1
|
Freudenhammer M, Hufnagel M, Steib-Bauert M, Mansmann U, de With K, Fellhauer M, Kern WV. Antibiotic use in pediatric acute care hospitals: an analysis of antibiotic consumption data from Germany, 2013-2020. Infection 2024; 52:825-837. [PMID: 37917396 PMCID: PMC11143023 DOI: 10.1007/s15010-023-02112-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/08/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Antimicrobial stewardship (AMS) programs are effective tools for improving antibiotic prescription quality. Their implementation requires the regular surveillance of antibiotic consumption at the patient and institutional level. Our study captured and analyzed antibiotic consumption density (ACD) for hospitalized pediatric patients. METHOD We collected antibacterial drug consumption data for 2020 from hospital pharmacies at 113 pediatric departments of acute care hospitals in Germany. ACD was calculated as defined daily dose (DDD, WHO/ATC Index 2019) per 100 patient days (pd). In addition, we analyzed the trends in antibiotic use during 2013-2020. RESULTS In 2020, median ACD across all participating hospitals was 26.7 DDD/100 pd, (range: 10.1-79.2 DDD/100 pd). It was higher at university vs. non-university hospitals (38.6 vs. 25.2 DDD/100 pd, p < 0.0001). The highest use densities were seen on oncology wards and intensive care units at university hospitals (67.3 vs. 38.4 DDD/100 pd). During 2013-2020, overall ACD declined (- 10%) and cephalosporin prescriptions also decreased (- 36%). In 2020, cephalosporins nevertheless remained the most commonly dispensed class of antibiotics. Interhospital variability in cephalosporin/penicillin ratio was substantial. Antibiotics belonging to WHO AWaRe "Watch" and "Reserve" categories, including broad-spectrum penicillins (+ 31%), linezolid (+ 121%), and glycopeptides (+ 43%), increased over time. CONCLUSION Significant heterogeneity in ACD and prescription of different antibiotic classes as well as high prescription rates for cephalosporins and an increased use of reserve antibiotics indicate improvable antibiotic prescribing quality. AMS programs should urgently prioritize these issues to reduce antimicrobial resistance.
Collapse
Affiliation(s)
- Mirjam Freudenhammer
- Division of Pediatric Infectious Diseases and Rheumatology, Department of Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Freiburg, Germany.
- Center for Chronic Immunodeficiency, Institute for Immunodeficiency, University Medical Center Freiburg, Freiburg, Germany.
| | - Markus Hufnagel
- Division of Pediatric Infectious Diseases and Rheumatology, Department of Pediatrics and Adolescent Medicine, University Medical Center Freiburg, Freiburg, Germany
| | - Michaela Steib-Bauert
- Division of Infectious Diseases, Department of Internal Medicine II, University Medical Center Freiburg, Freiburg, Germany
| | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry and Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Katja de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus Dresden at the TU Dresden, Dresden, Germany
| | - Matthias Fellhauer
- Pharmacy/Institute for Clinical Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Internal Medicine II, University Medical Center Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
2
|
Turner K, McNett M, Potter C, Cramer E, Al Taweel M, Shorr RI, Mion LC. Alarm with care-a de-implementation strategy to reduce fall prevention alarm use in US hospitals: a study protocol for a hybrid 2 effectiveness-implementation trial. Implement Sci 2023; 18:70. [PMID: 38053114 PMCID: PMC10696656 DOI: 10.1186/s13012-023-01325-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Fall prevention alarms are commonly used among US hospitals as a fall prevention strategy despite limited evidence of effectiveness. Further, fall prevention alarms are harmful to healthcare staff (e.g., alarm fatigue) and patients (e.g., sleep disturbance, mobility restriction). There is a need for research to develop and test strategies for reducing use of fall prevention alarms in US hospitals. METHODS To address this gap, we propose testing the effectiveness and implementation of Alarm with Care, a de-implementation strategy to reduce fall prevention alarm use using a stepped-wedge randomized controlled trial among 30 adult medical or medical surgical units from nonfederal US acute care hospitals. Guided by the Choosing Wisely De-Implementation Framework, we will (1) identify barriers to fall prevention alarm de-implementation and develop tailored de-implementation strategies for each unit and (2) compare the implementation and effectiveness of high- versus low-intensity coaching to support site-specific de-implementation of fall prevention alarms. We will evaluate effectiveness and implementation outcomes and examine the effect of multi-level (e.g., hospital, unit, and patient) factors on effectiveness and implementation. Rate of fall prevention alarm use is the primary outcome. Balancing measures will include fall rates and fall-related injuries. Implementation outcomes will include feasibility, acceptability, appropriateness, and fidelity. DISCUSSION Findings from this line of research could be used to support scale-up of fall prevention alarm de-implementation in other healthcare settings. Further, research generated from this proposal will advance the field of de-implementation science by determining the extent to which low-intensity coaching is an effective and feasible de-implementation strategy. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT06089239 . Date of registration: October 17, 2023.
Collapse
Affiliation(s)
- Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, MFC-EDU, 12902 USF Magnolia Drive, Tampa, FL, 33612-9416, USA.
| | - Molly McNett
- Helene Fuld Health Trust National Institute for Evidence-Based Practice, The Ohio State University, 760 Kinnear Road, Columbus, OH, 43212, USA
| | - Catima Potter
- Press Ganey Associates, 1173 Ignition Dr, South Bend, IN, 46601, USA
| | - Emily Cramer
- Department of Health Outcomes and Health Services Research, Children's Mercy Hospital and Clinics, 2401 Gilham Road, Kansas City, MO, 64108, USA
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO, 64108, USA
| | - Mona Al Taweel
- College of Nursing, The Ohio State University, 1577 Neil Avenue, Columbus, OH, 43210, USA
| | - Ronald I Shorr
- Geriatric Research Education and Clinical Center, North Florida/South Georgia Veterans Health System, 1601 SW Archer Road, Gainesville, FL, 32608, USA
- Department of Epidemiology, College of Public Health and Health Professions, University of Florida, 1225 Center Drive, Gainesville, FL, 32611, USA
| | - Lorraine C Mion
- College of Nursing, The Ohio State University, 1577 Neil Avenue, Columbus, OH, 43210, USA
| |
Collapse
|
3
|
Kushala, Pemde H, Kumar V, Datta V, Saxena S. Quality improvement initiative improves the empiric antibiotic prescribing practices in a tertiary care children's hospital in India. BMJ Open Qual 2023; 12:e002181. [PMID: 37863510 PMCID: PMC10603470 DOI: 10.1136/bmjoq-2022-002181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 08/19/2023] [Indexed: 10/22/2023] Open
Abstract
INTRODUCTION Infections are a common cause of paediatric morbidity. Antibiotics are vital in treating them. Erratic prescribing practices are an important cause for the development of antibiotic resistance. Our objective was to estimate the effectiveness of educational interventions to improve empirical antibiotic prescribing practices among paediatric trainees. We aimed to improve the compliance to antibiotic protocols and to sustain it over 6 months. METHODS It is a time interrupted non-randomised trial conducted in a tertiary hospital in India. Initially, 200 admitted children were selected randomly. Their antibiotic prescriptions, adherence of prescriptions to the then existing antibiotics guidelines, course during hospital stay and the final outcome were noted. The existing antibiotic policy and its use were reviewed. It was then considered essential to prepare a fresh antibiotic policy based on national guidelines, local sensitivity patterns and with inputs from microbiologists. This was distributed to the residents through seminars, posters and cellphone friendly documents. Compliance to the policy was also tracked twice a week. The adherence to guideline was recorded in the subsequent 6 months. RESULTS The adherence of empirical antibiotic prescriptions was 59% before intervention which improved to 72% in the first month, 90% in the second month, 86% and 78% in the third and sixth months, respectively. There was no significant difference in duration of stay and the outcome at discharge in the patients in adherent and non-adherent groups. CONCLUSION Educational interventions and frequent monitoring improved antibiotic prescribing practices among residents with no negative impact on patient outcomes. Quality improvements need persistent reinforcement and frequent monitoring to be sustainable.
Collapse
Affiliation(s)
- Kushala
- Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India
| | - Harish Pemde
- Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India
| | - Virendra Kumar
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
| | - Vikram Datta
- Department of Neonatology, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Sonal Saxena
- Department of Microbiology, Maulana Azad Medical College, New Delhi, India
| |
Collapse
|
4
|
Scheithauer S, Karasimos B, Manamayil D, Häfner H, Lewalter K, Mischke K, Heintz B, Tacke F, Brücken D, Lüring C, Heidenhain C, Tewarie L, Hilgers RD, Lemmen SW. A prospective cluster trial to increase antibiotic prescription quality in seven non-ICU wards. GMS HYGIENE AND INFECTION CONTROL 2023; 18:Doc14. [PMID: 37405250 PMCID: PMC10316282 DOI: 10.3205/dgkh000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Aim To evaluate general shortcomings and faculty-specific pitfalls as well as to improve antibiotic prescription quality (ABQ) in non-ICU wards, we performed a prospective cluster trial. Methods An infectious-disease (ID) consulting service performed a prospective investigation consisting of three 12-week phases with point prevalence evaluation conducted once per week (=36 evaluations in total) at seven non-ICU wards, followed by assessment of sustainability (weeks 37-48). Baseline evaluation (phase 1) defined multifaceted interventions by identifying the main shortcomings. Then, to distinguish intervention from time effects, the interventions were performed in four wards, and the 3 remaining wards served as controls; after assessing effects (phase 2), the same interventions were performed in the remaining wards to test the generalizability of the interventions (phase 3). The prolonged responses after all interventions were then analyzed in phase 4. ABQ was evaluated by at least two ID specialists who assessed the indication for therapy, the adherence to the hospital guidelines for empirical therapy, and the overall antibiotic prescription quality. Results In phase 1, 406 of 659 (62%) patients cases were adequately treated with antibiotics; the main reason for inappropriate prescription was the lack of an indication (107/253; 42%). The antibiotic prescription quality (ABQ) significantly increased, reaching 86% in all wards after the focused interventions (502/584; nDf=3, ddf=1,697, F=6.9, p=0.0001). In phase 2 the effect was only seen in wards that already participated in interventions (248/347; 71%). No improvement was seen in wards that received interventions only after phase 2 (189/295; 64%). A given indication significantly increased from about 80% to more than 90% (p<.0001). No carryover effects were observed. Discussion ABQ can be improved significantly by intervention bundles with apparent sustainable effects.
Collapse
Affiliation(s)
- Simone Scheithauer
- Department of Infection Control and Infectious Diseases, University Medical Center Göttingen (UMG), Georg-August University Göttingen, Germany
| | - Britta Karasimos
- Clinic for Orthopedics and Trauma Surgery, Hospital Düren, Düren, Germany
| | - David Manamayil
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| | - Helga Häfner
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| | - Karl Lewalter
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| | - Karl Mischke
- Medical Clinic 1, Leopoldina Hospital Schweinfurt, Schweinfurt, Germany
| | - Bernhard Heintz
- Clinic for Nephrology, University Hospital Aachen, Aachen, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte (CCM)/Campus Virchow-Klinikum (CVK, Charité – University Medical Center Berlin, Berlin, Germany
| | - David Brücken
- Clinic for Traumatology, University Hospital Aachen, Aachen, Germany
| | | | - Christoph Heidenhain
- Clinic for Visceral Surgery, AGAPLESION MARKUS Krankenhaus Frankfurt, Frankfurt/Main, Germany
| | | | | | - Sebastian W. Lemmen
- Infection Control and Infectious Diseases, University Hospital Aachen, Aachen, Germany
| |
Collapse
|
5
|
Karimi G, Kabir K, Farrokhi B, Abbaszadeh E, Esmaeili ED, Khodamoradi F, Sarbazi E, Azizi H. Prescribing pattern of antibiotics by family physicians in primary health care. J Pharm Policy Pract 2023; 16:11. [PMID: 36658638 PMCID: PMC9854067 DOI: 10.1186/s40545-023-00515-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 01/06/2023] [Indexed: 01/20/2023] Open
Abstract
PURPOSE Irrational prescription of antibiotics is an ongoing global public health concern, leading to antibiotic resistance. Understanding the prescribing pattern of antibiotics is important to tackling mal-prescription and antibiotic resistance. We aimed to investigate the pattern and factors affecting outpatients' antibiotic prescribing by family physicians in Primary Health Care (PHC). METHODS A cross-sectional study was conducted in 19 PHC facilities in Alborz province. Prescribing pattern of antibiotics was evaluated among 1068 prescriptions by family physicians. Prescribing pattern of antibiotics included prescriptions containing antibiotics, the number of antibiotics per prescription, type, name of antibiotic, and mal-prescription. Multiple logistic regression analysis was used to estimate the adjusted odds ratios and 95% confidence intervals. RESULTS Overall, 57% of the prescriptions had ≥ 1 antibiotic and the average number of antibiotics per prescription was 1.27. Amoxicillin was the commonly prescribed antibiotic. There was a significant relationship between age, sex, type of health insurance, work experience of the physician, and seasons with antibiotic prescribing (P < 0.05). In 59.31% of antibiotic prescriptions at least one of the scientific criteria was not fulfilled. In the final analysis, after adjusting for the potential confounders, field experts of physicians (OR = 1.59; 95% CI: 1.08-6.17), female sex (OR = 2.23; 95% CI: 1.18-4.21), and winter season (OR = 3.34; 95% CI: 1.26-8.15) were found associated factors with antibiotic prescribing. CONCLUSION The average number of antibiotics per prescription and the percentage of irrational prescriptions were relatively high in this study. There is need to improve antibiotic prescribing patterns among family physicians working in primary health care.
