1
|
Kien C, Daxenbichler J, Titscher V, Baenziger J, Klingenstein P, Naef R, Klerings I, Clack L, Fila J, Sommer I. Effectiveness of de-implementation of low-value healthcare practices: an overview of systematic reviews. Implement Sci 2024; 19:56. [PMID: 39103927 DOI: 10.1186/s13012-024-01384-6] [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: 03/04/2024] [Accepted: 07/12/2024] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Reducing low-value care (LVC) is crucial to improve the quality of patient care while increasing the efficient use of scarce healthcare resources. Recently, strategies to de-implement LVC have been mapped against the Expert Recommendation for Implementing Change (ERIC) compilation of strategies. However, such strategies' effectiveness across different healthcare practices has not been addressed. This overview of systematic reviews aimed to investigate the effectiveness of de-implementation initiatives and specific ERIC strategy clusters. METHODS We searched MEDLINE (Ovid), Epistemonikos.org and Scopus (Elsevier) from 1 January 2010 to 17 April 2023 and used additional search strategies to identify relevant systematic reviews (SRs). Two reviewers independently screened abstracts and full texts against a priori-defined criteria, assessed the SR quality and extracted pre-specified data. We created harvest plots to display the results. RESULTS Of 46 included SRs, 27 focused on drug treatments, such as antibiotics or opioids, twelve on laboratory tests or diagnostic imaging and seven on other healthcare practices. In categorising de-implementation strategies, SR authors applied different techniques: creating self-developed strategies (n = 12), focussing on specific de-implementation strategies (n = 14) and using published taxonomies (n = 12). Overall, 15 SRs provided evidence for the effectiveness of de-implementation interventions to reduce antibiotic and opioid utilisation. Reduced utilisation, albeit inconsistently significant, was documented in the use of antipsychotics and benzodiazepines, as well as in laboratory tests and diagnostic imaging. Strategies within the adapt and tailor to context, develop stakeholder interrelationships, and change infrastructure and workflow ERIC clusters led to a consistent reduction in LVC practices. CONCLUSION De-implementation initiatives were effective in reducing medication usage, and inconsistent significant reductions were observed for LVC laboratory tests and imaging. Notably, de-implementation clusters such as change infrastructure and workflow and develop stakeholder interrelationships emerged as the most encouraging avenues. Additionally, we provided suggestions to enhance SR quality, emphasising adherence to guidelines for synthesising complex interventions, prioritising appropriateness of care outcomes, documenting the development process of de-implementation initiatives and ensuring consistent reporting of applied de-implementation strategies. REGISTRATION OSF Open Science Framework 5ruzw.
Collapse
Affiliation(s)
- Christina Kien
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria.
| | - Julia Daxenbichler
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Viktoria Titscher
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Julia Baenziger
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006, Zurich, Switzerland
| | - Pauline Klingenstein
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Rahel Naef
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006, Zurich, Switzerland
- Centre of Clinical Nursing Science, University Hospital of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - Irma Klerings
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Lauren Clack
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006, Zurich, Switzerland
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich, Rämistrasse 100, Zurich, 8091, Switzerland
| | - Julian Fila
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| | - Isolde Sommer
- Department for Evidence-based Medicine and Evaluation, University for Continuing Education Krems (Danube University Krems), Dr.-Karl-Dorrek Straße 30, 3500, Krems a.d. Donau, Austria
| |
Collapse
|
2
|
Freudenberger DC, Scheese D, Wolfe LG, Ramamoorthy BU, Burrell LM, Puig CA, Shah RD, Julliard WA. More isn't always better: antibiotic duration after surgical decortication in pleural empyema. J Thorac Dis 2024; 16:3873-3881. [PMID: 38983133 PMCID: PMC11228736 DOI: 10.21037/jtd-24-61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/24/2024] [Indexed: 07/11/2024]
Abstract
Background While ample high-level evidence supports the limited use of antibiotics post-source control in intraabdominal infections, there is a paucity of available data in guiding antibiotic duration for intrathoracic infections. This study aims to analyze patient outcomes among those who have undergone surgical decortication for parapneumonic pleural empyema, comparing cases managed with infectious disease (ID) specialists against those without, and to identify predictive factors influencing antibiotic duration post-source control. We hypothesized that antibiotic duration would vary depending on the involvement of ID specialists. Methods A retrospective chart review was completed on patients with parapneumonic pleural empyemas who underwent surgical decortication at a single tertiary center from January 2011 to March 2021. Differences in patient characteristics and outcomes for those whose antibiotics were managed by ID or not were compared with Wilcoxon two-sample tests and Fisher's exact tests. Linear regression was used to evaluate for significant factors predictive of antibiotic duration. Results A total of 116 patients underwent surgical decortication for pleural empyema of parapneumonic etiology. ID specialists were involved with antibiotic management in 62 (53.4%) cases, while the remaining cases were not managed by ID. Demographics and patient comorbidities were similar between both groups. Growth of preoperative fluid cultures was higher in patients managed by ID (40.3% vs. 20.4%, P=0.03). Postoperatively, patients managed by ID had longer durations of antibiotics (28.7 vs. 20.9 days, P<0.001) and were more likely to be on IV antibiotics than patients not managed by ID (59.7% vs. 38.9%, P=0.04). However, postoperative outcomes were similar, including rates of disease recurrence, readmission, and 30-day mortality. Linear regression revealed length of antibiotics was significantly dependent on preoperative ventilator status [estimate: 16.346; 95% confidence interval (CI): 6.365-26.326; P=0.002], growth of preoperative pleural fluid cultures (estimate: 10.203; 95% CI: 2.502-17.904; P=0.01), and ID involvement (estimate: 8.097; 95% CI: 1.003-15.191; P=0.03). Conclusions Antibiotic duration for pleural empyema managed with surgical decortication is significantly dependent on ID involvement, preoperative growth of cultures, and preoperative ventilator status. However, outcomes, including disease recurrence and 30-day mortality, were similar between patients regardless of ID involvement and longer length of antibiotics, raising the question of what the adequate duration of antibiotics is for patients who receive appropriate source control for pleural empyema. Further study with randomized control trials should be conducted to provide high-level evidence regarding length of antibiotics in this patient population.
Collapse
Affiliation(s)
- Devon C Freudenberger
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Daniel Scheese
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Luke G Wolfe
- Biostatistician, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Bhavishya U Ramamoorthy
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Leslie M Burrell
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Carlos A Puig
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Rachit D Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Walker A Julliard
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| |
Collapse
|
3
|
Abejew AA, Wubetu GY, Fenta TG. Assessment of challenges and opportunities in antibiotic stewardship program implementation in Northwest Ethiopia. Heliyon 2024; 10:e32663. [PMID: 38912506 PMCID: PMC11193037 DOI: 10.1016/j.heliyon.2024.e32663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 06/06/2024] [Accepted: 06/06/2024] [Indexed: 06/25/2024] Open
Abstract
Background Indiscriminate use of antibiotics leads to antibiotic resistance (AMR) and results in mortality, morbidity, and financial burden. Antibiotic stewardship programs (ASPs) with education can resolve a number of barriers recognized in the implementation of successful ASPs. The aim of this study was to assess health professionals' perceptions and status of ASPs in hospitals in 2022. Methods A cross-sectional study was conducted from September 1, 2022 to October 30, 2022. A total of 181 health professionals were included, and a self-administered questionnaire was used to collect data. The status of hospitals was assessed using a checklist. The data were analyzed using SPSS version 23, and descriptive statistics and Chi-square tests (X2) at a P-value of <0.05 were used. Results Of the 181 respondents, 163 (90.1 %), and 161 (89.0 %) believed that AMR is a significant problem in Ethiopia and globally, respectively. Easy access to antibiotics 155 (85.6 %), and inappropriate use 137 (75.7 %) were perceived as key contributors to AMR. Antibiotics were believed to be prescribed/dispensed without laboratory results 86 (47.5 %), and antibiotic susceptibility patterns were not considered to guide empiric therapy 81 (44.8 %). ASP was believed to reduce the duration of hospital stays and associated costs 137 (75.7 %), and improve the quality of patient care 133 (73.5 %), whereas 151 (83.4 %), 143 (79 %), and 142 (78.5 %) suggested education, institutional guidelines, and prospective audits with feedback interventions to combat AMR in their hospitals, respectively. There were significant differences in perception among professionals based on professional category and attempts by hospitals to implement ASPs. Although ASPs were not functioning according to standard, there have been attempts to implement it in three hospitals. The issue of ASP had never been heard in general hospitals. Currently, it is feasible to implement ASPs in four hospitals. Conclusion The status of ASP in hospitals was very poor. Despite a lack of prior knowledge on ASPs, most respondents do have a positive perception of AMR and the implementation of ASPs. Pharmacist-led prospective audits and feedback with education and institutional guidelines for empiric antibiotic use can be better implemented in hospitals. Involvement of representatives from infection prevention and control, and collaboration among hospitals in ASP implementation will help establish a strong ASP in the area.
Collapse
Affiliation(s)
- Asrat Agalu Abejew
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Pharmacy, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | | | - Teferi Gedif Fenta
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| |
Collapse
|
4
|
White AT, Vaughn VM, Petty LA, Gandhi TN, Horowitz JK, Flanders SA, Bernstein SJ, Hofer TP, Ratz D, McLaughlin ES, Nielsen D, Czilok T, Minock J, Gupta A. Development of Patient Safety Measures to Identify Inappropriate Diagnosis of Common Infections. Clin Infect Dis 2024; 78:1403-1411. [PMID: 38298158 PMCID: PMC11175682 DOI: 10.1093/cid/ciae044] [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: 11/20/2023] [Revised: 12/28/2023] [Accepted: 01/26/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Inappropriate diagnosis of infections results in antibiotic overuse and may delay diagnosis of underlying conditions. Here we describe the development and characteristics of 2 safety measures of inappropriate diagnosis of urinary tract infection (UTI) and community-acquired pneumonia (CAP), the most common inpatient infections on general medicine services. METHODS Measures were developed from guidelines and literature and adapted based on data from patients hospitalized with UTI and CAP in 49 Michigan hospitals and feedback from end-users, a technical expert panel (TEP), and a patient focus group. Each measure was assessed for reliability, validity, feasibility, and usability. RESULTS Two measures, now endorsed by the National Quality Forum (NQF), were developed. Measure reliability (derived from 24 483 patients) was excellent (0.90 for UTI; 0.91 for CAP). Both measures had strong validity demonstrated through (a) face validity by hospital users, the TEPs, and patient focus group, (b) implicit case review (ĸ 0.72 for UTI; ĸ 0.72 for CAP), and (c) rare case misclassification (4% for UTI; 0% for CAP) due to data errors (<2% for UTI; 6.3% for CAP). Measure implementation through hospital peer comparison in Michigan hospitals (2017 to 2020) demonstrated significant decreases in inappropriate diagnosis of UTI and CAP (37% and 32%, respectively, P < .001), supporting usability. CONCLUSIONS We developed highly reliable, valid, and usable measures of inappropriate diagnosis of UTI and CAP for hospitalized patients. Hospitals seeking to improve diagnostic safety, antibiotic use, and patient care should consider using these measures to reduce inappropriate diagnosis of CAP and UTI.
Collapse
Affiliation(s)
- Andrea T White
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Health System Innovation & Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer K Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Steven J Bernstein
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan, USA
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Timothy P Hofer
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan, USA
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - David Ratz
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Elizabeth S McLaughlin
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Daniel Nielsen
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Tawny Czilok
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer Minock
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ashwin Gupta
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| |
Collapse
|
5
|
Del Fabro G, Venturini S, Avolio M, Basaglia G, Callegari A, Bramuzzo I, Basso B, Zanusso C, Rizzo A, Tonutti G, Chittaro M, Fiappo E, Tonizzo M, Crapis M. Time is running out. No excuses to delay implementation of antimicrobial stewardship programmes: impact, sustainability, resilience and efficiency through an interrupted time series analysis (2017-2022). JAC Antimicrob Resist 2024; 6:dlae072. [PMID: 38752207 PMCID: PMC11094472 DOI: 10.1093/jacamr/dlae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 04/20/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction The WHO declared antimicrobial resistance (AMR) a significant concern in 2014, sparking initiatives to ensure responsible antibiotic use. In human medicine, Antimicrobial Stewardship Programmes (ASPs) in hospitals play a pivotal role in combating AMR. Although evidence supports the effectiveness of ASPs in optimizing antimicrobial use, often the lack of resources becomes an excuse to limit their dissemination and use. This paper provides a comprehensive report on a 6-year analysis of an ASP implemented in a healthcare region in north-east Italy. Methods A retrospective data collection was conducted to assess the programme's impact on antibiotic consumption expressed as DDDs/100 patient-days, its sustainability over time, resilience during the COVID-19 pandemic and the efficiency of the ASP (relationship between workload and human resources). Results A substantial overall reduction in antibiotic consumption (-14%), particularly in fluoroquinolones (-64%) and carbapenems (-68%), was demonstrated, showcasing the programme's impact. Sustainability was confirmed through enduring trends in antibiotic consumption and ecological analysis over time. The ASP demonstrates resilience by maintaining positive trends even amid the challenging COVID-19 pandemic. Efficiency was underscored by an increase in on-site consultations despite consistent human resources until 2021. Conclusions This study offers insights into the prolonged success of a resource-efficient ASP, emphasizing the crucial role of long-term commitment in fostering responsible antibiotic use in the context of global health challenges such as AMR.
Collapse
Affiliation(s)
- Giovanni Del Fabro
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| | - Sergio Venturini
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| | - Manuela Avolio
- Department of Microbiology, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Giancarlo Basaglia
- Department of Microbiology, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Astrid Callegari
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| | - Igor Bramuzzo
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| | - Barbara Basso
- Hospital Pharmacy, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Chiara Zanusso
- Hospital Pharmacy, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Anna Rizzo
- Hospital Pharmacy, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Giuseppe Tonutti
- Hospital Health Direction, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Michele Chittaro
- Hospital Health Direction, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Eva Fiappo
- Hospital Health Direction, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Maurizio Tonizzo
- Department of Internal Medicine, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, Pordenone, Italy
| | - Massimo Crapis
- Department of Infectious Diseases, ASFO ‘Santa Maria degli Angeli’ Hospital of Pordenone, via Montereale 24, Pordenone 33170, Italy
| |
Collapse
|
6
|
Zhang H, Wang Y, Diao R, Huo X, Zhao Q. The practice and evaluation of antifungal stewardship programs at a tertiary first-class hospital in China. BMC Infect Dis 2024; 24:506. [PMID: 38773459 PMCID: PMC11106957 DOI: 10.1186/s12879-024-09405-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/15/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND The sharp increase in fungal infections, insufficient diagnostic and treatment capabilities for fungal infections, poor prognosis of patients with fungal infections as well as the increasing drug resistance of fungi are serious clinical problems. It is necessary to explore the implementation and evaluation methods of antifungal stewardship (AFS) to promote the standardized use of antifungal drugs. METHODS The AFS programme was implemented at a tertiary first-class hospital in China using a plan-do-check-act (PDCA) quality management tool. A baseline investigation was carried out to determine the utilization of antifungal drugs in pilot hospitals, analyse the existing problems and causes, and propose corresponding solutions. The AFS programme was proposed and implemented beginning in 2021, and included various aspects, such as team building, establishment of regulations, information construction, prescription review and professional training. The management effectiveness was recorded from multiple perspectives, such as the consumption of antifungal drugs, the microbial inspection rate of clinical specimens, and the proportion of rational prescriptions. The PDCA management concept was used for continuous improvement to achieve closed-loop management. RESULTS In the first year after the implementation of the AFS programme, the consumption cost, use intensity and utilization rate of antifungal drugs decreased significantly (P < 0.01). The proportion of rational antifungal drug prescriptions markedly increased, with the proportion of prescriptions with indications increasing from 86.4% in 2019 to 97.0% in 2022, and the proportion of prescriptions with appropriate usage and dosage increased from 51.9 to 87.1%. In addition, after the implementation of the AFS programme, physicians' awareness of the need to complete microbial examinations improved, and the number of fungal cultures and serological examinations increased substantially. Statistics from drug susceptibility tests revealed a decrease in the resistance rate of Candida to fluconazole. CONCLUSION This study indicated that the combination of AFS and the PDCA cycle could effectively reduce antifungal consumption and promote the rational use of antifungal drugs, providing a reference for other health care systems to reduce the overuse of antifungal drugs and delay the progression of fungal resistance.
