51
|
Albarillo FS, Labuszewski L, Lopez J, Santarossa M, Bhatia NK. Use of a Clinical Decision Support System (CDSS) to improve antimicrobial stewardship efforts at a single academic medical center. Germs 2019; 9:106-109. [PMID: 31341839 DOI: 10.18683/germs.2019.1165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/18/2022]
Affiliation(s)
- Fritzie S Albarillo
- MD, Division of Infectious Diseases, Loyola University Medical Center, 2160 S. 1st Ave., Maywood, IL 60153, USA
| | - Laurie Labuszewski
- PharmD, Division of Infectious Diseases, Loyola University Medical Center, 2160 S. 1st Ave., Maywood, IL 60153, USA
| | - Jenna Lopez
- PharmD, Division of Infectious Diseases, Loyola University Medical Center, 2160 S. 1st Ave., Maywood, IL 60153, USA
| | - Maressa Santarossa
- PharmD, Division of Infectious Diseases, Loyola University Medical Center, 2160 S. 1st Ave., Maywood, IL 60153, USA
| | - Nitin K Bhatia
- PharmD, Becton, Dickinson and Company (BD), Franklin Lakes, NJ 07417, USA
| |
Collapse
|
52
|
Wang F, Prier B, Bauer KA, Mellett J. Pharmacist-driven initiative for management of Staphylococcus aureus bacteremia using a clinical decision support system. Am J Health Syst Pharm 2019; 75:S35-S41. [PMID: 29802177 DOI: 10.2146/ajhp170087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The development and implementation of a clinical decision support system (CDSS) for pharmacists to use for identification of and intervention on patients with Staphylococcus aureus bacteremia (SAB) are described. SUMMARY A project team consisting of 3 informatics pharmacists and 2 infectious diseases (ID) pharmacists was formed to develop the CDSS. The primary CDSS component was a scoring system that generates a score in real time for a patient with a positive blood culture for S. aureus. In addition, 4 tools were configured in the CDSS to facilitate pharmacists' workflow and documentation tasks: a patient list, a patient list report, a handoff note, and a standardized progress note. Pharmacists are required to evaluate the patient list at least once per shift to identify newly listed patients with a blood culture positive for S. aureus and provide recommendations if necessary. The CDSS was implemented over a period of 2.5 months, with a pharmacy informatics resident dedicating approximately 200 hours in total. An audit showed that the standardized progress note was completed for 100% of the patients, with a mean time to completion of 8.5 hours. Importantly, this initiative can be implemented in hospitals without specialty-trained ID pharmacists. This study provides a framework for future antimicrobial stewardship program initiatives to incorporate pharmacists into the process of providing real-time recommendations. CONCLUSION A pharmacist-driven patient scoring system was successfully used to improve adherence to quality performance measures for management of SAB. A pharmacist-driven CDSS can be utilized to assist in the management of SAB.
Collapse
Affiliation(s)
- Fei Wang
- Wake Forest Baptist Medical Center, Winston-Salem, NC
| | - Beth Prier
- Ohio State University Wexner Medical Center, Columbus, OH
| | | | - John Mellett
- Ohio Sate University Wexner Medical Center, Columbus, OH
| |
Collapse
|
53
|
Baubie K, Shaughnessy C, Kostiuk L, Varsha Joseph M, Safdar N, Singh SK, Siraj D, Sethi A, Keating J. Evaluating antibiotic stewardship in a tertiary care hospital in Kerala, India: a qualitative interview study. BMJ Open 2019; 9:e026193. [PMID: 31092653 PMCID: PMC6530383 DOI: 10.1136/bmjopen-2018-026193] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To determine what barriers and facilitators to antibiotic stewardship exist within a healthcare facility. SETTING 1300-bed tertiary care private hospital located in the state of Kerala, India. PARTICIPANTS 31 semistructured interviews and 4 focus groups with hospital staff ranging from physicians, nurses, pharmacists and a clinical microbiologist. RESULTS Key facilitators of antibiotic stewardship (AS) at the hospital included a dedicated committee overseeing appropriate inpatient antibiotic use, a prompt microbiology laboratory, a high level of AS understanding among staff, established guidelines for empiric prescribing and an easily accessible antibiogram. We identified the following barriers: limited access to clinical pharmacists, physician immunity to change regarding stewardship policies, infrequent antibiotic de-escalation, high physician workload, an incomplete electronic medical record (EMR), inadequate AS programme (ASP) physical visibility and high antibiotic use in the community. CONCLUSIONS Opportunities for improvement at this institution include increasing accessibility to clinical pharmacists, implementing strategies to overcome physician immunity to change and establishing a more accessible and complete EMR. Our findings are likely to be of use to institutions developing ASPs in lower resource settings.
Collapse
Affiliation(s)
- Kelsey Baubie
- Infectious Disease, University of Wisconsin Madison, Madison, Wisconsin, USA
| | | | - Lia Kostiuk
- Infectious Disease, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Mariam Varsha Joseph
- Pharmacy, Amrita Institute of Medical Sciences and Research Centre, Cochin, India
| | - Nasia Safdar
- Infectious Disease, University of Wisconsin Madison, Madison, Wisconsin, USA
- Research, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
| | - Sanjeev K Singh
- Hospital Administration, Amrita Institute of Medical Sciences and Research Centre, Cochin, India
| | - Dawd Siraj
- Infectious Disease, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Ajay Sethi
- Population Health Sciences, University of Wisconsin Madison, Madison, Wisconsin, USA
| | - Julie Keating
- Research, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
| |
Collapse
|
54
|
The role of electronic health record and "add-on" clinical decision support systems to enhance antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2019; 40:501-511. [PMID: 31020944 DOI: 10.1017/ice.2019.51] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Increasingly, demands are placed on healthcare systems to meet antimicrobial stewardship standards and reporting requirements. This trend, combined with reduced financial and personnel resources, has created a need to adopt information technology (IT) to help ease these burdens and facilitate action. The incorporation of IT into an antimicrobial stewardship program can help improve stewardship intervention efficiencies and facilitate the tracking and reporting of key metrics, including outcomes. This paper provides a review of the stewardship-related functionality within these IT systems, describes how these platforms can be used to improve antimicrobial use, and identifies how they can support current and potential future antimicrobial stewardship regulatory and accreditation standards. Finally, recommendations to help close the gaps in existing systems are provided and suggestions for future areas of development within these programs are delineated.
Collapse
|
55
|
El-Lababidi RM, Mooty M, Bonilla MF, Nusair A, Alatoom A, Mohamed S. Implementation and outcomes of an advanced antimicrobial stewardship program at a quaternary care hospital in the United Arab Emirates. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Rania Mohammad El-Lababidi
- Pharmacy Education and Training, Department of Pharmacy Services; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
- Antimicrobial Stewardship Program; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| | - Mohammad Mooty
- Infectious Diseases; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| | | | - Ahmad Nusair
- Infectious Diseases; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| | - Adnan Alatoom
- Pathology and Laboratory Medicine Institute, Clinical Microbiology Section; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| | - Shafii Mohamed
- Infection Prevention and Control; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| |
Collapse
|
56
|
Alghamdi S, Atef-Shebl N, Aslanpour Z, Berrou I. Barriers to implementing antimicrobial stewardship programmes in three Saudi hospitals: Evidence from a qualitative study. J Glob Antimicrob Resist 2019; 18:284-290. [PMID: 30797087 PMCID: PMC7104169 DOI: 10.1016/j.jgar.2019.01.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 01/09/2019] [Accepted: 01/25/2019] [Indexed: 11/17/2022] Open
Abstract
Adoption of ASPs in Saudi hospitals remains low despite a national implementation strategy. Lack of enforcement of policies and guidelines is a main contributor to inappropriate antimicrobial prescribing. Barriers to ASP adoption in Saudi hospitals are mainly organisational. Physicians’ fears and concerns inhibit their adoption of antimicrobial stewardship practices.
