Programas de optimización de uso de antimicrobianos (PROA) en hospitales españoles: documento de consenso GEIH-SEIMC, SEFH y SEMPSPH

Diagnosis and treatment of catheter-related bloodstream infection: Clinical guidelines of the Spanish Society of Infectious Diseases and Clinical Microbiology and (SEIMC) and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)

Catheter-related bloodstream infections (CRBSI) constitute an important cause of hospital-acquired infection associated with morbidity, mortality, and cost. The aim of these guidelines is to provide updated recommendations for the diagnosis and management of CRBSI in adults. Prevention of CRBSI is excluded. Experts in the field were designated by the two participating Societies (the Spanish Society of Infectious Diseases and Clinical Microbiology and [SEIMC] and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units [SEMICYUC]). Short-term peripheral venous catheters, non-tunneled and long-term central venous catheters, tunneled catheters and hemodialysis catheters are covered by these guidelines. The panel identified 39 key topics that were formulated in accordance with the PICO format. The strength of the recommendations and quality of the evidence were graded in accordance with ESCMID guidelines. Recommendations are made for the diagnosis of CRBSI with and without catheter removal and of tunnel infection. The document establishes the clinical situations in which a conservative diagnosis of CRBSI (diagnosis without catheter removal) is feasible. Recommendations are also made regarding empirical therapy, pathogen-specific treatment (coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus spp., Gram-negative bacilli, and Candida spp.), antibiotic lock therapy, diagnosis and management of suppurative thrombophlebitis and local complications.

Antibiotic resistance profile in eye infections in a reference centre in Floridablanca, Colombia

BACKGROUND AND OBJECTIVE

In view of the increasing bacterial resistance to antibiotics, it is necessary to determine it locally in order to serve as a guide in clinical management. The purpose of this study was to characterise the pattern of antibiotic sensitivity in cases of eye infections in a third level ophthalmological institution in Floridablanca (Colombia).

MATERIALS AND METHODS

An observational cross-sectional study in which an analysis was made of the culture and antibiogram reports of specimens taken from cases of conjunctivitis, infectious keratitis, and endophthalmitis between January 2013 and June 2016.

RESULTS

A total of 833 specimens were positive for bacteria. Considering both gram-positive and gram-negative microorganisms gentamicin, tobramycin, and ciprofloxacin showed high resistance rates (64.4%, 40.3%, and 29.1%, respectively). Moxifloxacin, vancomycin, imipenem, and gatifloxacin showed low percentages of resistance: 2.6%, 2.1%, 0.6%, and 0.4%, respectively. When comparing the results with previous studies in our institution, there was a decrease in sensitivity to the fourth-generation quinolones and imipenem, especially within the gram-negative ones.

CONCLUSION

Fourth generation quinolones, imipenem and vancomycin continue to have a low in vitro resistance to bacteria that cause eye infections. However, there was a tendency to an increase in the resistance of gram-negative bacteria. Measures should be taken to try to control this phenomenon, and consider possible antimicrobial therapy alternatives to infections caused by these microorganisms.

Assessment of Quality Indicators for Appropriate Antibiotic Use

One of the critical elements of antimicrobial stewardship programs is the ability to measure the quality of antibiotic prescriptions. The aims of the present study were to evaluate the performance properties of a set of previously developed quality indicators (QIs) and to identify the potential room for improvement in antibiotic use in our setting. A monthly cross-sectional point prevalence survey was conducted in a 400-bed acute care teaching hospital, from June to November 2015. All adult patients treated for ≥24 hours with antibiotic therapy for a suspected hospital- or community-acquired bacterial infection were included. Performance scores (adherence, room for improvement, interobserver reliability, and applicability) were calculated for 8 QIs. A total of 362 patients were evaluated. Adherence to the whole set of QIs was accomplished for 14.1% of evaluable patients. The QIs with greater room for improvement were adequate request for blood cultures (60.6%), therapeutic drug monitoring (TDM) (59.1%), sequential antibiotic therapy within 72 hours (48.2%), and empirical antibiotic therapy according to local guidelines (30.4%). The percentage of patients receiving unnecessary antibiotic treatment in the absence of clinical or microbiological evidence of infection after 5 days was 12.2%. All indicators scored kappa values of ≥0.6, suggesting good interobserver reliability. Low applicability (6.1% of reviewed patients) was found only for the TDM QI. The QIs analyzed were found to be applicable, showed good interobserver reliability, and were useful tools to identify areas with potential room for improvement in antibiotic use.