Collapse
Affiliation(s)
- Huiyuan Zhang
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Yinglin Wang
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Ruigang Diao
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China
| | - Xuechen Huo
- Department of Hepatobiliary Surgery, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China.
| | - Quan Zhao
- Department of Pharmacy, Yantai Yuhuangding Hospital, Yantai, Shandong Province, China.
| |
Collapse
|
7
|
Ward MJ, Matheny ME, Rubenstein MD, Bonnet K, Dagostino C, Schlundt DG, Anders S, Reese T, Mixon AS. Determinants of appropriate antibiotic and NSAID prescribing in unscheduled outpatient settings in the veterans health administration. BMC Health Serv Res 2024; 24:640. [PMID: 38760660 PMCID: PMC11102113 DOI: 10.1186/s12913-024-11082-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 05/07/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Despite efforts to enhance the quality of medication prescribing in outpatient settings, potentially inappropriate prescribing remains common, particularly in unscheduled settings where patients can present with infectious and pain-related complaints. Two of the most commonly prescribed medication classes in outpatient settings with frequent rates of potentially inappropriate prescribing include antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDs). In the setting of persistent inappropriate prescribing, we sought to understand a diverse set of perspectives on the determinants of inappropriate prescribing of antibiotics and NSAIDs in the Veterans Health Administration. METHODS We conducted a qualitative study guided by the Consolidated Framework for Implementation Research and Theory of Planned Behavior. Semi-structured interviews were conducted with clinicians, stakeholders, and Veterans from March 1, 2021 through December 31, 2021 within the Veteran Affairs Health System in unscheduled outpatient settings at the Tennessee Valley Healthcare System. Stakeholders included clinical operations leadership and methodological experts. Audio-recorded interviews were transcribed and de-identified. Data coding and analysis were conducted by experienced qualitative methodologists adhering to the Consolidated Criteria for Reporting Qualitative Studies guidelines. Analysis was conducted using an iterative inductive/deductive process. RESULTS We conducted semi-structured interviews with 66 participants: clinicians (N = 25), stakeholders (N = 24), and Veterans (N = 17). We identified six themes contributing to potentially inappropriate prescribing of antibiotics and NSAIDs: 1) Perceived versus actual Veterans expectations about prescribing; 2) the influence of a time-pressured clinical environment on prescribing stewardship; 3) Limited clinician knowledge, awareness, and willingness to use evidence-based care; 4) Prescriber uncertainties about the Veteran condition at the time of the clinical encounter; 5) Limited communication; and 6) Technology barriers of the electronic health record and patient portal. CONCLUSIONS The diverse perspectives on prescribing underscore the need for interventions that recognize the detrimental impact of high workload on prescribing stewardship and the need to design interventions with the end-user in mind. This study revealed actionable themes that could be addressed to improve guideline concordant prescribing to enhance the quality of prescribing and to reduce patient harm.
Collapse
Affiliation(s)
- Michael J Ward
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA.
- Medicine Service, Tennessee Valley Healthcare System, Nashville, TN, USA.
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Michael E Matheny
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Melissa D Rubenstein
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kemberlee Bonnet
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Chloe Dagostino
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - David G Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Shilo Anders
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Research and Innovation in Systems Safety, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda S Mixon
- Education, and Clinical Center (GRECC), VA , Geriatric Research, Tennessee Valley Healthcare System, 2525 West End Avenue, Ste. 1430, Nashville, TN, 37203, USA
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
8
|
Langford BJ, Bailey P, Livorsi DJ, Brown KA, Advani SD, Dodds Ashley E, Bearman G, Nori P. Five steps to high quality antimicrobial stewardship research. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e82. [PMID: 38751942 PMCID: PMC11094375 DOI: 10.1017/ash.2024.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 05/18/2024]
Abstract
The escalating threat of antimicrobial resistance (AMR) necessitates impactful, reproducible, and scalable antimicrobial stewardship strategies. This review addresses the critical need to enhance the quality of antimicrobial stewardship intervention research. We propose five considerations for authors planning and evaluating antimicrobial stewardship initiatives. Antimicrobial stewards should consider the following mnemonic ABCDE: (A) plan Ahead using implementation science; (B) Be clear and thoroughly describe the intervention by using the TidIER checklist; (C) Use a Checklist to comprehensively report study components; (D) Select a study Design carefully; and (E) Assess Effectiveness and implementation by selecting meaningful outcomes. Incorporating these recommendations will help strengthen the evidence base of antimicrobial stewardship literature and support optimal implementation of strategies to mitigate AMR.
Collapse
Affiliation(s)
- Bradley J. Langford
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Daniel J. Livorsi
- Center for Access and Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Kevin A. Brown
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Elizabeth Dodds Ashley
- Division of Infectious Diseases, Duke University School of Medicine and Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
| | - Gonzalo Bearman
- Healthcare Infection Prevention Program, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Priya Nori
- Department of Medicine, Division of Infectious Diseases, Montefiore Medical Center, Bronx, NY, USA
| |
Collapse
|
9
|
Pant S, Corwin A, Adhikari P, Acharya SP, Acharya U, Silwal S, Dawadi P, Poudyal A, Paudyal V, Bhumiratana A. Evaluating Antibiotic Treatment Guideline Adherence to Ongoing Antibiotic Stewardship in a Tertiary Care Setting: A Retrospective Observational Study. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2024; 2024:6663119. [PMID: 38660495 PMCID: PMC11042908 DOI: 10.1155/2024/6663119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 03/27/2024] [Accepted: 03/30/2024] [Indexed: 04/26/2024]
Abstract
Antimicrobial resistance (AMR) is widely regarded as an increasing threat to global public health. Antibiotic treatment guidelines have been increasingly recognized as an effective tool to guide appropriate prescriptions and help curtail antibiotic resistance. The present study aimed to assess physician's adherence to hospital antibiotic treatment guideline recommendations in Nepal and determine predictive variables with a significant association. This was a retrospective, monocentric observational review to investigate the adherence to endorsed guidelines using the medical records of adults admitted to the hospital with a diagnosis of urinary tract infection (UTI), pneumonia, or skin and soft tissue infection (SSTI) from January 2018 to December 2019. Of the 2,077 medical records that were reviewed (954 UTI, 754 pneumonia, and 369 SSTI), 354 (17%) met the study inclusion criteria, which included 87 UTI, 180 pneumonia, and 87 SSTI patients. Among eligible patients with antibiotic prescriptions, the following were adherent to guideline recommendations: 33 (37.9%) UTI, 78 (43.3%) pneumonia, and 23 (26.4%) SSTI. The overall extent of adherence to hospital antibiotic treatment guidelines for the use of antibiotics among adult inpatients diagnosed with these common infections was 37.9%. Patients who received ceftriaxone (OR = 2.09, 95% CI = 1.18-3.71, p=0.012) and levofloxacin (OR = 4.63, 95% CI = 1.30-16.53, p=0.018) had significantly higher adherence to treatment guidelines. This study revealed a low adherence rate despite the availability of updated guidelines for antibiotic prescriptions. The findings confer an urgent need to confront antibiotic prescription patterns in such tertiary care centers for tailored interventions to improve adherence to antibiotic guidelines.
Collapse
Affiliation(s)
- Suman Pant
- Government of Nepal, Nepal Health Research Council, Kathmandu, Nepal
- Faculty of Public Health, Thammasat University, Rangsit Campus, Khlong Nueng, Pathum Thani 12121, Thailand
| | - Andrew Corwin
- Faculty of Public Health, Thammasat University, Rangsit Campus, Khlong Nueng, Pathum Thani 12121, Thailand
| | - Prabhat Adhikari
- Department of Infection Prevention and Control, Grande International Hospital, Kathmandu, Nepal
| | - Subhash Prasad Acharya
- Department of Infection Prevention and Control, Grande International Hospital, Kathmandu, Nepal
| | - Upasana Acharya
- Department of Infection Prevention and Control, Grande International Hospital, Kathmandu, Nepal
| | - Sashi Silwal
- Government of Nepal, Nepal Health Research Council, Kathmandu, Nepal
| | - Pratima Dawadi
- Government of Nepal, Nepal Health Research Council, Kathmandu, Nepal
| | | | - Vibhu Paudyal
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Adisak Bhumiratana
- Faculty of Public Health, Thammasat University, Rangsit Campus, Khlong Nueng, Pathum Thani 12121, Thailand
- Thammasat University Research Unit in One Health and EcoHealth, Rangsit Campus, Khlong Nueng, Pathum Thani 12121, Thailand
| |
Collapse
|
10
|
Pham HT, Mai-Phan TA, Nguyen AD, Nguyen VQH, Tran MH. Antimicrobial stewardship program for gastrointestinal surgeries at a Vietnamese tertiary hospital. Front Med (Lausanne) 2024; 11:1345698. [PMID: 38695034 PMCID: PMC11061432 DOI: 10.3389/fmed.2024.1345698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/25/2024] [Indexed: 05/04/2024] Open
Abstract
Background Antimicrobial Stewardship Programs (ASP) have been applied widely in high-resource countries to prevent surgical site infections (SSI). Evidence favoring ASP interventions (ASPi) in gastrointestinal surgeries from low and middle-income countries has been limited, especially in antimicrobial prophylaxis. We aimed to investigate this gap at a Vietnamese tertiary hospital. Methods We conducted a retrospective cohort study on patients undergoing clean-contaminated surgeries in 2015 who received standard of care (SoC) or SoC + ASPi. Primary outcome was 30-day SSI incidence. Secondary outcomes included length of stay (LoS) after surgery (days), cost of antibiotics, and cost of treatment (USD). Results were controlled for multiplicity and reported with treatment effect and 95% confidence interval (95%CI). A predictive model was built and cross-validated to detect patients at high risk of SSI. Results We included 395 patients for analysis (48.1% being female, mean age 49.4 years). Compared to patients receiving SoC, those with SoC + ASPi had a lower incidence of 30-day SSI (-8.8, 95%CI: -16.0 to -1.6, p = 0.042), shorter LoS after surgery (-1.1 days, 95%CI: -1.8 to -0.4, p = 0.004), and lower cost of antibiotics (-37.3 USD, 95%CI: -59.8 to -14.8, p = 0.012) and treatment (-191.1 USD, 95%CI: -348.4 to -33.8, p = 0.042). We estimated that by detecting patients at high risk of SSI with the predictive model and providing prophylactic measures, we could save 398120.7 USD per 1,000 cases of SSI. Conclusion We found that ASPi were associated with a reduction in risks of SSI, hospital stays, and cost of antibiotics/treatment in a Vietnamese tertiary hospital.
Collapse
Affiliation(s)
- Hong Tham Pham
- Faculty of Pharmacy, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
- Department of Pharmacy, Nhan Dan Gia Dinh Hospital, Ho Chi Minh City, Vietnam
| | - Tuong-Anh Mai-Phan
- Department of Surgical Gastroenterology, Nhan Dan Gia Dinh Hospital, Ho Chi Minh City, Vietnam
| | - Anh Dung Nguyen
- Department of Surgical Gastroenterology, Nhan Dan Gia Dinh Hospital, Ho Chi Minh City, Vietnam
| | | | - Minh-Hoang Tran
- NTT Hi-Tech Institute, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
| |
Collapse
|
11
|
Engel-Dettmers EM, Al Naiemi N, Dijkema HE, Braakman-Jansen AL, van Gemert-Pijnen LJ, Sinha B. Positive effects of audit and feedback on antimicrobial use in hospitalized patients limited to audited patients. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e46. [PMID: 38628373 PMCID: PMC11019582 DOI: 10.1017/ash.2024.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/23/2024] [Accepted: 02/29/2024] [Indexed: 04/19/2024]
Abstract
Objective Audit and feedback is an antimicrobial stewardship (AMS) strategy, with the potential to also optimize antimicrobial use in non-audited patients. This study aimed to determine whether audit and feedback reduce antimicrobial use in both audited and non-audited patients. Design Before-after trial with a 1-year intervention period and 2.5-year historical cohort. Setting 750-bed community hospital in the Netherlands. Patients All patients admitted to the urology wards during the 3.5-year study period were observed. Patients were classified as using antimicrobials if any antimicrobial was used for therapeutic reasons. Patients using antimicrobials prophylactically were excluded from measurements. Intervention The AMS team provided audit and feedback on antimicrobial use for patients using antimicrobials for 2 days. Retrospectively, antimicrobial use and length of stay (LOS) were compared with the historical cohort. Results Audits modified antimicrobial treatment in 52.8% of the cases. De-escalating, stopping, and switching from intravenous to oral treatment accounted for 72% of these modifications. Compared to patients from the cohort, who also used antimicrobials for 2 days, antimicrobial use decreased from 14.21 DDD/patient (95% CI, 13.08-15.34) to 11.45 DDD/patient (95% CI, 8.26-14.64; P = .047) for audited patients. Furthermore, mean LOS decreased from 7.42 days (95% CI, 6.79-8.06) to 6.13 days (95% CI, 5.38-6.89; P = .031). However, looking at all patients admitted to the urology wards, the percentage of patients using antimicrobials and total antimicrobial use remained unchanged. Conclusions Audit and feedback reduce antimicrobial use and LOS, but only for audited patients. Positive effects are not automatically transferred to patients for whom no audits have been performed.
Collapse
Affiliation(s)
- Elske M. Engel-Dettmers
- Faculty of Behavioral, Management and Social Sciences, Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
- Department of Clinical Pharmacy, ZGT, Almelo and Hengelo, The Netherlands
| | - Nashwan Al Naiemi
- Department of Medical Microbiology, Labmicta, Hengelo, The Netherlands
| | - Hero E. Dijkema
- Department of Urology, ZGT, Almelo and Hengelo, The Netherlands
| | - Annemarie L.M.A. Braakman-Jansen
- Faculty of Behavioral, Management and Social Sciences, Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Lisette J.E.W.C. van Gemert-Pijnen
- Faculty of Behavioral, Management and Social Sciences, Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Bhanu Sinha
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
12
|
Tokgöz P, Krayter S, Hafner J, Dockweiler C. Decision support systems for antibiotic prescription in hospitals: a survey with hospital managers on factors for implementation. BMC Med Inform Decis Mak 2024; 24:96. [PMID: 38622595 PMCID: PMC11020884 DOI: 10.1186/s12911-024-02490-7] [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: 10/22/2023] [Accepted: 03/25/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Inappropriate antimicrobial use, such as antibiotic intake in viral infections, incorrect dosing and incorrect dosing cycles, has been shown to be an important determinant of the emergence of antimicrobial resistance. Artificial intelligence-based decision support systems represent a potential solution for improving antimicrobial prescribing and containing antimicrobial resistance by supporting clinical decision-making thus optimizing antibiotic use and improving patient outcomes. OBJECTIVE The aim of this research was to examine implementation factors of artificial intelligence-based decision support systems for antibiotic prescription in hospitals from the perspective of the hospital managers, who have decision-making authority for the organization. METHODS An online survey was conducted between December 2022 and May 2023 with managers of German hospitals on factors for decision support system implementation. Survey responses were analyzed from 118 respondents through descriptive statistics. RESULTS Survey participants reported openness towards the use of artificial intelligence-based decision support systems for antibiotic prescription in hospitals but little self-perceived knowledge in this field. Artificial intelligence-based decision support systems appear to be a promising opportunity to improve quality of care and increase treatment safety. Along with the Human-Organization-Technology-fit model attitudes were presented. In particular, user-friendliness of the system and compatibility with existing technical structures are considered to be important for implementation. The uptake of decision support systems also depends on the ability of an organization to create a facilitating environment that helps to address the lack of user knowledge as well as trust in and skepticism towards these systems. This includes the training of user groups and support of the management level. Besides, it has been assessed to be important that potential users are open towards change and perceive an added value of the use of artificial intelligence-based decision support systems. CONCLUSION The survey has revealed the perspective of hospital managers on different factors that may help to address implementation challenges for artificial intelligence-based decision support systems in antibiotic prescribing. By combining factors of user perceptions about the systems´ perceived benefits with external factors of system design requirements and contextual conditions, the findings highlight the need for a holistic implementation framework of artificial intelligence-based decision support systems.
Collapse
Affiliation(s)
- Pinar Tokgöz
- School of Life Sciences, Department Digital Health Sciences and Biomedicine, Professorship of Digital Public Health, University of Siegen, 57068, Siegen, Germany.
| | - Stephan Krayter
- School of Life Sciences, Department Digital Health Sciences and Biomedicine, Professorship of Digital Public Health, University of Siegen, 57068, Siegen, Germany
| | - Jessica Hafner
- School of Life Sciences, Department Digital Health Sciences and Biomedicine, Professorship of Digital Public Health, University of Siegen, 57068, Siegen, Germany
| | - Christoph Dockweiler
- School of Life Sciences, Department Digital Health Sciences and Biomedicine, Professorship of Digital Public Health, University of Siegen, 57068, Siegen, Germany
| |
Collapse
|
13
|
Kourbeti I, Kamiliou A, Samarkos M. Antibiotic Stewardship in Surgical Departments. Antibiotics (Basel) 2024; 13:329. [PMID: 38667005 PMCID: PMC11047567 DOI: 10.3390/antibiotics13040329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/31/2024] [Accepted: 03/31/2024] [Indexed: 04/29/2024] Open
Abstract
Antimicrobial resistance (AMR) has emerged as one of the leading public health threats of the 21st century. New evidence underscores its significance in patients' morbidity and mortality, length of stay, as well as healthcare costs. Globally, the factors that contribute to antimicrobial resistance include social and economic determinants, healthcare governance, and environmental interactions with impact on humans, plants, and animals. Antimicrobial stewardship (AS) programs have historically overlooked surgical teams as they considered them more difficult to engage. This review aims to summarize the evolution and significance of AS in surgical wards, including the surgical intensive care unit (SICU) and the role of diagnostic stewardship (DS). The contribution of AS team members is presented. The new diagnostic modalities and the new technologies including artificial intelligence (AI) are also reviewed.
