Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years

Complete restriction of fluoroquinolone use to control an outbreak of Clostridium difficile infection at a community hospital

OBJECTIVE

To review the effect of interventions, including a complete restriction in the use of fluoroquinolones (FQs), used to control an outbreak of hospital-onset Clostridium difficile infection (HO-CDI) caused primarily by the epidemic North American pulsed-field gel electrophoresis type 1 strain.

DESIGN

Retrospective cohort and case-control study of all episodes of HO-CDI both before and after 2 interventions.

SETTING

Community hospital; January 1, 2005, through March 31, 2007. Interventions. Complete, 5-month, facility-wide restriction of fluoroquinolone use, during which a change in the environmental-services contractor occurred.

RESULTS

During a 27-month period, 319 episodes of HO-CDI occurred. The hospital-wide mean defined daily doses of antimicrobials decreased 22% after restricting FQ use, primarily because of a 66% decrease in the use of FQs. The interventions were also associated with a significant change in the HO-CDI incidence trends and with an absolute decrease of 22% in HO-CDI cases caused by the epidemic strain (from 66% before the intervention period to 44% during and after the intervention period; P=.02). Univariate analysis revealed that case patients with HO-CDI due to the epidemic strain were more likely than control patients, who did not have diarrhea, to receive a FQ, whereas case patients with HO-CDI due to a nonepidemic strain were not. However, FQ use was not significantly associated with HO-CDI in multivariable analysis.

CONCLUSIONS

An outbreak of epidemic-strain HO-CDI was controlled at a community hospital after an overall decrease in antimicrobial use, primarily because of a restriction of FQ use and a change in environmental-services contractors. The restriction of FQ use may be useful as an adjunct control measure in a healthcare facilities during outbreaks of epidemic-strain HO-CDI.

Analysis of antimicrobials' consumption profile in a University Hospital of Western Paraná, Brazil

The objective of this study was to analyze the variation in antimicrobials' consumption and the costs related to their use at a University Hospital between 1999 and 2004. The annual consumption of nine antimicrobials, expressed in DDD/100 patients-day, and the direct costs with their acquisition were evaluated. Analysis of variance and regression techniques were used to compare data, considering a significance level of 5%. The most consumed antimicrobials were amikacin and ceftriaxone. In general, antimicrobials consumption, expressed in DDD/100 patients-day, increased from 9.21 in 1999 to 25.08 in 2004 (p<0.0001). When analyzing antimicrobial consumption as related to specific hospital units, the ICU showed the highest consumption followed by Chemotherapy and Medical Clinical units, respectively. In addition, the number of patients-day increased from 2671/month in 1999 to 3502/month in 2004, p<0.0001. As a consequence, total expenditure with antimicrobials increased from R$ 98.89 per 100 patients-day in 1999 to R$ 731.26 in 2004, p<0.0001. Between 1999 and 2004 significant increases in both consumption and financial expenditure with antimicrobials were observed.

Health Care-Associated Infection Prevention and Control: Pharmacists' Role in Meeting National Patient Safety Goal 7

Health care-associated infections and antimicrobial resistance are continually increasing, with fewer drugs available for effective treatment. Potential benefits of infection control and antimicrobial stewardship programs include improvements in antibiotic use and conversion from intravenous (IV) to oral antibiotics and reductions in resistance and infection rates and length of hospital stay. NorthShore University HealthSystem in Evanston, Illinois, was the first large hospital system in North America that adopted universal inpatient surveillance for methicillin-resistant Staphylococcus aureus (MRSA). Results showed that nasal MRSA was a powerful predictor of MRSA disease and antibiotic resistance in other organisms. MRSA infections occurring up to 30 days posthospitalization decreased by approximately 70%. At the Hospital of Saint Raphael, a community teaching hospital in New Haven, Connecticut, an antimicrobial stewardship pilot program focused on automatic conversation from IV to oral antimicrobials and appropriate antimicrobial use. The percentage of patients receiving oral fluconazole increased from 63% to 77%; the percentage of those receiving oral linezolid increased from 54% to 71%. Total antibiotic use decreased by 6%. Based on the 60-day trial, potential cost savings were estimated as $874,000 annually, less the cost of a pharmacist's salary and benefits. Infection control and antimicrobial stewardship programs offer pharmacists new opportunities for helping improve patient safety and quality of care. Pharmacy-medical staff partnership, combined with support from microbiology, infection control, information technology, and hospital administration, is key to a successful program.

