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Couture S, Frenette C, Schiller I, Alfaro R, Dendukuri N, Thirion D, Longtin Y, Loo VG. The changing epidemiology of Clostridioides difficile infection and the NAP1/027 strain in two Québec hospitals: a 17-year time-series study. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e99. [PMID: 38836044 PMCID: PMC11149029 DOI: 10.1017/ash.2024.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 06/06/2024]
Abstract
Objective To describe the epidemiology of healthcare-associated Clostridioides difficile infection (HA-CDI) in two Québec hospitals in Canada following the 2003 epidemic and to evaluate the impact of antibiotic stewardship on the incidence of HA-CDI and the NAP1/027 strain. Design Time-series analysis. Setting Two Canadian tertiary care hospitals based in Montréal, Québec. Patients Patients with a positive assay for toxigenic C. difficile were identified through infection control surveillance. All cases of HA-CDI, defined as symptoms occurring after 72 hours of hospital admission or within 4 weeks of hospitalization, were included. Methods The incidence of HA-CDI and antibiotic utilization from 2003 to 2020 were analyzed with available C. difficile isolates. The impact of antibiotic utilization on HA-CDI incidence was estimated by a dynamic regression time-series model. Antibiotic utilization and the proportion of NAP1/027 strains were compared biannually for available isolates from 2010 to 2020. Results The incidence of HA-CDI decreased between 2003 and 2020 at both hospitals from 26.5 cases per 10,000 patient-days in 2003 to 4.9 cases per 10,000 patient-days in 2020 respectively. Over the study period, there were an increase in the utilization of third-generation cephalosporins and a decrease in usage of fluoroquinolones and clindamycin. A decrease in fluoroquinolone utilization was associated with a significant decrease in HA-CDI incidence as well as decrease in the NAP1/027 strain by approximately 80% in both hospitals. Conclusions Decreased utilization of fluoroquinolones in two Québec hospitals was associated with a decrease in the incidence of HA-CDI and a genotype shift from NAP1/027 to non-NAP1/027 strains.
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Affiliation(s)
| | - Charles Frenette
- McGill University, Montréal, QC, Canada
- Division of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montréal, QC, Canada
| | - Ian Schiller
- Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Rowin Alfaro
- Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Nandini Dendukuri
- McGill University, Montréal, QC, Canada
- Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Daniel Thirion
- Université de Montréal, Montréal, QC, Canada
- Department of Pharmacy, McGill University Health Centre, Montréal, QC, Canada
| | - Yves Longtin
- McGill University, Montréal, QC, Canada
- Jewish General Hospital, Montréal, QC, Canada
| | - Vivian G Loo
- McGill University, Montréal, QC, Canada
- Division of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montréal, QC, Canada
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Lewnard JA, Charani E, Gleason A, Hsu LY, Khan WA, Karkey A, Chandler CIR, Mashe T, Khan EA, Bulabula ANH, Donado-Godoy P, Laxminarayan R. Burden of bacterial antimicrobial resistance in low-income and middle-income countries avertible by existing interventions: an evidence review and modelling analysis. Lancet 2024; 403:2439-2454. [PMID: 38797180 DOI: 10.1016/s0140-6736(24)00862-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/18/2024] [Accepted: 04/22/2024] [Indexed: 05/29/2024]
Abstract
National action plans enumerate many interventions as potential strategies to reduce the burden of bacterial antimicrobial resistance (AMR). However, knowledge of the benefits achievable by specific approaches is needed to inform policy making, especially in low-income and middle-income countries (LMICs) with substantial AMR burden and low health-care system capacity. In a modelling analysis, we estimated that improving infection prevention and control programmes in LMIC health-care settings could prevent at least 337 000 (95% CI 250 200-465 200) AMR-associated deaths annually. Ensuring universal access to high-quality water, sanitation, and hygiene services would prevent 247 800 (160 000-337 800) AMR-associated deaths and paediatric vaccines 181 500 (153 400-206 800) AMR-associated deaths, from both direct prevention of resistant infections and reductions in antibiotic consumption. These estimates translate to prevention of 7·8% (5·6-11·0) of all AMR-associated mortality in LMICs by infection prevention and control, 5·7% (3·7-8·0) by water, sanitation, and hygiene, and 4·2% (3·4-5·1) by vaccination interventions. Despite the continuing need for research and innovation to overcome limitations of existing approaches, our findings indicate that reducing global AMR burden by 10% by the year 2030 is achievable with existing interventions. Our results should guide investments in public health interventions with the greatest potential to reduce AMR burden.
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Affiliation(s)
- Joseph A Lewnard
- Division of Epidemiology, School of Public Health, University of California, Berkeley, CA, USA.
| | - Esmita Charani
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Alec Gleason
- One Health Trust, Bengaluru, India; High Meadows Environmental Institute, Princeton University, Princeton, NJ, USA
| | - Li Yang Hsu
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Wasif Ali Khan
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Clare I R Chandler
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK; Antimicrobial Resistance Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Tapfumanei Mashe
- One Health Office, Ministry of Health and Child Care, Harare, Zimbabwe; Health System Strengthening Unit, WHO, Harare, Zimbabwe
| | - Ejaz Ahmed Khan
- Department of Pediatrics, Shifa Tameer-e-Millat University, Shifa International Hospital, Islamabad, Pakistan
| | - Andre N H Bulabula
- Division of Disease Control and Prevention, Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Pilar Donado-Godoy
- AMR Global Health Research Unit, Colombian Integrated Program of Antimicrobial Resistance Surveillance, Corporación Colombiana de Investigación Agropecuaria, Cundinamarca, Colombia
| | - Ramanan Laxminarayan
- One Health Trust, Bengaluru, India; High Meadows Environmental Institute, Princeton University, Princeton, NJ, USA.
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Arenz L, Porger A, De Michel M, Weber A, Jung J, Horns H, Gscheidle S, Weiglein T, Pircher J, Becker-Lienau J, Horster S, Klein M, Draenert R. Effect and sustainability of a stepwise implemented multidisciplinary antimicrobial stewardship programme in a university hospital emergency department. JAC Antimicrob Resist 2024; 6:dlae026. [PMID: 38410248 PMCID: PMC10895698 DOI: 10.1093/jacamr/dlae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/02/2024] [Indexed: 02/28/2024] Open
Abstract
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.
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Affiliation(s)
- Lukas Arenz
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Medicine II, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Annika Porger
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Michaela De Michel
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Alexandra Weber
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Hospital Pharmacy, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Jette Jung
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Max-von-Pettenkofer-Institute Munich, LMU Munich, Elisabeth-Winterhalter-Weg 6, 81377 München, Germany
| | - Heidi Horns
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Sandra Gscheidle
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Hospital Pharmacy, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Tobias Weiglein
- Department of Medicine III, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Joachim Pircher
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Medicine I, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Johanna Becker-Lienau
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Sophia Horster
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Matthias Klein
- Emergency Department, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
- Department of Neurology, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
| | - Rika Draenert
- Antibiotic Stewardship Programme, University Hospital, LMU Munich, Marchioninistraße 15, 81377 München, Germany
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Kisil OV, Gabrielyan NI, Maleev VV. [Antibiotic resistance - what can be done? A review]. TERAPEVT ARKH 2023; 95:90-95. [PMID: 37167120 DOI: 10.26442/00403660.2023.01.202040] [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: 04/13/2022] [Indexed: 05/13/2023]
Abstract
Serious work is being carried out in the world in the field of combating antibiotic resistance: reducing the prescribing of antibiotics, banning the use of antibiotics as stimulators of animal growth, improving infection control. Antimicrobial resistance is systematically monitored not only in every medical center, but also at the national level. The collected data is successfully used to implement local and national recommendations on the optimal use of antibiotics.
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Affiliation(s)
| | - N I Gabrielyan
- Shumakov National Medical Research Center of Transplantology and Artificial Organs
| | - V V Maleev
- Central Research Institute of Epidemiology
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Appropriateness of Empirical Prescriptions of Ceftriaxone and Identification of Opportunities for Stewardship Interventions: A Single-Centre Cross-Sectional Study. Antibiotics (Basel) 2023; 12:antibiotics12020288. [PMID: 36830199 PMCID: PMC9952766 DOI: 10.3390/antibiotics12020288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Third-generation cephalosporins are widely used due to the convenient spectrum of activity, safety, and posology. However, they are associated with the emergence of multidrug-resistant organisms, which makes them important targets for antimicrobial stewardship interventions. We aimed to assess the appropriateness of empirical prescriptions of ceftriaxone in a tertiary hospital. This cross-sectional study analysed empirical ceftriaxone prescriptions in January and June 2021. Patients under other antimicrobials 48 h before admission were excluded. The quality of ceftriaxone prescription was assessed regarding the initial appropriateness, duration of inappropriate ceftriaxone therapy, and missed opportunities for de-escalation. Of 465 prescriptions, 46.5% were inappropriate. The ceftriaxone prescription was inappropriate in 95.7% of lower respiratory tract infections (LRTI) globally and in nearly 40% of urinary tract infections (UTI) in medical and intensive care departments. Intensive care, internal medicine, and palliative care departments showed the highest number of inappropriate ceftriaxone prescriptions and longer length of inappropriate ceftriaxone prescriptions compared to the hospital's average. Improvement of empirical ceftriaxone prescription in LRTI and urinary infections, adherence to local guidelines and de-escalation practices, and targeted interventions focusing on critical departments may significantly reduce the inappropriate empirical use of ceftriaxone.
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Chahine EB, Cook RO, Carrion T, Sarkissian RJ. Impact of the Antimicrobial Stewardship Mandate on Multidrug-Resistant Organisms and Clostridioides difficile Infection Among Long-term Care Facility Residents. Sr Care Pharm 2022; 37:345-356. [PMID: 35879843 DOI: 10.4140/tcp.n.2022.345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective To determine whether the long-term care facility (LTCF) Centers for Medicare & Medicaid Services (CMS) Antimicrobial Stewardship (AMS) mandate was associated with a change in the combined rate of LTCF-acquired multidrug-resistant organism infection or colonization (MDRO-I/C) and Clostridioides difficile infection (CDI). Design Retrospective quasi-experimental study. Setting A 233-bed community hospital. Participants LTCF residents 75 years of age and older with MDRO-I/C or CDI admitted to the hospital before the AMS mandate in 2015 through 2016 or after the mandate in 2018 through 2019. Intervention LTCF CMS AMS mandate. Main Outcomes Measures Rates of LTCF-acquired MDRO-I/C and CDI. MDRO-I/C were defined by a culture positive for methicillin-resistant Staphylococcus aureus or extended-spectrum beta-lactamase-producing Enterobacterales. CDI was defined by a positive test for C. difficile using a multistep algorithm of toxin, glutamate dehydrogenase, and nucleic acid amplification tests. These specimens must have been collected within 48 hours of hospital admission. Results There were 33 residents with either LTCF-acquired MDRO-I/C or CDI out of a total of 205 hospitalized residents with MDRO-I/C or CDI in 2015 and 2016, resulting in a rate of 16.10%. In comparison, there were 38 residents with either LTCF-acquired MDRO-I/C or CDI out of a total of 253 hospitalized residents with MDRO-I/C or CDI in 2018 and 2019 resulting in a rate of 15.02%. The difference in the combined rate of LTCF-acquired MDRO-I/C and CDI was -1.08% (P = 0.75). Conclusion The AMS mandate was not associated with a significant change in the combined rate of LTCF-acquired MDRO-I/C and CDI, suggesting a need for more robust AMS programs in LTCFs.
