) what are the clinical consequences of these variations, and (iii) what are the perspectives for maintaining these markers at low levels.

Preventing clostridium difficile infection in the intensive care unit

Clostridium difficile is a formidable problem in the twenty-first century. Because of injudicious use of antibiotics, the emergence of the hypervirulent epidemic strain of this organism has been difficult to contain. The NAP1/BI/027 strain causes more-severe disease than other widely prevalent strains and affects patients who were not traditionally thought to be at risk for Clostridium difficile infection. Critically ill patients remain at high risk for this pathogen, and preventive measures, such as meticulous contact precautions, hand hygiene, environmental disinfection, and, most importantly, antibiotic stewardship, are the cornerstones of mitigation in the intensive care unit.

Interventions to improve antibiotic prescribing practices for hospital inpatients

BACKGROUND

The first publication of this review in Issue 3, 2005 included studies up to November 2003. This update adds studies to December 2006 and focuses on application of a new method for meta-analysis of interrupted time series studies and application of new Cochrane Effective Practice and Organisation of Care (EPOC) Risk of Bias criteria to all studies in the review, including those studies in the previously published version. The aim of the review is to evaluate the impact of interventions from the perspective of antibiotic stewardship. The two objectives of antibiotic stewardship are first to ensure effective treatment for patients with bacterial infection and second support professionals and patients to reduce unnecessary use and minimize collateral damage.

OBJECTIVES

To estimate the effectiveness of professional interventions that, alone or in combination, are effective in antibiotic stewardship for hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial-resistant pathogens or Clostridium difficile infection and their impact on clinical outcome.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE from 1980 to December 2006 and the EPOC specialized register in July 2007 and February 2009 and bibliographies of retrieved articles. The main comparison is between interventions that had a restrictive element and those that were purely persuasive. Restrictive interventions were implemented through restriction of the freedom of prescribers to select some antibiotics. Persuasive interventions used one or more of the following methods for changing professional behaviour: dissemination of educational resources, reminders, audit and feedback, or educational outreach. Restrictive interventions could contain persuasive elements.

SELECTION CRITERIA

We included randomized clinical trials (RCTs), controlled clinical trials (CCT), controlled before-after (CBA) and interrupted time series studies (ITS). Interventions included any professional or structural interventions as defined by EPOC. The intervention had to include a component that aimed to improve antibiotic prescribing to hospital inpatients, either by increasing effective treatment or by reducing unnecessary treatment. The results had to include interpretable data about the effect of the intervention on antibiotic prescribing or microbial outcomes or relevant clinical outcomes.

DATA COLLECTION AND ANALYSIS

Two authors extracted data and assessed quality. We performed meta-regression of ITS studies to compare the results of persuasive and restrictive interventions. Persuasive interventions advised physicians about how to prescribe or gave them feedback about how they prescribed. Restrictive interventions put a limit on how they prescribed; for example, physicians had to have approval from an infection specialist in order to prescribe an antibiotic. We standardized the results of some ITS studies so that they are on the same scale (percent change in outcome), thereby facilitating comparisons of different interventions. To do this, we used the change in level and change in slope to estimate the effect size with increasing time after the intervention (one month, six months, one year, etc) as the percent change in level at each time point. We did not extrapolate beyond the end of data collection after the intervention. The meta-regression was performed using standard weighted linear regression with the standard errors of the coefficients adjusted where necessary.

MAIN RESULTS

For this update we included 89 studies that reported 95 interventions. Of the 89 studies, 56 were ITSs (of which 4 were controlled ITSs), 25 were RCT (of which 5 were cluster-RCTs), 5 were CBAs and 3 were CCTs (of which 1 was a cluster-CCT).Most (80/95, 84%) of the interventions targeted the antibiotic prescribed (choice of antibiotic, timing of first dose and route of administration). The remaining 15 interventions aimed to change exposure of patients to antibiotics by targeting the decision to treat or the duration of treatment. Reliable data about impact on antibiotic prescribing data were available for 76 interventions (44 persuasive, 24 restrictive and 8 structural). For the persuasive interventions, the median change in antibiotic prescribing was 42.3% for the ITSs, 31.6% for the controlled ITSs, 17.7% for the CBAs, 3.5% for the cluster-RCTs and 24.7% for the RCTs. The restrictive interventions had a median effect size of 34.7% for the ITSs, 17.1% for the CBAs and 40.5% for the RCTs. The structural interventions had a median effect of 13.3% for the RCTs and 23.6% for the cluster-RCTs. Data about impact on microbial outcomes were available for 21 interventions but only 6 of these also had reliable data about impact on antibiotic prescribing.Meta-analysis of 52 ITS studies was used to compare restrictive versus purely persuasive interventions. Restrictive interventions had significantly greater impact on prescribing outcomes at one month (32%, 95% confidence interval (CI) 2% to 61%, P = 0.03) and on microbial outcomes at 6 months (53%, 95% CI 31% to 75%, P = 0.001) but there were no significant differences at 12 or 24 months. Interventions intended to decrease excessive prescribing were associated with reduction in Clostridium difficile infections and colonization or infection with aminoglycoside- or cephalosporin-resistant gram-negative bacteria, methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis. Meta-analysis of clinical outcomes showed that four interventions intended to increase effective prescribing for pneumonia were associated with significant reduction in mortality (risk ratio 0.89, 95% CI 0.82 to 0.97), whereas nine interventions intended to decrease excessive prescribing were not associated with significant increase in mortality (risk ratio 0.92, 95% CI 0.81 to 1.06).