Correlation between meticillin-resistant Staphylococcus aureus prevalence and infection control initiatives within southern and eastern Mediterranean hospitals

The Mediterranean region has been identified as an area of hyper-endemicity for multi-resistant hospital pathogens. To better understand potential drivers behind this situation, we attempted to correlate already published meticillin-resistant Staphylococcus aureus (MRSA) data from 27 hospitals, participants in the Antibiotic Resistance Surveillance & Control in the Mediterranean Region (ARMed) project, with responses received from the same institutions to questionnaires which dealt with various aspects of infection control and antibiotic stewardship. No difference could be ascertained between high and low prevalence hospitals in terms of scores from replies to structured questions regarding infection control set-up, hand hygiene facilities and antibiotic stewardship practices. However, we did identify differences in terms of bed occupancy and isolation facilities. Hospitals reporting frequent episodes of overcrowding, particularly involving several departments, and which found regular difficulties sourcing isolation beds, had significantly higher MRSA proportions. This suggests that infrastructural deficits related to insufficient bed availability and compounded by inadequate isolation facilities could potentiate MRSA hyper-endemicity in south-eastern Mediterranean hospitals.

The value of infectious diseases specialists: non-patient care activities

Recent developments in health care have focused efforts on both the national and local levels to reduce unnecessary health care costs and the number of hospital stays while increasing the quality of care, particularly in the context of hospital-associated infections. Infectious diseases specialists who contract to oversee infection-control and antibiotic-stewardship programs are uniquely positioned to play a pivotal role in helping hospitals to prosper in this new environment. This article will detail the available data supporting the value of infectious diseases specialists in their roles of directing antimicrobial-management and infection-control programs, maintaining health care workers' well-being, and minimizing exposure. The evidence in support of the influence of infectious diseases specialists to achieve cost-savings, decrease the length of hospital stays, and improve outcomes is robust and can be used as the framework for negotiating appropriate compensation from hospital management for these activities. Presenting this information in an amicable but definitive framework may be the linchpin to the overall success of the movement to improve quality of care while minimizing hospital costs and antimicrobial use. Developing this ability is critical to infectious diseases specialists' success as they redefine their role in the quality-of-care and risk-management arenas.

Control of endemic methicillin-resistant Staphylococcus aureus--recent advances and future challenges

Although the exact burden of disease caused by methicillin-resistant Staphylococcus aureus (MRSA) remains largely unknown, most experts agree that MRSA infections are an important clinical and public health problem. Thousands of reports have been published during the last four decades concerning epidemiological and microbiological aspects of MRSA, but uncertainty remains about the best approach to prevent and control this worldwide plague, especially endemic MRSA. Epidemiological methods, e.g., risk scores for targeted screening upon admission, rapid molecular tests and pre-emptive isolation of high-risk patients, new decontamination regimens and restriction of certain antibiotic classes, are all promising approaches that may decrease MRSA cross-transmission; however, further evidence is needed before these strategies can be implemented on a wide scale. Control of community MRSA is an additional challenge for the future, requiring improved surveillance and contact tracing, as well as education and treatment of both infected cases and colonised contacts. This review summarises recent advances and studies that address these issues. Overall, it seems that there is no level of MRSA prevalence for which active control measures are no longer warranted.

Hospital antibiotic stewardship

PURPOSE OF REVIEW

Antibiotic stewardship is designed to optimize antimicrobial therapy administered to hospitalized patients, to ensure cost-effective therapy and improve patients' outcome while containing bacterial resistance. Current data on the development of effective programmes, including guidelines for their implementation, have demonstrated some efficacy and controversies are reviewed.

RECENT FINDINGS

Guidelines have been recently issued for the development and implementation of active antibiotic stewardship programmes in hospitals. A multidisciplinary team including at least an infectious disease physician and a clinical pharmacist is required. Multiple strategies are available, including prospective audit with feedback to the provider, education and antimicrobial restriction. Interventions have shown a positive effect on optimization of antimicrobial use, reduced costs and bacterial resistance, but studies showing improvement in patient outcomes are sparse. Results of studies may be confounded by several factors, mainly due to their before-after design and lack of control for cointerventions.

SUMMARY

Combined with an effective infection control programme, antibiotic stewardship can help contain antimicrobial resistance. Studies demonstrating improvement of patients' outcomes are needed to increase acceptance by a broader audience of physicians. A proactive strategy of prospective auditing with direct counsels and feedback to the prescriber, ensuring systematic reassessment of ongoing therapy, appears most useful.