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Affiliation(s)
- Elias B Chahine
- Palm Beach Atlantic University, Gregory School of Pharmacy, West Palm Beach, Florida
| | - Ryan O Cook
- Palm Beach Atlantic University, Gregory School of Pharmacy, West Palm Beach, Florida
| | - Tanya Carrion
- Palm Beach Atlantic University, Gregory School of Pharmacy, West Palm Beach, Florida
| | - Robert J Sarkissian
- Palm Beach Atlantic University, Gregory School of Pharmacy, West Palm Beach, Florida
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Muro FJ, Lyamuya FS, Kwobah C, Bollinger J, Bodinayake CK, Nagahawatte A, Piyasiri B, Kurukulasooriya R, Ali S, Mallya R, Rolfe R, Ruwanpathirana A, Sheng T, Østbye T, Drew R, Kussin P, Woods CW, Anderson DJ, Mmbaga BT, Tillekeratne LG. Opportunities for Improving Antimicrobial Stewardship: Findings From a Prospective, Multi-Center Study in Three Low- or Middle-Income Countries. Front Public Health 2022; 10:848802. [PMID: 35548085 PMCID: PMC9081325 DOI: 10.3389/fpubh.2022.848802] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/24/2022] [Indexed: 11/26/2022] Open
Abstract
Background To develop effective antimicrobial stewardship programs (ASPs) for low- and middle-income countries (LMICs), it is important to identify key targets for improving antimicrobial use. We sought to systematically describe the prevalence and patterns of antimicrobial use in three LMIC hospitals. Methods Consecutive patients admitted to the adult medical wards in three tertiary care hospitals in Tanzania, Kenya, and Sri Lanka were enrolled in 2018-2019. The medical record was reviewed for clinical information including type and duration of antimicrobials prescribed, indications for antimicrobial use, and microbiologic testing ordered. Results A total of 3,149 patients were enrolled during the study period: 1,103 from Tanzania, 750 from Kenya, and 1,296 from Sri Lanka. The majority of patients were male (1,783, 56.6% overall) with a median age of 55 years (IQR 38-68). Of enrolled patients, 1,573 (50.0%) received antimicrobials during their hospital stay: 35.4% in Tanzania, 56.5% in Kenya, and 58.6% in Sri Lanka. At each site, the most common indication for antimicrobial use was lower respiratory tract infection (LRTI; 40.2%). However, 61.0% received antimicrobials for LRTI in the absence of LRTI signs on chest radiography. Among patients receiving antimicrobials, tools to guide antimicrobial use were under-utilized: microbiologic cultures in 12.0% and microbiology consultation in 6.5%. Conclusion Antimicrobials were used in a substantial proportion of patients at tertiary care hospitals across three LMIC sites. Future ASP efforts should include improving LRTI diagnosis and treatment, developing antibiograms to direct empiric antimicrobial use, and increasing use of microbiologic tests.
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Affiliation(s)
- Florida J. Muro
- Community Health Department, Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania
- Institute of Public Health, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
| | - Furaha S. Lyamuya
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Internal Medicine Department, Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania
| | - Charles Kwobah
- Moi University/Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - John Bollinger
- Duke-Margolis Center for Health Policy, Washington, DC, United States
- Duke Global Health Institute, Durham, NC, United States
- Duke University, Durham, NC, United States
| | - Champica K. Bodinayake
- Duke Global Health Institute, Durham, NC, United States
- University of Ruhuna, Galle, Sri Lanka
| | - Ajith Nagahawatte
- Duke Global Health Institute, Durham, NC, United States
- University of Ruhuna, Galle, Sri Lanka
| | | | | | - Shamim Ali
- Moi University/Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Rose Mallya
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Reproductive and Child Health, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Robert Rolfe
- Duke Global Health Institute, Durham, NC, United States
- Duke University, Durham, NC, United States
| | | | - Tianchen Sheng
- Duke Global Health Institute, Durham, NC, United States
- Duke University, Durham, NC, United States
| | - Truls Østbye
- Duke Global Health Institute, Durham, NC, United States
- Duke University, Durham, NC, United States
| | - Richard Drew
- Duke University, Durham, NC, United States
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, United States
| | | | - Christopher W. Woods
- Duke Global Health Institute, Durham, NC, United States
- Duke University, Durham, NC, United States
| | - Deverick J. Anderson
- Duke University, Durham, NC, United States
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC, United States
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Duke Global Health Institute, Durham, NC, United States
- Paediatric and Child Health Department, Kilimanjaro Christian Medical Centre, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - L. Gayani Tillekeratne
- Duke Global Health Institute, Durham, NC, United States
- Duke University, Durham, NC, United States
- University of Ruhuna, Galle, Sri Lanka
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8
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Pédeboscq S, Issa N, Lahouati M, Labadie A, Pereyre S, Camou F. Impact of a 5-year antimicrobial stewardship program focusing on fluoroquinolone prescriptions. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2021; 29:616-621. [PMID: 34355739 DOI: 10.1093/ijpp/riab047] [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: 01/26/2021] [Accepted: 07/02/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Within the context of the wide use of fluoroquinolones (FQs) and the emergence of multidrug-resistant bacteria, French recommendations concerning the appropriate use of systemic FQs in adults were published in 2015. This study assessed the impact of antibiotic stewardship intervention on the use of FQs over a 5-year period. METHODS Five annual audits were performed to evaluate FQ prescriptions. Following the baseline audit, a campaign of appropriate antibiotic use was initiated with courses on antibiotics including FQs. All audits included quantitative and qualitative evaluations to calculate an index of therapeutic adequacy (ITA) with six criteria: indication, molecule type, dosage, duration, route of administration and association. These audits were performed annually from 2015 to 2019. KEY FINDINGS The number of prescriptions decreased substantially from 90 in 2015 to 17 in 2019. This reduction was consistent with consumption data, such that the defined daily dose for 1000 bed days diminished from 67 in 2015 to 42 in 2019. Between 2015 and 2016, the ITA decreased significantly from 3.27 to 1.79 (P = 0.001), corresponding to an improvement in prescription quality. The ITA stabilised between 2016 and 2019. Moreover, improvements were observed in the proportion of entirely conforming prescriptions, conformity of indications, choice of molecule type among FQs and proportion of prescriptions with non-conforming treatment durations. CONCLUSIONS Between 2015 and 2019, we observed quantitative and qualitative improvements in FQ prescriptions within the hospital. Prescription follow-up through annual audits, combined with training courses, contributed to consistent results.
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Affiliation(s)
- Stéphane Pédeboscq
- Pharmacy Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Nahema Issa
- Intensive Care and Infectious Disease Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Marin Lahouati
- Pharmacy Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Aurélie Labadie
- Pharmacy Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Sabine Pereyre
- Bacteriology Laboratory, University Hospital of Bordeaux, Bordeaux, France
| | - Fabrice Camou
- Intensive Care and Infectious Disease Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
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Egle L, Sauter K, Ockfen S, Haber M, Becker S, Wagenpfeil G, Zemlin M, Meyer S, Simon A. Retrospective audit of antibiotic use in a university general pediatrics department using hospital pharmacy dispensing data. GMS INFECTIOUS DISEASES 2021; 9:Doc06. [PMID: 34956817 PMCID: PMC8662896 DOI: 10.3205/id000075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Antibiotics are among the most frequently prescribed drugs in children's hospitals, which is why regular monitoring of antibiotic use in hospitals is of great importance. This retrospective audit (60 months, January 2014 - December 2018) analyzes the antibiotic consumption at a university inpatient department of general pediatrics including neonatal and pediatric intensive care based on pharmacy dispensing data in units of grams per 100 patient days and in Defined Daily Doses per 100 patient days. The results provide potential targets for Antibiotic Stewardship interventions. Conversely, this audit elicits methodological limitations of the method of antibiotic surveillance in pediatrics recommended by the Robert Koch Institute, Berlin.
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Affiliation(s)
- Leonie Egle
- Pediatric Hematology and Oncology, Children’s Hospital Medical Center, Saarland University Hospital, Homburg/Saar, Germany
| | - Katharina Sauter
- Pediatric Hematology and Oncology, Children’s Hospital Medical Center, Saarland University Hospital, Homburg/Saar, Germany
| | - Svenja Ockfen
- Pediatric Hematology and Oncology, Children’s Hospital Medical Center, Saarland University Hospital, Homburg/Saar, Germany
| | - Manfred Haber
- Pharmacy, Saarland University Hospital, Homburg/Saar, Germany
| | - Sören Becker
- Center for Infectious Diseases, Institute of Medical Microbiology and Hygiene, Saarland University Hospital, Homburg/Saar, Germany
| | - Gudrun Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, University Medical Center, Saarland University, Campus Homburg, Homburg, Germany
| | - Michael Zemlin
- Department Clinic for General Pediatrics and Neonatology, Children’s Hospital Medical Center, Saarland University Hospital, Homburg/Saar, Germany
| | - Sascha Meyer
- Department Clinic for General Pediatrics and Neonatology, Children’s Hospital Medical Center, Saarland University Hospital, Homburg/Saar, Germany
| | - Arne Simon
- Pediatric Hematology and Oncology, Children’s Hospital Medical Center, Saarland University Hospital, Homburg/Saar, Germany,*To whom correspondence should be addressed: Arne Simon, Pediatric Oncology and Hematology, Children’s Hospital Medical Center, Saarland University Hospital, Kirrberger Str. Building 09, 66424 Homburg/Saar, Germany, Phone: +49 6841 1628409, Fax: +49 6841 1628424, E-mail:
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10
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Lee AS, Huttner BD, Catho G, Harbarth S. Methicillin-Resistant Staphylococcus aureus: An Update on Prevention and Control in Acute Care Settings. Infect Dis Clin North Am 2021; 35:931-952. [PMID: 34752226 DOI: 10.1016/j.idc.2021.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of health-care-associated infections. Controversies regarding the effectiveness of various control strategies have contributed to varying approaches to MRSA control. However, new evidence from large-scale studies has emerged, particularly concerning screening and decolonization. Importantly, implementation and outcomes of control measures in practice are not only influenced by scientific evidence, but also economic, administrative, and political factors, as demonstrated by decreasing MRSA rates in a number of countries after concerted and coordinated efforts at a national level. Flexibility to adapt measures based on local epidemiology and resources is essential for successful MRSA control.
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Affiliation(s)
- Andie S Lee
- Departments of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, University of Sydney, Missenden Road, Camperdown, Sydney, NSW 2050, Australia.
| | - Benedikt D Huttner
- Division of Infectious Diseases, University of Geneva Hospitals, University of Geneva, Rue Gabrielle-Perret-Gentil 4, Geneva CH-1205, Switzerland
| | - Gaud Catho
- Infection Control Programme, University of Geneva Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva CH-1205, Switzerland
| | - Stephan Harbarth
- Infection Control Programme, University of Geneva Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva CH-1205, Switzerland
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11
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Acceptability and effectiveness of antimicrobial stewardship implementation strategies on fluoroquinolone prescribing. Infect Control Hosp Epidemiol 2021; 42:1361-1368. [PMID: 33843527 PMCID: PMC9999290 DOI: 10.1017/ice.2021.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the effectiveness and acceptability of antimicrobial stewardship-focused implementation strategies on inpatient fluoroquinolones. METHODS Stewardship champions at 15 hospitals were surveyed regarding the use and acceptability of strategies to improve fluoroquinolone prescribing. Antibiotic days of therapy (DOT) per 1,000 days present (DP) for sites with and without prospective audit and feedback (PAF) and/or prior approval were compared. RESULTS Among all of the sites, 60% had PAF or prior approval implemented for fluoroquinolones. Compared to sites using neither strategy (64.2 ± 34.4 DOT/DP), fluoroquinolone prescribing rates were lower for sites that employed PAF and/or prior approval (35.5 ± 9.8; P = .03) and decreased from 2017 to 2018 (P < .001). This decrease occurred without an increase in advanced-generation cephalosporins. Total antibiotic rates were 13% lower for sites with PAF and/or prior approval, but this difference did not reach statistical significance (P = .20). Sites reporting that PAF and/or prior approval were "completely" accepted had lower fluoroquinolone rates than sites where it was "moderately" accepted (34.2 ± 5.7 vs 48.7 ± 4.5; P < .01). Sites reported that clinical pathways and/or local guidelines (93%), prior approval (93%), and order forms (80%) "would" or "may" be effective in improving fluoroquinolone use. Although most sites (73%) indicated that requiring infectious disease consults would or may be effective in improving fluoroquinolones, 87% perceived implementation to be difficult. CONCLUSIONS PAF and prior approval implementation strategies focused on fluoroquinolones were associated with significantly lower fluoroquinolone prescribing rates and nonsignificant decreases in total antibiotic use, suggesting limited evidence for class substitution. The association of acceptability of strategies with lower rates highlights the importance of culture. These results may indicate increased acceptability of implementation strategies and/or sensitivity to FDA warnings.
