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Wrenn RH, Slaton CN, Diez T, Turner NA, Yarrington ME, Anderson DJ, Moehring RW. The devil's in the defaults: An interrupted time-series analysis of the impact of default duration elimination on exposure to fluoroquinolone therapy. Infect Control Hosp Epidemiol 2024; 45:733-739. [PMID: 38347810 DOI: 10.1017/ice.2024.16] [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: 05/18/2024]
Abstract
OBJECTIVE To determine whether removal of default duration, embedded in electronic prescription (e-script), influenced antibiotic days of therapy. DESIGN Interrupted time-series analysis. SETTING The study was conducted across 2 community hospitals, 1 academic hospital, 3 emergency departments, and 86 ambulatory clinics. PATIENTS Adults prescribed a fluoroquinolone with a duration <31 days. INTERVENTIONS Removal of standard 10-day fluoroquinolone default duration and addition of literature-based duration guidance in the order entry on December 19, 2017. The study period included data for 12 months before and after the intervention. RESULTS The study included 35,609 fluoroquinolone e-scripts from the preintervention period and 31,303 fluoroquinolone e-scripts from the postintervention period, accounting for 520,388 cumulative fluoroquinolone DOT. Mean durations before and after the intervention were 7.8 (SD, 4.3) and 7.7 (SD, 4.5), a nonsignificant change. E-scripts with a 10-day duration decreased prior to and after the default removal. The inpatient setting showed a significant 8% drop in 10-day e-scripts after default removal and a reduced median duration by 1 day; 10-day scripts declined nonsignificantly in ED and ambulatory settings. In the ambulatory settings, both 7- and 14-day e-script durations increased after default removal. CONCLUSION Removal of default 10-day antibiotic durations did not affect overall mean duration but did shift patterns in prescribing, depending on practice setting. Stewardship interventions must be studied in the context of practice setting. Ambulatory stewardship efforts separate from inpatient programs are needed because interventions cannot be assumed to have similar effects.
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Affiliation(s)
- Rebekah H Wrenn
- Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
| | - Cara N Slaton
- Orlando Health Orlando Regional Medical Center, Orlando, Florida
| | - Tony Diez
- Duke University Medical Center, Durham, North Carolina
| | | | | | | | - Rebekah W Moehring
- Duke University Medical Center, Durham, North Carolina
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina
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2
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Menkem EZ, Labo Nanfah A, Takang T, Ryan Awah L, Awah Achua K, Ekane Akume S, Fekam Boyom F. Attitudes and Practices of the Use of Third-Generation Cephalosporins among Medical Doctors Practicing in Cameroon. Int J Clin Pract 2023; 2023:8074413. [PMID: 36846498 PMCID: PMC9946740 DOI: 10.1155/2023/8074413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Third-generation cephalosporins (3GC) are among the most prescribed antibiotics worldwide. Antibiotic resistance, usually due to misuse and overuse, is a feared complication of public health concern. However, there are limited data in Cameroon concerning the knowledge and use of 3GC in our health services. The aim of this study was to assess the knowledge and use of 3GC among medical doctors in Cameroon and to generate baseline information for a wider scale research and policy implementation. METHODS This study was a cross-sectional study conducted among medical doctors practicing in Cameroon in general. Convenience sampling was used and the data were collected from both the online questionnaire and the review of files of patients admitted and discharged within the month of April 2021 and analysed with the use of IBM SPSS v25. Results and Discussion. A total of 52 respondents from the online questionnaire and 31 reviewed files were retained. Of the respondents, 27% were female and 73% were male. The mean age and years of experience were 29.6 ± 2.9 and 3.6 ± 2.1 years, respectively. Only 32.7% had correct knowledge of the number of generations of cephalosporins, and 48.1% had knowledge of the antimicrobial target. All medical doctors (MD) identified ceftriaxone as a 3GC, and it was the most commonly prescribed 3GC (71%). Most of the MD considered 3GC to be an efficient antibiotic. Just over half (54.7%) knew the correct posology of ceftriaxone. Only 17% and 9.4% knew the right posology for cefotaxime and ceftazidime, respectively, for the management of early-onset neonatal infection (EONNI). The misuse of 3GC was mostly attributed to nurses, MD, and poor institutional policies. CONCLUSION There is average knowledge on 3GC among MD, with ceftriaxone being the most widely known and prescribed. Misuse is common among nurses and doctors. Poor institutional policies and limited laboratory capacities are to be blamed.
