Human resources required for antimicrobial stewardship activities for hospitalized patients in Korea

Prospective Audit and Feedback for Antimicrobial Treatment of Patients Receiving Renal Replacement Therapy in Community-Based University Hospitals: A before-and-after Study

In South Korea, because of manpower and budgetary limitations, antimicrobial stewardship programs have relied on preauthorization. This study analyzed the impact of a prospective audit and feedback (PAF) program targeting inpatients undergoing intermittent hemodialysis or continuous renal replacement therapy, which was implemented at two community-based university hospitals. During three years of PAF, 27,906 antimicrobial prescriptions were reviewed, with 622 (2.2%) interventions. The mean incidence density per 1000 patient days of multidrug-resistant organisms, except for carbapenem-resistant Acinetobacter baumannii, decreased in the study population, whereas it increased among inpatients. Multivariable Poisson regression analysis revealed that after PAF, the incidences of vancomycin-resistant Enterococcus and mortality decreased (incidence risk ratio, 95% confidence interval: 0.53, 0.31-0.93 and 0.70, 0.55-0.90, respectively). Notably, after PAF, incorrect antimicrobial dosing rates significantly decreased (tau -0.244; p = 0.02). However, the incidences of other multidrug-resistant organisms, Clostridioides difficile, length of stay, and readmission did not significantly change. This study shows that in patients undergoing intermittent hemodialysis or continuous renal replacement, targeted PAF can significantly reduce multidrug-resistant organism rates and all-cause hospital mortality, despite limited resources. Furthermore, it can improve antimicrobial dosage accuracy.

Time is running out. No excuses to delay implementation of antimicrobial stewardship programmes: impact, sustainability, resilience and efficiency through an interrupted time series analysis (2017-2022)

Introduction

The WHO declared antimicrobial resistance (AMR) a significant concern in 2014, sparking initiatives to ensure responsible antibiotic use. In human medicine, Antimicrobial Stewardship Programmes (ASPs) in hospitals play a pivotal role in combating AMR. Although evidence supports the effectiveness of ASPs in optimizing antimicrobial use, often the lack of resources becomes an excuse to limit their dissemination and use. This paper provides a comprehensive report on a 6-year analysis of an ASP implemented in a healthcare region in north-east Italy.

Methods

A retrospective data collection was conducted to assess the programme's impact on antibiotic consumption expressed as DDDs/100 patient-days, its sustainability over time, resilience during the COVID-19 pandemic and the efficiency of the ASP (relationship between workload and human resources).

Results

A substantial overall reduction in antibiotic consumption (-14%), particularly in fluoroquinolones (-64%) and carbapenems (-68%), was demonstrated, showcasing the programme's impact. Sustainability was confirmed through enduring trends in antibiotic consumption and ecological analysis over time. The ASP demonstrates resilience by maintaining positive trends even amid the challenging COVID-19 pandemic. Efficiency was underscored by an increase in on-site consultations despite consistent human resources until 2021.

Conclusions

This study offers insights into the prolonged success of a resource-efficient ASP, emphasizing the crucial role of long-term commitment in fostering responsible antibiotic use in the context of global health challenges such as AMR.

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.

Developing a framework for regular and sustainable qualitative assessment of antibiotic use in Korean medical institutions: a Delphi study

BACKGROUND

We aimed to develop a roadmap for conducting regular, sustainable, and strategic qualitative assessments of antibiotic use in medical institutions within the Republic of Korea.

METHODS

A literature review on the current state of qualitative antibiotic assessments was conducted, followed by one open round to collect ideas, two scoring rounds to establish consensus, and one panel meeting between them. The expert panel comprised 20 experts in infectious disease or antibiotic stewardship.

RESULTS

The response rate for all three surveys was 95% (19/20), while the panel meeting attendance rate was 90% (18/20). The following long-term goals were defined to assess the annual use of antibacterial and antifungal agents in all medical institutions, including clinics. The panel agreed that random sampling of antibiotic prescriptions was the most suitable method of selecting antibiotics for qualitative assessment, with the additional possibility of evaluating specific antibiotics or infectious diseases that warrant closer evaluation for promoting appropriate antibiotic use. The plan for utilization of results from evaluation involves providing feedback while maintaining anonymity and disclosure. It includes a quantitative assessment of antibiotic prescriptions and resistance rates to compare against institutional benchmarks. Furthermore, it was agreed to link the evaluation findings to the national antibiotic stewardship programme, enabling policy and institutional approaches to address frequently misused items, identified during the evaluation.

