Antimicrobial stewardship-qualitative and quantitative outcomes: the role of measurement

Evaluating Antimicrobial Use and Spectrum of Activity in Ontario Hospitals: Feasibility of a Multicentered Point Prevalence Study

Background

Antimicrobial stewardship, a key component of an overall strategy to address antimicrobial resistance, has been recognized as a global priority. The ability to track and benchmark antimicrobial use (AMU) is critical to advancing stewardship from an organizational and provincial perspective. As there are few comprehensive systems in Canada that allow for benchmarking, Public Health Ontario conducted a pilot in 2016/2017 to assess the feasibility of using a point prevalence methodology as the basis of a province-wide AMU surveillance program.

Methods

Three acute care hospitals of differing sizes in Ontario, Canada, participated. Adults admitted to inpatient acute care beds on the survey date were eligible for inclusion; a sample size of 170 per hospital was targeted, and data were collected for the 24-hour period before and including the survey date. Debrief sessions at each site were used to gather feedback about the process. Prevalence of AMU and the Antimicrobial Spectrum Index (ASI) was reported for each hospital and by indication per patient case.

Results

Participants identified required improvements for scalability including streamlining ethics, data sharing processes, and enhancing the ability to compare with peer organizations at a provincial level. Of 457 patients, 172 (38%) were receiving at least 1 antimicrobial agent. Beta-lactam/beta-lactamase inhibitors were the most common (18%). The overall mean ASI per patient was 6.59; most cases were for treatment of infection (84%).

Conclusions

This pilot identified factors and features required for a scalable provincial AMU surveillance program; future efforts should harmonize administrative processes and enable interfacility benchmarking.

Landscape of antimicrobial stewardship programs in Ontario: a survey of hospitals

BACKGROUND

Antimicrobial resistance is an important public health issue globally and in Canada. To understand the current state of antimicrobial stewardship programs in Ontario health care facilities, Public Health Ontario conducted a voluntary survey of hospitals in the province.

METHODS

The Ontario Antimicrobial Stewardship Program Landscape Survey was distributed online to hospitals, targeting front-line antimicrobial stewardship clinicians. The survey was open for 5 weeks in fall 2016. We used email and telephone reminders to encourage response. We performed descriptive and inferential statistical analyses at an aggregate level and by hospital type. Mental health and ambulatory sites were excluded.

RESULTS

The response rate was 74.0% (97/131 organizations). Of the 97, 90 (93%) reported having a formal antimicrobial stewardship program or were in the process of implementing a formal program. Just over half (50 [56%]) identified appropriate antibiotic use as part of the organization's quality-improvement plan, strategic goal or priority. Half (45 [50%]) of programs did not have designated resources; those that did are underresourced with respect to physician and pharmacist staffing. The scope of implementation of program strategies was variable. Fifty hospitals (56%) reported tracking antimicrobial expenditures, 47 (52%) reported tracking defined daily dose, and 35 (39%) reported tracking days of therapy.

INTERPRETATION

Most Ontario hospitals have a formal antimicrobial stewardship program, but there are opportunities for improvement. Future efforts should increase the priority of and improve resource allocation for antimicrobial stewardship programs so that programs can continue to grow in scope and impact.

Impact of a Prospective Audit and Feedback Antimicrobial Stewardship Program at a Veterans Affairs Medical Center: A Six-Point Assessment

Background

Prospective audit and feedback is a core antimicrobial stewardship program (ASP) strategy; however its impact is difficult to measure.

Methods

Our quasi-experimental study measured the effect of an ASP on clinical outcomes, antimicrobial use, resistance, costs, patient safety (adverse drug events [ADE] and Clostridium difficile infection [CDI]), and process metrics pre- (9/10–10/11) and post-ASP (9/12–10/13) using propensity adjusted and matched Cox proportional-hazards regression models and interrupted time series (ITS) methods.