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Affiliation(s)
- Elisabeth Zeuko'o Menkem
- Department of Biomedical Sciences, Faculty of Health Sciences, University of Buea, Buea, Cameroon
- Antimicrobial and Biocontrol Agents Unit, Laboratory for Phytobiochemistry and Medicinal Plants Studies, University of Yaounde 1, Yaoundé, Cameroon
| | - Astride Labo Nanfah
- Department of Clinical Studies, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Tiku Takang
- Department of Clinical Studies, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Lesley Ryan Awah
- Department of Clinical Studies, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Kenneth Awah Achua
- Department of Public Health, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Stanley Ekane Akume
- Department of Clinical Studies, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Fabrice Fekam Boyom
- Antimicrobial and Biocontrol Agents Unit, Laboratory for Phytobiochemistry and Medicinal Plants Studies, University of Yaounde 1, Yaoundé, Cameroon
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3
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O'Riordan F, Shiely F, Byrne S, O'Brien D, Palmer B, Dahly D, O'Connor TM, Curran D, Fleming A. An investigation of the effects of procalcitonin testing on antimicrobial prescribing in respiratory tract infections in an Irish university hospital setting: a feasibility study. J Antimicrob Chemother 2020; 74:3352-3361. [PMID: 31325313 DOI: 10.1093/jac/dkz313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/03/2019] [Accepted: 06/20/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Diagnostic uncertainty and a high prevalence of viral infections present unique challenges for antimicrobial prescribing for respiratory tract infections (RTIs). Procalcitonin (PCT) has been shown to support prescribing decisions and reduce antimicrobial use safely in patients with RTIs, but recent study results have been variable. METHODS We conducted a feasibility study of the introduction of PCT testing in patients admitted to hospital with a lower RTI to determine if PCT testing is an effective and worthwhile intervention to introduce to support the existing antimicrobial stewardship (AMS) programme and safely decrease antimicrobial prescribing in patients admitted with RTIs. RESULTS A total of 79 patients were randomized to the intervention PCT-guided treatment group and 40 patients to the standard care respiratory control group. The addition of PCT testing led to a significant decrease in duration of antimicrobial prescriptions (mean 6.8 versus 8.9 days, P = 0.012) and decreased length of hospital stay (median 7 versus 8 days, P = 0.009) between the PCT and respiratory control group. PCT did not demonstrate a significant reduction in antimicrobial consumption when measured as DDDs and days of therapy. CONCLUSIONS PCT testing had a positive effect on antimicrobial prescribing during this feasibility study. The successful implementation of PCT testing in a randomized controlled trial requires an ongoing comprehensive education programme, greater integration into the AMS programme and delivery of PCT results in a timely manner. This feasibility study has shown that a larger randomized controlled trial would be beneficial to further explore the positive aspects of these findings.
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Affiliation(s)
- F O'Riordan
- Pharmacy Department, Mercy University Hospital, Grenville Place, Cork, Ireland.,Clinical Pharmacy Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - F Shiely
- HRB Clinical Research Facility Cork, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - S Byrne
- Clinical Pharmacy Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - D O'Brien
- Department of Microbiology, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - B Palmer
- HRB Clinical Research Facility Cork, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - D Dahly
- HRB Clinical Research Facility Cork, Mercy University Hospital, Grenville Place, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - T M O'Connor
- Department of Respiratory Medicine, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - D Curran
- Department of Respiratory Medicine, Mercy University Hospital, Grenville Place, Cork, Ireland
| | - A Fleming
- Pharmacy Department, Mercy University Hospital, Grenville Place, Cork, Ireland.,Clinical Pharmacy Research Group, School of Pharmacy, University College Cork, Cork, Ireland
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4
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Vaughn VM, Gandhi TN, Chopra V, Petty LA, Giesler DL, Malani AN, Bernstein SJ, Hsaiky LM, Pogue JM, Dumkow L, Ratz D, McLaughlin ES, Flanders SA. Antibiotic Overuse after Hospital Discharge: A Multi-Hospital Cohort Study. Clin Infect Dis 2020; 73:e4499-e4506. [PMID: 32918077 PMCID: PMC7947015 DOI: 10.1093/cid/ciaa1372] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/09/2020] [Indexed: 12/19/2022] Open
Abstract
Background Antibiotics are commonly prescribed to patients as they leave the hospital. We aimed to create a comprehensive metric to characterize antibiotic overuse after discharge among hospitalized patients treated for pneumonia or urinary tract infection (UTI), and to determine whether overuse varied across hospitals and conditions. Methods In a retrospective cohort study of hospitalized patients treated for pneumonia or UTI in 46 hospitals between 1 July 2017–30 July 2019, we quantified the proportion of patients discharged with antibiotic overuse, defined as unnecessary antibiotic use, excess antibiotic duration, or suboptimal fluoroquinolone use. Using linear regression, we assessed hospital-level associations between antibiotic overuse after discharge in patients treated for pneumonia versus a UTI. Results Of 21 825 patients treated for infection (12 445 with pneumonia; 9380 with a UTI), nearly half (49.1%) had antibiotic overuse after discharge (56.9% with pneumonia; 38.7% with a UTI). For pneumonia, 63.1% of overuse days after discharge were due to excess duration; for UTIs, 43.9% were due to treatment of asymptomatic bacteriuria. The percentage of patients discharged with antibiotic overuse varied 5-fold among hospitals (from 15.9% [95% confidence interval, 8.7%–24.6%] to 80.6% [95% confidence interval, 69.4%–88.1%]) and was strongly correlated between conditions (regression coefficient = 0.85; P < .001). Conclusions Antibiotic overuse after discharge was common and varied widely between hospitals. Antibiotic overuse after discharge was associated between conditions, suggesting that the prescribing culture, physician behavior, or organizational processes contribute to overprescribing at discharge. Multifaceted efforts focusing on all 3 types of overuse and multiple conditions should be considered to improve antibiotic prescribing at discharge.