AUTHORS' CONCLUSIONS

The results show that interventions to reduce excessive antibiotic prescribing to hospital inpatients can reduce antimicrobial resistance or hospital-acquired infections, and interventions to increase effective prescribing can improve clinical outcome. This update provides more evidence about unintended clinical consequences of interventions and about the effect of interventions to reduce exposure of patients to antibiotics. The meta-analysis supports the use of restrictive interventions when the need is urgent, but suggests that persuasive and restrictive interventions are equally effective after six months.

Global impact of an educational antimicrobial stewardship programme on prescribing practice in a tertiary hospital centre

The misuse of antibiotics has been related to increased morbidity, mortality and bacterial resistance. The development of antimicrobial stewardship programmes (ASPs) has been encouraged by scientific societies as an essential measure. An educational, institutionally supported ASP was developed in our tertiary-care centre. Local guidelines on the management of infectious syndromes were created. Antimicrobial prescriptions were chosen arbitrarily weekly and counselling interviews by expert clinicians were carried out, using a paedagogic, non-restrictive methodology. Satisfaction with the interview was assessed using anonymous questionnaires. The appropriateness of antimicrobial prescriptions as well as consumption was assessed prospectively throughout the year. Feedback regarding the correct use of treatments was communicated to each participating department periodically. The improvement in antimicrobial prescription was included among the annual objectives linked to economic incentives in every department. A total of 1206 counselling interviews were carried out during the first year. Fifty-three per cent of antimicrobial prescriptions (176/332) were inappropriate when the programme started. The rate of inappropriate prescriptions continuously declined to 26.4% (107/405) in the fourth trimester (p <0.001; RR = 0.38; 95% CI, 0.23-0.43). Antimicrobial consumption decreased from 1150 defined daily doses (DDDs) per 1000 occupied bed-days in the first trimester to 852 DDDs in the fourth, reflecting a reduction in antimicrobial expenditures of 42%. A total of 352 satisfaction questionnaires were received and 98% described the advice as positive. In conclusion, the implementation of an education-based ASP achieved a significant improvement in all antimicrobial prescriptions in the centre and a reduction in antimicrobial consumption, even when no restrictive measures were implemented. The programme was highly accepted by all prescribers.

The Effects of Cranberries on Preventing Urinary Tract Infections

Despite considerable controversy about their effects, cranberries in various forms have been used widely for several decades to prevent as well as treat urinary tract infections (UTIs). The purpose of this article is to present a review of research-based information regarding the ability of cranberries to prevent UTIs in adults at risk for UTIs. Current evidence suggests that cranberries decrease bacterial adherence to uroepithelial cells and thus decrease the incidence of UTIs without adverse effects in most individuals. Thus clinicians may safely advise patients that cranberries are helpful in preventing UTIs. Cranberries may be a viable adjunct to antibiotics for patients with repeated UTIs.

How to educate prescribers in antimicrobial stewardship practices

Widespread antimicrobial use has compromised its value, leading to a crisis of antimicrobial resistance. A major cause of misuse is insufficient knowledge of prescribing of antimicrobials in many categories of professionals. An important principle of antimicrobial stewardship is avoiding selection pressure in the patient, both on pathogen and commensal by avoiding unnecessary use, choosing the least broad-spectrum antibiotic, adequate doses, a good timing and the shortest possible duration. Up to now, most educational efforts have been targeted at professionals (mostly medical doctors) after their training and at the adult public. In the past few years, progress has been made in educating children. It is now crucial that academia and ministries of Health and Education jointly focus on an adapted undergraduate medical/professional curriculum that teaches all necessary principles of microbiology, infectious diseases and clinical pharmacology, with emphasis on the principles of prudent prescribing.

