Effect of discontinuation of an antimicrobial stewardship programme on the antibiotic usage pattern

Sustainment of perioperative antimicrobial prophylaxis guidelines in children following discontinuation of an educational intervention to support stewardship

Adherence to perioperative antimicrobial guidelines among Greek children was markedly decreased years after the discontinuation of an antimicrobial stewardship (AS) intervention. An educational intervention is effective to improve the perioperative antimicrobial use, but the continuous implementation of AS is important for its long-term sustainability.

The Changes in Broad-spectrum Antimicrobial Consumption during the COVID-19 Pandemic in a Japanese Acute Tertiary-care Hospital: An Interrupted Time-series Analysis

Objective The novel coronavirus disease 2019 (COVID-19) pandemic has spread worldwide, and hospitals in Japan have been forced to respond to the situation. This study evaluated the broad-spectrum antimicrobial use before and during the COVID-19 pandemic in an acute tertiary-care hospital. Methods This single-center, retrospective study was conducted between January 2019 and June 2021. Patients We reviewed patients treated with three broad-spectrum antipseudomonal agents: carbapenems, tazobactam/piperacillin, and cefepime. Monthly aggregated hospital antimicrobial consumption was measured as days of therapy (DOTs) per 1,000 patient-days, and the monthly incidences of Clostridioides difficile infection (CDI), multidrug-resistant Pseudomonas aeruginosa (MRPA), and carbapenemase-producing Enterobacteriaceae (CPE) were recorded. Results The median monthly carbapenem-DOTs during the pre-pandemic and pandemic era were 8.4 and 8.2 per 1,000 patient-days, respectively. A time-series analysis showed non-significant changes in the level between periods (coefficients: 2.08; 95% confidence interval [CI]: -2.9 to 7.0; p=0.44). No change in the trend of monthly carbapenem-DOTs was observed after intervention. No post-intervention changes in the incidence of MRPA or CPE were observed; however, the trend in the incidence of CDI per 1,000 patient-days significantly differed between the two periods (coefficient: -0.04; 95% CI: -0.07, 0.00; p=0.01), and a downward trend was observed in the monthly CDI incidence during the COVID-19 period. Conclusion The consumption of broad intravenous antimicrobial agents has not changed significantly during the pandemic. We need to maintain the quality of medical care, including antimicrobial stewardship, even in specialized resource-limited facilities during a pandemic.

The Impact of an Antimicrobial Stewardship Program on Days of Therapy in the Pediatric Center: An Interrupted Time-Series Analysis of a 19-Year Study

BACKGROUND

We aimed to analyze the effects of an antimicrobial stewardship program (ASP) on the proportion of antimicrobial-resistant pathogens in bacteremia, antimicrobial use, and mortality in pediatric patients.

METHODS

A retrospective single-center study was performed on pediatric inpatients under 19 years old who received systemic antimicrobial treatment from 2001 to 2019. A pediatric infectious disease attending physician started ASP in January 2008. The study period was divided into the pre-intervention (2001-2008) and the post-intervention (2009-2019) periods. The amount of antimicrobial use was defined as days of therapy per 1,000 patient-days, and the differences were compared using delta slope (= changes in slopes) between the two study periods by an interrupted time-series analysis. The proportion of resistant pathogens and the 30-day overall mortality rate were analyzed by the χ².

RESULTS

The proportion of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae bacteremia increased from 17% (39 of 235) in the pre-intervention period to 35% (189 of 533) in the post-intervention period (P < 0.001). The total amount of antimicrobial use significantly decreased after the introduction of ASP (delta slope value = -16.5; 95% confidence interval [CI], -30.6 to -2.3; P = 0.049). The 30-day overall mortality rate in patients with bacteremia did not increase, being 10% (55 of 564) in the pre-intervention and 10% (94 of 941) in the post-intervention period (P = 0.881).

