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Yoo JS, Park JY, Chun HJ, Kim YR, Kim EJ, Choi YH, Ha KH, Heo JY. Impact of prolonged carbapenem use-focused antimicrobial stewardship on antimicrobial consumption and factors affecting acceptance of recommendations: a quasi-experimental study. Sci Rep 2023; 13:14501. [PMID: 37666900 PMCID: PMC10477184 DOI: 10.1038/s41598-023-41710-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/30/2023] [Indexed: 09/06/2023] Open
Abstract
This study aimed to assess the impact of a prolonged carbapenem use-focused antimicrobial stewardship program (ASP) on antimicrobial consumption and clinical outcomes and to analyze factors affecting adherence to interventions. Patients prescribed carbapenems for ≥ 2 weeks received intervention. Interrupted time-series analysis was performed to compare antimicrobial consumption before and after intervention. Factors associated with non-adherence to intervention were investigated. Of 273 patients who were eligible for intervention, discontinuation or de-escalation was recommended in 256 (94.1%) and intervention was accepted in 136 (53.1%) patients. Before intervention, carbapenem consumption significantly increased to 1.14 days of therapy (DOT)/1000 patient days (PD)/month (P = 0.018). However, it significantly declined by - 2.01 DOT/1000 PD/month without an increase in other antibiotic consumption (P < 0.001). Factors affecting non-adherence to intervention were younger age (odds ratio [OR] = 0.98; 95% confidence interval [CI] 0.96-1.00), solid organ malignancy (OR = 2.53, 95% CI 1.16-5.50), and pneumonia (OR = 2.59, 95% CI 1.08-6.17). However, ASP intervention was not associated with clinical outcomes such as length of hospital stay or mortality. Prolonged carbapenem prescription-focused ASP significantly reduced carbapenem consumption without adverse outcomes. Non-adherence to interventions was attributed more to prescriber-related factors, such as attitude, than patient-related factors including clinical severity.
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Affiliation(s)
- Jin Sae Yoo
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
- Department of Acute Care Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jeong Yong Park
- Department of Pharmaceutical Service, Ajou University Hospital, Suwon, Republic of Korea
| | - Ha-Jin Chun
- Department of Pharmaceutical Service, Ajou University Hospital, Suwon, Republic of Korea
| | - Young Rong Kim
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Eun Jin Kim
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Young Hwa Choi
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Kyoung Hwa Ha
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea.
| | - Jung Yeon Heo
- Department of Infectious Diseases, Ajou University School of Medicine, Worldcup-ro, 164, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Republic of Korea.
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Song JU, Lee J. The impact of antimicrobial de-escalation therapy in culture-negative pneumonia: a systematic review and meta-analysis. Korean J Intern Med 2023; 38:704-713. [PMID: 37586813 PMCID: PMC10493446 DOI: 10.3904/kjim.2023.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/07/2023] [Accepted: 06/09/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND/AIMS Antimicrobial de-escalation (ADE) remains a challenging strategy in the treatment of pneumonia. We investigated the outcomes of ADE as measured by mortality and duration of the use of antibiotics in patients with culture- negative pneumonia. METHODS We performed a systematic review and meta-analysis in accordance with PRISMA guidelines. The primary outcome was inpatient mortality. RESULTS We examined six studies comprising 11,933 subjects, of whom 1,152 received ADE. Overall, the ADE strategy was associated with a statistically lower risk of in-hospital mortality compared with non-ADE (risk ratio [RR] = 0.60, 95% confidence interval [CI] = 0.38 to 0.93). Although substantial heterogeneity was found among the included studies (I2 = 66%), a meta-regression analysis could not reveal plausible sources of heterogeneity. And ADE was associated with a shorter duration of total and initial antibiotic therapies and total length of hospital stay compared with non-ADE. CONCLUSION Our findings suggest that ADE seems to be significantly associated with better clinical outcomes compared with non-ADE. Caution is demanded when interpreting data of this study because of substantial between-study heterogeneity.