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Affiliation(s)
- Valerie M Vaughn
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Vineet Chopra
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Daniel L Giesler
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Division of Infectious Diseases, Department of Internal Medicine, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Department of Infection Prevention and Control, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Steven J Bernstein
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA.,Division of General Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Lama M Hsaiky
- Department of Pharmaceutical Services, Beaumont Hospital Dearborn, Dearborn, Michigan
| | - Jason M Pogue
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Lisa Dumkow
- Department of Clinical Pharmacy Services, Mercy Health Saint Mary's, Grand Rapids, USA
| | - David Ratz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Elizabeth S McLaughlin
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
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5
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Yi SH, Hatfield KM, Baggs J, Hicks LA, Srinivasan A, Reddy S, Jernigan JA. Duration of Antibiotic Use Among Adults With Uncomplicated Community-Acquired Pneumonia Requiring Hospitalization in the United States. Clin Infect Dis 2019; 66:1333-1341. [PMID: 29126268 DOI: 10.1093/cid/cix986] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 11/02/2017] [Indexed: 11/13/2022] Open
Abstract
Background Previous studies suggest that duration of antibiotic therapy for community-acquired pneumonia (CAP) often exceeds national recommendations and might represent an important opportunity to improve antibiotic stewardship nationally. Our objective was to determine the average length of antibiotic therapy (LOT) for patients treated for uncomplicated CAP in US hospitals and the proportion of patients with excessive durations. Methods Records of retrospective cohorts of patients aged 18-64 years with private insurance and aged ≥65 years with Medicare hospitalized for CAP in 2012-2013 were used. Inpatient LOT was estimated as a function of length of stay. Outpatient LOT was based on prescriptions filled post discharge based on data from outpatient pharmacy files. Excessive duration was defined as outpatient LOT >3 days. Results Inclusion criteria were met for 22128 patients aged 18-64 years across 2100 hospitals and 130746 patients aged ≥65 years across 3227 hospitals. Median total LOT was 9.5 days. LOT exceeded recommended duration for 74% of patients aged 18-64 years and 71% of patients aged ≥65 years. Patients aged 18-64 years had a median (quartile 1-quartile 3) 6 (3-7) days outpatient LOT and those aged ≥65 years had 5 (3-7) days. Conclusions In this nationwide sample of patients hospitalized for CAP, median total LOT was just under 10 days, with more than 70% of patients having likely excessive treatment duration. Better adherence to recommended CAP therapy duration by improving prescribing at hospital discharge may be an important target for antibiotic stewardship programs.
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Affiliation(s)
- Sarah H Yi
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kelly M Hatfield
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - James Baggs
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sujan Reddy
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John A Jernigan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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6
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Feller J, Lund BC, Perencevich EN, Alexander B, Heintz B, Beck B, Nair R, Goto M, Livorsi DJ. Post-discharge oral antimicrobial use among hospitalized patients across an integrated national healthcare network. Clin Microbiol Infect 2019; 26:327-332. [PMID: 31600582 DOI: 10.1016/j.cmi.2019.09.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/04/2019] [Accepted: 09/15/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVES Antimicrobial stewardship programmes have focused on reducing inappropriate inpatient antimicrobial prescribing, but several small studies have found a large portion of antimicrobial exposure occurs immediately after hospital discharge. In this study, we describe the prescribing of oral antimicrobials at hospital discharge across an integrated national healthcare system. At the hospital level, we also compare total inpatient antimicrobial use and post-discharge oral antimicrobial use. METHODS This retrospective cross-sectional study used national administrative data to identify all acute-care admissions during 2014-2016 within the Veterans Health Administration (VHA). We evaluated inpatient days of therapy (DOT) and post-discharge DOT, defined as oral outpatient antimicrobials dispensed at the time of hospital discharge. At the hospital level, inpatient DOT/100 admissions were compared with post-discharge DOT/100 admissions using Spearman's rank-order correlation. RESULTS There were 1 681 701 acute-care admissions across 122 hospitals, and 335 369 (19.9%) were prescribed an oral antimicrobial at discharge. Fluoroquinolones (38.3%) were the most common post-discharge antimicrobial. At the hospital level, median inpatient antimicrobial use was 331.3 (interquartile range (IQR) 284.9-367.9) DOT/100 admissions and median post-discharge use was 209.5 (IQR 181.5-239.6) DOT/100 admissions. Thirty-nine per cent of the total duration of antimicrobial exposure occurred after discharge. At the hospital-level, the metrics of inpatient DOT/100 admissions and post-discharge DOT/100 admissions were weakly positively correlated with rho=0.44 (p < 0.001). CONCLUSIONS A large proportion of antimicrobial exposure among hospitalized patients occurred immediately following discharge. Antimicrobial-prescribing at hospital discharge provides an opportunity for antimicrobial stewardship. Hospital-level stewardship metrics need to include both inpatient and post-discharge antimicrobial-prescribing to provide a comprehensive assessment of hospital-associated antimicrobial use.
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Affiliation(s)
- J Feller
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - B C Lund
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - E N Perencevich
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA; Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - B Alexander
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - B Heintz
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - B Beck
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - R Nair
- Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA; Division of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - M Goto
- 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
| | - D J Livorsi
- 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.
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7
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Total duration of antimicrobial therapy resulting from inpatient hospitalization. Infect Control Hosp Epidemiol 2019; 40:847-854. [DOI: 10.1017/ice.2019.118] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AbstractObjective:To assess the feasibility of electronic data capture of postdischarge durations and evaluate total durations of antimicrobial exposure related to inpatient hospital stays.Design:Multicenter, retrospective cohort study.Setting:Two community hospitals and 1 academic medical center.Patients:Hospitalized patients who received ≥1 dose of a systemic antimicrobial agent.Methods:We collected and reviewed electronic data on inpatient and discharge antimicrobial prescribing from April to September 2016 in 3 pilot hospitals. Inpatient antimicrobial use was obtained from electronic medication administration records. Postdischarge antimicrobial use was calculated from electronic discharge prescriptions. We completed a manual validation to evaluate the ability of electronic prescriptions to capture intended postdischarge antibiotics. Inpatient, postdischarge, and total lengths of therapy (LOT) per admission were calculated to assess durations of antimicrobial therapy attributed to hospitalization.Results:A total of 45,693 inpatient admissions were evaluated. Antimicrobials were given during 23,447 admissions (51%), and electronic discharge prescriptions were captured in 7,442 admissions (16%). Manual validation revealed incomplete data capture in scenarios in which prescribers avoided the electronic system. The postdischarge LOT among admissions with discharge antimicrobials was median 8 days (range, 1–360) with peaks at 5, 7, 10, and 14 days. Postdischarge days accounted for 38% of antimicrobial exposure days.Conclusion:Discharge antimicrobial therapy accounted for a large portion of antimicrobial exposure related to inpatient hospital stays. Discharge prescription data can feasibly be captured through electronic prescribing records and may aid in designing stewardship interventions at transitions of care.