CONCLUSION

The introduction of ASP for pediatric patients reduced the delta slope of the total antimicrobial use without increasing the mortality rate despite an increased incidence of ESBL-producing gram-negative bacteremia.

Effect and sustainability of a stepwise implemented multidisciplinary antimicrobial stewardship programme in a university hospital emergency department

Objectives

To explore effectiveness and sustainability of guideline adherence and antibiotic consumption after establishing treatment guidelines and initiating antimicrobial stewardship (AMS) ward rounds in a university hospital emergency department (ED).

Methods

Data were gathered retrospectively from 2017 to 2021 in the LMU University Hospital in Munich, Germany. Four time periods were compared: P1 (pre-intervention period); P2 (distribution of guideline pocket cards); P3 (reassessment after 3 years); and P4 (refresher of guideline pocket cards and additional daily AMS ward rounds for different medical disciplines). Primary outcome was adherence to guideline pocket cards for community-acquired pneumonia, cystitis, pyelonephritis and COVID-19-associated bacterial pneumonia. Secondary outcomes were reduction in antibiotic consumption and adherence to AMS specialist recommendations.

Results

The study included 1324 patients. Guideline adherence increased in P2 for each of the infectious diseases entities. After 3 years (P3), guideline adherence decreased again, but was mostly on a higher level than in P1. AMS ward rounds resulted in an additional increase in guideline adherence (P1/P2: 47% versus 58.6%, P = 0.005; P2/P3: 58.6% versus 57.3%, P = 0.750; P3/P4: 57.3% versus 72.5%, P < 0.001). Adherence increased significantly, not only during workdays but also on weekends/nightshifts. Adherence to AMS specialist recommendations was excellent (91.3%). We observed an increase in use of narrow-spectrum antibiotics and a decrease in the application of fluoroquinolones and cephalosporins.

Conclusions

Establishing treatment guidelines in the ED is effective. However, positive effects can be diminished over time. Daily AMS ward rounds are useful, not only to restore but to further increase guideline adherence significantly.

The COVID-19 Pandemic Enhanced the Decade-Long Trend of the Decreasing Utilization of Antibiotics

PURPOSE/INTRODUCTION

A decline in antibiotic (AB) prescriptions was reported during the coronavirus 2019 (COVID-19) pandemic. Therefore, we investigated AB utilization during the COVID-19 pandemic using data from a large database in Germany.

METHODS

AB prescriptions in the Disease Analyzer database (IQVIA) were analyzed for each year between 2011 and 2021. Descriptive statistics were used to assess developments in relation to age group, sex, and antibacterial substances. Infection incidence rates were also investigated.

RESULTS

In total, 1,165,642 patients received antibiotic prescriptions during the entire study period (mean age: 51.8; SD: 18.4 years; 55.3% females). AB prescriptions started to decline in 2015 (505 patients per practice), and this development persisted until 2021 (2020: 300 patients per practice and 2021: 266 patients per practice). The sharpest drop was observed in 2020 and occurred in both women and men (27.4% and 30.1%). In the youngest age group (≤30), the decrease was -56%, while in the age group >70, it was -38%. The number of patients with prescriptions for fluoroquinolones dropped the most, falling from 117 in 2015 to 35 in 2021 (-70%), followed by macrolides (-56%) and tetracyclines (-56%). In 2021, 46% fewer patients were diagnosed with acute lower respiratory infections, 19% fewer with chronic lower respiratory diseases, and just 10% fewer with diseases of the urinary system.

CONCLUSION

AB prescriptions decreased more in the first year (2020) of the COVID-19 pandemic than infectious diseases did. While the factor of older age influenced this trend negatively, it remained unaffected by the factor of sex and the selected antibacterial substance.

Antibiotic stewardship implementation at the largest solid organ transplantation center in Asia: a retrospective cohort study

BACKGROUND

Using Antimicrobial stewardship programs (ASP) to monitor the use of antibiotics can lead to improved antibiotic use and reduced costs.