Collapse
Affiliation(s)
- Irene Kourbeti
- Department of Internal Medicine, School of Medicine, National and Kapodistrian, University of Athens, 11527 Athens, Greece; (A.K.); (M.S.)
| | | | | |
Collapse
|
14
|
Soucy JPR, Low M, Acharya KR, Ellen M, Hulth A, Löfmark S, Garber GE, Watson W, Moran-Gilad J, Davidovitch N, Amar T, McCready J, Orava M, Brownstein JS, Brown KA, Fisman DN, MacFadden DR. Evaluation of an automated feedback intervention to improve antibiotic prescribing among primary care physicians (OPEN Stewardship): a multinational controlled interrupted time-series study. Microbiol Spectr 2024; 12:e0001724. [PMID: 38411087 PMCID: PMC10986525 DOI: 10.1128/spectrum.00017-24] [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: 01/22/2024] [Accepted: 02/06/2024] [Indexed: 02/28/2024] Open
Abstract
Tools to advance antimicrobial stewardship in the primary health care setting, where most antimicrobials are prescribed, are urgently needed. The aim of this study was to evaluate OPEN Stewarship (Online Platform for Expanding aNtibiotic Stewardship), an automated feedback intervention, among a cohort of primary care physicians. We performed a controlled, interrupted time-series study of 32 intervention and 725 control participants, consisting of primary care physicians from Ontario, Canada and Southern Israel, from October 2020 to December 2021. Intervention participants received three personalized feedback reports targeting several aspects of antibiotic prescribing. Study outcomes (overall prescribing rate, prescribing rate for viral respiratory conditions, prescribing rate for acute sinusitis, and mean duration of therapy) were evaluated using multilevel regression models. We observed a decrease in the mean duration of antibiotic therapy (IRR = 0.94; 95% CI: 0.90, 0.99) in intervention participants during the intervention period. We did not observe a significant decline in overall antibiotic prescribing (OR = 1.01; 95% CI: 0.94, 1.07), prescribing for viral respiratory conditions (OR = 0.87; 95% CI: 0.73, 1.03), or prescribing for acute sinusitis (OR = 0.85; 95% CI: 0.67, 1.07). In this antimicrobial stewardship intervention among primary care physicians, we observed shorter durations of therapy per antibiotic prescription during the intervention period. The COVID-19 pandemic may have hampered recruitment; a dramatic reduction in antibiotic prescribing rates in the months before our intervention may have made physicians less amenable to further reductions in prescribing, limiting the generalizability of the estimates obtained.IMPORTANCEAntibiotic overprescribing contributes to antibiotic resistance, a major threat to our ability to treat infections. We developed the OPEN Stewardship (Online Platform for Expanding aNtibiotic Stewardship) platform to provide automated feedback on antibiotic prescribing in primary care, where most antibiotics for human use are prescribed but where the resources to improve antibiotic prescribing are limited. We evaluated the platform among a cohort of primary care physicians from Ontario, Canada and Southern Israel from October 2020 to December 2021. The results showed that physicians who received personalized feedback reports prescribed shorter courses of antibiotics compared to controls, although they did not write fewer antibiotic prescriptions. While the COVID-19 pandemic presented logistical and analytical challenges, our study suggests that our intervention meaningfully improved an important aspect of antibiotic prescribing. The OPEN Stewardship platform stands as an automated, scalable intervention for improving antibiotic prescribing in primary care, where needs are diverse and technical capacity is limited.
Collapse
Affiliation(s)
- Jean-Paul R. Soucy
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Low
- Chief Physician’s Office, Clalit Health Services, Tel Aviv, Israel
| | - Kamal R. Acharya
- Department of Population Medicine, University of Guelph Ontario Veterinary College, Guelph, Ontario, Canada
| | - Moriah Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Anette Hulth
- The Public Health Agency of Sweden, Stockholm, Sweden
| | - Sonja Löfmark
- The Public Health Agency of Sweden, Stockholm, Sweden
| | | | - William Watson
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jacob Moran-Gilad
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Nadav Davidovitch
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Tamar Amar
- Department of Epidemiology, Biostatistics, and Community Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Janine McCready
- Division of Infectious Diseases, Department of Medicine, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Matthew Orava
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Barrie and Community Family Health Team, Barrie, Ontario, Canada
| | - John S. Brownstein
- Computational Epidemiology Lab, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Kevin A. Brown
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
| | - David N. Fisman
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Derek R. MacFadden
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
15
|
Küpper-Tetzel CP, Idris R, Kessel J, Schüttfort G, Hoehl S, Kohmer N, Graf C, Hogardt M, Besier S, Wichelhaus TA, Vehreschild MJGT, Stephan C, Wetzstein N. Coinfections and antimicrobial treatment in a cohort of falciparum malaria in a non-endemic country: a 10-year experience. Infection 2024; 52:461-469. [PMID: 37889376 PMCID: PMC10954839 DOI: 10.1007/s15010-023-02103-x] [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: 03/13/2023] [Accepted: 09/27/2023] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Falciparum malaria remains one of the deadliest infectious diseases worldwide. In Germany, it is mainly an imported infection among travellers. Rates of coinfection are often unknown, and a clinical rationale for the beneficial use of calculated antibiotic therapy in patients with malaria and suspected coinfection is lacking. METHODS We conducted an analysis of all in-patients treated with falciparum malaria at a German infectious diseases centre in vicinity to one of Europe's major airports for 2010-2019. Logistic regression and time-to-event analysis were used to evaluate predictors for bacterial coinfection, the use of antibacterial substances, as well as their influence on clinical course. RESULTS In total, 264 patients were included. Of those, 64% received an additional antibacterial therapy (n = 169). Twenty-nine patients (11.0%) were found to have suffered from a relevant bacterial coinfection, while only a small fraction had relevant bacteremia (n = 3, 1.4%). However, patients with severe malaria did not suffer from coinfections more frequently (p = 0.283). CRP levels were not a reliable predictor for a bacterial coinfection (OR 0.99, 95% CI 0.94-1.06, p = 0.850), while another clinical focus of infection was positively associated (OR 3.86, 95% CI 1.45-11.55, p = 0.010). CONCLUSION Although bacterial coinfections were rare in patients with malaria at our centre, the risk does not seem negligible. These data point rather towards individual risk assessment in respective patients than to general empiric antibiotic use.
Collapse
Affiliation(s)
- Claus P Küpper-Tetzel
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Raja Idris
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Johanna Kessel
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Gundolf Schüttfort
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Sebastian Hoehl
- Institute of Medical Virology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Niko Kohmer
- Institute of Medical Virology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Christiana Graf
- Institute of Medical Virology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
- Department of Internal Medicine, Gastroenterology and Hepatology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Silke Besier
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Thomas A Wichelhaus
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Maria J G T Vehreschild
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Christoph Stephan
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Nils Wetzstein
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
| |
Collapse
|
16
|
Menchinelli G, Oliveti A, Fiori B, D'Inzeo T, Spanu T, Murri R, Fantoni M, Sanguinetti M, Posteraro B, De Angelis G. Early assessment of blood culture negativity as a potential support tool for antimicrobial stewardship. Heliyon 2024; 10:e27849. [PMID: 38524553 PMCID: PMC10958360 DOI: 10.1016/j.heliyon.2024.e27849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/09/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024] Open
Abstract
Objective To assess whether 48-h negative blood culture (BC) bottles are still negative at the classic 120-h incubation endpoint and whether 48 h might be the time to make antimicrobial therapy decisions. Methods Data from the first collected bottles from bloodstream infection (BSI) episodes of single patients were retrospectively analyzed. Probabilities of bottles being negative at the classic endpoint were calculated from 0 to 120 h of incubation. Results Among BC-negative episodes (4018/4901 [82.0%]), most (2097/4018 (52.2%) occurred in medicine patients. At 48 h, probability was 100.0% (95% CI, 99.9-100.0) for all 4018 patients. Of these, 1244 (31.0%) patients remained on antibiotics until 120 h. Excluding 401 (32.2%) patients who received antibiotics for another (non-bloodstream) infection, 843 (67.8%) of 1244 patients could have merited early (48-h) discontinuation of antibiotics. Stopping treatment in these patients would have led to saving 5201 days of access (943 [18.1%] days), watch (3624 [69.7%] days), or reserve (634 [12.2%]) AWaRe groups' antibiotics, which correspond to 65.6% (5201/7928) of days of administered antibiotics in all 1244 patients. Conclusion As an early indicator of BC negativity, the 48-h endpoint could reliably support antimicrobial stewardship, but the clinical judgment remains imperative especially when BSI is highly suspected.
Collapse
Affiliation(s)
- Giulia Menchinelli
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Alice Oliveti
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Barbara Fiori
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Tiziana D'Inzeo
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Teresa Spanu
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Rita Murri
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
- Dipartimento di Sicurezza e Bioetica, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Massimo Fantoni
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
- Dipartimento di Sicurezza e Bioetica, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Maurizio Sanguinetti
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Brunella Posteraro
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
- Dipartimento di Scienze Mediche e Chirurgiche Addominali ed Endocrino Metaboliche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
| | - Giulia De Angelis
- Dipartimento di Scienze di Laboratorio e Infettivologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| |
Collapse
|
17
|
Al-Nasir J, Belančić A, Palčevski D, Dyar OJ. 2015 versus 2021: Self-Reported Preparedness to Prescribe Antibiotics Prudently among Final Year Medical Students in Sweden. Antibiotics (Basel) 2024; 13:303. [PMID: 38666979 PMCID: PMC11047482 DOI: 10.3390/antibiotics13040303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/29/2024] Open
Abstract
Cross-sectional surveys have found variations in how prepared medical students feel to prescribe antibiotics responsibly, but insights are lacking on the stability of these outcomes. In a 2015 survey, final-year Swedish medical students reported very high preparedness levels across a comprehensive range of relevant curriculum topics. We repeated this survey in 2021 to assess the stability of previous findings and to capture the potential impacts of the COVID-19 pandemic. Final-year students in 2015 and 2021 at all seven Swedish medical schools were eligible to participate in an online survey covering curricula topics, teaching methods and COVID-19 impacts (2021). Eligible students received email invitations and reminders from local coordinators. Students from six of seven medical schools participated in both surveys, with response rates of 24.1% (309/1281) in 2021 and 21.3% (239/1124) in 2015. The average global preparedness was 77.0% and 83.2%, respectively (p < 0.001), with lower preparedness levels in 24/27 curriculum topics in 2021. Students at certain universities reported COVID-19 impacts on antibiotic prescribing education (format, duration and perceived quality). Self-reported preparedness levels have fallen slightly but remain high compared with 2015 levels in other European countries. Students consistently reported lower preparedness in specific topics; improvement efforts should consider focusing on these areas, particularly in the context of the ongoing implementation of programmes leading to a full licence upon graduation.
Collapse
Affiliation(s)
- Jasmine Al-Nasir
- Department of Public Health and Caring Sciences, Uppsala University, 75236 Uppsala, Sweden;
| | - Andrej Belančić
- Department of Clinical Pharmacology, Clinical Hospital Centre Rijeka, 51000 Rijeka, Croatia;
- Department of Basic and Clinical Pharmacology with Toxicology, Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
| | - Dora Palčevski
- Department of Internal Medicine, Clinical Hospital Centre Rijeka, 51000 Rijeka, Croatia;
| | - Oliver J. Dyar
- Department of Public Health and Caring Sciences, Uppsala University, 75236 Uppsala, Sweden;
| | | |
Collapse
|
18
|
Jung N, Schommers P, Leisse C. [Precision medicine in infectious diseases]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:220-227. [PMID: 38038764 DOI: 10.1007/s00108-023-01620-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 12/02/2023]
Abstract
Infectious medicine faces a variety of challenges, such as the increase in antibiotic resistance and the emergence and spread of infectious diseases fueled by climate change and globalization. Precision medicine can provide solutions to many of these challenges. Since an untargeted request for diagnostic tests can lead to test results without clinical relevance, which can increase the use of non-indicated antibiotics, the principle aimed at is: targeted diagnostics (the right test) and consideration of patient characteristics (the right person) to optimize management (the right action). At the same time, one must always decide whether empirical therapy must be immediately initiated, even if the results of the initiated diagnostics are not yet available. In addition, many new diagnostics as well as therapies have recently been developed for the rapid detection and more specific treatment of bacterial infections. Molecular genetic methods, which offer more rapid results than classical bacterial cultures, are gaining ground as new diagnostics. New therapeutics such as bacteriophages, antibodies or antibacterial peptides allow increasingly precise treatment of certain bacterial infections. Precision medicine will also play an increasingly important role in infectious medicine in the future.
Collapse
Affiliation(s)
- N Jung
- Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Klinik I für Innere Medizin, Infektiologie, Köln, Deutschland.
| | - P Schommers
- Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Klinik I für Innere Medizin, Infektiologie, Köln, Deutschland
| | - C Leisse
- Universität zu Köln, Medizinische Fakultät und Uniklinik Köln, Klinik I für Innere Medizin, Infektiologie, Köln, Deutschland
| |
Collapse
|
19
|
Monari C, Onorato L, Allegorico E, Minerva V, Macera M, Bosso G, Calò F, Pagano A, Russo T, Sansone G, D'Isanto M, Casciotta A, Vanni M, Numis FG, Coppola N. The impact of a non-restrictive Antimicrobial Stewardship Program in the emergency department of a secondary-level Italian hospital. Intern Emerg Med 2024; 19:493-500. [PMID: 37700179 PMCID: PMC10954915 DOI: 10.1007/s11739-023-03418-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 08/29/2023] [Indexed: 09/14/2023]
Abstract
Evidence supporting the effectiveness of Antimicrobial Stewardship (AMS) Programs in the emergency department (ED) setting is limited. We conducted a prospective cohort study to assess the efficacy of an AMS program in an ED and a short-stay observation unit. The intervention included periodic prospective audits (twice a week), conducted by four infectious disease consultants. Primary outcomes included the difference in the hospital mortality rate, antibiotic consumption, and the incidence of bloodstream infections (BSI) caused by multidrug resistant (MDR) bacteria, before March 2020-February 2021 and after March 2021-February 2022 when the program was implemented. Interrupted time-series analysis was performed to assess the effect of our program. During the 12-month program, we performed 152 audits and evaluated 366 antibiotic therapies out of a total of 853 patients admitted. In the intervention period, we observed a non-statistically significant decrease in total antibiotic consumption, with a change in level of - 31.2 defined daily dose/100 patient-days (PD) (p = 0.71). Likewise, we found no significant variations in the rate of BSI due to MDR Gram-positive (CT - 0.02 events/PD, p = 0.84), MDR Gram-negative bacteria (CT 0.08, p = 0.71), or Candida spp. (CT 0.008, p = 0.86). Conversely, we found a significant decrease in the mortality rate between the pre- and post-intervention periods (- 1.98 deaths/100 PD, CI - 3.9 to - 0.007, p = 0.049). The Antibiotic Stewardship Program in the ED was associated with a significant decrease in the mortality rate. More high-quality studies are needed to determine the most effective ASP strategies in this unique setting.
