Impact of an Antimicrobial Stewardship Program on the Use of Carbapenems in a Tertiary Women's and Children's Hospital, Singapore

Effects of pay-for-performance based antimicrobial stewardship on antimicrobial consumption and expenditure: An interrupted time series analysis

Objectives

To evaluate the impact of pay-for-performance on antimicrobial consumption and antimicrobial expenditure in a large teaching hospital in Guangzhou, China.

Methods

We collected data from hospital information system from January 2018 through September 2022 in the inpatient wards. Antimicrobial consumption was evaluated using antibiotic use density (AUD) and antibiotic use rate (AUR). The economic impact of intervention was assessed by antimicrobial expenditure percentage. The data was analyzed using interrupted time series (ITS) analysis.

Results

Following the implementation of the intervention, immediate decreases in the level of AUD were observed in Department of Hematology Unit 3 (β = -66.93 DDDs/100PD, P = 0.002), Urology (β = -32.80 DDDs/100PD, P < 0.001), Gastrointestinal Surgery Unit 3 (β = -11.44 DDDs/100PD, P = 0.03), Cardiac Surgery (β = -14.30 DDDs/100PD, P = 0.01), ICU, Unit 2 (β = -81.91 DDDs/100PD, P = 0.02) and Cardiothoracic Surgery ICU (β = -41.52 DDDs/100PD, P = 0.05). Long-term downward trends in AUD were also identified in Organ Transplant Unit (β = -1.64 DDDs/100PD, P = 0.02). However, only Urology (β = -6.56 DDDs/100PD, P = 0.02) and Gastrointestinal Surgery Unit 3 (β = -8.50 %, P = 0.01) showed an immediate decrease in AUR, and long-term downward trends in AUR were observed in Pediatric ICU (β = -1.88 %, P = 0.05) and ICU Unit 1 (β = -0.55 %, P = 0.02).

Conclusion

This study demonstrates that the adoption of pay-for-performance effectively reduces antibiotic consumption in specific departments of a hospital in Guangzhou in the short term. However, it is important to recognize that the long-term impact of such interventions is often limited. Additionally, it should be noted that the overall effectiveness of the intervention across the entire hospital was not significant.

Long-term outcomes of an educational paediatric antimicrobial stewardship programme: a quality improvement study

BACKGROUND AND OBJECTIVES

Antimicrobial stewardship programmes (ASPs) have resulted in antimicrobial consumption (AMC) reduction and quality of prescription (QOP) improvement. However, evidence of ASP impact in paediatrics is still limited. This study aims to assess a paediatric ASP long-term outcomes.

METHODS

A quality improvement study assessed by a interrupted time series analysis was conducted in a paediatric tertiary hospital. QOP expressed as proportion of adequate prescriptions, AMC measured by defined daily dose incidence per 1000 occupied bed days, incidence density of bloodstream infections (BSIs) and its related all-cause crude death rate (CDR) were compared between pre (from January 2013 to December 2015) and post (from January 2016 to December 2019) ASP activities intensification, which included a dedicated paediatric infectious diseases physician to actively perform educational interviews with prescribers.

RESULTS

Inappropriate prescribing showed a significant downward shift associated to the intervention with a -51.4% (-61.2% to -41.8%) reduction with respect to the expected values. Overall AMC showed no trend change after the intervention. For neonatology a28.8% (-36.8% to -20.9%) reduction was observed. Overall anti-pseudomonal cephalosporin use showed a -51.2% (-57.0% to -45.4%) reduction. Decreasing trends were observed for carbapenem use, with a quarterly per cent change (QPC) of -2.4% (-4.3% to -0.4%) and BSI-related CDR (QPC=-3.6%; -5.4% to -1.7%) through the study period. Healthcare-associated multi-drug-resistant BSI remained stable (QPC=2.1; -0.6 to 4.9).

CONCLUSIONS

Intensification of counselling educational activities within an ASP suggests to improve QOP and to partially reduce AMC in paediatric patients. The decreasing trends in mortality remained unchanged.

Quality indicators of hospitalized children influenced by clinical pharmacist services: A systematic review

BACKGROUND

Care for children who are hospitalized can be optimized if the pharmacist, in conjunction with the multidisciplinary team, promotes the rational use of medicines. In this sense, the evaluation of the quality of these clinical services through indicators is important in the planning, decision making of pharmacists and managers of these services.

OBJECTIVE

To characterize which health indicators were influenced by the pharmaceutical clinical services for the care of children in hospitals.

METHODS

A systematic review was performed. The search for data was made on the bases: Cochrane, Embase, Lilacs, Pubmed and Web of Science. Then, the search included studies in which evaluated the impact of pharmaceutical clinical services on clinical, economic and humanistic outcomes.

RESULTS

The search resulted in 11 included studies. In this review, four pharmaceutical clinical services were found: pharmacotherapy review, multiprofessional team interventions, antimicrobial stewardship program and pharmaceutical services at discharge hospital. The most influenced outcome indicators were length of hospital stay, with average time in the group that received the pharmacotherapy review service, and interventions multiprofessional team with a 6.45-day vs. 10.83 days in the control group; hospital readmissions with a significant reduction of non-scheduled readmission of 30 days in the ntimicrobial stewardship program; reduction of hospital costs and caregiver satisfaction.

CONCLUSION

In this study, we can highlight that pharmacotherapy review, multiprofessional team interventions and Antimicrobial Stewardship Program that significantly reduced the clinical results of length of hospital stay and hospital readmission, as well as a significant reduction of hospital costs.