Antibiotic prophylaxis habits in dental implant surgery among dentists in Spain. A cross-sectional survey

BACKGROUND

The use of antibiotics to prevent dental implant failures and postoperative infections remains a controversial issue. The objectives of this study were to assess the current antibiotic prescribing patterns and antibiotic prescribing frequency of dentists in Biscay (Spain) in conjunction with routine dental implant surgery among healthy patients and to determine whether any consensus has been reached by such practitioners and last published evidence was being followed.

MATERIAL AND METHODS

Observational cross-sectional study: electronic survey. This study was reported according to the STROBE guidelines. This anonymous questionnaire contained open-ended and close-ended questions. An email was sent 26 October 2017 to all the registered members of the Biscay dentists' College (n=989). The collected data were analyzed using STATA® 14 software, and 95% confidence intervals (CI) were used to assess the frequency of prescription for each antibiotic regimen.

RESULTS

The survey was responded to by a total of 233 participants (response rate=23.56%). Overall, 210 participants finished the survey completely, and 23 surveys were answered partially. The questionnaire was responded to by 122 females (58.1%) and 88 males (41.9%). Of the participants, 88% (n=207) always routinely prescribed prophylactic antibiotics in conjunction with dental implant surgery (95% CI: 84.79-92.88%). Approximately 9% (n=22) prescribed antibiotics sometimes (95% CI: 5.68-13.19%), and only 4 dentists (1.72%) never prescribed antibiotics (95% CI: 0.04-3.38%). Overall, 179 of 233 respondents prescribed both pre- and postoperative antibiotics (78.85%, 95% CI: 72.96-83.97%), 13 prescribed antibiotics only preoperatively (5.73%, 95% CI: 3.08-9.59%), and 35 prescribed antibiotics exclusively after routine dental implant surgery (15.42%, 95% CI: 10.98-20.78%).

CONCLUSIONS

Most of the dentists working in Biscay routinely prescribe prophylactic antibiotics in conjunction with dental implant surgery among healthy patients. A large range of prophylactic regimens are prescribed and the most recently published evidence is not being followed.

Unsolicited consultation by infectious diseases specialist improves outcomes in patients with bloodstream infection: A prospective cohort study

INTRODUCTION

The objective of this study was to evaluate the impact of an intervention based on unsolicited consultations by an infectious diseases specialist (IDS) on the adequacy of antimicrobial treatment and mortality in patients with BSI.

METHODS

A prospective cohort study was performed in a 410-bed hospital. An intervention based on unsolicited consultation by an IDS for patients with BSI was performed only on days when an IDS was available. Outcomes were the percentage of days on optimal antimicrobial treatment (PDOAT) and mortality. Analyses were performed by linear regression and multivariate logistic regression.

RESULTS

Of 400 episodes of BSI included, 292 received the intervention. The median (interquartile range) PDOAT among those with and without the intervention was 93 (6-100) and 0 (0-53), respectively. The intervention was independently associated with a higher PDOAT (r = 0.5; p < 0.001) but not with mortality. The IDS recommendations were followed in full in 183 episodes, and not in 109. Mortality was 10.4% and 27.6%, respectively. Adherence to recommendations was associated with lower mortality (adjusted OR = 0.3; 95% CI: 0.1-0.5).

CONCLUSIONS

An intervention based on unsolicited IDS consultation for BSI episodes was associated with improved use of antibiotics and, when the recommendations were fully followed, with lower mortality.

Epidemiological aspects and prevalence study of nosocomial infections in a general hospital of specialties: retrospective analysis 2012-2017

Nosocomial infections (NIs) currently represent one of the main health problems for both professionals and health authorities. These continue to cause high mortality, which has led to its study and the development of prevention measures to reduce the impact and minimise the incidence.

Objective

Analysis of the epidemiological aspects of NIs in a tertiary hospital.

Materials and methods

A5-year retrospective study in which NIs verified at admission, their prevalence, associated risk factors and their location were analysed and classified. The data were collected through cross sections for hospitalisation episodes, using standardised forms for them issued by the Spanish Society of Preventive Medicine and Public Health.

Results

2905 episodes of hospitalised patients were analysed, where 52.94% were men. The NI acquired in the centre was the most prevalent of all registered, having registered in the last year 53 cases. The infections acquired in the study income remained stable throughout the study, although there was a slight decrease in the last two years.

Conclusions

The multidisciplinary nature of the NIs allows to improve their approach, reducing the harmful effects on health.