Infection control measures to limit the spread of Clostridium difficile

Clostridium difficile-associated diarrhoea (CDAD) presents mainly as a nosocomial infection, usually after antimicrobial therapy. Many outbreaks have been attributed to C. difficile, some due to a new hyper-virulent strain that may cause more severe disease and a worse patient outcome. As a result of CDAD, large numbers of C. difficile spores may be excreted by affected patients. Spores then survive for months in the environment; they cannot be destroyed by standard alcohol-based hand disinfection, and persist despite usual environmental cleaning agents. All these factors increase the risk of C. difficile transmission. Once CDAD is diagnosed in a patient, immediate implementation of appropriate infection control measures is mandatory in order to prevent further spread within the hospital. The quality and quantity of antibiotic prescribing should be reviewed to minimise the selective pressure for CDAD. This article provides a review of the literature that can be used for evidence-based guidelines to limit the spread of C. difficile. These include early diagnosis of CDAD, surveillance of CDAD cases, education of staff, appropriate use of isolation precautions, hand hygiene, protective clothing, environmental cleaning and cleaning of medical equipment, good antibiotic stewardship, and specific measures during outbreaks. Existing local protocols and practices for the control of C. difficile should be carefully reviewed and modified if necessary.

The changing spectrum of clostridium difficile associated disease: implications for dentistry

BACKGROUND

Clostridium difficile is an anaerobic, spore-forming bacterium that causes a wide range of diseases of the gastrointestinal tract. It is best known for its association with uncomplicated antimicrobial-agent-associated diarrhea.

CASE DESCRIPTION

The authors describe two previously published cases of Clostridium difficile-associated disease (CDAD) to highlight its varied clinical manifestations. A 48-year-old woman had mild CDAD after receiving antibiotics after undergoing endodontic surgery. She took metronidazole, and her C. difficile infection resolved. A 31-year-old pregnant woman developed severe CDAD after receiving antibiotics for a urinary tract infection. She underwent surgery to remove part of her colon, but her condition worsened, and she died.

CLINICAL IMPLICATIONS

Dentists often prescribe antimicrobial agents to treat infections. Until recently, these agents also were recommended as prophylaxis for infective endocarditis during invasive oral procedures. An important risk factor for CDAD and recurrent CDAD is antimicrobial agent exposure. Dentists should be aware of CDAD to help prevent its spread and facilitate early recognition and treatment to minimize severe outcomes.

Prevention and treatment of health care-acquired infections

Health care-acquired infections present a tremendous challenge to the care of hospitalized patients. Unfortunately, the risk of acquiring a health care-associated infection (HAI) is rising. The vast majority of HAI are of four types: urinary tract infections, surgical site infections, bloodstream infections, and pneumonia. This chapter aims to provide current data and strategies relating to the prevention of HAIs among hospitalized patients.

Antimicrobial-associated risk factors for Clostridium difficile infection

Antimicrobial therapy plays a central role in the pathogenesis of Clostridium difficile infection (CDI), presumably through disruption of indigenous intestinal microflora, thereby allowing C. difficile to grow and produce toxin. Investigations involving animal models and studies performed in vitro suggest that inhibitory activity against C. difficile and differences in the propensity to stimulate toxin production may also influence the likelihood that particular drugs may cause CDI. Although nearly all antimicrobial classes have been associated with CDI, clindamycin, third-generation cephalosporins, and penicillins have traditionally been considered to harbor the greatest risk. Recent studies have also implicated fluoroquinolones as high-risk agents, a finding that is most likely to be related in part to increasing fluoroquinolone resistance among epidemic strains (i.e., restriction-endonuclease analysis group BI/North American PFGE type 1 strains) and some nonepidemic strains of C. difficile. Restrictions in the use of clindamycin and third-generation cephalosporins have been associated with reductions in CDI. Because use of any antimicrobial has the potential to induce the onset of CDI and disease caused by other health care-associated pathogens, antimicrobial stewardship programs that promote judicious use of antimicrobials are encouraged in concert with environmental and infection control-related efforts.

Evaluation of an antimicrobial stewardship program at a pediatric teaching hospital

BACKGROUND

Thirty to 50% of hospitalized patients receive antimicrobial therapy. Previous data suggest that inappropriate use results in higher mortality rates, longer lengths of stay, and increased medical costs. Antimicrobial Stewardship Programs (ASPs) reduce the improper use of antimicrobials and improve patient safety. Despite increased awareness about the benefits of these programs, few pediatric ASPs exist and fewer comprehensive studies evaluate their effects.

METHODS

A prospective observational study was conducted to describe the use and impact of a pediatric ASP. Data were collected on the clinician's request for targeted antibiotics and the interventions made by the ASP. Retrospective chart review was performed to assess outcomes and compliance on empiric antimicrobial therapy decisions and recommendations to discontinue antimicrobial therapy.

RESULTS

During the 4-month study period, calls were placed to the ASP for 652 patients. Forty-five percent of those calls required an intervention by the ASP. These interventions included: (1) Targeting the known or suspected pathogens (20%); (2) Consultation (43%); (3) Optimize antimicrobial treatment (33%); and (4) Stop antimicrobial treatment (4%). Three of the 84 (3.5%) patients recommended to receive alternative therapy developed an infection not covered by the ASP recommendations or the antimicrobial initially requested by the clinician.