Antibiotic utilisation and resistance over the first decade of nationally funded antimicrobial stewardship programmes in Singapore acute-care hospitals

OBJECTIVE

The aim of this study was to describe the time series of broad-spectrum antibiotic utilisation and incidence of antibiotic-resistant organisms during the implementation of antimicrobial stewardship programmes (ASP) in Singapore.

METHODS

An observational study was conducted using data from 2011 to 2020 in seven acute-care public hospitals. We applied joinpoint regressions to investigate changes in antibiotic utilisation rate and incidence density of antibiotic-resistant organisms.

RESULTS

Across the seven hospitals, quarterly broad-spectrum antibiotic utilisation rate remained stable. Half-yearly incidence density of antibiotic-resistant organisms with two joinpoints at first half (H1) of 2012 and second half (H2) of 2014 decreased significantly in the second and third period with a half-yearly percentage change (HPC) of -2.9% and - 0.5%, respectively. Across the five hospitals with complete data, half-yearly broad-spectrum antibiotic utilisation rate with one joinpoint decreased significantly from H1 of 2011 to H2 of 2018 (HPC - 4.0%) and H2 of 2018 to H2 2020 (HPC - 0.5%). Incidence density of antibiotic-resistant organisms decreased significantly in the two joinpoint periods from H1 of 2012 to H2 of 2014 (HPC - 2.7%) and H2 of 2014 to H2 of 2020 (HPC - 1.0%). Ceftriaxone with one joinpoint decreased significantly from H1 of 2011 to H1 of 2014 (HPC - 6.0%) and H1 of 2014 to H2 of 2020 (HPC - 1.8%) and ceftriaxone-resistant E. coli and K. pneumoniae decreased significantly in later periods, from H2 of 2016 to H2 of 2020 (HPC - 2.5%) and H1 of 2012 to H2 of 2015 (HPC - 4.6%) respectively. Anti-pseudomonal antibiotics with one joinpoint decreased significantly from H1 of 2011 to H2 of 2014 (HPC - 4.5%) and H2 of 2014 to H2 of 2020 (HPC - 0.8%) and that of quinolones with one joinpoint at H1 of 2015 decreased significantly in the first period. C. difficile with one joinpoint increased significantly from H1 of 2011 to H1 of 2015 (HPC 3.9%) and decreased significantly from H1 of 2015 to H2 of 2020 (HPC - 4.9%).

CONCLUSIONS

In the five hospitals with complete data, decrease in broad-spectrum antibiotic utilisation rate was followed by decrease in incidence density of antibiotic-resistant organisms. ASP should continue to be nationally funded as a key measure to combat antimicrobial resistance in acute care hospitals.

An overview of the hospitals’ antimicrobial stewardship programs implemented to improve antibiotics’ utilization, cost and resistance patterns

Introduction: The high reliance of the physicians and surgeons on the antibiotics since their discovery has led to an irrational antibiotic utilization which not only has raised the incidence of antimicrobial resistance (AMR) but also increased the cost of treatment with antibiotics as high use of antibiotics has been found related to the occurrence of certain nosocomial infections which need extra antibiotic courses to be cured. In order to overcome these antibiotic utilization related problems an antimicrobial stewardship (AMS) program being the set of various persuasive, restrictive and structural interventions is considered an effective tool to rationalize the in-patient antimicrobial utilization worldwide. Method: The focus of this review is on the interventions that are being implemented during the in-patient AMS programs and have been described effective in controlling the antibiotic utilization, their cost of treatment and an overall infection control. The literature containing the information about various AMS interventions effecting the utilization and cost patterns along with the impact on AMR was searched in various databases such as PubMed, Google Scholar, Science Direct, Ovid (Medline) and Scopus. The categorical sorting of the published data is based on various AMS interventions such as the guideline development, formulary restriction (pre-authorization), educative interventions, clinical pathway development and prospective (post prescription) audit. Considering the objectives of the study such as the goal to curb overutilization of antibiotics, control of their cost of treatment for in-patients and infection control the sorted literature is presented in three different tables describing the AMS impact on the said outcomes. Results: The post AMS changes in utilization patterns are described as fall of antibiotics defined daily doses (DDD) and days of therapy (DOT) which resulted in the reduction of the cost of treatment with antibiotics. The reduction of the cost of treatment with antibiotics also resulted due to the AMS impact on the control of various nosocomial and multi-drug resistant (MDR) infections. Conclusion:  It has been concluded that the AMS program if implemented under the supervision of an expert AMS team mainly comprising of an infectious disease (ID) physician, clinical pharmacists and microbiologists with considerable support by the hospital authorities could be a highly efficient tool of the pharmacovigilance for rationalizing the in-patient antimicrobial practice.

Acceptance and outcome of interventions in a meropenem de-escalation antimicrobial stewardship program in pediatrics

BACKGROUND

Prospective audit and feedback is a method that allows the antimicrobial stewardship program (ASP) team to interact with attending physicians to tailor antibiotic therapy, including de-escalation, as appropriate. This study aimed to evaluate the acceptance and outcomes of ASP de-escalation recommendations in children who received meropenem.

METHODS

A prospective cohort study was conducted in children aged 1 month to 18 years who received meropenem in a tertiary-care teaching hospital. The ASP team gave recommendation between 72 and 120 h after initiating meropenem therapy. Acceptance of de-escalation recommendations among primary physicians was evaluated within 24 h of recommendation. Outcomes included clinical success rate on the 7th day and incidence rate of acquisition of carbapenem-resistant gram-negative bacteria (CR-GNB) within 30 days.