METHODS

This retrospective cohort study was done at Shiraz Organ Transplant Center, the largest transplant center in Asia. Antimicrobial use, cost, clinical outcomes, and antibiotic resistance pattern were evaluated before and after ASP.

RESULTS

This study included 2791 patients, 1154 of whom were related to the time before ASP and 1637 to the time after ASP. During the period of the research, a total of 4051 interventions were done. The use of all classes of antibiotics was significantly reduced by ASP, with 329 DDD/100PD before the intervention compared to 201 DDD/100PD after it (p = 0.04). In addition, the overall cost of antibiotics purchased was much lower after the ASP measures were implemented ($43.10 per PD) than before implementation of the ASP measures ($60.60 per PD) (p = 0.03). After the implementation of ASP, the number of MDR isolates was significantly reduced.

CONCLUSION

The results of our study showed that the implementation of ASP significantly reduced the number and costs of antibiotics and also the number of resistant pathogens, but did not affect the patients' length of stay.

Antimicrobial stewardship programs in the Intensive Care Unit in patients with infections caused by multidrug-resistant Gram-negative bacilli

Antimicrobial stewardship programs (ASPs) have been shown to be effective and safe, contributing to reducing and adjusting antimicrobial use in clinical practice. Such programs not only reduce antibiotic selection pressure and therefore the selection of multidrug-resistant strains, but also reduce the potential deleterious effects for individual patients and even improve the prognosis by adjusting the choice of drug and dosage, and lessening the risk of adverse effects and interactions. Gram-negative bacilli (GNB), particularly multidrug-resistant strains (MDR-GNB), represent the main infectious problem in the Intensive Care Unit (ICU), and are therefore a target for ASPs. The present review provides an update on the relationship between ASPs and MDR-GNB.

Impact of coronavirus disease 2019 (COVID-19) pandemic on antimicrobial consumption and antimicrobial resistance at a small, local hospital in Japan

The coronavirus disease 2019 (COVID-19) pandemic negatively affected antimicrobial stewardship programs at hospitals throughout Japan by diverting resources toward managing the pandemic. However, antimicrobial stewardship needs to continue regardless of hospital size or supervening crises. Herein, we discuss the impact of COVID-19 on antimicrobial stewardship at a small, local hospital in Japan.

[What is the proportion of infectiology in the specialization urology? : A pilot study to underline the significance of Antibiotic Stewardship in urology]

BACKGROUND

Urinary tract infections account for one of the most bacterial infectious diseases worldwide.

OBJECTIVES

The primary aim of this pilot project was to identify the relative percentage of antibiotic use in comparison to all patients in a university medical center for the better establishment of antibiotic stewardship (ABS) programs.

MATERIAL AND METHODS

This is an epidemiological pilot project. In the time period of three months it was evaluated which relative percentage of the patients was treated with antibiotics for bacterial urinary tract infection in comparison to all patients.

RESULTS

In summary, about 40% of all urological patients received an antibiotic treatment against urinary tract infections or as perioperative prophylaxis against bacterial infection in the operating room (OR). The antibiotic use at the urological ward is highest in comparison to ambulance or OR.

CONCLUSION

Infectious diseases, especially bacterial infections, account for a significant part of urology. This knowledge is essential to establish ABS programs and to tackle the progression of antibiotic resistance. Detailed studies are necessary to understand antibiotic prescription practice in urology to develop targeted ABS interventions.

Antimicrobial stewardship

PURPOSE OF REVIEW

The optimal use of antimicrobials is necessary to slow resistance development and improve patient outcomes. Antimicrobial stewardship (AMS) is a bundle of interventions aimed at promoting the responsible use of antiinfectives. The ICU is an important field of activity for AMS because of high rates of antimicrobial use, high prevalence of resistant pathogens and complex pharmacology. This review discusses aims and interventions of AMS with special emphasis on the ICU.