[Appropriateness of antimicrobial prescriptions in the emergency department of a tertiary hospital]

OBJECTIVE

Antibiotics are widely prescribed in the Emergency Department (ED), representing 26-62% of outpatient antibiotic prescriptions. Around 40% of antibiotic prescriptions in hospitalized patients are inappropriate or unnecessary. The aim of the study was to assess the appropriateness of antibiotic prescriptions according to local empirical antibiotic treatment guidelines, in the ED of a tertiary hospital.

METHODS

Observational, retrospective study including patients attending the ED in November 2016, with an antibiotic prescription, excluding those from residents.

RESULTS

A total of 676 patients were included, 57.1% women, mean age 47.4 ± 21.2 years. Patient's diagnoses were 27.2% urinary tract infections (UTI), 24.1% lower respiratory tract infections, 15.4% skin and soft tissue infections (SSTI), 13.8% upper respiratory tract infections, 11.8% oral infections, 2.7% genital/sexually transmitted infections, 1.6% gastrointestinal infections, 0.3% ocular infections and 3.1% other. The most prescribed antibiotic families were: 44.1% penicillins, 21.3% fluoroquinolones. The most prescribed antibiotics were: fosfomycin trometamol in UTI (32.1%), levofloxacin in lower respiratory tract (46.2%) and amoxicillin/clavulanate in oral infections (71.6%), SSTI (62.5%) and upper respiratory tract (46.6%). In 56.8% (384) of the prescriptions antibiotics were indicated. An appropriated antibiotic was selected in 62% (238) of the prescriptions. Appropriated dosage and duration were selected in 82.8% (197) and 45.4% (108) of the prescriptions, respectively.

CONCLUSIONS

Appropriateness of antibiotic prescriptions was low, mainly due to an overuse of antibiotics when not indicated, broad spectrum and incorrect treatment duration. These data reinforce the need to enhance adherence to local empirical antibiotic treatment guidelines by developing an antimicrobial stewardship program in the ED.

Developing core elements and checklist items for global hospital antimicrobial stewardship programmes: a consensus approach

OBJECTIVES

With increasing global interest in hospital antimicrobial stewardship (AMS) programmes, there is a strong demand for core elements of AMS to be clearly defined on the basis of principles of effectiveness and affordability. To date, efforts to identify such core elements have been limited to Europe, Australia, and North America. The aim of this study was to develop a set of core elements and their related checklist items for AMS programmes that should be present in all hospitals worldwide, regardless of resource availability.

METHODS

A literature review was performed by searching Medline and relevant websites to retrieve a list of core elements and items that could have global relevance. These core elements and items were evaluated by an international group of AMS experts using a structured modified Delphi consensus procedure, using two-phased online in-depth questionnaires.

RESULTS

The literature review identified seven core elements and their related 29 checklist items from 48 references. Fifteen experts from 13 countries in six continents participated in the consensus procedure. Ultimately, all seven core elements were retained, as well as 28 of the initial checklist items plus one that was newly suggested, all with ≥80% agreement; 20 elements and items were rephrased.

CONCLUSIONS

This consensus on core elements for hospital AMS programmes is relevant to both high- and low-to-middle-income countries and could facilitate the development of national AMS stewardship guidelines and adoption by healthcare settings worldwide.

A Before-and-After Study of the Effectiveness of an Antimicrobial Stewardship Program in Critical Care

We evaluated the use of antimicrobials expressed as defined daily doses (DDDs) per 1,000 patient days and days of therapy (DOT) per 100 occupied bed-days in a intensive care unit (ICU) of a general hospital in Barcelona, Spain, before and after implementation of an antimicrobial stewardship (AMS) program (2007 to 2010 versus 2011 to 2015). The quarterly costs of antimicrobials used in the ICU and its weight in the overall hospital costs of antimicrobials were calculated. The effect of the applied AMS program on DDDs and DOT time series data was analyzed by means of intervention time series analysis. A total of 5,002 patients were included (1,971 for the first [before] period and 3,031 for the second [after] period). The percentage of patients treated with one or more antimicrobials decreased from 88.6 to 77.2% (P < 0.001). DDDs decreased from 246.8 to 192.3 (mean difference, -54.5; P = 0.001) and DOT from 66.7 to 54.6 (mean difference, -12.1; P = 0.066). The mean cost per trimester decreased from €115,543 to €73,477 (mean difference, -42,065.4 euros; P < 0.001), and the percentage of ICU antimicrobials cost with respect to the total cost of hospital antimicrobials decreased from 28.5 to 22.8% (mean difference, -5.59; P = 0.023). Implementation of an AMS program in the ICU was associated with a marked reduction in the use of antimicrobials, with cost savings close to one million euros since its implementation. An AMS program can have a significant impact on optimizing antimicrobial use in critical care practice.