RESULTS

From March to December 2019, 217 children with a median (interquartile range) age of 2.1 (0.6, 9.5) years received meropenem. The ASP team gave recommendations in 127 (58.5%) of cases for continuation of meropenem therapy and 90 (41.5%) of cases for de-escalation. The overall acceptance of ASP de-escalation recommendations was 57.8% (95%CI: 46.9-68.1%). Clinical success rates were 85.2% in the accepted group compared to 77.5% in the rejected group (P = 0.06). The incidence rate of acquisition of CR-GNB within 30 days after treatment was 5.8% in the accepted group and 15.8% in the rejected group (P = 0.03).

CONCLUSIONS

About half of the recommendations to de-escalate meropenem prescriptions were accepted through the ASP intervention. Carbapenem-resistant gram-negative bacteria acquisitions was less likely in the de-escalation group. A robust de-escalation strategy 72 h following carbapenem initiation should be encouraged to combat multidrug-resistant organisms.

Impact of pharmacist intervention in antibiotic stewardship programmes for critically ill neonates: A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Antibiotic stewardship programmes (ASPs) are introduced to ensure effective antibiotic use. Pharmacists can be involved in ASPs to facilitate the appropriate antibiotic use. Prolonged use of antibiotics causes adverse events in critically ill neonates. Hence, this systematic review and meta-analysis was aimed at investigating pharmacists' functions in ASPs in critically ill neonates and the effect of ASP implementation on antibiotic use.

METHODS

A comprehensive search of PubMed/Medline, Embase, and Cochrane Library databases until January 2021 was conducted and studies that reported the functions of pharmacists in ASPs for critically ill neonates and the results of ASP implementation were included in this review. All processes were performed by two reviewers independently, and any discordance between the two was resolved by discussion.

RESULTS AND DISCUSSION

In all, 19 studies were included in this review. Pharmacists were found to have various functions in ASPs, such as participating in the development of antibiotic use guidelines, auditing antibiotic prescriptions, participating in multidisciplinary ward rounds, educating other ASP team members, checking blood culture or laboratory data, and monitoring antibiotic use. A meta-analysis revealed that ASP implementation in critically ill neonates was significantly associated with a 23% reduction in the overall antibiotic use rate (ratio of means: 0.77, 95% confidence interval: 0.69-0.87, p < 0.001). Moreover, the overall duration of antibiotic therapy significantly reduced by 15% with ASP implementation (ratio of means: 0.85, 95% confidence interval: 0.78-0.91, p < 0.001).

WHAT IS NEW AND CONCLUSION

The implementation of ASPs involving pharmacists, especially in critically ill neonates, was associated with the reduced use and duration of antibiotic treatment. Thus, pharmacists played a key role in ASPs in critically ill neonates.

Trends of Antibiotic Use and Expenditure After an Intensified Antimicrobial Stewardship Policy at a 2,200-Bed Teaching Hospital in China

Objective: This study aimed to evaluate the effects of intensified Chinese special rectification activity on clinical antibiotic use (CSRA) policy on a tertiary-care teaching hospital. Methods: A 48-month longitudinal dataset involving inpatients, outpatients, and emergency patients were collected. Study period included pre-intervention stage (adopting soft measures like systemic training) and post-intervention stage (applying antibiotic control system to intensify CSRA policy). Antibiotic use was evaluated by antibiotic use rate (AUR) or antibiotic use density (AUD). Economic indicator was evaluated by antibiotic cost in prescription or antibiotic expenditure in hospitalization. Data was analyzed by interrupted time series (ITS) analysis. Results: The medical quality indicators remained stable or improved during the study period. AUR of inpatients (AURI) declined 0.553% per month (P = 0.025) before the intervention and declined 0.354% per month (P = 0.471) after the intensified CSRA policy was implemented. AUD, expressed as defined daily doses per 100 patients per day (DDDs/100PD), decreased by 1.102 DDDs/100PD per month (P = 0.021) before and decreased by 0.597 DDDs/100PD per month (P = 0.323) thereafter. The ratio of antibiotic expenditure to medication expenditure (AE/ME) decreased by 0.510% per month (P = 0.000) before and fell by 0.096% (P = 0.000) per month thereafter. AE per patient decreased by 25.309 yuan per month (P = 0.002) before and decreased by 7.987 yuan per month (P = 0.053) thereafter. AUR of outpatient (AURO) decreased by 0.065% per month before (P = 0.550) and decreased by 0.066% per month (P = 0.994) thereafter. The ratio of antibiotic cost to prescription cost in outpatient (ACO/PCO) decreased by 0.182% per month (P = 0.506) before and decreased by 0.216% per month (P = 0.906) thereafter. AUR of emergency patient (AURE) decreased by 0.400% per month (P = 0.044) before and decreased by 0.092% per month (P = 0.164) thereafter. The ratio of antibiotic cost to prescription cost in emergency patient (ACE/PCE) decreased by 0.616% per month (P < 0.001) before and decreased by 0.151% per month (P < 0.001) thereafter. Conclusions: Implementation of CSRA policy was associated with declining antibiotic use and antibiotic expenditure in inpatients, outpatients, and emergency patients. However, it is also important to note that the declining trend of antibiotic consumption slowed due to the limited capacity for decline in the later stages of CSRA intervention.