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12
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Yoon YK, Kwon KT, Jeong SJ, Moon C, Kim B, Kiem S, Kim HS, Heo E, Kim SW. Guidelines on Implementing Antimicrobial Stewardship Programs in Korea. Infect Chemother 2021; 53:617-659. [PMID: 34623784 PMCID: PMC8511380 DOI: 10.3947/ic.2021.0098] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Korean Society for Antimicrobial Therapy, Seoul, Korea
| | - Ki Tae Kwon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Korean Society of Infectious Diseases, Seoul, Korea
| | - Chisook Moon
- Korean Society of Infectious Diseases, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Bongyoung Kim
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungmin Kiem
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyung-Sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Eunjeong Heo
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Shin-Woo Kim
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
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13
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Okeah BO, Morrison V, Huws JC. Antimicrobial stewardship and infection prevention interventions targeting healthcare-associated Clostridioides difficile and carbapenem-resistant Klebsiella pneumoniae infections: a scoping review. BMJ Open 2021; 11:e051983. [PMID: 34348956 PMCID: PMC8340296 DOI: 10.1136/bmjopen-2021-051983] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/23/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES This study assessed antimicrobial stewardship (AMS) and infection prevention (IP) interventions targeting healthcare-associated Clostridioides difficile and carbapenem-resistant Klebsiella pneumoniae (CRKP) infections, their key outcomes and the application of behaviour change principles in these interventions. DESIGN This scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines while focusing on acute healthcare settings in both low-to-middle income and high-income countries. DATA SOURCES The databases searched were MEDLINE, PubMed, Web of Science and CINAHL between 22 April 2020 and 30 September 2020. ELIGIBILITY The review included peer-reviewed articles published in English language between 2010 and 2019. Studies that focussed on IP and/or AMS interventions primarily targeting C. difficile or CRKP were included. Studies that assessed effectiveness of diagnostic devices or treatment options were excluded from this review. DATA EXTRACTION AND SYNTHESIS An abstraction sheet calibrated for this study was used to extract data on the main study characteristics including the population, intervention and outcomes of interest (antimicrobial use, compliance with IP interventions and risk for C. difficile and CRKP). A narrative synthesis of the results is provided. RESULTS The review included 34 studies. Analysis indicates that interventions targeting C. difficile and CRKP include Education, Surveillance/Screening, Consultations, Audits, Policies and Protocols, Environmental measures, Bundles, Isolation as well as Notifications or alerts (represented using the ESCAPE-BIN acronym). The identified outcomes include antimicrobial use, resistance rates, risk reduction, adherence to contact precautions, hospital stay and time savings. AMS and IP interventions tend to be more adhoc with limited application of behaviour change principles. CONCLUSION This scoping review identified the AMS and IP interventions targeting C. difficile and CRKP in healthcare settings and described their key outcomes. The application of behaviour change principles in AMS and IP interventions appears to be limited.
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Affiliation(s)
| | | | - Jaci C Huws
- School of Medical & Health Sciences, Bangor University, Bangor, UK
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14
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Impact of antifungal stewardship interventions on the susceptibility of colonized Candida species in pediatric patients with malignancy. Sci Rep 2021; 11:14099. [PMID: 34238976 PMCID: PMC8266849 DOI: 10.1038/s41598-021-93421-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 06/18/2021] [Indexed: 12/28/2022] Open
Abstract
There is a worldwide concern regarding the antimicrobial resistance and the inappropriate use of antifungal agents, which had led to an ever-increasing antifungal resistance. This study aimed to identify the antifungal susceptibility of colonized Candida species isolated from pediatric patients with cancer and evaluate the clinical impact of antifungal stewardship (AFS) interventions on the antifungal susceptibility of colonized Candida species. Candida species colonization was evaluated among hospitalized children with cancer in a tertiary teaching hospital, Shiraz 2017–2018. Samples were collected from the mouth, nose, urine, and stool of the patients admitted to our center and cultured on sabouraud dextrose agar. The isolated yeasts identified by polymerase chain reaction–restriction fragment length polymorphisms (PCR–RFLP). DNA Extracted and PCR amplification was performed using the ITS1 and ITS4 primer pairs and Msp I enzyme. The broth microdilution method was used to determine the minimum inhibitory concentrations (MICs) for amphotericin B, caspofungin, and azoles. The prevalence of Candida albicans in the present study was significantly higher than other Candida species. Candida albicans species were completely susceptible to the azoles. The susceptibility rate of C. albicans to amphotericin B and caspofungin was 93.1% and 97.1%, respectively. The fluconazole MIC values of Candida albicans decreased significantly during the post-AFS period (P < 0.001; mean difference: 72.3; 95% CI of the difference: 47.36–98.62). We found that 52.5% (53/117) of the isolated C. albicans were azole-resistant before AFS implementation, while only 1.5% (2/102) of the isolates were resistant after implementation of the AFS program (P < 0.001). C. albicans fluconazole and caspofungin resistant rate also decreased significantly (P < 0.001) after implementation of the AFS program [26 (32.9%) versus 0 (0.0%) and 11 (10.9%) versus 1 (0.9%), respectively]. Besides, fluconazole use (p < 0.05) and fluconazole expenditure reduced significantly (about one thousand US$ per year) after the AFS program. Our results confirm the positive effect of optimized antifungal usage and bedside intervention on the susceptibility of Candida species after the implementation of the AFS program. C. albicans and C. glabrata exhibited a significant increase in susceptibility after the execution of the AFS program.
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15
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Gerber JS, Jackson MA, Tamma PD, Zaoutis TE. Policy Statement: Antibiotic Stewardship in Pediatrics. J Pediatric Infect Dis Soc 2021; 10:641-649. [PMID: 33595086 DOI: 10.1093/jpids/piab002] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/04/2021] [Indexed: 11/15/2022]
Abstract
Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting the use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy and duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs (ASPs); essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient ASPs are provided.
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Affiliation(s)
- Jeffrey S Gerber
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mary Anne Jackson
- Department of Pediatrics, Section of Infectious Disease, Children's Mercy Hospital, UMKC School of Medicine, Kansas City, Missouri, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Pediatric Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Theoklis E Zaoutis
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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16
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Chukwu EE, Oshun PO, Osuolale KA, Chuka-Ebene VO, Salako A, Idigbe IE, Oladele D, Audu RA, Ogunsola FT. Antimicrobial stewardship programmes in healthcare facilities in Lagos State, Nigeria: a needs assessment. J Glob Antimicrob Resist 2021; 25:162-170. [PMID: 33812050 DOI: 10.1016/j.jgar.2021.02.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/29/2021] [Accepted: 02/23/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Optimising antibiotic use in healthcare settings through antimicrobial stewardship programmes (ASPs) is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antimicrobial resistance. This needs assessment was designed to provide the current status of ASPs in healthcare facilities in Lagos State and identify gaps for future interventions. METHODS A descriptive cross-sectional survey was conducted using a self-administered questionnaire to ascertain the extent and nature of ongoing ASPs among selected healthcare facilities and identify gaps for future interventional studies. RESULTS Of 32 questionnaires distributed, 25 (78%) were completed and returned from three tertiary, six secondary, eleven primary and five private healthcare facilities. The mean years of practice of respondents was 13.96 ± 7.8 years (2-31 years). Six facilities (24%) had a team responsible for ASP operating at varying degrees of capacity, while five (20%) had a formal ASP. All six facilities with an antimicrobial stewardship (AMS) team had a medical doctor as the team lead, and 5 (20%) also had a pharmacist involved in implementation efforts. Routine pre-authorisation for specific antibiotic was performed in six facilities (24%), four of which monitor pre-authorisation interventions. Only two facilities (8%) performed prospective audit and feedback for specific antibiotic agents. Private healthcare facilities were more likely to have information technology (IT) capability to support the needs of AMS activities. CONCLUSION This study revealed minimal ASP activities in healthcare facilities in Lagos State and highlighted possibilities of leveraging on available IT resources for a co-ordinated AMS strategy.
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Affiliation(s)
- Emelda E Chukwu
- Microbiology Department, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria.
| | - Philip O Oshun
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos State, Nigeria
| | - Kazeem A Osuolale
- Monitoring and Evaluation Unit, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | | | - Abideen Salako
- Clinical Science Department, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Ifeoma E Idigbe
- Clinical Science Department, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - David Oladele
- Clinical Science Department, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Rosemary A Audu
- Microbiology Department, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Folasade T Ogunsola
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos State, Nigeria
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17
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Abstract
Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy, duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs; essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient antibiotic stewardship programs are provided.
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Affiliation(s)
- Jeffrey S Gerber
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
| | - Mary Anne Jackson
- Section of Infectious Disease, Department of Pediatrics, Children's Mercy Hospital and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; and
| | - Pranita D Tamma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Theoklis E Zaoutis
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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18
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Kazakova SV, Baggs J, McDonald LC, Yi SH, Hatfield KM, Guh A, Reddy SC, Jernigan JA. Association Between Antibiotic Use and Hospital-onset Clostridioides difficile Infection in US Acute Care Hospitals, 2006-2012: An Ecologic Analysis. Clin Infect Dis 2020; 70:11-18. [PMID: 30820545 DOI: 10.1093/cid/ciz169] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/25/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Unnecessary antibiotic use (AU) contributes to increased rates of Clostridioides difficile infection (CDI). The impact of antibiotic restriction on hospital-onset CDI (HO-CDI) has not been assessed in a large group of US acute care hospitals (ACHs). METHODS We examined cross-sectional and temporal associations between rates of hospital-level AU and HO-CDI using data from 549 ACHs. HO-CDI was defined as a discharge with a secondary International Classification of Diseases, Ninth Revision, Clinical Modification code for CDI (008.45), and treatment with metronidazole or oral vancomycin > 3 days after admission. Analyses were performed using multivariable generalized estimating equation models adjusting for patient and hospital characteristics. RESULTS During 2006-2012, the unadjusted annual rates of HO-CDI and total AU were 7.3 per 10 000 patient-days (PD) (95% confidence interval [CI], 7.1-7.5) and 811 days of therapy (DOT)/1000 PD (95% CI, 803-820), respectively. In the cross-sectional analysis, for every 50 DOT/1000 PD increase in total AU, there was a 4.4% increase in HO-CDI. For every 10 DOT/1000 PD increase in use of third- and fourth-generation cephalosporins or carbapenems, there was a 2.1% and 2.9% increase in HO-CDI, respectively. In the time-series analysis, the 6 ACHs with a ≥30% decrease in total AU had a 33% decrease in HO-CDI (rate ratio, 0.67 [95% CI, .47-.96]); ACHs with a ≥20% decrease in fluoroquinolone or third- and fourth-generation cephalosporin use had a corresponding decrease in HO-CDI of 8% and 13%, respectively. CONCLUSIONS At an ecologic level, reductions in total AU, use of fluoroquinolones, and use of third- and fourth-generation cephalosporins were each associated with decreased HO-CDI rates.
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Affiliation(s)
- Sophia V Kazakova
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - James Baggs
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sarah H Yi
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kelly M Hatfield
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alice Guh
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sujan C Reddy
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John A Jernigan
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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19
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Goltsman G, Gal G, Mizrahi EH, Mardanov S, Pinco E, Lubart E. The impact of intensive staff education on rate of Clostridium difficile-associated disease in hospitalized geriatric patients. Aging Clin Exp Res 2020; 32:2393-2398. [PMID: 31776858 DOI: 10.1007/s40520-019-01424-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 11/15/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Toxin-producing Clostridium difficile is the most common cause of nosocomial diarrhea in geriatric units. AIM The purpose of study was to check the impact of intensive staff education on rate of Clostridium difficile-associated disease in hospitalized geriatric patients. METHODS The sampling frame was all patients suffering from diarrhea checked for Clostridium difficile toxin during the years 2017-2018. Clostridium difficile-positive patients were compared to a similar number of Clostridium difficile toxin-negative patients. The data were compared to our previous study, followed by medical staff's educational program for Clostridium difficile control and prevention. RESULTS Among 217 patients with diarrhea, 60 (27.6%) were positive for Clostridium difficile toxin. The study group tended to be of older age (p = 0.06), and showed higher rate of functional impairment (p < 0.001) and mortality (p < 0.001) than Clostridium difficile toxin negative patients. The rate of Clostridium difficile toxin-positive patients did not significantly differ between the previous and current studies (20.0% and 27.6%, respectively). CONCLUSIONS AND DISCUSSION In spite of findings, that patients tended to be older, with high rate of mortality, the rate of Clostridium difficile did not change from the previous study.
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Affiliation(s)
- G Goltsman
- Internal Medicine Department, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Internal Medicine G Department, Asaf Harofeh Medical Center, Zerifin, 70300, Israel
| | - G Gal
- School of Behavioral Sciences, Tel Aviv-Yaffo Academic College, Jaffa, Israel
| | - E H Mizrahi
- Internal Medicine Department, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Acute Geriatric Department A, Shmuel Harofe Geriatric Medical Center, POB 2, Be'er Ya'akov, Israel
| | - S Mardanov
- Acute Geriatric Department A, Shmuel Harofe Geriatric Medical Center, POB 2, Be'er Ya'akov, Israel
| | - E Pinco
- Acute Geriatric Department A, Shmuel Harofe Geriatric Medical Center, POB 2, Be'er Ya'akov, Israel
| | - Emily Lubart
- Internal Medicine Department, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Acute Geriatric Department A, Shmuel Harofe Geriatric Medical Center, POB 2, Be'er Ya'akov, Israel.