Collapse
Affiliation(s)
- Gholamali Karimi
- grid.449129.30000 0004 0611 9408Student Research Committee, Department of Epidemiology, School of Public Health, Ilam University of Medical Sciences, Ilam, Iran ,grid.411705.60000 0001 0166 0922Savojbolagh Health Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Kourosh Kabir
- grid.411705.60000 0001 0166 0922Department of Community Medicine , School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Babak Farrokhi
- Executive Deputy National Director for Family Medicine, Health Network Administration Center, Undersecretary for Health Affairs, Ministry of Health, Tehran, Iran
| | - Effat Abbaszadeh
- grid.411705.60000 0001 0166 0922Savojbolagh Health Center, Alborz University of Medical Sciences, Karaj, Iran
| | - Elham Davtalab Esmaeili
- grid.412888.f0000 0001 2174 8913Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farzad Khodamoradi
- grid.411230.50000 0000 9296 6873Department of Social Medicine, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ehsan Sarbazi
- grid.412888.f0000 0001 2174 8913Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hosein Azizi
- grid.412888.f0000 0001 2174 8913Women’s Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran ,grid.411705.60000 0001 0166 0922Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
6
|
Martínez-de la Cruz P, Moreno-Núñez L, Álvarez-Atienza S, Sanz-Márquez S, Valverde-Canovas JF, Losa-García JE. Antibiotic discontinuation through an antibiotic treatment optimization program in emergency department patients with low suspicion of infection. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2022:S2529-993X(22)00212-X. [PMID: 36347790 DOI: 10.1016/j.eimce.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION One of the most important strategies of PROA in the Emergency Department (ED) is the accurate diagnosis of infection to avoid inappropriate prescription. Our objective is to evaluate patients who receive antibiotics despite not having objective data of infection. METHODS We carried out a cross-sectional study of patients admitted to the ED of the Hospital Universitario Fundación Alcorcón in which it was recommended to suspend the antibiotic through the PROA. Clinical and epidemiological characteristics and 30-day follow-up were analyzed to assess readmissions and mortality. RESULTS 145 patients were analyzed. It was recommended to suspend the antibiotic in 25. 44% of them had a diagnosis of urinary infection. The suspension recommendation was accepted by 88%. No patient died and one was readmitted. CONCLUSIONS An important percentage of patients are prescribed antibiotics despite not having infection criteria, the clinical evolution after suspension of antibiotics was favorable.
Collapse
Affiliation(s)
| | - Leonor Moreno-Núñez
- Servicio de Medicina Interna, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | - Sira Sanz-Márquez
- Servicio de Farmacia, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | | | | |
Collapse
|
7
|
Papanikolopoulou A, Maltezou HC, Kritikou H, Papadopoulos T, Kandalepas G, Pentzouris A, Kartsonakis I, Chronopoulou G, Gargalianos-Kakolyris P, Pantazis N, Tsakris A, Kantzanou M. Six-Year Time-Series Data on Multidrug-Resistant Bacteremia, Antibiotic Consumption, and Infection Control Interventions in a Hospital. Microb Drug Resist 2022; 28:806-818. [PMID: 35834622 DOI: 10.1089/mdr.2022.0074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Background: Multidrug-resistant (MDR) bacteremia is a serious health care-associated infection with significant morbidity and excess hospitalization costs. Our aim is to study the association between incidences of MDR bacteremia, antibiotic consumption, and infection control measures in a hospital from 2013 to 2018. Methods: We analyzed the following indices: (1) incidence of bacteremia (carbapenem-resistant Acinetobacter baumanii, Pseudomonas aeruginosa, and Klebsiella pneumoniae, methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci); (2) use of antibiotics; (3) consumption of disinfectant solutions for hand hygiene; and (4) isolation rates of MDR carrier patients. Findings: The use of advanced antibiotics (p = 0.001) and carbapenems (p = 0.008) decreased significantly in all hospital departments but the incidence of total MDR bacteremia did not change significantly. Increased use of hand disinfectant solutions was statistically associated with decreased incidence of total MDR bacteremia (incidence rate ratio [IRR]: 0.94, confidence interval [95% CI]: 0.90-0.99, p: 0.020) in all hospital. Also, increased isolation rates of MDR carrier patients 2 months before correlated with decreased incidence of bacteremia due to carbapenem-resistant gram-negative pathogens (IRR: 0.35, 95% CI: 0.18-0.66, p: 0.001) in adults intensive care unit. Conclusion: In our hospital, hand hygiene and isolation of MDR carrier patients controlled MDR bacteremia.
Collapse
Affiliation(s)
| | - Helena C Maltezou
- Directorate of Research, Studies and Documentation, National Public Health Organization, Athens, Greece
| | - Helen Kritikou
- Department of Pharmacy, Alexandra General Hospital, Athens, Greece
| | - Thomas Papadopoulos
- Department of Pharmacy, European Interbalkan Medical Center, Thessaloniki, Greece
| | | | | | | | | | | | - Nikos Pantazis
- Department of Hygiene, Epidemiology and Medical Statistics, Faculty of Medicine, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Tsakris
- Department of Microbiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Kantzanou
- Department of Hygiene, Epidemiology and Medical Statistics, Faculty of Medicine, School of Health Sciences, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
8
|
High J, Enne VI, Barber JA, Brealey D, Turner DA, Horne R, Peters M, Dhesi Z, Wagner AP, Pandolfo AM, Stirling S, Russell C, O'Grady J, Swart AM, Gant V, Livermore DM. INHALE: the impact of using FilmArray Pneumonia Panel molecular diagnostics for hospital-acquired and ventilator-associated pneumonia on antimicrobial stewardship and patient outcomes in UK Critical Care-study protocol for a multicentre randomised controlled trial. Trials 2021; 22:680. [PMID: 34620213 PMCID: PMC8496625 DOI: 10.1186/s13063-021-05618-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 09/13/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Hospital-acquired and ventilator-associated pneumonias (HAP and VAP) are common in critical care and can be life-threatening. Rapid microbiological diagnostics, linked to an algorithm to translate their results into antibiotic choices, could simultaneously improve patient outcomes and antimicrobial stewardship. METHODS The INHALE Randomised Controlled Trial is a multi-centre, parallel study exploring the potential of the BioFire FilmArray molecular diagnostic to guide antibiotic treatment of HAP/VAP in intensive care units (ICU); it identifies pathogens and key antibiotic resistance in around 90 min. The comparator is standard care whereby the patient receives empirical antibiotics until microbiological culture results become available, typically after 48-72 h. Adult and paediatric ICU patients are eligible if they are about to receive antibiotics for a suspected lower respiratory infection (including HAP/VAP) for the first time or a change in antibiotic because of a deteriorating clinical condition. Breathing spontaneously or intubated, they must have been hospitalised for 48 h or more. Patients are randomised 1:1 to receive either antibiotics guided by the FilmArray molecular diagnostic and its trial-based prescribing algorithm or standard care, meaning empirical antibiotics based on local policy, adapted subsequently based upon local microbiology culture results. Co-primary outcomes are (i) non-inferiority in clinical cure of pneumonia at 14 days post-randomisation and (ii) superiority in antimicrobial stewardship at 24 h post-randomisation (defined as % of patients on active and proportionate antibiotics). Secondary outcomes include further stewardship reviews; length of ICU stay; co-morbidity indicators, including septic shock, change in sequential organ failure assessment scores, and secondary pneumonias; ventilator-free days; adverse events over 21 days; all-cause mortality; and total antibiotic usage. Both cost-effectiveness of the molecular diagnostic-guided therapy and behavioural aspects determining antibiotic prescribing are being explored. A sample size of 552 will be required to detect clinically significant results with 90% power and 5% significance for the co-primary outcomes. DISCUSSION This trial will test whether the potential merits of rapid molecular diagnostics for pathogen and resistance detection in HAP/VAP are realised in patient outcomes and/or improved antibiotic stewardship. TRIAL REGISTRATION ISRCTN Registry ISRCTN16483855 . Retrospectively registered on 15 July 2019.
Collapse
Affiliation(s)
- Juliet High
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, NR4 7TJ, UK.
| | - Virve I Enne
- University College London, Gower Street, London, WC1E 6BT, UK
| | - Julie A Barber
- University College London, Gower Street, London, WC1E 6BT, UK
| | - David Brealey
- NIHR University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, NW1 2PG, UK
| | - David A Turner
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Robert Horne
- University College London, Gower Street, London, WC1E 6BT, UK
| | - Mark Peters
- University College London Great Ormond Street Institute of Child Health and Great Ormond Street Hospital NIHR Biomedical Research Centre, WC1N 3JH, London, WC1N 3JH, UK
| | - Zaneeta Dhesi
- University College London, Gower Street, London, WC1E 6BT, UK
| | - Adam P Wagner
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, NR4 7TJ, UK
| | | | - Sue Stirling
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Charlotte Russell
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Justin O'Grady
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
- Quadram Institute Bioscience, Norwich Research Park, Norwich, NR4 7UA, UK
| | - Ann Marie Swart
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, NR4 7TJ, UK
| | - Vanya Gant
- University College London Hospitals NHS Foundation Trust, London, NW1 2PG, UK
| | - David M Livermore
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| |
Collapse
|
9
|
Ang CY, Dhaliwal JS, Muharram SH, Akkawi ME, Hussain Z, Rahman H, Kok YY, Dhaliwal SKS, Ming LC. Educational resource for antimicrobial resistance and stewardship for dentistry programmes: a research protocol. BMJ Open 2021; 11:e048609. [PMID: 34233993 PMCID: PMC8264905 DOI: 10.1136/bmjopen-2021-048609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Antimicrobial resistance (AMR) is a global public and patient safety issue. With the high AMR risk, ensuring that the next generation of dentists that have optimal knowledge and confidence in the area of AMR is crucial. A systematic approach is vital to design an AMR content that is comprehensive and clinically relevant. The primary objective of this research study will be to implement a consensus-based approach to elucidate AMR content and curriculum priorities for professional dentistry programmes. This research aims to establish consensus along with eliciting opinion on appropriate AMR topics to be covered in the Bachelor of Dental Surgery syllabus. METHODS AND ANALYSIS A three-phase approach to validate content for curriculum guidelines on AMR will be adopted. First, literature review and content analysis were conducted to find out the available pertinent literature in dentistry programmes. A total of 23 potential literature have been chosen for inclusion within this study following literature review and analysis in phase 1. The materials found will be used to draft curriculum on antimicrobials for dentistry programmes. The next phase involves the validation of the drafted curriculum content by recruiting local and foreign experts via a survey questionnaire. Finally, Delphi technique will be conducted to obtain consensus on the important or controversial modifications to the revised curriculum. ETHICS AND DISSEMINATION An ethics application is currently under review with the Institute of Health Science Research Ethics Committee, Universiti Brunei Darussalam. All participants are required to provide a written consent form. Findings will be used to identify significant knowledge gaps on AMR aspect in a way that results in lasting change in clinical practice. Moreover, AMR content priorities related to dentistry clinical practice will be determined in order to develop need-based educational resource on microbes, hygiene and prudent antimicrobial use for dentistry programmes.
Collapse
Affiliation(s)
- Chuan Yok Ang
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences, Universiti Brunei Darussalam (UBD), Gadong, Brunei Darussalam
| | - Jagjit Singh Dhaliwal
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences, Universiti Brunei Darussalam (UBD), Gadong, Brunei Darussalam
| | - Siti Hanna Muharram
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences, Universiti Brunei Darussalam (UBD), Gadong, Brunei Darussalam
| | - Muhammad Eid Akkawi
- Kulliyyah of Pharmacy, International Islamic University, Kuantan Campus, Kuantan, Malaysia
| | - Zahid Hussain
- University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Hanif Rahman
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences, Universiti Brunei Darussalam (UBD), Gadong, Brunei Darussalam
| | - Yuh Yen Kok
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences, Universiti Brunei Darussalam (UBD), Gadong, Brunei Darussalam
| | - Sachinjeet Kaur Sodhi Dhaliwal
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences, Universiti Brunei Darussalam (UBD), Gadong, Brunei Darussalam
| | - Long Chiau Ming
- Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah Institute of Health Sciences, Universiti Brunei Darussalam (UBD), Gadong, Brunei Darussalam
| |
Collapse
|
10
|
Yusef D, Hayajneh WA, Bani Issa A, Haddad R, Al-Azzam S, Lattyak EA, Lattyak WJ, Gould I, Conway BR, Bond S, Conlon-Bingham G, Aldeyab MA. Impact of an antimicrobial stewardship programme on reducing broad-spectrum antibiotic use and its effect on carbapenem-resistant Acinetobacter baumannii (CRAb) in hospitals in Jordan. J Antimicrob Chemother 2021; 76:516-523. [PMID: 33219679 DOI: 10.1093/jac/dkaa464] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/06/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate the impact of an antimicrobial stewardship programme (ASP) on reducing broad-spectrum antibiotic use and its effect on carbapenem-resistant Acinetobacter baumannii (CRAb) in hospitalized patients. METHODS The study was a retrospective, ecological assessment in a tertiary teaching hospital over 6 years (January 2014 to December 2019). The intervention involved the implementation of an ASP in February 2018, which remains in effect today. This ASP consists of several components, including education, antibiotic guidelines, antibiotic restriction policy with prior approval, audit of compliance to the restriction policy and feedback. Restricted antibiotics were imipenem/cilastatin, ertapenem, meropenem, vancomycin, teicoplanin, tigecycline, colistin, amikacin, piperacillin/tazobactam, levofloxacin and ciprofloxacin. The intervention was evaluated by time-series methods. RESULTS Statistically significant decreases in the level of antibiotic use, after the introduction of the ASP, were observed for the following antibiotics: imipenem/cilastatin (P = 0.0008), all carbapenems (P = 0.0001), vancomycin (P = 0.0006), colistin (P = 0.0016) and third-generation cephalosporins (P = 0.0004). A statistically significant decrease in the slope, after the introduction of the ASP, for ertapenem (P = 0.0044) and ciprofloxacin (P = 0.0117) was observed. For piperacillin/tazobactam, there was a significant increasing trend (P = 0.0208) before the introduction of the ASP. However, this increased trend was halted post-introduction of the ASP (P = 0.4574). The introduction of the ASP was associated with a significant impact on reducing the levels of CRAb (P = 0.0237). CONCLUSIONS The introduced antimicrobial stewardship interventions contributed to a reduction in the use of several broad-spectrum antibiotics, reversed the trends of increasing use of other antibiotics and were associated with a significant reduction in CRAb.