Collapse
Affiliation(s)
- Caterina Monari
- Infectious Diseases Unit, Section of Infectious Diseases, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80131, Naples, Italy
| | - Lorenzo Onorato
- Infectious Diseases Unit, Section of Infectious Diseases, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80131, Naples, Italy
| | - Enrico Allegorico
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Valentina Minerva
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Margherita Macera
- Infectious Diseases Unit, Section of Infectious Diseases, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80131, Naples, Italy
| | - Giorgio Bosso
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Federica Calò
- Infectious Diseases Unit, Section of Infectious Diseases, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80131, Naples, Italy
| | - Antonio Pagano
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Teresa Russo
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Gennaro Sansone
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Marina D'Isanto
- Microbiology Unit, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Antonio Casciotta
- Department of Pharmacology, "Santa Maria Delle Grazie Hospital, Pozzuoli, Italy
| | | | - Fabio Giuliano Numis
- Department of Emergency and Critical Care, "Santa Maria Delle Grazie Hospital", Pozzuoli, Italy
| | - Nicola Coppola
- Infectious Diseases Unit, Section of Infectious Diseases, Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Via L. Armanni 5, 80131, Naples, Italy.
| |
Collapse
|
20
|
Li P, Li Y, Zhang Y, Zhu S, Pei Y, Zhang Q, Liu J, Bao J, Sun M. A dynamic nomogram to predict invasive fungal super-infection during healthcare-associated bacterial infection in intensive care unit patients: an ambispective cohort study in China. Front Cell Infect Microbiol 2024; 14:1281759. [PMID: 38469345 PMCID: PMC10925706 DOI: 10.3389/fcimb.2024.1281759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 02/08/2024] [Indexed: 03/13/2024] Open
Abstract
Objectives Invasive fungal super-infection (IFSI) is an added diagnostic and therapeutic dilemma. We aimed to develop and assess a nomogram of IFSI in patients with healthcare-associated bacterial infection (HABI). Methods An ambispective cohort study was conducted in ICU patients with HABI from a tertiary hospital of China. Predictors of IFSI were selected by both the least absolute shrinkage and selection operator (LASSO) method and the two-way stepwise method. The predictive performance of two models built by logistic regression was internal-validated and compared. Then external validity was assessed and a web-based nomogram was deployed. Results Between Jan 1, 2019 and June 30, 2023, 12,305 patients with HABI were screened in 14 ICUs, of whom 372 (3.0%) developed IFSI. Among the fungal strains causing IFSI, the most common was C.albicans (34.7%) with a decreasing proportion, followed by C.tropicalis (30.9%), A.fumigatus (13.9%) and C.glabrata (10.1%) with increasing proportions year by year. Compared with LASSO-model that included five predictors (combination of priority antimicrobials, immunosuppressant, MDRO, aCCI and S.aureus), the discriminability of stepwise-model was improved by 6.8% after adding two more predictors of COVID-19 and microbiological test before antibiotics use (P<0.01).And the stepwise-model showed similar discriminability in the derivation (the area under curve, AUC=0.87) and external validation cohorts (AUC=0.84, P=0.46). No significant gaps existed between the proportion of actual diagnosed IFSI and the frequency of IFSI predicted by both two models in derivation cohort and by stepwise-model in external validation cohort (P=0.16, 0.30 and 0.35, respectively). Conclusion The incidence of IFSI in ICU patients with HABI appeared to be a temporal rising, and our externally validated nomogram will facilitate the development of targeted and timely prevention and control measures based on specific risks of IFSI.
Collapse
Affiliation(s)
- Peng Li
- Department of Infection Control, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan Li
- Department of Infection Control, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Youjian Zhang
- Department of Infection Control, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Shichao Zhu
- Central Intensive Care Unit, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Yongju Pei
- Respiratory Intensive Care Unit, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Qi Zhang
- Department of Clinical Microbiology, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Junping Liu
- Department of Infectious Disease, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Junzhe Bao
- College of Public Health, Zhengzhou University, Zhengzhou, China
| | - Mingjie Sun
- Department of Infection Control, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
21
|
Durand C, Risso K, Loschi M, Retur N, Emery A, Courjon J, Cluzeau T, Carles M. Efficacy of an antimicrobial stewardship intervention for early adaptation of antibiotic therapy in high-risk neutropenic patients. Antimicrob Resist Infect Control 2024; 13:5. [PMID: 38233960 PMCID: PMC10795280 DOI: 10.1186/s13756-023-01354-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 12/11/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND The 4th European Conference on Infections in Leukemia recommends early adaptation of empirical antibiotic therapy (EAT) for febrile neutropenia in stable patients. OBJECTIVES To assess the efficacy of an antimicrobial stewardship (AMS) intervention promoting early de-escalation and discontinuation of EAT in high-risk neutropenic patients. METHODS This before-after study was conducted in the hematology department of the University Hospital of Nice, France. The AMS intervention included the development of clinical decision support algorithms, a twice-weekly face-to-face review of all antibiotic prescriptions and monthly feedback on the intervention. The primary endpoint was overall antibiotic consumption during hospital stay, expressed as days of therapy (DOT). RESULTS A total of 113 admissions were included: 56 during the pre-intervention period and 57 during the intervention period. Induction chemotherapy and conditioning for allogeneic stem cell transplantation were the most frequent reasons for admission. In the intervention period, there was a significant decrease in overall antibiotic consumption (median DOT 20 vs. 28 days, p = 0.006), carbapenem consumption (median DOT 5.5 vs. 9 days, p = 0.017) and anti-resistant Gram-positive agents consumption (median DOT 8 vs. 11.5 days, p = 0.017). We found no statistical difference in the rates of intensive care unit admission (9% in each period) and 30-day mortality (5% vs. 0%, p = 0.243). Compliance with de-escalation and discontinuation strategies was significantly higher in the intervention period (77% vs. 8%, p < 0.001). CONCLUSION A multifaceted AMS intervention led to high compliance with early de-escalation and discontinuation of EAT and lower overall antibiotic consumption, without negatively affecting clinical outcomes.
Collapse
Affiliation(s)
- Claire Durand
- Infectious Disease Department, University Hospital of Nice, Cote D'Azur University, Nice, France.
| | - Karine Risso
- Infectious Disease Department, University Hospital of Nice, Cote D'Azur University, Nice, France
| | - Michael Loschi
- Hematology Department, University Hospital of Nice, Cote D'Azur University, Nice, France
- Université Côte d'Azur, INSERM U1065, Cote D'Azur University, Nice, C3M, France
| | - Nicolas Retur
- Pharmacy Department, University Hospital of Nice, Cote D'Azur University, Nice, France
| | - Audrey Emery
- Bacteriology Department, University Hospital of Nice, Cote D'Azur University, Nice, France
| | - Johan Courjon
- Infectious Disease Department, University Hospital of Nice, Cote D'Azur University, Nice, France
- Université Côte d'Azur, INSERM U1065, Cote D'Azur University, Nice, C3M, France
| | - Thomas Cluzeau
- Hematology Department, University Hospital of Nice, Cote D'Azur University, Nice, France
- Université Côte d'Azur, INSERM U1065, Cote D'Azur University, Nice, C3M, France
| | - Michel Carles
- Infectious Disease Department, University Hospital of Nice, Cote D'Azur University, Nice, France
- Université Côte d'Azur, INSERM U1065, Cote D'Azur University, Nice, C3M, France
| |
Collapse
|
22
|
Chibabhai V, Bekker A, Black M, Demopoulos D, Dramowski A, du Plessis NM, Lorente VPF, Nana T, Rabie H, Reubenson G, Thomas R. Appropriate use of colistin in neonates, infants and children: Interim guidance. S Afr J Infect Dis 2023; 38:555. [PMID: 38223435 PMCID: PMC10784269 DOI: 10.4102/sajid.v38i1.555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/24/2023] [Indexed: 01/16/2024] Open
Affiliation(s)
- Vindana Chibabhai
- Division of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Microbiology, National Health Laboratory Service, Johannesburg, South Africa
| | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Marianne Black
- Division of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Microbiology, Lancet Laboratories, Johannesburg, South Africa
| | - Despina Demopoulos
- Department of Paediatrics, Donald Gordon Medical Centre, Johannesburg, South Africa
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Nicolette M. du Plessis
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Veshni Pillay-Fuentes Lorente
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Trusha Nana
- Division of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Microbiology, Lancet Laboratories, Johannesburg, South Africa
| | - Helena Rabie
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gary Reubenson
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Reenu Thomas
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Paediatrics and Child Health, Christ Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| |
Collapse
|
23
|
Krishna M, Makwana N, Kakde GS, Puri S, Kharat AS. Knowledge and Attitude toward Antibiotic Use and Identification of Financially Feasible Options to Curb the Spread of Antibiotics in Environment. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2023; 2023:6403250. [PMID: 38116033 PMCID: PMC10728364 DOI: 10.1155/2023/6403250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/02/2023] [Accepted: 10/14/2023] [Indexed: 12/21/2023]
Abstract
A survey on antibiotic literacy in terms of the use and abuse of antibiotics to track and understand antibiotic consumption is crucial to optimize the use of antibiotics and minimizing antimicrobial resistance (AMR). Purposive random sampling, using the snow-ball questionnaire technique, was adopted to ensure that the respondents distributed across India, coming from rural and urban settings, were adolescents as well as adults and had completed at least the higher secondary school level of education. Respondents were divided into five subcategories. The questionnaire was distributed between April 2021 and July 2021, during the second COVID-19 wave in India. The survey questionnaire included 34 questions, comprising multiple-choice and 5-point Likert scale-type questions. This study composed of 972 respondents. Most respondents considered antibiotics safe and frequently failed to discriminate between the symptoms of bacterial and viral infections, most often leading to self-prescription. About 34% of the rural participants and 50% of the urban participants considered antibiotic resistance a serious health concern. Antibiotic prescriptions by the medical or paramedical practitioner were largely empirical. At least 95% of participants acknowledged having heard about antibiotics; nearly 20% of antibiotic consumption came from nonprescription users, while 30% had not completed their antibiotic therapy for a variety of reasons. Sixty-two percent consumed antibiotics to treat cold and flu symptoms. Results from the survey suggest the presence of a crucial gap between the respondents' perception of antibiotics and levels of information regarding antibiotic use and misuse. The present study may serve as a benchmark that strongly recommends a financially feasible policy, which includes educating society regarding the spread of AMR and its severe consequences by incorporating AMR into the curriculum at the levels of senior secondary school and higher education.
Collapse
Affiliation(s)
- Mayank Krishna
- Department of Environmental Sciences, Kalindi College, University of Delhi, New Delhi 110008, India
| | - Nilesh Makwana
- Laboratory of Applied Microbiology, School of Life Sciences, Jawaharlal Nehru University, New Delhi 110067, India
| | - Ganesh S. Kakde
- Department of Biochemistry, Central University Haryana, Mahendragarh, Haryana, India
| | - Sapna Puri
- Ohio State University, Columbus, OH, USA
| | - Arun S. Kharat
- Laboratory of Applied Microbiology, School of Life Sciences, Jawaharlal Nehru University, New Delhi 110067, India
| |
Collapse
|
24
|
Khadse SN, Ugemuge S, Singh C. Impact of Antimicrobial Stewardship on Reducing Antimicrobial Resistance. Cureus 2023; 15:e49935. [PMID: 38179391 PMCID: PMC10765068 DOI: 10.7759/cureus.49935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
Antimicrobial resistance has become a serious global issue, posing a significant threat to public health and healthcare professionals. Since the advent of penicillin, many antibiotics have lost their effectiveness in combating microbes simply due to inappropriate, irrational, unnecessary, and unrestricted use. The ineffectiveness of an increasing number of antibiotics necessitates the utilization of more potent antimicrobial agents for combatting uncomplicated infections. In response to the escalating prevalence of multidrug-resistant pathogens and the imperative to curtail the demand for novel antibiotics, the Antimicrobial Stewardship Program was conceived and implemented. This initiative is characterized by a lead physician, ideally possessing expertise in infectious diseases, alongside a pharmacist serving as a secondary leader and a microbiologist with defined responsibilities to achieve several objectives. These objectives include reducing indiscriminate usage of antimicrobial agents, promoting selective antimicrobial utilization based on culture results, de-escalating therapy from broad-spectrum to targeted antimicrobial agents, and transitioning from parenteral to oral administration when feasible. These objectives are pursued through a combination of pre-prescription and post-prescription strategies. While the Antimicrobial Stewardship Program is widely established in developed nations, a pressing need exists for its more comprehensive implementation in less developed regions. This review aims to examine the strategies used in antimicrobial stewardship programs to evaluate their effectiveness in preventing the development of multidrug-resistant organisms (MDROs) based on existing research studies. Under the Antimicrobial Stewardship Program, education of healthcare professionals and continuous disposal of information about antimicrobial resistance have helped to restrict the emergence of multidrug-resistant organisms.
Collapse
Affiliation(s)
- Sagar N Khadse
- Medical Education, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research, Nagpur, IND
| | - Sarita Ugemuge
- Microbiology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research, Nagpur, IND
| | - Charu Singh
- Microbiology, Datta Meghe Medical College, Datta Meghe Institute of Higher Education and Research, Nagpur, IND
| |
Collapse
|
25
|
Mzumara GW, Mambiya M, Iroh Tam PY. Protocols, policies and practices for antimicrobial stewardship in hospitalized patients in least-developed and low-income countries: a systematic review. Antimicrob Resist Infect Control 2023; 12:131. [PMID: 37993964 PMCID: PMC10666353 DOI: 10.1186/s13756-023-01335-8] [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: 09/15/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND We aimed to identify interventions used to implement antimicrobial stewardship practices among hospitalized patients in least-developed countries. METHODS The research team searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials for studies of AMS interventions in the least developed and low-income countries, published between 2000 and 2023. Included studies had a population of hospitalized patients of all age groups in least-developed countries, implemented an AMS intervention, and reported its impact on prescription practices, clinical outcomes, or microbiological results. The risk of bias was assessed using the integrated quality criteria for review of multiple study designs. A total of 443 articles were identified, 386 articles were screened, 16 full-text papers were reviewed, and 10 studies were included in the analysis. RESULTS The ten studies included three controlled before and after, two qualitative, one controlled interrupted time series, two non-controlled interrupted time series, one quasi-experimental study, and one randomized controlled trial. Three studies implemented either enabling, persuasive, or structural interventions respectively. The rest used bundled strategies, including a combination of persuasive, enabling, structural, and restrictive interventions. Bundled interventions using enabling and persuasive strategies were the most common. These involved creating a prescription guideline, training prescribers on updated methods, and subsequent review and feedback of patient files by members of an AMS team. Improved microbiological surveillance was important to most studies but, sustained improvement in appropriate prescriptions was dependent on enabling or persuasive efforts. Studies noted significant improvements in appropriate prescriptions and savings on the costs of antibiotics. None evaluated the impact of AMS on AMR. CONCLUSION AMS practices generally involve multiple strategies to improve prescription practices. In the setting of least-developed countries, enabling and persuasive interventions are popular AMS measures. However, measured outcomes are heterogeneous, and we suggest that further studies assessing the impact of AMS should report changes in AMR patterns (microbiological outcomes), patient length of stay and mortality (patient outcomes), and changes in prescription practices (prescription outcomes). Reporting on these as outcomes of AMS interventions could make it easier for policymakers to compare which interventions have desirable outcomes that can be generalized to similar settings.
Collapse
Affiliation(s)
- Grace Wezi Mzumara
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
- Kamuzu University of Health Sciences, P/Bag 320, Blantyre, Malawi.
| | - Michael Mambiya
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Pui-Ying Iroh Tam
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Kamuzu University of Health Sciences, P/Bag 320, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| |
Collapse
|
26
|
Crawshaw J, Meyer C, Antonopoulou V, Antony J, Grimshaw JM, Ivers N, Konnyu K, Lacroix M, Presseau J, Simeoni M, Yogasingam S, Lorencatto F. Identifying behaviour change techniques in 287 randomized controlled trials of audit and feedback interventions targeting practice change among healthcare professionals. Implement Sci 2023; 18:63. [PMID: 37990269 PMCID: PMC10664600 DOI: 10.1186/s13012-023-01318-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/19/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Audit and feedback (A&F) is among the most widely used implementation strategies, providing healthcare professionals with summaries of their practice performance to prompt behaviour change and optimize care. Wide variability in effectiveness of A&F has spurred efforts to explore why some A&F interventions are more effective than others. Unpacking the variability of the content of A&F interventions in terms of their component behaviours change techniques (BCTs) may help advance our understanding of how A&F works best. This study aimed to systematically specify BCTs in A&F interventions targeting healthcare professional practice change. METHODS We conducted a directed content analysis of intervention descriptions in 287 randomized trials included in an ongoing Cochrane systematic review update of A&F interventions (searched up to June 2020). Three trained researchers identified and categorized BCTs in all trial arms (treatment & control/comparator) using the 93-item BCT Taxonomy version 1. The original BCT definitions and examples in the taxonomy were adapted to include A&F-specific decision rules and examples. Two additional BCTs ('Education (unspecified)' and 'Feedback (unspecified)') were added, such that 95 BCTs were considered for coding. RESULTS In total, 47/95 BCTs (49%) were identified across 360 treatment arms at least once (median = 5.0, IQR = 2.3, range = 129 per arm). The most common BCTs were 'Feedback on behaviour' (present 89% of the time; e.g. feedback on drug prescribing), 'Instruction on how to perform the behaviour' (71%; e.g. issuing a clinical guideline), 'Social comparison' (52%; e.g. feedback on performance of peers), 'Credible source' (41%; e.g. endorsements from respected professional body), and 'Education (unspecified)' (31%; e.g. giving a lecture to staff). A total of 130/287 (45%) control/comparator arms contained at least one BCT (median = 2.0, IQR = 3.0, range = 0-15 per arm), of which the most common were identical to those identified in treatment arms. CONCLUSIONS A&F interventions to improve healthcare professional practice include a moderate range of BCTs, focusing predominantly on providing behavioural feedback, sharing guidelines, peer comparison data, education, and leveraging credible sources. We encourage the use of our A&F-specific list of BCTs to improve knowledge of what is being delivered in A&F interventions. Our study provides a basis for exploring which BCTs are associated with intervention effectiveness. TRIAL REGISTRATIONS N/A.