Objectives This study explored antimicrobial stewardship programme (ASP) team members’ perspectives regarding factors influencing the adoption and implementation of these programmes in Saudi hospitals. Methods This was a qualitative study based on face-to-face semistructured interviews with healthcare professionals involved in ASPs and activities across three Ministry of Health (MoH) hospitals in Saudi Arabia (n = 18). Interviews were also conducted with two representatives of a General Directorate of Health Affairs in a Saudi region and two representatives of the Saudi MoH (n = 4) between January–February 2017. Results Despite the existence of a national strategy to implement ASPs in Saudi MoH hospitals, their adoption and implementation remains low. Hospitals have their own antimicrobial stewardship policies, but adherence to these is poor. ASP team members highlight that lack of enforcement of policies and guidelines from the MoH and hospital administration is a significant barrier to ASP adoption and implementation. Other barriers include disintegration of teams, poor communication, lack of recruitment/shortage of ASP team members, lack of education and training, and lack of health information technology (IT). Physicians’ fears and concerns in relation to liability are also a barrier to their adoption of ASPs. Conclusion This is the first qualitative study exploring barriers to ASP adoption and implementation in Saudi hospitals from the perspective of ASP team members. Formal endorsement of ASPs from the MoH as well as hospital enforcement of policies and provision of human and health IT resources would improve the adoption and implementation of ASPs in Saudi hospitals.
Collapse
Affiliation(s)
- Saleh Alghamdi
- Department of Clinical & Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK; Department of Clinical Pharmacy, Faculty of Clinical Pharmacy, Albaha University, Albaha, Saudi Arabia
| | - Nada Atef-Shebl
- Department of Clinical & Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Zoe Aslanpour
- Department of Clinical & Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Ilhem Berrou
- Faculty of Health & Applied Sciences, University of the West of England, Staple Hill, Bristol BS16 1DD, UK.
| |
Collapse
|
57
|
She RC, Bender JM. Advances in Rapid Molecular Blood Culture Diagnostics: Healthcare Impact, Laboratory Implications, and Multiplex Technologies. J Appl Lab Med 2018; 3:617-630. [PMID: 31639730 DOI: 10.1373/jalm.2018.027409] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 09/28/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND For far too long, the diagnosis of bloodstream infections has relied on time-consuming blood cultures coupled with traditional organism identification and susceptibility testing. Technologies to define the culprit in bloodstream infections have gained sophistication in recent years, notably by application of molecular methods. CONTENT In this review, we summarize the tests available to clinical laboratories for molecular rapid identification and resistance marker detection in blood culture bottles that have flagged positive. We explore the cost-benefit ratio of such assays, covering aspects that include performance characteristics, effect on patient care, and relevance to antibiotic stewardship initiatives. SUMMARY Rapid blood culture diagnostics represent an advance in the care of patients with bloodstream infections, particularly those infected with resistant organisms. These diagnostics are relatively easy to implement and appear to have a positive cost-benefit balance, particularly when fully incorporated into a hospital's antimicrobial stewardship program.
Collapse
Affiliation(s)
- Rosemary C She
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA;
| | - Jeffrey M Bender
- Division of Infectious Diseases of the Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| |
Collapse
|
58
|
Knowledge discovery and visualization in antimicrobial resistance surveillance systems: a scoping review. Artif Intell Rev 2018. [DOI: 10.1007/s10462-018-9659-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
59
|
Bouza E, Muñoz P, Burillo A. Role of the Clinical Microbiology Laboratory in Antimicrobial Stewardship. Med Clin North Am 2018; 102:883-898. [PMID: 30126578 DOI: 10.1016/j.mcna.2018.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
For adequate antimicrobial stewardship, microbiology needs to move from the laboratory to become physically and verbally amenable to the caregivers of an institution. Herein, we describe the contributions of our microbiology department to the antimicrobial stewardship program of a large teaching hospital as 10 main points ranging from the selection of patients deemed likely to benefit from a fast track approach, to their clinical samples, or the rapid reporting of results via a microbiology hotline, to rapid searches for pathogens and susceptibility testing. These points should serve as guidelines for similar programs designed to decrease the unnecessary use of antimicrobials.
Collapse
Affiliation(s)
- Emilio Bouza
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Plaza Ramón y Cajal s/n, Madrid 28040, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Doctor Esquerdo, 46, Madrid 28007, Spain; Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, Madrid 28007, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Doctor Esquerdo 46, Madrid 28007, Spain.
| | - Patricia Muñoz
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Plaza Ramón y Cajal s/n, Madrid 28040, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Doctor Esquerdo, 46, Madrid 28007, Spain; Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, Madrid 28007, Spain; CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0058), Doctor Esquerdo 46, Madrid 28007, Spain
| | - Almudena Burillo
- Medicine Department, School of Medicine, Universidad Complutense de Madrid (UCM), Plaza Ramón y Cajal s/n, Madrid 28040, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Doctor Esquerdo, 46, Madrid 28007, Spain; Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Doctor Esquerdo 46, Madrid 28007, Spain
| |
Collapse
|
60
|
Simões AS, Maia MR, Gregório J, Couto I, Asfeldt AM, Simonsen GS, Póvoa P, Viveiros M, Lapão LV. Participatory implementation of an antibiotic stewardship programme supported by an innovative surveillance and clinical decision-support system. J Hosp Infect 2018; 100:257-264. [PMID: 30071264 DOI: 10.1016/j.jhin.2018.07.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Antibiotic resistance will cause about 10 million deaths per year by 2050. Fighting antimicrobial resistance is a health priority. Interventions aimed to reduce antimicrobial resistance, such as antibiotic stewardship programmes (ASPs), must be implemented. To be effective, those interventions, and the implementation process, should be matched with social-cultural context. The complexity of ASPs can no longer be developed without considering both organizational and information systems. AIM To support ASPs through the co-design and implementation, in collaboration with healthcare workers, of a surveillance and clinical decision-support system to monitor antibiotic resistance and improve antibiotic prescription. METHODS The surveillance and clinical decision-support system was designed and implemented in three Portuguese hospitals, using a participatory approach between researchers and healthcare workers following the Design Science Research Methodology. FINDINGS Based on healthcare workers' requirements, we developed HAITooL, a real-time surveillance and clinical decision-support system that integrates visualizations of patient, microbiology, and pharmacy data, facilitating clinical decision. HAITooL monitors antibiotic usage and rates of antibiotic-resistant bacteria, allowing early identification of outbreaks. It is a clinical decision-support tool that integrates evidence-based algorithms to support proper antibiotic prescription. HAITooL was considered valuable to support monitoring of antibiotic resistant infections and an important tool for ASP sustainability. CONCLUSION ASP implementation can be leveraged through a surveillance and clinical decision-support system such as HAITooL that allows antibiotic resistance monitoring and supports antibiotic prescription, once it has been adapted to the context and specific needs of healthcare workers and hospitals.
Collapse
Affiliation(s)
- A S Simões
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - M R Maia
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - J Gregório
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - I Couto
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - A M Asfeldt
- University Hospital of North Norway and UiT - Arctic University of Norway, Tromsø, Norway
| | - G S Simonsen
- University Hospital of North Norway and UiT - Arctic University of Norway, Tromsø, Norway
| | - P Póvoa
- NOVA Medical School, CEDOC, Universidade Nova de Lisboa, Lisbon, Portugal; Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - M Viveiros
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - L V Lapão
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal.
| |
Collapse
|
61
|
Psychosocial determinants of physician acceptance toward an antimicrobial stewardship program and its computerized decision support system in an acute care tertiary hospital. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2018. [DOI: 10.1002/jac5.1028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
62
|
Widmer MA, Swanson RC, Zink BJ, Pines JM. Complex systems thinking in emergency medicine: A novel paradigm for a rapidly changing and interconnected health care landscape. J Eval Clin Pract 2018; 24:629-634. [PMID: 29280244 DOI: 10.1111/jep.12862] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 11/13/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The specialty of emergency medicine is experiencing the convergence of a number of transformational forces in the United States, including health care reform, technological advancements, and societal shifts. These bring both opportunity and uncertainty. 21ST CENTURY CHALLENGES: Persistent challenges such as the opioid epidemic, rising health care costs, misaligned incentives, patients with multiple chronic diseases, and emergency department crowding continue to plague the acute, unscheduled care system. REDUCTIONISM AND COMPLEX SYSTEMS THINKING The traditional approach to health care practice and improvement-reductionism-is not adequate for the complexity of the twenty-first century. Reductionist thinking will likely continue to produce unintended consequences and suboptimal outcomes. Complex systems thinking provides a perspective and set of tools better suited for the challenges and opportunities facing public health in general, and emergency medicine more specifically. IMPLICATIONS FOR EMERGENCY MEDICINE This article introduces complex systems thinking and argues for its application in the context of emergency medicine by drawing on the history of the circumstances surrounding the formation of the specialty and by providing examples of its application to several practice challenges.