Collapse
Affiliation(s)
- Dawood Yusef
- Department of Paediatrics and Neonatology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Wail A Hayajneh
- Department of Paediatrics and Neonatology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Ali Bani Issa
- Infection Control Division, King Abdullah University Hospital, Irbid, Jordan
| | - Rami Haddad
- Information Technology Department, King Abdullah University Hospital, Irbid, Jordan
| | - Sayer Al-Azzam
- Clinical Pharmacy Department, Jordan University of Science and Technology, Irbid, Jordan
| | | | | | - Ian Gould
- Medical Microbiology Department, Aberdeen Royal Infirmary, Aberdeen, Scotland, UK
| | - Barbara R Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK.,Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield, UK
| | - Stuart Bond
- Pharmacy Department, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | | | - Mamoon A Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield, UK
| |
Collapse
|
11
|
Dos Santos FM, Pflüger PF, Lazzarotto L, Uczay M, de Aguida WR, da Silva LS, Boaretto FBM, de Sousa JT, Picada JN, da Silva Torres IL, Pereira P. Gamma-Decanolactone Alters the Expression of GluN2B, A 1 Receptors, and COX-2 and Reduces DNA Damage in the PTZ-Induced Seizure Model After Subchronic Treatment in Mice. Neurochem Res 2021; 46:2066-2078. [PMID: 34019198 DOI: 10.1007/s11064-021-03345-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 04/05/2021] [Accepted: 05/12/2021] [Indexed: 11/26/2022]
Abstract
Gamma-decanolactone (GD) has been shown to reduce epileptic behavior in different models, inflammatory decreasing, oxidative stress, and genotoxic parameters. This study assessed the GD effect on the pentylenetetrazole (PTZ) model after acute and subchronic treatment. We evaluated the expression of the inflammatory marker cyclooxygenase-2 (COX-2), GluN2B, a subunit of the NMDA glutamate receptor, adenosine A1 receptor, and GD genotoxicity and mutagenicity. Male and female mice were treated with GD (300 mg/kg) for 12 days. On the tenth day, they were tested in the Hot Plate test. On the thirteenth day, all animals received PTZ (90 mg/kg), and epileptic behavior PTZ-induced was observed for 30 min. Pregabalin (PGB) (30 mg/kg) was used as a positive control. Samples of the hippocampus and blood were collected for Western Blotting analyses and Comet Assay and bone marrow to the Micronucleus test. Only the acute treatment of GD reduced the seizure occurrence and increased the latency to the first stage 3 seizures. Males treated with GD for 12 days demonstrated a significant increase in the expression of the GluN2B receptor and a decrease in the COX-2 expression. Acute and subchronic treatment with GD and PGB reduced the DNA damage produced by PTZ in males and females. There is no increase in the micronucleus frequency in bone marrow after subchronic treatment. This study suggests that GD, after 12 days, could not reduce PTZ-induced seizures, but it has been shown to protect against DNA damage, reduce COX-2 and increase GluN2B expression.
Collapse
Affiliation(s)
- Fernanda Marcelia Dos Santos
- Laboratory of Neuropharmacology and Preclinical Toxicology, Health Basic Sciences Institute, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Pricila Fernandes Pflüger
- Laboratory of Neuropharmacology and Preclinical Toxicology, Health Basic Sciences Institute, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Leticia Lazzarotto
- Laboratory of Neuropharmacology and Preclinical Toxicology, Health Basic Sciences Institute, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Mariana Uczay
- Laboratory of Neuropharmacology and Preclinical Toxicology, Health Basic Sciences Institute, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Wesley Roberto de Aguida
- Laboratory of Neuropharmacology and Preclinical Toxicology, Health Basic Sciences Institute, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Lisiane Santos da Silva
- Laboratory of Pain Pharmacology and Neuromodulation: Pre-Clinical Research. Postgraduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | | | | | | | - Iraci Lucena da Silva Torres
- Laboratory of Pain Pharmacology and Neuromodulation: Pre-Clinical Research. Postgraduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Patrícia Pereira
- Laboratory of Neuropharmacology and Preclinical Toxicology, Health Basic Sciences Institute, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil.
- Laboratory of Neuropharmacology and Preclinical Toxicology, Department of Pharmacology, Institute of Basic Health Sciences, Federal University of Rio Grande do Sul, Sarmento Leite 500/305, Porto Alegre, RS, CEP 90050-170, Brazil.
| |
Collapse
|
12
|
Patey AM, Grimshaw JM, Francis JJ. Changing behaviour, 'more or less': do implementation and de-implementation interventions include different behaviour change techniques? Implement Sci 2021; 16:20. [PMID: 33632274 PMCID: PMC7905859 DOI: 10.1186/s13012-021-01089-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/10/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Decreasing ineffective or harmful healthcare practices (de-implementation) may require different approaches than those used to promote uptake of effective practices (implementation). Few psychological theories differentiate between processes involved in decreasing, versus increasing, behaviour. However, it is unknown whether implementation and de-implementation interventions already use different approaches. We used the behaviour change technique (BCT) taxonomy (version 1) (which includes 93 BCTs organised into 12 groupings) to investigate whether implementation and de-implementation interventions for clinician behaviour change use different BCTs. METHODS Intervention descriptions in 181 articles from three systematic reviews in the Cochrane Library were coded for (a) implementation versus de-implementation and (b) intervention content (BCTs) using the BCT taxonomy (v1). BCT frequencies were calculated and compared using Pearson's chi-squared (χ2), Yates' continuity correction and Fisher's exact test, where appropriate. Identified BCTs were ranked according to frequency and rankings for de-implementation versus implementation interventions were compared and described. RESULTS Twenty-nine and 25 BCTs were identified in implementation and de-implementation interventions respectively. Feedback on behaviour was identified more frequently in implementation than de-implementation (Χ2(2, n=178) = 15.693, p = .000057). Three BCTs were identified more frequently in de-implementation than implementation: Behaviour substitution (Χ2(2, n=178) = 14.561, p = .0001; Yates' continuity correction); Monitoring of behaviour by others without feedback (Χ2(2, n=178) = 16.187, p = .000057; Yates' continuity correction); and Restructuring social environment (p = .000273; Fisher's 2-sided exact test). CONCLUSIONS There were some significant differences between BCTs reported in implementation and de-implementation interventions suggesting that researchers may have implicit theories about different BCTs required for de-implementation and implementation. These findings do not imply that the BCTs identified as targeting implementation or de-implementation are effective, rather simply that they were more frequently used. These findings require replication for a wider range of clinical behaviours. The continued accumulation of additional knowledge and evidence into whether implementation and de-implementation is different will serve to better inform researchers and, subsequently, improve methods for intervention design.
Collapse
Affiliation(s)
- Andrea M Patey
- School of Health Sciences, City, University of London, 10 Northampton Square, London, EC1V 0HB, UK. .,Centre of Implementation Research, Ottawa Hospital Research Institute - General Campus, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada.
| | - Jeremy M Grimshaw
- Centre of Implementation Research, Ottawa Hospital Research Institute - General Campus, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada.,Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8M5, Canada
| | - Jill J Francis
- School of Health Sciences, City, University of London, 10 Northampton Square, London, EC1V 0HB, UK.,Centre of Implementation Research, Ottawa Hospital Research Institute - General Campus, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada.,School of Health Sciences, University of Melbourne, Melbourne, Victoria, 3010, Australia
| |
Collapse
|
13
|
Evaluation of an Antimicrobial Stewardship Program for Wound and Burn Care in Three Hospitals in Nepal. Antibiotics (Basel) 2020; 9:antibiotics9120914. [PMID: 33339283 PMCID: PMC7766399 DOI: 10.3390/antibiotics9120914] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 01/01/2023] Open
Abstract
Antimicrobial stewardship (AMS) programs can decrease non-optimal use of antibiotics in hospital settings. There are limited data on AMS programs in burn and chronic wound centers in low- and middle-income countries (LMIC). A post-prescription review and feedback (PPRF) program was implemented in three hospitals in Nepal with a focus on wound and burn care. A total of 241 baseline and 236 post-intervention patient chart data were collected from three hospitals. There was a significant decrease in utilizing days of therapy per 1000 patient days (DOT/1000 PD) of penicillin (p = 0.02), aminoglycoside (p < 0.001), and cephalosporin (p = 0.04). Increases in DOT/1000 PD at post-intervention were significant for metronidazole (p < 0.001), quinolone (p = 0.01), and other antibiotics (p < 0.001). Changes in use of antibiotics varied across hospitals, e.g., cephalosporin use decreased significantly at Kirtipur Hospital (p < 0.001) and Pokhara Academy of Health Sciences (p = 0.02), but not at Kathmandu Model Hospital (p = 0.59). An independent review conducted by infectious disease specialists at the Henry Ford Health System revealed significant changes in antibiotic prescribing practices both overall and by hospital. There was a decrease in mean number of intravenous antibiotic days between baseline (10.1 (SD 8.8)) and post-intervention (8.8 (SD 6.5)) (t = 3.56; p < 0.001), but no difference for oral antibiotics. Compared to baseline, over the 6-month post-intervention period, we found an increase in justified use of antibiotics (p < 0.001), de-escalation (p < 0.001), accurate documentation (p < 0.001), and adherence to the study antibiotic prescribing guidelines at 72 h (p < 0.001) and after diagnoses (p < 0.001). The evaluation data presented provide evidence that PPRF training and program implementation can contribute to hospital-based antibiotic stewardship for wound and burn care in Nepal.
Collapse
|
14
|
Bouza E, Aguado JM, Alcalá L, Almirante B, Alonso-Fernández P, Borges M, Cobo J, Guardiola J, Horcajada JP, Maseda E, Mensa J, Merchante N, Muñoz P, Pérez Sáenz JL, Pujol M, Reigadas E, Salavert M, Barberán J. Recommendations for the diagnosis and treatment of Clostridioides difficile infection: An official clinical practice guideline of the Spanish Society of Chemotherapy (SEQ), Spanish Society of Internal Medicine (SEMI) and the working group of Postoperative Infection of the Spanish Society of Anesthesia and Reanimation (SEDAR). REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2020; 33:151-175. [PMID: 32080996 PMCID: PMC7111242 DOI: 10.37201/req/2065.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/26/2020] [Indexed: 12/12/2022]
Abstract
This document gathers the opinion of a multidisciplinary forum of experts on different aspects of the diagnosis and treatment of Clostridioides difficile infection (CDI) in Spain. It has been structured around a series of questions that the attendees considered relevant and in which a consensus opinion was reached. The main messages were as follows: CDI should be suspected in patients older than 2 years of age in the presence of diarrhea, paralytic ileus and unexplained leukocytosis, even in the absence of classical risk factors. With a few exceptions, a single stool sample is sufficient for diagnosis, which can be sent to the laboratory with or without transportation media for enteropathogenic bacteria. In the absence of diarrhoea, rectal swabs may be valid. The microbiology laboratory should include C. difficile among the pathogens routinely searched in patients with diarrhoea. Laboratory tests in different order and sequence schemes include GDH detection, presence of toxins, molecular tests and toxigenic culture. Immediate determination of sensitivity to drugs such as vancomycin, metronidazole or fidaxomycin is not required. The evolution of toxin persistence is not a suitable test for follow up. Laboratory diagnosis of CDI should be rapid and results reported and interpreted to clinicians immediately. In addition to the basic support of all diarrheic episodes, CDI treatment requires the suppression of antiperistaltic agents, proton pump inhibitors and antibiotics, where possible. Oral vancomycin and fidaxomycin are the antibacterials of choice in treatment, intravenous metronidazole being restricted for patients in whom the presence of the above drugs in the intestinal lumen cannot be assured. Fecal material transplantation is the treatment of choice for patients with multiple recurrences but uncertainties persist regarding its standardization and safety. Bezlotoxumab is a monoclonal antibody to C. difficile toxin B that should be administered to patients at high risk of recurrence. Surgery is becoming less and less necessary and prevention with vaccines is under research. Probiotics have so far not been shown to be therapeutically or preventively effective. The therapeutic strategy should be based, rather than on the number of episodes, on the severity of the episodes and on their potential to recur. Some data point to the efficacy of oral vancomycin prophylaxis in patients who reccur CDI when systemic antibiotics are required again.
Collapse
Affiliation(s)
- E Bouza
- Emilio Bouza MD, PhD, Instituto de Investigación Sanitaria Gregorio Marañón, Servicio de Microbiología Clínica y E. Infecciosas C/ Dr. Esquerdo, 46 - 28007 Madrid, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Tulloch LG, Relan A, Curello J, Martin E, Patel R, Vijayan T. Using Modified Team-Based Learning to Teach Antimicrobial Stewardship to Medical Students: One Institution's Approach. MEDICAL SCIENCE EDUCATOR 2019; 29:1179-1185. [PMID: 34457601 PMCID: PMC8368895 DOI: 10.1007/s40670-019-00804-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Educational interventions are a critical feature of antimicrobial stewardship programs. Most of these interventions target practicing physicians whose prescribing habits are usually difficult to influence. Consequently, there has been increasing interest in familiarizing early learners with the principles of antimicrobial stewardship. However, there is limited data regarding the utility of active learning interventions, such as team-based learning (TBL), for this purpose. In this article, we report the results of a post-course survey eliciting the opinions of the 168 second year medical students who completed the first implementation of a modified TBL course on antimicrobial stewardship. The course consisted of two 120-min modules, each of which guided participant students through most of the characteristic stages of TBL. The post-course survey was analyzed using qualitative and quantitative methodologies. In general, students found the readiness assurance testing, application activity, and team dynamics of TBL effective and the webcasts, used for pre-class preparation, ineffective. This study offers a first glimpse into the attitudes of pre-clinical medical students toward TBL as a strategy for introducing antimicrobial stewardship. It can serve as a roadmap for educators contemplating the implementation of a similar program at their institution and as a launching pad for research on the effects of this type of intervention on physician prescribing habits.
