Quality indicators for appropriate antimicrobial therapy in the emergency department: a pragmatic Delphi procedure

Quantitative and qualitative evaluation of antimicrobial usage: the first step for antimicrobial stewardship

The identification of antimicrobial use patterns is essential for determining key targets for antimicrobial stewardship interventions and evaluating the effectiveness thereof. Accurately identifying antimicrobial use patterns requires quantitative evaluation, which focuses on measuring the quantity and frequency of antimicrobial use, and qualitative evaluation, which assesses the appropriateness, effectiveness, and potential side effects of antimicrobial prescriptions. This paper summarizes the quantitative and qualitative methods used to evaluate antimicrobials, drawing insights from overseas and domestic cases.

Antimicrobial Stewardship in the Emergency Department Observation Unit: Definition of a New Indicator and Evaluation of Antimicrobial Use and Clinical Outcomes

We aimed to define a novel indicator for monitoring antimicrobial use specifically in the Emergency Department Observation Unit (EDOU) and to assess the long-term impact of an institutional education-based antimicrobial stewardship program (ASP) on the antimicrobial prescribing pattern and clinical outcomes in this setting. A quasi-experimental interrupted time-series study was performed from 2011 to 2022. An educational ASP was implemented at the EDOU in 2015. To estimate changes in antimicrobial use, we designed an indicator adjusted for patients at risk of antimicrobial prescribing: defined daily doses (DDDs) per 100 patients transferred from the Emergency Department to the Observation Unit (TOs) per quarter. The number of bloodstream infections (BSIs) and the crude all-cause 14-day mortality were assessed as clinical outcomes. Antimicrobial use showed a sustained reduction with a trend change of -1.17 DDD per 100 TO and a relative effect of -45.6% (CI95% -64.5 to -26.7), particularly relevant for meropenem and piperacillin-tazobactam, with relative effects of -80.4% (-115.0 to -45.7) and -67.9% (-93.9 to -41.9), respectively. The incidence density of all BSIs increased significantly during the ASP period, with a relative effect of 123.2% (41.3 to 284.7). The mortality rate remained low and stable throughout the study period, with an absolute effect of -0.7% (-16.0 to 14.7). The regular monitoring of antimicrobial use in the EDOU by using this new quantitative indicator was useful to demonstrate that an institutional education-based ASP successfully achieved a long-term reduction in overall antimicrobial use, with a low and steady BSI mortality rate.

Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department

OBJECTIVE

To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department.

METHODS

A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritization level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritization order and rated the new indicators in the same manner as in the first round.

RESULTS

61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analyzing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority.

CONCLUSIONS

The experts agreed on a panel of ASP indicators adapted to the emergency services prioritized by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.

[Translated article] Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department

OBJECTIVE

To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department.

METHODS

A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritisation level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritisation order and rated the new indicators in the same manner as in the first round.

RESULTS

61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analysing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority.

CONCLUSIONS

The experts agreed on a panel of ASP Indicators adapted to the emergency services prioritised by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.

The Interventions and Challenges of Antimicrobial Stewardship in the Emergency Department

Over the last decades, we have witnessed a constant increase in infections caused by multi-drug-resistant strains in emergency departments. Despite the demonstrated effectiveness of antimicrobial stewardship programs in antibiotic consumption and minimizing multi-drug-resistant bacterium development, the characteristics of emergency departments pose a challenge to their implementation. The inclusion of rapid diagnostic tests, tracking microbiological results upon discharge, conducting audits with feedback, and implementing multimodal educational interventions have proven to be effective tools for optimizing antibiotic use in these units. Nevertheless, future multicenter studies are essential to determine the best way to proceed and measure outcomes in this scenario.

How to use quality indicators for antimicrobial stewardship in your hospital: a practical example on outpatient parenteral antimicrobial therapy

BACKGROUND

Antimicrobial stewardship (AMS) teams are responsible for performing an AMS programme in their hospitals that aims to improve the quality of antibiotic use. Measuring the quality of antimicrobial use is a core task of a stewardship team. Measurement provides insight into the current quality of antibiotic use and allows for the establishment of goals for improvement. Yet, a practical description of how such a quality measurement using quality indicators (QIs) should be performed is lacking.

OBJECTIVES

To provide practical guidance on how a stewardship team can use QIs to measure the quality of antibiotic use in their hospital and identify targets for improvement.

SOURCES

General principles from implementation science, peer-reviewed publications, and experience from clinicians and researchers with AMS experience.

CONTENT

We provide step-by-step guidance on how AMS teams can use QIs to measure the quality of antibiotic use. The principles behind each step are explained and illustrated with the description and results of an audit of patients receiving outpatient parenteral antimicrobial therapy in four Dutch hospitals.

IMPLICATIONS

Improving the quality of antibiotic use is impossible without first gaining insight into that quality by performing a measurement with validated QIs. This step-by-step practice example of how to use quality indicators in a hospital will help AMS teams to identify targets for improvement. This enables them to perform their AMS programme more effectively and efficiently.

Current Status and Prospect of Qualitative Assessment of Antibiotics Prescriptions

Identifying inappropriately prescribed antibiotics for infectious diseases by monitoring the quality of antibiotics use is essential for effective implementation of antibiotic stewardship. Qualitative assessment of the use of antibiotics has been conducted in some countries, including Korea, since the 2000s. The qualitative assessment generally involves an assessment of each component of the antibiotics prescription process, based on specific criteria. However, there is no standardized assessment method or cycle, and infectious diseases or antibiotics included in the assessments vary from country-to-country. According to the results reported in the United States, Europe, Australia, and Korea so far, approximately 20 - 55% of all antibiotics prescriptions are inappropriate. In this review, we describe the current progress in the quality assessment of the use of antibiotics on a global scale. Further, we highlight the future directions to improve antibiotic stewardship activities and the quality assessment of the use of antibiotics in Korea.

A nationwide evaluation of antibiotics consumption in Swedish intensive care units

BACKGROUND

Around 70% of all ICU patients are treated with antibiotics whereas up to 30% are suggested as unnecessary. Measuring antibiotic consumption is a prerequisite to improving its use and the purpose of the present investigation was to explore the use of antibiotics in Swedish ICUs.

MATERIAL AND METHODS

Daily Defined Doses (DDDs) of antimicrobials delivered to Swedish ICUs, 2016-2018, were retrieved from Swedish pharmacies. From the Swedish Intensive Care Registry, we extracted data on a number of patient admissions, occupied bed days and Simplified Acute Physiology Score (SAPS)3.

RESULTS

There was a similar annual rate of total DDDs per admission of 3.7, 3.5, 3.8 and total DDDs per 100 occupied bed days of 111, 111, and 115 but with an approximately 6-fold difference of DDDs per occupied bed days (61-366) between the ICUs. The most frequently used antibiotics were isoxazolyl penicillins (J01CF), penicillins with betalactamase-inhibitors, mainly piperacillin/tazobactam (J01CR), 3rd and 4th generation cephalosporins (J01DD + DE) and carbapenems (J01DH). Together these four classes accounted for a median of 52% of all antibiotic use. The use of carbapenems had a moderate positive correlation with the mean SAPS3 score (r = 0.6, p = .01). The use of other broad-spectrum antibiotics showed no such correlation.

CONCLUSION

Overall antibiotic use remained similar in Swedish ICUs during the years 2016-2018. Broad-spectrum antibiotics accounted for 50% of all DDDs but with a large inter-ICU variation which only partly can be explained by differences in patient case mix and microbial resistance. Presumably, it also reflects varying local prescribing practices.