Collapse
Affiliation(s)
- Matthew A Widmer
- Romney Institute of Public Management, Brigham Young University, Provo, UT, USA
| | - R Chad Swanson
- Arizona State University, School for the Science of Healthcare Delivery, Tempe, AZ, USA.,Department of Emergency Medicine, Intermountain Healthcare, Provo, UT, USA
| | - Brian J Zink
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Jesse M Pines
- Departments of Emergency Medicine and Health Policy and Management, and the Center for Healthcare Innovation and Policy Research, the George Washington University, Washington, DC, USA
| |
Collapse
|
63
|
Wenzler E, Wang F, Goff DA, Prier B, Mellett J, Mangino JE, Bauer KA. An Automated, Pharmacist-Driven Initiative Improves Quality of Care for Staphylococcus aureus Bacteremia. Clin Infect Dis 2018; 65:194-200. [PMID: 28379326 DOI: 10.1093/cid/cix315] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 03/31/2017] [Indexed: 01/07/2023] Open
Abstract
Background Infectious diseases (ID) consultation and antimicrobial stewardship intervention have been shown to improve the management of Staphylococcus aureus bacteremia (SAB). As the workload of antimicrobial stewardship programs (ASPs) continues to increase, ASPs must find a way to maximize the efficiency of the program while optimizing patient outcomes. The objective of this study was to evaluate the impact of incorporating health informatics into the management of SAB via a pharmacist-driven initiative. Methods Retrospective, single-center quasi-experimental study of hospitalized patients with SAB. During the intervention period, pharmacists were alerted to patients with SAB via a patient scoring tool integrated into the electronic medical record. Pharmacists utilized the scoring tool and the institution's evidence-based practice guideline to make standardized recommendations to promote adherence to SAB quality-of-care measures and encourage ID consultation. The primary outcome was overall compliance along with adherence to individual quality-of-care components. Secondary clinical outcomes were also analyzed. Results In sum, 84 patients were identified for study inclusion, 45 in the pre-intervention and 39 in the intervention group. As a whole, all 4 quality-of-care components for the management of SAB were significantly more frequently adhered to in the intervention group (68.9% vs 92.3%; P = .008). The incidence of ID consult improved significantly by almost 20% in the intervention group (75.6% vs 94.9%, P = .015). No statistically significant differences in duration of bacteremia, length-of-stay, infection-related length-of-stay, or readmission were observed between the groups. The incidence of all-cause mortality was 6-fold higher in the pre- intervention group compared to the intervention group (15.6% vs 2.6%, P = .063). Conclusion An automated, pharmacist-driven intervention for the management of patients with SAB demonstrated a significant improvement in patients receiving an ID consult, targeted antimicrobial therapy, and adherence to all SAB quality-of-care measures. As antimicrobial stewardship becomes a mandatory aspect of healthcare in all hospitals in the United States, ASPs will be forced to find ways to provide more efficient, impactful, disease state-based patient care. Our study provides the framework for and data to support this intervention in one of the most clinically important infectious diseases.
Collapse
Affiliation(s)
- Eric Wenzler
- College of Pharmacy, University of Illinois at Chicago
| | | | | | | | | | - Julie E Mangino
- Internal Medicine, Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus
| | | |
Collapse
|
64
|
|
65
|
Owens RC, Bulik CC, Andes DR. Pharmacokinetics-pharmacodynamics, computer decision support technologies, and antimicrobial stewardship: the compass and rudder. Diagn Microbiol Infect Dis 2018; 91:371-382. [PMID: 29776710 DOI: 10.1016/j.diagmicrobio.2018.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 03/21/2018] [Accepted: 03/26/2018] [Indexed: 12/19/2022]
Abstract
The first guidelines for conducting antimicrobial stewardship in the hospitalized setting were published in 2007. These guidelines recommend that stewardship programs employ the science of pharmacokinetics-pharmacodynamics (PK-PD) as well as adopting computerized decision support technologies when possible. The United States Food and Drug Administration have adopted PK-PD as a cornerstone in the evaluation of antimicrobial agents during clinical development. The core principles of PK-PD center around describing the relationship between drug exposure indexed to the susceptibility of the infecting bacterial pathogen and patient response. Using such relationships with population pharmacokinetic models and simulation, rational drug and dosing regimens can be selected. But because PK-PD modeling and simulation programs are generally absent in clinical practice, systematic application of this science is missing. Herein we explain advances in technology that allow clinicians to apply PK-PD to optimize the agents and dosing regimens selected for the treatment of hospitalized patients with infection.
Collapse
Affiliation(s)
- Robert C Owens
- Institute for Clinical Pharmacodynamics, Schenectady, New York.
| | | | - David R Andes
- University of Wisconsin, School of Medicine, Madison, Wisconsin
| |
Collapse
|
66
|
Giuliano CA, Binienda J, Kale-Pradhan PB, Fakih MG. "I Never Would Have Caught That Before": Pharmacist Perceptions of Using Clinical Decision Support for Antimicrobial Stewardship in the United States. QUALITATIVE HEALTH RESEARCH 2018; 28:745-755. [PMID: 29334865 DOI: 10.1177/1049732317750863] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
To systematically improve the appropriateness of antibiotic prescribing, antimicrobial stewardship programs have been developed. There is a paucity of literature examining how pharmacists perform antimicrobial stewardship using a clinical decision support system in a hospital setting. The purpose of this qualitative study was to develop a model exploring how pharmacists perform antimicrobial stewardship to identify areas for programmatic improvement. Semistructured interviews were conducted across a health care system until saturation of themes was reached. Pharmacists identified that self-efficacy and time were vital for antimicrobial stewardship to be performed, while culture of the hospital and attitude facilitated the process of stewardship. Antimicrobial stewardship programs using clinical decision support tools should ensure pharmacists have adequate time to address rules, provide easy-to-use resources and training to support self-efficacy, and engage influential physicians to support a culture of collaboration.
Collapse
Affiliation(s)
- Christopher A Giuliano
- 1 Wayne State University, Detroit, Michigan, USA
- 2 Ascension St. John Hospital, Detroit, Michigan, USA
| | | | - Pramodini B Kale-Pradhan
- 1 Wayne State University, Detroit, Michigan, USA
- 2 Ascension St. John Hospital, Detroit, Michigan, USA
| | - Mohamad G Fakih
- 1 Wayne State University, Detroit, Michigan, USA
- 2 Ascension St. John Hospital, Detroit, Michigan, USA
| |
Collapse
|
67
|
TELE-EXPERTISE SYSTEM BASED ON THE USE OF THE ELECTRONIC PATIENT RECORD TO SUPPORT REAL-TIME ANTIMICROBIAL USE. Int J Technol Assess Health Care 2018; 34:156-162. [PMID: 29490710 DOI: 10.1017/s0266462318000089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The aims of this study are (i) to present the design of a tele-expertise system, based on the telephone and electronic patient record (EPR), which supports the counseling of the infectious diseases specialist (IDS) for appropriate antimicrobial use, in a French University hospital; and (ii) to assess the diffusion of the system, the users' adherence, and their perceived utility. METHODS A prospective observational study was conducted to measure (i) the number and patterns of telephone calls for tele-expertise council, the number of initial and secondary assessments from the IDS and multidisciplinary meetings; (ii) the clinicians' adherence rate to therapeutic proposals by the IDS and the number of clinical situations for which the IDS decided to move to bedside; and (iii) the perceived utility of the system by the medical managers of the most demanding departments. RESULTS The review of patients' records for 1 year period indicates that 87 percent of the therapeutic recommendations were fully followed. The adherence was high, despite the IDS moving to the bedside only in 6 percent of cases. Medical managers of the most demanding departments considered the system to be useful. Moreover, 6,994 tele-expertise notifications have been recorded into the EPR for 48 months. CONCLUSIONS The tele-expertise system is an original way to design information technology supported antimicrobial stewardship intervention based on the remote access to relevant information by the IDS and on the traceability of the medical counseling for the clinicians.