Antibiotic stewardship: a European perspective

Antibiotic stewardship programmes, which are a set of interventions aiming at prescribing antibiotics appropriately and responsibly, are one of the key strategies to tackle the current worldwide bacterial resistance crisis. We will present here some examples of international and national initiatives, with a focus on Europe, discuss the role of clinical microbiologists, and present some perspectives and future developments.

[Perception of surgeons on the use of antimicrobial stewardships programs]

INTRODUCTION

The misuse and overuse of antimicrobials can contribute to an increase in antimicrobial resistance, increasing the risk of infections caused by drug-resistant bacteria. Most common surgical pathologies are infectious (either primary or as a complication), often being over-treated. Exploring the perception of surgeons on the use of implementing Antimicrobial stewardship programs (ASPs) is relevant in order to adapt the program to local context.

OBJECTIVE

To determine the perception of surgeons on the management of infections and antibiotic (AB) prescription in a General Surgery Department (GSD).

METHODS

A cross-sectional and descriptive study was conducted using an anonymous questionnaire that was distributed to assess the aspects related to AB management.

RESULTS

A total of 42 questionnaires were completed, with a 65% response rate. The large majority (75%) considered that antimicrobial resistance was an important problem. The main situations considered with medium/high margin of improvement were: time from taking the specimen to receiving the results (70%), use of a wide spectrum AB, and excessive duration (88% and 89%), dose adjustment according to renal function (81%), unnecessary prolongation of intravenous AB treatment (87%) and excessive duration of it (89%), preference for intravenous AB administration until discharge of the patient (73%). There were also difficulties in ASP implementation, as well as established and solid AB patterns (84%) and the heterogeneity of the GSD (84%).

CONCLUSIONS

Organisational aspects of the GSD constitute one of the problems to implement the ASPs. A specific multidisciplinary team has been constituted to address different training aspects. This will also serve as a forum of discussion of certain complex patients with difficulties in antibiotic management.

Antimicrobial stewardship programme in critical care medicine: A prospective interventional study

OBJECTIVE

Hospital antimicrobial stewardship programmes have achieved savings and a more rational use of antimicrobial treatments in general wards. The purpose of this report is to evaluate the experience of an antimicrobial stewardship programme in an intensive care unit (ICU).

DESIGN

Prospective interventional, before-and-after study.

SCOPE

24-bed medical ICU in a tertiary hospital.

INTERVENTION

Prospective audit and feedback antimicrobial stewardship programme.

ENDPOINTS

Antimicrobial consumption, antimicrobial related costs, multi-drug resistant microorganisms (MDRM) prevalence, nosocomial infections incidence, ICU length of stay, and ICU mortality rates were compared before and after one-year intervention.

RESULTS

A total of 218 antimicrobial episodes of 182 patients were evaluated in 61 team meetings. Antimicrobial stewardship suggestions were accepted in 91.5% of the cases. Total antimicrobial DDD/100 patient-days consumption was reduced from 380.6 to 295.2 (-22.4%; p=0.037). Antimicrobial stewardship programme was associated with a significant decrease in the prescription of penicillins plus b-lactamase inhibitors, linezolid, cephalosporins, and aminoglycosides. Overall antimicrobial spending was reduced by €119,636. MDRM isolation and nosocomial infections per 100 patient-days did not change after the intervention period. No changes in length of stay or mortality rate were observed.

CONCLUSIONS

An ICU antimicrobial stewardship programme significantly reduced antimicrobial use without affecting inpatient mortality and length of stay. Our results further support the implementation of an antimicrobial stewardship programme in critical care units.

EPICO 4.0. 'Total quality' in the management of invasive candidiasis in critically ill patients by analysing the integrated process

BACKGROUND

A high quality integrated process in the clinical setting of non-neutropenic critically ill patients at risk for invasive candidiasis is a necessary tool to improve the management of these patients.

AIMS

To identify the key points on invasive candidiasis in order to develop a set of recommendations with a high level of consensus required for the creation of a total quality integrated process for the management of non-neutropenic critically ill patients at risk of invasive candidiasis.