Collapse
Affiliation(s)
- Jacob Crawshaw
- Centre for Evidence-Based Implementation, Hamilton Health Sciences, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Carly Meyer
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, London, WC1E 7HB, UK
| | - Vivi Antonopoulou
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, London, WC1E 7HB, UK
- NIHR Policy Research Unit in Behavioural Science, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Jesmin Antony
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Jeremy M Grimshaw
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Noah Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Kristin Konnyu
- Department of Health Services, Policy and Practice, Center for Evidence Synthesis in Health, Brown University School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Meagan Lacroix
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Justin Presseau
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Michelle Simeoni
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Sharlini Yogasingam
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Fabiana Lorencatto
- Department of Clinical, Educational and Health Psychology, Centre for Behaviour Change, University College London, London, WC1E 7HB, UK.
- NIHR Policy Research Unit in Behavioural Science, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
| |
Collapse
|
27
|
Singh S, Nurek M, Mason S, Moore LS, Mughal N, Vizcaychipi MP. WHY STOP? A prospective observational vignette-based study to determine the cognitive-behavioural effects of rapid diagnostic PCR-based point-of-care test results on antibiotic cessation in ICU infections. BMJ Open 2023; 13:e073577. [PMID: 37989388 PMCID: PMC10668237 DOI: 10.1136/bmjopen-2023-073577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 10/19/2023] [Indexed: 11/23/2023] Open
Abstract
OBJECTIVES Point-of-care tests (POCTs) for infection offer accurate rapid diagnostics but do not consistently improve antibiotic stewardship (ASP) of suspected ventilator-associated pneumonia. We aimed to measure the effect of a negative PCR-POCT result on intensive care unit (ICU) clinicians' antibiotic decisions and the additional effects of patient trajectory and cognitive-behavioural factors (clinician intuition, dis/interest in POCT, risk averseness). DESIGN Observational cohort simulation study. SETTING ICU. PARTICIPANTS 70 ICU consultants/trainees working in UK-based teaching hospitals. METHODS Clinicians saw four case vignettes describing patients who had completed a course of antibiotics for respiratory infection. Vignettes comprised clinical and biological data (ie, white cell count, C reactive protein), varied to create four trajectories: clinico-biological improvement (the 'improvement' case), clinico-biological worsening ('worsening'), clinical improvement/biological worsening ('discordant clin better'), clinical worsening/biological improvement ('discordant clin worse'). Based on this, clinicians made an initial antibiotics decision (stop/continue) and rated confidence (6-point Likert scale). A PCR-based POCT was then offered, which clinicians could accept or decline. All clinicians (including those who declined) were shown the result, which was negative. Clinicians updated their antibiotics decision and confidence. MEASURES Antibiotics decisions and confidence were compared pre-POCT versus post-POCT, per vignette. RESULTS A negative POCT result increased the proportion of stop decisions (54% pre-POCT vs 70% post-POCT, χ2(1)=25.82, p<0.001, w=0.32) in all vignettes except improvement (already high), most notably in discordant clin worse (49% pre-POCT vs 74% post-POCT). In a linear regression, factors that significantly reduced clinicians' inclination to stop antibiotics were a worsening trajectory (b=-0.73 (-1.33, -0.14), p=0.015), initial confidence in continuing (b=0.66 (0.56, 0.76), p<0.001) and involuntary receipt of POCT results (clinicians who accepted the POCT were more inclined to stop than clinicians who declined it, b=1.30 (0.58, 2.02), p<0.001). Clinician risk averseness was not found to influence antibiotic decisions (b=-0.01 (-0.12, 0.10), p=0.872). CONCLUSIONS A negative PCR-POCT result can encourage antibiotic cessation in ICU, notably in cases of clinical worsening (where the inclination might otherwise be to continue). This effect may be reduced by high clinician confidence to continue and/or disinterest in POCT, perhaps due to low trust/perceived utility. Such cognitive-behavioural and trajectorial factors warrant greater consideration in future ASP study design.
Collapse
Affiliation(s)
- Suveer Singh
- Faculty of Medicine, Imperial College London, London, UK
- Respiratory and Intensive Care Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Martine Nurek
- Surgery and Cancer, Imperial College London, London, UK
| | - Sonia Mason
- Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Luke Sp Moore
- Imperial College London, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nabeela Mughal
- Imperial College London, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Marcela P Vizcaychipi
- APMIC, Imperial College London, London, UK
- Magill Department of Anaesthesia and Intensive Care Medicine, Chelsea and Westminster Healthcare NHS Trust, London, UK
| |
Collapse
|
28
|
Patel HH, Benny B, Nahar P, Landis A. The Impact of Antimicrobial Stewardship in Treating Patients with Escherichia coli Bacteremia in a Small Single Center Community Hospital. Innov Pharm 2023; 14:10.24926/iip.v14i4.5526. [PMID: 38495353 PMCID: PMC10939489 DOI: 10.24926/iip.v14i4.5526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024] Open
Abstract
Purpose: There are many challenges that pharmacist led antimicrobial stewardship programs can encounter including lack of resources, costs, and inaccurate antimicrobial susceptibility testing (AST) results. The COVID-19 pandemic has led to increased resistance especially with gram negative infections. At a small single center community hospital, gram negative infections, particularly Escherichia coli infections, predominately occur. Therefore, this study aims to address gram negative bacteremia burden and its impact on antimicrobial stewardship efforts for combatting Escherichia coli and ESBL organisms with such barriers during the pandemic. Methods: In a retrospective cohort study, patients ≥ 18 years of age from a small community hospital were reviewed. Patients were excluded if their blood cultures were not positive for Escherichia coli and if antibiotics were not initiated during hospital stay. The primary endpoint was to determine the length of hospital stay. Critical secondary endpoints include antibiotic de-escalations, duration of antibiotics, time to definitive antibiotic therapy, serum procalcitonin levels, blood culture availabilities, MIC breakpoints, co-infection of COVID-19, and Clostridioides difficile occurrences. Results: Out of 74 patients with gram negative bacteremia, 41 patients specifically had Escherichia coli bacteremia. The primary endpoint results showed that patients with Escherichia coli bacteremia that stayed in the ICU had a length of stay of 13.6 days. Patients with Escherichia coli bacteremia in the Non-ICU setting has a length of stay of 7.3 days, and patients with ESBL bacteremia in the Non-ICU setting had a length of stay of 6.8 days. Conclusions: Despite the various challenges that antimicrobial stewardship programs (ASP) face in a single center small community hospital, the ASP at this small community hospital utilizes various policies and tools to increase appropriate antibiotic use and decrease hospital length of stay in patients with Escherichia coli bacteremia.
Collapse
Affiliation(s)
| | - Betcy Benny
- Saint Joseph’s University Philadelphia College of Pharmacy
| | | | | |
Collapse
|
29
|
Sartelli M, Barie PS, Coccolini F, Abbas M, Abbo LM, Abdukhalilova GK, Abraham Y, Abubakar S, Abu-Zidan FM, Adebisi YA, Adamou H, Afandiyeva G, Agastra E, Alfouzan WA, Al-Hasan MN, Ali S, Ali SM, Allaw F, Allwell-Brown G, Amir A, Amponsah OKO, Al Omari A, Ansaloni L, Ansari S, Arauz AB, Augustin G, Awazi B, Azfar M, Bah MSB, Bala M, Banagala ASK, Baral S, Bassetti M, Bavestrello L, Beilman G, Bekele K, Benboubker M, Beović B, Bergamasco MD, Bertagnolio S, Biffl WL, Blot S, Boermeester MA, Bonomo RA, Brink A, Brusaferro S, Butemba J, Caínzos MA, Camacho-Ortiz A, Canton R, Cascio A, Cassini A, Cástro-Sanchez E, Catarci M, Catena R, Chamani-Tabriz L, Chandy SJ, Charani E, Cheadle WG, Chebet D, Chikowe I, Chiara F, Cheng VCC, Chioti A, Cocuz ME, Coimbra R, Cortese F, Cui Y, Czepiel J, Dasic M, de Francisco Serpa N, de Jonge SW, Delibegovic S, Dellinger EP, Demetrashvili Z, De Palma A, De Silva D, De Simone B, De Waele J, Dhingra S, Diaz JJ, Dima C, Dirani N, Dodoo CC, Dorj G, Duane TM, Eckmann C, Egyir B, Elmangory MM, Enani MA, Ergonul O, Escalera-Antezana JP, Escandon K, Ettu AWOO, Fadare JO, Fantoni M, Farahbakhsh M, Faro MP, Ferreres A, Flocco G, Foianini E, Fry DE, Garcia AF, Gerardi C, Ghannam W, Giamarellou H, Glushkova N, Gkiokas G, Goff DA, Gomi H, Gottfredsson M, Griffiths EA, Guerra Gronerth RI, Guirao X, Gupta YK, Halle-Ekane G, Hansen S, Haque M, Hardcastle TC, Hayman DTS, Hecker A, Hell M, Ho VP, Hodonou AM, Isik A, Islam S, Itani KMF, Jaidane N, Jammer I, Jenkins DR, Kamara IF, Kanj SS, Jumbam D, Keikha M, Khanna AK, Khanna S, Kapoor G, Kapoor G, Kariuki S, Khamis F, Khokha V, Kiggundu R, Kiguba R, Kim HB, Kim PK, Kirkpatrick AW, Kluger Y, Ko WC, Kok KYY, Kotecha V, Kouma I, Kovacevic B, Krasniqi J, Krutova M, Kryvoruchko I, Kullar R, Labi KA, Labricciosa FM, Lakoh S, Lakatos B, Lansang MAD, Laxminarayan R, Lee YR, Leone M, Leppaniemi A, Hara GL, Litvin A, Lohsiriwat V, Machain GM, Mahomoodally F, Maier RV, Majumder MAA, Malama S, Manasa J, Manchanda V, Manzano-Nunez R, Martínez-Martínez L, Martin-Loeches I, Marwah S, Maseda E, Mathewos M, Maves RC, McNamara D, Memish Z, Mertz D, Mishra SK, Montravers P, Moro ML, Mossialos E, Motta F, Mudenda S, Mugabi P, Mugisha MJM, Mylonakis E, Napolitano LM, Nathwani D, Nkamba L, Nsutebu EF, O’Connor DB, Ogunsola S, Jensen PØ, Ordoñez JM, Ordoñez CA, Ottolino P, Ouedraogo AS, Paiva JA, Palmieri M, Pan A, Pant N, Panyko A, Paolillo C, Patel J, Pea F, Petrone P, Petrosillo N, Pintar T, Plaudis H, Podda M, Ponce-de-Leon A, Powell SL, Puello-Guerrero A, Pulcini C, Rasa K, Regimbeau JM, Rello J, Retamozo-Palacios MR, Reynolds-Campbell G, Ribeiro J, Rickard J, Rocha-Pereira N, Rosenthal VD, Rossolini GM, Rwegerera GM, Rwigamba M, Sabbatucci M, Saladžinskas Ž, Salama RE, Sali T, Salile SS, Sall I, Kafil HS, Sakakushev BE, Sawyer RG, Scatizzi M, Seni J, Septimus EJ, Sganga G, Shabanzadeh DM, Shelat VG, Shibabaw A, Somville F, Souf S, Stefani S, Tacconelli E, Tan BK, Tattevin P, Rodriguez-Taveras C, Telles JP, Téllez-Almenares O, Tessier J, Thang NT, Timmermann C, Timsit JF, Tochie JN, Tolonen M, Trueba G, Tsioutis C, Tumietto F, Tuon FF, Ulrych J, Uranues S, van Dongen M, van Goor H, Velmahos GC, Vereczkei A, Viaggi B, Viale P, Vila J, Voss A, Vraneš J, Watkins RR, Wanjiru-Korir N, Waworuntu O, Wechsler-Fördös A, Yadgarova K, Yahaya M, Yahya AI, Xiao Y, Zakaria AD, Zakrison TL, Zamora Mesia V, Siquini W, Darzi A, Pagani L, Catena F. Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action. World J Emerg Surg 2023; 18:50. [PMID: 37845673 PMCID: PMC10580644 DOI: 10.1186/s13017-023-00518-3] [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: 08/23/2023] [Accepted: 09/23/2023] [Indexed: 10/18/2023] Open
Abstract
Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.
Collapse
|
30
|
Parzen-Johnson S, Toia J, Sun S, Patel SJ. Antimicrobial stewardship for nurse practitioners and physician assistants: enhancing patient safety through education. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e165. [PMID: 38028918 PMCID: PMC10644159 DOI: 10.1017/ash.2023.434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/03/2023] [Accepted: 08/01/2023] [Indexed: 12/01/2023]
Abstract
Background As nurse practitioners and physician assistants (APPs) become more prevalent in delivering pediatric care, their involvement in antimicrobial stewardship efforts increases in importance. This project aimed to create and assess the efficacy of a problem-based learning (PBL) approach to teaching APPs antimicrobial stewardship principles. Methods A PBL education initiative was developed after communication with local APP leadership and focus group feedback. It was offered to all APPs associated with Lurie Children's Hospital of Chicago. Participants completed a survey which assessed opinions on antimicrobial stewardship and included knowledge-based questions focused on antimicrobial stewardship. Prescriptions for skin and soft tissue infections associated with APPs were recorded via chart review before and after the education campaign. Results Eighty APPs participated in the initial survey and teaching initiative with 44 filling out the 2-week follow-up and 29 filling out the 6-month follow-up. Subjective opinions of antimicrobial stewardship and comfort with basic principles of AS increased from pre-intervention. Correct responses to knowledge-based assessments increased from baseline after 2-week follow-up (p < 0.01) and were maintained at the 6-month follow-up (p = 0.03). Simple skin and soft tissue infection prescriptions for clindamycin went from 44.4% pre-intervention to 26.5% (p = 0.2) post-intervention. Conclusions A PBL approach for APP education on antimicrobial stewardship can be effective in increasing knowledge and comfort with principles of antimicrobial stewardship. These changes are maintained in long-term follow-up. Changes in prescribing habits showed a strong trend towards recommended empiric therapy choice. Institutions should develop similar education campaigns for APPs.
Collapse
Affiliation(s)
| | - Jacquie Toia
- Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of ChicagoIL60611, USA
| | - Shan Sun
- Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of ChicagoIL60611, USA
| | - Sameer J. Patel
- Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of ChicagoIL60611, USA
- Feinberg School of Medicine, Northwestern University, Chicago, IL60611, USA
| |
Collapse
|
31
|
Martinato M, Comoretto RI, Biban P, Zanonato E, Simonini A, Montaguti A, Gitto E, Caramelli F, Ferrario S, Sagredini R, Alaimo N, Zito Marinosci G, Rossetti E, Cecchetti C, L'erario M, Vasile B, Ivani G, Bonanomi E, Astuto M, Gregori D, Mondardini MC, Amigoni A. Italian pediatric intensive care units admitting critically ill cancer children: results from a national survey. Minerva Anestesiol 2023; 89:850-858. [PMID: 37378625 DOI: 10.23736/s0375-9393.23.17329-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
BACKGROUND Pediatric patients affected by oncologic disease have a significant risk of clinical deterioration that requires admission to the intensive care unit. This study reported the results of a national survey describing the characteristics of Italian onco-hematological units (OHUs) and pediatric intensive care units (PICUs) that admit pediatric patients, focusing on the high-complexity treatments available before PICU admission, and evaluating the approach to the end-of-life (EOL) when cared in a PICU setting. METHODS A web-based electronic survey has been performed in April 2021, involving all Italian PICUs admitting pediatric patients with cancer participating in the study. RESULTS Eighteen PICUs participated, with a median number of admissions per year of 350 (IQR 248-495). Availability of Extracorporeal Membrane Oxygenation therapy and the presence of intermediate care unit are the only statistically different characteristics between large or small PICUs. Different high-level treatments and protocols are performed in OHUs, non depending on the volume of PICU. Palliative sedation is mainly performed in the OHUs (78%), however, in 72% it is also performed in the PICU. In most centers protocols that address EOL comfort care and treatment algorithms are missing, non depending on PICU or OHU volume. CONCLUSIONS A non-homogeneous availability of high-level treatments and in OHUs is described. Moreover, protocols addressing EOL comfort care and treatment algorithms in palliative care are lacking in many centers.