Collapse
|
68
|
Gunn LR, Tunney R, Kelly K. Nonmodal Clinical Decision Support and Antimicrobial Restriction Effects on Rates of Fluoroquinolone Use in Uncomplicated Infections. Appl Clin Inform 2018; 9:149-155. [PMID: 29490408 DOI: 10.1055/s-0038-1626726] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Medication alert overrides remain persistently high over the past decade, influenced by factors such as "alert fatigue" and lack of provider acceptance. OBJECTIVE We compared the aggregate rate of fluoroquinolone (FQ) prescribing for the treatment of acute sinusitis, acute bronchitis, and uncomplicated urinary tract infections (UTIs) in adult inpatients prior to (historical control group) and after (prospective intervention group) implementation of a program requiring indication when ordering FQ antibiotics in combination with a nonmodal best-practice alert regarding the latest U.S. Food and Drug Administration (FDA) recommendations. We then compared rates of prescribing among provider type, severity of infection, and patient age. METHODS Qualified orders were defined as new FQ orders for acute sinusitis, acute bronchitis, and uncomplicated UTI for adult inpatients between July 2016 through September 2016 (control) or November 2016 through January 2017 (intervention). The primary endpoint was a provider-initiated FQ order for a target indication. Secondary endpoints included FQ orders by provider type and patient age. Rates of FQ use among the target indications were compared between groups by chi-square test of independence with Yates' correction in the analysis of the primary endpoint and Fisher's exact test for secondary endpoints. RESULTS FQ prescribing for acute bronchitis, and uncomplicated UTI occurred at a rate of 86/350 (24.6%) and 62/394 (15.7%) in the control and experimental groups, respectively (p = 0.0035). No patients receiving FQ qualified for a diagnosis of acute sinusitis. CONCLUSION A program combining FQ restriction in combination with nonmodal messaging may have decreased the rate of prescribing for acute bronchitis and uncomplicated UTI, although the contributions of each individual element could not be rigorously assessed.
Collapse
|
69
|
Antimicrobial Stewardship Program Implementation of a Quality Improvement Intervention Using Real-Time Feedback and an Electronic Order Set for the Management of Staphylococcus aureus Bacteremia. Infect Control Hosp Epidemiol 2018; 39:346-349. [DOI: 10.1017/ice.2017.325] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Antimicrobial stewardship programs can optimize the management of Staphylococcus aureus bacteremia by integrating information technology and microbiology laboratory resources. This study describes our experience implementing an intervention consisting of real-time feedback and the use of an electronic order set for the management of S. aureus bacteremia.Infect Control Hosp Epidemiol 2018;39:346–349
Collapse
|
70
|
Research Agenda for Antimicrobial Stewardship in the Veterans Health Administration. Infect Control Hosp Epidemiol 2018; 39:196-201. [PMID: 29417925 PMCID: PMC9793410 DOI: 10.1017/ice.2017.299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Antimicrobial stewardship is vital to reducing the spread of antimicrobial resistance. A group of investigators and clinicians within the Veterans Health Administration set forth a research agenda for antimicrobial stewardship, including research targets for inpatient and outpatient stewardship activities, metrics, and antimicrobial dosing and duration.
Collapse
|
71
|
Simões AS, Alves DA, Gregório J, Couto I, Dias S, Póvoa P, Viveiros M, Gonçalves L, Lapão LV. Fighting antibiotic resistance in Portuguese hospitals: Understanding antibiotic prescription behaviours to better design antibiotic stewardship programmes. J Glob Antimicrob Resist 2018; 13:226-230. [PMID: 29409949 DOI: 10.1016/j.jgar.2018.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/27/2017] [Accepted: 01/19/2018] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES Since physicians play an important role in antibiotic usage, it is vital to understand their antibiotic-prescribing behaviour and knowledge on antimicrobial resistance in order to develop and implement effective antibiotic stewardship interventions. The aim of this study was to evaluate Portuguese physicians' knowledge and to understand prescription behaviours, difficulties and barriers in their antibiotic prescription process in order to promote better and well-adapted antibiotic stewardship policies. METHODS This study was conducted in 2016 using a self-administered questionnaire to physicians in two tertiary public hospitals from two different regions in Portugal. RESULTS Participating physicians [response rate 47.6% (30/63)] identified antibiotic resistance as a global problem; however, one-third did not recognise antibiotic resistance as a major problem on their own hospital. Factors that most influenced antibiotic prescription were 'microbiology laboratory results', 'patient clinical situation' and patient 'co-morbidities'. On the other hand, 'colleagues' opinion' and 'costs control' were considered as less determining factors. Regarding difficulties and bottlenecks in the antibiotic prescription process, participant physicians reported 'lack of (or delayed) microbiological results' and 'no access to antibiotic susceptibility patterns' as major barriers. 'Education and training' was considered the most effective intervention to improve antibiotic prescription. CONCLUSION These results suggest that the design and implementation of antibiotic stewardship interventions should provide better data management and sharing tools between physicians and the microbiology laboratory, especially through the creation of antimicrobial prescribing guidelines according to hospital epidemiology, and easy access to hospital antibiotic susceptibility patterns and epidemiological data.
Collapse
Affiliation(s)
- Alexandra S Simões
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Rua da Junqueira no 100, 1349-008 Lisbon, Portugal.
| | - Daniela A Alves
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Rua da Junqueira no 100, 1349-008 Lisbon, Portugal
| | - João Gregório
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Rua da Junqueira no 100, 1349-008 Lisbon, Portugal
| | - Isabel Couto
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Rua da Junqueira no 100, 1349-008 Lisbon, Portugal
| | - Sónia Dias
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Rua da Junqueira no 100, 1349-008 Lisbon, Portugal
| | - Pedro Póvoa
- CEDOC, NOVA Medical School, UNL, Lisbon, Portugal; Unidade de Cuidados Intensivos Polivalente, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Miguel Viveiros
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Rua da Junqueira no 100, 1349-008 Lisbon, Portugal
| | - Luzia Gonçalves
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Rua da Junqueira no 100, 1349-008 Lisbon, Portugal; Centro de Estatística e Aplicações da Universidade de Lisboa, Lisbon, Portugal
| | - Luís V Lapão
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical (IHMT), Universidade Nova de Lisboa (UNL), Rua da Junqueira no 100, 1349-008 Lisbon, Portugal
| |
Collapse
|
72
|
Charani E, Gharbi M, Moore LSP, Castro-Sanchéz E, Lawson W, Gilchrist M, Holmes AH. Effect of adding a mobile health intervention to a multimodal antimicrobial stewardship programme across three teaching hospitals: an interrupted time series study. J Antimicrob Chemother 2017; 72:1825-1831. [PMID: 28333297 PMCID: PMC5437525 DOI: 10.1093/jac/dkx040] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 01/20/2017] [Indexed: 11/30/2022] Open
Abstract
Objectives: To evaluate the impact of adding a mobile health (mHealth) decision support system for antibiotic prescribing to an established antimicrobial stewardship programme (ASP). Methods: In August 2011, the antimicrobial prescribing policy was converted into a mobile application (app). A segmented regression analysis of interrupted time series was used to assess the impact of the app on prescribing indicators, using data (2008–14) from a biannual point prevalence survey of medical and surgical wards. There were six data points pre-implementation and six data points post-implementation. Results: There was an increase in compliance with policy (e.g. compliance with empirical therapy or expert advice) in the two specialties of medicine (6.48%, 95% CI = −1.25 to 14.20) and surgery (6.63%, 95% CI = 0.15–13.10) in the implementation period, with a significant sudden change in level in surgery (P < 0.05). There was an increase, though not significant, in medicine (15.20%, 95% CI = −17.81 to 48.22) and surgery (35.97%, 95% CI = −3.72 to 75.66) in the percentage of prescriptions that had a stop/review date documented. The documentation of indication decreased in both medicine (−16.25%, 95% CI = −42.52 to 10.01) and surgery (−14.62%, 95% CI = −42.88 to 13.63). Conclusions: Introducing the app into an existing ASP had a significant impact on the compliance with policy in surgery, and a positive, but not significant, effect on documentation of stop/review date in both specialties. The negative effect on the third indicator may reflect a high level of compliance pre-intervention, due to existing ASP efforts. The broader value of providing an antimicrobial policy on a digital platform, e.g. the reach and access to the policy, should be measured using indicators more sensitive to mHealth interventions.
