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Langford BJ, Bailey P, Livorsi DJ, Brown KA, Advani SD, Dodds Ashley E, Bearman G, Nori P. Five steps to high quality antimicrobial stewardship research. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e82. [PMID: 38751942 PMCID: PMC11094375 DOI: 10.1017/ash.2024.73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 05/18/2024]
Abstract
The escalating threat of antimicrobial resistance (AMR) necessitates impactful, reproducible, and scalable antimicrobial stewardship strategies. This review addresses the critical need to enhance the quality of antimicrobial stewardship intervention research. We propose five considerations for authors planning and evaluating antimicrobial stewardship initiatives. Antimicrobial stewards should consider the following mnemonic ABCDE: (A) plan Ahead using implementation science; (B) Be clear and thoroughly describe the intervention by using the TidIER checklist; (C) Use a Checklist to comprehensively report study components; (D) Select a study Design carefully; and (E) Assess Effectiveness and implementation by selecting meaningful outcomes. Incorporating these recommendations will help strengthen the evidence base of antimicrobial stewardship literature and support optimal implementation of strategies to mitigate AMR.
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Affiliation(s)
- Bradley J. Langford
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Daniel J. Livorsi
- Center for Access and Delivery Research and Evaluation (CADRE), 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
| | - Kevin A. Brown
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Elizabeth Dodds Ashley
- Division of Infectious Diseases, Duke University School of Medicine and Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, USA
| | - Gonzalo Bearman
- Healthcare Infection Prevention Program, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Priya Nori
- Department of Medicine, Division of Infectious Diseases, Montefiore Medical Center, Bronx, NY, USA
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Silva JT, Montoro J, Pérez-Jacoiste Asín MA, Fernández-Ruiz M, Polanco N, González E, Caro-Teller JM, Andrés A, Aguado JM, López-Medrano F. A joint program of antimicrobial stewardship and hospital-acquired infection control to reduce healthcare-associated infections after kidney transplantation: The Hipomenes study. Am J Transplant 2023; 23:1949-1960. [PMID: 37479034 DOI: 10.1016/j.ajt.2023.07.009] [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: 02/13/2023] [Revised: 06/28/2023] [Accepted: 07/13/2023] [Indexed: 07/23/2023]
Abstract
Infection is a common complication in kidney transplant recipients (KTRs). The usefulness of antimicrobial stewardship programs (ASP) and hospital-acquired infection control (HAIC) initiatives in the general inpatient population is well established. We performed a quasi-experimental study to evaluate a joint ASP/HAIC initiative focused on KTRs. A dedicated ASP team optimized antimicrobial prescriptions in consecutive KTRs during the intervention period (June 2015-March 2016). A multifaceted, evidence-based HAIC program was concurrently implemented. Results were compared with the preceding period (June 2014-March 2015). We included 96 and 100 KTRs in the intervention and preintervention periods, respectively. There was a reduction in the consumption of meropenem (rate ratio [RR]: 0.63; 95% confidence interval [CI]: 0.53-0.75; P <.0001), ceftazidime (RR: 0.31; 95% CI: 0.21-0.45; P <.0001), vancomycin (RR: 0.65; 95% CI: 0.53-0.8; P <.0001), and ciprofloxacin (RR: 0.66; 95% CI: 0.55-0.81; P <.0001) and an increase of fosfomycin (RR: 1.80; 95% CI: 1.17-2.76; P =.008) during the intervention period. The incidence of cystitis (RR: 0.30; 95% CI: 0.28-0.33; P <.001) and upper urinary tract infection (RR: 0.56; 95% CI: 0.33-0.95; P =.04) decreased. A specific ASP/HAIC initiative was effective in optimizing antimicrobial use and reducing the incidence of common bacterial infections among KTRs.
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Affiliation(s)
- José Tiago Silva
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Antimicrobial Stewardship Team in Hospitalized Patients, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | - Juan Montoro
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | | | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; School of Medicine, Universidad Complutense, Madrid, Spain
| | - Natalia Polanco
- Department of Nephrology, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | - Esther González
- Department of Nephrology, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | - José Manuel Caro-Teller
- Antimicrobial Stewardship Team in Hospitalized Patients, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Department of Pharmacy, University Hospital "12 de Octubre", Madrid, Spain
| | - Amado Andrés
- School of Medicine, Universidad Complutense, Madrid, Spain; Department of Nephrology, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; School of Medicine, Universidad Complutense, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; School of Medicine, Universidad Complutense, Madrid, Spain.
