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Kwon KT, Kim SW. Principles and practices of antimicrobial stewardship programs in Korea. Korean J Intern Med 2024; 39:373-382. [PMID: 38649160 PMCID: PMC11076894 DOI: 10.3904/kjim.2023.482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/22/2023] [Accepted: 01/07/2024] [Indexed: 04/25/2024] Open
Abstract
This review addresses the escalating challenge posed by antibiotic resistance, highlighting its profound impact on global public health, including increased mortality rates and healthcare expenditures. The review focuses on the need to adopt the One Health approach to effectively manage antibiotic usage across human, animal, and environmental domains. Antimicrobial stewardship programs (ASPs) are considered as comprehensive strategies that encompass both core and supplementary initiatives aimed at enhancing prudent antibiotic use. The 2021 "Guidelines on Implementing ASP in Korea" introduced such strategies, with a strong emphasis on fostering multidisciplinary and collaborative efforts. Furthermore, the "Core Elements for Implementing ASPs in Korean General Hospitals," established in 2022, provide a structured framework for ASPs, delineating leadership responsibilities, the composition of interdisciplinary ASP teams, a range of interventions, and continuous monitoring and reporting mechanisms. In addition, this review examines patient-centric campaigns such as "Speak Up, Get Smart" and emphasizes the pivotal role of a multidisciplinary approach and international cooperation in addressing the multifaceted challenges associated with antibiotic resistance.
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Affiliation(s)
- Ki Tae Kwon
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Shin-Woo Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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Abstract
Most antibiotics are prescribed in ambulatory setting and at least 30% to 50% of these prescriptions are unnecessary. The use of antibiotics when not needed promotes the development of antibiotic resistant organisms and harms patients by placing them at risk for adverse drug events and Clostridioides difficile infections. National guidelines recommend that health systems implement antibiotic stewardship programs in ambulatory settings. However, uptake of stewardship in ambulatory setting has remained low. This review discusses the current state of ambulatory stewardship in the United States, best practices for the successful implementation of effective ambulatory stewardship programs, and future directions to improve antibiotic use in ambulatory settings.
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Affiliation(s)
- Holly M Frost
- Center for Health Systems Research, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, Denver Health and Hospital Authority, Denver, CO, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Adam L Hersh
- Division of Infectious Disease, Department of Pediatrics, 295 Chipeta Way, Salt Lake City, UT 8413, USA
| | - David Y Hyun
- Antimicrobial Resistance Project, The Pew Charitable Trusts, 901 East Street NW, Washington, DC 20004-2008, USA
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Nedved AC, Lee BR, Wirtz A, Monsees E, Burns A, Turcotte Benedict FG, El Feghaly RE. Socioeconomic differences in antibiotic use for common infections in pediatric urgent-care centers-A quasi-experimental study. Infect Control Hosp Epidemiol 2023; 44:2009-2016. [PMID: 37381724 DOI: 10.1017/ice.2023.107] [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: 06/30/2023]
Abstract
OBJECTIVE To investigate differences in the rate of firstline antibiotic prescribing for common pediatric infections in relation to different socioeconomic statuses and the impact of an antimicrobial stewardship program (ASP) in pediatric urgent-care clinics (PUCs). DESIGN Quasi-experimental. SETTING Three PUCs within a Midwestern pediatric academic center. PATIENTS AND PARTICIPANTS Patients aged >60 days and <18 years with acute otitis media, group A streptococcal pharyngitis, community-acquired pneumonia, urinary tract infection, or skin and soft-tissue infections who received systemic antibiotics between July 2017 and December 2020. We excluded patients who were transferred, admitted, or had a concomitant diagnosis requiring systemic antibiotics. INTERVENTION We used national guidelines to determine the appropriateness of antibiotic choice in 2 periods: prior to (July 2017-July 2018) and following ASP implementation (August 2018-December 2020). We used multivariable regression analysis to determine the odds ratios of appropriate firstline agent by age, sex, race and ethnicity, language, and insurance type. RESULTS The study included 34,603 encounters. Prior to ASP implementation in August 2018, female patients, Black non-Hispanic children, those >2 years of age, and those who self-paid had higher odds of receiving recommended firstline antibiotics for all diagnoses compared to male patients, children of other races and ethnicities, other ages, and other insurance types, respectively. Although improvements in prescribing occurred after implementation of our ASP, the difference within the socioeconomic subsets persisted. CONCLUSIONS We observed socioeconomic differences in firstline antibiotic prescribing for common pediatric infections in the PUCs setting despite implementation of an ASP. Antimicrobial stewardship leaders should consider drivers of these differences when developing improvement initiatives.