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8
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Alemkere G, Tenna A, Engidawork E. Antibiotic use practice and predictors of hospital outcome among patients with systemic bacterial infection: Identifying targets for antibiotic and health care resource stewardship. PLoS One 2019; 14:e0212661. [PMID: 30794660 PMCID: PMC6386277 DOI: 10.1371/journal.pone.0212661] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 02/07/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Malpractice and excess use of antimicrobials have been associated with multiple costs, including the development of resistant bacteria, which has become a threat to the human health. The aim of this study, therefore, was to assess the antibiotic use practice and to identify predictors of hospital outcome to uncover targets for stewardship. METHODS An Institution-based prospective observational study was performed from 9 April to 7 July 2014 in the internal medicine wards of Tikur Anbessa Specialized Hospital. Patients with suspected systemic bacterial infections during this period were strictly followed and data were abstracted using data abstraction format. Descriptive statistics and binary logistic regression were used for statistical analysis. RESULTS About half of the attended patients had suspected systemic bacterial infections, in which pneumonia is the most common. Cephalosporins were the most widely prescribed class of drugs in all the wards. Initial antibiotics were empiric in almost all of the cases. About 28% of the ward and 59% of the ICU patients died during the in-hospital stay. The mean length of stay (LoS) was 18.5+12.2 in the wards and 8.9+4.9 days in the ICU. Whilst digestive disease (AOR = 6.94, 95% CI: 2.24, 21.49), different signs and symptoms of disease (AOR = 2.43, 95% CI: 1.30, 4.56), sepsis (AOR = 2.59, 95% CI: 1.12, 5.99) and vancomycin use (AOR = 2.60, 95% CI: 1.30, 5.21) were independent positive predictors, antibiotic days (> 10) (AOR = 0.37, 95% CI: 0.20, 0.70) was a negative predictor for mortality. On the other hand, hospital-acquired infection (AOR = 3.01, 95% CI: 1.05, 8.62), beyond the median antibiotic days (> 10) (AOR = 4.05, 95% CI: 1.96, 8.37) and agent days beyond 21 days (AOR = 2.18, 95% CI: 1.01-4.68) were independently associated with prolonged LoS. CONCLUSION Generally, this observation entails an appropriate infection management and antimicrobial use policy. Any future policy should better start by addressing cases like pneumonia, and sepsis and drugs like cephalosporins.
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Affiliation(s)
- Getachew Alemkere
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia
| | - Admasu Tenna
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ephrem Engidawork
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia
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9
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Jones BE, Collingridge DS, Vines CG, Post H, Holmen J, Allen TL, Haug P, Weir CR, Dean NC. CDS in a Learning Health Care System: Identifying Physicians' Reasons for Rejection of Best-Practice Recommendations in Pneumonia through Computerized Clinical Decision Support. Appl Clin Inform 2019; 10:1-9. [PMID: 30602195 PMCID: PMC6327742 DOI: 10.1055/s-0038-1676587] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/09/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Local implementation of guidelines for pneumonia care is strongly recommended, but the context of care that affects implementation is poorly understood. In a learning health care system, computerized clinical decision support (CDS) provides an opportunity to both improve and track practice, providing insights into the implementation process. OBJECTIVES This article examines physician interactions with a CDS to identify reasons for rejection of guideline recommendations. METHODS We implemented a multicenter bedside CDS for the emergency department management of pneumonia that integrated patient data with guideline-based recommendations. We examined the frequency of adoption versus rejection of recommendations for site-of-care and antibiotic selection. We analyzed free-text responses provided by physicians explaining their clinical reasoning for rejection, using concept mapping and thematic analysis. RESULTS Among 1,722 patient episodes, physicians rejected recommendations to send a patient home in 24%, leaving text in 53%; reasons for rejection of the recommendations included additional or alternative diagnoses beyond pneumonia, and comorbidities or signs of physiologic derangement contributing to risk of outpatient failure that were not processed by the CDS. Physicians rejected broad-spectrum antibiotic recommendations in 10%, leaving text in 76%; differences in pathogen risk assessment, additional patient information, concern about antibiotic properties, and admitting physician preferences were given as reasons for rejection. CONCLUSION While adoption of CDS recommendations for pneumonia was high, physicians rejecting recommendations frequently provided feedback, reporting alternative diagnoses, additional individual patient characteristics, and provider preferences as major reasons for rejection. CDS that collects user feedback is feasible and can contribute to a learning health system.