Collapse
Affiliation(s)
- E Charani
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, Du Cane Road, London W12 0NN, UK
| | - M Gharbi
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, Du Cane Road, London W12 0NN, UK
| | - L S P Moore
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, Du Cane Road, London W12 0NN, UK
| | - E Castro-Sanchéz
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, Du Cane Road, London W12 0NN, UK
| | - W Lawson
- Imperial College Healthcare National Health Service Trust, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - M Gilchrist
- Imperial College Healthcare National Health Service Trust, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - A H Holmes
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London, Du Cane Road, London W12 0NN, UK
| |
Collapse
|
73
|
Joerger T, Chan S, Swami SK, Handy LK. Impact of an Antimicrobial Stewardship Policy to Restrict Palivizumab Use. J Pediatric Infect Dis Soc 2017; 8:189-190. [PMID: 29096027 PMCID: PMC6510943 DOI: 10.1093/jpids/pix091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Torsten Joerger
- Division of Infectious Diseases, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Shannon Chan
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Sanjeev K Swami
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia, Pennsylvania
| | - Lori K Handy
- Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia, Pennsylvania,Correspondence: L. K. Handy, MD, MSCE, Children’s Hospital of Philadelphia, Division of Infectious Diseases, Department of Pediatrics, 3401 Civic Center Blvd, Philadelphia, PA 19104 ()
| |
Collapse
|
74
|
Nault V, Pepin J, Beaudoin M, Perron J, Moutquin JM, Valiquette L. Sustained impact of a computer-assisted antimicrobial stewardship intervention on antimicrobial use and length of stay. J Antimicrob Chemother 2017; 72:933-940. [PMID: 27999034 DOI: 10.1093/jac/dkw468] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 10/04/2016] [Indexed: 01/08/2023] Open
Abstract
Objectives : Prospective audit and feedback interventions are the core components of an antimicrobial stewardship programme. Herein, we describe the sustained impact of an antimicrobial stewardship programme, based on a novel clinical decision-support system (Antimicrobial Prescription Surveillance System; APSS), on antimicrobial use and costs, hospital length of stay (LOS) in days and the proportion of inappropriate antimicrobial prescriptions. Methods A quasi-experimental, retrospective study was conducted using interrupted time series between 2008 and 2013. Data on all hospitalized adults receiving antimicrobials were extracted from the data warehouse of a 677 bed academic centre. The intervention started in August 2010. Prospective audit and feedback interventions, led by a pharmacist, were triggered by APSS based on deviations from published and local guidelines. Changes in outcomes before and after the intervention were compared using segmented regression analysis. Results APSS reviewed 40 605 hospitalizations for 35 778 patients who received antimicrobials. The intervention was associated with a decrease in the average LOS (level change -0.92, P < 0.01; trend -0.08, P < 0.01; intercept 11.4 days), antimicrobial consumption in DDDs/1000 inpatient days (level change -32.4, P < 0.01; trend -1.12, P < 0.02; intercept 243 DDDs per 1000 days of hospitalization), antimicrobial spending in Canadian dollars (level change -19 649, P = 0.01; trend -1881, P < 0.01; intercept $74 683) and proportion of non-concordance with local guidelines for prescribing antimicrobials (level change -2.3, P = 0.04; intercept 41%). Conclusions The implementation of the APSS-initiated strategy was associated with a positive impact on antimicrobial use and spending, LOS and inappropriate prescriptions. The high rate of accepted interventions may have contributed to these results.
Collapse
Affiliation(s)
- Vincent Nault
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, Québec J1H 5N4, Canada
| | - Jacques Pepin
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, Québec J1H 5N4, Canada
| | - Mathieu Beaudoin
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, Québec J1H 5N4, Canada
| | - Julie Perron
- Department of Pharmacy, Centre Intégré Universitaire de Santé et des Services Sociaux de l'Estrie - Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Jean-Marie Moutquin
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Louis Valiquette
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12ème Avenue Nord, Sherbrooke, Québec J1H 5N4, Canada
| |
Collapse
|
75
|
Yin H, Jha NK. A Health Decision Support System for Disease Diagnosis Based on Wearable Medical Sensors and Machine Learning Ensembles. ACTA ACUST UNITED AC 2017. [DOI: 10.1109/tmscs.2017.2710194] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
76
|
Dubrovskaya Y, Scipione MR, Siegfried J, Jen SP, Pham V, Papadopoulos J, Decano A, Lewis T, Dabestani A. Multilayer Model of Pharmacy Participation in the Antimicrobial Stewardship Program at a Large Academic Medical Center. Hosp Pharm 2017; 52:628-634. [PMID: 29276300 PMCID: PMC5735737 DOI: 10.1177/0018578717726993] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: Leveraging pharmacy personnel resources for the purpose of antimicrobial stewardship program (ASP) operations presents a challenging task. We describe our experience integrating all pharmacists into an ASP, and evaluate the impact on ASP interventions, antimicrobial utilization, rate of selected hospital-onset infections and readmission. Summary: During a study period (January 1 to December 31, 2015), a total of 14 552 ASP-related pharmacy interventions were performed (ASP clinical pharmacotherapy specialists [CPS] n = 4025; non-ASP CPS n = 4888; hospital pharmacists n = 5639). Sixty percent of interventions by ASP CPS were initiated utilizing the dedicated ASP phone, and 40% through prospective audit and feedback. Non-ASP CPS performed interventions during bedside rounds (dose adjustment 23%, initiate new or alternative anti-infective 21%, discontinue antibiotic(s) 12%, therapeutic drug monitoring 11%, de-escalation 4%), whereas hospital pharmacists participated at the point of verification (dose adjustment 75%, restricted antibiotic verification 15%, and reporting major drug-drug interactions 4%). The acceptance rate of interventions by providers and clinicians was >90% for all groups. Annual aggregate antimicrobial use decreased by 6.4 days of therapy/1000 patient-days (DOT/1000 PD; P = 1.0). Ceftriaxone use increased by 8.4 DOT/1000 PD (P = .029) without a significant compensatory increase in the use of antipseudomonal agents. Sustained low rates of hospital-onset Clostridium difficile (CDI) and carbapenem-resistant Enterobacteriaceae (CRE) infections were observed in 2015 compared with the prior year (1.1 and 1.2 cases/1000 PD, 0.2 and 0.1 cases/1000 PD, respectively). Thirty-day readmission rate decreased by 0.6% (P = .019). Conclusions: Integration of all pharmacists into ASP activities based on the level of patient care and responsibilities is an effective strategy to expand clinical services provided by ASP.
Collapse
Affiliation(s)
| | - Marco R. Scipione
- NYU Langone Health, New York, NY, USA
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Vinh Pham
- NYU Langone Health, New York, NY, USA
| | | | - Arnold Decano
- NYU Langone Health, New York, NY, USA
- NYU Langone Hospital–Brooklyn, NY, USA
| | | | | |
Collapse
|
77
|
Lambl BB, Kaufman N, Kurowski J, O’Neill W, Buckley Jr F, Duram M, Swartz B, Phillips D, Rein M, Rubin M. Does electronic stewardship work? J Am Med Inform Assoc 2017; 24:981-985. [PMID: 28371928 PMCID: PMC7651978 DOI: 10.1093/jamia/ocx024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 12/21/2016] [Accepted: 03/15/2017] [Indexed: 02/04/2023] Open
Abstract
Faced with national requirements to promote antimicrobial stewardship and reduce drug-resistant infections, community hospitals are challenged to make the best use of existing resources. Eighteen months after building antibiotic decision support into our electronic order platform, high-risk antibiotic use decreased by 83% (P < .001) at our community hospital. Hospital-acquired Clostridium difficile infections declined 24% (P = .07).
