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Mylotte JM. Determining the Appropriateness of Initiating Antibiotic Therapy in Nursing Home Residents. J Am Med Dir Assoc 2023; 24:1619-1628. [PMID: 37572691 DOI: 10.1016/j.jamda.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/14/2023]
Abstract
One approach for improving antibiotic prescribing in nursing homes is evaluating appropriateness of initiating antibiotic therapy. However, determining appropriateness has been a challenge. To investigate this problem literature review identified studies evaluating appropriateness of initiating antibiotic therapy in nursing homes. Two criteria were used most often to assess appropriateness: infection surveillance criterion or criteria specifically designed to assist clinicians for prescribing antibiotics. Development of these criteria and results of studies using these criteria were reviewed. There was considerable variability in percentage appropriateness of initiating therapy for these criteria, variation in the methodology for conducting these studies, and limitations of the criteria. The main limitation of infection surveillance criteria is that they are specifically designed to be highly specific but this results in low sensitivity. Thus, surveillance criteria should not be used for assessing appropriateness of antibiotic therapy. The other criterion is limited because it uses only localizing signs and symptoms of infection and these findings may not be documented in the medical record when evaluating appropriateness retrospectively. Several alternative methods to assess appropriateness were identified but evaluation of these methods have not been published. Several changes are suggested to improve the evaluation of the appropriateness of initiating antibiotic therapy in nursing home residents: confirmation by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services that surveillance definitions should not be used to evaluate appropriateness; develop and validate definitions of clinical infections in residents; standardize methods to evaluate appropriateness prospectively by the facility antimicrobial stewardship program; educate clinicians and nursing staff regarding the criteria for assessing appropriateness; and investigate the influence of provider-, resident-, family-, and facility-level factors on antibiotic use in nursing home residents.
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Affiliation(s)
- Joseph M Mylotte
- Division of Infectious Diseases, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY.
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Alkhawaldeh R, Abu Farha R, Abu Hammour K, Alefishat E. Optimizing antimicrobial therapy in urinary tract infections: A focus on urine culture and sensitivity testing. Front Pharmacol 2022; 13:1058669. [PMID: 36532780 PMCID: PMC9748416 DOI: 10.3389/fphar.2022.1058669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/15/2022] [Indexed: 09/29/2023] Open
Abstract
Objectives: This cross-sectional study was conducted at Jordan university hospital to evaluate the impact of microbial culture data and sensitivity results on optimizing UTI treatment. Methods: All positive urine cultures requested for adult patients (≥18 years) admitted to Jordan University Hospital (JUH) within the period from January 2019-July 2021 were evaluated. The antibiotics prescribed before and after culture data and sensitivity results were compared to evaluate the impact of these diagnostic measures on optimizing UTI treatment. Results: During the study period, 2400 urine cultures revealed positive results. Among those patients, 1,600 (66.7%) were discharged before the availability of culture results and excluded. Of the remaining 800 patients, 701 patients (87.6%) received empiric treatment. After culture and sensitivity results were available, overall, 84 (10.5%) patients had optimization (improvement) in their UTI management after culture results were known, while 6 (0.8%) patients had a worsening in their treatments. Based on the culture results, we found that only 12.4% of patients were appropriately treated before and after the culture results. Moreover, our results revealed that 31.9% were inappropriately treated for their UTIs before and after culture results. Conclusion: This study revealed an alarmingly high rate of inappropriate treatment of UTIs despite the availability of urine culture and sensitivity data, and that culture results were not used to optimize treatment strategies for UTI. This practice can potentially result in poor health-related outcomes and adversely affects efforts to battle AMR. Multifaceted strategies must be implemented to help clinicians follow the best current evidence and current guidelines in their selection of antibiotics for the management of UTIs.