CONCLUSIONS

Our data demonstrate that an ASP improves the appropriate use of antimicrobial medications in hospitalized children. In addition, the ASP plays an integral role in providing guidance to clinicians and ensures that the appropriate antimicrobial agents are used.

Impact of a Reduction in the Use of High-Risk Antibiotics on the Course of an Epidemic of Clostridium difficile-Associated Disease Caused by the Hypervirulent NAP1/027 Strain

A series of measures were implemented, in a secondary/tertiary-care hospital in Quebec, to control an epidemic of nosocomial Clostridium difficile-associated disease (n-CDAD) caused by a virulent strain; these measures included the development of a nonrestrictive antimicrobial stewardship program. Interrupted time-series analysis was used to evaluate the impact of these measures on n-CDAD incidence. From 2003-2004 to 2005-2006, total and targeted antibiotic consumption, respectively, decreased by 23% and 54%, and the incidence of n-CDAD decreased by 60%. No change in n-CDAD incidence was noted after strengthening of infection control procedures (P=.63), but implementation of the antimicrobial stewardship program was followed by a marked reduction in incidence (P=.007). This suggests that nonrestrictive measures to optimize antibiotic usage can yield exceptional results when physicians are motivated and that such measures should be a mandatory component of n-CDAD control. The inefficacy of infection control measures targeting transmission through hospital personnel might be a result of their implementation late in the epidemic, when the environment was heavily contaminated with spores.

Predictors of Clostridium difficile colitis infections in hospitals

Hospital-level predictors of high rates of 'Clostridium difficile-associated disease' (CDAD) were evaluated in over 2300 hospitals across California, Arizona, and Minnesota. American Hospital Association data were used to determine hospital characteristics associated with high rates of CDAD. Significant correlations were found between hospital rates of CDAD, common infections and other identified pathogens. Hospitals in urban areas had higher average rates of CDAD; yet, irrespective of geographic location, hospital rates of CDAD were associated with other infections. In addition, hospitals with 'high CDAD' rates had slower turnover of beds and were more likely to offer transplant services. These results reveal large differences in rates of CDAD across regions. Hospitals with high rates of CDAD have high rates of other common infections, suggesting a need for broad infection control policies.

Antibiotic pharmacists in the ascendancy

Specialist pharmacists have become an established feature of the antibiotic stewardship landscape in hospitals throughout the UK over the last decade. This review examines the origins of the specialist antibiotic pharmacist and how the role has developed in recent years. Antibiotic pharmacists fulfil a vital function in modern National Health Service hospitals as key members of the infection control team with overall responsibility for initiatives to promote rational antibiotic prescribing. Evidence of the impact of antibiotic pharmacists on clinical, microbiological and financial outcomes is presented along with examples of innovative practice. Finally, a vision for the future of the antibiotic pharmacist role is outlined.

The challenges posed by reemerging Clostridium difficile infection

There have been recent, marked increases in the incidence and severity of Clostridium difficile-associated disease (CDAD). These may be attributable to the emergence of a hypervirulent strain of C. difficile that produces increased levels of toxins A and B, as well as an extra toxin known as "binary toxin." This previously uncommon strain has become epidemic, coincident with its development of increased resistance to fluoroquinolones, the use of which is increasingly associated with CDAD outbreaks. Although not necessarily related to this epidemic strain, unusually severe CDAD has been reported in populations that had previously been thought to be at low risk, including peripartum women and healthy persons living in the community. Challenges posed by the changing epidemiology of CDAD are compounded by current limitations in diagnostic testing, treatment, and infection control. Overcoming these challenges and limitations will require a concerted effort from a variety of sources, including an ongoing partnership between infectious disease clinicians and public health professionals.

Implications of the changing face of Clostridium difficile disease for health care practitioners

Recent reported outbreaks of Clostridium difficile-associated disease in Canada have changed the profile of C difficile infections. Historically, C difficile disease was thought of mainly as a nosocomial disease associated with broad-spectrum antibiotics, and the disease was usually not life threatening. The emergence of an epidemic strain, BI/NAP1/027, which produces a binary toxin in addition to the 2 classic C difficile toxins A and B and is resistant to some fluoroquinolones, was associated with large numbers of cases with high rates of mortality. Recently, C difficile has been reported more frequently in nonhospital-based settings, such as community-acquired cases. The C difficile disease is also being reported in populations once considered of low risk (children and young healthy women). In addition, poor response to metronidazole treatment is increasing. Faced with an increasing incidence of C difficile infections and the changing profile of patients who become infected, this paper will reexamine the current concepts on the epidemiology and treatment of C difficile-associated disease, present new hypotheses for risk factors, examine the role of spores in the transmission of C difficile, and provide recommendations that may enhance infection control practices.