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3
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Belan M, Thilly N, Pulcini C. Antimicrobial stewardship programmes in nursing homes: a systematic review and inventory of tools. J Antimicrob Chemother 2021; 75:1390-1397. [PMID: 32108883 DOI: 10.1093/jac/dkaa013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/05/2020] [Accepted: 01/07/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Antimicrobial overuse/misuse is common in nursing homes and although the effectiveness of antimicrobial stewardship (AMS) programmes has been well explored and demonstrated in hospitals, data are scarce for the nursing-home setting. Our objectives for this systematic review were to make an inventory of: (i) all interventions that could be considered as part of AMS programmes in nursing homes; and (ii) all stewardship tools and guidance that are freely available. METHODS We performed a systematic review using the MEDLINE database from inception to June 2018, including all interventional studies, reviews, opinion pieces and guidelines/guidance exploring AMS programmes in nursing homes. For the inventory of freely available tools and guidance to help implement an AMS programme, we also performed screening of professional societies and official agencies' websites and a questionnaire survey among a panel of international experts. RESULTS A total of 36 articles were included in our systematic review. Most interventions took place in North America and have explored education or persuasive interventions within multifaceted interventions, showing that they can improve guideline adherence and decrease antibiotic use and unnecessary microbiological testing. Most reviews also highlighted the importance of accountability, monitoring and feedback. A large number of tools (156) available for free on the internet were identified, mostly about education, patient assessment and outcome measurement. CONCLUSIONS Although high-quality interventional studies are lacking, multifaceted interventions including education, monitoring and feedback seem the most promising strategy. Many tools are available on the internet and can be used to help implement AMS programmes in nursing homes.
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Affiliation(s)
- Martin Belan
- Université de Lorraine, CHRU-Nancy, Département de maladies infectieuses, Nancy, France
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, Nancy, France.,Université de Lorraine, CHRU-Nancy, Département Méthodologie Promotion Investigation, Nancy, France
| | - Céline Pulcini
- Université de Lorraine, CHRU-Nancy, Département de maladies infectieuses, Nancy, France.,Université de Lorraine, APEMAC, Nancy, France
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Kahlmeter G, Thilly N, Pulcini C. Selective reporting of antibiotic susceptibility testing results: less is more. Clin Microbiol Infect 2020; 27:503-505. [PMID: 33253937 DOI: 10.1016/j.cmi.2020.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/15/2020] [Accepted: 11/19/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Gunnar Kahlmeter
- Department of Clinical Microbiology, Central Hospital, Växjö, Sweden; EUCAST Development Laboratory, Växjö, Sweden
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Département Méthodologie, Promotion et Investigation, Nancy, France
| | - Céline Pulcini
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Département de Maladies Infectieuses et Tropicales, Nancy, France.
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Pulcini C. Being a CMI editor. Clin Microbiol Infect 2019; 25:1449-1450. [PMID: 31449871 DOI: 10.1016/j.cmi.2019.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 08/17/2019] [Indexed: 02/08/2023]
Affiliation(s)
- C Pulcini
- Université de Lorraine, APEMAC, équipe MICS, Nancy, France; Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, Nancy, France.
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Le Maréchal M, Agrinier N, Cattoir V, Pulcini C. A nationwide survey on involvement of clinical microbiologists in antibiotic stewardship programmes in large French hospitals. Eur J Clin Microbiol Infect Dis 2019; 38:2235-2241. [PMID: 31396831 DOI: 10.1007/s10096-019-03665-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/29/2019] [Indexed: 12/27/2022]
Abstract
Antibiotic stewardship programmes (ASP) are essential to tackle antibiotic resistance. Clinical microbiologists (CMs) play a key role in these programmes; however, few studies describe their actual involvement. Our objective was to explore CMs' involvement in French hospital ASP. In 2018, we conducted a survey among CMs working in large public French hospitals (600 acute care beds or more). The questionnaire focused on the following topics: microbiology department's characteristics, hospital ASP, and CMs' involvement in this programme, including their use of rapid diagnostic tests (RDT). Fifty/74 CMs answered (response rate 68%), with 68% working in a teaching hospital. CMs were leading the ASP in 6% of cases, and 57% of hospitals had a multidisciplinary antibiotic stewardship team. Most microbiology departments (92%) were using specific PCR, processed 24/7 in 74% of hospitals. More than half (58%) were using syndromic panel-based testing, 94% mass spectrometry, and 96% immunochromatographic/colorimetric RDT. Blood cultures were processed 24/7 in 44% of hospitals. CMs were involved in this. Finally, 42% of CMs wished to be more involved in their hospital's ASP, the most frequently reported barrier being lack of time (36%). CMs should be more involved in ASP. RDT are widely used, but not implemented in an optimal way.