Collapse
Affiliation(s)
- Barbara B Lambl
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - Nathan Kaufman
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - Janice Kurowski
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - W O’Neill
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | | | - Maureen Duram
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - Barbara Swartz
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - Duncan Phillips
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - Mitchell Rein
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - Marc Rubin
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| |
Collapse
|
78
|
Ghamrawi RJ, Kantorovich A, Bauer SR, Pallotta AM, Sekeres JK, Gordon SM, Neuner EA. Evaluation of Antimicrobial Stewardship-Related Alerts Using a Clinical Decision Support System. Hosp Pharm 2017; 52:679-684. [PMID: 29276239 DOI: 10.1177/0018578717726869] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Information technology, including clinical decision support systems (CDSS), have an increasingly important and growing role in identifying opportunities for antimicrobial stewardship-related interventions. Objective: The aim of this study was to describe and compare types and outcomes of CDSS-built antimicrobial stewardship alerts. Methods: Fifteen alerts were evaluated in the initial antimicrobial stewardship program (ASP) review. Preimplementation, alerts were reviewed retrospectively. Postimplementation, alerts were reviewed in real-time. Data collection included total number of actionable alerts, recommendation acceptance rates, and time spent on each alert. Time to de-escalation to narrower spectrum agents was collected. Results: In total, 749 alerts were evaluated. Overall, 306 (41%) alerts were actionable (173 preimplementation, 133 postimplementation). Rates of actionable alerts were similar for custom-built and prebuilt alert types (39% [53 of 135] vs 41% [253 of 614], P = .68]. In the postimplementation group, an intervention was attempted in 97% of actionable alerts and 70% of interventions were accepted. The median time spent per alert was 7 minutes (interquartile range [IQR], 5-13 minutes; 15 [12-17] minutes for actionable alerts vs 6 [5-7] minutes for nonactionable alerts, P < .001). In cases where the antimicrobial was eventually de-escalated, the median time to de-escalation was 28.8 hours (95% confidence interval [CI], 10.0-69.1 hours) preimplementation vs 4.7 hours (95% CI, 2.4-22.1 hours) postimplementation, P < .001. Conclusions: CDSS have played an important role in ASPs to help identify opportunities to optimize antimicrobial use through prebuilt and custom-built alerts. As ASP roles continue to expand, focusing time on customizing institution specific alerts will be of vital importance to help redistribute time needed to manage other ASP tasks and opportunities.
Collapse
Affiliation(s)
- Riane J Ghamrawi
- University of Cincinnati- West Chester Hospital, OH, USA.,University of Cincinnati- Daniel Drake Center for Post-Acute Care, OH, USA
| | | | | | | | | | | | | |
Collapse
|
79
|
Outpatient antibiotic stewardship: Interventions and opportunities. J Am Pharm Assoc (2003) 2017; 57:464-473. [DOI: 10.1016/j.japh.2017.03.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 03/07/2017] [Accepted: 03/31/2017] [Indexed: 01/10/2023]
|
80
|
Jones W, Drake C, Mack D, Reeder B, Trautner B, Wald H. Developing Mobile Clinical Decision Support for Nursing Home Staff Assessment of Urinary Tract Infection using Goal-Directed Design. Appl Clin Inform 2017. [PMID: 28636060 DOI: 10.4338/aci-2016-12-ra-0209] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Unique characteristics of nursing homes (NHs) contribute to high rates of inappropriate antibiotic use for asymptomatic bacteriuria (ASB), a benign condition. A mobile clinical decision support system (CDSS) may support NH staff in differentiating urinary tract infections (UTI) from ASB and reducing antibiotic days. OBJECTIVES We used Goal-Directed Design to: 1) Characterize information needs for UTI identification and management in NHs; 2) Develop UTI Decide, a mobile CDSS prototype informed by personas and scenarios of use constructed from Aim 1 findings; 3) Evaluate the UTI Decide prototype with NH staff. METHODS Focus groups were conducted with providers and nurses in NHs in Denver, Colorado (n= 24). Qualitative descriptive analysis was applied to focus group transcripts to identify information needs and themes related to mobile clinical decision support for UTI identification and management. Personas representing typical end users were developed; typical clinical context scenarios were constructed using information needs as goals. Usability testing was performed using cognitive walk-throughs and a think-aloud protocol. RESULTS Four information needs were identified including guidance regarding resident assessment; communication with providers; care planning; and urine culture interpretation. Design of a web-based application incorporating a published decision support algorithm for evidence-based UTI diagnoses proceeded with a focus on nursing information needs during resident assessment and communication with providers. Certified nursing assistant (CNA) and registered nurse (RN) personas were constructed in 4 context scenarios with associated key path scenarios. After field testing, a high fidelity prototype of UTI Decide was completed and evaluated by potential end users. Design recommendations and content recommendations were elicited. CONCLUSIONS Goal-Directed Design informed the development of a mobile CDSS supporting participant-identified information needs for UTI assessment and communication in NHs. Future work will include iterative deployment and evaluation of UTI Decide in NHs to decrease inappropriate use of antibiotics for suspected UTI.
Collapse
Affiliation(s)
| | | | | | | | | | - Heidi Wald
- Heidi L Wald, MD, MSPH, Division of Health Care Policy Research, Box F 480, 13199 E. Montview Blvd, Suite 400, Aurora, CO 80045, Phone: 303-724-2446, E-mail:
| |
Collapse
|
81
|
Antimicrobial resistance in human populations: challenges and opportunities. GLOBAL HEALTH EPIDEMIOLOGY AND GENOMICS 2017; 2:e4. [PMID: 29276617 PMCID: PMC5732576 DOI: 10.1017/gheg.2017.4] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 01/05/2017] [Accepted: 03/30/2017] [Indexed: 12/24/2022]
Abstract
Antimicrobial resistance (AMR) is a global public health threat. Emergence of AMR occurs naturally, but can also be selected for by antimicrobial exposure in clinical and veterinary medicine. Despite growing worldwide attention to AMR, there are substantial limitations in our understanding of the burden, distribution and determinants of AMR at the population level. We highlight the importance of population-based approaches to assess the association between antimicrobial use and AMR in humans and animals. Such approaches are needed to improve our understanding of the development and spread of AMR in order to inform strategies for the prevention, detection and management of AMR, and to support the sustainable use of antimicrobials in healthcare.
Collapse
|
82
|
Saier MH, Trevors JT. Science, Innovation and the Future of Humanity. J Mol Microbiol Biotechnol 2017; 27:128-132. [PMID: 28448972 DOI: 10.1159/000467401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Milton H Saier
- Division of Biological Sciences, University of California at San Diego, La Jolla, CA, USA
| | | |
Collapse
|
83
|
Abstract
Antimicrobial stewardship is a bundle of integrated interventions employed to optimize the use of antimicrobials in health care settings. While infectious-disease-trained physicians, with clinical pharmacists, are considered the main leaders of antimicrobial stewardship programs, clinical microbiologists can play a key role in these programs. This review is intended to provide a comprehensive discussion of the different components of antimicrobial stewardship in which microbiology laboratories and clinical microbiologists can make significant contributions, including cumulative antimicrobial susceptibility reports, enhanced culture and susceptibility reports, guidance in the preanalytic phase, rapid diagnostic test availability, provider education, and alert and surveillance systems. In reviewing this material, we emphasize how the rapid, and especially the recent, evolution of clinical microbiology has reinforced the importance of clinical microbiologists' collaboration with antimicrobial stewardship programs.
Collapse
|
84
|
Hsieh L, Amin A. Antimicrobial Stewardship: The Role of Hospitalists and the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2016. [DOI: 10.1007/s40138-016-0112-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
85
|
Huber SR, Fullas F, Nelson KR, Ailts LB, Stratton JM, Padomek MT. Retrospective Evaluation of Pharmacist Interventions on Use of Antimicrobials Using a Clinical Surveillance Software in a Small Community Hospital. PHARMACY 2016; 4:E32. [PMID: 28970405 PMCID: PMC5419378 DOI: 10.3390/pharmacy4040032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/13/2016] [Accepted: 10/18/2016] [Indexed: 11/25/2022] Open
Abstract
The Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America "Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship" recommend the use of computer-based surveillance programs for efficient and thorough identification of potential interventions as part of an antimicrobial stewardship program (ASP). This retrospective study examined the benefit of utilizing a clinical surveillance software program to help guide antimicrobial therapy in an inpatient setting, in a small community hospital, without a formal ASP. The electronic health record (EHR) was used to retrieve documentations for the following types of antibiotic interventions: culture surveillance, duplicate therapy, duration of therapy and renal dose adjustments. The numbers of interventions made during the three-month periods before and after implementation of the clinical surveillance software were compared. Antibiotic related interventions aggregated to 144 and 270 in the pre- and post-implementation time frame, respectively (p < 0.0001). The total number of antibiotic interventions overall and interventions in three of the four sub-categories increased significantly from the pre-implementation to post-implementation period. Clinical surveillance software is a valuable tool to assist pharmacists in evaluating antimicrobial therapy.
