Appropriate use of vancomycin in a pediatric emergency department through the use of a standardized electronic guideline

The impact of Antimicrobial Stewardship Programmes in paediatric emergency departments and primary care: a systematic review

Background

Antibiotics remain the most prescribed medicine in children worldwide, but half of the prescriptions are unnecessary or inappropriate, leading to an increase in antibiotic resistance. This study aims to systemically review the effects of different Antimicrobial Stewardship Programmes (ASPs) on reducing the rates of both antibiotic prescriptions and changes in antimicrobial resistance, and on the economic impact in paediatric emergency departments (PED) and primary care settings.

Materials and methods

Embase, MEDLINE, and Cochrane Library were systematically searched, combining Medical Subject Heading and free-text terms for 'children' and 'antimicrobial' and 'stewardship'. The search strategy involved restrictions on dates (from 1 January 2007 to 30 December 2020) but not on language. Randomized controlled trials, controlled and non-controlled before and after studies, controlled and non-controlled interrupted time series, and cohort studies were included for review. The review protocol was registered at the PROSPERO International Prospective Register of Systematic Reviews: Registration Number CRD42021270630.

Results

Of the 47,158 articles that remained after removing duplicates, 59 were eligible for inclusion. Most of the studies were published after 2015 (37/59, 62.7%) and in high-income countries (51/59, 86.4%). Almost half of the studies described the implementation of an ASP in the primary care setting (28/59, 47.5%), while 15 manuscripts described the implementation of ASPs in EDs (15/59, 25.4%). More than half of the studies (43/59, 72.9%) described the implementation of multiple interventions, whereas few studies considered the implementation of a single intervention. Antibiotic prescriptions and compliance with guidelines were the most frequent outcomes (47/59, 79.7% and 20/59, 33.9%, respectively). Most of the articles reported an improvement in these outcomes after implementing an ASP. Meanwhile, only very few studies focused on health care costs (6/59, 10.2%) and antimicrobial resistance (3/59 5.1%).

Conclusion

The implementation of ASPs has been proven to be feasible and valuable, even in challenging settings such as Emergency Departments and Primary care.

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review

Background

Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally.

Methods

MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data.

Results

Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides.

Conclusions

Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

Evaluation of vancomycin use in university-affiliated hospitals in Southern Khorasan Province (East Iran) based on HICPAC guidelines

Background

Vancomycin resistance has raised concerns about its effectiveness prospect in the treatment of patients with Gram-positive infections. The Healthcare Infection Control Practices Advisory Committee (HICPAC) has recently established guidelines to delineate improper use of vancomycin. In this light, we sought out to determine the appropriateness of vancomycin prescription using the HICPAC guidelines.

Setting

The study was carried out in two university-affiliated hospitals, Valiasr and Imam Reza, with 297 and 234 beds, respectively, from May 2012 to May 2013.

Methods

This retrospective study evaluated the vancomycin prescription and usage in the hospitals. Total vancomycin use was determined and expressed as vancomycin courses per 298 admitted patients. The patient information was collected on a data collection sheet as follows: demographic variables, etiology and localization of infection, microbiological data, duration of vancomycin treatment, reasons for vancomycin prescription, prescribed antibiotic dosing, and patient regimen.

Results

The average age of the patients and vancomycin treatment duration were 55.965 years and 10.5 days, respectively. Septicemia (15.7%) was the most common cause of vancomycin administration. Vancomycin use was documented to be appropriate and inappropriate in 236 (89.4%) and 28 (10.6%) patients, respectively. No statistically significant differences were found among the wards and hospitals (P values =0.66 and 0.54, respectively) in terms of appropriateness of vancomycin use based on the HICPAC criteria. In addition, 29.21% and 62% of all patients exhibited complete and partial recovery, respectively. We found that 90% of the cases showed compliance with the HICPAC recommendations.

Conclusion

Comprehensive programs are required to improve the vancomycin use in the hospitals. Vancomycin use should be monitored due to its large-scale empiric use. The rate of improper use of vancomycin in the infection and intensive care unit services may be high, and pharmacists must take appropriate action to optimize the use of the drug.

A Systematic Review of Antimicrobial Stewardship Interventions in the Emergency Department

BACKGROUND/OBJECTIVE

To improve antimicrobial utilization, development and implementation of antimicrobial stewardship programs in the emergency department (ED) has been recommended. The primary objective of this review was to characterize antimicrobial stewardship (AMS) in the ED and to identify interventions that improve patient outcomes or process of care and/or reduce consequences of antimicrobial use.

METHODS

This study was completed as a systematic review. The following databases were searched from inception through November, 2016: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Scopus, and Web of Science. Randomized controlled trials, nonrandomized controlled trials, controlled and uncontrolled before-and-after studies, interrupted time series studies, and repeated-measures studies evaluating AMS interventions in the ED were included in the review. Studies published in languages other than English were excluded.

RESULTS

A total of 43 studies meeting inclusion criteria were identified from our search. Patient or provider education and guideline or clinical pathway implementation were the most commonly reported interventions. Few studies reported on audit and feedback, and no study evaluated preauthorization. Impact of interventions showed variable results. Where identified, benefits of AMS interventions primarily included improvement in delivery of care or a decrease in antimicrobial utilization; however, most studies were rated as having unclear or high risk of bias.

CONCLUSION

AMS interventions in the ED may improve patient care. However, the optimal combination of interventions is unclear. Additional studies with more rigorous design evaluating core components of AMS programs, including prospective audit and feedback are needed.

A new approach to Vancomycin utilization evaluation: A cross-sectional study in intensive care unit

Objective:

The risk of methicillin-resistant Staphylococcus aureus infections in Intensive Care Unit (ICU) is increasing in recent years with high rate of morbidity and mortality. Therefore, in this study, we aimed to evaluate the rationale use of vancomycin in ICU patients.

Methods:

A total of 200 patients who received at least 48 h intravenous vancomycin were randomly selected from ICU wards, during 9 months. Vancomycin administration and related clinical and laboratory data were gathered from patients' charts and health information system to evaluate the appropriateness of different aspects of vancomycin use during all days which vancomycin were ordered.

Findings:

During the study, 15,230 ± 1216 mg (mean ± standard error of the mean [SEM]) vancomycin was administered for 200 patients in the mean period of 9.79 ± 0.64 (SEM) days of ICU stay, for prophylaxis and empiric therapy. Results showed the appropriateness of vancomycin uses were 30.5%, 9%, and 5.5% in the first 24 h, after 72 h and during the whole time of treatment, respectively. In addition, infectious consultation was the only significantly different parameter between appropriate and inappropriate vancomycin administration groups (P < 0.001).

Conclusion:

Although vancomycin utilization evaluation were mentioned in previous studies, but data related to ICU patients and during all days of vancomycin therapy are limited. High prevalence of inappropriate use of vancomycin in ICU is alarming for health systems and necessitates implementation of antibiotic policies.