Collapse
Affiliation(s)
- Matteo Martinato
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Giuseppe Parenti Department of Statistics, Computer Science, Applications, University of Florence, Florence, Italy
| | - Rosanna I Comoretto
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Department of Sciences of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Paolo Biban
- University Hospital of Verona, Verona, Italy
| | | | | | | | | | - Fabio Caramelli
- S. Orsola-Malpighi IRCCS University Hospital, Bologna, Italy
| | | | | | | | | | | | | | | | | | - Giorgio Ivani
- AOU Città della Salute e della Scienza, Turin, Italy
| | | | | | - Dario Gregori
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | | | | |
Collapse
|
32
|
Mbatia FN, Orwa J, Adam MB, Mahomoud G, Adam RD. Outpatient management of urinary tract infections by medical officers in Nairobi, Kenya: lack of benefit from audit and feedback on adherence to treatment guidelines. BMC Infect Dis 2023; 23:608. [PMID: 37723454 PMCID: PMC10506338 DOI: 10.1186/s12879-023-08567-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 08/25/2023] [Indexed: 09/20/2023] Open
Abstract
INTRODUCTION Acute uncomplicated urinary tract infections are common in outpatient settings but are not treated optimally. Few studies of the outpatient use of antibiotics for specific diagnoses have been done in sub-Saharan Africa, so little is known about the prescribing patterns of medical officers in the region. METHODS Aga Khan University has 16 outpatient clinics throughout the Nairobi metro area with a medical officer specifically assigned to that clinic. A baseline assessment of evaluation and treatment of suspected UTI was performed from medical records in these clinics. Then the medical officer from each of the 16 clinics was recruited from each clinic was recruited with eight each randomized to control vs. feedback groups. Both groups were given a multimodal educational session including locally adapted UTI guidelines and emphasis on problems identified in the baseline assessment Each record was scored using a scoring system that was developed for the study according to adequacy of history, physical examination, clinical diagnosis matching recorded data, diagnostic workup and treatment. Three audits were done for both groups; baseline (audit 1), post-CME (audit 2), and a final audit, which was after feedback for the feedback group (audit 3). The primary analysis assessed overall guideline adherence in the feedback group versus the CME only group. RESULTS The overall scores in both groups showed significant improvement after the CME in comparison to baseline and for each group, the scores in most domains also improved. However, audit 3 showed persistence of the gains attained after the CME but no additional benefit from the feedback. Some deficiencies that persisted throughout the study included lack of workup of possible STI and excess use of non-UTI laboratory tests such as CBC, stool culture and H. pylori Ag. After the CME, the use of nitrofurantoin rose from only 4% to 8% and cephalosporin use increased from 49 to 67%, accompanied by a drop in quinolone use. CONCLUSION The CME led to modest improvements in patient care in the categories of history taking, treatment and investigations, but feedback had no additional effect. Future studies should consider an enforcement element or a more intensive feedback approach.
Collapse
Affiliation(s)
| | - James Orwa
- Department of Population Health, Aga Khan University Nairobi, Nairobi, Kenya
| | | | - Gulnaz Mahomoud
- Department of Family Medicine, Aga Khan University Nairobi, Nairobi, Kenya
| | - Rodney D Adam
- Department of Pathology, Aga Khan University Nairobi, Nairobi, Kenya.
- Department of Medicine, Aga Khan University Nairobi, Nairobi, Kenya.
| |
Collapse
|
33
|
Dantes RB, Kaur H, Bouwkamp BA, Haass KA, Patel P, Dudeck MA, Srinivasan A, Magill SS, Wilson WW, Whitaker M, Gladden NM, McLaughlin ES, Horowitz JK, Posa PJ, Prescott HC. Sepsis Program Activities in Acute Care Hospitals - National Healthcare Safety Network, United States, 2022. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2023; 72:907-911. [PMID: 37616184 PMCID: PMC10468219 DOI: 10.15585/mmwr.mm7234a2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
Sepsis, life-threatening organ dysfunction secondary to infection, contributes to at least 1.7 million adult hospitalizations and at least 350,000 deaths annually in the United States. Sepsis care is complex, requiring the coordination of multiple hospital departments and disciplines. Sepsis programs can coordinate these efforts to optimize patient outcomes. The 2022 National Healthcare Safety Network (NHSN) annual survey evaluated the prevalence and characteristics of sepsis programs in acute care hospitals. Among 5,221 hospitals, 3,787 (73%) reported having a committee that monitors and reviews sepsis care. Prevalence of these committees varied by hospital size, ranging from 53% among hospitals with 0-25 beds to 95% among hospitals with >500 beds. Fifty-five percent of all hospitals provided dedicated time (including assigned protected time or job description requirements) for leaders of these committees to manage a program and conduct daily activities, and 55% of committees reported involvement with antibiotic stewardship programs. These data highlight opportunities, particularly in smaller hospitals, to improve the care and outcomes of patients with sepsis in the United States by ensuring that all hospitals have sepsis programs with protected time for program leaders, engagement of medical specialists, and integration with antimicrobial stewardship programs. CDC's Hospital Sepsis Program Core Elements provides a guide to assist hospitals in developing and implementing effective sepsis programs that complement and facilitate the implementation of existing clinical guidelines and improve patient care. Future NHSN annual surveys will monitor uptake of these sepsis core elements.
Collapse
|
34
|
Williams DJ, Martin JM, Nian H, Weitkamp AO, Slagle J, Turer RW, Suresh S, Johnson J, Stassun J, Just SL, Reale C, Beebe R, Arnold DH, Antoon JW, Rixe NS, Sartori LF, Freundlich RE, Ampofo K, Pavia AT, Smith JC, Weinger MB, Zhu Y, Grijalva CG. Antibiotic clinical decision support for pneumonia in the ED: A randomized trial. J Hosp Med 2023; 18:491-501. [PMID: 37042682 PMCID: PMC10247532 DOI: 10.1002/jhm.13101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/06/2023] [Accepted: 03/23/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Electronic health record-based clinical decision support (CDS) is a promising antibiotic stewardship strategy. Few studies have evaluated the effectiveness of antibiotic CDS in the pediatric emergency department (ED). OBJECTIVE To compare the effectiveness of antibiotic CDS vs. usual care for promoting guideline-concordant antibiotic prescribing for pneumonia in the pediatric ED. DESIGN Pragmatic randomized clinical trial. SETTING AND PARTICIPANTS Encounters for children (6 months-18 years) with pneumonia presenting to two tertiary care children s hospital EDs in the United States. INTERVENTION CDS or usual care was randomly assigned during 4-week periods within each site. The CDS intervention provided antibiotic recommendations tailored to each encounter and in accordance with national guidelines. MAIN OUTCOME AND MEASURES The primary outcome was exclusive guideline-concordant antibiotic prescribing within the first 24 h of care. Safety outcomes included time to first antibiotic order, encounter length of stay, delayed intensive care, and 3- and 7-day revisits. RESULTS 1027 encounters were included, encompassing 478 randomized to usual care and 549 to CDS. Exclusive guideline-concordant prescribing did not differ at 24 h (CDS, 51.7% vs. usual care, 53.3%; odds ratio [OR] 0.94 [95% confidence interval [CI]: 0.73, 1.20]). In pre-specified stratified analyses, CDS was associated with guideline-concordant prescribing among encounters discharged from the ED (74.9% vs. 66.0%; OR 1.53 [95% CI: 1.01, 2.33]), but not among hospitalized encounters. Mean time to first antibiotic was shorter in the CDS group (3.0 vs 3.4 h; p = .024). There were no differences in safety outcomes. CONCLUSIONS Effectiveness of ED-based antibiotic CDS was greatest among those discharged from the ED. Longitudinal interventions designed to target both ED and inpatient clinicians and to address common implementation challenges may enhance the effectiveness of CDS as a stewardship tool.
Collapse
Affiliation(s)
- Derek J Williams
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Judith M Martin
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Hui Nian
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Asli O Weitkamp
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jason Slagle
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Srinivasan Suresh
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jakobi Johnson
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Justine Stassun
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Shari L Just
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Carrie Reale
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Russ Beebe
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Donald H Arnold
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - James W Antoon
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Nancy S Rixe
- UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura F Sartori
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robert E Freundlich
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Krow Ampofo
- University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Andrew T Pavia
- University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Joshua C Smith
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Matthew B Weinger
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Yuwei Zhu
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Carlos G Grijalva
- Monroe Carell Jr. Children's Hospital at VUMC, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| |
Collapse
|
35
|
Flateau C, Pitsch A, Cornaglia C, Picque M, de Pontfarcy A, Leroy P, Jault T, Thach C, Camus M, Dolveck F, Diamantis S. Management of imported malaria in the emergency department: Adequacy compared to guidelines, and impact of the SARS-CoV-2 pandemic. Infect Dis Now 2023; 53:104672. [PMID: 36773811 PMCID: PMC9912039 DOI: 10.1016/j.idnow.2023.104672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 01/13/2023] [Accepted: 02/03/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVES Adequacy of imported malaria management with respect to guidelines in emergency departments (ED) is low. We aimed to identify factors associated with this non-compliance, and a potential impact of the SARS-CoV-2 pandemic. PATIENTS AND METHODS Patients presenting with imported malaria at the ED of the hospital of Melun (France), from January 1, 2017 to February 14, 2022 were retrospectively included. RESULTS Among 205 adults and 25 children, biological criteria of severity were fully assessed in 10% of cases; lactates (40%) and blood pH (21%) levels were the main missing variables. Of 74 patients (32%) with severe malaria, 13 were misclassified as uncomplicated malaria. The choice and dosage of treatment were adequate in 85% and 92% of cases, respectively. Treatment conformity was lower in severe malaria cases than in non-severe malaria cases (OR 0.15 [95% CI 0.07-0.31]), with oral treatment in 17 patients with severe malaria; conformity was higher in the intensive care unit (OR 4.10 [95% CI 1.21-13.95]). Patients with severe malaria were more likely to start treatment within 6hours than patients with uncomplicated malaria (OR 1.97 [95% CI 1.08-3.43]), as were patients infected by P.falciparum compared to other species (OR 4.63 [95% CI 1.03-20.90]). Consulting during the SARS-CoV-2 pandemic was the only organizational factor associated with a lower probability of adequate management (OR 0.42 [95% CI 0.23-0.75]). CONCLUSION Initial evaluation of malaria severity and time to treatment administration could be improved. These have been adversely impacted by the SARS-CoV-2 pandemic.
Collapse
Affiliation(s)
- C. Flateau
- Service des maladies infectieuses, Groupe hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77 000 Melun, France,Corresponding author at: Service des maladies infectieuses, Groupe hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77 000 Melun, France. Fax: + 33 1 81 74 18 12
| | - A. Pitsch
- Laboratoire de biologie médicale, Groupe hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77 000 Melun, France
| | - C. Cornaglia
- Service d’accueil des urgences, Groupe hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77 000 Melun, France
| | - M. Picque
- Laboratoire de biologie médicale, Groupe hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77 000 Melun, France
| | - A. de Pontfarcy
- Service des maladies infectieuses, Groupe hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77 000 Melun, France
| | - P. Leroy
- Service des maladies infectieuses, Groupe hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77 000 Melun, France
| | - T. Jault
- Service de gynécologie-obstétrique, Groupe hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77 000 Melun, France
| | - C. Thach
- Service de pédiatrie, Groupe hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77 000 Melun, France
| | - M. Camus
- Pharmacie hospitalière, Groupe hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77 000 Melun, France
| | - F. Dolveck
- Service d’accueil des urgences, Groupe hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77 000 Melun, France
| | - S. Diamantis
- Service des maladies infectieuses, Groupe hospitalier Sud Ile de France, 270 avenue Marc Jacquet, 77 000 Melun, France
| |
Collapse
|
36
|
Sette AL, François P, Lesprit P, Vitrat V, Rogeaux O, Breugnon E, Baldeyrou M, Mondain V, Issartel B, Kerneis S, Diamantis S, Poitrenaud D, Boussat B, Pavese P. Infectious disease hotlines to provide advice to general practitioners: a prospective study. BMC Health Serv Res 2023; 23:502. [PMID: 37198604 DOI: 10.1186/s12913-023-09515-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/08/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Telephone hotlines in infectious diseases (ID) are part of antimicrobial stewardship programs designed to provide support and expertise in ID and to control antibiotic resistance. The aim of the study was to characterize the activity of the ID hotlines and estimate their usefulness for general practitioners (GPs). METHODS This was a multicenter prospective observational study in different French regions. ID teams involved in antimicrobial stewardship with a hotline for GPs were asked to record their advice from April 2019 to June 2022. In these regions, all GPs were informed of the ID hotline's operating procedures. The main outcome was usage rate of the hotlines by GPs. RESULTS Ten volunteer ID teams collected 4138 requests for advice from 2171 GPs. The proportion of GPs using the hotline varied pronouncedly by region, from 54% in the Isere department, to less than 1% in departments with the lowest usage. These differences were associated with the number of physicians in ID teams and with the age of the hotline. These results highlighted the value of working time as a means of ensuring the permanence of expertise. The main reasons for calling were: a diagnostic question (44%); choice of antibiotic (31%). The ID specialist provided advice on antibiotic therapy (43%) or a proposal for specialized consultation or hospitalization (11%). CONCLUSIONS ID hotlines could help to strengthen cooperation between primary care and hospital medicine. However, the deployment and perpetuation of this activity require reflection concerning its institutional and financial support.
Collapse
Affiliation(s)
- Anna Luce Sette
- Médecine Générale, Centre Hospitalier Universitaire Grenoble-Alpes, Grenoble, France.
| | - Patrice François
- Service d'épidémiologie et évaluation médicale, Centre Hospitalier Universitaire Grenoble-Alpes, Pavillon Taillefer, La Tronche, 38700, France.
| | - Philippe Lesprit
- Service des maladies infectieuses et tropicales, Centre Hospitalier Universitaire Grenoble-Alpes, Pavillon Taillefer, La Tronche, France
| | - Virginie Vitrat
- Service de maladies infectieuses, Centre Hospitalier d'Annecy, Annecy, France
| | - Olivier Rogeaux
- Service des maladies infectieuses et tropicales, Centre Hospitalier Métropole Savoie, Chambéry, France
| | - Emma Breugnon
- Service de maladies infectieuses, Centre Hospitalier Universitaire de Saint-Etienne, Saint- Etienne, France
| | - Marion Baldeyrou
- Maladies Infectieuses et Réanimation Médicale, Hôpital Pontchaillou, Centre Hospitalo-Universitaire, Rennes, France
| | - Véronique Mondain
- Maladies Infectieuses, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Bertrand Issartel
- Médecine Interne Infectieuse et Tropicale, MiiT médical selarl, Lyon-Villeurbanne, France
| | - Solen Kerneis
- Equipe Mobile d'Infectiologie, APHP, Hôpital Cochin, Paris, F-75014, France
| | - Sylvain Diamantis
- Service de Maladies infectieuses, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Delphine Poitrenaud
- Maladies infectieuses et tropicales, Centre Hospitalier d'Ajaccio, Ajaccio, France
| | - Bastien Boussat
- Laboratoire TIMC-IMAG, Université de Grenoble Alpes, Grenoble, France
| | - Patricia Pavese
- Service des maladies infectieuses et tropicales, Centre Hospitalier Universitaire Grenoble-Alpes, Pavillon Taillefer, La Tronche, France
| |
Collapse
|
37
|
Mokrani D, Chommeloux J, Pineton de Chambrun M, Hékimian G, Luyt CE. Antibiotic stewardship in the ICU: time to shift into overdrive. Ann Intensive Care 2023; 13:39. [PMID: 37148398 PMCID: PMC10163585 DOI: 10.1186/s13613-023-01134-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/20/2023] [Indexed: 05/08/2023] Open
Abstract
Antibiotic resistance is a major health problem and will be probably one of the leading causes of deaths in the coming years. One of the most effective ways to fight against resistance is to decrease antibiotic consumption. Intensive care units (ICUs) are places where antibiotics are widely prescribed, and where multidrug-resistant pathogens are frequently encountered. However, ICU physicians may have opportunities to decrease antibiotics consumption and to apply antimicrobial stewardship programs. The main measures that may be implemented include refraining from immediate prescription of antibiotics when infection is suspected (except in patients with shock, where immediate administration of antibiotics is essential); limiting empiric broad-spectrum antibiotics (including anti-MRSA antibiotics) in patients without risk factors for multidrug-resistant pathogens; switching to monotherapy instead of combination therapy and narrowing spectrum when culture and susceptibility tests results are available; limiting the use of carbapenems to extended-spectrum beta-lactamase-producing Enterobacteriaceae, and new beta-lactams to difficult-to-treat pathogen (when these news beta-lactams are the only available option); and shortening the duration of antimicrobial treatment, the use of procalcitonin being one tool to attain this goal. Antimicrobial stewardship programs should combine these measures rather than applying a single one. ICUs and ICU physicians should be at the frontline for developing antimicrobial stewardship programs.
Collapse
Affiliation(s)
- David Mokrani
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Juliette Chommeloux
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Marc Pineton de Chambrun
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Guillaume Hékimian
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France
| | - Charles-Edouard Luyt
- Service de Médecine Intensive Réanimation, Institut de Cardiologie, ICAN, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne-Université, Hôpital Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, 75651, Paris Cedex 13, France.