Novel ways of preventing antibiotic-resistant infections: what might the future hold?

Most antibiotic-resistant bacteria are opportunistic pathogens; they colonize the skin and mucosal surfaces and only cause infection when the opportunity arises. Thus, the processes that lead to an infection attributable to antibiotic-resistant bacteria can be broadly divided into those processes that lead to acquisition of antibiotic-resistant bacteria and those that lead to the development of an infection with that organism. We review the processes that lead to the development of infections attributable to antibiotic-resistant bacteria. We then discuss options that may become available to interrupt these processes and, thus, may reduce the rate of infections attributable to antibiotic-resistant bacteria in the future.

Antimicrobial stewardship

Antimicrobial stewardship is a key component of a multifaceted approach to preventing emergence of antimicrobial resistance. Good antimicrobial stewardship involves selecting an appropriate drug and optimizing its dose and duration to cure an infection while minimizing toxicity and conditions for selection of resistant bacterial strains. Studies conducted over the years indicate that antibiotic use is unnecessary or inappropriate in as many as 50% of cases in the United States, and this creates unnecessary pressure for the selection of resistant species. Because the pharmaceutical industry pipeline for new antibiotics has been curtailed in recent years, and it may be > or = 10 years before important new antibiotics to treat certain resistant bacteria find their way to market, a premium has been set on maintaining the effectiveness of currently available agents. Several strategies, including prescriber education, formulary restriction, prior approval, streamlining, antibiotic cycling, and computer-assisted programs have been proposed to improve antibiotic use. Although rigorous clinical data in support of these strategies are lacking, the most effective means of improving antimicrobial stewardship will most likely involve a comprehensive program that incorporates multiple strategies and collaboration among various specialties within a given healthcare institution. Computer-assisted software programs may be especially useful in implementing these comprehensive programs. The antimicrobial stewardship program at the Hospital of the University of Pennsylvania, which has been shown to improve appropriateness of antibiotic use and cure rates, decrease failure rates, and reduce healthcare-related costs, is used as an example in support of this multifaceted, multidisciplinary approach. At this time, data from well-controlled studies examining the effect of antibacterial stewardship on emergence of resistance are limited, but available data suggest that good antibiotic stewardship reduces rates of Clostridium difficile-associated diarrhea, resistant gram-negative bacilli, and vancomycin-resistant enterococci.

An update on diagnosis, treatment, and prevention of Clostridium difficile-associated disease

Clostridium difficile is an important cause of nosocomial morbidity and mortality and is implicated in recent epidemics. Data support the treatment of colitis with oral metronidazole in a dose of 1.0 to 1.5 g/d, with oral vancomycin as a second-line agent, not because its efficacy is questioned but because of environmental concerns. Nitazoxanide and other drugs are currently under intense study as alternatives. Treatment of asymptomatic patients is not recommended. Current management strategies appear to be increasingly ineffective, especially for patients who experience multiple recurrences. Biotherapy and vaccination are currently being explored as treatment options for patients who have recurrent disease. Greater attention should be paid to hospital infection control policies and restriction of broad-spectrum antibiotics.

Antimicrobial stewardship

Antimicrobial stewardship is a key component of a multifaceted approach to preventing emergence of antimicrobial resistance. Good antimicrobial stewardship involves selecting an appropriate drug and optimizing its dose and duration to cure an infection while minimizing toxicity and conditions for selection of resistant bacterial strains. Studies conducted over the years indicate that antibiotic use is unnecessary or inappropriate in as many as 50% of cases in the United States, and this creates unnecessary pressure for the selection of resistant species. Because the pharmaceutical industry pipeline for new antibiotics has been curtailed in recent years, and it may be >/=10 years before important new antibiotics to treat certain resistant bacteria find their way to market, a premium has been set on maintaining the effectiveness of currently available agents. Several strategies, including prescriber education, formulary restriction, prior approval, streamlining, antibiotic cycling, and computer-assisted programs have been proposed to improve antibiotic use. Although rigorous clinical data in support of these strategies are lacking, the most effective means of improving antimicrobial stewardship will most likely involve a comprehensive program that incorporates multiple strategies and collaboration among various specialties within a given healthcare institution. Computer-assisted software programs may be especially useful in implementing these comprehensive programs. The antimicrobial stewardship program at the Hospital of the University of Pennsylvania, which has been shown to improve appropriateness of antibiotic use and cure rates, decrease failure rates, and reduce healthcare-related costs, is used as an example in support of this multifaceted, multidisciplinary approach. At this time, data from well-controlled studies examining the effect of antibacterial stewardship on emergence of resistance are limited, but available data suggest that good antibiotic stewardship reduces rates of Clostridium difficile-associated diarrhea, resistant gram-negative bacilli, and vancomycin-resistant enterococci.