Antimicrobial stewardship program in pediatric medicine

The rising threats from antimicrobial resistance due to inappropriate utilization of antimicrobial agents in health care including the pediatric population has been a topic of concern at the global level for the last several decades. The antimicrobial stewardship program (ASP) is a multidisciplinary institutional initiative focusing primarily on the improvement of antimicrobial prescribing practices and limiting inappropriate use. ASPs play an important role in the implementation of healthcare strategies in pediatrics worldwide to reduce antimicrobial resistance. Many published reports demonstrate how adapted ASPs in pediatrics result in improvement of unnecessary antimicrobial utilization, decreasing drug resistance and treatment failure, minimization of adverse clinical outcomes, decreasing healthcare costs and hospital length of stay, and optimization of diagnostic strategies. However, some barriers in pediatric ASP still exist. This narrative review describes core elements of ASP, the impact of implemented ASPs on pediatric healthcare, and challenges of pediatric ASP as seen by the authors.

Stewardship program on carbapenem prescriptions in a tertiary hospital for adults and children in France: a cohort study

Antimicrobial stewardship programs aim at reducing the overuse of broad-spectrum antibiotics such as carbapenems, but their impact remains unclear. We compared the use of carbapenems between paediatric and adult subjects admitted to a French tertiary hospital and described the intervention of an antibiotic stewardship team (AST). As part of AST routine activity, all adult and paediatric patients receiving carbapenems are identified in real time using a computer-generated alert system and reviewed by the AST. Data associated with carbapenem prescriptions were extracted for 2 years (2014-2015) and were compared between paediatric and adult wards. Prescription appropriateness (i.e. no clinically suitable narrower spectrum alternative to carbapenem for de-escalation) and AST intervention were analysed. In total, 775 carbapenem prescriptions for 291 children and 262 adults were included. Most patients (95%) had a comordity and 52% had known recent carriage of extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBLE). Most carbapenem prescriptions came from intensive care units (n = 269, 35%) and were initiated for urinary tract (n = 200, 27%), sepsis (n = 181, 25%), and lung (n = 153, 21%) infections. Carbapenems were initiated empirically in 537 (70%) cases, and an organism was isolated in 523 (67%) cases. Among the isolated organisms, 47% (n = 246) were ESBLE and 90% (n = 468) were susceptible to carbapenems, but an alternative existed in 61% (n = 320) of cases according to antibiotic susceptibility testing. Among prescriptions reviewed by the AST, 39% (n = 255) were considered non-appropriate and led to either antibiotic discontinuation (n = 47, 7%) or de-escalation (n = 208, 32%). Non-appropriate prescriptions were more frequent in paediatric wards (p = 0.01) and in microbiologically documented infections (p = 0.013), and less observed in immunocompromised patients (p = 0.009) or with a known ESBLE carriage (p < 0.001). Tailored stewardship programs are essential to better control carbapenem use and subsequent antimicrobial resistance.

A Narrative Review of Antimicrobial Stewardship Interventions within In-patient Settings and Resultant Patient Outcomes

The overuse of antibiotics has led to various healthcare problems such as the emergence of resistance in infectious microbes and mortality due to antibiotic resistant healthcare associated infections (HAIs). An antimicrobial stewardship (AMS) program is the set of interventions used worldwide to enhance the rational use of antibiotics especially for the hospitalized patients. This review aimed to describe the characteristics of the implemented AMS programs in various hospitals of the world mainly focusing on the interventions and patients outcomes. The literature about AMS program was searched through various databases such as PubMed, Google Scholar, Science Direct, Cochran Library, Ovid (Medline), Web of Science and Scopus. In this review the literature pertaining to the AMS programs for hospitalized patients is sorted on the basis of various interventions that are categorized as formulary restriction (pre-authorization), guideline development, clinical pathway development, educative interventions and prospective audit. Moreover a clear emphasis is laid on the patient outcomes obtained as a result of these interventions namely the infection control, drop in readmission rate, mortality control, resistance control and the control of an overall cost of antibiotic treatment obtained mainly by curbing the overuse of antibiotics within the hospital wards. AMS program is an efficient strategy of pharmacovigilance to rationalize the antimicrobial practice for hospitalized patients as it prevents the misuse of antibiotics, which ultimately retards the health threatening effects of various antibiotics.

Effectiveness of antimicrobial stewardship programmes in neonatology: a systematic review

INTRODUCTION

Antimicrobial stewardship programmes (ASPs) are recommended to improve antibiotic use in healthcare and reduce antimicrobial resistance (AMR). Our aim was to investigate the effectiveness of ASPs in reducing antibiotic consumption, use of broad-spectrum/restricted antibiotics, antibiotic resistance and healthcare-associated infections (HAIs) in neonates.

METHODS

We searched PUBMED, SCIELO, EMBASE and the Cochrane Database (January 2000-April 2019) to identify studies on the effectiveness of ASPs in neonatal wards and/or neonatal intensive care units (NICUs). Outcomes were as follows: reduction of antibiotic consumption overall and of broad-spectrum/target antibiotics, inappropriate antibiotic use, antibiotic resistance and HAIs. ASPs conducted in settings other than acute care hospitals, for children older than 1 month, and ASPs addressing antifungal and antiviral agents, were excluded.

RESULTS

The initial search identified 53 173 titles and abstracts; following the application of filters and inclusion criteria, a total of six publications were included in the final analysis. All studies, of which one was multi-centre study, were published after 2010. Five studies were conducted exclusively in NICUs. Four articles applied multimodal interventions. Reduction of antibiotic consumption overall and/or inappropriate antibiotic use were reported by four articles; reduction of broad-spectrum/targeted antibiotics were reported by four studies; No article evaluated the impact of ASPs on AMR or the incidence of HAI in neonates.

CONCLUSION

ASPs can be effectively applied in neonatal settings. Limiting the use of broad-spectrum antibiotics and shorting the duration of antibiotic treatment are the most promising approaches. The impact of ASPs on AMR and HAI needs to be evaluated in long-term studies.