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Affiliation(s)
- Amanda C Nedved
- Division of Urgent Care, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Brian R Lee
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- Division of Health Services and Outcomes Research, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Ann Wirtz
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- Department of Pharmacy, Children's Mercy Kansas City, Kansas City, Missouri
| | - Elizabeth Monsees
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- Division of Performance Excellence, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Alaina Burns
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- Department of Pharmacy, Children's Mercy Kansas City, Kansas City, Missouri
| | - Frances G Turcotte Benedict
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Rana E El Feghaly
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
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Karageorgos S, Hibberd O, Mullally PJW, Segura-Retana R, Soyer S, Hall D. Antibiotic Use for Common Infections in Pediatric Emergency Departments: A Narrative Review. Antibiotics (Basel) 2023; 12:1092. [PMID: 37508188 PMCID: PMC10376281 DOI: 10.3390/antibiotics12071092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/17/2023] [Accepted: 06/20/2023] [Indexed: 07/30/2023] Open
Abstract
Antibiotics are one of the most prescribed medications in pediatric emergency departments. Antimicrobial stewardship programs assist in the reduction of antibiotic use in pediatric patients. However, the establishment of antimicrobial stewardship programs in pediatric EDs remains challenging. Recent studies provide evidence that common infectious diseases treated in the pediatric ED, including acute otitis media, tonsillitis, community-acquired pneumonia, preseptal cellulitis, and urinary-tract infections, can be treated with shorter antibiotic courses. Moreover, there is still controversy regarding the actual need for antibiotic treatment and the optimal dosing scheme for each infection.
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Affiliation(s)
- Spyridon Karageorgos
- Faculty of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London E1 2AT, UK; (S.K.)
- First Department of Pediatrics, Aghia Sophia Children’s Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Owen Hibberd
- Faculty of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London E1 2AT, UK; (S.K.)
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Patrick Joseph William Mullally
- Faculty of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London E1 2AT, UK; (S.K.)
- Department of Medicine, Cardiff University, Cardiff CF10 3AT, UK
| | - Roberto Segura-Retana
- Faculty of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London E1 2AT, UK; (S.K.)
- Pediatric Emergency Department, Hospital Nacional de Niños, San José 0221, Costa Rica
| | - Shenelle Soyer
- Faculty of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London E1 2AT, UK; (S.K.)
| | - Dani Hall
- Faculty of Medicine and Dentistry, Blizard Institute, Queen Mary University of London, London E1 2AT, UK; (S.K.)
- Department of Emergency Medicine, Children’s Health Ireland at Crumlin, D12 N512 Dublin, Ireland
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Hamner M, Nedved A, Austin H, Wyly D, Burns A, Berg K, Lee B, El Feghaly RE. Improving Duration of Antibiotics for Skin and Soft-tissue Infections in Pediatric Urgent Cares. Pediatrics 2022; 150:189945. [PMID: 36377382 DOI: 10.1542/peds.2022-057974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVES National guidelines recommend a 5- to 7-day course of antibiotics for most skin and soft-tissue infections (SSTIs). Our aim was to increase the percentage of pediatric patients receiving 5 to 7 days of oral antibiotics for SSTIs in our pediatric urgent care clinics (UCCs) from 60% to 75% by December 31, 2021. METHODS We performed cause-and-effect analysis and surveyed UCC providers to uncover reasons for hesitation with short antibiotic courses for SSTIs. Plan- Do-Study-Act (PDSA) cycle 1 provided an update on current guidelines for UCC providers and addressed providers' concerns. PDSA cycle 2 modified the electronic health record to display antimicrobial prescription sentences from shortest to longest duration. PDSA cycle 3 provided project outcome and balancing measure updates to UCC providers at regular intervals. We created a monthly report of patients 90 days and older in UCCs with a final diagnosis of SSTIs. We used a Shewhart control chart to identify special cause variations. RESULTS After completing our PDSA cycles, we found that the percentage of children receiving 5 to 7 days of oral antibiotics for SSTIs exceeded 85%. The improvement was sustained over multiple months. There was no increase in the proportion of patients returning to the UCCs with an SSTI diagnosis within 14 days. CONCLUSIONS By addressing primary drivers uncovered through quality improvement methodology, we shortened the antibiotic course for children seen in our UCCs with SSTIs. Outpatient antimicrobial stewardship programs may apply similar methods to other diagnoses to further improve duration of antibiotic prescriptions.