METHODS

After a thorough review of the literature of the previous five years, a Spanish prospective questionnaire, which measured consensus by the Delphi technique, was anonymously conducted by e-mail, including 31 national multidisciplinary experts with extensive experience in invasive fungal infections, from six national scientific societies. The experts included a specialist in intensive care medicine, anesthetists, microbiologists, pharmacologists, and specialists in infectious diseases that responded 27 questions prepared by the coordination group. The educational objectives considered six processes that included knowledge of the local epidemiology, the creation and development of multidisciplinary teams, the definitions of the process, protocols, and indicators (KPI), an educational phase, hospital implementation, and the measurement of outcomes. The level of agreement among experts in each category to be selected should exceed 70%. In a second phase, after drawing up the recommendations of the selected processes, a face to face meeting with more than 60 specialists was held. The specialists were asked to validate the pre-selected recommendations.

MEASURES AND MAIN OUTCOMES

Firstly, 20 recommendations from all the sections were pre-selected: Knowledge of local epidemiology (3 recommendations), creation and development of multidisciplinary teams (3), definition of the process, protocols and indicators (1), educational phase (3), hospital implementation (3), and measurement of outcomes (7). After the second phase, 18 recommendations were validated, and it was concluded that the minimum team or core necessary for the development of an efficient program in the use of antifungal drugs in non-neutropenic critically ill patients must consist of a specialist in infectious diseases, a clinical pharmacist, a microbiologist, a specialist in intensive care medicine, a specialist in anesthesia and recovery, and an administrator or member of the medical management team, and, in order to be cost-effective, it should be implemented in hospitals with over 200 beds. In addition, it is recommended to apply a consensual check list for the evaluation of the diagnostic process and treatment of invasive candidiasis in patients that have started an antifungal treatment. The management of external knowledge and individual learning stand out as active educational strategies. The main strategies for measuring patient safety outcomes are the analysis of the results achieved, and learning activities; assess, review and refine the deployment of the processes; quality control; epidemiological surveillance and applied research; benchmarking; and basic research. The results of the integrated process should be annually disseminated outside the hospital.

CONCLUSIONS

Optimizing the management of invasive candidiasis requires the application of the knowledge and skills detailed in our recommendations. These recommendations, based on the Delphi methodology, facilitate the creation of a total quality integrated process in critically-ill patients at risk for invasive candidiasis.

Targeted simplification versus antipseudomonal broad-spectrum beta-lactams in patients with bloodstream infections due to Enterobacteriaceae (SIMPLIFY): a study protocol for a multicentre, open-label, phase III randomised, controlled, non-inferiority clinical trial

INTRODUCTION

Within the context of antimicrobial stewardship programmes, de-escalation of antimicrobial therapy is one of the proposed strategies for reducing the unnecessary use of broad-spectrum antibiotics (BSA). The empirical treatment of nosocomial and some healthcare-associated bloodstream infections (BSI) frequently includes a beta-lactam with antipseudomonal activity as monotherapy or in combination with other drugs, so there is a great opportunity to optimise the empirical therapy based on microbiological data. De-escalation is assumed as standard of care for experts in infectious diseases. However, it is less frequent than it would desirable.

METHODS AND ANALYSIS

The SIMPLIFY trial is a multicentre, open-label, non-inferiority phase III randomised controlled clinical trial, designed as a pragmatic 'real-practice' trial. The aim of this trial is to demonstrate the non-inferiority of de-escalation from an empirical beta-lactam with antipseudomonal activity to a targeted narrow-spectrum antimicrobial in patients with BSI due to Enterobacteriaceae. The primary outcome is clinical cure, which will be assessed at the test of cure visit. It will be conducted at 19 Spanish public and university hospitals.

ETHICS AND DISSEMINATION

Each participating centre has obtained the approval of the ethics review committee, the agreement of the directors of the institutions and authorisation from the Spanish Regulatory Agency (Agencia Española del Medicamento y Productos Sanitarios). Data will be presented at international conferences and published in peer-reviewed journals.

DISCUSSION

Strategies to reduce the use of BSA should be a priority. Most of the studies that support de-escalation are observational, retrospective and heterogeneous. A recent Cochrane review stated that well-designed clinical trials should be conducted to assess the safety and efficacy of de-escalation.

TRIAL REGISTRATION NUMBER

The European Union Clinical Trials Register: EudraCT number 2015-004219-19. Clinical trials.gov: NCT02795949. Protocol version: V.2.0, dated 16 May 2016. All items from the WHO Trial Registration Data Set are included in the registry.

Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients

The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.

Effect of the inadequacy of antibiotic therapy in the Emergency Department on hospital stays

INTRODUCTION

The main objective of the study was to determine the frequency of patients receiving inappropriate empiric antibiotic therapy and to assess the impact in terms of increase length of hospital stay, 30-day re-admissions, and 30-day mortality.