CONCLUSION

This study provides a framework for establishing a qualitative assessment of antimicrobial use for medical institutions at a national level in the Republic of Korea.

Impact of prolonged carbapenem use-focused antimicrobial stewardship on antimicrobial consumption and factors affecting acceptance of recommendations: a quasi-experimental study

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.

Professional Status of Infectious Disease Specialists in Korea: A Nationwide Survey

BACKGROUND

Infectious disease (ID) specialists are skilled facilitators of medical consultation who promote better outcomes in patient survival, antibiotic stewardship as well as healthcare safety in pandemic response. This study aimed to assess the working status of ID specialists and identify problems faced by ID professionals in Korea.

METHODS

This was a nationwide cross-sectional study in Korea. An online-based survey was conducted over 11 days (from December 17-27, 2020), targeting all active adult (n = 281) and pediatric (n = 71) ID specialists in Korea (N = 352). Questions regarding the practice areas of the specialists were divided into five categories: 1) clinical practices of outpatient care, inpatient care, and consultations; 2) infection control; 3) antibiotic stewardship; 4) research; and 5) education and training. We investigated the weekly time-use patterns for these areas of practice.

RESULTS

Of the 352 ID specialists, 195 (55.4%; 51.2% [144/281] adult and 71.8% [51/71] pediatric ID specialists) responded in the survey. Moreover, 144 (73.8%) of the total respondents were involved in all practice categories investigated. The most common practice area was outpatient service (93.8%), followed by consultation (91.3%) and inpatient service (87.7%). Specialists worked a median of 61 (interquartile range: 54-71) hours weekly: patient care, 29 (14-37) hours; research 11 (5-19) hours; infection control 4 (2-10) hours; antibiotic stewardship, 3 (1-5) hours; and education/training, 2 (2-6) hours.

CONCLUSION

ID specialists in Korea simultaneously undertake multiple tasks and work long hours, highlighting the need for training and employing more ID specialists.

Core Elements for Implementing Antimicrobial Stewardship Programs in Korean General Hospitals

Currently, antimicrobial resistance (AMR) is a major threat to global public health. The antimicrobial stewardship program (ASP) has been proposed as an important approach to overcome this crisis. ASP supports the optimal use of antimicrobials, including appropriate dosing decisions, administration duration, and administration routes. In Korea, efforts are being made to overcome AMR using ASPs as a national policy. The current study aimed to develop core elements of ASP that could be introduced in domestic medical facilities. A Delphi survey was conducted twice to select the core elements through expert consensus. The core elements for implementing the ASP included (1) leadership commitment, (2) operating system, (3) action, (4) tracking, (5) reporting, and (6) education. To ensure these core elements are present at medical facilities, multiple departments must collaborate as teams for ASP operations. Establishing a reimbursement system and a workforce for ASPs are prerequisites for implementing ASPs. To ensure that ASP core elements are actively implemented in medical facilities, it is necessary to provide financial support for ASPs in medical facilities, nurture the healthcare workforce in performing ASPs, apply the core elements to healthcare accreditation, and provide incentives to medical facilities by quality evaluation criteria.

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.

Stepwise Expansion of Antimicrobial Stewardship Programs and Its Impact on Antibiotic Use and Resistance Rates at a Tertiary Care Hospital in Korea