Systematic review of antimicrobial drug prescribing in hospitals

Standardizing methods and reporting could improve interventions that reduce Clostridium difficile–associated diarrhea and antimicrobial drug resistance.

Prudent prescribing of antimicrobial drugs to hospital inpatients may reduce incidences of antimicrobial drug resistance and healthcare-associated infection. We reviewed the literature from January 1980 to November 2003 to identify rigorous evaluations of interventions to improve hospital prescribing of antimicrobial drugs. We identified 66 studies with interpretable data, of which 16 reported 20 microbiologic outcomes: gram-negative resistant bacteria, 10 studies; Clostridium difficile–associated diarrhea, 5 studies; vancomycin-resistant enterococci, 3 studies; and methicillin-resistant Staphylococcus aureus, 2 studies. Four studies provided strong evidence that the intervention changed microbial outcomes with low risk for alternative explanations, 8 studies provided less convincing evidence, and 4 studies provided no evidence. The strongest and most consistent evidence was for C. difficile–associated diahrrea, but we were able to analyze only the immediate impact of interventions because of nonstandardized durations of follow-up. The ability to compare results of studies could be substantially improved by standardizing methods and reporting.

Implementation of antibiotic management teams in Belgian hospitals

In 2002-03, the Belgian government subsidized in part the activities of local Antibiotic Managers (AMs) in 36 hospitals selected based on the presence of an operational multidisciplinary Antibiotic Management Team (AMT). AMs were trained as Internists (28), Microbiologists (13) and Hospital Pharmacists (13). The hospitals were representative of Belgian hospitals in affiliation, regional origin and size. The financing scheme allowed the implementation of 175 antibiotic management interventions, with a mean of 5 interventions/hospital. The activities reported in the first 9-month progress reports were analyzed according to national guidelines for AMTs. All hospitals irrespective of size or affiliation had undertaken a wide range of measures: review of formulary (29), implementation of new clinical guidelines (24), restricted access to selected antibiotics (25), improvement of antibiotic susceptibility testing methods (12), development of antibiotic consumption database (35) and analysis of antibacterial susceptibility data (31). Advertisement type categorization of communication methods showed that education of prescribers was based on multimodal communication. All hospitals used at least one passive method, 39% at least one active method and 55% at least one personalized method. The quality of communication was higher in hospitals with teaching affiliation. In conclusion, hospitals that received a financial incentive under theAMT pilot phase have developed multimodal antibiotic policy interventions independently of the hospital size and teaching status. Extension to all Belgian hospitals appears warranted. The impact of AMTs and AMs on the quality of use of antibiotics and trends of antibiotic resistance and cost will be monitored based on standardized indicators.

Colitis due to Clostridium difficile toxins: underdiagnosed, highly virulent, and nosocomial

Clostridium difficile colitis is a major complication of antibiotic therapy. Antibiotics cause a reduction in bacteria that normally reside in the colon. If an antibiotic-treated patient ingests C. difficile bacteria, this organism may proliferate in the colon because it is resistant to most antibiotics and because it does not have to compete with the normal bacteria for nutrients. If the C. difficile organism has the gene for toxin production, the toxin can produce a colitis. In addition to antibiotics, other proposed risk factors for development of C. difficile colitis include advanced age, contact with infected patients and with their health care providers, impaired immune function, suppression of gastric acid secretion by a proton pump inhibitor, and postpyloric tube feeding. Many of the risk factors become simultaneously focused on patients admitted to the hospital. The incidence of C. difficile disease has been rising, and strains have become more virulent. In some forms of the disease, the patient doesn't have diarrhea, and in such patients C. difficile can be deadly but difficult to diagnose. The standard treatment, with metronidazole or vancomycin, fails to work in up to 25% of patients with the fulminant form of colitis. Since C. difficile causes only 20% of cases of antibiotic-associated diarrhea, a specific test is needed to diagnose this organism. Toxigenic cultureis highly specific but not available at most institutions. The tests that are available--enzyme-linked immunosorbent assay and fecal cytotoxicity assay--have high false-negative rates, even in patients with severe clinical disease, creating a diagnostic dilemma. The only proven way to reduce the risk of C. difficile disease is implementation of an antibiotic management program in conjunction with enhanced infection control procedures.