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Affiliation(s)
- Barbara E. Jones
- VA Salt Lake City IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah, United States
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, Utah, United States
| | | | | | - Herman Post
- Homer Warner Center for Informatics, Intermountain Healthcare, Murray, Utah, United States
| | - John Holmen
- Homer Warner Center for Informatics, Intermountain Healthcare, Murray, Utah, United States
| | - Todd L. Allen
- Department of Emergency Medicine, Intermountain Healthcare, Murray, Utah, United States
| | - Peter Haug
- Homer Warner Center for Informatics, Intermountain Healthcare, Murray, Utah, United States
| | - Charlene R. Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, United States
| | - Nathan C. Dean
- Division of Pulmonary and Critical Care Medicine, Intermountain Healthcare and University of Utah, Murray, Utah, United States
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10
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Carugati M, Aliberti S, Reyes LF, Franco Sadud R, Irfan M, Prat C, Soni NJ, Faverio P, Gori A, Blasi F, Restrepo MI. Microbiological testing of adults hospitalised with community-acquired pneumonia: an international study. ERJ Open Res 2018; 4:00096-2018. [PMID: 30474036 PMCID: PMC6174282 DOI: 10.1183/23120541.00096-2018] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/19/2018] [Indexed: 12/11/2022] Open
Abstract
This study aimed to describe real-life microbiological testing of adults hospitalised with community-acquired pneumonia (CAP) and to assess concordance with the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) and 2011 European Respiratory Society (ERS) CAP guidelines. This was a cohort study based on the Global Initiative for Methicillin-resistant Staphylococcus aureus Pneumonia (GLIMP) database, which contains point-prevalence data on adults hospitalised with CAP across 54 countries during 2015. In total, 3702 patients were included. Testing was performed in 3217 patients, and included blood culture (71.1%), sputum culture (61.8%), Legionella urinary antigen test (30.1%), pneumococcal urinary antigen test (30.0%), viral testing (14.9%), acute-phase serology (8.8%), bronchoalveolar lavage culture (8.4%) and pleural fluid culture (3.2%). A pathogen was detected in 1173 (36.5%) patients. Testing attitudes varied significantly according to geography and disease severity. Testing was concordant with IDSA/ATS and ERS guidelines in 16.7% and 23.9% of patients, respectively. IDSA/ATS concordance was higher in Europe than in North America (21.5% versus 9.8%; p<0.01), while ERS concordance was higher in North America than in Europe (33.5% versus 19.5%; p<0.01). Testing practices of adults hospitalised with CAP varied significantly by geography and disease severity. There was a wide discordance between real-life testing practices and IDSA/ATS/ERS guideline recommendations. Testing practices vary based on geography and disease severity, and IDSA/ATS/ERS testing recommendations are rarely followedhttp://ow.ly/80Iy30lxo1c
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Affiliation(s)
- Manuela Carugati
- Division of Infectious Diseases, San Gerardo Hospital, ASST Monza, Monza, Italy.,Division of Infectious Diseases and International Health, Duke University, Durham, NC, USA.,Internal Medicine Dept, Infectious Diseases Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Stefano Aliberti
- Dept of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.,Internal Medicine Dept, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Luis Felipe Reyes
- Dept of Microbiology, Universidad de La Sabana, Chia, Colombia.,Dept of Critical Care Medicine, Clinica Universidad de La Sabana, Chia, Colombia
| | | | - Muhammad Irfan
- Section of Pulmonary and Critical Care Medicine, Dept of Medicine, Aga Khan University, Karachi, Pakistan
| | - Cristina Prat
- Dept of Microbiology, Hospital Universitari Germans Trias i Pujol, Institut d'Investigació Germans Trias i Pujol, Universitat Autònoma de Barcelona, CIBER Enfermedades Respiratorias, Badalona, Spain
| | - Nilam J Soni
- South Texas Veterans Health Care System and University of Texas Health San Antonio, San Antonio, TX, USA
| | - Paola Faverio
- Cardio-Thoracic-Vascular Dept, University of Milan Bicocca, Respiratory Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Andrea Gori
- Internal Medicine Dept, Infectious Diseases Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milan, Italy.,Dept of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Francesco Blasi
- Dept of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.,Internal Medicine Dept, Respiratory Unit and Adult Cystic Fibrosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Marcos I Restrepo
- South Texas Veterans Health Care System and University of Texas Health San Antonio, San Antonio, TX, USA
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Abstract
The goals of antimicrobial stewardship are to optimize antimicrobial use to improve patient outcomes and minimize adverse consequences. A successful antimicrobial stewardship program is one that is multidisciplinary. Pharmacists are core members of antimicrobial stewardship and undertake multiple roles to accomplish the goals of the program. As antimicrobial stewardship continues to expand across the patient care continuum, pharmacists will serve a vital role in preserving the armamentarium of antimicrobials and improving quality of patient care.
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Affiliation(s)
- Diane M Parente
- Infectious Diseases and Antimicrobial Stewardship, Department of Pharmacy, The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906, USA.
| | - Jacob Morton
- Infectious Diseases, Department of Pharmacy, Saint Vincent Hospital, 123 Summer Street, Worcester, MA 01608, USA
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12
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Walsh TL, DiSilvio BE, Hammer C, Beg M, Vishwanathan S, Speredelozzi D, Moffa MA, Hu K, Abdulmassih R, Makadia JT, Sandhu R, Naddour M, Chan-Tompkins NH, Trienski TL, Watson C, Obringer TJ, Kuzyck J, Bremmer DN. Impact of Procalcitonin Guidance with an Educational Program on Management of Adults Hospitalized with Pneumonia. Am J Med 2018; 131:201.e1-201.e8. [PMID: 28947168 DOI: 10.1016/j.amjmed.2017.08.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 08/30/2017] [Accepted: 08/31/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Community-acquired pneumonia and healthcare-associated pneumonia are often treated with prolonged antibiotic therapy. Procalcitonin (PCT) has effectively and safely reduced antibiotic use for pneumonia in controlled studies. However, limited data exist regarding PCT guidance in real-world settings for management of pneumonia. METHODS A retrospective, preintervention/postintervention study was conducted to compare management for patients admitted with pneumonia before and after implementation of PCT guidance at 2 teaching hospitals in Pittsburgh, Pennsylvania. The preintervention period was March 1, 2014 through October 31, 2014, and the postintervention period was March, 1 2015 through October 31, 2015. RESULTS A total of 152 and 232 patients were included in the preintervention and postintervention cohorts, respectively. When compared with the preintervention group, mean duration of therapy decreased (9.9 vs 6.0 days; P < .001). More patients received an appropriate duration of 7 days or less (26.9% vs 66.4%; P < .001). Additionally, mean hospital length of stay decreased in the postintervention group (4.9 vs 3.5 days; P = .006). Pneumonia-related 30-day readmission rates (7.2% vs 4.3%; P = .26) were unaffected. In the postintervention group, patients with PCT levels <0.25 µg/L received shorter mean duration of therapy compared with patients with levels >0.25 µg/L (4.6 vs 8.0 days; P < .001), as well as reduced hospital length of stay (3.2 vs 3.9 days; P = .02). CONCLUSIONS In this real-world study, PCT guidance led to shorter durations of total antibiotic therapy and abridged inpatient length of stay without affecting hospital readmissions.