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Affiliation(s)
- Rama Alkhawaldeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Rana Abu Farha
- Department of Clinical Pharmacy, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Khawla Abu Hammour
- Department Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman, Jordan
| | - Eman Alefishat
- Department Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman, Jordan
- Department of Pharmacology, College of Medicine and Health Science, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
- Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
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Panditrao A, Shafiq N, Kumar-M P, Sekhon AK, Biswal M, Singh G, Kaur K, Ray P, Malhotra S, Gautam V, Gupta R, Gupta V, Yadav TD, Laroiya I, Kumar H, Salvania A. Impact of an antimicrobial stewardship and monitoring of infection control bundle in a surgical intensive care unit of a tertiary-care hospital in India. J Glob Antimicrob Resist 2021; 24:260-265. [PMID: 33476838 DOI: 10.1016/j.jgar.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 12/29/2020] [Accepted: 01/11/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES Antimicrobial stewardship (AMS) in resource-limited settings lacks models that can be readily adapted to their settings. Here we discuss the impact of a combined strategy of AMS and monitoring of infection control practices in a tertiary-care centre of a developing country. METHODS This study was undertaken in the surgical unit of a tertiary-care hospital over an 8-month period. In the first 2 months (baseline phase), prospective audit and feedback alone was undertaken, while in the next 6 months (intervention phase) this was supplemented with strategies such as antimicrobial timeout, correction of doses and bundle approach for prevention of hospital-acquired infections. RESULTS A total of 337 patients were included (94 in the baseline phase and 243 in the intervention phase). There was a decrease in days of therapy per 1000 patient-days (1000PD) (1112.3 days vs. 1048.6 days), length of therapy per 1000PD (956 days vs. 936.3 days) and defined daily doses (DDD) per 1000PD for most antimicrobials. A decrease in double cover for Gram-negative infections (9.6% vs. 2.9%) but an increase in double anaerobic cover (4.2% vs. 7.4%) was observed. There was a decrease in the incidence of ventilator-associated pneumonia per 1000 ventilator-days in the intervention phase (46.4 vs. 35.4), whereas central line-associated bloodstream infections per 1000 central line-days remained the same (14.7 vs. 14.8). CONCLUSION This study shows that implementation of routine AMS activities with monitoring of infection control practices can help decrease overall antimicrobial use. With furtherance of measures to control infection, antimicrobial use may be further curtailed.
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Affiliation(s)
- Aditi Panditrao
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Nusrat Shafiq
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India.
| | - Praveen Kumar-M
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Amritpal Kaur Sekhon
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Manisha Biswal
- Department of Medical Microbiology, PGIMER, Chandigarh, India
| | - Gurpreet Singh
- Department of General Surgery, PGIMER, Chandigarh, India
| | | | - Pallab Ray
- Department of Medical Microbiology, PGIMER, Chandigarh, India
| | - Samir Malhotra
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Vikas Gautam
- Department of Medical Microbiology, PGIMER, Chandigarh, India
| | - Rajesh Gupta
- Department of General Surgery, PGIMER, Chandigarh, India
| | - Vikas Gupta
- Department of General Surgery, PGIMER, Chandigarh, India
| | - T D Yadav
- Department of General Surgery, PGIMER, Chandigarh, India
| | - Ishita Laroiya
- Department of General Surgery, PGIMER, Chandigarh, India
| | - Hemanth Kumar
- Department of General Surgery, PGIMER, Chandigarh, India
| | - Ajay Salvania
- Department of General Surgery, PGIMER, Chandigarh, India
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Langford BJ, Daneman N, Leung V, Langford DJ. Cognitive bias: how understanding its impact on antibiotic prescribing decisions can help advance antimicrobial stewardship. JAC Antimicrob Resist 2020; 2:dlaa107. [PMID: 34223057 DOI: 10.1093/jacamr/dlaa107] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The way clinicians think about decision-making is evolving. Human decision-making shifts between two modes of thinking, either fast/intuitive (Type 1) or slow/deliberate (Type 2). In the healthcare setting where thousands of decisions are made daily, Type 1 thinking can reduce cognitive load and help ensure decision making is efficient and timely, but it can come at the expense of accuracy, leading to systematic errors, also called cognitive biases. This review provides an introduction to cognitive bias and provides explanation through patient vignettes of how cognitive biases contribute to suboptimal antibiotic prescribing. We describe common cognitive biases in antibiotic prescribing both from the clinician and the patient perspective, including hyperbolic discounting (the tendency to favour small immediate benefits over larger more distant benefits) and commission bias (the tendency towards action over inaction). Management of cognitive bias includes encouraging more mindful decision making (e.g., time-outs, checklists), improving awareness of one's own biases (i.e., meta-cognition), and designing an environment that facilitates safe and accurate decision making (e.g., decision support tools, nudges). A basic understanding of cognitive biases can help explain why certain stewardship interventions are more effective than others and may inspire more creative strategies to ensure antibiotics are used more safely and more effectively in our patients.
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Affiliation(s)
- Bradley J Langford
- Public Health Ontario, Toronto, Ontario, Canada.,Hotel Dieu Shaver Health and Rehabilitation Centre, St Catharines, Ontario, Canada
| | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES (formerly Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada.,Toronto East Health Network, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Dale J Langford
- Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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