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Affiliation(s)
- Marion Le Maréchal
- Département de Santé Publique, Hôpital l'Archet, CHU de Nice, 151 Route de Saint Antoine, 06200, Nice, France.
| | - Nelly Agrinier
- Université de Lorraine, EA 4360 APEMAC, Nancy, France.,Université de Lorraine, CHRU-Nancy, INSERM, CIC-1433, Epidémiologie Clinique, 54000, Nancy, France
| | - Vincent Cattoir
- CHU de Rennes, Service de Bactériologie-Hygiène hospitalière & CNR de la Résistance aux Antibiotiques (laboratoire associé 'Entérocoques'), Rennes, France.,Faculté de Médecine & Unité Inserm U1230, Université de Rennes 1, Rennes, France
| | - Céline Pulcini
- Université de Lorraine, EA 4360 APEMAC, Nancy, France.,Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, Nancy, France
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Binda F, Fougnot S, De Monchy P, Fagot-Campagna A, Pulcini C, Thilly N. Impact of selective reporting of antibiotic susceptibility test results in urinary tract infections in the outpatient setting: a protocol for a pragmatic, prospective quasi-experimental trial. BMJ Open 2019; 8:e025810. [PMID: 30798294 PMCID: PMC6278878 DOI: 10.1136/bmjopen-2018-025810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/03/2018] [Accepted: 09/28/2018] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Antibiotic resistance is a serious and increasing worldwide threat to global public health. One of antibiotic stewardship programmes' objectives are to reduce inappropriate broad-spectrum antibiotics' prescription. Selective reporting of antibiotic susceptibility test (AST) results, which consists of reporting to prescribers only few (n=5-6) antibiotics, preferring first-line and narrow-spectrum agents, is one possible strategy advised in recommendations. However, selective reporting of AST has never been evaluated using an experimental design. METHODS AND ANALYSIS This study is a pragmatic, prospective, multicentre, controlled (selective reporting vs usual complete reporting of AST), before-after (year 2019 vs 2017) study. Selective reporting of AST is scheduled to be implemented from September 2018 in the ATOUTBIO group of 21 laboratories for all Escherichia coli identified in urine cultures in adult outpatients, and to be compared with the usual complete AST performed in the EVOLAB group of 20 laboratories. The main objective is to assess the impact of selective reporting of AST for E. coli-positive urine cultures in the outpatient setting on the prescription of broad-spectrum antibiotics frequently used for urinary tract infections (amoxicillin-clavulanate, third-generation cephalosporins and fluoroquinolones). The primary end point is the after (2019)-before (2017) difference in prescription rates for the previously mentioned antibiotics/classes that will be compared between the two laboratory groups, using linear regression models. Secondary objectives are to evaluate the feasibility of selective reporting of AST implementation by French laboratories and their acceptability by organising focus groups and individual semi-structured interviews with general practitioners and laboratory professionals. ETHICS AND DISSEMINATION This protocol was approved by French national ethics committees (Comité d'expertise pour les recherches, les études et les évaluations dans le domaine de la santé (TPS 29064) and Commission Nationale de l'Informatique et des Libertés (Décision DR-2018-141)). Findings of this study will be widely disseminated through conference presentations, reports, factsheets and academic publications and generalisation will be further discussed. TRIAL REGISTRATION NUMBER NTC03612297.