- Sorbonne Université, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
| |
Collapse
|
38
|
Hodoșan V, Daina LG, Zaha DC, Cotrău P, Vladu A, Dorobanțu FR, Negrău MO, Babeș EE, Babeș VV, Daina CM. Pattern of Antibiotic Use among Hospitalized Patients at a Level One Multidisciplinary Care Hospital. Healthcare (Basel) 2023; 11:1302. [PMID: 37174844 PMCID: PMC10178860 DOI: 10.3390/healthcare11091302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/19/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Antimicrobial resistance is one of the world's most serious health issues. Antibiotic resistance, excessive drug expense, and an increased risk of adverse reactions are all common outcomes of incorrect antibiotic prescribing. The goal of this study was to evaluate the prevalence of antibiotic prescriptions for inpatients to find areas for improvement. METHODS A retrospective study at Emergency Clinical County Hospital of Oradea, Romania was performed for five years between 2017 and 2021. Data was collected using medical records of the patients and reports from the pharmacy. Antibiotic consumption was expressed as DDD/100 BD according to the World Health Organization (WHO) by antibiotics, classes, and AWaRe classification. RESULTS The prevalence of antibiotic prescription was 53.8% during five years evaluated with a significant increase in 2021. A total of 13,677.42 DDD/100 BD antibiotics were prescribed, especially for surgical and medical prophylaxes. The most prescribed antibiotics were ceftriaxone, followed by metronidazole, and cefuroxime but there were some differences between years and wards. The most frequent antibiotic classes prescribed were cephalosporins (43.73%). The use of Watch Group antibiotics was high in all wards (59.69%). CONCLUSIONS The prevalence of antibiotic use was high with cephalosporins being the most prescribed antibiotics. As a result, interventions are required.
Collapse
Affiliation(s)
- Viviana Hodoșan
- Faculty of Medicine and Pharmacy, Doctoral School of Biomedical Sciences, University of Oradea, 1st University Street, 410087 Oradea, Romania
| | - Lucia Georgeta Daina
- Psycho-Neurosciences and Recovery Department, Faculty of Medicine and Pharmacy, University of Oradea, 1st University Street, 410087 Oradea, Romania
| | - Dana Carmen Zaha
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1st University Street, 410087 Oradea, Romania
| | - Petru Cotrău
- Faculty of Medicine and Pharmacy, Doctoral School of Biomedical Sciences, University of Oradea, 1st University Street, 410087 Oradea, Romania
| | - Adriana Vladu
- Faculty of Medicine and Pharmacy, Doctoral School of Biomedical Sciences, University of Oradea, 1st University Street, 410087 Oradea, Romania
| | - Florica Ramona Dorobanțu
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1st University Street, 410087 Oradea, Romania
| | - Marcel Ovidiu Negrău
- Department of Surgical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1st University Street, 410087 Oradea, Romania
| | - Elena Emilia Babeș
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1st University Street, 410087 Oradea, Romania
| | - Victor Vlad Babeș
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1st University Street, 410087 Oradea, Romania
| | - Cristian Marius Daina
- Psycho-Neurosciences and Recovery Department, Faculty of Medicine and Pharmacy, University of Oradea, 1st University Street, 410087 Oradea, Romania
| |
Collapse
|
39
|
MacKenzie P, Färber J, Post M, Esser T, Bechmann L, Kropf S, Croner R, Geginat G. Previous antibiotic therapy as independent risk factor for the presence of vancomycin-resistant enterococci in surgical inpatients. Results from a matched case-control study. BMC Infect Dis 2023; 23:274. [PMID: 37131139 PMCID: PMC10155433 DOI: 10.1186/s12879-023-08238-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/10/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Investigation of risk factors for the presence of vancomycin-resistant enterococci (VRE) in inpatients on surgical wards and associated intensive care units of a German tertiary care hospital. METHODS A single-centre retrospective matched case-control study was performed with surgical inpatients admitted between July 2013 and December 2016. Patients with in-hospital detection of VRE later than 48 h after admission were included and comprised 116 VRE-positive cases and 116 VRE-negative matched controls. VRE isolates of cases were typed by multi-locus sequence typing. RESULTS ST117 was identified as the dominant VRE sequence type. Next to length of stay in hospital or on an intensive care unit and previous dialysis the case-control study revealed previous antibiotic therapy as a risk factor for the in-hospital detection of VRE. The antibiotics piperacillin/tazobactam, meropenem, and vancomycin were associated with the highest risks. After taking into account length of stay in hospital as possible confounder other potential contact-related risk factors such as previous sonography, radiology, central venous catheter, and endoscopy were not significant. CONCLUSIONS Previous dialysis and previous antibiotic therapy were identified as independent risk factors for the presence of VRE in surgical inpatients.
Collapse
Affiliation(s)
- Philip MacKenzie
- Department of Medical Microbiology and Infection Control, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Jacqueline Färber
- Department of Medical Microbiology and Infection Control, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Marius Post
- Department of Medical Microbiology and Infection Control, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Torben Esser
- Department of Medical Microbiology and Infection Control, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Lukas Bechmann
- Department of Medical Microbiology and Infection Control, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Siegfried Kropf
- Institute for Biometry and Medical Informatics, Otto-von-Guericke University, Magdeburg, Germany
| | - Roland Croner
- Department of General, Visceral, Vascular and Transplant Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Gernot Geginat
- Department of Medical Microbiology and Infection Control, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.
- Institut für medizinische Mikrobiologie und Krankenhaushygiene, Otto-von-Guericke University, Leipziger Straße 44, 39120, Magdeburg, Germany.
| |
Collapse
|
40
|
Yoon CH, Nolan I, Humphrey G, Duffy EJ, Thomas MG, Ritchie SR. Long-Term Impact of a Smartphone App on Prescriber Adherence to Antibiotic Guidelines for Adult Patients With Community-Acquired Pneumonia: Interrupted Time-Series Study. J Med Internet Res 2023; 25:e42978. [PMID: 37129941 PMCID: PMC10189620 DOI: 10.2196/42978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Mobile health platforms like smartphone apps that provide clinical guidelines are ubiquitous, yet their long-term impact on guideline adherence remains unclear. In 2016, an antibiotic guidelines app, called SCRIPT, was introduced in Auckland City Hospital, New Zealand, to provide local antibiotic guidelines to clinicians on their smartphones. OBJECTIVE We aimed to assess whether the provision of antibiotic guidelines in a smartphone app resulted in sustained changes in antibiotic guideline adherence by prescribers. METHODS We analyzed antibiotic guideline adherence rates during the first 24 hours of hospital admission in adults diagnosed with community-acquired pneumonia using an interrupted time-series study with 3 distinct periods post app implementation (ie, 3, 12, and 24 months). RESULTS Adherence increased from 23% (46/200) at baseline to 31% (73/237) at 3 months and 34% (69/200) at 12 months, reducing to 31% (62/200) at 24 months post app implementation (P=.07 vs baseline). However, increased adherence was sustained in patients with pulmonary consolidation on x-ray (9/63, 14% at baseline; 23/77, 30% after 3 months; 32/92, 35% after 12 month; and 32/102, 31% after 24 months; P=.04 vs baseline). CONCLUSIONS An antibiotic guidelines app increased overall adherence, but this was not sustained. In patients with pulmonary consolidation, the increased adherence was sustained.
Collapse
Affiliation(s)
- Chang Ho Yoon
- Big Data Institute, Oxford, United Kingdom
- Infectious Diseases Department, Auckland City Hospital, Auckland, New Zealand
| | - Imogen Nolan
- Infectious Diseases Department, Auckland City Hospital, Auckland, New Zealand
| | - Gayl Humphrey
- National Institute for Health Innovation, University of Auckland, Auckland, New Zealand
| | - Eamon J Duffy
- Infectious Diseases Department, Auckland City Hospital, Auckland, New Zealand
| | - Mark G Thomas
- School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Stephen R Ritchie
- School of Medical Sciences, University of Auckland, Auckland, New Zealand
| |
Collapse
|
41
|
Cortegiani A, Antonelli M, Falcone M, Giarratano A, Girardis M, Leone M, Pea F, Stefani S, Viaggi B, Viale P. Rationale and clinical application of antimicrobial stewardship principles in the intensive care unit: a multidisciplinary statement. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2023; 3:11. [PMID: 37386615 DOI: 10.1186/s44158-023-00095-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/21/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Antimicrobial resistance represents a major critical issue for the management of the critically ill patients hospitalized in the intensive care unit (ICU), since infections by multidrug-resistant bacteria are characterized by high morbidity and mortality, high rates of treatment failure, and increased healthcare costs worldwide. It is also well known that antimicrobial resistance can emerge as a result of inadequate antimicrobial therapy, in terms of drug selection and/or treatment duration. The application of antimicrobial stewardship principles in ICUs improves the quality of antimicrobial therapy management. However, it needs specific considerations related to the critical setting. METHODS The aim of this consensus document gathering a multidisciplinary panel of experts was to discuss principles of antimicrobial stewardship in ICU and to produce statements that facilitate their clinical application and optimize their effectiveness. The methodology used was a modified nominal group discussion. CONCLUSION The final set of statements underlined the importance of the specific interpretation of antimicrobial stewardship's principles in critically ill patient management, quasi-targeted therapy, the use of rapid diagnostic methods, the personalization of antimicrobial therapies' duration, obtaining microbiological surveillance data, the use of PK/PD targets, and the use of specific indicators in antimicrobial stewardship programs.
Collapse
Affiliation(s)
- Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science, University of Palermo, Via Liborio Giuffrè 5, 90127, Palermo, Italy.
- Department of Anaesthesia, Intensive Care and Emergency, University Hospital Policlinico Paolo Giaccone, 90127, Palermo, Italy.
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
- Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Falcone
- Infectious Diseases Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliera Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science, University of Palermo, Via Liborio Giuffrè 5, 90127, Palermo, Italy
- Department of Anaesthesia, Intensive Care and Emergency, University Hospital Policlinico Paolo Giaccone, 90127, Palermo, Italy
| | - Massimo Girardis
- Intensive Care Unit, University Hospital of Modena, Modena, Italy
| | - Marc Leone
- Department of Anaesthesia and Intensive Care Unit, Aix-Marseille University, AP-HM, North Hospital, Marseille, France
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40138, Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, 40138, Bologna, Italy
| | - Stefania Stefani
- Microbiology Section, Dept of Biomedical and Biotechnological Science, University of Catania, Catania, Italy
- Unità Operativa Complessa (UOC) Laboratory Analysis, University Hospital Policlinico-San Marco, Catania, Italy
| | - Bruno Viaggi
- Department of Anesthesiology, Neuro-Intensive Care Unit, Careggi University Hospital, 50139, Florence, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Infectious Disease Unit, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| |
Collapse
|
42
|
Spernovasilis N, Kritsotakis EI, Mathioudaki A, Vouidaski A, Spanias C, Petrodaskalaki M, Ioannou P, Chamilos G, Kofteridis DP. A carbapenem-focused antimicrobial stewardship programme implemented during the COVID-19 pandemic in a setting of high endemicity for multidrug-resistant Gram-negative bacteria. J Antimicrob Chemother 2023; 78:1000-1008. [PMID: 36790896 PMCID: PMC11023244 DOI: 10.1093/jac/dkad035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/26/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Greece is among the countries characterized by high rates of antimicrobial resistance and high consumption of antibiotics, including carbapenems. OBJECTIVES To measure the impact of a carbapenem-focused antimicrobial stewardship programme (ASP) on the antibiotic consumption and patient outcomes in a Greek tertiary hospital during the COVID-19 pandemic. METHODS A quasi-experimental, before-after study, comparing a 12 month pre-intervention period with a 12 month intervention period in which a carbapenem-focused ASP was implemented. RESULTS A total of 1268 patients were enrolled. The proportion of admitted patients who received carbapenems decreased from 4.1% (842 of 20 629) to 2.3% (426 of 18 245) (-1.8%; P < 0.001). A decrease of -4.9 DDD/100 patient-days (PD) (95% CI -7.3 to -2.6; P = 0.007) in carbapenem use and an increase in the use of piperacillin/tazobactam [+2.1 DDD/100 PD (95% CI 1.0-3.3; P = 0.010)] were observed. Thirty-day mortality following initiation of carbapenem treatment and all-cause in-hospital mortality remained unaltered after ASP implementation. In contrast, length of hospital stay increased (median 17.0 versus 19.0 days; P < 0.001), while the risk of infection-related readmission within 30 days of hospital discharge decreased (24.6% versus 16.8%; P = 0.007). In the post-implementation period, acceptance of the ASP intervention was associated with lower daily hazard of in-hospital death [cause-specific HR (csHR) 0.49; 95% CI 0.30-0.80], lower odds of 30 day mortality (OR 0.36; 95% CI 0.18-0.70) and higher rate of treatment success (csHR 2.45; 95% CI 1.59-3.77). CONCLUSIONS Implementing and maintaining a carbapenem-focused ASP is feasible, effective and safe in settings with high rates of antimicrobial resistance, even during the COVID-19 pandemic.
Collapse
Affiliation(s)
- Nikolaos Spernovasilis
- School of Medicine, University of Crete, Heraklion, Greece
- Department of Internal Medicine and Infectious Diseases, University Hospital of Heraklion, Heraklion, Greece
| | - Evangelos I Kritsotakis
- School of Medicine, University of Crete, Heraklion, Greece
- Laboratory of Biostatistics, School of Medicine, University of Crete, Heraklion, Greece
| | - Anna Mathioudaki
- Department of Internal Medicine and Infectious Diseases, University Hospital of Heraklion, Heraklion, Greece
| | - Alexandra Vouidaski
- Department of Internal Medicine and Infectious Diseases, University Hospital of Heraklion, Heraklion, Greece
| | - Christos Spanias
- Department of Pharmacy, University Hospital of Heraklion, Heraklion, Greece
| | - Maria Petrodaskalaki
- Department of Quality & Research, University Hospital of Heraklion, Heraklion, Greece
| | - Petros Ioannou
- School of Medicine, University of Crete, Heraklion, Greece
- Department of Internal Medicine and Infectious Diseases, University Hospital of Heraklion, Heraklion, Greece
| | - Georgios Chamilos
- School of Medicine, University of Crete, Heraklion, Greece
- Department of Clinical Microbiology, University Hospital of Heraklion, Heraklion, Greece
| | - Diamantis P Kofteridis
- School of Medicine, University of Crete, Heraklion, Greece
- Department of Internal Medicine and Infectious Diseases, University Hospital of Heraklion, Heraklion, Greece
| |
Collapse
|
43
|
Vecchia M, Colaneri M, Sacchi P, Marvulli LN, Salvaderi A, Lanza J, Boschini S, Ragni F, Marone P, Cutti S, Muzzi A, Marena C, Calvi M, Scudeller L, Marone EM, Bruno R. Implementation of an antimicrobial stewardship program in the Vascular Surgery ward of a university tertiary care hospital in Pavia, Northern Italy. BMC Infect Dis 2023; 23:138. [PMID: 36882761 PMCID: PMC9993681 DOI: 10.1186/s12879-023-08061-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/07/2023] [Indexed: 03/09/2023] Open
Abstract
PURPOSE The commitment of multidisciplinary teams in antimicrobial stewardship programs (ASPs) is often inadequately considered, especially in surgical wards. We wanted to evaluate clinical, microbiological, and pharmacological outcomes before and after the implementation of an ASP in the Vascular Surgery ward of Fondazione IRCCS Policlinico San Matteo, a tertiary care hospital in Pavia, Italy. METHODS This was a quasi-experimental quality-improvement study. The antimicrobial stewardship activity was conducted twice a week for 12 months and consisted of both prospective audit and feedback of all the ongoing antimicrobial prescriptions by the infectious diseases' consultants and educational meetings for the healthcare workers of the Vascular Surgery ward. For comparison between the study periods, Student t test (Mann-Whitney test for skewed distributions) was used for quantitative variables (ANOVA or Kruskall-Wallis for > 2 groups respectively), and Pearson's chi-squared test (Fisher exact test where appropriate) for categorical variables. 2-tailed tests were used. P-value significance cut-off was 0.05. RESULTS During the 12-month intervention period, among a total number of 698 patients, 186 prescriptions were revised, mostly leading to de-escalating an ongoing antimicrobial therapy (39, 20.97%). A statistically significant reduction in isolates of carbapenem-resistant Pseudomonas aeruginosa (p-value 0.003) and the absence of Clostridioides difficile infections were reported. No statistically significant changes were observed in terms of length of stay and all-cause in-hospital mortality. A significant decrease in the administration of carbapenems (p-value 0.01), daptomycin (p-value < 0.01) and linezolid (p-value 0.43) was registered. A significant reduction in antimicrobial costs was also observed. CONCLUSIONS The implementation of a 12-month ASP brought significant clinical and economic results, highlighting the benefits of a multidisciplinary teamwork.
