Impact of an antibiotic restriction program on antibiotic utilization in the treatment of community-acquired pneumonia in a Veterans Affairs Medical Center

Effect of β-Lactam Plus Macrolide Versus Fluoroquinolone on 30-Day Readmissions for Community-Acquired Pneumonia

BACKGROUND

Antibiotic therapy with a macrolide and β-lactam or a fluoroquinolone for the empirical treatment of community-acquired pneumonia (CAP) in an inpatient non-intensive care setting is recommended per guidelines. Studies show that these treatments have similar outcomes, including death, adverse effects, and bacterial eradication. However, a comparison of 30-day readmission rates between these treatments is limited.

STUDY QUESTION

To determine whether 30-day readmissions for patients treated for CAP in a regional hospital differed between a fluoroquinolone monotherapy and a β-lactam plus macrolide combination therapy.

STUDY DESIGN

Retrospective cohort study of patients aged ≥18 years with a CAP diagnosis who were admitted to the same regional hospital from December 1, 2011, through December 1, 2016.

MEASURES AND OUTCOMES

Patients receiving a third-generation cephalosporin plus macrolide were compared with those receiving a respiratory fluoroquinolone. Exclusion criteria were concurrent or recent use of the study antibiotics; death, transfer, or transition to hospice; and diagnosis of hospital-acquired pneumonia or health care-associated pneumonia. The collected data were 30-day readmission rates, antibiotic regimens, demographic characteristics, and pneumonia severity index and comorbidity scores. Association between treatment group and readmissions was assessed with logistic regression. Association between readmissions and individual data points between the 2 treatment groups was calculated with multivariate regression and odds ratio (95% confidence interval).

RESULTS

Of 432 patients, 171 met inclusion criteria (fluoroquinolone group, n = 101; β-lactam plus macrolide group, n = 70). Thirty-day readmissions were not significantly different between the fluoroquinolone group and β-lactam plus macrolide group (P = 0.58). Increased 30-day readmissions were independently associated with male sex and hospital length of stay (P < 0.05). Length of stay was approximately 3 days and did not differ between treatment groups.

CONCLUSIONS

No difference was seen in 30-day readmissions between CAP patients who received fluoroquinolone monotherapy and those who received β-lactam plus macrolide combination therapy.

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.

The Pharmacoeconomic Aspects of Antibiotic Stewardship Programs

Optimal antimicrobial therapy must take into account the key factors in antibiotic selection, that is, spectrum, tissue penetration, resistance potential, safety profile, and relative cost-effectiveness. The least expensive drug is usually accompanied by other concerns, such as high resistance potential, poor side effect profile, pharmacokinetic properties that limit penetration into target tissue (site of infection), and/or suboptimal activity against the presumed/known pathogen. It is false economy to preferentially select the least expensive antibiotics solely because of its acquisition cost. Therapeutic failure and hidden costs may make an apparently less expensive antibiotic most costly in the end.

The Hospital Antimicrobial Use Process: From Beginning to End

Hospital antimicrobial stewardship (AMS) programs are responsible for ensuring that all antimicrobials are utilized in the most appropriate and safe manner to improve patient outcomes, prevent adverse drug reactions, and prevent the development of antimicrobial resistance. This Perspectives article outlines the hospital antimicrobial use process (AUP), the foundational system that ensures that all antimicrobials are utilized in the most appropriate and safe manner. The AUP consists of the following steps: antimicrobial ordering, order verification, preparation and delivery, administration, monitoring, and discharge prescribing. AMS programs should determine how each step contributes to how an antimicrobial is used appropriately or inappropriately at their institution. Through this understanding, AMS programs can integrate stewardship activities at each step to ensure that every opportunity is taken to optimize antimicrobial use during a patient's treatment course. Hence, approaching AMS through the framework of a hospital's AUP is essential to improving appropriate antimicrobial use.

Drug utilisation study in a tertiary care center: recommendations for improving hospital drug dispensing policies

Drug therapy accounts for a major portion of health expenditure. A useful strategy for achieving cost efficient healthcare is drug utilisation research as it forms the basis for making amendments in drug policies and helps in rational drug use. The present observational study was conducted to generate data on drug utilization in inpatients of our tertiary care hospital to identify potential targets for improving drug prescribing patterns. Data was collected retrospectively from randomly selected 231 medical records of patients admitted in various wards of the hospital. WHO Anatomical Therapeutic Chemical/Defined Daily Dose methodology was used to assess drug utilisation data and drug prescriptions were analysed by WHO core drug indicators. Antibiotics were prescribed most frequently and also accounted for majority of drug costs. The prescribed daily dose for most of the antibiotics corresponded to defined daily dose reflecting adherence to international recommendations. Brand name prescribing and polypharmacy was very common.78% of the total drugs prescribed were from the National List of Essential Medicines 2003. Restricting the use of newer and costlier antibiotics, branded drugs and number of drugs per prescription could be considered as targets to cut down the cost of drug therapysignificantly.

Targets for antibiotic and healthcare resource stewardship in inpatient community-acquired pneumonia: a comparison of management practices with National Guideline Recommendations

PURPOSE

Community-acquired pneumonia (CAP) is the most common infection leading to hospitalization in the USA. The objective of this study was to evaluate management practices for inpatient CAP in relation to Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines to identify opportunities for antibiotic and health care resource stewardship.

METHODS

This was a retrospective cohort study of adults hospitalized for CAP at a single institution from 15 April 2008 to 31 May 2009.

RESULTS

Of the 209 patients with CAP who presented to Denver Health Medical Center during the study period and were hospitalized, 166 (79 %) and 43 (21 %) were admitted to a medical ward and the intensive care unit (ICU), respectively. Sixty-one (29 %) patients were candidates for outpatient therapy per IDSA/ATS guidance with a CURB-65 score of 0 or 1 and absence of hypoxemia. Sputum cultures were ordered for 110 specimens; however, an evaluable sample was obtained in only 49 (45 %) cases. Median time from antibiotic initiation to specimen collection was 11 [interquartile range (IQR) 6-19] h, and a potential pathogen was identified in only 18 (16 %) cultures. Blood cultures were routinely obtained for both non-ICU (81 %) and ICU (95 %) cases, but 15 of 36 (42 %) positive cultures were false-positive results. The most common antibiotic regimen was ceftriaxone + azithromycin (182, 87 % cases). Discordant with IDSA/ATS recommendations, oral step-down therapy consisted of a new antibiotic class in 120 (66 %), most commonly levofloxacin (101, 55 %). Treatment durations were typically longer than suggested with a median of 10 (IQR 8-12) days.

CONCLUSIONS

In this cohort of patients hospitalized for CAP, management was frequently inconsistent with IDSA/ATS guideline recommendations, revealing potential targets to reduce unnecessary antibiotic and healthcare resource utilization.