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20
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Stephenson B, Lanzas C, Lenhart S, Ponce E, Bintz J, Dubberke ER, Day J. Comparing intervention strategies for reducing Clostridioides difficile transmission in acute healthcare settings: an agent-based modeling study. BMC Infect Dis 2020; 20:799. [PMID: 33115427 PMCID: PMC7594474 DOI: 10.1186/s12879-020-05501-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 10/12/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is one of the most common healthcare infections. Common strategies aiming at controlling CDI include antibiotic stewardship, environmental decontamination, and improved hand hygiene and contact precautions. Mathematical models provide a framework to evaluate control strategies. Our objective is to evaluate the effectiveness of control strategies in decreasing C. difficile colonization and infection using an agent-based model in an acute healthcare setting. METHODS We developed an agent-based model that simulates the transmission of C. difficile in medical wards. This model explicitly incorporates healthcare workers (HCWs) as vectors of transmission, tracks individual patient antibiotic histories, incorporates varying risk levels of antibiotics with respect to CDI susceptibility, and tracks contamination levels of ward rooms by C. difficile. Interventions include two forms of antimicrobial stewardship, increased environmental decontamination through room cleaning, improved HCW compliance, and a preliminary assessment of vaccination. RESULTS Increased HCW compliance with CDI patients was ranked as the most effective intervention in decreasing colonizations, with reductions up to 56%. Antibiotic stewardship practices were highly ranked after contact precaution compliance. Vaccination and reduction of high-risk antibiotics were the most effective intervention in decreasing CDI. Vaccination reduced CDI cases to up to 90%, and the reduction of high-risk antibiotics decreased CDI cases up to 23%. CONCLUSIONS Overall, interventions that decrease patient susceptibility to colonization by C. difficile, such as antibiotic stewardship, were the most effective interventions in reducing both colonizations and CDI cases.
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Affiliation(s)
- Brittany Stephenson
- Department of Engineering, Computing, and Mathematical Sciences, Lewis University, 1 University Parkway, Romeoville, 60446 IL USA
| | - Cristina Lanzas
- Department of Population Health and Pathobiology, North Carolina State University, 1052 William Moore Drive, Raleigh, 27606 NC USA
| | - Suzanne Lenhart
- Department of Mathematics, University of Tennessee, 1403 Circle Drive, Knoxville, 37996 TN USA
| | - Eduardo Ponce
- Department of Electrical Engineering and Computer Science, University of Tennessee, 1520 Middle Drive, Knoxville, 37996 TN USA
| | - Jason Bintz
- School of Arts and Sciences, Johnson University, Knoxville, 37998 TN USA
| | - Erik R. Dubberke
- Division of Infectious Disease, Washington University School of Medicine, 660 S Euclid Ave, St. Louis, 63110 MO USA
| | - Judy Day
- Department of Mathematics, University of Tennessee, 1403 Circle Drive, Knoxville, 37996 TN USA
- Department of Electrical Engineering and Computer Science, University of Tennessee, 1520 Middle Drive, Knoxville, 37996 TN USA
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21
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Nachtigall I, Tafelski S, Heucke E, Witzke O, Staack A, Recknagel-Friese S, Geffers C, Bonsignore M. Time and personnel requirements for antimicrobial stewardship in small hospitals in a rural area in Germany. J Infect Public Health 2020; 13:1946-1950. [PMID: 33121907 DOI: 10.1016/j.jiph.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/02/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND In order to control their anti-infectives consumption, hospitals are required to provide multidisciplinary teams comprising among others an infectiologist, a microbiologist and a pharmacist. Small hospitals though often do not dispose of the defaulted personnel. This study illustrates a solution for an antimicrobial stewardship program (ASP) in small community hospitals in a rural area in Germany. METHODS Four hospitals of ca. 200 beds each, jointly hired an antimicrobial stewardship expert to start a common ASP. This expert did rounds on every ward once a week, mostly as chard reviews with the physician in charge. Outside the rounds, he could be consulted by mail. Working time and number of visited patients were documented. Anti-infectives consumption, incidence of Clostridioides difficile infections (CDI) and mortality rates were retrieved from routinely collected data. The intervention period (01/2018-12/2018) was compared to the preintervention period (01/2017-12/2017). RESULTS 3321 patients were visited in the intervention period. In average, 20 patients were seen per day and 20 min were needed per patient/ chard. About 65% of the expert's working time was needed for rounds, 15% for driving between the hospitals. The anti-infectives consumption of the 4 hospitals in the preintervention period amounted to 50 defined daily doses per 100 occupied bed days. The total consumption was reduced by 10% and of quinolones by 36%. The incidence of hospital-acquired CDI receded from 0.14 to 0.07 cases per 100 patient days (-50%, p = 0.001). The overall in-hospital mortality did not change. CONCLUSIONS A single expert was able to implement a successfull ASP in 4 hospitals. While multidisciplinary antimicrobial stewardship teams are ideal for tertiary care hospitals, small hospitals need a more practical solution. This survey shows that one expert can be sufficient for several small hospitals even with the distances in a rural setting.
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Affiliation(s)
- Irit Nachtigall
- Department for Hygiene, Helios Kliniken Ost and Bad Saarow, Pieskower Str. 33, 15526 Bad Saarow, Germany; Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt Operative Intensivmedizin, Campus Charité Mitte, Charitéplatz 1, 10115 Berlin, Germany.
| | - Sascha Tafelski
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt Operative Intensivmedizin, Campus Charité Mitte, Charitéplatz 1, 10115 Berlin, Germany
| | - Edwin Heucke
- Helios Cluster Saxony-Anhalt, Helios Bördeklinik, Kreiskrankenhaus 4, 39387 Oschersleben, Germany
| | - Oliver Witzke
- Universitätsmedizin Essen, Department of Infectious Diseases, West German Centre of Infectious Diseases, University Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Annedore Staack
- Helios Klinik Jerichower Land, August-Bebel-Str. 55a, 39288 Burg, Germany
| | | | - Christine Geffers
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Hygiene und Umweltmedizin, Hindenburgdamm 27, 12203 Berlin, Germany
| | - Marzia Bonsignore
- Zentrum für Hygiene, Evangelische Kliniken Gelsenkirchen, Munckelstr. 27, 45879 Gelsenkirchen, Germany.
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22
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Vaughn VM, Gandhi TN, Chopra V, Petty LA, Giesler DL, Malani AN, Bernstein SJ, Hsaiky LM, Pogue JM, Dumkow L, Ratz D, McLaughlin ES, Flanders SA. Antibiotic Overuse after Hospital Discharge: A Multi-Hospital Cohort Study. Clin Infect Dis 2020; 73:e4499-e4506. [PMID: 32918077 PMCID: PMC7947015 DOI: 10.1093/cid/ciaa1372] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/09/2020] [Indexed: 12/19/2022] Open
Abstract
Background Antibiotics are commonly prescribed to patients as they leave the hospital. We aimed to create a comprehensive metric to characterize antibiotic overuse after discharge among hospitalized patients treated for pneumonia or urinary tract infection (UTI), and to determine whether overuse varied across hospitals and conditions. Methods In a retrospective cohort study of hospitalized patients treated for pneumonia or UTI in 46 hospitals between 1 July 2017–30 July 2019, we quantified the proportion of patients discharged with antibiotic overuse, defined as unnecessary antibiotic use, excess antibiotic duration, or suboptimal fluoroquinolone use. Using linear regression, we assessed hospital-level associations between antibiotic overuse after discharge in patients treated for pneumonia versus a UTI. Results Of 21 825 patients treated for infection (12 445 with pneumonia; 9380 with a UTI), nearly half (49.1%) had antibiotic overuse after discharge (56.9% with pneumonia; 38.7% with a UTI). For pneumonia, 63.1% of overuse days after discharge were due to excess duration; for UTIs, 43.9% were due to treatment of asymptomatic bacteriuria. The percentage of patients discharged with antibiotic overuse varied 5-fold among hospitals (from 15.9% [95% confidence interval, 8.7%–24.6%] to 80.6% [95% confidence interval, 69.4%–88.1%]) and was strongly correlated between conditions (regression coefficient = 0.85; P < .001). Conclusions Antibiotic overuse after discharge was common and varied widely between hospitals. Antibiotic overuse after discharge was associated between conditions, suggesting that the prescribing culture, physician behavior, or organizational processes contribute to overprescribing at discharge. Multifaceted efforts focusing on all 3 types of overuse and multiple conditions should be considered to improve antibiotic prescribing at discharge.
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Affiliation(s)
- Valerie M Vaughn
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Vineet Chopra
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Daniel L Giesler
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Division of Infectious Diseases, Department of Internal Medicine, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Department of Infection Prevention and Control, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Steven J Bernstein
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA.,Division of General Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Lama M Hsaiky
- Department of Pharmaceutical Services, Beaumont Hospital Dearborn, Dearborn, Michigan
| | - Jason M Pogue
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Lisa Dumkow
- Department of Clinical Pharmacy Services, Mercy Health Saint Mary's, Grand Rapids, USA
| | - David Ratz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Elizabeth S McLaughlin
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
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23
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Tischendorf J, Brunner M, Knobloch MJ, Schulz L, Barker A, Wright MO, Lepak A, Safdar N. Evaluation of a successful fluoroquinolone restriction intervention among high-risk patients: A mixed-methods study. PLoS One 2020; 15:e0237987. [PMID: 32841259 PMCID: PMC7446965 DOI: 10.1371/journal.pone.0237987] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/06/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We conducted a quality improvement initiative to restrict fluoroquinolone prescribing on two inpatient units housing high-risk patients and applied a human factors approach to understanding the barriers and facilitators to success of this intervention by front-line providers. METHODS This was a mixed-methods, quasi-experimental study. This study was conducted on two inpatient units at a tertiary care academic medical center: the medical-surgical intensive care and abdominal solid organ transplant units. Unit-level data were collected retrospectively for 24 months pre- and post- fluoroquinolone restriction intervention, implemented in July 2016, for all admissions to the study units. Our restriction intervention required antimicrobial stewardship pre-approval for fluoroquinolone prescribing. We explored barriers and facilitators to optimal fluoroquinolone prescribing using semi-structured interviews attending, fellow and resident physicians, advanced practice providers and pharmacists on these units. RESULTS Hospital-onset C. difficile infection did not decrease significantly, but fluoroquinolone use declined significantly from 111.6 to 19.8 days of therapy per 1000 patient-days without negatively impacting length of stay, readmissions or mortality. Third generation cephalosporin and aminoglycoside use increased post-restriction. Providers identified our institution's strong antimicrobial stewardship program and pharmacy involvement in antimicrobial decision making as key facilitators of fluoroquinolone optimization and patient complexity, lack of provider education and organizational culture as barriers to optimal prescribing. CONCLUSIONS Fluoroquinolones can be safely restricted even among high-risk patients without negatively impacting length of stay, readmissions or mortality. Our study provides a framework for successful antimicrobial stewardship interventions informed by perceptions of front line providers.