Collapse
Affiliation(s)
- Marco Vecchia
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Marta Colaneri
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paolo Sacchi
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lea Nadia Marvulli
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Salvaderi
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jessica Lanza
- Division of Vascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefano Boschini
- Division of Vascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Franco Ragni
- Division of Vascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Piero Marone
- Microbiology and Virology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sara Cutti
- Medical Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alba Muzzi
- Medical Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlo Marena
- Medical Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Monica Calvi
- Pharmacy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luigia Scudeller
- Head, Research and Innovation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Enrico Maria Marone
- Division of Vascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, Pavia, Italy
| | - Raffaele Bruno
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, Pavia, Italy
| |
Collapse
|
44
|
Knowledge, Attitudes and Practice Regarding Antibiotic Prescription by Medical Interns: A Qualitative Study in Spain. Antibiotics (Basel) 2023; 12:antibiotics12030457. [PMID: 36978321 PMCID: PMC10044181 DOI: 10.3390/antibiotics12030457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
Antibiotic resistance is an issue of growing importance in the public health sphere. Medical interns are of great relevance when it comes to the source of this problem. This study therefore sought to ascertain which factors influence the management of antibiotic therapy by this population, in order to pinpoint the possible causes of misprescribing habits. We conducted a qualitative study based on focus group techniques, with groups consisting of medical interns from the Santiago de Compostela Clinical University Teaching Hospital. Our study identified factors which the participants considered to be determinants of antibiotic use and their relationship with the appearance of resistance. The single most repeated factor was the influence of the attending physician’s judgement; other factors included a high healthcare burden or prescribing inertia. This stage is an opportunity to correct misprescribing habits, by implementing educational interventions aimed at modifying the identified factors.
Collapse
|
45
|
Rolland L, Mainguy A, Boissier S, Ki Zerbo M, Tardivel A, Sébillotte M, Cailleaux M, Patrat-Delon S, Revest M, Tattevin P. A pilot project of expert nurses for the follow-up of complex intravenous antimicrobial treatment. Infect Dis Now 2023; 53:104670. [PMID: 36736828 DOI: 10.1016/j.idnow.2023.104670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/16/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To report a pilot project of expert nurses for outpatient parenteral antimicrobial treatment (OPAT) follow-up. METHODS Three nurses with specific training on antibiotics started a state-funded programme including: i) consultations for OPAT follow-up; ii) hotline for satellite hospitals; iii) peer training. Patients' data were prospectively collected. A representative sample of patients and physicians was interviewed to learn about their opinion on the project. RESULTS From December 2020 to December 2021, 118 patients (median age 66.5 years [52-75], male-to-female ratio 2.5) were enrolled, for a total of 621 consultations. Patients were mostly on OPAT for bone and joint infections (n = 76, 64 %) and cardiovascular infections (n = 16, 14 %), for a median duration of 29 days [22-57]. Eleven patients (9 %) required unplanned hospital admissions, and three experienced treatment failure. Most patients (21/22) and physicians in charge (10/10) reported a high level of satisfaction. CONCLUSIONS Nurses may be important actors for OPAT follow-up.
Collapse
Affiliation(s)
- L Rolland
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - A Mainguy
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - S Boissier
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - M Ki Zerbo
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - A Tardivel
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - M Sébillotte
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - M Cailleaux
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - S Patrat-Delon
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - M Revest
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France; INSERM U1230, IFR140, Rennes 1 University, Rennes, France
| | - P Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France; INSERM U1230, IFR140, Rennes 1 University, Rennes, France.
| |
Collapse
|
46
|
Matzaras R, Nikopoulou A, Protonotariou E, Christaki E. Gut Microbiota Modulation and Prevention of Dysbiosis as an Alternative Approach to Antimicrobial Resistance: A Narrative Review. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2022; 95:479-494. [PMID: 36568836 PMCID: PMC9765331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background: The importance of gut microbiota in human health is being increasingly studied. Imbalances in gut microbiota have been associated with infection, inflammation, and obesity. Antibiotic use is the most common and significant cause of major alterations in the composition and function of the gut microbiota and can result in colonization with multidrug-resistant bacteria. Methods: The purpose of this review is to present existing evidence on how microbiota modulation and prevention of gut dysbiosis can serve as tools to combat antimicrobial resistance. Results: While the spread of antibiotic-resistant pathogens requires antibiotics with novel mechanisms of action, the number of newly discovered antimicrobial classes remains very low. For this reason, the application of alternative modalities to combat antimicrobial resistance is necessary. Diet, probiotics/prebiotics, selective oropharyngeal or digestive decontamination, and especially fecal microbiota transplantation (FMT) are under investigation with FMT being the most studied. But, as prevention is better than cure, the implementation of antimicrobial stewardship programs and strict infection control measures along with newly developed chelating agents could also play a crucial role in decreasing colonization with multidrug resistant organisms. Conclusion: New alternative tools to fight antimicrobial resistance via gut microbiota modulation, seem to be effective and should remain the focus of further research and development.
Collapse
Affiliation(s)
- Rafail Matzaras
- Infectious Diseases Unit, Department of Medicine,
University General Hospital of Ioannina, University of Ioannina, Ioannina,
Greece
| | - Anna Nikopoulou
- Department of Internal Medicine, G. Papanikolaou
General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Efthimia Protonotariou
- Department of Microbiology, AHEPA University Hospital,
Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eirini Christaki
- Infectious Diseases Unit, Department of Medicine,
University General Hospital of Ioannina, University of Ioannina, Ioannina,
Greece,To whom all correspondence should be addressed:
Eirini Christaki, University General Hospital of Ioannina, St. Niarchou,
Ioannina, Greece; ; ORCID:
https://www.orcid.org/0000-0002-8152-6367
| |
Collapse
|
47
|
Ayton D, Watson E, Betts JM, Doyle J, Teh B, Valoppi G, Cotta M, Robertson M, Peel T. Implementation of an antimicrobial stewardship program in the Australian private hospital system: qualitative study of attitudes to antimicrobial resistance and antimicrobial stewardship. BMC Health Serv Res 2022; 22:1554. [PMID: 36536350 PMCID: PMC9764684 DOI: 10.1186/s12913-022-08938-8] [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] [Received: 11/22/2021] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Antimicrobial Stewardship (AMS) is a key method to tackle antimicrobial resistance (AMR). In Australia, private hospitals have a higher rate of inappropriate prescribing and non-compliance with antimicrobial guidelines, yet this phenomenon is poorly described. Private hospitals make up 49% of hospitals in Australia, making it vital to understand AMS in this setting. METHODS This study aimed to explore capabilities, opportunities and motivations for AMR and AMS with stakeholders at an Australian private hospital, and identify barriers and enablers 5 years post-implementation of an AMS program comparing with pre-implementation findings. A mixed-methods study was performed, involving three focus groups with stakeholders. All doctors, nurses and pharmacists at the hospital were invited to complete a survey on their experiences with and awareness of AMR, AMS and antimicrobial prescribing. RESULTS Thirteen staff took part in the focus groups, 100 staff responded to the survey. Staff understood the importance of the AMS program, but active engagement was low. Staff felt more thorough feedback and monitoring could improve prescribing behaviour, but acknowledged difficulty in private hospitals in changing habits of staff who valued autonomy in making prescribing decisions. Half of respondents felt the current AMS restrictions should continue. Executive engagement may be needed to drive system changes across a complex network. CONCLUSION AMS awareness increased post-implementation, but staff remained sceptical of its benefits. Engagement and education of medical consultants regarding local benefits of AMS must improve. Enhanced understanding of feedback provision, methods for engagement, and advocacy from leadership will ensure success and longevity for the program.
Collapse
Affiliation(s)
- Darshini Ayton
- grid.1002.30000 0004 1936 7857Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC Australia ,grid.1002.30000 0004 1936 7857Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC Australia
| | - Eliza Watson
- grid.1002.30000 0004 1936 7857Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Level 2, 85 Commercial Road, VIC Melbourne, 3004 Australia
| | - Juliana M. Betts
- grid.1002.30000 0004 1936 7857Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC Australia
| | - Joseph Doyle
- grid.1002.30000 0004 1936 7857Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Level 2, 85 Commercial Road, VIC Melbourne, 3004 Australia ,grid.414539.e0000 0001 0459 5396Epworth HealthCare, Melbourne, VIC Australia
| | - Benjamin Teh
- grid.414539.e0000 0001 0459 5396Epworth HealthCare, Melbourne, VIC Australia ,grid.1055.10000000403978434Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia ,grid.1008.90000 0001 2179 088XSir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC Australia
| | - Glenn Valoppi
- grid.414539.e0000 0001 0459 5396Epworth HealthCare, Melbourne, VIC Australia ,Slade Pharmacy, Melbourne, VIC Australia
| | - Menino Cotta
- grid.1003.20000 0000 9320 7537UQCCR, Faculty of Medicine, The University of Queensland, Brisbane, QLD Australia
| | - Megan Robertson
- grid.414539.e0000 0001 0459 5396Epworth HealthCare, Melbourne, VIC Australia
| | - Trisha Peel
- grid.1002.30000 0004 1936 7857Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Level 2, 85 Commercial Road, VIC Melbourne, 3004 Australia
| |
Collapse
|
48
|
Armas Freire PI, Gaspar GG, Zurita J, Salazar G, Velez JW, Bollela VR. E-Learning versus Face-to-Face Methodology for Learning Antimicrobial Resistance and Prescription Practice in a Tertiary Hospital of a Middle-Income Country. Antibiotics (Basel) 2022; 11:antibiotics11121829. [PMID: 36551486 PMCID: PMC9774894 DOI: 10.3390/antibiotics11121829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/04/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
Abstract
Background: Antimicrobial resistance is a growing health problem worldwide. One strategy to face this problem in a reasonable way is training health personnel for the rational use of antimicrobials. There are some difficulties associated with medical staff to receiving training with E-learning education, but there is a lack of studies and insufficient evidence of the effectiveness of this method compared to face-to-face learning. Methods: An educational intervention on antimicrobial resistance (AMR) and antimicrobial prescription practice (APP) was designed and implemented using two approaches: face-to-face and E-learning among physicians of the intensive care unit (ICU) and internal medicine ward (IMW) at Eugenio Espejo Hospital in Quito. Modalities of interventions were compared to propose a strategy of continuous professional development (CPD) for all hospital staff. An interventional study was proposed using a quasi-experimental approach that included 91 physicians, of which 49 belong to the IMW and 42 to the ICU. All of them received training on AMR—half in a face-to-face mode and the other half in an asynchronous E-learning mode. They then all participated on APP training but with switched groups; those who previously participated in the face-to-face experience participated in an E-learning module and vice-versa. We evaluated self-perception about basic knowledge, attitudes and referred practices towards AMR and APP before and after the intervention. A review of medical records was conducted before and after training by checking antimicrobial prescriptions for all patients in the ICU and IMW with bacteremia, urinary tract infection (UTI), pneumonia, and skin and soft tissue infection. The study received IRB clearance, and we used SPSS for statistical analysis. Results: No statistically significant difference was observed between the E-learning and the face-to-face methodology for AMR and APP. Both methodologies improved knowledge, attitudes and referred practices. In the case of E-learning, there was a self-perception of improved attitudes (p < 0.05) and practices (p < 0.001) for both AMR and APP. In face-to-face, there was a perception of improvement only in attitudes (p < 0.001) for APP. In clinical practice, the use of antimicrobials significantly improved in all domains after training, including empirical and targeted treatment of bacteremia and pneumonia (p < 0.001) and targeted treatment of UTI (p < 0.05). For the empirical treatment of pneumonia, the mean number of antibiotics was reduced from 1.87 before to 1.05 after the intervention (p = 0.003), whereas in the targeted management of bacteremia, the number of antibiotics was reduced from 2.19 to 1.53 (p = 0.010). Conclusions: There was no statistically significant difference between the effect of E-learning and face-to-face strategy in terms of teaching AMR and APP. Adequate self-reported attitudes and practices in E-learning exceed those of the face-to-face approach. The empiric and targeted use of antimicrobials improved in all reviewed cases, and we observed an overall decrease in antibiotic use. Satisfaction with training was high for both methods, and participants valued the flexibility and accessibility of E-learning.
Collapse
Affiliation(s)
| | - Gilberto Gambero Gaspar
- Infection Control Service, University Hospital of Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14049-900, Brazil
| | - Jeannete Zurita
- Biomedical Research Unit, Zurita & Zurita Laboratories and Medical School, Pontifical Catholic University of Ecuador, Quito 170104, Ecuador
| | - Grace Salazar
- Infection Service, Oncologic Solca Hospital, Quito 170138, Ecuador
| | - Jorge Washington Velez
- Division of Education and Research, Hospital de Especialidades Eugenio Espejo, Central University of Ecuador, Quito 170136, Ecuador
| | - Valdes Roberto Bollela
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14049-900, Brazil
| |
Collapse
|
49
|
Ito H, Wada T, Ichinose G, Tanimoto J, Yoshimura J, Yamamoto T, Morita S. Social dilemma in the excess use of antimicrobials incurring antimicrobial resistance. Sci Rep 2022; 12:21084. [PMID: 36473931 PMCID: PMC9726979 DOI: 10.1038/s41598-022-25632-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
The emergence of antimicrobial resistance (AMR) caused by the excess use of antimicrobials has come to be recognized as a global threat to public health. There is a 'tragedy of the commons' type social dilemma behind this excess use of antimicrobials, which should be recognized by all stakeholders. To address this global threat, we thus surveyed eight countries/areas to determine whether people recognize this dilemma and showed that although more than half of the population pays little, if any, attention to it, almost 20% recognize this social dilemma, and 15-30% of those have a positive attitude toward solving that dilemma. We suspect that increasing individual awareness of this social dilemma contributes to decreasing the frequency of AMR emergencies.
Collapse
Affiliation(s)
- Hiromu Ito
- grid.174567.60000 0000 8902 2273Department of International Health and Medical Anthropology, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Takayuki Wada
- Graduate School of Human Life and Ecology, Osaka Metropolitan University, Osaka, Japan
| | - Genki Ichinose
- grid.263536.70000 0001 0656 4913Graduate School of Science and Technology and Department of Mathematical and Systems Engineering, Shizuoka University, Shizuoka, Japan
| | - Jun Tanimoto
- grid.177174.30000 0001 2242 4849Department of Energy and Environmental Engineering, Interdisciplinary Graduate School of Engineering Sciences, Kyushu University, Fukuoka, Japan ,grid.177174.30000 0001 2242 4849Department of Advanced Environmental Science and Engineering, Faculty of Engineering Sciences, Kyushu University, Fukuoka, Japan
| | - Jin Yoshimura
- grid.174567.60000 0000 8902 2273Department of International Health and Medical Anthropology, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan ,grid.263536.70000 0001 0656 4913Graduate School of Science and Technology and Department of Mathematical and Systems Engineering, Shizuoka University, Shizuoka, Japan ,grid.136304.30000 0004 0370 1101Marine Biosystems Research Center, Chiba University, Chiba, Japan ,grid.265074.20000 0001 1090 2030Department of Biological Science, Tokyo Metropolitan University, Tokyo, Japan ,grid.26999.3d0000 0001 2151 536XUniversity Museum, The University of Tokyo, Tokyo, Japan
| | - Taro Yamamoto
- grid.174567.60000 0000 8902 2273Department of International Health and Medical Anthropology, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Satoru Morita
- grid.263536.70000 0001 0656 4913Graduate School of Science and Technology and Department of Mathematical and Systems Engineering, Shizuoka University, Shizuoka, Japan
| |
Collapse
|
50
|
Limato R, Broom A, Nelwan EJ, Hamers RL. A qualitative study of barriers to antimicrobial stewardship in Indonesian hospitals: governance, competing interests, cost, and structural vulnerability. Antimicrob Resist Infect Control 2022; 11:85. [PMID: 35701826 PMCID: PMC9195390 DOI: 10.1186/s13756-022-01126-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Antimicrobial resistance (AMR) is one of the leading global public health threats of the 21st Century. Antimicrobial stewardship (AMS) programmes have been shown to improve antibiotic use and clinical outcomes in high-income settings, but context-specific evidence is lacking on the value and effectiveness of current AMS programmes in low-resource settings. This study sought to explore context-specific underlying barriers to AMS implementation in Indonesian hospitals with a focus on governance practices and structural vulnerabilities. Methods We conducted semi-structured interviews with physicians, surgeons, clinical microbiologists, pharmacists, AMS team leaders, hospital managers, medical students, and national AMR stakeholders, and performed a thematic analysis. Results Based on 51 interviews conducted between January and October 2020, four main barriers to AMS implementation were evident in the participants' experiences: (1) Ineffective resourcing and institutional buy-in regarding mandatory AMS under hospital accreditation; (2) Entangled priorities to generate profits and interprofessional relationships between doctors and hospital managers or AMS leaders; (3) Cost-prohibitive bacterial culture testing and thresholds of national health insurance coverage; (4) Unreliable infrastructures, including microbiology laboratory and surgical facilities, ensuring high antibiotic usage to cover structural vulnerabilities. Conclusions Limited progress will be made with implementing AMS in Indonesian hospitals, and in settings with similar structural features, without addressing concerns around governance, competing interests, cost and structural vulnerabilities.
Collapse
|