METHODS

An observational retrospective cohort study was conducted over a one-month period that included all patients hospitalised from an Emergency Department (ED) due to infection. Demographic variables, comorbidity, multi-resistance risk factors, site of infection, microbiological findings, and antibiotic prescribed in ED were collected. Outcomes were length of hospital stay, 30-day re-admissions, and 30-day mortality.

RESULTS

A total of 376 patients were included, with a mean age of 71.1 (SD 21) years. The most frequent causes were respiratory (45.7%) and urine (23.9%) infections. The number of patients with length of stay over the median (≥9 days) was 165 (46.1%), with re-admissions 74 (19.7%), and mortality at 30 days 44 (11.7%). There was inappropriate antibiotic treatment in 42 (11.2%) cases. After adjusting for demographic data, comorbidity, risk factors for multidrug resistant organism, presence of sepsis criteria in ED, and site of infection, inappropriate treatment was associated with an extended length of hospital stay (OR 2.22; 95% CI; 1.07-4.60; P=.032), but did not to an increase in mortality (P=.271) or re-admission (P=.784) at 30 days.

CONCLUSION

The inappropriate empirical antibiotic therapy in patients admitted from the ED leads to an extended hospital stay, but did not increase mortality or readmission.

Opportunities to improve antimicrobial use in paediatric intensive care units: a nationwide survey in Spain

Improving antimicrobial use is a complex process that requires an accurate assessment of ongoing problems and barriers. Paediatric intensive care units (PICU) have seldom been assessed from this perspective. Two Internet-based, self-administered surveys were conducted nationwide in Spain between January and February 2014. The first survey aimed to assess those characteristics of Spanish PICUs that could influence antimicrobial prescribing or antimicrobial stewardship. The second survey targeted Spanish PICU physicians and pursued to assess their attitudes and perceptions regarding antimicrobial resistance and antimicrobial use. Information about 29/39 contacted PICUs was obtained. A total of 114/206 (55.3%) paediatric intensivists responded. PICUs were heterogeneous regarding years since foundation, number of beds, type of patients admitted and staffing. Only 11 (37.9%) PICUs had available e-prescribing systems. Procalcitonin was available in 24 (89.1%) PICUs, but there were no procalcitonin-based protocols in 14 (60.9%) of them. Half of surveyed PICUs had implemented antimicrobial stewardship activities. Ninety-eight of the 114 PICU physicians (86%) who participated considered that antimicrobial resistance was a significantly relevant problem for their daily and that improving antimicrobial use in their PICU should be a priority (103; 90.4%). The main perceived problems regarding antimicrobial use were the excessive use of antimicrobials in patients with nonconfirmed infections and excessive use of broad-spectrum antimicrobials. The most valued antimicrobial stewardship interventions were the implementation of protocols to guide antimicrobial therapy. Spanish PICU doctors are aware of the relevance of the problem of antimicrobial resistance and the need to improve antimicrobial use. Targeted interventions should take into account their difficulties and preferences when feasible.

Clinical and economic impact of urinary tract infections caused by ESBL-producing Escherichia coli requiring hospitalization: A matched cohort study

OBJECTIVE

To analyze the clinical and economic impact of urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli requiring hospitalization.

METHODS

Matched cohort study including adults with UTI caused by ESBL-producing E. coli admitted to a tertiary care hospital in Barcelona, Spain, between August 2010 and July 2013. Demographic, clinical and economic data were analyzed.

RESULTS

One hundred and twenty episodes of UTI were studied: 60 due to ESBL-producing E. coli and 60 due to non-ESBL-producing E. coli. Bivariate analysis showed that prior antimicrobial treatment (p = 0.007) and ESBL production (p < 0.001) were related to clinical failure during the first 7 days. Multivariate analysis selected ESBL as the sole risk factor for clinical failure (p = 0.002). Regarding the economic impact of infections caused by ESBL-producing E. coli, an ESBL-producing infection cost more than a non-ESBL-producing E. coli infection (mean €4980 vs. €2612). Looking at hospital expenses separately, the total pharmacy costs and antibiotic costs of ESBL infections were considerably higher than for non-ESBL infections (p < 0.001), as was the need for outpatient parenteral antibiotic therapy (OPAT) and its related costs. Multivariate analysis performed for the higher costs of UTI episodes found statistically significant differences for males (p = 0.004), chronic renal failure (p = 0.025), ESBL production (p = 0.008) and OPAT (p = 0.009).

CONCLUSION

UTIs caused by EBSL-producing E. coli requiring hospital admission are associated with worse clinical and economic outcomes.