Systematic review of antimicrobial drug prescribing in hospitals

Prudent prescribing of antimicrobial drugs to hospital inpatients may reduce incidences of antimicrobial drug resistance and healthcare-associated infection. We reviewed the literature from January 1980 to November 2003 to identify rigorous evaluations of interventions to improve hospital prescribing of antimicrobial drugs. We identified 66 studies with interpretable data, of which 16 reported 20 microbiologic outcomes: gram-negative resistant bacteria, 10 studies; Clostridium difficile-associated diarrhea, 5 studies; vancomycin-resistant enterococci, 3 studies; and methicillin-resistant Staphylococcus aureus, 2 studies. Four studies provided strong evidence that the intervention changed microbial outcomes with low risk for alternative explanations, 8 studies provided less convincing evidence, and 4 studies provided no evidence. The strongest and most consistent evidence was for C. difficile-associated diarrhea, but we were able to analyze only the immediate impact of interventions because of nonstandardized durations of follow-up. The ability to compare results of studies could be substantially improved by standardizing methods and reporting.

Unnatural selection: reducing antibiotic resistance in neonatal units

Antibiotic use selects for antibiotic resistant bacteria. This is an example of rapid Darwinian natural selection in action. It occurs in neonatal intensive care units with the use of parenteral antibiotics, and in the community with oral antibiotic use. A 10 point plan is put forward to reduce antibiotic resistance in neonatal units.

Antimicrobial stewardship programs in health care systems

Antimicrobial stewardship programs in hospitals seek to optimize antimicrobial prescribing in order to improve individual patient care as well as reduce hospital costs and slow the spread of antimicrobial resistance. With antimicrobial resistance on the rise worldwide and few new agents in development, antimicrobial stewardship programs are more important than ever in ensuring the continued efficacy of available antimicrobials. The design of antimicrobial management programs should be based on the best current understanding of the relationship between antimicrobial use and resistance. Such programs should be administered by multidisciplinary teams composed of infectious diseases physicians, clinical pharmacists, clinical microbiologists, and infection control practitioners and should be actively supported by hospital administrators. Strategies for changing antimicrobial prescribing behavior include education of prescribers regarding proper antimicrobial usage, creation of an antimicrobial formulary with restricted prescribing of targeted agents, and review of antimicrobial prescribing with feedback to prescribers. Clinical computer systems can aid in the implementation of each of these strategies, especially as expert systems able to provide patient-specific data and suggestions at the point of care. Antibiotic rotation strategies control the prescribing process by scheduled changes of antimicrobial classes used for empirical therapy. When instituting an antimicrobial stewardship program, a hospital should tailor its choice of strategies to its needs and available resources.

Politique d'utilisation des antibiotiques : état des lieux dans 99 établissements de santé de l'interrégion Sud-Ouest

OBJECTIVE

Increasing antimicrobial resistance in bacteria is a major health problem and requires the implementation of stringent policies to optimize the use of antibiotics.

DESIGN

In 2003 the authors conducted a study in southwestern French hospitals, using a questionnaire to assess the implementation of antibiotic policies according to national guidelines issued by the French government in 2002.

RESULTS

The most frequent actions quoted by the 99 respondents were: issuing of a list of available antibiotics, issuing of information regarding antibiotic consumption and bacterial resistance, and control of antibiotics dispensation. Local guidelines were available in 45% of hospitals for curative treatment and in 87% for antibioprophylaxis in surgery. The evaluation of antibiotic use and computer links between clinical settings, pharmacy and microbiology lab were the less widespread measures. The number and type of actions were related to hospital size and activity.

CONCLUSIONS

These findings support that policies for an appropriate use of antimicrobials should be reinforced by issuing treatment guidelines and specific tools for dispensation and evaluation. This survey also emphasizes the need for appropriate policies relating to the size and medical activities of healthcare institutions.

Interventions to improve antibiotic prescribing practices for hospital inpatients

BACKGROUND

Up to 50% of antibiotic usage in hospitals is inappropriate. In hospitals infections caused by antibiotic-resistant bacteria are associated with higher mortality, morbidity and prolonged hospital stay compared with infections caused by antibiotic-susceptible bacteria. Clostridium difficile associated diarrhoea (CDAD) is a hospital acquired infection that is caused by antibiotic prescribing.

OBJECTIVES

To estimate the effectiveness of professional interventions that alone, or in combination, are effective in promoting prudent antibiotic prescribing to hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial resistant pathogens or CDAD and their impact on clinical outcome.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialized register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE from 1980 to November 2003. Additional studies were obtained from the bibliographies of retrieved articles

SELECTION CRITERIA

We included all randomised and controlled clinical trials (RCT/CCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies of antibiotic prescribing to hospital inpatients. Interventions included any professional or structural interventions as defined by EPOC.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data and assessed quality.