Impact of an antimicrobial stewardship program in the antimicrobial-resistant and prevalence of clostridioides difficile infection and amount of antimicrobial consumed in cancer patients

OBJECTIVE

The The impact of a hospital antimicrobial stewardship was determined on antimicrobial-resistant, Clostridioides difficile rates and the amount of antimicrobial consumed in cancer patients.The intervention effects of antimicrobial stewardship (ASP) plans in 2017-2018 and 2018-2019 were respectively evaluated among hematology/oncology and bone marrow transplant patients in Ayatollah Taleghani University Hospital, Tehran, Iran. In this interventional quasi-experimental study, the ASP repository was utilized to capture four survey questions encompassed in these immunocompromised patients: amount of antibiotics (meropenem and vancomycin) consumption gr-year, the number of positive Clostridioides difficile infection and multidrug-resistant positive cases in blood cultures.

RESULTS

The number of MDR cases in the periods of 2017-2018 and 2018-2019 were 145 and 75, respectively (p = 0.011). A significant reduction in all positive blood cultures from 2017-2018 to 2018-2019 was found (p = 0.001). 574 patients admitted to our hospital in these periods of 2017- 2018 and 2018- 2019were assessed for MPM and VMN use. The amounts of MPM prescriptions in 2018-2019 was significantly decreased from 22464 to 17262 g (p = 0.043). The significant reduction in antibiotic consumption, MDR organisms, and CDI can highly promote patients' health and decreasing medical costs and long-term defects for patients.

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

Background

Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally.

Methods

MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data.

Results

Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides.

Conclusions

Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

Impact of a Prospective Audit and Feedback Antimicrobial Stewardship Program in Pediatric Units in Tertiary Care Teaching Hospital in Thailand

BACKGROUND

Antimicrobial stewardship programs (ASPs) have been proven to be beneficial in reducing the use of antimicrobial agents, antibiotic resistance, and health care costs. The data supporting the utility of ASPs has come largely from adult hospital units, but few pediatric hospital units have implemented ASPs. Our objective for this study was to assess the impact of ASPs in pediatric units in tertiary care teaching hospitals.

METHODS

We conducted a retrospective chart review to compare antimicrobial use pre- and post-ASP over a 6-month period in a tertiary care hospital in which an ASP had been in use since July 2017. Meropenem, vancomycin, and colistin were selected to be monitored. ASP rounds were conducted twice a week to assess and provide feedback on antimicrobial prescriptions. Antimicrobial use was measured as days of therapy (DOTs) per 1000 patient-days and was compared pre- and post-ASP by using independent t tests.

RESULTS

Charts of children hospitalized who were in antimicrobial treatment pre-ASP (44.3%) and post-ASP (41.7%) were reviewed. The percentages of children who received selected antimicrobial agents did not differ between pre- and post-ASP. During the post-ASP period, a significant reduction in DOT with vancomycin and colistin was observed. Vancomycin use decreased from 58.5 to 40.2 DOTs per 1000 patient-days (P = .038), and colistin decreased from 36.3 to 13.8 DOTs per 1000 patient-days (P = .026). Meropenem use decreased from 126.8 to 111.2 DOTs per 1000 patient-days (P = .467). Between the 2 periods, there was no effect on length of stay and mortality.

CONCLUSIONS

ASPs can lead to a significant reduction in selected antimicrobial use in children who are hospitalized, with no effect on length of stay or mortality rate.

Ten-year narrative review on antimicrobial resistance in Singapore

Antimicrobial resistance (AMR) results in drug-resistant infections that are harder to treat, subsequently leading to increased morbidity and mortality. In 2008, we reviewed the problem of AMR in Singapore, limiting our discussion to the human healthcare sector. Ten years later, we revisit this issue again, reviewing current efforts to contain it in order to understand the progress made as well as current and emerging challenges. Although a significant amount of work has been done to control AMR and improve antibiotic prescribing in Singapore, most of it has focused on the hospital setting, with mixed impact. The role of antibiotic use and AMR in food animals and the environment - and the link to human health - is better understood today. This issue of AMR encompasses both human health as well as animal/food safety, and efforts to control it will need to continually evolve to maintain or improve on current gains.

The impact of paediatric antimicrobial stewardship programmes on patient outcomes

PURPOSE OF REVIEW

Although there has been an unprecedented global effort to reduce the spread of antimicrobial resistance, little emphasis has been placed on children. This review aims to evaluate the impact of paediatric antimicrobial stewardship programmes as well as providing a practical approach for effectively implementing them in community-based settings and in hospitals.

RECENT FINDINGS

Although rates of serious bacterial infection are low in children, the rates of antimicrobial use and resistance are comparable with adults. Different strategies are required to implement antimicrobial stewardship in community-based settings compared to in hospitals. Nationally coordinated, whole-system approaches have achieved long-term, sustainable reductions in antimicrobial prescribing, as well as reductions in resistance rates at population level, with no evidence of an increase in rate of serious infection or bacterial complications.

SUMMARY

Antimicrobial stewardship programmes in neonates and children have unique characteristics and issues. There is currently no consensus on how to measure consumption of antimicrobials in neonates and children. This is a research priority. Benchmarking and clinical networks in neonates and paediatrics are important to share practice and drive best use of antimicrobials.

Assessing the relevance of carbapenem prescriptions by an antibiotic stewardship team

OBJECTIVES

To assess the level and factors of compliance of carbapenem prescriptions with guidelines and to determine the impact of an antibiotic stewardship team in a university hospital.