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Affiliation(s)
- Thomas L Walsh
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa; Division of Infectious Diseases, The Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh.
| | - Briana E DiSilvio
- Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Crystal Hammer
- Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Moeezullah Beg
- Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Swati Vishwanathan
- Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Daniel Speredelozzi
- Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Matthew A Moffa
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa; Division of Infectious Diseases, The Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh
| | - Kurt Hu
- Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Rasha Abdulmassih
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa; Division of Infectious Diseases, The Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh
| | - Jina T Makadia
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa; Division of Infectious Diseases, The Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh
| | - Rikinder Sandhu
- Division of Infectious Diseases, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa; Division of Infectious Diseases, The Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh
| | - Mouhib Naddour
- Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Noreen H Chan-Tompkins
- Department of Pharmacy, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Tamara L Trienski
- Department of Pharmacy, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Courtney Watson
- Center for Inclusion Health, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Terrence J Obringer
- Division of Pulmonary Medicine, The Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh
| | - Jim Kuzyck
- Department of Microbiology, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pa
| | - Derek N Bremmer
- Department of Pharmacy, The Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh
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13
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Hadfield J, Bennett L. Determining best outcomes from community-acquired pneumonia and how to achieve them. Respirology 2017; 23:138-147. [PMID: 29150897 DOI: 10.1111/resp.13218] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 10/12/2017] [Accepted: 10/19/2017] [Indexed: 12/12/2022]
Abstract
Community-acquired pneumonia (CAP) is a common acute medical illness with a standard, effective treatment that was introduced before the evidenced-based medicine era. Mortality rates have improved in recent decades but improvements have been minimal when compared to other conditions such as acute coronary syndromes. The standardized approach to treatment makes CAP a target for comparative performance and outcome measures. While easy to collect, simplistic outcomes such as mortality, readmission and length of stay are difficult to interpret as they can be affected by subjective choices and health care resources. Proposed clinical- and patient-reported outcomes are discussed below and include measures such as the time to clinical stability (TTCS) and patient satisfaction, which can be compared between health institutions. Strategies to improve these outcomes include use of a risk stratification tool, local antimicrobial guidelines with antibiotic stewardship and care bundles to include early administration of antibiotics and early mobilization.
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Affiliation(s)
- Jane Hadfield
- Department of Respiratory Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - Lesley Bennett
- Department of Respiratory Medicine, Royal Perth Hospital, Perth, WA, Australia
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14
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Intervention to Reduce Broad-Spectrum Antibiotics and Treatment Durations Prescribed at the Time of Hospital Discharge: A Novel Stewardship Approach. Infect Control Hosp Epidemiol 2017; 38:534-541. [PMID: 28260538 DOI: 10.1017/ice.2017.10] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE For most common infections requiring hospitalization, antibiotic treatment is completed after hospital discharge. Postdischarge therapy is often unnecessarily broad spectrum and prolonged. We developed an intervention to improve antibiotic selection and shorten treatment durations. DESIGN Single center, quasi-experimental retrospective cohort study METHODS Patients prescribed oral antibiotics at hospital discharge before (July 2012-June 2013) and after (October 2014-February 2015) an intervention consisting of (1) institutional guidance for oral step-down antibiotic selection and duration of therapy and (2) pharmacy audit of discharge prescriptions with real-time prescribing recommendations to providers. The primary outcomes measured were total prescribed duration of therapy and use of antibiotics with broad gram-negative activity (ie, fluoroquinolones or amoxicillin-clavulanate). RESULTS Overall, 300 cases from the preintervention period and 200 cases from the intervention period were included. Compared with the preintervention period, the use of antibiotics with broad gram-negative activity decreased during the intervention (51% vs 40%; P=.02), particularly fluoroquinolones (38% vs 25%; P=.002). The total duration of therapy decreased from a median of 10 days (interquartile range [IQR], 7-13 days) to 9 days (IQR, 6-13 days) but did not reach statistical significance (P=.13). However, the duration prescribed at discharge declined from 6 days (IQR, 4-10 days) to 5 days (IQR, 3-7 days) (P=.003). During the intervention, there was a nonsignificant increase in the overall appropriateness of discharge prescriptions from 52% to 66% (P=.15). CONCLUSIONS A multifaceted intervention to optimize antibiotic prescribing at hospital discharge was associated with less frequent use of antibiotics with broad gram-negative activity and shorter postdischarge treatment durations. Infect Control Hosp Epidemiol 2017;38:534-541.
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16
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Cole J, Stark JE, Hodge B. A Primary Hospital Antimicrobial Stewardship Intervention on Pneumonia Treatment Duration. Fed Pract 2017; 34:14-18. [PMID: 30766252 PMCID: PMC6372026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
A primary hospital pharmacy intervention resulted in a significant decrease in antibiotic therapy duration for the treatment of uncomplicated pneumonia.