Antimicrobial stewardship: a review of prospective audit and feedback systems and an objective evaluation of outcomes

Antimicrobial stewardship is an emerging field currently defined by a series of strategies and interventions aimed toward improving appropriate prescription of antibiotics in humans in all healthcare settings. The ultimate goal is the preservation of current and future antibiotics against the threat of antimicrobial resistance, although improving patient safety and reducing healthcare costs are important concurrent aims. Prospective audit and feedback interventions are probably the most widely practiced of all antimicrobial stewardship strategies. Although labor-intensive, they are more easily accepted by physicians compared with formulary restriction and preauthorization strategies and have a higher potential for educational opportunities. Objective evaluation of antimicrobial stewardship is critical for determining the success of such programs. Nonetheless, there is controversy over which outcomes to measure and there is a pressing need for novel study designs that can objectively assess antimicrobial stewardship interventions despite the limitations inherent in the structure of most such programs.

An analysis of the development and implementation of a smartphone application for the delivery of antimicrobial prescribing policy: lessons learnt

Objectives

Smartphone usage amongst clinicians is widespread. Yet smartphones are not widely used for the dissemination of policy or as clinical decision support systems. We report here on the development, adoption and implementation process of the Imperial Antimicrobial Prescribing Application across five teaching hospitals in London.

Methods

Doctors and clinical pharmacists were recruited to this study, which employed a mixed methods in-depth case-study design with focus groups, structured pre- and post-intervention survey questionnaires and live data on application uptake. The primary outcome measure was uptake of the application by doctors and its acceptability. The development and implementation processes were also mapped.

Results

The application was downloaded by 40% (376) of junior doctors with smartphones (primary target user group) within the first month and by 100% within 12 months. There was an average of 1900 individual access sessions per month, compared with 221 hits on the Intranet version of the policy. Clinicians (71%) reported that using the application improved their antibiotic knowledge.

Conclusions

Clinicians rapidly adopted the mobile application for antimicrobial prescribing at the point of care, enabling the policy to reach a much wider audience in comparison with paper- and desktop-based versions of the policy. Organizations seeking to optimize antimicrobial prescribing should consider utilizing mobile technology to deliver point-of-care decision support. The process revealed a series of barriers, which will need to be addressed at individual and organizational levels to ensure safe and high-quality delivery of local policy at the point of care.

The impact of antibiotic use on the incidence and resistance pattern of extended-spectrum beta-lactamase-producing bacteria in primary and secondary healthcare settings

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

• The emergence and spread of bacteria producing extended-spectrum beta-lactamases (ESBLs) has important therapeutic and epidemiologic implications. • A key target for the establishment of hospital antibiotic stewardship is reducing the occurrence of additional antibiotic resistance. • Further research is needed to accumulate supporting evidence that reducing antibiotic use will result in a parallel reduction in antibiotic resistance.

WHAT THIS STUDY ADDS

• Fluoroquinolone restriction reversed ciprofloxacin resistance in primary and secondary healthcare settings. • Fluoroquinolone restriction reduced ESBL-producing bacteria incidence rates in both the primary and secondary healthcare settings. • This study highlights the value of time-series analysis in designing efficient antibiotic stewardship.

AIMS

The objective of the present study was to study the relationship between hospital antibiotic use, community antibiotic use and the incidence of extended-spectrum beta-lactamase (ESBL)-producing bacteria in hospitals, while assessing the impact of a fluoroquinolone restriction policy on ESBL-producing bacteria incidence rates.

METHODS

The study was retrospective and ecological in design. A multivariate autoregressive integrated moving average (ARIMA) model was built to relate antibiotic use to ESB-producing bacteria incidence rates and resistance patterns over a 5 year period (January 2005-December 2009).

RESULTS

Analysis showed that the hospital incidence of ESBLs had a positive relationship with the use of fluoroquinolones in the hospital (coefficient = 0.174, P= 0.02), amoxicillin-clavulanic acid in the community (coefficient = 1.03, P= 0.03) and mean co-morbidity scores for hospitalized patients (coefficient = 2.15, P= 0.03) with various time lags. The fluoroquinolone restriction policy was implemented successfully with the mean use of fluoroquinolones (mainly ciprofloxacin) being reduced from 133 to 17 defined daily doses (DDDs)/1000 bed days (P < 0.001) and from 0.65 to 0.54 DDDs/1000 inhabitants/day (P= 0.0007), in both the hospital and its surrounding community, respectively. This was associated with an improved ciprofloxacin susceptibility in both settings [ciprofloxacin susceptibility being improved from 16% to 28% in the community (P < 0.001)] and with a statistically significant reduction in ESBL-producing bacteria incidence rates.