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Affiliation(s)
- Jessica Tischendorf
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Matthew Brunner
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Mary Jo Knobloch
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States of America
| | - Lucas Schulz
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, United States of America
| | - Anna Barker
- Department of Population Health Sciences, University of Wisconsin Madison, Madison, Wisconsin, United States of America
- Department of Internal Medicine, University of Michigan Ann Arbor, Ann Arbor, Michigan, United States of America
| | - Marc-Oliver Wright
- Infection Prevention Program, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, United States of America
| | - Alexander Lepak
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States of America
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24
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Vandael E, Magerman K, Coenen S, Goossens H, Catry B. Antibiotic consumption in Belgian acute care hospitals: analysis of the surveillance methodology, consumption evolution 2003 to 2016 and future perspectives. ACTA ACUST UNITED AC 2020; 24. [PMID: 31771707 PMCID: PMC6864973 DOI: 10.2807/1560-7917.es.2019.24.46.1900098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BackgroundStudies have demonstrated the link between antimicrobial consumption and the development of antimicrobial resistance. Surveillance of antimicrobial consumption is an action point of the European Commission's 'One Health Action Plan Against Antimicrobial Resistance'.AimThis study aims to compare two methodologies for antibiotic consumption surveillance, investigate the 14-year evolution of antibiotic consumption in Belgian acute care hospitals and discuss future perspectives.MethodsWe compared self-reported data (old methodology) and reimbursement data (new methodology) of national antibiotic consumption surveillance in hospitals. Descriptive analyses were performed on the reimbursement data collected per year and per trimester (2003-2016), per hospital and per unit. Antibiotic consumption was compared with European Surveillance of Antimicrobial Consumption Network (ESAC-Net) results.ResultsThe median differences for defined daily doses (DDDs)/1,000 patient days and DDDs/1,000 admissions were 3.09% and 3.94% when comparing the old vs new methodology. Based on reimbursement data, the median antibiotic consumption in 2016 in 102 Belgian acute care hospitals was 577.1 DDDs/1,000 patient days and 3,890.3 DDDs/1,000 admissions with high variation between hospitals (interquartile ranges (IQR): 511.3-655.0 and 3,450.0-4,400.5, respectively), and similar to 2015. Based on DDDs/1,000 patient days, the magnitude of consumption is comparable with the Netherlands, Denmark and Sweden, but is higher when based on DDDs/1,000 admissions.ConclusionAntibiotic consumption in Belgian acute care hospitals has remained overall stable over time. However, the high variation across hospitals should be further investigated. This surveillance data could be used for benchmarking and assessing interventions to improve antibiotic consumption in these hospitals.
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Affiliation(s)
- Eline Vandael
- Healthcare-associated infections and antimicrobial resistance, Sciensano, Brussels, Belgium
| | - Koen Magerman
- Department of Microbiology, UHasselt, Hasselt, Belgium.,Jessa Hospital, Hasselt, Belgium.,Belgian Antibiotic Policy Coordination Committee (BAPCOC), Brussels, Belgium
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.,Belgian Antibiotic Policy Coordination Committee (BAPCOC), Brussels, Belgium
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium.,Belgian Antibiotic Policy Coordination Committee (BAPCOC), Brussels, Belgium
| | - Boudewijn Catry
- Faculty of Medicine, Université libre de Bruxelles (ULB), Brussels, Belgium.,Healthcare-associated infections and antimicrobial resistance, Sciensano, Brussels, Belgium
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25
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Wilder-Smith A, Gillespie T, Taylor DR. Antimicrobial use and misuse at the end of life: a retrospective analysis of a treatment escalation/limitation plan. J R Coll Physicians Edinb 2020; 49:188-192. [PMID: 31497784 DOI: 10.4997/jrcpe.2019.304] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Antimicrobial treatment is common at end of life. A treatment escalation/limitation plan (TELP) offers the opportunity to avoid non-beneficial treatment in critically ill patients. Our aim was to evaluate antimicrobial prescribing in terminally ill patients, and assess whether it was modified using a TELP. METHODS Appropriateness of antimicrobial treatment was audited using a priori criteria in 94 consecutive hospital deaths. Prescribing in patients whose death was expected/unexpected, and who had a TELP with/without a 'ceiling' for antimicrobials, were compared. RESULTS Twenty three of 94 patients (24.5%) were receiving antimicrobials at time of death. This was not influenced by evidence of infection or whether death was expected. The use of a TELP (n = 81) with an antimicrobial 'ceiling' (28 with, 53 without) was associated with a significant reduction in antimicrobials administered (28.6% vs 81.1%; p < 0.0005). CONCLUSIONS Many complex factors contribute to antimicrobial misuse at end of life. An appropriately constructed TELP reduces inappropriate prescribing.
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Affiliation(s)
- Adrian Wilder-Smith
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | | | - D Robin Taylor
- Department of Respiratory Medicine, University Hospital Wishaw, Wishaw ML2 0DP, UK, .,College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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26
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Zequinao T, Gasparetto J, Oliveira DDS, Silva GT, Telles JP, Tuon FF. A broad-spectrum beta-lactam-sparing stewardship program in a middle-income country public hospital: antibiotic use and expenditure outcomes and antimicrobial susceptibility profiles. Braz J Infect Dis 2020; 24:221-230. [PMID: 32504551 PMCID: PMC9392143 DOI: 10.1016/j.bjid.2020.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 05/03/2020] [Accepted: 05/07/2020] [Indexed: 12/17/2022] Open
Abstract
Background Antimicrobial stewardship programs are an efficient way to reduce inappropriate use of antimicrobials and costs; however, supporting data are scarce in middle-income countries. The aim of this study was to evaluate antibiotic use, bacterial susceptibility profiles, and the economic impact following implementation of a broad-spectrum beta-lactam-sparing antimicrobial stewardship program. Methods An interrupted time-series analysis was performed to evaluate antibiotic use and expenditure over a 24-month period (12 months before the antimicrobial stewardship program and in the 12 months after implementation of the antimicrobial stewardship program). Antibiotics were classified into one of two groups: beta-lactam antibiotics and beta-lactam-sparing antibiotics. We also compared the antimicrobial susceptibility profiles of key pathogens in each period. Results Beta-lactam antibiotics use decreased by 43.04 days of therapy/1000 patient-days (p = 0.04) immediately following antimicrobial stewardship program implementation, whereas beta-lacta-sparing antibiotics use increased during the intervention period (slope change 6.17 days of therapy/1000 patient-days, p < 0.001). Expenditure decreased by $2089.99 (p < 0.001) immediately after intervention and was maintained at this level over the intervention period ($−38.45; p = 0.24). We also observed that a greater proportion of pathogens were susceptible to cephalosporins and aminoglycosides after the antimicrobial stewardship program. Conclusions The antimicrobial stewardship program significantly reduced the use of broad-spectrum beta-lactam-antibiotics associated with a decrease in expenditure and maintenance of the susceptibility profile in Gram-negative bacteria.
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Affiliation(s)
- Tiago Zequinao
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Juliano Gasparetto
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | | | | | - João Paulo Telles
- Laboratory of Emerging Infectious Diseases, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil; AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Felipe Francisco Tuon
- Laboratory of Emerging Infectious Diseases, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil.
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27
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Prescriber perceptions of fluoroquinolones, extended-spectrum cephalosporins, and Clostridioides difficile infection. Infect Control Hosp Epidemiol 2020; 41:914-920. [PMID: 32468967 DOI: 10.1017/ice.2020.183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Fluoroquinolones (FQs) and extended-spectrum cephalosporins (ESCs) are associated with higher risk of Clostridioides difficile infection (CDI). Decreasing the unnecessary use of FQs and ESCs is a goal of antimicrobial stewardship. Understanding how prescribers perceive the risks and benefits of FQs and ESCs is needed. METHODS We conducted interviews with clinicians from 4 hospitals. Interviews elicited respondent perceptions about the risk of ESCs, FQs, and CDI. Interviews were audio recorded, transcribed, and analyzed using a flexible coding approach. RESULTS Interviews were conducted with 64 respondents (38 physicians, 7 nurses, 6 advance practice providers, and 13 pharmacists). ESCs and FQs were perceived to have many benefits, including infrequent dosing, breadth of coverage, and greater patient adherence after hospital discharge. Prescribers stated that it was easy to make decisions about these drugs, so they were especially appealing to use in the context of time pressures. They described having difficulty discontinuing these drugs when prescribed by others due to inertia and fear. Prescribers were skeptical about targeting specific drugs as a stewardship approach and felt that the risk of a negative outcome from under treatment of a suspected bacterial infection was a higher priority than the prevention of CDI. CONCLUSIONS Prescribers in this study perceived many advantages to using ESCs and FQs, especially under conditions of time pressure and uncertainty. In making decisions about these drugs, prescribers balance risk and benefit, and they believed that the risk of CDI was acceptable in compared with the risk of undertreatment.
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28
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Impact of implementing a non-restrictive antibiotic stewardship program in an emergency department: a four-year quasi-experimental prospective study. Sci Rep 2020; 10:8194. [PMID: 32424172 PMCID: PMC7235006 DOI: 10.1038/s41598-020-65222-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/27/2020] [Indexed: 11/08/2022] Open
Abstract
Antibiotic resistance is increasing worldwide. The implementation of antibiotic stewardship programmes (ASPs) is of utmost importance to optimize antibiotic use in order to prevent resistance development without harming patients. The emergency department (ED), cornerstone between hospital and community, represents a crucial setting for addressing ASP implementation; however, evidence data on ASP in ED are poor. In this study, a 4-year, non-restrictive, multi-faceted ASP was implemented in a general ED with the aim to evaluate its impact on antibiotic use and costs. Secondly, the study focused on assessing the impact on length of hospital stay (LOS), Clostridioides difficile infection (CDI) incidence rate, and mortality in the patients' group admitted from ED to medical wards. The ASP implementation was associated with a reduction of antibiotic use and costs. A mild but sustained LOS decrease in all medical wards and a significant downward trend of CDI incidence rate were observed, while mortality did not significantly change. In conclusion, the implementation of our ED-based ASP has demonstrated to be feasible and safe and might clinically benefit the hospital admitted patients' group. Further research is needed to identify the most suitable ASP design for ED and the key outcome measures to reliably assess its effectiveness.
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Karabay O, Ince N, Aypak A, Guclu E, Bodur H. Antibiotic usage in hospitalized patients: a one-day point prevalence study. J Chemother 2020; 32:188-192. [PMID: 32393151 DOI: 10.1080/1120009x.2020.1755592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Measurements are one of the most important means of evaluating the quality of antibiotic consumption. This study has evaluated the antibiotic consumption using one-day point prevalence study data collected from different hospitals in Turkey. This research was planned as a multicenter point surveillance study which aimed demonstrating the use of antibiotics among inpatients in Turkey. On the day of surveillance, demographic data from 21,920 inpatients, names of antibiotics used by the inpatients, number of antibiotics approved by infectious disease specialist (IDS), and the length of antibiotic use were recorded. These results showed that 30.3% of patients were using antibiotics and 57.7% of those were IDS-approved. The rate of IDS-approved antibiotic consumption was higher for internal medicine wards and in intensive care units, whereas non-IDS-approved antibiotics were used among inpatients of surgical wards.
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Affiliation(s)
- Oguz Karabay
- Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Sakarya University Education and Research Hospital, Sakarya, Turkey
| | - Nevin Ince
- Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Düzce University School of Medicine, Düzce, Turkey
| | - Adalet Aypak
- Clinic of infectious Diseases and Clinical Microbiology, Ankara Numune Teaching and Research Hospital, Health Sciences University, Ankara, Turkey
| | - Ertugrul Guclu
- Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Sakarya University Education and Research Hospital, Sakarya, Turkey
| | - Hurrem Bodur
- Clinic of infectious Diseases and Clinical Microbiology, Ankara Numune Teaching and Research Hospital, Health Sciences University, Ankara, Turkey
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30
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Chardavoyne PC, Kasmire KE. Appropriateness of Antibiotic Prescriptions for Urinary Tract Infections. West J Emerg Med 2020; 21:633-639. [PMID: 32421512 PMCID: PMC7234695 DOI: 10.5811/westjem.2020.1.45944] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/31/2020] [Indexed: 01/02/2023] Open
Abstract
Introduction Urinary tract infections (UTI) are a common indication for antibiotic use in the emergency department (ED). With antibiotic resistance on the rise, it is essential that antibiotics be prescribed appropriately for UTIs. Our objective was to evaluate the appropriateness of antibiotic prescriptions by ED providers for uncomplicated cystitis and pyelonephritis. Methods We conducted a retrospective study of females ages 2–50 years seen in an academic ED from January 2017 to April 2018 diagnosed with UTI. We assessed the appropriateness of discharge antibiotic prescriptions, as determined by adherence to clinical practice guidelines, best evidence for the particular indication (cystitis vs pyelonephritis for children and adults), and the local antibiogram. Results A total of 421 patients were included in this study. Of these, 60 children and 198 adults were diagnosed with cystitis, and 47 children and 116 adults were diagnosed with pyelonephritis. Treatment in the absence of true infection was common, with culture-confirmed UTI occurring in only 17/50 (34%) of children and 60/129 (47%) of adults diagnosed with cystitis, and 23/40 (58%) of children and 58/87 (67%) of adults diagnosed with pyelonephritis, among patients who had urine cultures. The type of antibiotic prescribed was appropriate in 53/60 (88%) of children and 135/198 (68%) of adults with cystitis, and 38/47 (81%) of children and 53/116 (46%) of adults with pyelonephritis. The most common inappropriate antibiotic types were beta-lactams in adults (n = 92), nitrofurantoin for pyelonephritis (n = 16), and amoxicillin (n = 15). Dosing and duration errors were also common, occurring in 122/279 (44%) of prescriptions of an appropriate antibiotic type. The frequency of errors in the type of antibiotic prescribed was similar among provider types (attending physician, resident physician, and advanced practice clinician; p = 0.926). Conclusion This study reveals room for improvement in antibiotic prescription practices across provider cohorts in the ED for the management of uncomplicated cystitis and pyelonephritis in females.