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Affiliation(s)
| | - Amanda Nedved
- Departments of Pediatrics.,School of Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Holly Austin
- Departments of Pediatrics.,School of Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | | | - Alaina Burns
- Pharmacy.,School of Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Kathleen Berg
- Departments of Pediatrics.,School of Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Brian Lee
- Health Services and Outcomes Research, Children's Mercy Hospitals and Clinics, Kansas City, Missouri.,School of Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Rana E El Feghaly
- Departments of Pediatrics.,School of Medicine, University of Missouri Kansas City, Kansas City, Missouri
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Miranda-Novales G, Flores-Moreno K, López-Vidal Y, Ponce de León-Rosales S. Limited Therapeutic Options in Mexico for the Treatment of Urinary Tract Infections. Antibiotics (Basel) 2022; 11:antibiotics11111656. [PMID: 36421299 PMCID: PMC9687036 DOI: 10.3390/antibiotics11111656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/22/2022] Open
Abstract
The rise in antimicrobial resistance (AMR) has complicated the management of urinary tract infections (UTIs). The objective of this study was to evaluate the antimicrobial susceptibility patterns of Escherichia coli and Klebsiella pneumoniae. Design: prospective observational study. Bacteria were classified as susceptible or resistant to ampicillin-sulbactam, amikacin, gentamicin, ciprofloxacin, norfloxacin, nitrofurantoin, trimethoprim-sulfamethoxazole (TMP/SMZ), ertapenem, meropenem, and fosfomycin. The sensitivity to fosfomycin and chloramphenicol was evaluated by the disk diffusion method. Statistical analysis: the chi-square test and Fisher’s exact test were used to compare differences between categories. A p value < 0.05 was considered statistically significant. Isolates were collected from January 2019 to November 2020 from 21 hospitals and laboratories. A total of 238 isolates were received: a total of 156 E. coli isolates and 82 K. pneumoniae isolates. The majority were community-acquired infections (64.1%). Resistance was >20% for beta-lactams, aminoglycosides, fluoroquinolones, and TMP/SMZ. For E. coli isolates, resistance was <20% for amikacin, fosfomycin, and nitrofurantoin; for K. pneumoniae, amikacin, fosfomycin, chloramphenicol, and norfloxacin. All were susceptible to carbapenems. K. pneumoniae isolates registered a higher proportion of extensively drug-resistant bacteria in comparison with E. coli (p = 0.0004). In total, multidrug-resistant bacteria represented 61% of all isolates. Isolates demonstrated high resistance to beta-lactams, fluoro-quinolones, and TMP/SMZ.
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Affiliation(s)
- Guadalupe Miranda-Novales
- Analysis and Synthesis of Evidence Research Unit, Mexican Institute of Social Security, Mexico City 06720, Mexico
- Microbiome Laboratory, Faculty of Medicine, National Autonomous University of Mexico, Mexico City 04360, Mexico
- Correspondence: ; Tel.: +52-55-4026-7372
| | - Karen Flores-Moreno
- Microbiome Laboratory, Faculty of Medicine, National Autonomous University of Mexico, Mexico City 04360, Mexico
| | - Yolanda López-Vidal
- Microbiology and Parasitology Department, Faculty of Medicine, National Autonomous University of Mexico, Mexico City 04360, Mexico
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