DISCUSSION

This study supports the value of restricting the use of certain antimicrobial classes to control ESBL, and demonstrates the feasibility of reversing resistance patterns post successful antibiotic restriction. The study also highlights the potential value of the time-series analysis in designing efficient antibiotic stewardship.

Clinical impact of unsolicited post-prescription antibiotic review in surgical and medical wards: a randomized controlled trial

This study aimed to determine the clinical course of patients and the quality of antibiotic use using a systematic and unsolicited post-prescription antibiotic review. Seven hundred and fifty-three adult patients receiving antibiotic therapy for 3-5 days were randomized to receive either a post-prescription review by the infectious disease physician (IDP), followed by a recommendation to the attending physician to modify the prescription when appropriate, or no systematic review of the prescription. In the intervention group, 63.3% of prescriptions prompted IDP recommendations, which were mostly followed by ward physicians (90.3%). Early antibiotic modifications were more frequent in the intervention group (57.1% vs. 25.7%, p <0.0001), including stopping therapy, shortening duration and de-escalating broad-spectrum antibiotics. IDP intervention led to a significant reduction of the median [IQR] duration of antibiotic therapy (6 [4-9] vs. 7 days [5-9], p <0.0001). In-hospital mortality, ICU admission and new course of antibiotic therapy rates did not differ between the two groups. Fewer patients in the intervention group were readmitted for relapsing infection (3.4% vs. 7.9%, p 0.01). There was a trend for a shorter length of hospital stay in patients suffering from community-acquired infections in the intervention group (5 days [3-10] vs. 6 days [3-14], p 0.06). This study provides clinical evidence that a post-prescription antibiotic review followed by unsolicited IDP advice is effective in reducing antibiotic exposure of patients and increasing the quality of antibiotic use, and may reduce hospital stay and relapsing infection rates, with no adverse effects on other patient outcomes.

Risk factors for community- and health facility-acquired extended-spectrum β-lactamase-producing bacterial infections in patients at the University of Minnesota Medical Center, Fairview

BACKGROUND

This study examined risk factors for extended-spectrum β-lactamase (ESBL) infection in patients at the University of Minnesota Medical Center, Fairview.

METHODS

Laboratory-confirmed cases of ESBL infection between January 2005 and June 2008 were evaluated in a case-control study. Risk factors were assessed based on source of infection, either health facility-acquired (HFA) or community-acquired (CA). Cases were identified through hospital infection control department ESBL surveillance records. Controls were selected from the patient population present within the same facility as the cases.

RESULTS

Our evaluation revealed that 60.6% of the health facility-acquired ESBL infections were due to Escherichia coli. Risk factors included previous antibiotic use (odds ratio [OR], 23.7; P < .0001), recurrent urinary tract infection (OR, 7.0; P < .022), venous or arterial catheter use (OR, 12.5; P < .0001), and long-term care facility residence (OR, 7.7; P = .043). For each day of antibiotic use, the risk of infection increased by 2%. Similarly, 76.5% of the community-acquired ESBL infections were due to E coli. Risk factors included previous antibiotic use (OR, 5.1; P = .0005) and recurrent urinary tract infection (OR, 9.1; P = .0098). For each day of antibiotic use, the risk of infection increased by 1%.

CONCLUSIONS

Developing policies and methods to promote good antibiotic stewardship and reduce the incidence of urinary tract infections will decrease the risk of ESBL infection.

Implementation of an Antimicrobial Stewardship Program in a Community Hospital: Results of a Three-Year Analysis

Background

In July 2007, the Pharmacy Department at Suburban Hospital implemented an antimicrobial stewardship program (ASP) using existing clinical pharmacy resources that did not include an on-site infectious diseases (ID) pharmacist. Medical staff personnel were supportive of the ASP, but there were no ID physician resources actively dedicated to the program. Remote access to an ID pharmacist was available.

Objectives

This program evaluated the impact of a pharmacy-driven ASP on cost, antimicrobial utilization, and quality indicators in a community hospital with limited ID professional resources.

Methods

The tenets of the program were adopted from recommendations in the most current Infectious Diseases Society of America/Society for Healthcare Epidemiology of America antimicrobial stewardship guidelines. Antimicrobial utilization, cost, prospective medication use data, and interventions were tracked using customized spreadsheets. Three years of utilization and cost data were captured to provide a baseline and post implementation comparison.