Collapse
Affiliation(s)
- Luis Gonzaga Tulloch
- Puget Sound Veterans Affairs Healthcare System, Hospital and Specialty Medicine, 1660 S. Columbian Way, S-111-MED, Seattle, WA USA
| | - Anju Relan
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA USA
| | - Jennifer Curello
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA USA
| | - Elise Martin
- University of Pittsburg Medical Center, Pittsburg, PA USA
| | - Roma Patel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA USA
| | - Tara Vijayan
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA USA
| |
Collapse
|
16
|
Huynh N, Baumann A, Loeb M. Reporting quality of the 2014 Ebola outbreak in Africa: A systematic analysis. PLoS One 2019; 14:e0218170. [PMID: 31237909 PMCID: PMC6592536 DOI: 10.1371/journal.pone.0218170] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 05/28/2019] [Indexed: 11/18/2022] Open
Abstract
The objective of this study was to conduct a systematic analysis of the reporting quality of the Ebola Virus Disease (EVD) outbreak in West Africa from 2014-2018 using the Modified STROBE statement. We included studies on the 2014 EVD outbreak alone, limited to those on human patients in Africa. We searched the following databases (MEDLINE, EMBASE, and Web of Science) for outbreak reports published between 2014-2018. We assessed factors potentially associated with the quality of reporting. A total of 69 of 131 (53%) articles within the full-text review fulfilled our eligibility criteria and underwent the Modified STROBE assessment for analyzing the quality of reporting. The Modified STROBE scores of the included studies ranged from 11-26 points and the mean was found to be 19.54 out of 30 with a standard deviation (SD) of ± 4.30. The top three reported Modified STROBE components were descriptive characteristics of study participants, scientific background and evidence rational, and clinical significance of observations. More than 75% of the studies met a majority of the criteria in the Modified STROBE assessment tool. Information that was commonly missing included addressing potential source of bias, sensitivity analysis, further results/analysis such as risk estimates and odds ratios, presence of a flowchart, and addressing missing data. In multivariable analysis, peer-reviewed publication was the only predictor that remained significantly associated with a higher Modified STROBE score. In conclusion, the large range of Modified STROBE scores observed indicates variability in the quality of outbreak reports for EVD. The review identified strong reporting in some areas, whereas other areas are in need of improvement, in particular providing an important description of the outbreak setting and identifying any external elements (potential biases and confounding factors) that could hinder the credibility of the findings.
Collapse
Affiliation(s)
- Nina Huynh
- Global Health Office, McMaster University, Hamilton, Ontario, Canada
| | - Andrea Baumann
- Global Health Office, McMaster University, Hamilton, Ontario, Canada
| | - Mark Loeb
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Michael G DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
17
|
Charani E, Holmes A. Antibiotic Stewardship-Twenty Years in the Making. Antibiotics (Basel) 2019; 8:E7. [PMID: 30678365 PMCID: PMC6466570 DOI: 10.3390/antibiotics8010007] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/09/2019] [Accepted: 01/21/2019] [Indexed: 11/21/2022] Open
Abstract
In the last 20 years, efforts were made to optimize antibiotic use in hospitals across the world as a means of addressing the increasing threat of antibiotic resistance. Despite robust evidence supporting optimal practice, antibiotic decision-making remains sub-optimal in many settings, including in hospitals. Globally, resources remain a limiting factor in the implementation of antibiotic stewardship programs. In addition, antibiotic decision-making is a social process dependent on cultural and contextual factors. Cultural boundaries in healthcare and across specialties still limit the involvement of allied healthcare professionals in stewardship interventions. There is variation in the social norms and antibiotic-prescribing behaviors between specialties in hospitals. The cultural differences between specialties and healthcare professionals (1) shape the shared knowledge within and across specialties in the patient pathway, and (2) result in variation in care, thus impacting patient outcomes. Bespoke stewardship interventions that account for contextual variation in practice are necessary.
Collapse
Affiliation(s)
- Esmita Charani
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, 8th Floor Commonwealth Building, Imperial College London, London W12 0HS, UK.
| | - Alison Holmes
- National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, 8th Floor Commonwealth Building, Imperial College London, London W12 0HS, UK.
| |
Collapse
|
18
|
Abstract
While antimicrobial resistance is already a public health crisis in human medicine, therapeutic failure in veterinary medicine due to antimicrobial resistance remains relatively uncommon. However, there are many pathways by which antimicrobial resistance determinants can travel between animals and humans: by close contact, through the food chain, or indirectly via the environment. Antimicrobial stewardship describes measures that can help mitigate the public health crisis and preserve the effectiveness of available antimicrobial agents. Antimicrobial stewardship programs have been principally developed, implemented, and studied in human hospitals but are beginning to be adapted for other applications in human medicine. Key learning from the experiences of antimicrobial stewardship programs in human medicine are summarized in this article-guiding the development of a stewardship framework suitable for adaptation and use in both companion animal and livestock practice. The antimicrobial stewardship program for veterinary use integrates infection prevention and control together with approaches emphasizing avoidance of antimicrobial agents. The 5R framework of continuous improvement that is described recognizes the importance of executive support; highly motivated organizations and teams (responsibility); the need to review the starting position, set objectives, and determine means of measuring progress and success; and a critical focus on reducing, replacing, and refining the use of antimicrobial agents. Significant issues that are currently the focus of intensive research include improved detection and diagnosis of infections, refined dosing regimens that are simultaneously effective while not selecting resistance, searches for alternatives to antimicrobial agents, and development of improved vaccines to enhance immunity and reduce disease.
Collapse
|
19
|
Charani E, Smith I, Skodvin B, Perozziello A, Lucet JC, Lescure FX, Birgand G, Poda A, Ahmad R, Singh S, Holmes AH. Investigating the cultural and contextual determinants of antimicrobial stewardship programmes across low-, middle- and high-income countries-A qualitative study. PLoS One 2019; 14:e0209847. [PMID: 30650099 PMCID: PMC6335060 DOI: 10.1371/journal.pone.0209847] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 12/12/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Most of the evidence on antimicrobial stewardship programmes (ASP) to help sustain the effectiveness of antimicrobials is generated in high income countries. We report a study investigating implementation of ASP in secondary care across low-, middle- and high-income countries. The objective of this study was to map the key contextual, including cultural, drivers of the development and implementation of ASP across different resource settings. MATERIALS AND METHODS Healthcare professionals responsible for implementing ASP in hospitals in England, France, Norway, India, and Burkina Faso were invited to participate in face-to face interviews. Field notes from observations, documentary evidence, and interview transcripts were analysed using grounded theory approach. The key emerging categories were analysed iteratively using constant comparison, initial coding, going back the field for further data collection, and focused coding. Theoretical sampling was applied until the categories were saturated. Cross-validation and triangulation of the findings were achieved through the multiple data sources. RESULTS 54 participants from 24 hospitals (England 9 participants/4 hospitals; Norway 13 participants/4 hospitals; France 9 participants/7 hospitals; India 13 participants/ 7 hospitals; Burkina Faso 8 participants/2 hospitals) were interviewed. Across Norway, France and England there was consistency in ASP structures. In India and Burkina Faso there were country level heterogeneity in ASP. State support for ASP was perceived as essential in countries where it is lacking (India, Burkina Faso), and where it was present, it was perceived as a barrier (England, France). Professional boundaries are one of the key cultural determinants dictating involvement in initiatives with doctors recognised as leaders in ASP. Nurse and pharmacist involvement was limited to England. The surgical specialty was identified as most difficult to engage with in each country. Despite challenges, one hospital in India provided the best example of interdisciplinary ASP, championed through organisational leadership. CONCLUSIONS ASP initiatives in this study were restricted by professional boundaries and hierarchies, with lack of engagement with the wider healthcare workforce. There needs to be promotion of interdisciplinary team work including pharmacists and nurses, depending on the available healthcare workforce in different countries, in ASP. The surgical pathway remains a hard to reach, but critical target for ASP globally. There is a need to develop contextually driven ASP targeting the surgical pathway in different resource settings.
Collapse
Affiliation(s)
- Esmita Charani
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - Ingrid Smith
- Department of Essential medicines and Health Products, World health Organization, Geneva, Switzerland
| | - Brita Skodvin
- Norwegian advisory unit for Antibiotic use in Hospitals, Haukeland University Hospital, Bergen, Norway
| | - Anne Perozziello
- Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat-Claude Bernard Hospital, Infection Control Unit, Paris, France
| | - Jean-Christophe Lucet
- Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat-Claude Bernard Hospital, Infection Control Unit, Paris, France
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - François-Xavier Lescure
- Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat-Claude Bernard Hospital, Infection Control Unit, Paris, France
- IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Gabriel Birgand
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - Armel Poda
- School of Medicine, University Hospital Souro Sanou, University of Bobo Dioulasso, Bobo Dioulasso, Burkina Faso
| | - Raheelah Ahmad
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| | - Sanjeev Singh
- Department of Medicine, Amrita Institute of Medical Sciences, Amrita University, Kerala, India
| | - Alison Helen Holmes
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom
| |
Collapse
|
20
|
Eley CV, Young VL, Hayes CV, Parkinson G, Tucker K, Gobat N, McNulty CAM. A mixed methods pilot of Beat the Bugs: A community education course on hygiene, self-care and antibiotics. J Infect Prev 2018; 19:278-286. [PMID: 38617883 PMCID: PMC11009556 DOI: 10.1177/1757177418780990] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/23/2018] [Indexed: 04/16/2024] Open
Abstract
Background e-Bug is an international health education resource which support World Health Organization (WHO) public health recommendations by educating young people about microbes, hygiene and antibiotics use. The e-Bug team collaborated with Kingfisher Treasure Seekers to develop a six-session course for community groups called Beat the Bugs covering: microbes; hygiene; antibiotic use; and self-care. A pilot was used to inform further development and evaluation. Methods Pilot courses with 9-12 adults with learning difficulties and young parents were delivered by community leaders and observed by researchers. Participants completed before and after knowledge questionnaires. Two participant focus groups and two course leader interviews explored views on the course and retention of knowledge. Results Completed questionnaires and qualitative results showed an improvement in participant knowledge in each session; microbes and antibiotics sessions showed the greatest knowledge improvement. Self-care showed the greatest knowledge retention and participants reported behaviour change including an increase in appropriate hand-washing and tooth-brushing. Conclusion The Beat the Bugs course is a useful intervention for communities to give individuals the knowledge and confidence to manage their own infection and change behaviour around hygiene, self-care and antibiotics. Beat the Bugs is freely available to download.
Collapse
Affiliation(s)
- Charlotte Victoria Eley
- Public Health England Primary Care Unit, Microbiology Department, Gloucester Royal Hospital, Great Western Road, Gloucester, GL1 3NN, UK
| | - Vicki Louise Young
- Public Health England Primary Care Unit, Microbiology Department, Gloucester Royal Hospital, Great Western Road, Gloucester, GL1 3NN, UK
| | - Catherine Victoria Hayes
- Public Health England Primary Care Unit, Microbiology Department, Gloucester Royal Hospital, Great Western Road, Gloucester, GL1 3NN, UK
| | | | | | - Nina Gobat
- Cardiff University, School of Medicine, Cardiff
| | - Cliodna Ann Miriam McNulty
- Public Health England Primary Care Unit, Microbiology Department, Gloucester Royal Hospital, Great Western Road, Gloucester, GL1 3NN, UK
| |
Collapse
|
21
|
Abstract
The ability to treat infectious diseases with antimicrobials is an essential component of medical management. Antimicrobial therapy is based on the characteristics of the patient, drug, microorganisms causing the infection, and colonizing flora. Prudent antibiotic use is the only option to delay the emergence of resistance. Training in infectious diseases and knowledge of the principles of responsible antibiotic prescribing and uses must be improved. To change practice, health care professionals should be educated at all levels of their training.
Collapse
Affiliation(s)
- Inge C Gyssens
- Department of Medicine, Radboud University Medical Center, AIG 463, PO Box 9101, Nijmegen 6500 HB, The Netherlands; Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Martelarenlaan 42, BE 3500, Hasselt, Belgium.
| |
Collapse
|
22
|
Powell N, McGraw-Allen K, Menzies A, Peet B, Simmonds C, Wild A. Identifying antibiotic stewardship interventions to meet the NHS England CQUIN: an evaluation of antibiotic -prescribing against published evidence-based antibiotic audit tools . Clin Med (Lond) 2018; 18:276-281. [PMID: 30072548 PMCID: PMC6334038 DOI: 10.7861/clinmedicine.18-4-276] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Evidence-based audit tools were used to identify the antibiotic stewardship improvements necessary to meet the NHS England targets in a 750-bed teaching hospital.Antibiotic prescribing was reviewed against published evidence-based audit tools for 139 patients treated with antibiotics. Severe community-acquired pneumonia (CAP) median course length was 8.5 days. Ninety-six percent of non-severe CAP patients were initiated on intravenous antibiotics (IV); median antibiotic course length 9 days. Twenty-six percent of urinary tract infection (UTI) patients without an indwelling catheter met the UTI diagnostic criteria. IV antibiotics initiated in 79% patients with other infections. Of these, 17% met the IV to oral switch criteria at 72 hours but were not switched. On average, antibiotic courses were 19% longer than recommended. Three key areas for improvement consist of: (a) implement the National Institute of Health and Care Excellence UTI Quality Standard - only 38% of patients treated for UTI met the UTI definition; (b) ensure antibiotic course lengths are in line with local prescribing guidelines - antibiotics were continued for 14% longer than recommended in local guidelines; (c) switch antibiotic therapy to oral when switch criteria met - 17% percent of patients initiated on IV antibiotics were eligible for oral switch by 72 hours and were not switched.
