Status of antimicrobial stewardship programmes in Korean hospitals including small to medium-sized hospitals and the awareness and demands of physicians: a nationwide survey in 2020

Evaluating antimicrobial utilization in 20 Korean long-term care hospitals: a call to action for antimicrobial stewardship

BACKGROUND

Evaluation of hospital-specific antimicrobial use is necessary for successful national antimicrobial stewardship. This study aimed to identify antimicrobial use in long-term care hospitals (LCHs) in Korea.

METHODS

A multi-centre retrospective study was conducted to evaluate the prescription patterns and appropriateness of antimicrobials in 20 LCHs in Korea. The medical record data of hospitalized patients who were newly prescribed antimicrobials at each hospital were collected manually between 10th July and 31st October 2023 to evaluate the appropriateness of antimicrobial use.

RESULTS

The prevalence of antimicrobial prescriptions was 8.9% (365/4086) and 10.3% (402/3892) on 12th July 2023 and 18th October 2023, respectively. In total, 885 antimicrobials were prescribed to 740 patients. Among the antimicrobials, third- or fourth-generation cephalosporins (31.9%) represented the most prescribed antimicrobial class. A large majority of antimicrobials (96.6%, 855/885) were prescribed for the treatment of infectious diseases; however, only 37.7% (322/855) of antimicrobials were prescribed appropriately for infections. The route of administration, dosage and prescribed antimicrobial were appropriate in 99.6% (852/855), 56.1% (480/855) and 62.0% (530/855) of cases, respectively. In total, 35.2% (252/715) of patients were prescribed antimicrobials appropriately. The diagnosis of infectious disease was appropriate for 52.9% (472/892) of cases. Of the five, 15 and 10 antimicrobials used for surgical site infection prophylaxis, medical prophylaxis and other purposes, respectively, none were used appropriately.

CONCLUSION

The proportion of antimicrobials used appropriately is low in Korean LCHs. These data highlight the importance of establishing antimicrobial stewardship in LCHs.

Difference in Baseline Antimicrobial Prescription Patterns of Hospitals According to Participation in the National Antimicrobial Monitoring and Feedback System in Korea

This study aimed to evaluate the differences in the baseline characteristics and patterns of antibiotic usage among hospitals based on their participation in the Korea National Antimicrobial Use Analysis System (KONAS). We obtained claims data from the National Health Insurance for inpatients admitted to all secondary- and tertiary-care hospitals between January 2020 and December 2021 in Korea. 15.9% (58/395) of hospitals were KONAS participants, among which the proportion of hospitals with > 900 beds (31.0% vs. 2.6%, P < 0.001) and tertiary care (50.0% vs. 5.2%, P < 0.001) was higher than that among non-participants. The consumption of antibiotics targeting antimicrobial-resistant gram positive bacteria (33.7 vs. 27.1 days of therapy [DOT]/1,000 patient-days, P = 0.019) and antibiotics predominantly used for resistant gram-negative bacteria (4.8 vs. 3.7 DOT/1,000 patient-days, P = 0.034) was higher in KONAS-participating versus -non-participating hospitals. The current KONAS data do not fully represent all secondary- and tertiary-care hospitals in Korea; thus, the KONAS results should be interpreted with caution.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Principles and practices of antimicrobial stewardship programs in Korea

This review addresses the escalating challenge posed by antibiotic resistance, highlighting its profound impact on global public health, including increased mortality rates and healthcare expenditures. The review focuses on the need to adopt the One Health approach to effectively manage antibiotic usage across human, animal, and environmental domains. Antimicrobial stewardship programs (ASPs) are considered as comprehensive strategies that encompass both core and supplementary initiatives aimed at enhancing prudent antibiotic use. The 2021 "Guidelines on Implementing ASP in Korea" introduced such strategies, with a strong emphasis on fostering multidisciplinary and collaborative efforts. Furthermore, the "Core Elements for Implementing ASPs in Korean General Hospitals," established in 2022, provide a structured framework for ASPs, delineating leadership responsibilities, the composition of interdisciplinary ASP teams, a range of interventions, and continuous monitoring and reporting mechanisms. In addition, this review examines patient-centric campaigns such as "Speak Up, Get Smart" and emphasizes the pivotal role of a multidisciplinary approach and international cooperation in addressing the multifaceted challenges associated with antibiotic resistance.