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Affiliation(s)
| | - Kathryn E Kasmire
- Pennsylvania State College of Medicine, Hershey, Pennsylvania.,Penn State Health Milton S. Hershey Medical Center, Division of Emergency Medicine, Hershey, Pennsylvania
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31
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Akpan MR, Isemin NU, Udoh AE, Ashiru-Oredope D. Implementation of antimicrobial stewardship programmes in African countries: a systematic literature review. J Glob Antimicrob Resist 2020; 22:317-324. [PMID: 32247077 DOI: 10.1016/j.jgar.2020.03.009] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/22/2020] [Accepted: 03/12/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Antimicrobial stewardship is one of the strategic objectives of the WHO global action plan on antimicrobial resistance. This paper sought to review the extent of implementation of antimicrobial stewardship programmes (ASPs) in African countries and the reported outcomes. METHODS We searched five electronic databases, including PubMed, Scopus, Cochrane library, African Journal Online, CINAHL and Google scholar for papers published between 1990 and March 2019. We combined the names of countries in the five regions of Africa with antimicrobial stewardship terms. Studies of any design, employing any stewardship strategies were included. The quality of included studies was assessed using the National Heart, Lung and Blood Institute (NHLBI) quality assessment tool for before and after studies. RESULTS Of 1752 titles identified, 13 studies met the criteria for inclusion. Seven of the studies were conducted in South Africa, three in Kenya and one each in Sudan, Tanzania and Egypt. Eleven studies were of high quality with low risk of bias. The included studies mainly assessed the outcome using process measures and these were associated with improved compliance with antibiotic guidelines, appropriateness of prescribing, reduction in antibiotic use and cost savings. Decrease in rate of surgical site infections and nonsignificant change in mortality and 30-day readmission rate were reported in two studies respectively. CONCLUSION Findings of this review show the paucity of data on implementation of ASPs in African countries. Although the continent is faced with challenges which impact on effective implementation of ASPs, the successes reported in the included studies show that other African countries can implement these programmes.
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Affiliation(s)
- Mary Richard Akpan
- Faculty of Pharmacy, University of Uyo, P.M.B. 1017, Uyo, Akwa Ibom State, Nigeria.
| | - Nsisong Udom Isemin
- Faculty of Pharmacy, University of Uyo, P.M.B. 1017, Uyo, Akwa Ibom State, Nigeria.
| | - Arit Esio Udoh
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom.
| | - Diane Ashiru-Oredope
- Antimicrobial Resistance Strategy, Public Health England, London, NW9 5EQ, United Kingdom.
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32
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Karp J, Edman-Wallér J, Toepfer M, Lundqvist A, Jacobsson G. Clostridioides difficile incidence related to in-hospital cephalosporin use: a tale of two highly comparable hospitals. J Antimicrob Chemother 2020; 74:182-189. [PMID: 30358837 DOI: 10.1093/jac/dky408] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/07/2018] [Indexed: 11/14/2022] Open
Abstract
Background Antibiotic treatment is a well-known risk factor for healthcare facility-associated Clostridioides (Clostridium) difficile infection (HCF-CDI). Antibiotic stewardship programmes (ASPs) targeting high-risk antibiotics have been shown to decrease HCF-CDI incidence. HCF-CDI incidence is high in Nordic countries despite relatively low antibiotic use in hospital. Objectives To determine if HCF-CDI incidence was modified by a hospital ASP that restricted cephalosporin use. Methods The effects of an ASP on HCF-CDI incidence were evaluated in a two-centre setting using a retrospective design. We exploited a strategy of both individual case ascertainment based on chart reviews and aggregated data from the hospitals. Cases were attributed to the antibiotics given prior to disease onset, in proportion to the number of DDDs used. Three periods were studied: 2007 (before the ASP), 2012 and 2015. Results At the ASP hospital, cephalosporin use decreased by 87% and the number of HCF-CDI/1000 hospital admissions decreased significantly from 2.25 (2007) to 1.16 (2015) (P = 0.0014). The corresponding results at the non-ASP hospital showed a non-significant increase from 2.09 to 2.38. A high number of cases could be attributed to cephalosporins at both hospitals. The increased use of other broad-spectrum antibiotics, e.g. piperacillin/tazobactam, at the ASP hospital was not associated with offsetting increases in attributable HCF-CDI cases. Conclusions Decreased use of cephalosporins is an effective strategy to decrease HCF-CDI incidence over time in a setting with high incidence and low antibiotic use.
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Affiliation(s)
- Johan Karp
- Department of Infectious Diseases, Skaraborg Hospital, Lövängsvägen, Skövde, Sweden.,Center for Antibiotic Resistance Research (CARe), Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Jon Edman-Wallér
- Center for Antibiotic Resistance Research (CARe), Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.,Department of Hospital Infection Control, Södra Älvsborg Hospital, Brämhultsvägen, Borås, Sweden
| | - Michael Toepfer
- Clinical Microbiology, Unilabs AB, Rådhusgatan 6, Skövde, Sweden
| | - Anders Lundqvist
- Department of Infectious Diseases, Södra Älvsborg Hospital, Brämhultsvägen 53, Borås, Sweden
| | - Gunnar Jacobsson
- Department of Infectious Diseases, Skaraborg Hospital, Lövängsvägen, Skövde, Sweden.,Center for Antibiotic Resistance Research (CARe), Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
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Dancer SJ. How Much Impact Do Antimicrobial Surfaces Really Have on Healthcare-acquired Infection? Clin Infect Dis 2019; 71:1814-1816. [DOI: 10.1093/cid/ciz1078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/25/2019] [Indexed: 01/03/2023] Open
Affiliation(s)
- Stephanie J Dancer
- Department of Microbiology, Hairmyres Hospital, NHS Lanarkshire, Scotland, United Kingdom
- School of Applied Sciences, Edinburgh Napier University, Scotland, United Kingdom
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Vallès J, Fernández S, Cortés E, Morón A, Fondevilla E, Oliva JC, Diaz E. Comparison of the defined daily dose and days of treatment methods for evaluating the consumption of antibiotics and antifungals in the intensive care unit. Med Intensiva 2019; 44:294-300. [PMID: 31378384 DOI: 10.1016/j.medin.2019.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/05/2019] [Accepted: 06/14/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To compare the measurement of antimicrobial consumption by defined daily dose (DDD) versus by days of therapy (DOT). DESIGN Retrospective analysis of clinical and administrative data from patients admitted to a polyvalent ICU. SETTING ICU at a University Hospital in Spain. PATIENTS All patients admitted to the ICU. INTERVENTIONS None. MAIN VARIABLES OF INTEREST For the DDD method, the World Health Organization (WHO)-assigned DDD was determined for the all the prescribed antimicrobials. For the DOT method, one DOT represented the administration of a single agent on a given day regardless of the number of doses administered. To express aggregate use, total DDDs and total DOTs were normalized to 100 patient-days. RESULTS During the study period, 2393 adult patients were admitted to the ICU. Total median antimicrobial drugs measured by DDDs was 535.3 (IQR 319.8-845.5) vs. 344.0 (IQR 117.2-544.5) when measured by DOTs, p<0.001. When antimicrobial consumption was normalized to 100 patient-days, median antimicrobial consumption was also higher when measured by DDDs [2.98/100 patient-days (IQR 1.76-5.25) vs. 1.89/100 patient-days (IQR 0.64-3.0) when measured by DOTs, p<0.001]. CONCLUSIONS For most antibacterial and antifungal drugs used in critically ill patients, estimates of aggregate antibiotic use by DDDs per 100 patient-days and DOTs per 100 patient-days are discordant because the administered dose is dissimilar from the WHO-assigned DDD. DOT methods should be recommended to avoid the overestimation that occurs with DDDs in adult critically ill patients.
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Affiliation(s)
- J Vallès
- Critical Care Department, Hospital Universitari Parc Taulí, Sabadell, Spain.
| | - S Fernández
- Critical Care Department, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - E Cortés
- Critical Care Department, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - A Morón
- Department of Pharmacy, Hospital Universitari Parc Taulí, Sabadell, Spain
| | | | - J C Oliva
- Critical Care Department, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - E Diaz
- Critical Care Department, Hospital Universitari Parc Taulí, Sabadell, Spain
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Munson E, Rodriguez S, Riederer N, Munson KL, Block D, Land G, Stone R, Villalobos A, Dewey E, Block TK. Outcome of Electronic Order Alert Intervention Relative to Toxigenic Clostridium difficile PCR Analysis and Hospital-Onset C difficile Infection in a Multihospital Health Care System. Am J Clin Pathol 2019; 151:622-627. [PMID: 30989227 DOI: 10.1093/ajcp/aqz022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 12/23/2018] [Accepted: 02/21/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Concern exists regarding overdiagnosis of Clostridium difficile infection (CDI) via molecular modalities. We determined effects of a preanalytic order intervention on laboratory and CDI prevention measures in a multihospital system. METHODS Intervals before and following implementation of a CDI electronic order alert (relative to appropriate testing scenario) were assessed for C difficile test volume and positivity rate, hospital-onset CDI frequency, and hospital-onset C difficile standardized infection ratio (SIR). C difficile detection occurred by PCR throughout the study. RESULTS During the first half of 2015, testing volume was 1,578, with 88 hospital-onset CDIs. Following implementation, 18.9% and 56.8% reductions in volume and hospital-onset CDIs were realized, respectively, in the first half of 2017. Regression analysis revealed decreasing trends in PCR volume, positivity rate, hospital-onset CDI frequency, and SIR in larger facilities. CONCLUSIONS Preanalytic considerations affect not only the microbiology laboratory but also hospital infection prevention in the context of CDI.
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Affiliation(s)
- Erik Munson
- College of Health Sciences, Marquette University, Milwaukee, WI
- Wisconsin Clinical Laboratory Network Technical Advisory Group, Madison
| | | | - Nancy Riederer
- Wheaton Franciscan Healthcare, Ascension Wisconsin, Milwaukee
| | | | - Denise Block
- Wheaton Franciscan Healthcare, Ascension Wisconsin, Milwaukee
| | - Gayle Land
- Wheaton Franciscan Healthcare, Ascension Wisconsin, Milwaukee
| | - Rosalyn Stone
- Wheaton Franciscan Healthcare, Ascension Wisconsin, Milwaukee
| | | | - Erin Dewey
- College of Health Sciences, Marquette University, Milwaukee, WI
| | - Timothy K Block
- Wisconsin Clinical Laboratory Network Technical Advisory Group, Madison
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Patton A, Davey P, Harbarth S, Nathwani D, Sneddon J, Marwick CA. Impact of antimicrobial stewardship interventions on Clostridium difficile infection and clinical outcomes: segmented regression analyses. J Antimicrob Chemother 2019; 73:517-526. [PMID: 29177477 DOI: 10.1093/jac/dkx413] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 10/10/2017] [Indexed: 12/12/2022] Open
Abstract
Background Antimicrobial exposure is associated with increased risk of Clostridium difficile infection (CDI), but the impact of prescribing interventions on CDI and other outcomes is less clear. Objectives To evaluate the effect of an antimicrobial stewardship intervention targeting high-risk antimicrobials (HRA), implemented in October 2008, and to compare the findings with similar studies from a systematic review. Methods All patients admitted to Medicine and Surgery in Ninewells Hospital from October 2006 to September 2010 were included. Intervention effects on HRA use (dispensed DDD), CDI cases and mortality rates, per 1000 admissions per month, were analysed separately in Medicine and Surgery using segmented regression of interrupted time series (ITS) data. Data from comparable published studies were reanalysed using the same method. Results Six months post-intervention, there were relative reductions in HRA use of 33% (95% CI 11-56) in Medicine and 32% (95% CI 19-46) in Surgery. At 12 months, there was an estimated reduction in CDI of 7.0 cases/1000 admissions [relative change -24% (95% CI - 55 to 6)] in Medicine, but no change in Surgery {estimated 0.1 fewer cases/1000 admissions [-2% (95% CI - 116 to 112)]}. Mortality reduced throughout the study period, unaffected by the intervention. In all six comparable studies, HRA use reduced significantly, but reductions in CDI rates were only statistically significant in two and none measured mortality. Pre-intervention CDI rates and trends influenced the intervention effect. Conclusions Despite large reductions in HRA prescribing and reductions in CDI, demonstrating real-world impact of stewardship interventions remains challenging.