RECENT FINDINGS

AMS-interventions can improve the quality and quantity of antimicrobial prescribing in the ICU without compromising patient outcomes. The de-escalation of empiric therapy according to microbiology results and the limitation of treatment duration are important steps to reduce resistance pressure. Owing to the complex nature of critical illness, the pharmacological optimization of antimicrobial therapy is an important goal in the ICU. AMS-objectives and strategies are also applicable to patients with sepsis. This is reflected in the most recent guidelines by the Surviving Sepsis Campaign. AMS-interventions need to be adapted to their respective setting and be mindful of local prescribing cultures and prescribers' attitudes.

SUMMARY

AMS in the ICU is effective and safe. Intensivists should be actively involved in AMS-programs and propagate responsible use of antimicrobials.

Clinical and Microbiological Effects of an Antimicrobial Stewardship Program in Urology-A Single Center Before-After Study

Antimicrobial resistance is a major public health issue caused by antibiotic overuse and misuse. Antimicrobial stewardship (AMS) has been increasingly endorsed worldwide, but its effect has been studied scarcely in urologic settings. A before-after study was performed from 2018 through 2020 to evaluate changes in antimicrobial prescription, resistance rates and clinical safety upon implementation of an AMS audit and feedback program in the Urology Department of a large German academic medical center. The primary endpoints were safety clinical outcomes: the rate of infection-related readmissions and of infectious complications after transrectal prostate biopsies. Resistance rates and antimicrobial consumption rates were the secondary endpoints. The AMS team reviewed 196 cases (12% of all admitted in the department). The overall antibiotic use dropped by 18.7%. Quinolone prescriptions sank by 78.8% (p = 0.02) and 69.8% (p > 0.05) for ciprofloxacin and levofloxacin, respectively. The resistance rate of E. coli isolates declined against ceftriaxone (−9%), ceftazidime (−12%) and quinolones (−25%) in the AMS period. No significant increase in infection-related readmissions or infectious complications after prostate biopsies was observed (p = 0.42). Due to the potential to reduce antibiotic use and resistance rates with no surge of infection-related complications, AMS programs should be widely implemented in urologic departments.

The Impact of the SARS-Cov2 Pandemic on a Persuasive Educational Antimicrobial Stewardship Program in a University Hospital in Southern Italy: A Pre-Post Study

Objectives: We evaluated the effect of the pandemic on the disruption of a persuasive educational antimicrobial stewardship program (ASP) conducted in a university hospital in southern Italy. Methods: In March 2020, the ASP, which began in January 2017 and was carried out at different times in 10 wards, was stopped due to the COVID-19 pandemic. We conducted an observational study with interrupted time series analysis to compare the antibiotic consumption and costs, average length of hospital stay and in-hospital mortality between 12 months before and 9 months after the interruption. Results: Four medical, four surgical wards and two ICUs were included in the study, for a total of 35,921 patient days. Among the medical wards we observed after the interruption a significant increase in fluoroquinolone use, with a change in trend (CT) of 0.996, p = 0.027. In the surgical wards, we observed a significant increase in the overall consumption, with a change in level (CL) of 24.4, p = 0.005, and in the use of third and fourth generation cephalosporins (CL 4.7, p = 0.003). In two ICUs, we observed a significant increase in piperacillin/tazobactam and fluoroquinolone consumption (CT 9.28, p = 0.019, and 2.4, p = 0.047). In the wards with a duration of ASP less than 30 months, we observed a significant increase in antibiotic consumption in the use of piperacillin/tazobactam and fluoroquinolones (CT 12.9, p = 0.022: 4.12, p = 0.029; 1.004, p = 0.011). Conclusions: The interruption of ASP during COVID-19 led to an increase in the consumption of broad-spectrum antibiotics, particularly in surgical wards and in those with a duration of ASP less than 30 months.

Guidelines on Implementing Antimicrobial Stewardship Programs in Korea

These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.