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Affiliation(s)
- Jae-Uk Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Jonghoo Lee
- Department of Internal Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Jeju,
Korea
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Ilges D, Ritchie DJ, Krekel T, Neuner EA, Hampton N, Kollef MH, Micek S. Assessment of Antibiotic De-escalation by Spectrum Score in Patients With Nosocomial Pneumonia: A Single-Center, Retrospective Cohort Study. Open Forum Infect Dis 2021; 8:ofab508. [PMID: 34805436 PMCID: PMC8600177 DOI: 10.1093/ofid/ofab508] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/11/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Hospital-acquired and ventilator-associated pneumonia (HAP/VAP) cause significant mortality. Guidelines recommend empiric broad-spectrum antibiotics followed by de-escalation (DE). This study sought to assess the impact of DE on treatment failure. METHODS This single-center retrospective cohort study screened all adult patients with a discharge diagnosis code for pneumonia from 2016 to 2019. Patients were enrolled if they met predefined criteria for HAP/VAP ≥48 hours after admission. Date of pneumonia diagnosis was defined as day 0. Spectrum scores were calculated, and DE was defined as a score reduction on day 3 versus day 1. Patients with DE were compared to patients with no de-escalation (NDE). The primary outcome was composite treatment failure, defined as all-cause mortality or readmission for pneumonia within 30 days of diagnosis. RESULTS Of 11860 admissions screened, 1812 unique patient-admissions were included (1102 HAP, 710 VAP). Fewer patients received DE (876 DE vs 1026 NDE). Groups were well matched at baseline, although more patients receiving DE had respiratory cultures ordered (56.6% vs 50.6%, P = .011). There was no difference in composite treatment failure (35.0% DE vs 33.8% NDE, P = .604). De-escalation was not associated with treatment failure on multivariable Cox regression analysis (hazard ratio, 1.13; 95% confidence interval, 0.96-1.33). Patients receiving DE had fewer antibiotic days (median 9 vs 11, P < .0001), episodes of Clostridioides difficile infection (2.2% vs 3.8%, P = .046), and hospital days (median 20 vs 22 days, P = .006). CONCLUSIONS De-escalation and NDE resulted in similar rates of 30-day treatment failure; however, DE was associated with fewer antibiotic days, episodes of C difficile infection, and days of hospitalization.
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Affiliation(s)
- Dan Ilges
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - David J Ritchie
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
| | - Tamara Krekel
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Elizabeth A Neuner
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Nicholas Hampton
- Center for Clinical Excellence, BJC HealthCare, St. Louis, Missouri, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Scott Micek
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
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Guidry CA, Sawyer RG, Winfield RD. Challenging the Dogma of Aggressive Initiation of Antibiotics in Sepsis. Surg Infect (Larchmt) 2020; 22:473-476. [PMID: 33232638 DOI: 10.1089/sur.2020.244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Christopher A Guidry
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Critical Care, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker School of Medicine, Kalamazoo, Michigan, USA
| | - Robert D Winfield
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Critical Care, The University of Kansas Medical Center, Kansas City, Kansas, USA
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Discontinuation of Glycopeptides in Patients with Culture Negative Severe Sepsis or Septic Shock: A Propensity-Matched Retrospective Cohort Study. Antibiotics (Basel) 2020; 9:antibiotics9050250. [PMID: 32414054 PMCID: PMC7277931 DOI: 10.3390/antibiotics9050250] [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: 04/24/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 11/17/2022] Open
Abstract
Implementation of antibiotic stewardship is difficult in patients with sepsis because of severity of disease. We evaluated the impact of glycopeptide discontinuation (GD) in patients with culture negative severe sepsis or septic shock who received glycopeptides as initial empiric antibiotic therapy at admission. We conducted a single center retrospective cohort study between January 2010 and March 2018. GD was defined as discontinuation of initial empiric glycopeptides on availability of culture results, revealing the absence of identified pathogens. In 92 included patients, the leading causes of sepsis were pneumonia (34.8%) and intra-abdominal infection (23.9%); 28-day mortality and overall mortality were 14% and 21%, respectively. Glycopeptides were discontinued in 42/92 patients. After propensity score matching, baseline characteristics were not significantly different between the GD and non-GD (GND) groups. GND was associated with development of acute kidney injury (OR 5.54, 95% CI 1.49–20.6, P = 0.011). GD did not increase the 7-day, 14-day, and 28-day mortality compared with GND. The length of hospital stay was shorter in the GD group than in GND group (16.33 ± 17.11 vs. 25.05 ± 14.37, P = 0.082), though not statistically significant. GD may be safe and reduce adverse events of prolonged antibiotic use in patients with culture negative severe sepsis or septic shock receiving glycopeptides as initial empiric antibiotic therapy.
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