Implementing antimicrobial stewardship: lessons and perspectives from a university-affiliated tertiary hospital in Korea

Antimicrobial stewardship programs (ASPs) can lower antibiotic use, decrease medical expenses, prevent the emergence of resistant bacteria, and enhance treatment for infectious diseases. This study summarizes the stepwise implementation and effects of ASPs in a single university-affiliated tertiary care hospital in Korea; it also presents future directions and challenges in resource-limited settings. At the study hospital, the core elements of the ASP such as leadership commitment, accountability, and operating system were established in 2000, then strengthened by the formation of the Antimicrobial Stewardship (AMS) Team in 2018. The actions of ASPs entail key components including a computerized restrictive antibiotic prescription system, prospective audit, post-prescription review through quantitative and qualitative intervention, and pharmacy-based interventions to optimize antibiotic usage. The AMS Team regularly tracked antibiotic use, the effects of interventions, and the resistance patterns of pathogens in the hospital. The reporting system was enhanced and standardized by participation in the Korea National Antimicrobial Use Analysis System, and educational efforts are ongoing. Stepwise implementation of the ASP and the efforts of the AMS Team have led to a substantial reduction in the overall consumption of antibiotics, particularly regarding injectables, and optimization of antibiotic use. Our experience highlights the importance of leadership, accountability, institution-specific interventions, and the AMS Team.

Impact of financial incentives for infection prevention and management on antibiotic use: A Korea National Health Insurance cohort study

BACKGROUND

The Korean government implemented financial incentives to enhance infection prevention and management within general hospital settings. This study aimed to evaluate the impact of infection control compensation on antibiotic usage using a controlled interrupted time series analysis.

METHODS

The main unit of analysis was 270,901 inpatient episodes extracted from the Korean National Health Insurance Service Cohort Database from 2013 to 2019. The 96-month period was examined before and after the intervention, which was set to September 1, 2017, by applying a 1-year lag time after the incentive was introduced. Segmented regression was used to estimate the effects of interventions in a controlled interrupted time series. Hospitals that received nationwide financial incentives for infection prevention and management were included in the analysis. The study's primary outcome was the use of antibiotics based on the WHO Access, Watch, and Reserve (AWaRe) classification of antibiotics, and the secondary outcome was the number of days of antibiotic use as days of therapy (DOTs) per patient day (PD).

RESULTS

The probability of overall antibiotic use decreased between incentivized and unincentivized hospitals (odds ratio [OR], 0.922; 95% confidence interval [CI], 0.859-1.000). The difference in level change in the use of third-generation cephalosporins (OR,0.894; 95% CI, 0.817-0.977) and carbapenem (OR,0.790; 95% CI, 0.630-0.992) was significantly reduced between incentivized and unincentivized hospitals. The difference in slope change on DOTs/PD of glycopeptides was - 0.005 DOT/PDs, and that of carbapenem was - 0.003 between incentivized and unincentivized hospitals.

CONCLUSION

We observed that incentives for infection prevention and management have had a positive impact on some aspects of antibiotic usage. A partial decrease was observed in antibiotic use, accompanied by a modest reduction in DOTs/PD, particularly for antibiotics aimed at addressing multidrug-resistant pathogens. Further investigation is necessary to establish evidence for extending these incentives.

Participation in and perceptions of antibiotic stewardship behaviors among nurses at a children's hospital in South Korea: a descriptive study

PURPOSE

This study investigated participation in and perceptions of antibiotic stewardship among nurses at a children's hospital.

METHODS

This descriptive study included 125 nurses working in the inpatient ward, intensive care unit and emergency room of a single tertiary children's hospital. The study measured 14 factors influencing antibiotic stewardship behaviors using the theoretical domains framework. Each factor was analyzed by categorizing it into components (capability, opportunity, and motivation) that have been proposed as influencing factors in the COM-B model of behavior. One-way analysis of variance and Pearson correlation coefficients were used to explore differences in antibiotic stewardship behaviors and influencing factors according to general characteristics and the correlation between antibiotic stewardship behaviors and COM-B components.

RESULTS

No statistically significant difference in antibiotic stewardship behaviors was found based on the experience of antibiotic stewardship education or the nursing department. However, significant differences were observed in the perception levels of factors related to antibiotic stewardship behaviors according to the experience of antibiotic stewardship education in skill (physical) (p=.042), knowledge (p=.027), intentions (p=.028), and social influences (p=.010). Additionally, significant differences were observed in perception levels according to the sub-components of the COM-B model, specifically physical capability (p=.042), psychological capability (p=.027), and social opportunity (p=.010).

CONCLUSION

To expand nurses' involvement and roles in antibiotic stewardship, nurses should acknowledge the significance of appropriate antibiotic use, aiming to enhance the quality of medical care and ensure patient safety. In pursuit of this objective, tailored education aligning with the specific needs and practices of nurses is essential.