Results

Antimicrobial utilization decreased 5.2% compared to baseline ( P < .001) as measured by the defined daily dose (DDD) per 1,000 patient days. The associated cost reduction during the period was 24% compared to baseline ( P < .001), resulting in estimated savings of approximately $290,000. Quality of care indicators improved, and physicians were responsive to daily clinical pharmacist review and pharmacy interventions.

Conclusions

An ASP can be implemented in a community hospital setting with existing clinical pharmacy resources that do not include an ID specialist dedicated full time to the program. Prospective monitoring of antimicrobial usage resulted in decreased antimicrobial cost and utilization and improvements on key quality of care indicators. Based on this evidence of success, the program continues.

Clinical benefit of infectious diseases consultation: a monocentric prospective cohort study

PURPOSE

To determine the association of clinical outcomes with the adherence to Infectious Diseases Consultation (IDC) recommendations.

METHODS

From March to August 2009, all patients hospitalized in our hospital, for whom an IDC was requested, were prospectively enrolled. The adherence to recommendations was ascertained after 72 h from the IDC. The primary objective of the study was to evaluate the clinical cure rate 1 month after the IDC, according to the adherence to IDC recommendations.

RESULTS

An IDC was requested for 258 inpatients. The infectious disease (ID) was most often non-severe (66%), community-acquired (62%), and already under treatment (47%). IDC proposals were most often formulated via a formal consultation (57%). Physicians' adherence to IDC recommendations was 87% for diagnostic tests and 90% for antibiotherapy. In the multivariate analysis, severe infections and direct consultation were independently associated with increased odds of adherence to recommendations for performing diagnostic tests (odds ratios 5.4 and 4.0, respectively). The overall clinical cure rate was 84% and this did not differ according to the adherence to IDC recommendations for diagnostic tests (84.3 vs. 71.4%, p = 0.15) and antimicrobial treatment (84.8 vs. 77.8%, p = 0.34).

CONCLUSIONS

Some limitations of the study may explain the lack of evidence of a clinical benefit, such as the very high level of adherence to IDC recommendations and the low proportion of severe infections. However, clinical improvement was always better when recommendations were followed. Therefore, further larger randomized multicentric studies including more patients suffering from more severe IDs may be needed in order to demonstrate a clinical impact.

Detection, treatment, and prevention of Clostridium difficile infection

Clostridium difficile is a gram-positive anaerobic bacillus responsible for approximately 1 of 5 cases of antibiotic-associated diarrhea. C difficile infection (CDI) is defined by at least 3 unformed stools in a 24-hour period and stool, endoscopic, or histopathologic test results that indicate the presence of this bacteria. The history of CDI research can be divided into early (before 2000) and modern eras (after 2000). C difficile was first described in 1935, and the characteristics and causes of CDI as well as therapies were identified during the early era of research. During the modern era, CDI has become a more common, aggressive nosocomial infection. Our understanding of the epidemiology, diagnosis, treatment, and prevention of CDI has increased at a rapid pace. We review features of CDI diagnosis, treatment, and prevention.

Changes in fluoroquinolone use for gonorrhea following publication of revised treatment guidelines

OBJECTIVES

We evaluated the impact of revised national treatment recommendations on fluoroquinolone use for gonorrhea in selected states.

METHODS

We evaluated gonorrhea cases reported through the Sexually Transmitted Disease Surveillance Network as treated between July 1, 2006 and May 31, 2008, using interrupted time series analysis. Outcomes were fluoroquinolone treatment overall, by area, and by practice setting.

RESULTS

Of 16,126 cases with treatment dates in this period, 15,669 noted the medication used. After revised recommendations were released, fluoroquinolone use decreased abruptly overall (21.5%; 95% confidence interval [CI] = 15.9%, 27.2%), in most geographic areas evaluated, and in sexually transmitted disease clinics (28.5%; 95% CI = 19.0%, 37.9%). More gradual decreases were seen in primary care (8.6%; 95% CI = 2.6%, 14.6%), and in emergency departments, urgent care, and hospitals (2.7%; 95% CI = 1.7%, 3.7%).

CONCLUSIONS

Fluoroquinolone use decreased after the publication of revised national guidelines, particularly in sexually transmitted disease clinics. Additional mechanisms are needed to increase the speed and magnitude of changes in prescribing in primary care, emergency departments, urgent care, and hospitals.