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Affiliation(s)
- Jennifer Cole
- and are clinical pharmacy specialists, and is the pharmacy informatics manager, all in the department of pharmacy at Veterans Health Care System of the Ozarks in Fayetteville, Arkansas
| | - Jennifer E Stark
- and are clinical pharmacy specialists, and is the pharmacy informatics manager, all in the department of pharmacy at Veterans Health Care System of the Ozarks in Fayetteville, Arkansas
| | - Bradley Hodge
- and are clinical pharmacy specialists, and is the pharmacy informatics manager, all in the department of pharmacy at Veterans Health Care System of the Ozarks in Fayetteville, Arkansas
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17
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Caplinger C, Crane K, Wilkin M, Bohan J, Remington R, Madaras-Kelly K. Evaluation of a protocol to optimize duration of pneumonia therapy at hospital discharge. Am J Health Syst Pharm 2016; 73:2043-2054. [DOI: 10.2146/ajhp160011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Christina Caplinger
- Pharmacy Service, Boise Veterans Affairs Medical Center, Boise, ID, and Truven Healthcare Analytics, Greenwood Village, CO
| | - Kendall Crane
- Pharmacy Service, Boise Veterans Affairs Medical Center, Boise, ID
| | | | - Jefferson Bohan
- Pharmacy Service, Boise Veterans Affairs Medical Center, Boise, ID
| | - Richard Remington
- Research Service, Boise Veterans Affairs Medical Center, Boise, ID, and Quantified Inc., Boise, ID
| | - Karl Madaras-Kelly
- College of Pharmacy, Idaho State University, Meridian ID, and Pharmacy Service, Boise, Veterans Affairs Medical Center, Boise, ID
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18
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Madaras-Kelly KJ, Burk M, Caplinger C, Bohan JG, Neuhauser MM, Goetz MB, Zhang R, Cunningham FE. Total duration of antimicrobial therapy in veterans hospitalized with uncomplicated pneumonia: Results of a national medication utilization evaluation. J Hosp Med 2016; 11:832-839. [PMID: 27527659 DOI: 10.1002/jhm.2648] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 06/23/2016] [Accepted: 06/28/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Practice guidelines recommend the shortest duration of antimicrobial therapy appropriate to treat uncomplicated pneumonia be prescribed to reduce the emergence of resistant pathogens. A national evaluation was conducted to assess the duration of therapy for pneumonia. DESIGN Retrospective medication utilization evaluation. SETTING Thirty Veterans Affairs medical centers. PATIENTS Inpatients discharged with a diagnosis of pneumonia. MEASUREMENTS A manual review of electronic medical records of inpatients discharged with uncomplicated community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HCAP) was conducted. Appropriate CAP therapy duration was defined as at least 5 days, and up to 3 additional days beginning the first day the patient achieved clinical stability criteria; the appropriate HCAP therapy duration was defined as 8 days. The duration of antimicrobial therapy for intravenous (IV) and oral (PO) inpatient administration, PO therapy dispensed upon discharge, Clostridium difficile infection (CDI), hospital readmission, and death rates were measured. RESULTS Of 3881 pneumonia admissions, 1739 met inclusion criteria (CAP [n = 1195]; HCAP [n = 544]). Overall, 13.9% of patients (CAP [6.9%], HCAP [29.0%]) received therapy duration consistent with guideline recommendations. The median (interquartile range) days of therapy were 4 days (3-6 days), 1 day (0-3 days), and 6 days (4-8 days) for inpatient IV, inpatient PO, and outpatient PO antimicrobials, respectively. CDI was rare but more common in patients who received therapy duration consistent with guidelines. Therapy duration was not associated with the readmission or mortality rate. CONCLUSIONS Antimicrobials were commonly prescribed for a longer duration than guidelines recommend. The majority of excessive therapy was completed upon discharge, identifying the need for strategies to curtail unnecessary use postdischarge. Journal of Hospital Medicine 2015;11:832-839. © 2015 Society of Hospital Medicine.
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Affiliation(s)
- Karl J Madaras-Kelly
- Pharmacy Service, Veterans Affairs Medical Center and Department of Pharmacy Practice, College of Pharmacy, Idaho State University, Meridian, Idaho
| | - Muriel Burk
- Center for Medication Safety, Hines VA, Hines, Illinois
- VA Pharmacy Benefits Management Services, Hines VA, Hines, Illinois
| | | | | | | | - Matthew Bidwell Goetz
- Infectious Diseases Section, VA Greater Los Angeles Health Care System and David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California
| | | | - Francesca E Cunningham
- Center for Medication Safety, Hines VA, Hines, Illinois
- VA Pharmacy Benefits Management Services, Hines VA, Hines, Illinois
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19
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Haas MK, Dalton K, Knepper BC, Stella SA, Cervantes L, Price CS, Burman WJ, Mehler PS, Jenkins TC. Effects of a Syndrome-Specific Antibiotic Stewardship Intervention for Inpatient Community-Acquired Pneumonia. Open Forum Infect Dis 2016; 3:ofw186. [PMID: 27747254 PMCID: PMC5063573 DOI: 10.1093/ofid/ofw186] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/26/2016] [Indexed: 12/18/2022] Open
Abstract
A syndrome-specific intervention to improve the management of community-acquired pneumonia in non-intensive care settings was associated with shorter treatment durations, less fluoroquinolone use, and a reduction in use of low-yield diagnostic tests. Background. Syndrome-specific interventions are a recommended approach to antibiotic stewardship, but additional data are needed to understand their potential impact. We implemented an intervention to improve the management of inpatient community-acquired pneumonia (CAP) and evaluated its effects on antibiotic and resource utilization. Methods. A stakeholder group developed and implemented a clinical practice guideline and order set for inpatient, non-intensive care unit CAP recommending a short course (5 days) of a fluoroquinolone-sparing antibiotic regimen in uncomplicated cases. Unless there was suspicion for complications or resistant pathogens, chest computed tomography (CT) and sputum cultures were discouraged. This was a retrospective preintervention postintervention study of patients hospitalized for CAP before (April 15, 2008–May 31, 2009) and after (July 1, 2011–July 31, 2012) implementation of the guideline. The primary comparison was the difference in duration of therapy during the baseline and intervention periods. Secondary outcomes included changes in use of levofloxacin, CT scans, and sputum culture. Results. One hundred sixty-six and 84 cases during the baseline and intervention periods, respectively, were included. From the baseline to intervention period, the median duration of therapy decreased from 10 to 7 days (P < .0001). Prescription of levofloxacin at discharge decreased from 60% to 27% of cases (P < .0001). Use of chest CT and sputum culture decreased from 47% to 32% of cases (P = .02) and 51% to 31% of cases (P = .03), respectively. The frequency of clinical failure between the 2 periods was similar. Conclusions. A syndrome-specific intervention for inpatient CAP was associated with shorter treatment durations and reductions in use of fluoroquinolones and low-yield diagnostic tests.