Current Status of Antibiotic Stewardship and the Role of Biomarkers in Antibiotic Stewardship Programs

The importance of antibiotic stewardship is increasingly emphasized in accordance with the increasing incidences of multidrug-resistant organisms and accompanying increases in disease burden. This review describes the obstacles in operating an antibiotic stewardship program (ASP), and whether the use of biomarkers within currently available resources can help. Surveys conducted around the world have shown that major obstacles to ASPs are shortages of time and personnel, lack of appropriate compensation for ASP operation, and lack of guidelines or appropriate manuals. Sufficient investment, such as the provision of full-time equivalent ASP practitioners, and adoption of computerized clinical decision systems are useful measures to improve ASP within an institution. However, these methods are not easy in terms of both time commitments and cost. Some biomarkers, such as C-reactive protein, procalcitonin, and presepsin are promising tools in ASP due to their utility in diagnosis and forecasting the prognosis of sepsis. Recent studies have demonstrated the usefulness of algorithmic approaches based on procalcitonin level to determine the initiation or discontinuation of antibiotics, which would be helpful in decreasing antibiotics use, resulting in more appropriate antibiotics use.

Implementation of antimicrobial stewardship programs

Background: The antimicrobial stewardship program (ASP) is a coordinated intervention designed to improve and measure the appropriate antibiotics use by selecting an optimal antibiotic drug regimen, including dosing, therapy duration, and administration route. The implementation of ASPs decreases the consumption, cost, and adverse effects of antibiotic use. Additionally, it improves the clinical outcomes, and decreases Clostridium difficile infection and antimicrobial resistance.Current Concepts: To overcome the antimicrobial resistance and implement ASPs worldwide, various efforts are underway, such as enacting ASP guidelines, developing core elements for ASP implementation, introducing ASPs to the healthcare accreditation system, and providing healthcare facilities with adequate incentives to implement ASPs. In Korea, ASP guidelines were published in September 2021, and core elements for ASP implementation are being developed at the time of writing. However, there is a shortage of personnel required for the ASP team, including healthcare workforce and infectious disease specialists for leading the team Moreover, financial support for ASP implementation in the National Health Insurance Service is not provided yet. The awareness of hospital leadership and clinicians prescribing antibiotics for ASP implementation is still low. The reimbursement system establishment and workforce for ASPs are prerequisite for the implementation of ASPs.Discussion and Conclusion: At the national level, it is necessary to provide financial support for ASPs in healthcare facilities, nurture the healthcare workforce in performing ASPs, and advocate ASP education and publicity.

Prescriptions patterns and appropriateness of usage of antibiotics in non-teaching community hospitals in South Korea: a multicentre retrospective study

Background

Although non-teaching community hospitals form the majority of healthcare providers in South Korea, there is limited data on antibiotic usage in them. To evaluate the pattern of antibiotic usage and its appropriateness in hospitals with < 400 beds in South Korea.

Methods

A multicentre retrospective study was conducted in 10 hospitals (six long-term care hospitals, three acute care hospitals, and one orthopaedic hospital), with < 400 beds in South Korea. We analysed patterns of antibiotic prescription in 2019, and their appropriateness in the participating hospitals. For the evaluation of the appropriateness of the prescription, 25 patients under antibiotic therapy were randomly selected at each hospital, over two separate periods. Due to the heterogeneity of their characteristics, the orthopaedics hospital was excluded from the analysis.

Results

The most commonly prescribed antibiotics in long-term care hospitals was fluoroquinolone, followed by beta-lactam/beta-lactamase inhibitor (anti-pseudomonal). In acute care hospitals, these were third generation cephalosporin, followed by first generation cephalosporin, and second generation cephalosporin. The major antibiotics that were prescribed in the orthopedics hospital was first generation cephalosporin Only 2.3% of the antibiotics were administered inappropriately. In comparison, 15.3% of patients were prescribed an inappropriate dose. The proportion of inappropriate antibiotic prescriptions was 30.6% of the total antibiotic prescriptions.

Conclusions

The antibiotic usage patterns vary between non-teaching community hospitals in South Korea. The proportion of inappropriate prescriptions exceeded 30% of the total antibiotic prescriptions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01082-2.

Guidelines on Implementing Antimicrobial Stewardship Programs in Korea

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

Core Elements for Successful Implementation of Antimicrobial Stewardship Programs

Antimicrobial resistance has emerged as a serious global public health threat. One of the countermeasures to increased antibiotic-resistant bacterial infections is the use of an integrative intervention strategy for the selection and administration of appropriate antibiotics and for the monitoring of antibiotic use, collectively known as "Antimicrobial Stewardship Programs" (ASPs). However, since the medical environment and policies vary by country and medical facilities, ASPs also need to be applied to each facility and condition accordingly. The United States Centers for Disease Control and Prevention announced the core elements for hospital ASPs, which outlines the specific structural and procedural components required to implement ASPs in 2014. As multidrug-resistant bacterial infections and use of broad-spectrum antibiotics in Korea are on the rise, ASPs must be urgently applied to medical facilities for appropriate management of antibiotic use. However, there is an ongoing limitation to the immediate adoption and application of ASPs in Korean medical facilities due to the lack of medical workforce and related financial resources. To address this issue, efforts of medical professionals and government are required, and core elements that match the characteristics and circumstances of Korean medical facilities must be urgently developed.