How to measure and monitor antimicrobial consumption and resistance

Collateral damage caused by antibiotic use includes resistance, which could be reduced if the global inappropriate use of antibiotics, especially in low-income countries, could be prevented. Surveillance of antimicrobial consumption can identify and target practice areas for quality improvement, both in the community and in healthcare institutions. The defined daily dose, the usual adult dose of an antimicrobial for treating one patient for one day, has been considered useful for measuring antimicrobial prescribing trends within a hospital. Various denominators from hospital activity including beds, admissions and discharges have been used to obtain some standard ratios for comparing antibiotic consumption between hospitals and countries. Laboratory information systems in Clinical Microbiology Services are the primary resource for preparing cumulative reports on susceptibility testing results. This information is useful for planning empirical treatment and for adopting infection control measures. Among the supranational initiatives on resistance surveillance, the EARS-Net provides information about trends on antimicrobial resistance in Europe. Resistance is the consequence of the selective pressure of antibiotics, although in some cases these agents also promote resistance by favouring the emergence of mutations that are subsequently selected. Multiple studies have shown a relationship between antimicrobial use and emergence or resistance. While in some cases a decrease in antibiotic use was associated with a reduction in resistance rates, in many other situations this has not been the case, due to co-resistance and/or the low biological cost of the resistance mechanisms involved. New antimicrobial agents are urgently needed, which coupled with infection control measures will help to control the current problem of antimicrobial resistance.

Implementation of a computerized decision support system to improve the appropriateness of antibiotic therapy using local microbiologic data

A prospective quasi-experimental study was undertaken in 218 patients with suspicion of nosocomial infection hospitalized in a polyvalent ICU where a new electronic device (GERB) has been designed for antibiotic prescriptions. Two GERB-based applications were developed to provide local resistance maps (LRMs) and preliminary microbiological reports with therapeutic recommendation (PMRTRs). Both applications used the data in the Laboratory Information System of the Microbiology Department to report on the optimal empiric therapeutic option, based on the most likely susceptibility profile of the microorganisms potentially responsible for infection in patients and taking into account the local epidemiology of the hospital department/unit. LRMs were used for antibiotic prescription in 20.2% of the patients and PMRTRs in 78.2%, and active antibiotics against the finally identified bacteria were prescribed in 80.0% of the former group and 82.4% of the latter. When neither LMRs nor PMRTRs were considered for empiric treatment prescription, only around 40% of the antibiotics prescribed were active. Hence, the percentage appropriateness of the empiric antibiotic treatments was significantly higher when LRM or PMRTR guidelines were followed rather than other criteria. LRMs and PMRTRs applications are dynamic, highly accessible, and readily interpreted instruments that contribute to the appropriateness of empiric antibiotic treatments.

[Self-assessment of patterns of antibiotic use in a university hospital]

INTRODUCTION

A questionnaire was used to determine the knowledge, attitudes and practices of antibiotic prescribing among doctors at a university hospital.

METHODS

An anonymous questionnaire was directly distributed by a staff member of the Infectious Diseases Department.

RESULTS

A total of 316 questionnaires were distributed with 100% response rate; antibiotic dose, route of administration, and treatment duration were always adjusted according to site of infection and underlying conditions in 65, 68 and 45%, respectively. Antibiotic de-escalation was recognized as usual practice in 20%; 31 and 10% considered potential microbiological resistances and economical-cost when taking prescription decisions, respectively; 16% admitted often prescribing antibiotics with no clinical indication. There were no major significant differences between staff and training physicians, or between surgical or medical specialists.

CONCLUSIONS

The self-perception of physicians and residents in our hospital is that they make improper use of antimicrobials.

['Third day intervention': an analysis of the factors associated with following the recommendations on the prescribing of antibiotics]

INTRODUCTION

Stewardship programs on the use of antibiotics usually include interventions based on non-compulsory recommendations for the prescribers. Factors related to the adherence to expert recommendations, and the implementation of these programmes in daily practice, are of interest.

METHODS

A randomized, controlled, multicentre intervention study was performed in 32 hospitalization units. Antibiotic prescriptions were evaluated by an infectious disease specialist on the third day. We describe the implementation of the intervention, the factors associated with adherence to recommendations, and the impact of the intervention.

RESULTS

A total of 3,192 interventions were carried out. Information sources used to prepare the recommendations varied significantly between centres. A modification was recommended in 65% of cases: withdrawal (47%), change in administration route (26%), change of drugs or number of antibiotics (27%), and change in dose (5%). Simplification of treatment accounted for 75% of all recommendations. Adherence was 68%, with significant differences between hospitals, and higher when the recommendations consisted of a dose adjustment or change of route, during the first intervention period, and also when recommendations were personally commented on, in addition to writing a note in the clinical chart. We did not find any reduction in antibiotic consumption or variation in the incidence of resistant pathogens.