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Affiliation(s)
- Michelle K Haas
- Divisions of Infectious Diseases; Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora; Denver Public Health, Colorado
| | | | | | | | | | - Connie S Price
- Divisions of Infectious Diseases; Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - William J Burman
- Divisions of Infectious Diseases; Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora; Denver Public Health, Colorado
| | | | - Timothy C Jenkins
- Divisions of Infectious Diseases; Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora
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Beam C, Fuss J, Stoelting-Gettelfinger W. A Comprehensive Review of Common Respiratory Infections Encountered in Urgent and Primary Care: A Reference Guide for Judicious Antibiotic Use with Complementary Therapies. J Emerg Nurs 2016; 42:376-86. [PMID: 27452150 DOI: 10.1016/j.jen.2016.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 01/26/2016] [Accepted: 02/06/2016] [Indexed: 10/21/2022]
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21
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Antibiotic prescribing at the transition from hospitalization to discharge: a target for antibiotic stewardship. Infect Control Hosp Epidemiol 2016; 36:474-8. [PMID: 25782905 DOI: 10.1017/ice.2014.85] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Of 300 patients prescribed oral antibiotics at the time of hospital discharge, urinary tract infection, community-acquired pneumonia, and skin infections accounted for 181 of the treatment indications (60%). Half of the prescriptions were antibiotics with broad Gram-negative activity. Discharge prescriptions were inappropriate in 79 of 150 cases reviewed (53%).
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22
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Reddy SC, Jacob JT, Varkey JB, Gaynes RP. Antibiotic use in US hospitals: quantification, quality measures and stewardship. Expert Rev Anti Infect Ther 2015; 13:843-54. [PMID: 25925531 DOI: 10.1586/14787210.2015.1040766] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A majority of patients hospitalized in the US hospitals receive an antibiotic during their hospitalization. Furthermore, up to half of antibiotics prescribed in hospitals are inappropriate. In the setting of continued emergence of antibiotic-resistant pathogens and a limited pipeline of new antimicrobials, attention to optimizing antibiotic use in healthcare settings is essential. We review the measures of antibiotic consumption in the USA, the evolving metrics for comparing antibiotic use (known as benchmarking), trends in antibiotic use, the structure and outcome measures of Antimicrobial Stewardship Programs and interventions to optimize antimicrobial use.
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Affiliation(s)
- Sujan C Reddy
- Division of Infectious Diseases, Emory University School of Medicine, 49 Jesse Hill Jr Drive, Atlanta, GA 30303, USA
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23
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Zhang YZ, Singh S. Antibiotic stewardship programmes in intensive care units: Why, how, and where are they leading us. World J Crit Care Med 2015; 4:13-28. [PMID: 25685719 PMCID: PMC4326760 DOI: 10.5492/wjccm.v4.i1.13] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 11/21/2014] [Accepted: 12/17/2014] [Indexed: 02/06/2023] Open
Abstract
Antibiotic usage and increasing antimicrobial resistance (AMR) mount significant challenges to patient safety and management of the critically ill on intensive care units (ICU). Antibiotic stewardship programmes (ASPs) aim to optimise appropriate antibiotic treatment whilst minimising antibiotic resistance. Different models of ASP in intensive care setting, include “standard” control of antibiotic prescribing such as “de-escalation strategies”through to interventional approaches utilising biomarker-guided antibiotic prescribing. A systematic review of outcomes related studies for ASPs in an ICU setting was conducted. Forty three studies were identified from MEDLINE between 1996 and 2014. Of 34 non-protocolised studies, [1 randomised control trial (RCT), 22 observational and 11 case series], 29 (85%) were positive with respect to one or more outcome: These were the key outcome of reduced antibiotic use, or ICU length of stay, antibiotic resistance, or prescribing cost burden. Limitations of non-standard antibiotic initiation triggers, patient and antibiotic selection bias or baseline demographic variance were identified. All 9 protocolised studies were RCTs, of which 8 were procalcitonin (PCT) guided antibiotic stop/start interventions. Five studies addressed antibiotic escalation, 3 de-escalation and 1 addressed both. Six studies reported positive outcomes for reduced antibiotic use, ICU length of stay or antibiotic resistance. PCT based ASPs are effective as antibiotic-stop (de-escalation) triggers, but not as an escalation trigger alone. PCT has also been effective in reducing antibiotic usage without worsening morbidity or mortality in ventilator associated pulmonary infection. No study has demonstrated survival benefit of ASP. Ongoing challenges to infectious disease management, reported by the World Health Organisation global report 2014, are high AMR to newer antibiotics, and regional knowledge gaps in AMR surveillance. Improved AMR surveillance data, identifying core aspects of successful ASPs that are transferable, and further well-conducted trials will be necessary if ASPs are to be an effective platform for delivering desired patient outcomes and safety through best antibiotic policy.
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Emergency Department and Inpatient Community-Acquired Pneumonia: Practical Decision Making and Management Issues. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013. [DOI: 10.1007/s40138-013-0018-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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