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Affiliation(s)
- Francesca Binda
- Université de Lorraine, APEMAC, Nancy, France
- Département des sciences cliniques et biomédicales «Luigi Sacco», Université de Milan, Milan, Italy
| | | | | | | | - Céline Pulcini
- Université de Lorraine, APEMAC, Nancy, France
- Université de Lorraine, CHRU-Nancy, Service des maladies infectieuses et tropicales, Nancy, France
| | - Nathalie Thilly
- Université de Lorraine, APEMAC, Nancy, France
- Université de Lorraine, CHRU-Nancy, Plateforme d’Aide à la Recherche Clinique, Nancy, France
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9
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Rzewuska M, Charani E, Clarkson JE, Davey PG, Duncan EM, Francis JJ, Gillies K, Kern WV, Lorencatto F, Marwick CA, McEwen J, Möhler R, Morris AM, Ramsay CR, Rogers Van Katwyk S, Skodvin B, Smith I, Suh KN, Grimshaw JM. Prioritizing research areas for antibiotic stewardship programmes in hospitals: a behavioural perspective consensus paper. Clin Microbiol Infect 2018; 25:163-168. [PMID: 30195471 DOI: 10.1016/j.cmi.2018.08.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/16/2018] [Accepted: 08/23/2018] [Indexed: 12/19/2022]
Abstract
SCOPE Antibiotic stewardship programmes (ASPs) are necessary in hospitals to improve the judicious use of antibiotics. While ASPs require complex change of key behaviours on individual, team organization and policy levels, evidence from the behavioural sciences is underutilized in antibiotic stewardship studies across the world, including high-income countries (HICs). A consensus procedure was performed to propose research priority areas for optimizing effective implementation of ASPs in hospital settings using a behavioural perspective. METHODS A workgroup for behavioural approaches to ASPs was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). Eighteen clinical and academic specialists in antibiotic stewardship, implementation science and behaviour change from four HICs with publicly funded healthcare systems (e.g. Canada, Germany, Norway and the UK) met face-to-face to agree on broad research priority areas using a structured consensus method. Question addressed and recommendations: The consensus process assessing the ten identified research priority areas resulted in recommendations that need urgent scientific interest and funding to optimize effective implementation of ASPs for hospital inpatients in HICs with publicly funded healthcare systems. We suggest and detail behavioural science evidence-guided research efforts in the following areas: (a) comprehensively identifying barriers and facilitators to implementing ASPs and clinical recommendations intended to optimize antibiotic prescribing; (b) identifying actors ('who') and actions ('what needs to be done') of ASPs and clinical teams; (c) synthesizing available evidence to support future research and planning for ASPs; (d) specifying the activities in current ASPs with the purpose of defining a control group for comparison with new initiatives; (e) defining a balanced set of outcomes and measures to evaluate the effects of interventions focused on reducing unnecessary exposure to antibiotics; (f) conducting robust evaluations of ASPs with built-in process evaluations and fidelity assessments; (g) defining and designing ASPs; (h) establishing the evidence base for impact of ASPs on resistance; (i) investigating the role and impact of government and policy contexts on ASPs; and (j) understanding what matters to patients in ASPs in hospitals. CONCLUSIONS Assessment, revisions and updates of our priority-setting exercise should be considered at intervals of 2 years. To propose research priority areas in low- and middle-income countries, the methodology reported here could be applied.
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Affiliation(s)
- M Rzewuska
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
| | - E Charani
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - J E Clarkson
- Schools of Dentistry, University of Dundee, Dundee, UK
| | - P G Davey
- Division of Population Health Sciences, Medical School, University of Dundee, Dundee, London, UK
| | - E M Duncan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - J J Francis
- School of Health Sciences, City University of London, London, UK
| | - K Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - W V Kern
- University of Freiburg Medical Center and Faculty of Medicine, Division of Infectious Diseases, Freiburg, Germany
| | - F Lorencatto
- Centre for Behaviour Change, University College London, London, UK
| | - C A Marwick
- Division of Population Health Sciences, Medical School, University of Dundee, Dundee, London, UK
| | | | - R Möhler
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - A M Morris
- Sinai Health System, University Health Network and University of Toronto, Toronto, Canada
| | - C R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - S Rogers Van Katwyk
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - B Skodvin
- Norwegian Advisory Unit for Antibiotic Use in Hospitals, Haukeland University Hospital, Bergen, Norway
| | - I Smith
- Department of Essential Medicines and Health Products, World Health Organization, Geneva, Switzerland
| | - K N Suh
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - J M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa, Ottawa, Canada
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Huttner A, Pulcini C. CMI and 'primary-care' infections. Clin Microbiol Infect 2018; 24:797-798. [PMID: 29807118 DOI: 10.1016/j.cmi.2018.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 05/22/2018] [Indexed: 10/16/2022]
Affiliation(s)
- A Huttner
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland; Clinical Microbiology and Infection Editorial Board, Israel.
| | - C Pulcini
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, Nancy, France; Clinical Microbiology and Infection Editorial Board, Israel
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Pulcini C, Beovic B, Howard P, Mendelson M. Human resources estimates and funding for antibiotic stewardship teams are urgently needed: authors' response. Clin Microbiol Infect 2018; 24:557. [DOI: 10.1016/j.cmi.2018.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 01/13/2018] [Indexed: 01/28/2023]
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