Collapse
Affiliation(s)
- Samuel R Huber
- Sentara Princess Ann Hospital, 2025 Green Mitchell Drive, Virginia Beach, VA 23456, USA.
| | - Fekadu Fullas
- UnityPoint Health-St. Luke's, Pharmacy Department, 2720 Stone Park Boulevard, Sioux City, IA 51104, USA.
| | - Kristel R Nelson
- UnityPoint Health-St. Luke's, Pharmacy Department, 2720 Stone Park Boulevard, Sioux City, IA 51104, USA.
| | - Lesleigh B Ailts
- UnityPoint Health-St. Luke's, Pharmacy Department, 2720 Stone Park Boulevard, Sioux City, IA 51104, USA.
| | - James M Stratton
- UnityPoint Health-St. Luke's, Pharmacy Department, 2720 Stone Park Boulevard, Sioux City, IA 51104, USA.
| | - Michael T Padomek
- UnityPoint Health-St. Luke's, Pharmacy Department, 2720 Stone Park Boulevard, Sioux City, IA 51104, USA.
| |
Collapse
|
86
|
|
87
|
Banerjee R, Özenci V, Patel R. Individualized Approaches Are Needed for Optimized Blood Cultures. Clin Infect Dis 2016; 63:1332-1339. [PMID: 27558570 DOI: 10.1093/cid/ciw573] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 08/14/2016] [Indexed: 01/12/2023] Open
Abstract
Many strategies and technologies are available to improve blood culture (BC)-based diagnostics. The ideal approach to BCs varies between healthcare institutions. Institutions need to examine clinical needs and practices in order to optimize BC-based diagnostics for their site. Before laboratories consider offering rapid matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-ToF MS) or expensive rapid panel-based molecular BC diagnostics, they should optimize preanalytical, analytical, and postanalytical processes and procedures surrounding BC systems. Several factors need to be considered, including local resistance rates, antibiotic prescribing patterns, patient- and provider-types, laboratory staffing, and personnel available to liaise with clinicians to optimize antibiotic use. While there is much excitement surrounding new high-technology diagnostics, cost-neutral benefits can be realized by optimizing existing strategies and using available tools in creative ways. Rapid BC diagnostics should be implemented in a manner that optimizes impact. Strategies to optimize these BC diagnostics in individual laboratories are presented here.
Collapse
Affiliation(s)
- Ritu Banerjee
- Department of Pediatric Infections Diseases, Vanderbilt University, Nashville, Tennessee
| | - Volkan Özenci
- Division of Clinical Microbiology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology.,Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
88
|
Kim M, Song KH, Kim CJ, Song M, Choe PG, Park WB, Bang JH, Hwang H, Kim ES, Park SW, Kim NJ, Oh MD, Kim HB. Electronic Alerts with Automated Consultations Promote Appropriate Antimicrobial Prescriptions. PLoS One 2016; 11:e0160551. [PMID: 27532125 PMCID: PMC4988717 DOI: 10.1371/journal.pone.0160551] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 07/21/2016] [Indexed: 12/02/2022] Open
Abstract
Background To promote appropriate antimicrobial use in bloodstream infections (BSIs), we initiated an intervention program consisting of electronic alerts and automated infectious diseases consultations in which the identification and antimicrobial susceptibility test (ID/AST) results were reported. Methods We compared the appropriateness of antimicrobial prescriptions and clinical outcomes in BSIs before and after initiation of the program. Appropriateness was assessed in terms of effective therapy, optimal therapy, de-escalation therapy, and intravenous to oral switch therapy. Results There were 648 BSI episodes in the pre-program period and 678 in the program period. The proportion of effective, optimal, and de-escalation therapies assessed 24 hours after the reporting of the ID/AST results increased from 87.8% (95% confidence interval [CI] 85.5–90.5), 64.4% (95% CI 60.8–68.1), and 10.0% (95% CI 7.5–12.6) in the pre-program period, respectively, to 94.4% (95% CI 92.7–96.1), 81.4% (95% CI 78.4–84.3), and 18.6% (95% CI 15.3–21.9) in the program period, respectively. Kaplan-Meier analyses and log-rank tests revealed that the time to effective (p<0.001), optimal (p<0.001), and de-escalation (p = 0.017) therapies were significantly different in the two periods. Segmented linear regression analysis showed the increase in the proportion of effective (p = 0.015), optimal (p<0.001), and de-escalation (p = 0.010) therapies at 24 hours after reporting, immediately after program initiation. No significant baseline trends or changes in trends were identified. There were no significant differences in time to intravenous to oral switch therapy, length of stay, and 30-day mortality rate. Conclusion This novel form of stewardship program based on intervention by infectious disease specialists and information technology improved antimicrobial prescriptions in BSIs.
Collapse
Affiliation(s)
- Moonsuk Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- * E-mail:
| | - Chung-Jong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Minkyo Song
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Hwan Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee Hwang
- Center of Medical Informatics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang-Won Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Myoung-don Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
89
|
Banerjee R, Humphries R. Clinical and laboratory considerations for the rapid detection of carbapenem-resistant Enterobacteriaceae. Virulence 2016; 8:427-439. [PMID: 27168451 DOI: 10.1080/21505594.2016.1185577] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Carbapenem resistance among the Enterobacteriaceae has become a significant clinical and public health dilemma. Rapid administration of effective antimicrobials and implementation of supplemental infection control practices is required to both improve patient outcomes and limit the spread of these highly resistant organisms. However, carbapenem-resistant Enterobacteriaceae (CRE)-infected patients are predominantly identified by routine culture methods, which take days to perform. Rapid genomic and phenotypic methods are currently available to accelerate the identification of carbapenemase-producing CRE. Effective use of these technologies is reliant on close collaboration between clinical microbiology, infection prevention, antimicrobial stewardship and infectious diseases specialists. This review discusses the performance characteristics of these technologies to date, and describes strategies for their optimal implementation.
Collapse
Affiliation(s)
- Ritu Banerjee
- a Department of Pediatric and Adolescent Medicine , Mayo Clinic , Rochester , MN , USA
| | - Romney Humphries
- b Department of Pathology and Laboratory Medicine , University of California , Los Angeles , CA , USA
| |
Collapse
|
90
|
Shallcross LJ, Freemantle N, Nisar S, Ray D. A cross-sectional study of blood cultures and antibiotic use in patients admitted from the Emergency Department: missed opportunities for antimicrobial stewardship. BMC Infect Dis 2016; 16:166. [PMID: 27091375 PMCID: PMC4835863 DOI: 10.1186/s12879-016-1515-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 04/14/2016] [Indexed: 11/25/2022] Open
Abstract
Background Early review of antimicrobial prescribing decisions within 48 h is recommended to reduce the overall use of unnecessary antibiotics, and in particular the use of broad-spectrum antibiotics. When parenteral antibiotics are used, blood culture results provide valuable information to help decide whether to continue, alter or stop antibiotics at 48 h. The objective of this study was to investigate the frequency of parenteral antibiotic use, broad spectrum antibiotic use and use of blood cultures when parenteral antibiotics are initiated in patients admitted via the Emergency Department. Methods We used electronic health records from patients admitted from the Emergency Department at University Hospital Birmingham in 2014. Results Six percent (4562/72939) of patients attending the Emergency department and one-fifth (4357/19034) of those patients admitted to hospital were prescribed a parenteral antimicrobial. More than half of parenteral antibiotics used were either co-amoxiclav or piperacillin-tazobactam. Blood cultures were obtained in less than one-third of patients who were treated with a parenteral antibiotic. Conclusions Parenteral antibiotics are frequently used in those admitted from the Emergency Department; they are usually broad spectrum and are usually initiated without first obtaining cultures. Blood cultures may have limited value to support prescribing review as part of antimicrobial stewardship initiatives.