MAIN RESULTS

Sixty six studies were included and 51 (77%) showed a significant improvement in at least one outcome. Six interventions only aimed to increase treatment, 57 interventions aimed to decrease treatment and three interventions aimed to both increase and decrease treatment. The intervention target was the decision to prescribe antibiotics (one study), timing of first dose (six studies), the regimen (drug, dosing interval etc, 61 studies) or the duration of treatment (10 studies); 12 studies had more than one target. Of the six interventions that aimed to increase treatment, five reported a significant improvement in drug outcomes and one a significant improvement in clinical outcome. Of the 60 interventions that aimed to decrease treatment 47 reported drug outcomes of which 38 (81%) significantly improved, 16 reported microbiological outcomes of which 12 (75%) significantly improved and nine reported clinical outcomes of which two (22%) significantly deteriorated and 3 (33%) significantly improved. Five studies aimed to reduce CDAD. Three showed a significant reduction in CDAD. Due to differences in study design and duration of follow up it was only possible to perform meta-regression on a few studies.

AUTHORS' CONCLUSIONS

The results show that interventions to improve antibiotic prescribing to hospital inpatients are successful, and can reduce antimicrobial resistance or hospital acquired infections.

Treatment of Clostridium difficile-associated disease: old therapies and new strategies

Clostridium difficile-associated disease (CDAD) causes substantial morbidity and mortality. The pathogenesis is multifactorial, involving altered bowel flora, production of toxins, and impaired host immunity, often in a nosocomial setting. Current guidelines recommend treatment with metronidazole; vancomycin is a second-line agent because of its potential effect on the hospital environment. We present the data that led to these recommendations and explore other therapeutic options, including antimicrobials, antibody to toxin A, probiotics, and vaccines. Treatment of CDAD has increasingly been associated with failure and recurrence. Recurrent disease may reflect relapse of infection due to the original infecting organism or infection by a new strain. Poor antibody responses to C difficile toxins have a permissive role in recurrent infection. Hospital infection control and pertinent use of antibiotics can limit the spread of CDAD. A vaccine directed against C difficile toxin may eventually offer a solution to the CDAD problem.

Squeezing the antibiotic balloon: the impact of antimicrobial classes on emerging resistance

The ongoing problem of emerging antimicrobial resistance has been likened to a balloon where settling one specific issue results in a 'bulge' of even worse problems. However, much has been learned about how to best use our critical antibacterial agents in ways to avoid or even repair some of the resistance damage that has been done. A compilation of current literature strongly suggests that to slow the development of resistance to antimicrobial agents it is optimal to use drugs with more than one mechanism of action or target, to prescribe those with demonstrated ability to minimise or reverse resistance problems, and to avoid underdosing of potent antibiotics. The most recent information also indicates that it is best to limit empirical use of beta-lactam plus fluoroquinolone combination therapy, since these two classes activate some common resistance responses, and using them together can facilitate multidrug resistance in important pathogens, particularly Pseudomonas aeruginosa and Acinetobacter species. This review discusses the role of each major antimicrobial class on resistance development and presents specific strategies for combating the growing problem of multidrug-resistant bacteria. We now have the knowledge to better manage our antimicrobial agent prescribing practices, but finding the will and resources to apply our understanding remains a formidable challenge.

A Systematic Review of Quasi-Experimental Study Designs in the Fields of Infection Control and Antibiotic Resistance

We performed a systematic review of articles published during a 2-year period in 4 journals in the field of infectious diseases to determine the extent to which the quasi-experimental study design is used to evaluate infection control and antibiotic resistance. We evaluated studies on the basis of the following criteria: type of quasi-experimental study design used, justification of the use of the design, use of correct nomenclature to describe the design, and recognition of potential limitations of the design. A total of 73 articles featured a quasi-experimental study design. Twelve (16%) were associated with a quasi-experimental design involving a control group. Three (4%) provided justification for the use of the quasi-experimental study design. Sixteen (22%) used correct nomenclature to describe the study. Seventeen (23%) mentioned at least 1 of the potential limitations of the use of a quasi-experimental study design. The quasi-experimental study is used frequently in studies of infection control and antibiotic resistance. Efforts to improve the conduct and presentation of quasi-experimental studies are urgently needed to more rigorously evaluate interventions.

A multidisciplinary approach to antimicrobial stewardship: evolution into the 21st century

In the 21st century, we face the problems of escalating antibiotic resistance, difficult-to-treat infections and slowed new drug development. Healthcare practitioners are increasingly recognising the importance of good antimicrobial stewardship. Various strategies such as formulary management, prior approval, clinical pathways, post-prescribing evaluation and intravenous to oral conversion have been used singly or in combination to improve prescribing and reduce costs. Combining a multifaceted approach with a full-time dedicated multidisciplinary team appears to be capable of yielding satisfactory clinical and economic outcomes and most importantly, sustaining efforts of antimicrobial stewardship. The multidisciplinary approach to antibiotic management should be tailored to fit the individual needs of an institution. More data are needed to document effects on curbing resistance.