PATIENTS AND METHODS

Five-month prospective study in the intensive care, surgery, and medicine units to measure the compliance of carbapenem prescriptions with guidelines from French scientific societies; compliance was assessed by an infectious disease specialist warned by the pharmacy, and the prescribers' compliance with the infectious disease specialist's advice was then assessed.

RESULTS

One hundred and four treatment initiations for 94 patients were included. Prescriptions were mostly empirical (64%), for pulmonary (35%), urinary tract (23%), and intra-abdominal (17%) infections. Prescriptions were mostly made in an intensive care unit (50%), by a junior physician (66%), with the use of imipenem (74%), and were followed by an objective reassessment (80%). Compliance with guidelines (82%) was significantly higher for empirical than documented prescriptions (91% vs 65%, P<0.001). Compliance was higher in intensive care units than medicine units (87% vs 61%, P=0.037). No change in the compliance rate was observed during the study. Compliance with the infectious disease specialist's advice (68%) improved, although not significantly (P=0.066).

CONCLUSIONS

Because of a higher than expected compliance of carbapenem prescriptions with guidelines and a lower than expected inclusions in the study, we did not show any impact. The diffusion of guidelines and long-term control of carbapenem prescriptions seem to be possible and necessary in hospitals to limit their ecological impact.

Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review

Background

Hospital antimicrobial stewardship programs (ASPs) aim to promote judicious use of antimicrobials to combat antimicrobial resistance. For ASPs to be developed, adopted, and implemented, an economic value assessment is essential. Few studies demonstrate the cost-effectiveness of ASPs. This systematic review aimed to evaluate the economic and clinical impact of ASPs.

Methods

An update to the Dik et al. systematic review (2000–2014) was conducted on EMBASE and Medline using PRISMA guidelines. The updated search was limited to primary research studies in English (30 September 2014–31 December 2017) that evaluated patient and/or economic outcomes after implementation of hospital ASPs including length of stay (LOS), antimicrobial use, and total (including operational and implementation) costs.

Results

One hundred forty-six studies meeting inclusion criteria were included. The majority of these studies were conducted within the last 5 years in North America (49%), Europe (25%), and Asia (14%), with few studies conducted in Africa (3%), South America (3%), and Australia (3%). Most studies were conducted in hospitals with 500–1000 beds and evaluated LOS and change in antibiotic expenditure, the majority of which showed a decrease in LOS (85%) and antibiotic expenditure (92%). The mean cost-savings varied by hospital size and region after implementation of ASPs. Average cost savings in US studies were $732 per patient (range: $2.50 to $2640), with similar trends exhibited in European studies. The key driver of cost savings was from reduction in LOS. Savings were higher among hospitals with comprehensive ASPs which included therapy review and antibiotic restrictions.

Conclusions

Our data indicates that hospital ASPs have significant value with beneficial clinical and economic impacts. More robust published data is required in terms of implementation, LOS, and overall costs so that decision-makers can make a stronger case for investing in ASPs, considering competing priorities. Such data on ASPs in lower- and middle-income countries is limited and requires urgent attention.

Antimicrobial stewardship program (ASP): an effective implementing technique for the therapy efficiency of meropenem and vancomycin antibiotics in Iranian pediatric patients

Background

Antimicrobial stewardship program (ASP) is a distinguished method to improve the prescription and efficacy of antibiotics.

Aim

The efficacy of ASP and conventional methods was compared to measure the effectiveness of meropenem (MPM) and vancomycin (VMN) antibiotics in pediatric patients.

Design

In an interventional quasi-experimental study, 135 children admitted in Children’s Hospital affiliated to University of Medical Sciences in time periods of 2014–2015 and 2015–2016 were assessed.

Methods

The conventional and ASP methods in 2014–2015 and 2015–2016 were respectively utilized to provide the best antimicrobial therapy of MPM and VMN antibiotics in patient children. The data of mortality rate (MR), antibiotic prescription (AP), antibiotic dose (ADe), antibiotic duration (ADn), length of hospital stay (LOHS), and blood cultures (BCs) were compared across the years using the Chi square, independent t test, and Fisher’s exact test.

Results

The levels of MR, AP, ADe, ADn, LOHS, and positive BCs using the ASP method in 2015–2016 were significantly lower those of in 2014–2015 using the conventional one (p < 0.05).

Conclusions

The ASP method versus conventional one with a better efficacy can be employed as an antibiotic administration guide for MPM and VMN in the therapy of patients in community-based hospitals.

Status of antimicrobial stewardship programmes in Nigerian tertiary healthcare facilities: Findings and implications

OBJECTIVES

The problem of antimicrobial resistance (AMR) is increasing worldwide, with health-related and economic consequences. This is a concern in Africa, including Nigeria, the most populous country in Africa, with its high rates of infectious diseases. Approaches to reducing AMR include instigating antimicrobial stewardship programmes (ASPs) in hospitals. Currently, no information is available regarding the extent of ASPs in Nigerian hospitals. Consequently, the objective was to address this starting in tertiary hospitals.

METHODS

This was a cross-sectional, questionnaire-based study among tertiary healthcare facilities. Tertiary hospitals were chosen initially since if there are concerns in these training hospitals, such concerns will likely to be exacerbated in other hospitals.