Collapse
Affiliation(s)
- Neil Powell
- Royal Cornwall Hospitals NHS Trust, Truro, UK and National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in healthcare associated infections and antimicrobial resistance at Imperial College London in partnership with Public Health England (PHE), London, UK
| | | | | | | | | | | |
Collapse
|
23
|
Labricciosa FM, Sartelli M, Correia S, Abbo LM, Severo M, Ansaloni L, Coccolini F, Alves C, Melo RB, Baiocchi GL, Paiva JA, Catena F, Azevedo A. Emergency surgeons' perceptions and attitudes towards antibiotic prescribing and resistance: a worldwide cross-sectional survey. World J Emerg Surg 2018; 13:27. [PMID: 29988647 PMCID: PMC6027784 DOI: 10.1186/s13017-018-0190-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/22/2018] [Indexed: 12/16/2022] Open
Abstract
Background Antibiotic resistance (AMR) is a growing public health problem worldwide, in part related to inadequate antibiotic use. A better knowledge of physicians' motivations, attitudes and practice about AMR and prescribing should enable the design and implementation of effective antibiotic stewardship programs (ASPs). The objective of the study was to assess attitudes and perceptions concerning AMR and use of antibiotics among surgeons who regularly perform emergency or trauma surgery. Methods A cross-sectional web-based survey was conducted contacting 4904 individuals belonging to a mailing list provided by the World Society of Emergency Surgery. Participation was voluntary and anonymous. The survey was open for 5 weeks (from May 3, 2017, to June 6, 2017), within which two reminders were sent. The self-administered questionnaire was developed by a multidisciplinary team; reliability and validity were assessed. Results The overall response rate was 12.5%. Almost all participants considered AMR an important worldwide problem, but 45.6% of them underrated the problem in their own hospitals. Surgeons provided with periodic reports on local AMR demonstrated a lower underrating in their hospital. Only 66.3% of the surgeons stated to receive periodic reports on local AMR data, and among them, 56.2% had consulted them to select an antibiotic in the previous month. Availability of systematic reports about AMR, availability of guidelines for therapy of infections, and advice from an infectious diseases specialist were considered very helpful measures to improve antibiotic prescribing by 68.0, 65.7, and 64.9%, respectively. Persuasive and restrictive ASPs were both considered helpful measures by 64.5%. Moreover, 86.3% considered locally developed guidelines more useful than national ones. Only 21.9% received formal training in antibiotic prescribing in the previous year; among them, 86.6% declared to be interested in receiving more training. Conclusions Availability of periodic reports on local AMR data was considered an important tool to guide surgeons in choosing the correct antibiotic and to increase awareness of the problem of AMR. Local guidelines for therapy of infections should be implemented in every emergency surgery setting, and developed by a multidisciplinary team directly involving surgeons, infectious diseases specialists, and microbiologists, and formally established in an ASP.
Collapse
Affiliation(s)
- Francesco M Labricciosa
- 1Department of Biomedical Science and Public Health, School of Hygiene and Preventive Medicine, Faculty of Medicine and Surgery, Università Politecnica delle Marche, Ancona, Italy
| | | | - Sofia Correia
- 3Epidemiology Research Unit (EPIUnit), Instituto de Saúde Pública, Universidade do Porto (ISPUP), Porto, Portugal.,4Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Lilian M Abbo
- 5Infection Prevention and Antimicrobial Stewardship Jackson Health System, University of Miami Miller School of Medicine, Miami, FL USA
| | - Milton Severo
- 3Epidemiology Research Unit (EPIUnit), Instituto de Saúde Pública, Universidade do Porto (ISPUP), Porto, Portugal.,4Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Luca Ansaloni
- 6General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Federico Coccolini
- 6General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Carlos Alves
- 7Unit of Prevention and Control of Infections and Antimicrobial Resistance (UPCIRA), Centro de Epidemiologia Hospitalar, Centro Hospitalar São João, Porto, Portugal
| | - Renato Bessa Melo
- 8Department of General Surgery, Centro Hospitalar São João, Porto, Portugal
| | - Gian Luca Baiocchi
- 9Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - José-Artur Paiva
- 10Department of Emergency and Intensive Care, Centro Hospitalar São João, Porto, Portugal.,11Department of Medicine, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Fausto Catena
- Department of Emergency Surgery, Maggiore Hospital, Parma, Italy
| | - Ana Azevedo
- 3Epidemiology Research Unit (EPIUnit), Instituto de Saúde Pública, Universidade do Porto (ISPUP), Porto, Portugal.,4Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,13Centro de Epidemiologia Hospitalar, Centro Hospitalar São João, Porto, Portugal
| |
Collapse
|
24
|
McElligott M, Welham G, Pop-Vicas A, Taylor L, Crnich CJ. Antibiotic Stewardship in Nursing Facilities. Infect Dis Clin North Am 2018; 31:619-638. [PMID: 29079152 DOI: 10.1016/j.idc.2017.07.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Misuse and overuse of antibiotic therapy is a frequent cause of resident harm in nursing facilities. As a result, newly released policy and regulatory initiatives will require antibiotic stewardship programs (ASPs) in nursing facilities. Although implementing ASPs can be challenging, improving the quality of antibiotic prescribing is achievable in this setting. The authors review the determinants of antibiotic prescribing in nursing facilities, strategies to improve antibiotic prescribing in this setting, current status of ASPs in nursing facilities, and steps that facilities can take to enhance existing ASP structure and process.
Collapse
Affiliation(s)
- Miranda McElligott
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA
| | - Grace Welham
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA
| | - Aurora Pop-Vicas
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA; University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Lyndsay Taylor
- University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Christopher J Crnich
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA; University of Wisconsin Hospital and Clinics, Madison, WI, USA; William S. Middleton Veterans Affairs Hospital, Madison, WI, USA.
| |
Collapse
|
25
|
Khdour MR, Hallak HO, Aldeyab MA, Nasif MA, Khalili AM, Dallashi AA, Khofash MB, Scott MG. Impact of antimicrobial stewardship programme on hospitalized patients at the intensive care unit: a prospective audit and feedback study. Br J Clin Pharmacol 2018; 84:708-715. [PMID: 29236303 DOI: 10.1111/bcp.13486] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 11/26/2017] [Accepted: 11/29/2017] [Indexed: 12/13/2022] Open
Abstract
AIMS Inappropriate use of antibiotics is one of the most important factors contributing to the emergence of drug resistant pathogens. The purpose of this study was to measure the clinical impact of antimicrobial stewardship programme (ASP) interventions on hospitalized patients at the Intensive care unit at Palestinian Medical Complex. METHODS A prospective audit with intervention and feedback by ASP team within 48-72 h of antibiotic administration began in September 2015. Four months of pre-ASP data were compared with 4 months of post-ASP data. Data collected included clinical and demographic data; use of antimicrobials measured by defined daily doses, duration of therapy, length of stay, readmission and all-cause mortality. RESULTS Overall, 176 interventions were made the ASP team with an average acceptance rate of 78.4%. The most accepted interventions were dose optimization (87.0%) followed by de-escalation based on culture results with an acceptance rate of 84.4%. ASP interventions significantly reduces antimicrobial use by 24.3% (87.3 defined daily doses/100 beds vs. 66.1 defined daily doses/100 beds P < 0.001). The median (interquartile range) of length of stay was significantly reduced post ASP [11 (3-21) vs. 7 (4-19) days; P < 0.01]. Also, the median (interquartile range) of duration of therapy was significantly reduced post-ASP [8 (5-12) days vs. 5 (3-9); P = 0.01]. There was no significant difference in overall 30-day mortality or readmission between the pre-ASP and post-ASP groups (26.9% vs. 23.9%; P = 0.1) and (26.1% vs. 24.6%; P = 0.54) respectively. CONCLUSIONS Our prospective audit and feedback programme was associated with positive impact on antimicrobial use, duration of therapy and length of stay.
Collapse
Affiliation(s)
- Maher R Khdour
- Faculty of Pharmacy, Al-Quds University, Abu Deis, PO Box 20002, West Bank, Palestine
| | - Hussein O Hallak
- Faculty of Pharmacy, Al-Quds University, Abu Deis, PO Box 20002, West Bank, Palestine
| | - Mamoon A Aldeyab
- School of Pharmacy and Pharmaceutical Sciences, Ulster University, Coleraine, County Londonderry, UK
| | - Mowaffaq A Nasif
- Head of Intensive Care Department at Palestinian Medical Complex, Baladiya St. 00972, Ramallah, West Bank, Palestine
| | - Aliaa M Khalili
- Internal Medicine Resident at Palestinian Medical Complex, Baladiya St. 00972, Ramallah, West Bank, Palestine
| | - Ahamad A Dallashi
- Internal Medicine Resident at Palestinian Medical Complex, Baladiya St. 00972, Ramallah, West Bank, Palestine
| | - Mohammad B Khofash
- Clinical Pharmacist at Palestinian Medical Complex, Baladiya St. 00972, Ramallah, Palestine
| | - Michael G Scott
- Pharmacy and Medicines Management Centre, Antrim Area Hospital, BT41 2RL, Northern Ireland
| |
Collapse
|
26
|
Jaafar G, Darkahi B, Lindhagen L, Persson G, Sandblom G. Disparities in the regional, hospital and individual levels of antibiotic use in gallstone surgery in Sweden. BMC Surg 2017; 17:128. [PMID: 29207972 PMCID: PMC5717817 DOI: 10.1186/s12893-017-0312-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 11/16/2017] [Indexed: 11/10/2022] Open
Abstract
Background Antimicrobial resistance may be promoted by divergent routines and lack of conformity in antibiotic treatment, especially regarding the practice of antibiotic prophylaxis. The aim of the present study was to assess differences in gallstone surgery regarding antibiotic use in Sweden. Methods The study was based on data from the Swedish Register for Gallstone Surgery and ERCP (GallRiks) 2005–2015. Funnel plots were used to test impact of grouping factors, including, hospital and surgeon and to identify units that deviated from the rest of the population. Results After adjusting for cofounders including age, gender, ASA classification, indication for surgery, operation time, gallbladder perforation and emergency status, there were 0/21 (0%) at the regional level, 18/76 (24%) at the hospital level and 128/1038 (12%) at the surgeon level outside the 99.9% confidence interval (CI). The estimated median odds ratios were 1.13 (95% CI 1.00–1.31) at the regional level, 1.93 (95% CI 1.70–2.19) at the hospital level and 2.38 (95% CI 2.26–2.50) at the surgeon level. Conclusion There are significant differences between hospitals and surgeons, but little or no differences between regions. These deviations confirm the lack of standardization in regards to prescription of antibiotic prophylaxis and the need more uniform routines regarding antibiotic usage. Randomized controlled trials and large population-based studies are necessary to assess assessing the effectiveness and safety of antibiotic prophylaxis in gallstone surgery.
Collapse
Affiliation(s)
- Gona Jaafar
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Center for Digestive Diseases, Karolinska University Hospital, -141 86, Stockholm, SE, Sweden.
| | - Bahman Darkahi
- Department of Surgery, Enköping Hospital, Kungsgatan 71, 74538, Enköping, Sweden
| | - Lars Lindhagen
- Uppsala Clinical Research Centre, Dag Hammarskjölds väg 14B, 75237, Uppsala, Sweden
| | - Gunnar Persson
- Department of Surgery, Växjö Hospital, Strandvägen 8, 35185, Växjö, Sweden
| | - Gabriel Sandblom
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Center for Digestive Diseases, Karolinska University Hospital, -141 86, Stockholm, SE, Sweden
| |
Collapse
|
27
|
Lo C, Mertz D, Loeb M. Assessing the reporting quality of influenza outbreaks in the community. Influenza Other Respir Viruses 2017; 11:556-563. [PMID: 29054122 PMCID: PMC5705690 DOI: 10.1111/irv.12516] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND High-quality reporting of outbreak characteristics is fundamental to understand the behaviour of various strains of influenza virus and the impact of outbreak management strategies. However, few studies have systematically evaluated the quality of outbreak reporting. OBJECTIVES To conduct a systematic analysis and assessment for reporting quality of influenza outbreaks based on a modified version of the STROBE statement, and to examine characteristics associated with reporting quality. METHODS A literature search was conducted across 3 online databases (PubMed, Web of Science, MEDLINE) for reports of influenza outbreaks (pandemic H1N1, avian, seasonal). The quality of reports meeting our eligibility criteria was assessed using the Modified STROBE criteria and assigned a score of 30. Mean differences (MD) and 95% confidence intervals (CI) were reported for comparisons of study characteristics. RESULTS Sixty-four outbreak reports were available for analyses. The average Modified STROBE score was 20/30. Peer-reviewed articles were associated with a better quality of reporting (MD 2.79, 95% CI 0.79-4.78). Likewise, reports from authors affiliated with public health agencies were associated with better quality than those from academic institutions (MD 1.65, 95% CI-0.27-3.56). CONCLUSIONS The development of explicit reporting guidelines specifically geared towards reporting of outbreak investigations proved to be useful. Providing information on patient characteristics, investigation details in introduction and results, as well as addressing limitations that could have biased the findings, were frequently missing in the published reports.
