Implementation of Hospital’s Antibiotic Policy Decreases Antimicrobial Use in the General Pediatric Ward

Estimating antibiotics consumption in a tertiary care hospital in Islamabad using a WHO's defined daily dose methodology

BACKGROUND

Antibiotics have helped to reduce the incidence of common infectious diseases in all modern healthcare systems, but improper use of antibiotics including their overuse and misuse can change the bacteria so much that antibiotics don't work against them. In case of developing imposable selective pressure with regard to the proportion of hospitalized patients who receive antibiotics, the quantity of antibiotics that are prescribed to them, and the proportion of patients who receive antibiotic treatment is one of the major contributors to the rising global health issue of antimicrobial resistance. Concerning the levels of antibiotic consumption in Pakistani hospitals, there is negligible research data available.

AIM

This study aimed to evaluate five-year inpatient antibiotic use in a tertiary care hospital in Islamabad using the World Health Organization (WHO) Recommended Anatomical Therapeutic Chemical (ATC) Classification / Defined Daily Dose (DDD) methodology.

METHOD

It was a descriptive study involving a retrospective record review of pharmacy records of antibiotics dispensed (amount in grams) to patients across different specialties of the hospital from January 2017 to December 2021 (i.e., 60 consecutive months). The antibiotic consumption was calculated by using the DDD/100-Bed Days (BDs) formula, and then relative percent change was estimated using Microsoft Excel 2021 edition.

RESULT

A total of 148,483 (77%) patients who received antibiotics were included in the study out of 193,436 patients admitted in the hospital. Antibiotic consumption trends showed considerable fluctuations over a five-year period. It kept on declining irregularly from 2017 to 2019, inclined vigorously in 2020, and then suddenly dropped to the lowest DDD/100 BDs value (96.02) in the last year of the study. The overall percentage of encounters in which antibiotics were prescribed at tertiary care hospital was 77% which is very high compared to the WHO standard reference value (< 30%). WATCH group antibiotics were prescribed (76%) and consumed more within inpatient settings than Access (12%) and Reserve (12%) antibiotics.

CONCLUSION

The hospital antibiotic consumption data is well maintained across different inpatient specialties but it is largely non-aligned with WHO AWaRe (Access-Watch-Reserve) antibiotics use and optimization during 2017-2021. Compared to the WHO standard reference figure, the overall percentage of antibiotics encountered was higher by about 47%. Antibiotic consumption trends vary with a slight increase in hospital occupancy rate, with positive relative changes being lower in number but higher in proportion than negative changes. Although the hospital antibiotics policy is in place but seems not to be followed with a high degree of adherence.

Antibiotic usage at a clinical paediatric hospital before and after the implementation of actions related to the hospital antibiotic policy

OBJECTIVES

The aim of this study was to determine the impact of undertaken interventions related to the hospital antibiotic policy (antibiotic stewardship programme (ASP)): participation in a point prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals (PPS ECDC), and Polish national programme to protect antibiotics (NPOA) on the modification of the amount and profile of antibacterial drug use at the Public Paediatric Teaching Clinical Hospital in Warsaw.

METHODS

A retrospective analysis of antimicrobials (with daily defined doses (DDD) assignment) usage expressed in DDD and DDD/100 bed days (BD) in the period 2013-2017 (5 years) on 14 hospital wards at the Public Paediatric Teaching Clinical Hospital in Warsaw before and after the implementation of ASP-related actions was conducted.

RESULTS

A total of 188 405.78 DDD were used and 553 485 paediatric BD were recorded in the wards selected for the present study in the period mentioned above. Wards with pre-authorisation duty for third-line antibiotics (group 1 of wards) used less DDD/100 BD (from 28.81 to 31.12 DDD/100 BD) than wards without such a duty (from 54.72 to 76.06 DDD/100 BD). We observed a temporary decrease of 6.37% in DDD/100 BD in group 1 of wards and a stable 9% to 21% decrease in DDD/100 BD tendency in group 2 of wards (wards without pre-authorisation duty: oncology, haematology and intensive care unit) compared with average values of DDD/100 BD in the period before ASP-related actions (2013-2014). Changes in drug utilisation (DU90%) profile were also observed, both positive and negative.

CONCLUSIONS

More frequent actions related to ASP, such as annual PPS ECDC participation and regular personnel education on the principles of antibiotic therapy, should improve and make antimicrobial treatment more rational.

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.