RESULTS

Completed questionnaires were received from 17 of 25 tertiary healthcare facilities across five of the six geopolitical regions of Nigeria. Ten (59%), four (24%), two (12%) and one (6%) respondents were in internal medicine, infectious diseases, medical microbiology and clinical pharmacology, respectively. Only six healthcare facilities (35%) had a formal organisational structure and a team responsible for ASP. Facility-specific treatment recommendations, based on local AMR patterns, were available in only four facilities (24%). Policies on approval for prescribing specified antimicrobials and formal procedures for reviewing their appropriateness after 48h were present in only two facilities (12%). A cumulative antimicrobial susceptibility report for the previous year was available in only two facilities (12%), and only one facility routinely monitored antimicrobial use.

CONCLUSION

Significant inadequacies in the availability of ASPs were observed. This needs to be urgently addressed to reduce AMR rates in Nigeria.

Mixed effects of restriction strategies in antimicrobial stewardship programs on antimicrobial use in 121 tertiary hospitals in China, 2013-2017

Background: The research evaluated the impact of intravenous antimicrobial restriction strategy (IARS) on different types of hospitals in China for evidence-based management, for outpatients implemented in 2016. Methods: Based on panel data on antimicrobial use in 121 tertiary hospitals in Zhejiang, China, segmented regression analysis was used to evaluate the impact of IARS in children's hospitals (CHs), obstetrics and gynecology hospitals (OGHs), women's and children's hospitals (WCHs), traditional Chinese medicine hospitals (TCMHs) and general hospitals (GHs). Antimicrobial use was measured using the percentage of total encounters with prescribing and the percentage of total drug expenditure relating to antimicrobials (APP and AEP). Results: There was a downward baseline slope of APP in all types of hospitals and AEP in WCHs, TCMHs and GHs (P < 0.01). After IARS, a level reduction in AEP in CHs (-3.14%, 95% CI = -6.21 to 0.06), WCHs (-1.33%, 95% CI = -2.44 to 0.22) and TCMHs (-0.85%, 95%CI = -1.51 to 0.18). After IARS, the slope of AEP changed significantly in OGHs (-0.42%, 95%CI = -0.81 to 0.03) and WCHs (0.29%, 95% CI = 0.08 to 0.49), and the slope of APP changed significantly in CHs (2.35%, 95%CI = 1.20 to 3.49). Conclusions: IARS had the mixed effects including positive effect in AEP and no significant change in APP, and an unexpected rise in APP in CHs needs further study.

Impact of clinical pharmacist intervention on antimicrobial use in a small 164-bed hospital

Objectives

To study the impact of clinical pharmacist interventions (PIs) on antimicrobial prescriptions in terms of physician acceptance rates, clinical benefits and antimicrobial use/cost outcomes.

Methods

This study retrospectively analysed the impact of antimicrobial PIs over a 2-year period (October 2012 to October 2014) in a private non-teaching 164-bed hospital without a formal antimicrobial stewardship programme. Excluded from the study were outpatients and patients admitted to the intensive care unit or the emergency department. The PIs focused on appropriate indication and appropriate dosage; drug adverse events, allergies, intolerance and interactions; sequential therapy; therapeutic de-escalation; excessive duration of treatment and therapeutic drug monitoring. Carbapenems and linezolid were classified as special-vigilance drugs. Amoxicillin-clavulanic, piperacillin-tazobactam and vancomycin were classified as preferred drugs. Clinical benefits evaluated in accordance with internal guidelines, were classified as enhancing appropriate antimicrobial prescription or potentially reducing toxicity. Antimicrobial use and expenditure were compared with that of the previous 2-year period.

Results

386 PIs were implemented in 303 patients. The overall acceptance rate was 83.4%. The acceptance rate for appropriate prescription PIs was significantly lower than for toxicity PIs (73.7% vs 90.9%; p<0.0001). Significant reductions in the use of special-vigilance drugs (from 39.9 (22.2-86.0) to 28.0 (6.0-43.4) defined daily doses (DDD)/1000 patient-days; p=0.0003) were seen and increases in the use of piperacillin-tazobactam (from 13.2 (0-22.9) to 17.2 (6.9-44.8) DDD/1000 patient-days; p=0.007) and of cephalosporins (from 123.5 (61.8-196.6) to 149.1 (80.3-228.2) DDD/1000 patient-days; p=0.027). Overall cost savings were 5.1%.

Conclusions

PIs on antimicrobial prescriptions may be effective in enhancing appropriate use of antimicrobials, reducing their toxicity, reducing the use of special-vigilance drugs and reducing overall antimicrobial cost.

Impact of a Carbapenem Antimicrobial Stewardship Program on Patient Outcomes

Antimicrobial stewardship programs (ASPs) aim to improve appropriate antimicrobial use. However, concerns of the negative consequences from accepting ASP interventions exist, particularly when deescalation or discontinuation of broad-spectrum antibiotics is recommended. Hence, we sought to evaluate the impact on clinical outcomes when ASP interventions for inappropriate carbapenem use were accepted or rejected by primary providers. We retrospectively reviewed all carbapenem prescriptions deemed inappropriate according to institutional guidelines with ASP interventions between July 2011 and December 2014. Intervention acceptance and outcomes, including carbapenem utilization, length of stay, hospitalization charges, 30-day readmission, and mortality rates were reviewed. Data were analyzed in two groups, one in which physicians accepted all interventions ("accepted") and one in which interventions were rejected ("rejected"). A total of 158 ASP interventions were made. These included carbapenem discontinuation (35%), change to narrower-spectrum antibiotic (32%), dose optimization (17%), further investigations (including imaging and procalcitonin) (11%), infectious diseases referral (3%), antibiotic discontinuation (other than carbapenem) (1%), and source control (1%). Of 220 unique patients, carbapenem use was inappropriate in 101 (45.9%) patients. A significant reduction in carbapenem utilization was observed in the accepted group versus rejected group (median defined daily doses, 0.224 versus 0.668 per 1,000 patient-days, respectively; P < 0.001). There was a significant reduction in 30-day mortality in the accepted (none) versus rejected group (10 deaths, P = 0.015), but there were no differences in length of stay, hospitalization charge, or 30-day readmission rates. Hypotension was independently associated with mortality in multivariate analysis (odds ratio, 5.25; 95% confidence interval, 1.34 to 20.6). In our institution, acceptance of carbapenem ASP interventions did not compromise patient safety in terms of clinical outcomes while reducing consumption.