CONCLUSIONS

An important proportion of antibiotic prescriptions may be susceptible to improvement, most of them towards simplification. The adherence to the intervention was high, but significant variations at different centres were observed, depending on the type of recommendation, and the study period. Those recommendations that were personally commented on were more followed more than those only written.

[The threat of the carbapenemase-producing enterobacteriaceae in Spain: positioning report of the SEIMC study groups, GEIH and GEMARA]

The emergence and spread of carbapenemase-producing Enterobacteriaceae (CPE), as the current paradigm of extensive drug-resistance and multi-drug resistance to antibiotics, is a serious threat to patient health and public health. The increase in OXA-48- and VIM-1-producing Klebsiella pneumoniae isolates represents the greatest impact of CPE in Spain. This evidence has lead the members of a representative panel of the Spanish Study Groups of Nosocomial Infections and Mechanisms of Action and Resistance to Antimicrobials of the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIH/GEMARA-SEIMC) to make a position statement expressing the need for: (i) definitive and coordinated action by all health professionals and authorities involved, and (ii) an adaptation of health systems to facilitate their early control and minimize their impact.

[The antibiotic policy. The Infection Committee and antimicrobial use]

The antibiotic policy is the set of strategies and activities undertaken to organize the antimicrobial treatment in the hospital, and achieve health outcomes for patients. The basic principles are to be direct evidence-based medicine, local epidemiology and freedom for prescribing physicians. An antibiotic policy is now more necessary than ever for clinical, epidemiological and economic reasons. The Infection Committee is responsible for the antibiotics policy in hospitals. Its functions as an advisory body to the medical directorate are the analysis of the epidemiology of the infections in the center, measures for its prevention and control, improving the appropriate use of antimicrobials, training, and knowledge production. To achieve clinical, environmental and economic policy objectives of antibiotics is not easy. The agreement of hundreds of professionals for recommendations on indications, dosage and duration of antibiotic treatment, based on the best scientific evidence and local guides is complex, but it can be done. The key to this is that the Infection Committee develops antimicrobial stewardship through a multidisciplinary team and professional leadership, and has the institutional support to ensure that the proper use of antimicrobials is a priority for the center, and therefore of each of the services involved, and that the team has the resources for antimicrobial stewardship.

[Carbapenem antibiotics in hospitalised paediatric patients. Adherence to a therapeutic protocol]

OBJECTIVE

To describe the use of carbapenems in children hospitalised outside intensive care and onco-haematology units, and assess adherence to a therapeutic protocol.

PATIENTS AND METHODS

A retrospective observational study was conducted on the use of carbapenems between January 2009 and December 2010. The study included children with a community-acquired infectious disease or a health care-associated infectious disease, and who were admitted to paediatric areas of the Vall d'Hebron University Hospital (Barcelona, Spain), other than intensive care, neonatology and onco-haematology units. Clinical data were collected and antibiotic consumption data were provided by the Pharmacy Department.

RESULTS

A total of 51 episodes fulfilled the inclusion criteria. Carbapenem as initial empirical treatment was indicated in 31.4%, and applied as rescue therapy in the remainder. The instructions of the protocol were adhered to in 70.6% of the empirical and 87.5% of the targeted prescriptions (77.6% overall). A better match was found for empirical carbapenem in patients with a previous admission or underlying condition. Factors such as diagnosis, age or antibiotic use prior to admission did not affect the empirical indication of carbapenem.

CONCLUSIONS

The establishment of a treatment protocol with carbapenem indications in our centre since 2007 has yielded significantly better results on the appropriateness of the prescription than those obtained in other studies.

Patient safety certification in a Department of Intensive Care Medicine: our experience with standard UNE 179003:2013

Systematic and structured methods must be used to ensure that healthcare risks are effectively managed. Spanish standard UNE 179003:2013 provides healthcare organizations with a framework and a systematic protocol for managing patient safety from a clinical and organizational perspective. Furthermore, it is useful in securing an efficient balance among health risk, health outcomes and costs. The UNE 179003:2013 certifies that a clinical service complies with rules and operating procedures aimed at reducing the incidence of adverse events. It also requires mandatory continuous improvement, given that the standard entails frequent monitoring of the risk management system through periodic audits. The aims of this paper are to describe the UNE 179003:2013 certification process in an Intensive Care Unit, propose a risk management program for critical patients, and offer some recommendations regarding its implementation.