Results

Among our 2,696 patients, median length of stay was 1 day shorter post-ASP (5, interquartile range [IQR] 3–8 vs. 4, IQR 2–7 days, p<0.001). Mortality was similar in both periods. Mean broad-spectrum (-11.3%), fluoroquinolone (-27.0%), and anti-pseudomonal (-15.6%) use decreased significantly (p<0.05). ITS analyses demonstrated a significant increase in monthly carbapenem use post-ASP (trend: +1.5 days of therapy/1,000 patient days [1000PD] per month; 95% CI 0.1–3.0). Total antimicrobial costs decreased 14%. Resistance rates did not change in the one-year post-ASP period. Mean CDI rates/10,000PD were low pre- and post-ASP (14.2 ± 10.4 vs. 13.8 ± 10.0, p = 0.94). Fewer patients experienced ADEs post-ASP (6.0% vs. 4.4%, p = 0.06).

Conclusions

Prospective audit and feedback has the potential to improve antimicrobial use and outcomes, and contain bacterial resistance. Our program demonstrated a trend towards decreased length of stay, broad-spectrum antimicrobial use, antimicrobial costs, and adverse events.

A Review of Quality Measures for Assessing the Impact of Antimicrobial Stewardship Programs in Hospitals

The growing problem of antimicrobial resistance (AMR) has led to calls for antimicrobial stewardship programs (ASP) to control antibiotic use in healthcare settings. Key strategies include prospective audit with feedback and intervention, and formulary restriction and preauthorization. Education, guidelines, clinical pathways, de-escalation, and intravenous to oral conversion are also part of some programs. Impact and quality of ASP can be assessed using process or outcome measures. Outcome measures are categorized as microbiological, patient or financial outcomes. The objective of this review was to provide an overview of quality measures for assessing ASP and the reported impact of ASP in peer-reviewed studies, focusing particularly on patient outcomes. A literature search of papers published in English between 1990 and June 2015 was conducted in five databases using a combination of search terms. Primary studies of any design were included. A total of 63 studies were included in this review. Four studies defined quality metrics for evaluating ASP. Twenty-one studies assessed the impact of ASP on antimicrobial utilization and cost, 25 studies evaluated impact on resistance patterns and/or rate of Clostridium difficile infection (CDI). Thirteen studies assessed impact on patient outcomes including mortality, length of stay (LOS) and readmission rates. Six of these 13 studies reported non-significant difference in mortality between pre- and post-ASP intervention, and five reported reductions in mortality rate. On LOS, six studies reported shorter LOS post intervention; a significant reduction was reported in one of these studies. Of note, this latter study reported significantly (p < 0.001) higher unplanned readmissions related to infections post-ASP. Patient outcomes need to be a key component of ASP evaluation. The choice of metrics is influenced by data and resource availability. Controlling for confounders must be considered in the design of evaluation studies to adequately capture the impact of ASP and it is important for unintended consequences to be considered. This review provides a starting point toward compiling standard outcome metrics for assessing ASP.

Early optimization of antimicrobial therapy improves clinical outcomes of patients administered agents targeting methicillin-resistant Staphylococcus aureus

WHAT IS KNOWN AND OBJECTIVE

Antimicrobial stewardship is required to ensure the appropriate use of antimicrobials. However, no reports have been published on clinical outcomes of implementation of antimicrobial stewardship in patients receiving pathogen-specific antibiotics.

METHOD

To evaluate the clinical outcomes of patients who received drugs, we conducted a single-centre, retrospective study of the effects of an antimicrobial stewardship programme targeting methicillin-resistant Staphylococcus aureus (MRSA).

RESULTS

The time to administer effective antimicrobials was significantly (median number of days, 3 before vs. 0 after, P < 0·001) shortened, and the rate of de-escalation was significantly elevated (47·1% vs. 96·2%, P < 0·001) after implementation of daily review. The 60-day clinical failure associated with Gram-positive bacterial infection was significantly reduced (33·3% vs. 17·6%, P = 0·007) after intervention.

WHAT IS NEW AND CONCLUSIONS

Daily review of administration of antimicrobials targeting MRSA was highly effective in improving clinical outcomes by optimizing early antimicrobial therapy.