Role of antimicrobial stewardship programmes in children: a systematic review

The United Nations and the World Health Organization have designated antimicrobial resistance (AMR) as a major health priority and developed action plans to reduce AMR in all healthcare settings. Establishment of institutional antimicrobial stewardship programmes (ASPs) is advocated as a key intervention to reduce antibiotic consumption in hospitals and address high rates of multi-drug-resistant (MDR) bacteria. PUBMED and the Cochrane Database of Systematic Reviews (January 2007-March 2017) were searched to identify studies reporting the effectiveness of ASPs in general paediatric wards and paediatric intensive care units (PICUs) for reducing antibiotic consumption, use of broad-spectrum/restricted antibiotics, and antibiotic resistance and healthcare-associated infections (HAIs). Neonatal units and antifungal agents were excluded. Of 2509 titles and abstracts, nine articles were eligible for inclusion in the final analysis. All studies reported a reduction in the use of broad-spectrum/restricted antibiotics or antibiotic consumption. One study reported a reduction in HAIs in a PICU, and another study evaluated bacterial resistance, showing no effect following ASP implementation. Prospective audit on antibiotic use was the most common ASP core component (eight of nine studies). Antibiotic pre-authorization was described in two studies. Other described interventions were the provision of guidelines or written information (five of nine studies), and training of healthcare professionals (one study). There is limited evidence for a reduction in antibiotic consumption and use of broad-spectrum/restricted agents following ASP implementation specifically in PICUs. Data evaluating the impact of ASPs on HAIs and AMR in PICUs are lacking. In addition, there is limited information on effective components of a successful ASP in PICUs.

The emergence and evolution of antimicrobial resistance: Impact on a global scale

The evolution of antimicrobial resistance is a multifaceted issue that is influenced by numerous factors. This growing healthcare problem has significantly impacted the public welfare and has substantially burdened the economic system on a global scale. In an effort to combat this rising problem, several strategies have been implemented in the recent years to stall the progression and decrease the emergence of antimicrobial resistance. The aim of this review article is to describe the various factors that have contributed to the current state of antimicrobial resistance and to evaluate potential strategies developed to reduce the burden of antimicrobial resistance.

Carbapenem Resistance in Gram-Negative Bacteria: The Not-So-Little Problem in the Little Red Dot

Singapore is an international travel and medical hub and faces a genuine threat for import and dissemination of bacteria with broad-spectrum resistance. In this review, we described the current landscape and management of carbapenem resistance in Gram-negative bacteria (GNB) in Singapore. Notably, the number of carbapenem-resistant Enterobacteriaceae has exponentially increased in the past two years. Resistance is largely mediated by a variety of mechanisms. Polymyxin resistance has also emerged. Interestingly, two Escherichia coli isolates with plasmid-mediated mcr-1 genes have been detected. Evidently, surveillance and infection control becomes critical in the local setting where resistance is commonly related to plasmid-mediated mechanisms, such as carbapenemases. Combination antibiotic therapy has been proposed as a last-resort strategy in the treatment of extensively drug-resistant (XDR) GNB infections, and is widely adopted in Singapore. The diversity of carbapenemases encountered, however, presents complexities in both carbapenemase detection and the selection of optimal antibiotic combinations. One unique strategy introduced in Singapore is a prospective in vitro combination testing service, which aids physicians in the selection of individualized combinations. The outcome of this treatment strategy has been promising. Unlike countries with a predominant carbapenemase type, Singapore has to adopt management strategies which accounts for diversity in resistance mechanisms.

Quasi experimental designs in pharmacist intervention research

Background In the field of pharmacist intervention research it is often difficult to conform to the rigorous requirements of the "true experimental" models, especially the requirement of randomization. When randomization is not feasible, a practice based researcher can choose from a range of "quasi-experimental designs" i.e., non-randomised and at time non controlled. Objective The aim of this article was to provide an overview of quasi-experimental designs, discuss their strengths and weaknesses and to investigate their application in pharmacist intervention research over the previous decade. Results In the literature quasi experimental studies may be classified into five broad categories: quasi-experimental design without control groups; quasi-experimental design that use control groups with no pre-test; quasi-experimental design that use control groups and pre-tests; interrupted time series and stepped wedge designs. Quasi-experimental study design has consistently featured in the evolution of pharmacist intervention research. The most commonly applied of all quasi experimental designs in the practice based research literature are the one group pre-post-test design and the non-equivalent control group design i.e., (untreated control group with dependent pre-tests and post-tests) and have been used to test the impact of pharmacist interventions in general medications management as well as in specific disease states. Conclusion Quasi experimental studies have a role to play as proof of concept, in the pilot phases of interventions when testing different intervention components, especially in complex interventions. They serve to develop an understanding of possible intervention effects: while in isolation they yield weak evidence of clinical efficacy, taken collectively, they help build a body of evidence in support of the value of pharmacist interventions across different practice settings and countries. However, when a traditional RCT is not feasible for logistical and/or ethical reasons researchers should endeavour to use the more robust of the quasi experimental designs.