Collapse
Affiliation(s)
- Calvin Lo
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonONCanada
| | - Dominik Mertz
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonONCanada
- Department of MedicineMcMaster UniversityHamiltonONCanada
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonONCanada
- Michael G. DeGroote Institute for Infectious Diseases ResearchMcMaster UniversityHamiltonONCanada
| | - Mark Loeb
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonONCanada
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonONCanada
- Michael G. DeGroote Institute for Infectious Diseases ResearchMcMaster UniversityHamiltonONCanada
| |
Collapse
|
28
|
Silverberg SL, Zannella VE, Countryman D, Ayala AP, Lenton E, Friesen F, Law M. A review of antimicrobial stewardship training in medical education. INTERNATIONAL JOURNAL OF MEDICAL EDUCATION 2017; 8:353-374. [PMID: 29035872 PMCID: PMC5694692 DOI: 10.5116/ijme.59ba.2d47] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 09/14/2017] [Indexed: 05/10/2023]
Abstract
OBJECTIVES We reviewed the published literature on antimicrobial stewardship training in undergraduate and postgraduate medical education to determine which interventions have been implemented, the extent to which they have been evaluated, and to understand which are most effective. METHODS We searched Ovid MEDLINE and EMBASE from inception to December 2016. Four thousand three hundred eighty-five (4385) articles were identified and underwent title and abstract review. Only those articles that addressed antimicrobial stewardship interventions for medical trainees were included in the final review. We employed Kirkpatrick's four levels of evaluation (reaction, learning, behaviour, results) to categorize intervention evaluations. RESULTS Our review included 48 articles. The types of intervention varied widely amongst studies worldwide. Didactic teaching was used heavily in all settings, while student-specific feedback was used primarily in the postgraduate setting. The high-level evaluation was sparse, with 22.9% reporting a Kirkpatrick Level 3 evaluation; seventeen reported no evaluation. All but one article reported positive results from the intervention. No articles evaluated the impact of an intervention on undergraduate trainees' prescribing behaviour after graduation. CONCLUSIONS This study enhances our understanding of the extent of antimicrobial stewardship in the context of medical education. While our study demonstrates that medical schools are implementing antimicrobial stewardship interventions, rigorous evaluation of programs to determine whether such efforts are effective is lacking. We encourage more robust evaluation to establish effective, evidence-based approaches to training prescribers in light of the global challenge of antimicrobial resistance.
Collapse
Affiliation(s)
| | | | - Drew Countryman
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ana Patricia Ayala
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - Erica Lenton
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - Farah Friesen
- Centre for Faculty Development, Faculty of Medicine, University of Toronto at St. Michael's Hospital, Toronto, Ontario, Canada
| | - Marcus Law
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
29
|
Doernberg SB, Chambers HF. Antimicrobial Stewardship Approaches in the Intensive Care Unit. Infect Dis Clin North Am 2017; 31:513-534. [PMID: 28687210 DOI: 10.1016/j.idc.2017.05.002] [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: 12/22/2022]
Abstract
Antimicrobial stewardship programs aim to monitor, improve, and measure responsible antibiotic use. The intensive care unit (ICU), with its critically ill patients and prevalence of multiple drug-resistant pathogens, presents unique challenges. This article reviews approaches to stewardship with application to the ICU, including the value of diagnostics, principles of empirical and definitive therapy, and measures of effectiveness. There is good evidence that antimicrobial stewardship results in more appropriate antimicrobial use, shorter therapy durations, and lower resistance rates. Data demonstrating hard clinical outcomes, such as adverse events and mortality, are more limited but encouraging; further studies are needed.
Collapse
Affiliation(s)
- Sarah B Doernberg
- Division of Infectious Diseases, Department of Medicine, University of California, 513 Parnassus Avenue, Box 0654, San Francisco, CA 94143, USA.
| | - Henry F Chambers
- Division of Infectious Diseases, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, Room 3400, Building 30, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| |
Collapse
|
30
|
Sviestina I, Usonis V, Gurksniene V, Burokiene S, Ivaskeviciene I, Mozgis D. Prescription of antibiotics in Riga and Vilnius tertiary children's hospitals. Eur J Hosp Pharm 2017; 25:189-194. [PMID: 31157017 DOI: 10.1136/ejhpharm-2016-001124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 02/01/2017] [Accepted: 02/27/2017] [Indexed: 11/04/2022] Open
Abstract
Objectives The aim of this study was to compare the use of antibiotics among hospitalised children in Riga (Latvia) and in Vilnius (Lithuania) at two tertiary paediatric centres. Methods A point prevalence survey (PPS) was conducted using validated and standardised Antibiotic Resistance and Prescribing in European Children (ARPEC) project methodology during November 2012. All inpatients less than 18 years old were included in the study. All data were recorded for patients with active antimicrobial prescriptions at 8 am on the day of the survey. Data were entered into the ARPEC-webPPS programme and were validated online for accuracy. Results The proportion of patients receiving antimicrobial therapy was statistically different: 128 (37.0%) patients in Riga and 83 (26.3%) in Vilnius. The most common age group in Riga and Vilnius was 1-5 years. The most commonly used antibiotic classes for the treatment and prophylaxis of infection were third-generation cephalosporins (38; 25.5% prescriptions) in Riga and second-generation cephalosporins (16; 19.8%) in Vilnius. Parenteral use of antimicrobials was higher in Riga than in Vilnius: 111 (74.5%) prescriptions to paediatric patients in Riga and 45 (55.6%) prescriptions in Vilnius. Conclusions The PPS identified differences in antibiotic use in both hospitals and problem areas for improvement: high use of third-generation cephalosporins for paediatric patients (in Riga) and predominant use of parenteral antibiotics. Further collaboration between both centres is needed because sharing audit data and antimicrobial stewardship initiatives may encourage further changes in practice at both institutions.
Collapse
Affiliation(s)
- Inese Sviestina
- University Children's Hospital, Riga, Latvia.,Faculty of Pharmacy, Riga Stradins University, Riga, Latvia.,Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Vytautas Usonis
- Vilnius University Faculty of Medicine, Clinic of Children's Diseases, Vilnius, Lithuania.,Vilnius University Children's Hospital, Affiliate of Vilnius University Hospital, Vilnius, Lithuania
| | - Vilija Gurksniene
- Vilnius University Children's Hospital, Affiliate of Vilnius University Hospital, Vilnius, Lithuania
| | - Sigita Burokiene
- Vilnius University Faculty of Medicine, Clinic of Children's Diseases, Vilnius, Lithuania.,Vilnius University Children's Hospital, Affiliate of Vilnius University Hospital, Vilnius, Lithuania
| | - Inga Ivaskeviciene
- Vilnius University Faculty of Medicine, Clinic of Children's Diseases, Vilnius, Lithuania.,Vilnius University Children's Hospital, Affiliate of Vilnius University Hospital, Vilnius, Lithuania
| | - Dzintars Mozgis
- Public Health and Epidemiology Department, Riga Stradins University, Riga, Latvia
| |
Collapse
|
31
|
de With K, Allerberger F, Amann S, Apfalter P, Brodt HR, Eckmanns T, Fellhauer M, Geiss HK, Janata O, Krause R, Lemmen S, Meyer E, Mittermayer H, Porsche U, Presterl E, Reuter S, Sinha B, Strauß R, Wechsler-Fördös A, Wenisch C, Kern WV. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2017; 44:395-439. [PMID: 27066980 PMCID: PMC4889644 DOI: 10.1007/s15010-016-0885-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. Materials and methods A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. Conclusion The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.
Collapse
Affiliation(s)
- K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - F Allerberger
- Division Public Health, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - S Amann
- Hospital Pharmacy, Munich Municipal Hospital, Munich, Germany
| | - P Apfalter
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - H-R Brodt
- Department of Infectious Disease Medical Clinic II, Goethe-University Frankfurt, Frankfurt, Germany
| | - T Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - M Fellhauer
- Hospital Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - H K Geiss
- Department of Hospital Epidemiology and Infectiology, Sana Kliniken AG, Ismaning, Germany
| | - O Janata
- Department for Hygiene and Infection Control, Danube Hospital, Vienna, Austria
| | - R Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
| | - S Lemmen
- Division of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany
| | - E Meyer
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Berlin, Germany
| | - H Mittermayer
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - U Porsche
- Department for Clinical Pharmacy and Drug Information, Landesapotheke, Landeskliniken Salzburg (SALK), Salzburg, Austria
| | - E Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - S Reuter
- Clinic for General Internal Medicine, Infectious Diseases, Pneumology and Osteology, Klinikum Leverkusen, Leverkusen, Germany
| | - B Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Strauß
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Erlangen, Germany
| | - A Wechsler-Fördös
- Department of Antibiotics and Infection Control, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Wenisch
- Medical Department of Infection and Tropical Medicine, Kaiser Franz Josef Hospital, Vienna, Austria
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, Freiburg University Medical Center, Freiburg, Germany
| |
Collapse
|
32
|
Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, Gould IM, Ramsay CR, Michie S. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2:CD003543. [PMID: 28178770 PMCID: PMC6464541 DOI: 10.1002/14651858.cd003543.pub4] [Citation(s) in RCA: 397] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotic resistance is a major public health problem. Infections caused by multidrug-resistant bacteria are associated with prolonged hospital stay and death compared with infections caused by susceptible bacteria. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. We updated this systematic review to evaluate the impact of interventions to improve antibiotic prescribing to hospital inpatients. OBJECTIVES To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and to investigate the effect of two intervention functions: restriction and enablement. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, and Embase. We searched for additional studies using the bibliographies of included articles and personal files. The last search from which records were evaluated and any studies identified incorporated into the review was January 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies (NRS). We included three non-randomised study designs to measure behavioural and clinical outcomes and analyse variation in the effects: non- randomised trials (NRT), controlled before-after (CBA) studies and interrupted time series (ITS) studies. For this update we also included three additional NRS designs (case control, cohort, and qualitative studies) to identify unintended consequences. Interventions included any professional or structural interventions as defined by the Cochrane Effective Practice and Organisation of Care Group. We defined restriction as 'using rules to reduce the opportunity to engage in the target behaviour (or increase the target behaviour by reducing the opportunity to engage in competing behaviours)'. We defined enablement as 'increasing means/reducing barriers to increase capability or opportunity'. The main comparison was between intervention and no intervention. DATA COLLECTION AND ANALYSIS Two review authors extracted data and assessed study risk of bias. We performed meta-analysis and meta-regression of RCTs and meta-regression of ITS studies. We classified behaviour change functions for all interventions in the review, including those studies in the previously published versions. We analysed dichotomous data with a risk difference (RD). We assessed certainty of evidence with GRADE criteria. MAIN RESULTS This review includes 221 studies (58 RCTs, and 163 NRS). Most studies were from North America (96) or Europe (87). The remaining studies were from Asia (19), South America (8), Australia (8), and the East Asia (3). Although 62% of RCTs were at a high risk of bias, the results for the main review outcomes were similar when we restricted the analysis to studies at low risk of bias.More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% confidence interval (CI) 14% to 16%; 23,394 participants; high-certainty evidence). This represents an increase from 43% to 58% .There were high levels of heterogeneity of effect size but the direction consistently favoured intervention.The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67; 14 RCTs; 3318 participants; high-certainty evidence) from 11.0 days. Information from non-randomised studies showed interventions to be associated with improvement in prescribing according to antibiotic policy in routine clinical practice, with 70% of interventions being hospital-wide compared with 31% for RCTs. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs; 15,827 participants; moderate-certainty evidence). Antibiotic stewardship interventions probably reduce length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs; 3834 participants; moderate-certainty evidence). One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence).Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions (high-certainty evidence). Enabling interventions that included feedback were probably more effective than those that did not (moderate-certainty evidence).There was very low-certainty evidence about the effect of the interventions on reducing Clostridium difficile infections (median -48.6%, interquartile range -80.7% to -19.2%; 7 studies). This was also the case for resistant gram-negative bacteria (median -12.9%, interquartile range -35.3% to 25.2%; 11 studies) and resistant gram-positive bacteria (median -19.3%, interquartile range -50.1% to +23.1%; 9 studies). There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use. Heterogeneity of intervention effect on prescribing outcomesWe analysed effect modifiers in 29 RCTs and 91 ITS studies. Enablement and restriction were independently associated with a larger effect size (high-certainty evidence). Feedback was included in 4 (17%) of 23 RCTs and 20 (47%) of 43 ITS studies of enabling interventions and was associated with greater intervention effect. Enablement was included in 13 (45%) of 29 ITS studies with restrictive interventions and enhanced intervention effect. AUTHORS' CONCLUSIONS We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment. Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Additional trials comparing antibiotic stewardship with no intervention are unlikely to change our conclusions. Enablement consistently increased the effect of interventions, including those with a restrictive component. Although feedback further increased intervention effect, it was used in only a minority of enabling interventions. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Consequently, effective dissemination of our findings could have considerable health service and policy impact. Future research should instead focus on targeting treatment and assessing other measures of patient safety, assess different stewardship interventions, and explore the barriers and facilitators to implementation. More research is required on unintended consequences of restrictive interventions.
Collapse
Affiliation(s)
- Peter Davey
- University of DundeePopulation Health SciencesMackenzie BuildingKirsty Semple WayDundeeScotlandUKDD2 4BF
| | - Charis A Marwick
- University of DundeePopulation Health Sciences Division, Medical Research InstituteDundeeUK
| | - Claire L Scott
- NHS Education for ScotlandScottish Dental Clinical Effectiveness ProgrammeDundee Dental Education CentreSmall's WyndDundeeUKDD1 4HN
| | - Esmita Charani
- Imperial College LondonNIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial ResistanceDu Cane RoadLondonUKW12 OHS
| | - Kirsty McNeil
- University of DundeeSchool of Medicine147 Forth CrescentDundeeScotlandUKDD2 4JA
| | - Erwin Brown
- No affiliation31 Park CrescentFrenchayBristolUKBS16 1NZ
| | - Ian M Gould
- Aberdeen Royal InfirmaryDepartment of Medical MicrobiologyForesterhillAberdeenUKAB25 2ZN
| | - Craig R Ramsay
- University of AberdeenHealth Services Research Unit, Division of Applied Health SciencesPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
| | - Susan Michie
- University College LondonResearch Department of Primary Care and Population HealthUpper Floor 3, Royal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | | |
Collapse
|
33
|
Stone SP, Cookson BD. Endorsing reporting guidelines: Infection control literature gets ahead of the game. Am J Infect Control 2016; 44:1446-1448. [PMID: 27776822 DOI: 10.1016/j.ajic.2016.06.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 06/14/2016] [Indexed: 10/20/2022]
|
34
|
Carbo JF, Ruh CA, Kurtzhalts KE, Ott MC, Sellick JA, Mergenhagen KA. Male veterans with complicated urinary tract infections: Influence of a patient-centered antimicrobial stewardship program. Am J Infect Control 2016; 44:1549-1553. [PMID: 27388268 DOI: 10.1016/j.ajic.2016.04.239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/05/2016] [Accepted: 04/05/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The influence of antimicrobial stewardship programs (ASPs) on outcomes in male veterans treated for complicated urinary tract infection has not been determined. METHODS This was a retrospective cohort study encompassing the study period January 1, 2005-October 31, 2014, which was conducted at a 150-bed Veterans Affairs Healthcare System facility in Buffalo, NY. Male veterans admitted for treatment of complicated urinary tract infection were identified using ICD-9-CM codes. Outcomes before and after implementation of a patient-centered ASP, including duration of antibiotic therapy, length of hospitalization, readmission within 30 days, and Clostridium difficile infection were compared. Interventions resulting from the ASP were categorized. RESULTS Of the 1,268 patients screened, 241 met criteria for inclusion in the study (n = 118 and n = 123 in the pre-ASP and ASP group, respectively). Duration of antibiotic therapy was significantly shorter in the ASP group (10.32 days vs 11.96 days; P < .0001), as was length of hospitalization (5.76 days vs 6.76 days; P = .015). There was no difference in 30-day readmission. A total of 170 interventions were identified that resulted from the ASP (1.39 interventions per patient). CONCLUSIONS ASPs may be useful to improve clinical outcomes in men with complicated urinary tract infection. Implementation of an ASP was associated with significant decreases in duration of antibiotic therapy and length of hospitalization, without adversely affecting 30-day readmission rates.