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Affiliation(s)
- Andrea Patton
- Population Health Sciences, School of Medicine, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK.,Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Delta House, West Nile Street, Glasgow G1 2NP, UK
| | - Peter Davey
- Population Health Sciences, School of Medicine, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Dilip Nathwani
- Department of Infection and Immunodeficiency, East Block, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Delta House, West Nile Street, Glasgow G1 2NP, UK
| | - Charis A Marwick
- Population Health Sciences, School of Medicine, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK.,Department of Infection and Immunodeficiency, East Block, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
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Metz J, Oehler P, Burggraf M, Burdach S, Behrends U, Rieber N. Improvement of Guideline Adherence After the Implementation of an Antibiotic Stewardship Program in a Secondary Care Pediatric Hospital. Front Pediatr 2019; 7:478. [PMID: 31799227 PMCID: PMC6865353 DOI: 10.3389/fped.2019.00478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/30/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction: The accelerating threat of multidrug-resistant bacteria (MRB) forces health care providers to use antibiotics more rationally. Antibiotic stewardship programs (ASP) are a proven and safe way to achieve that goal. They have been comprehensively studied in adults but data from secondary care pediatric hospitals are lacking. Material and Methods: In our study an ASP with standard operating procedures (SOPs), audits, a weekly ward round with experts in pediatric infectious diseases and an antibiotic pocket-card for selected infectious diseases was established in July 2017 in a Munich municipal secondary care children's hospital. All antibiotic prescriptions on general pediatric wards were reviewed each in the first quarter of 2017 and 2018. The primary outcome was adherence to treatment guidelines. Secondary outcomes were substance consumption, duration of therapy and death. Results: After the ASP was implemented guideline adherence increased significantly from 33 to 63%. The consumption of cephalosporins decreased significantly (-60%), whereas aminopenicillin use increased accordingly (+120%). Neither in the pre- nor in the post-intervention group deaths occurred. Discussion: Data on ASP in pediatric secondary care hospitals are scarce. Most previous studies have been performed at tertiary care/university children's hospitals. We demonstrate a significant improvement in guideline adherence regarding antibiotic treatments after the implementation of an ASP. Cephalosporin consumption decreased which might be relevant for the selection of MRB (e.g., vancomycin-resistant enterococci). Results are limited by the single-center design and the short observation period. The study encourages the implementation of ASPs in secondary care children's hospitals.
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Affiliation(s)
- Jakob Metz
- Klinik für Kinder- und Jugendmedizin, München Klinik Schwabing und Harlaching; and Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany
| | - Philipp Oehler
- Klinik für Kinder- und Jugendmedizin, München Klinik Schwabing und Harlaching; and Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany
| | - Manuela Burggraf
- Klinik für Kinder- und Jugendmedizin, München Klinik Schwabing und Harlaching; and Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany
| | - Stefan Burdach
- Klinik für Kinder- und Jugendmedizin, München Klinik Schwabing und Harlaching; and Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany
| | - Uta Behrends
- Klinik für Kinder- und Jugendmedizin, München Klinik Schwabing und Harlaching; and Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany.,German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| | - Nikolaus Rieber
- Klinik für Kinder- und Jugendmedizin, München Klinik Schwabing und Harlaching; and Department of Pediatrics, Technical University of Munich School of Medicine, Munich, Germany.,Children's Hospital, University of Tübingen, Tübingen, Germany
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Abstract
Microbes like bacteria, virus, parasites and fungi may naturally colonize skin and mucous membranes without any sign of illness, for a longer or shorter period, in all humans, animals, fish, parasites, plants and all other living beings. Some types may be more invasive in human tissue than others. Many microbes are free-living in the environment—in water, soil and air and on equipment—as a part of the normal microbial flora on the Earth. Most of them are not dangerous and live in peaceful symbiosis with other living beings and may also be transferred between living species, from man to animal or man to plants and environment—and vice versa. New and old human pathogenic microbes are increasing all over the world. Some agents, like drug-resistant bacteria and highly pathogenic viruses, are more dangerous than others, and some microbes may cause chronic devastating diseases. Transmission routes depend on the robustness of the microbe in the environment, virulence, infectious dose, anatomical site in the body, etc. Pathogenic microbes are spread by contact, air, water, food, beverages, contaminated equipment and environment and are more seldom vector-borne, by insects or animals. The following chapter is focused on the most frequent pathogenic microbes, their preselected localization in the body, transmission routes and survival in the environment.
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Bennett N, Schulz L, Boyd S, Newland JG. Understanding inpatient antimicrobial stewardship metrics. Am J Health Syst Pharm 2018; 75:230-238. [PMID: 29436469 DOI: 10.2146/ajhp160335] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Nicholas Bennett
- Department of Pharmacy, Saint Luke's Health System, Kansas City, MO
| | - Lucas Schulz
- Department of Pharmacy, University of Wisconsin Hospitals and Clinics, Madison, WI
| | - Sarah Boyd
- Department of Infectious Diseases, Saint Luke's Health System, Kansas City, MO
| | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.,St. Louis Children's Hospital, St. Louis, MO
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Fernando SA, Gray TJ, Gottlieb T. Healthcare-acquired infections: prevention strategies. Intern Med J 2018; 47:1341-1351. [PMID: 29224205 DOI: 10.1111/imj.13642] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 06/01/2017] [Accepted: 06/01/2017] [Indexed: 12/24/2022]
Abstract
Healthcare-acquired infections (HAI) impact on patient care and have cost implications for the Australian healthcare system. The management of HAI is exacerbated by rising rates of antimicrobial resistance (AMR). Health-care workers and a contaminated hospital environment are increasingly implicated in the transmission and persistence of multi-resistant organisms (MRO), as well as other pathogens, such as Clostridium difficile. This has resulted in a timely focus on a range of HAI prevention actions. Core components include antimicrobial stewardship, to reduce overuse and ensure evidence-based antimicrobial use; infection prevention strategies, to control MRO - particularly methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. (VRE) and, more recently, multi-resistant Gram-negative bacteria; enhanced institutional investment in hand hygiene; hospital cleaning and disinfection; and the development of prescribing guidelines and standards of care. AMR surveillance and comparisons of prescribing are useful feedback activities once effectively communicated to end users. Successful implementation of these strategies requires cultural shifts at local hospital level and, to tackle the serious threat posed by AMR, greater co-ordination at a national level. HAI prevention needs to be multi-modal, requires broad healthcare collaboration, and the strong support and accountability of all medical staff.
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Affiliation(s)
- Shelanah A Fernando
- Department of Microbiology & Infectious Diseases, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Timothy J Gray
- Department of Microbiology & Infectious Diseases, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Thomas Gottlieb
- Department of Microbiology & Infectious Diseases, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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Mizuno S, Iwami M, Kunisawa S, Naylor N, Yamashita K, Kyratsis Y, Meads G, Otter JA, Holmes AH, Imanaka Y, Ahmad R. Comparison of national strategies to reduce meticillin-resistant Staphylococcus aureus infections in Japan and England. J Hosp Infect 2018; 100:280-298. [PMID: 30369423 DOI: 10.1016/j.jhin.2018.06.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/28/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND National responses to healthcare-associated infections vary between high-income countries, but, when analysed for contextual comparability, interventions can be assessed for transferability. AIM To identify learning from country-level approaches to addressing meticillin-resistant Staphylococcus aureus (MRSA) in Japan and England. METHODS A longitudinal analysis (2000-2017), comparing epidemiological trends and policy interventions. Data from 441 textual sources concerning infection prevention and control (IPC), surveillance, and antimicrobial stewardship interventions were systematically coded for: (a) type: mandatory requirements, recommendations, or national campaigns; (b) method: restrictive, persuasive, structural in nature; (c) level of implementation: macro (national), meso (organizational), micro (individual) levels. Healthcare organizational structures and role of media were also assessed. FINDINGS In England significant reduction has been achieved in number of reported MRSA bloodstream infections. In Japan, in spite of reductions, MRSA remains a predominant infection. Both countries face new threats in the emergence of drug-resistant Escherichia coli. England has focused on national mandatory and structural interventions, supported by a combination of outcomes-based incentives and punitive mechanisms, and multi-disciplinary IPC hospital teams. Japan has focused on (non-mandatory) recommendations and primarily persuasive interventions, supported by process-based incentives, with voluntary surveillance. Areas for development in Japan include resourcing of dedicated data management support and implementation of national campaigns for healthcare professionals and the public. CONCLUSION Policy interventions need to be relevant to local epidemiological trends, while acceptable within the health system, culture, and public expectations. Cross-national learning can help inform the right mix of interventions to create sustainable and resilient systems for future infection and economic challenges.
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Affiliation(s)
- S Mizuno
- Department of Healthcare Economics and Quality Management, Kyoto University, Japan
| | - M Iwami
- Division of Infectious Diseases, Imperial College London, London, UK
| | - S Kunisawa
- Department of Healthcare Economics and Quality Management, Kyoto University, Japan
| | - N Naylor
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
| | - K Yamashita
- Department of Healthcare Economics and Quality Management, Kyoto University, Japan
| | - Y Kyratsis
- Health Services Research & Management Division, School of Health Sciences, City University of London, London, UK
| | - G Meads
- Health and Wellbeing Research Group, University of Winchester, Winchester, UK
| | - J A Otter
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK; Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - A H Holmes
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK; Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Y Imanaka
- Department of Healthcare Economics and Quality Management, Kyoto University, Japan
| | - R Ahmad
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK; Health Group, Management Department, Imperial College Business School, London, UK.
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King A, Mullish BH, Williams HRT, Aylin P. Comparative epidemiology of Clostridium difficile infection: England and the USA. Int J Qual Health Care 2018; 29:785-791. [PMID: 29025123 DOI: 10.1093/intqhc/mzx120] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 08/23/2017] [Indexed: 12/18/2022] Open
Abstract
Objective To examine whether there is an epidemiological difference between Clostridium difficile infection (CDI) inpatient populations in England and the United States. Design A cross-sectional study. Setting National administrative inpatient discharge data from England (Hospital Episode Statistics) and the USA (National Inpatient Sample) in 2012. Participants De-identifiable non-obstetric inpatient discharges from the national datasets were used to estimate national CDI incidence in the United States and England using ICD9-CM(008.45) and ICD10(A04.7) respectively. Main outcome measures The rate of CDI was calculated per 100 000 population using national population estimates. Rate per 100 000 inpatient discharges was also calculated separated by primary and secondary diagnosis of CDI. Age, sex and Elixhauser comorbidities profiles were examined. Results The USA had a higher rate of CDI compared to England: 115.1/100 000 vs. 19.3/100 000 population (P < 0.001). CDI age profiles differed between the countries (P < 0.001): in England, patients ≥75 years constitute a larger proportion of CDI cases, whilst those aged 25-70 constitute more cases in the US (P < 0.001). Overall adjusted odds of CDI in females compared to males was elevated in both England (odds ratios (OR) 1.26 95% CI [1.21,1.31] P < 0.001) and the USA (OR 1.20 95% CI [1.18,1.22] P < 0.001). The proportion of CDI patients with comorbidities was greater in the USA compared to England apart from dementia, which was greater in England (9.63% vs. 1.25%, P < 0.0001). Conclusions The 2012 inpatient CDI rate within the USA was much higher than in England. Age and comorbidity profiles also differed between CDI patients in both countries. The reasons for this are likely multi-factorial but may reflect national infection control policy.