Production of β-Lactamase Inhibitors by Streptomyces Species

β-Lactamase inhibitors have emerged as an effective alternative to reduce the effects of resistance against β-lactam antibiotics. The Streptomyces genus is known for being an exceptional natural source of antimicrobials and β-lactamase inhibitors such as clavulanic acid, which is largely applied in clinical practice. To protect against the increasing prevalence of multidrug-resistant bacterial strains, new antibiotics and β-lactamase inhibitors need to be discovered and developed. This review will cover an update about the main β-lactamase inhibitors producers belonging to the Streptomyces genus; advanced methods, such as genetic and metabolic engineering, to enhance inhibitor production compared with wild-type strains; and fermentation and purification processes. Moreover, clinical practice and commercial issues are discussed. The commitment of companies and governments to develop innovative strategies and methods to improve the access to new, efficient, and potentially cost-effective microbial products to combat the antimicrobial resistance is also highlighted.

Every antibiotic, every day: Maximizing the impact of prospective audit and feedback on total antibiotic use

Background

The success of antimicrobial stewardship is dependent on how often it is completed and which antimicrobials are targeted. We evaluated the impact of an antimicrobial stewardship program (ASP) in three non-ICU settings where all systemic antibiotics, regardless of spectrum, were targeted on the first weekday after initiation.

Methods

Prospective audit and feedback (PAAF) was initiated on the surgical, respiratory, and medical wards of a community hospital on July 1, 2010, October 1, 2010, and April 1, 2012, respectively. We evaluated rates of total antibiotic use, measured in days on therapy (DOTs), among all patients admitted to the wards before and after PAAF initiation using an interrupted time series analysis. Changes in antibiotic costs, rates of C. difficile infection (CDI), mortality, readmission, and length of stay were evaluated using univariate analyses.

Results

Time series modelling demonstrated that total antibiotic use decreased (± standard error) by 100 ± 51 DOTs/1,000 patient-days on the surgical wards (p = 0.049), 100 ± 46 DOTs/1,000 patient-days on the respiratory ward (p = 0.029), and 91 ± 33 DOTs/1,000 patient-days on the medical wards (p = 0.006) immediately following PAAF initiation. Reductions in antibiotic use were sustained up to 50 months after intervention initiation, and were accompanied by decreases in antibiotic costs. There were no significant changes to patient outcomes on the surgical and respiratory wards following intervention initiation. On the medical wards, however, readmission increased from 4.6 to 5.6 per 1,000 patient-days (p = 0.043), while mortality decreased from 7.4 to 5.0 per 1,000 patient-days (p = 0.001). CDI rates showed a non-significant declining trend after PAAF initiation.

Conclusions

ASPs can lead to cost-effective, sustained reductions in total antibiotic use when interventions are conducted early in the course of therapy and target all antibiotics. Shifting to such a model may help strengthen the effectiveness of ASPs in non-ICU settings.

Systematic Review and Meta-analysis of Clinical and Economic Outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs

The implementation of antimicrobial stewardship programs (ASPs) is a promising strategy to help address the problem of antimicrobial resistance. We sought to determine the efficacy of ASPs and their effect on clinical and economic parameters. We searched PubMed, EMBASE, and Google Scholar looking for studies on the efficacy of ASPs in hospitals. Based on 26 studies (extracted from 24,917 citations) with pre- and postimplementation periods from 6 months to 3 years, the pooled percentage change of total antimicrobial consumption after the implementation of ASPs was -19.1% (95% confidence interval [CI] = -30.1 to -7.5), and the use of restricted antimicrobial agents decreased by -26.6% (95% CI = -52.3 to -0.8). Interestingly, in intensive care units, the decrease in antimicrobial consumption was -39.5% (95% CI = -72.5 to -6.4). The use of broad-spectrum antibiotics (-18.5% [95% CI = -32 to -5.0] for carbapenems and -14.7% [95% CI = -27.7 to -1.7] for glycopeptides), the overall antimicrobial cost (-33.9% [95% CI = -42.0 to -25.9]), and the hospital length of stay (-8.9% [95% CI = -12.8 to -5]) decreased. Among hospital pathogens, the implementation of ASPs was associated with a decrease in infections due to methicillin-resistant Staphylococcus aureus (risk difference [RD] = -0.017 [95% CI = -0.029 to -0.005]), imipenem-resistant Pseudomonas aeruginosa (RD = -0.079 [95% CI = -0.114 to -0.040]), and extended-spectrum beta-lactamase Klebsiella spp. (RD = -0.104 [95% CI = -0.153 to -0.055]). Notably, these improvements were not associated with adverse outcomes, since the all-cause, infection-related 30-day mortality and infection rates were not significantly different after implementation of an ASP (RD = -0.001 [95% CI = -0.009 to 0.006], RD = -0.005 [95% CI = -0.016 to 0.007], and RD = -0.045% [95% CI = -0.241 to 0.150], respectively). Hospital ASPs result in significant decreases in antimicrobial consumption and cost, and the benefit is higher in the critical care setting. Infections due to specific antimicrobial-resistant pathogens and the overall hospital length of stay are improved as well. Future studies should focus on the sustainability of these outcomes and evaluate potential beneficial long-term effects of ASPs in mortality and infection rates.