Collapse
Affiliation(s)
- Laura J Shallcross
- UCL Centre for Infectious Disease Informatics, Farr Institute of Health Informatics Research, 222 Euston Road, London, NW1 2DA, UK.
| | - Nick Freemantle
- Department of Primary Care and Population Health, Upper Third floor, UCL Medical School, Rowland Hill Street, London, NW3 2PF, UK
| | - Shasta Nisar
- Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, Birmingham, B15 2TH, UK
| | - Daniel Ray
- UCL Centre for Infectious Disease Informatics, Farr Institute of Health Informatics Research, 222 Euston Road, London, NW1 2DA, UK.,Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, Birmingham, B15 2TH, UK
| |
Collapse
|
91
|
Hwang AY, Gums JG. The emergence and evolution of antimicrobial resistance: Impact on a global scale. Bioorg Med Chem 2016; 24:6440-6445. [PMID: 27117692 DOI: 10.1016/j.bmc.2016.04.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/06/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
Abstract
The evolution of antimicrobial resistance is a multifaceted issue that is influenced by numerous factors. This growing healthcare problem has significantly impacted the public welfare and has substantially burdened the economic system on a global scale. In an effort to combat this rising problem, several strategies have been implemented in the recent years to stall the progression and decrease the emergence of antimicrobial resistance. The aim of this review article is to describe the various factors that have contributed to the current state of antimicrobial resistance and to evaluate potential strategies developed to reduce the burden of antimicrobial resistance.
Collapse
Affiliation(s)
- Andrew Y Hwang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, P.O. Box 100486, Gainesville, FL 32610, USA; Department of Community Health and Family Medicine, College of Medicine, University of Florida, 1707 North Main Street, Gainesville, FL 32609, USA.
| | - John G Gums
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, P.O. Box 100486, Gainesville, FL 32610, USA; Department of Community Health and Family Medicine, College of Medicine, University of Florida, 1707 North Main Street, Gainesville, FL 32609, USA
| |
Collapse
|
92
|
Development of a clinical decision support system for antibiotic management in a hospital environment. PROGRESS IN ARTIFICIAL INTELLIGENCE 2016. [DOI: 10.1007/s13748-016-0089-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
93
|
Evaluation of a Computerized Decision Support Intervention to Decrease Use of Anti-Pseudomonal Carbapenems in Penicillin Allergic Patients. Antibiotics (Basel) 2016; 5:antibiotics5010007. [PMID: 27025522 PMCID: PMC4810409 DOI: 10.3390/antibiotics5010007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/31/2015] [Accepted: 01/08/2016] [Indexed: 12/01/2022] Open
Abstract
Allergies to β-lactam antibiotics are commonly documented in hospitalized patients; however, true allergy is uncommon. Cross-reactivity rates for advanced generation cephalosporins and carbapenems are low; particularly for patients without a history of symptoms consistent with type 1 hypersensitivity. We observed that providers preferentially prescribed antipseudomonal carbapenems (APC) over advanced generation cephalosporins for patients with β-lactam allergy history, including those with low risk for antimicrobial-resistant infections. Information was inserted into the computerized decision support system (CDSS) to aid clinicians in assessing β-lactam cross-reactivity risk and selecting appropriate therapy. A retrospective evaluation was conducted in a small hospital to assess the impact of the CDSS changes in APC prescribing. Inpatients (n = 68) who received at least one APC dose during hospitalization over a 13 month pre-intervention period were compared to inpatients who received an APC during the 15 month post-intervention period (n = 59) for documented APC indications and β-lactam allergy history. APC initiations were measured and corrected per 1000 patient-days; interrupted time-series analysis was performed to assess changes in use before and after implementation. Aggregate monthly APC initiations decreased from 7.01 to 6.14 per 1000 patient-days after the implementation (p = 0.03). Post-intervention APC initiations for patients with low-risk β-lactam histories decreased from 92% to 83% (p = 0.17). No adverse events were observed in patients with low-risk β-lactam histories. The intervention was associated with a reduction in APC initiations.
Collapse
|
94
|
Andreu-Perez J, Leff DR, Ip HMD, Yang GZ. From Wearable Sensors to Smart Implants-–Toward Pervasive and Personalized Healthcare. IEEE Trans Biomed Eng 2015; 62:2750-62. [DOI: 10.1109/tbme.2015.2422751] [Citation(s) in RCA: 221] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
95
|
When it comes to stewardship, it's time to get with the programmers. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2015; 26:234-6. [PMID: 26600805 PMCID: PMC4644000 DOI: 10.1155/2015/707348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
96
|
|
97
|
Enani MA. The antimicrobial stewardship program in Gulf Cooperation Council (GCC) states: insights from a regional survey. J Infect Prev 2015; 17:16-20. [PMID: 28989448 DOI: 10.1177/1757177415611220] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 09/19/2015] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The purpose of the current study is to describe the prevalence and characteristics of antimicrobial stewardship programs (ASP) in Gulf Cooperation Council (GCC) states to explore opportunities and overcome barriers to effective ASP implementation. METHODS A cross-sectional questionnaire survey was used to evaluate the current status of ASP: major stewardship components, barriers of implementation and program impact in acute care hospitals of GCC states. RESULTS Forty-seven healthcare professionals responded from four GCC states, the majority from Saudi Arabia (81%). Twenty-nine (62%) participating hospitals had ASP in place. Of these established programs, 35 (75%) reported lack of funding and personnel as major barriers to program implementation. The top three objectives cited for the hospital ASP were to reduce resistance (72.3%), improve clinical outcomes (70.2%) and reduce costs (44.7%). The reported impact of existing ASP was reduction of inappropriate prescribing (68%), reduction of broad spectrum antibiotic use (63.8%), reduction of healthcare-associated infections (61.7%), reduction of length of stay or mortality metrics (59.6%), reduction in direct antibiotic cost (57.4%) and reduction of reported antibiotic resistance (55.3%). CONCLUSION Survey participants from GCC states who have implemented ASP report significant impacts in the reduction of broad spectrum antibiotic use, hospital-acquired infection, inappropriate prescribing and antimicrobial resistance. These findings suggest a promising opportunity to enhance existing ASP through sharing of best practices and support the development of regional guidelines across GCC states.
Collapse
Affiliation(s)
- Mushira A Enani
- Infectious Diseases Section, Department of Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
98
|
Abstract
This paper provides an overview of recent developments in big data in the context of biomedical and health informatics. It outlines the key characteristics of big data and how medical and health informatics, translational bioinformatics, sensor informatics, and imaging informatics will benefit from an integrated approach of piecing together different aspects of personalized information from a diverse range of data sources, both structured and unstructured, covering genomics, proteomics, metabolomics, as well as imaging, clinical diagnosis, and long-term continuous physiological sensing of an individual. It is expected that recent advances in big data will expand our knowledge for testing new hypotheses about disease management from diagnosis to prevention to personalized treatment. The rise of big data, however, also raises challenges in terms of privacy, security, data ownership, data stewardship, and governance. This paper discusses some of the existing activities and future opportunities related to big data for health, outlining some of the key underlying issues that need to be tackled.
Collapse
|
99
|
Reddy SC, Jacob JT, Varkey JB, Gaynes RP. Antibiotic use in US hospitals: quantification, quality measures and stewardship. Expert Rev Anti Infect Ther 2015; 13:843-54. [PMID: 25925531 DOI: 10.1586/14787210.2015.1040766] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A majority of patients hospitalized in the US hospitals receive an antibiotic during their hospitalization. Furthermore, up to half of antibiotics prescribed in hospitals are inappropriate. In the setting of continued emergence of antibiotic-resistant pathogens and a limited pipeline of new antimicrobials, attention to optimizing antibiotic use in healthcare settings is essential. We review the measures of antibiotic consumption in the USA, the evolving metrics for comparing antibiotic use (known as benchmarking), trends in antibiotic use, the structure and outcome measures of Antimicrobial Stewardship Programs and interventions to optimize antimicrobial use.
Collapse
Affiliation(s)
- Sujan C Reddy
- Division of Infectious Diseases, Emory University School of Medicine, 49 Jesse Hill Jr Drive, Atlanta, GA 30303, USA
| | | | | | | |
Collapse
|
100
|
Wenzler E, Rodvold KA, Danziger LH. Editorial Commentary: Improving Prescribers to Advance Antimicrobial Stewardship. Clin Infect Dis 2015; 60:1259-61. [DOI: 10.1093/cid/civ021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
|