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Affiliation(s)
- Alice King
- Dr Foster Unit at Imperial College London, 3 Dorset Rise, London EC4Y 8EN, UK
| | - Benjamin H Mullish
- Division of Digestive Diseases, Department of Surgery and Cancer, Faculty of Medicine, St Mary's Hospital Campus, Imperial College London, South Wharf Road, London W2 1NY, UK
| | - Horace R T Williams
- Division of Digestive Diseases, Department of Surgery and Cancer, Faculty of Medicine, St Mary's Hospital Campus, Imperial College London, South Wharf Road, London W2 1NY, UK
| | - Paul Aylin
- Dr Foster Unit at Imperial College London, 3 Dorset Rise, London EC4Y 8EN, UK
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Bertollo LG, Lutkemeyer DS, Levin AS. Are antimicrobial stewardship programs effective strategies for preventing antibiotic resistance? A systematic review. Am J Infect Control 2018; 46:824-836. [PMID: 29472107 DOI: 10.1016/j.ajic.2018.01.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/05/2018] [Accepted: 01/05/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) have been proposed as a solution for the global burden of antibiotic resistance, despite the lack of evidence on the subject. OBJECTIVE To analyze the role of ASPs in reducing bacterial resistance to antibiotics in hospital settings. DATA SOURCES A review in PubMed, Scopus, LILACS, and SciELO databases was performed. The period analyzed was January 1, 2012-January 4, 2017. ELIGIBILITY CRITERIA Studies that related ASPs to bacterial resistance. DATA EXTRACTION All studies that did not focus on ASPs were removed. Antifungal and antiviral programs were excluded. RESULTS Only 8 studies had quasi-experimental designs, and none were controlled trials. ASP strategies and microorganism-antibiotic pairs evaluated varied widely. Seven studies were classified as presenting clearly positive results, 3 had limited positive results, 7 had doubtful results, 4 had negative results, and 5 had noninterpretable results. The implementation of new infection control practices occurred in 7 studies. LIMITATIONS There are yet few studies on this matter, and most of them have inadequate study designs. Great heterogeneity between study features was detrimental to drawing evidence-based conclusions. CONCLUSIONS There is no solid evidence that ASPs are effective in reducing antibiotic resistance in hospital settings. We uphold the need for more studies with appropriate study designs, standardized ASP interventions targeting common microorganism-antibiotic pairs, and avoiding simultaneous implementation of infection control practices.
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Affiliation(s)
- Leandro G Bertollo
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Diego S Lutkemeyer
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Anna S Levin
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Claeys KC, Hopkins TL, Vega AD, Heil EL. Fluoroquinolone Restriction as an Effective Antimicrobial Stewardship Intervention. Curr Infect Dis Rep 2018; 20:7. [PMID: 29572691 DOI: 10.1007/s11908-018-0615-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Fluoroquinolones are a commonly prescribed antibiotic class that has come under scrutiny in recent years due to mounting evidence of association between adverse drug events, C. difficile infection and isolation of antibiotic-resistant bacteria. RECENT FINDINGS Inpatient antimicrobial stewardship (AMS) programs have a toolbox of potential interventions to curb inappropriate antibiotic use, prevent antibiotic-associated adverse drug events, and avoid unnecessary costs of care. Fluoroquinolone restriction policies in the acute care setting have demonstrated beneficial effects, including decreased rates of C. difficile infection and ESBL-producing Enterobacteriaceae. However, a simple blanket restriction policy may "squeeze the antibiotic balloon" and will likely be insufficient if not implemented in conjunction with other AMS interventions. There is a growing body of evidence to support formulary restriction of fluoroquinolones in the acute care setting to decrease rates of C. difficile infection and development of ESBL-producing organisms. Data on how to best implement these restrictions or how to implement outside of acute care settings is limited.
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Affiliation(s)
- Kimberly C Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, N423, Baltimore, MD, 21201, USA. .,Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA.
| | - Teri L Hopkins
- Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Ana D Vega
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, N423, Baltimore, MD, 21201, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, N423, Baltimore, MD, 21201, USA.,Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
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McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018; 66:e1-e48. [PMID: 29462280 PMCID: PMC6018983 DOI: 10.1093/cid/cix1085] [Citation(s) in RCA: 1253] [Impact Index Per Article: 208.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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Affiliation(s)
| | | | - Stuart Johnson
- Edward Hines Jr Veterans Administration Hospital, Hines
- Loyola University Medical Center, Maywood, Illinois
| | | | - Karen C Carroll
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
| | | | - Carolyn V Gould
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciaran Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vivian Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
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Crew PE, Rhodes NJ, O'Donnell JN, Miglis C, Gilbert EM, Zembower TR, Qi C, Silkaitis C, Sutton SH, Scheetz MH. Correlation between hospital-level antibiotic consumption and incident health care facility-onset Clostridium difficile infection. Am J Infect Control 2018; 46:270-275. [PMID: 29169938 DOI: 10.1016/j.ajic.2017.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 09/12/2017] [Accepted: 09/12/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND The purpose of this single-center, ecologic study is to characterize the relationship between facility-wide (FacWide) antibiotic consumption and incident health care facility-onset Clostridium difficile infection (HO-CDI). METHODS FacWide antibiotic consumption and incident HO-CDI were tallied on a monthly basis and standardized, from January 2013 through April 2015. Spearman rank-order correlation coefficients were calculated using matched-months analysis and a 1-month delay. Regression analyses were performed, with P < .05 considered statistically significant. RESULTS FacWide analysis identified a matched-months correlation between ceftriaxone and HO-CDI (ρ = 0.44, P = .018). A unit of stem cell transplant recipients did not have significant correlation between carbapenems and HO-CDI in matched months (ρ = 0.37, P = .098), but a significant correlation was observed when a 1-month lag was applied (ρ = 0.54, P = .014). DISCUSSION Three statistically significant lag associations were observed between FacWide/unit-level antibiotic consumption and HO-CDI, and 1 statistically significant nonlagged association was observed FacWide. Antibiotic consumption may convey extended ward-level risk for incident CDI. CONCLUSIONS Consumption of antibiotic agents may have immediate and prolonged influence on incident CDI. Additional studies are needed to investigate the immediate and delayed associations between antibiotic consumption and C difficile colonization, infection, and transmission at the hospital level.
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Affiliation(s)
- Page E Crew
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL; Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL
| | - Nathaniel J Rhodes
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL; Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL
| | - J Nicholas O'Donnell
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL; Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL
| | - Cristina Miglis
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL; Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL
| | - Elise M Gilbert
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL; Department of Pharmacy Practice, College of Pharmacy, Chicago State University, Chicago, IL
| | - Teresa R Zembower
- Department of Internal Medicine, Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, IL
| | - Chao Qi
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Christina Silkaitis
- Department of Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, IL
| | - Sarah H Sutton
- Department of Internal Medicine, Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Healthcare Epidemiology and Infection Prevention, Northwestern Memorial Hospital, Chicago, IL
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL; Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL.
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Henderson A, Nimmo GR. Control of healthcare- and community-associated MRSA: recent progress and persisting challenges. Br Med Bull 2018; 125:25-41. [PMID: 29190327 DOI: 10.1093/bmb/ldx046] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/31/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Healthcare adapted meticillin-resistant Staphylococcus aureus (MRSA) has spread to hospitals around the world over 50 years. More recently, other strains of MRSA have emerged with the ability to spread in the community and infect otherwise healthy individuals. Morbidity and mortality associated with MRSA remains high and its control in both the healthcare and community setting has proven challenging. SOURCES OF DATA Pubmed (Medline). AREAS OF AGREEMENT The use of targeted screening and decolonization, hand hygiene and antimicrobial stewardship is supported by the most robust studies, though many studies have implemented bundles for effective healthcare-associated (HA)-MRSA control. AREAS OF CONTENTION Universal screening, universal decolonization and contact precautions for HA-MRSA control are supported by less evidence. Some interventions may not be cost-effective. Contact precautions may be associated with potential for patient harm. Evidence for effective control community acquired (CA)-MRSA is largely lacking. GROWING POINTS Programmes that focus on implementing bundles of interventions aimed at targeting HA-MRSA are more likely to be effective, with an emphasis on hand hygiene as a key component. Control of CA-MRSA is likely to be more difficult to achieve and relies on prevalence, risk factors and community healthcare interactions on a broader scale. AREAS TIMELY FOR DEVELOPING RESEARCH Further research in the area of CA-MRSA in particular is required. Antimicrobial stewardship for both CA and HA-MRSA is promising, as is the role of whole genome sequencing in characterizing transmission. However, further work is required to assess their long-term roles in controlling MRSA. With many institutions applying widespread use of chlorhexidine washes, monitoring for chlorhexidine resistance is paramount to sustaining efforts at controlling MRSA.
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Affiliation(s)
- Andrew Henderson
- Infection Management Services, Princess Alexandra Hospital, Woolloongabba, Queensland 4102, Australia.,School of Chemistry and Molecular Biosciences, University of Queensland, St Lucia, Queensland 4067, Australia.,University of Queensland Centre for Clinical Research, Herston, Queensland 4029, Australia
| | - Graeme R Nimmo
- Pathology Queensland Central Laboratory, Herston, Queensland 4029, Australia.,School of Medicine, Griffith University, Southport 4222, Queensland, Australia
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Clostridium Difficile Infection in Acute Care Hospitals: Systematic Review and Best Practices for Prevention. Infect Control Hosp Epidemiol 2018; 38:476-482. [PMID: 28300019 DOI: 10.1017/ice.2016.324] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Prevention of Clostridium difficile infection (CDI) in acute-care hospitals is a priority for hospitals and clinicians. We performed a qualitative systematic review to update the evidence on interventions to prevent CDI published since 2009. DESIGN We searched Ovid, MEDLINE, EMBASE, The Cochrane Library, CINAHL, the ISI Web of Knowledge, and grey literature databases from January 1, 2009 to August 1, 2015. SETTING We included studies performed in acute-care hospitals. PATIENTS OR PARTICIPANTS We included studies conducted on hospitalized patients that investigated the impact of specific interventions on CDI rates. INTERVENTIONS We used the QI-Minimum Quality Criteria Set (QI-MQCS) to assess the quality of included studies. Interventions were grouped thematically: environmental disinfection, antimicrobial stewardship, hand hygiene, chlorhexidine bathing, probiotics, bundled approaches, and others. A meta-analysis was performed when possible. RESULTS Of 3,236 articles screened, 261 met the criteria for full-text review and 46 studies were ultimately included. The average quality rating was 82% according to the QI-MQCS. The most effective interventions, resulting in a 45% to 85% reduction in CDI, included daily to twice daily disinfection of high-touch surfaces (including bed rails) and terminal cleaning of patient rooms with chlorine-based products. Bundled interventions and antimicrobial stewardship showed promise for reducing CDI rates. Chlorhexidine bathing and intensified hand-hygiene practices were not effective for reducing CDI rates. CONCLUSIONS Daily and terminal cleaning of patient rooms using chlorine-based products were most effective in reducing CDI rates in hospitals. Further studies are needed to identify the components of bundled interventions that reduce CDI rates. Infect Control Hosp Epidemiol 2017;38:476-482.
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Antimicrobial Stewardship Efforts to Improve Management of Uncomplicated Urinary Tract Infections in the Ambulatory Care Setting: a Review. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0150-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Is cohorting the only solution to control carbapenemase-producing Enterobacteriaceae outbreaks? A single-centre experience. J Hosp Infect 2018; 99:390-395. [PMID: 29438727 DOI: 10.1016/j.jhin.2018.02.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 02/05/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Carbapenemase-producing Enterobacteriaceae (CPE) are a major health issue. Cohorting may help to control spread of CPEs in hospitals, but is expensive and hard to implement. AIM To identify ward variables associated with CPE in-hospital transmission in a hospital where cohorting has never been implemented. METHODS Cohort prospective study, comparing 14-consecutive-day periods regarding in-hospital transmission. Each period met the two following conditions: (i) CPE carriers/infected admitted for ≥48 h; (ii) 80% of relative contact patients were screened at least twice. Periods (a) with no acquired CPE case among relative contact patients were compared to periods (b) during which one or more CPE case acquisition was identified. Variables potentially associated with CPE transmission were assessed: colonization pressure, caregiver:patient ratio, hand hygiene compliance, hydro-alcoholic product consumption, antibiotic consumption, and infection control team (ICT) involvement on the ward. FINDINGS Sixty-eight periods of two consecutive weeks were included, 18 (26.5%) included at least one CPE case acquisition. By multivariate analysis, colonization pressure (odds ratio: 1.12; 95% confidence interval: 1.0-1.25; P = 0.042) and antibiotic consumption (2.41; 1.02-5.66; P = 0.044) were associated with CPE in-hospital transmission. Caregiver:patient ratio potentiated both these variables, suggesting a role for understaffing in CPE transmission. CONCLUSION Understanding ward variables associated with CPE spread can help design suitable solutions. Colonization pressure and antibiotic consumption seems to be driving in-hospital transmission, along with caregiver:patient ratio. In presence of high colonization pressure, dedicated healthcare workers for managing CPE patients should be implemented. Co-ordination between ICT and antimicrobial stewardship team is also crucial to prevent CPE spread.
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