Collapse
|
35
|
Stone S, Cookson B. Endorsing Reporting Guidelines: the Journal of Infection Prevention helps show the way! J Infect Prev 2016; 17:264-266. [PMID: 28989489 PMCID: PMC5102088 DOI: 10.1177/1757177416671797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sheldon Stone
- Senior Lecturer and Stroke Physician and Consultant Physician for Older People
| | - Barry Cookson
- Hon Professor, Department of Microbiology, Royal Free Campus, University College London Medical School
| |
Collapse
|
36
|
Doll M, Hewlett AL, Bearman G. Infection Prevention in the Hospital from Past to Present: Evolving Roles and Shifting Priorities. Curr Infect Dis Rep 2016; 18:16. [PMID: 27106808 DOI: 10.1007/s11908-016-0523-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hospital epidemiologists are vital components of integrated health centers. This central place in the healthcare landscape has rapidly evolved over a half century. Early hospital epidemiologists possessed a visionary focus on patient safety many decades prior to the quality revolution of the 1990s. A systematic and scientific approach to infection prevention has facilitated the evolution of hospital epidemiology, along with advances in technology, and increasing public attention to infectious complications in the hospital. Currently, the growing expansion of tasks and moving regulatory targets strain existing resources. These challenges threaten to limit the effectiveness of some infection-prevention activities, while also providing important opportunities for improving care. It will be increasingly important to advocate for appropriate resources to address a diverse set of changing infection prevention priorities.
Collapse
Affiliation(s)
- Michelle Doll
- Division of Infectious Disease, Virginia Commonwealth University Medical Center, 1300 East Marshall Street, P.O. Box 980019, Richmond, VA, 23290-0019, USA.
| | - Angela L Hewlett
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, 68198-3332, USA
| | - Gonzalo Bearman
- Division of Infectious Disease, Virginia Commonwealth University School of Medicine, Richmond, VA, 23219, USA
| |
Collapse
|
37
|
Abstract
A survey was conducted to ascertain practice of antimicrobial stewardship programme (AMSP) in India for 2013. A total of 20 health care institutions (HCI) responded to a detailed questionnaire. All the institutions contacted were tertiary care HCI, of which 12 were funded by government (GHCI) and 8 were corporate/private HCI (PHCI). Further, all catered to both rural and urban populations and were spread across the country. Written documents were available with 40 per cent for AMSP, 75 per cent for hospital infection control (HIC) and HIC guidelines and 65 per cent for antimicrobial agents (AMA) prescription guidelines. Records were maintained for health care associated infections (HCAI) by 60 per cent HCI. Antimicrobial resistance (AMR) data were being analysed by 80 per cent HCI. AMA usage data were analysed by only 25 per cent HCI and AMA prescription audit and feedback by 30 per cent. PHCI performed better than GHCI across all fields of AMSP. The main contributory factor was possibly the much higher level of accreditation of PHCI hospitals and their diagnostic laboratories. The absence of infectious diseases physicians and clinical pharmacists is worrying and demands careful attention.
Collapse
Affiliation(s)
- Kamini Walia
- Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi, India
| | | | | | | |
Collapse
|
38
|
Fodero KE, Horey AL, Krajewski MP, Ruh CA, Sellick JA, Mergenhagen KA. Impact of an Antimicrobial Stewardship Program on Patient Safety in Veterans Prescribed Vancomycin. Clin Ther 2016; 38:494-502. [PMID: 26831569 DOI: 10.1016/j.clinthera.2016.01.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/04/2015] [Accepted: 01/05/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE This study aimed to determine the safety impact of an antimicrobial stewardship program (ASP) on vancomycin-associated nephrotoxicity and to examine risk factors contributing to the development of toxicity. METHODS This was a retrospective chart review of data from 453 veterans receiving vancomycin in the VA Western New York Healthcare System between October 2006 and July 2014. Nephrotoxicity was defined as an increase in serum creatinine of ≥ 0.5 mg/dL or by 50% of baseline for 2 consecutive days. FINDINGS Patients receiving vancomycin after the implementation of the ASP were less likely to develop nephrotoxicity (odds ratio [OR] = 2.06; 95% CI, 1.02-4.28). Nephrotoxicity occurred in 6.84% of patients from the pre-ASP cohort and in 3.75% of patients after the implementation of the ASP. Predictors of nephrotoxicity included hospital service (surgical service, OR = 2.29; 95% CI, 1.13-4.64), elevated maximum trough concentration (unit OR = 1.15; 95% CI, 1.10-1.20), and concurrent piperacillin/tazobactam therapy (OR = 3.21; 95% CI, 1.43-7.96). The number of vancomycin trough concentration measurements per patient did not vary between the pre-ASP and ASP groups. IMPLICATIONS ASPs represent an important aspect of a patient-safety initiative in order to reduce vancomycin-associated nephrotoxicity. Concurrent piperacillin/tazobactam therapy, surgical service, and elevated maximum trough concentration were risk factors for nephrotoxicity.
Collapse
Affiliation(s)
- Kristen E Fodero
- Department of Infectious Diseases and Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, New York
| | - Amy L Horey
- Department of Infectious Diseases and Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, New York
| | - Michael P Krajewski
- Department of Pharmacy Practice, The State University of New York, Buffalo, New York
| | - Christine A Ruh
- Department of Pharmacy Practice, The State University of New York, Buffalo, New York
| | - John A Sellick
- Department of Infectious Diseases and Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, New York; Department of Medicine, University at Buffalo, Buffalo, New York
| | - Kari A Mergenhagen
- Department of Infectious Diseases and Pharmacy, Veteran Affairs Western New York Healthcare System, Buffalo, New York.
| |
Collapse
|
39
|
Wenzler E, Wong JR, Goff DA, Jankowski CA, Bauer KA. Controversies in Antimicrobial Stewardship: Focus on New Rapid Diagnostic Technologies and Antimicrobials. Antibiotics (Basel) 2016; 5:E6. [PMID: 27025521 PMCID: PMC4810408 DOI: 10.3390/antibiotics5010006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 12/20/2015] [Accepted: 01/06/2016] [Indexed: 12/19/2022] Open
Abstract
Antimicrobial stewardship programs (ASPs) are challenged with ensuring appropriate antimicrobial use while minimizing expenditures. ASPs have consistently demonstrated improved patient outcomes and significant cost reductions but are continually required to justify the costs of their existence and interventions due to the silo mentality often adopted by hospital administrators. As new technologies and antimicrobials emerge, ASPs are in a constant tug-of-war between providing optimal clinical outcomes and ensuring cost containment. Additionally, robust data on cost-effectiveness of new rapid diagnostic technologies and antimicrobials with subsequent ASP interventions to provide justification are lacking. As the implementation of an ASP will soon be mandatory for acute care hospitals in the United States, ASPs must find ways to justify novel interventions to align themselves with healthcare administrators. This review provides a framework for the justification of implementing a rapid diagnostic test or adding a new antimicrobial to formulary with ASP intervention, reviews approaches to demonstrating cost-effectiveness, and proposes methods for which ASPs may reduce healthcare expenditures via alternative tactics.
Collapse
Affiliation(s)
- Eric Wenzler
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL 60612, USA.
| | - Jordan R Wong
- Department of Pharmacy, Grady Health System, Atlanta, GA 30303, USA.
| | - Debra A Goff
- Department of Pharmacy, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA.
| | - Christopher A Jankowski
- Department of Pharmacy, University of Florida Health Jacksonville, Jacksonville, FL 32209, USA.
| | - Karri A Bauer
- Department of Pharmacy, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA.
| |
Collapse
|
40
|
Teixeira Rodrigues A, Ferreira M, Roque F, Falcão A, Ramalheira E, Figueiras A, Herdeiro MT. Physicians' attitudes and knowledge concerning antibiotic prescription and resistance: questionnaire development and reliability. BMC Infect Dis 2016; 16:7. [PMID: 26746228 PMCID: PMC4705586 DOI: 10.1186/s12879-015-1332-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 12/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Understanding physicians' antibiotic-prescribing behaviour is fundamental when it comes to improving antibiotic use and tackling the growing rates of antimicrobial resistance. The aim of the study was to develop and validate--in terms of face validity, content validity and reliability--an instrument designed to assess the attitudes and knowledge underlying physician antibiotic prescribing. METHODS The questionnaire development and validation process comprised two different steps, namely: (1) content and face validation, which included a literature review and validation both by physicians and by Portuguese language and clinical psychology experts; and (2) reliability analysis, using the test-retest method, to assess the questionnaire's internal consistency (Cronbach's alpha) and reproducibility (intraclass correlation coefficient--ICC). The questionnaire includes 17 items assessing attitudes and knowledge about antibiotic prescribing and resistances and 9 items evaluating the importance of different sources of knowledge. The study was conducted in the catchment area covered by Portugal's Northern Regional Health Administration and used a convenience sample of 61 primary-care and 50 hospital-care physicians. RESULTS Response rate was 64% (49% to retest) for primary-care physicians and 66% (60% to retest) for hospital-care physicians. Content validity resulted in 9 changes to professional concepts. Face validity assessment resulted in 19 changes to linguistic and interpretative terms. In the case of the reliability analysis, the ICC values indicated a minimum of fair to good reproducibility (ICC > 0.4), and the Cronbach alpha values were satisfactory (α > 0.70). CONCLUSIONS The questionnaire developed is valid--in terms of face validity, content validity and reliability--for assessing physicians' attitudes to and knowledge of antibiotic prescribing and resistance, in both hospital and primary-care settings, and could be a very useful tool for characterising physicians' antibiotic-prescribing behaviour.
Collapse
Affiliation(s)
- António Teixeira Rodrigues
- Department of Medical Sciences and Institute for Biomedicine - iBiMED, University of Aveiro, Aveiro, 3810-193, Portugal. .,Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal.
| | - Mónica Ferreira
- Department of Medical Sciences and Institute for Biomedicine - iBiMED, University of Aveiro, Aveiro, 3810-193, Portugal.
| | - Fátima Roque
- Department of Medical Sciences and Institute for Biomedicine - iBiMED, University of Aveiro, Aveiro, 3810-193, Portugal. .,Research Unit for Inland Development, Polytechnic Institute of Guarda, Guarda, Portugal.
| | - Amílcar Falcão
- Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal. .,Centre for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal.
| | | | - Adolfo Figueiras
- University of Santiago de Compostela, Santiago de Compostela, Spain. .,Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública -CIBERESP), Santiago de Compostela, Spain.
| | - Maria Teresa Herdeiro
- Department of Medical Sciences and Institute for Biomedicine - iBiMED, University of Aveiro, Aveiro, 3810-193, Portugal. .,CESPU, IINFACTS, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, Gandra, Portugal.
| |
Collapse
|
41
|
Sabry N, Dawoud D, Alansary A, Hounsome N, Baines D. Evaluation of a protocol-based intervention to promote timely switching from intravenous to oral paracetamol for post-operative pain management: an interrupted time series analysis. J Eval Clin Pract 2015; 21:1081-8. [PMID: 26489529 DOI: 10.1111/jep.12463] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2015] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Timely switching from intravenous to oral therapy ensures optimized treatment and efficient use of health care resources. Intravenous (IV) paracetamol is widely used for post-operative pain management but not always switched to the oral form in a timely manner, leading to unnecessary increase in expenditure. This study aims to evaluate the impact of a multifaceted intervention to promote timely switching from the IV to oral form in the post-operative setting. METHODS An evidence-based prescribing protocol was designed and implemented by the clinical pharmacy team in a single district general hospital in Egypt. The protocol specified the criteria for appropriate prescribing of IV paracetamol. Doctors were provided with information and educational sessions prior to implementation. A prospective, quasi-experimental study was undertaken to evaluate its impact on IV paracetamol utilization and costs. Data on monthly utilization and costs were recorded for 12 months before and after implementation (January 2012 to December 2013). Data were analysed using interrupted time series analysis. RESULTS Prior to implementation, in 2012, total spending on IV paracetamol was 674 154.00 Egyptian Pounds (L.E.) ($23,668.00). There was a non-significant (P > 0.05) downward trend in utilization (-32 ampoules per month) and costs [reduction of 632 L.E. ($222) per month]. Following implementation, immediate decrease in utilization and costs (P < 0.05) and a trend change over the follow-up period were observed. Average monthly reduction was 26% (95% CI: 24% to 28%, P < 0.001). CONCLUSION A multifaceted, protocol-based intervention to ensure timely switching from IV-to-oral paracetamol achieved significant reduction in utilization and cost of IV paracetamol in the first 5 months of its implementation.
Collapse
Affiliation(s)
- Nirmeen Sabry
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Dalia Dawoud
- Clinical Pharmacy Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt.,Health Economics, Modelling and Systems Analysis (HeMaSa), Centre for Technology Enabled Health Research, Coventry University, Coventry, UK
| | - Adel Alansary
- Department of Anaesthesiology and Critical Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Natalia Hounsome
- Pragmatic Clinical Trials Unit (PCTU), Centre for Primary Care and Public Health, Queen Mary, University of London, London, UK
| | - Darrin Baines
- Health Economics, Modelling and Systems Analysis (HeMaSa), Centre for Technology Enabled Health Research, Coventry University, Coventry, UK
| |
Collapse
|
42
|
Graber CJ, Jones MM, Glassman PA, Weir C, Butler J, Nechodom K, Kay CL, Furman AE, Tran TT, Foltz C, Pollack LA, Samore MH, Goetz MB. Taking an Antibiotic Time-out: Utilization and Usability of a Self-Stewardship Time-out Program for Renewal of Vancomycin and Piperacillin-Tazobactam. Hosp Pharm 2015; 50:1011-24. [PMID: 27621509 PMCID: PMC4750836 DOI: 10.1310/hpj5011-1011] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Antibiotic time-outs can promote critical thinking and greater attention to reviewing indications for continuation. OBJECTIVE We pilot tested an antibiotic time-out program at a tertiary care teaching hospital where vancomycin and piperacillin-tazobactam continuation past day 3 had previously required infectious diseases service approval. METHODS The time-out program consisted of 3 components: (1) an electronic antimicrobial dashboard that aggregated infection-relevant clinical data; (2) a templated note in the electronic medical record that included a structured review of antibiotic indications and that provided automatic approval of continuation of therapy when indicated; and (3) an educational and social marketing campaign. RESULTS In the first 6 months of program implementation, vancomycin was discontinued by day 5 in 93/145 (64%) courses where a time-out was performed on day 4 versus in 96/199 (48%) 1 year prior (P = .04). Seven vancomycin continuations via template (5% of time-outs) were guideline-discordant by retrospective chart review versus none 1 year prior (P = .002). Piperacillin-tazobactam was discontinued by day 5 in 70/105 (67%) courses versus 58/93 (62%) 1 year prior (P = .55); 9 continuations (9% of time-outs) were guideline-discordant versus two 1 year prior (P = .06). A usability survey completed by 32 physicians demonstrated modest satisfaction with the overall program, antimicrobial dashboard, and renewal templates. CONCLUSIONS By providing practitioners with clinical informatics support and guidance, the intervention increased provider confidence in making decisions to de-escalate antimicrobial therapy in ambiguous circumstances wherein they previously sought authorization for continuation from an antimicrobial steward.
Collapse
Affiliation(s)
- Christopher J. Graber
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles
| | - Makoto M. Jones
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah
- Geriatric Research and Clinical Education Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Peter A. Glassman
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles
| | - Charlene Weir
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah
- University of Utah, Salt Lake City
| | - Jorie Butler
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah
- Geriatric Research and Clinical Education Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah
- University of Utah, Salt Lake City
| | - Kevin Nechodom
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah
- University of Utah, Salt Lake City
| | - Chad L. Kay
- VA Sierra Nevada Healthcare System, Palo Alto, California, and Reno, Nevada
| | - Amy E. Furman
- VA Sierra Nevada Healthcare System, Palo Alto, California, and Reno, Nevada
| | - Thuong T. Tran
- VA Greater Los Angeles Healthcare System, Los Angeles, California
| | | | - Lori A. Pollack
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew H. Samore
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah
- University of Utah, Salt Lake City
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles
| |
Collapse
|
43
|
Antimicrobial stewardship in outpatient settings: a systematic review. Infect Control Hosp Epidemiol 2015; 36:142-52. [PMID: 25632996 DOI: 10.1017/ice.2014.41] [Citation(s) in RCA: 187] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Evaluate the effect of outpatient antimicrobial stewardship programs on prescribing, patient, microbial outcomes, and costs. DESIGN Systematic review METHODS Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (eg, infectious conditions, prescription services) evaluating stewardship programs in outpatient settings and reporting outcomes of interest. Data regarding study characteristics and outcomes were extracted and organized by intervention type. RESULTS We identified 50 studies eligible for inclusion, with most (29 of 50; 58%) reporting on respiratory tract infections, followed by multiple/unspecified infections (17 of 50; 34%). We found medium-strength evidence that stewardship programs incorporating communication skills training and laboratory testing are associated with reductions in antimicrobial use, and low-strength evidence that other stewardship interventions are associated with improved prescribing. Patient-centered outcomes, which were infrequently reported, were not adversely affected. Medication costs were generally lower with stewardship interventions, but overall program costs were rarely reported. No studies reported microbial outcomes, and data regarding outpatient settings other than primary care clinics are limited. CONCLUSIONS Low- to moderate-strength evidence suggests that antimicrobial stewardship programs in outpatient settings improve antimicrobial prescribing without adversely effecting patient outcomes. Effectiveness depends on program type. Most studies were not designed to measure patient or resistance outcomes. Data regarding sustainability and scalability of interventions are limited.
Collapse
|
44
|
Aryee A, Price N. Antimicrobial stewardship - can we afford to do without it? Br J Clin Pharmacol 2015; 79:173-81. [PMID: 24803175 DOI: 10.1111/bcp.12417] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 04/29/2014] [Indexed: 11/30/2022] Open
Abstract
Antimicrobial resistance (AMR) is a rapidly developing and alarming global threat which has been highlighted by national governments and public health bodies including the World Health Organization. The spectre of a 'post-antibiotic era' is a real possibility unless curtailing the development and spread of these organisms is given high priority. Numerous studies have shown that AMR is associated with worse outcomes for patients and higher healthcare costs. While clinical data from low and middle income countries is lacking, there is increasing evidence that the problem in these areas is as great, or even greater, than in high income nations. Of the many drivers behind the development of AMR, the most significant is selection pressure caused by antibiotic use. Antimicrobial stewardship programmes are a set of interventions that aim to ensure the judicious use of antimicrobials by preventing their unnecessary use, and by providing targeted and limited therapy in situations where they are warranted. The ultimate goal of these programmes is to provide effective antimicrobial therapy whilst safeguarding their effectiveness for future generations. Whilst they do require an initial investment, they have been shown to be an effective way of controlling antimicrobial use, and have been associated with improved patient outcomes and reduced healthcare costs.
Collapse
Affiliation(s)
- Anna Aryee
- Department of Infection, Guy's & St Thomas' NHS Trust, St Thomas' Hospital, London; Centre for Clinical Infection and Diagnostics Research, King's College London, St Thomas' Hospital, London, UK
| | | |
Collapse
|
45
|
Welch S. Antimicrobial stewardship in Australian emergency departments. Emerg Med Australas 2015; 27:427-30. [DOI: 10.1111/1742-6723.12448] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Susan Welch
- Pharmacy Department; St Vincent's Hospital; Sydney New South Wales Australia
- Faculty of Pharmacy; The University of Sydney; Sydney New South Wales Australia
| |
Collapse
|
46
|
Goulding L, Parke H, Maharaj R, Loveridge R, McLoone A, Hadfield S, Helme E, Hopkins P, Sandall J. Improving critical care discharge summaries: a collaborative quality improvement project using PDSA. BMJ QUALITY IMPROVEMENT REPORTS 2015; 4:bmjquality_uu203938.w3268. [PMID: 26734368 PMCID: PMC4645923 DOI: 10.1136/bmjquality.u203938.w3268] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 02/20/2015] [Accepted: 04/30/2015] [Indexed: 11/04/2022]
Abstract
Around 110,000 people spend time in critical care units in England and Wales each year. The transition of care from the intensive care unit to the general ward exposes patients to potential harms from changes in healthcare providers and environment. Nurses working on general wards report anxiety and uncertainty when receiving patients from critical care. An innovative form of enhanced capability critical care outreach called 'iMobile' is being provided at King's College Hospital (KCH). Part of the remit of iMobile is to review patients who have been transferred from critical care to general wards. The iMobile team wished to improve the quality of critical care discharge summaries. A collaborative evidence-based quality improvement project was therefore undertaken by the iMobile team at KCH in conjunction with researchers from King's Improvement Science (KIS). Plan, Do, Study, Act (PDSA) methodology was used. Three PDSA cycles were undertaken. Methods adopted comprised: a scoping literature review to identify relevant guidelines and research evidence to inform all aspects of the quality improvement project; a process mapping exercise; informal focus groups / interviews with staff; patient story-telling work with people who had experienced critical care and subsequent discharge to a general ward; and regular audits of the quality of both medical and nursing critical care discharge summaries. The following behaviour change interventions were adopted, taking into account evidence of effectiveness from published systematic reviews and considering the local context: regular audit and feedback of the quality of discharge summaries, feedback of patient experience, and championing and education delivered by local opinion leaders. The audit results were mixed across the trajectory of the project, demonstrating the difficulty of sustaining positive change. This was particularly important as critical care bed occupancy and through-put fluctuates which then impacts on work-load, with new cohorts of staff regularly passing through critical care. In addition to presenting the results of this quality improvement project, we also reflect on the lessons learned and make suggestions for future projects.
Collapse
Affiliation(s)
- Lucy Goulding
- King's Improvement Science, King's College London and King's College Hospital NHS Foundation Trust; UK
| | - Hannah Parke
- King's Improvement Science, King's College London and King's College Hospital NHS Foundation Trust; UK
| | - Ritesh Maharaj
- King's Improvement Science, King's College London and King's College Hospital NHS Foundation Trust; UK
| | - Robert Loveridge
- King's Improvement Science, King's College London and King's College Hospital NHS Foundation Trust; UK
| | - Anne McLoone
- King's Improvement Science, King's College London and King's College Hospital NHS Foundation Trust; UK
| | - Sophie Hadfield
- King's Improvement Science, King's College London and King's College Hospital NHS Foundation Trust; UK
| | - Eloise Helme
- King's Improvement Science, King's College London and King's College Hospital NHS Foundation Trust; UK
| | - Philip Hopkins
- King's Improvement Science, King's College London and King's College Hospital NHS Foundation Trust; UK
| | - Jane Sandall
- King's Improvement Science, King's College London and King's College Hospital NHS Foundation Trust; UK
| |
Collapse
|
47
|
Teo CK, Baysari MT, Day RO. Understanding Compliance to an Antibiotic Prescribing Policy: Perspectives of Policymakers and Prescribers. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2013.tb00212.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Melissa T Baysari
- Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales; Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Faculty of Medicine; University of New South Wales; Sydney New South Wales
| |
Collapse
|
48
|
Chen AWJ, Khumra S, Eaton V, Kong DCM. Snapshot of Antimicrobial Stewardship in Australian Hospitals. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2010.tb00720.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Alex WJ Chen
- Regulatory Affairs Associate, Arrow Laboratories Ltd; Croydon
| | | | | | - David CM Kong
- Department of Pharmacy Practice, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences; Monash University; Parkville Victoria
| |
Collapse
|
49
|
Educational effectiveness, target, and content for prudent antibiotic use. BIOMED RESEARCH INTERNATIONAL 2015; 2015:214021. [PMID: 25945327 PMCID: PMC4402196 DOI: 10.1155/2015/214021] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 03/20/2015] [Indexed: 11/18/2022]
Abstract
Widespread antimicrobial use and concomitant resistance have led to a significant threat to public health. Because inappropriate use and overuse of antibiotics based on insufficient knowledge are one of the major drivers of antibiotic resistance, education about prudent antibiotic use aimed at both the prescribers and the public is important. This review investigates recent studies on the effect of interventions for promoting prudent antibiotics prescribing. Up to now, most educational efforts have been targeted to medical professionals, and many studies showed that these educational efforts are significantly effective in reducing antibiotic prescribing. Recently, the development of educational programs to reduce antibiotic use is expanding into other groups, such as the adult public and children. The investigation of the contents of educational programs for prescribers and the public demonstrates that it is important to develop effective educational programs suitable for each group. In particular, it seems now to be crucial to develop appropriate curricula for teaching medical and nonmedical (pharmacy, dentistry, nursing, veterinary medicine, and midwifery) undergraduate students about general medicine, microbial virulence, mechanism of antibiotic resistance, and judicious antibiotic prescribing.
Collapse
|
50
|
Time from onset of SIRS to antibiotic administration and outcomes after subarachnoid hemorrhage. Neurocrit Care 2015; 21:85-90. [PMID: 23839708 DOI: 10.1007/s12028-013-9846-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The interval from presentation with systemic inflammatory response syndrome (SIRS) to the start of antibiotic administration affects mortality in patients with sepsis. However, patients with subarachnoid hemorrhage (SAH) often develop SIRS directly from their brain injury, making it a less useful indicator of infection. We therefore hypothesized that SIRS would not be a suitable trigger for antibiotics in this population. METHODS We examined the time from the development of SIRS until antibiotic initiation and its relationship to long-term neurological outcomes in patients with nontraumatic SAH. Patients' baseline characteristics, time of antibiotic administration, and hospital course were collected from retrospective chart review. The primary outcome, 6-month functional status, was prospectively determined using blinded, structured interviews incorporating the modified Rankin Scale (mRS). RESULTS Sixty-six of 70 patients with SAH during the study period had 6-month follow-up and were included in this analysis. SIRS developed in 57 patients (86%, 95% CI 78-95%). In ordinal logistic regression models controlling for age and illness severity, the time from SIRS onset until antibiotic initiation was not associated with 6-month mRS scores (OR per hour, 0.994; 95% CI 0.987-1.001). CONCLUSIONS In this cohort of patients with SAH, time from SIRS onset until antibiotic administration was not related to functional outcomes. Our results indicate that SIRS is nonspecific in patients with SAH, and support the safety of withholding antibiotics in those who lack additional evidence of infection or hemodynamic deterioration.
Collapse
|