To optimize antibiotic use, the US CDC has outlined core elements of antimicrobial stewardship programs (ASP). However, they are difficult to implement in limited-resource settings. We report on the successful implementation of a series of ASP with insufficient number of infectious diseases specialists. We retrospectively collected data regarding antibiotic administration and culture results of all patients admitted to a tertiary care teaching hospital, Seoul National University Bundang Hospital (SNUBH), from January 2010 to December 2019. Trends of antibiotic use and antibiotic resistance rates were compared with those from Korean national data. Trend analyses were performed using nonparametric, two-sided, correlated seasonal Mann–Kendall tests. Total antibiotic agent usage has significantly decreased with ASP implementation at SNUBH since 2010. National claim data from tertiary care hospitals have revealed an increase in the use of all broad-spectrum antibiotics except for third-generation cephalosporins (3GC). In contrast, at SNUBH, glycopeptide and fluoroquinolone use gradually decreased, and 3GC and carbapenem use did not significantly change. Furthermore, the rate of colonization with methicillin-resistant Staphylococcus aureus showed a consistently decreasing trend, while that with 3GC- and fluoroquinolone-resistant Escherichia coli significantly increased. Unlike the national rate, the rate of colonization with antibiotic resistant-Klebsiella pneumoniae did not increase and that of 3GC- and fluoroquinolone-resistant Pseudomonas aeruginosa significantly decreased. Stepwise implementation of core ASP elements was effective in reducing antibiotic use despite a lack of sufficient manpower. Long-term multidisciplinary teamwork is necessary for successful and sustainable ASP implementation.

IMPORTANCE Antimicrobial stewardship programs aimed to optimize antibiotic use are difficult to implement in limited-resource settings. Our study indicates that stepwise implementation of core antimicrobial stewardship program elements was effective in reducing antibiotic use in a tertiary care hospital despite the lack of sufficient manpower.

Utility and applicability of rapid diagnostic testing in antimicrobial stewardship in Asia Pacific: A Delphi consensus

Rapid diagnostic tests (RDTs) facilitate fast and accurate identification of infectious disease microorganisms and are a valuable component of multimodal antimicrobial stewardship (AMS) programs but are currently underutilized in the Asia-Pacific region. An experienced group of infectious diseases clinicians, clinical microbiologists, and a clinical pharmacist used a modified Delphi consensus approach to construct 10 statements, aiming to optimize the utility and applicability of infection-related RDTs for AMS in the Asia-Pacific region. They provide guidance on definition, types, optimal deployment, measuring effectiveness, and overcoming key challenges. The Grading of Recommendations Assessment, Development, and Evaluation system was applied to indicate the strength of the recommendation and the quality of the underlying evidence. Given the diversity of the Asia-Pacific region, the trajectory of RDT development will vary widely; the collection of local data should be prioritized to allow realization and optimization of the full benefits of RDTs in AMS.

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.

Dedicated time for antimicrobial stewardship-How much and why? Lessons learned from South Korea

Antimicrobial resistance is a global and pressing problem that requires large-scale, federal coordination of efforts and tailored local interventions and surveillance. Given the urgency of the threat, many countries now have national policies to reduce inappropriate antimicrobial use. However, few countries have followed this with resources at the institutional level to support the implementation of practices to achieve this goal. In the United States, accreditation bodies such as Centers for Medicare and Medicaid Services and The Joint Commission have added antimicrobial stewardship standards to encourage uptake of antimicrobial stewardship programs (ASPs).

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

OBJECTIVES

This study aimed to analyse the effect of discontinuation of antimicrobial stewardship programme (ASP) activity on the usage pattern of antibiotics.

METHODS

An interrupted time-series analysis assessing the trends in antibiotic use was conducted between September 2015 and August 2019 in an 859-bed university-affiliated hospital in Korea, where all ASP activities were discontinued in March 2018. The major activity of the ASP was a restrictive antibiotic programme.

RESULTS

The use of restrictive antibiotics increased immediately after the discontinuation of the ASP by 41.06 days of therapy (DOT)/1000 patient-days in the general ward (95% confidence interval (CI) 21.04-61.08) and by 391.04 DOT/1000 patient-days in the intensive care unit (ICU) (95%CI 207.56-574.51). In addition, there were positive changes in the slope for the use of restrictive antibiotics in the general ward (7.06 DOT/1000 patient-days per month, 95%CI 4.63-9.50) and ICU (35.95 DOT/1000 patient-days per month, 95%CI 18.70-53.19). The use of broad-spectrum antibiotics in the general ward significantly decreased (-87.54 DOT/1000 patient-days, 95%CI -149.29 to -25.79). For non-broad-spectrum antibiotics, there were positive changes in the slope in the general ward (16.54 DOT/1000 patient-days per month, 95%CI 12.99-20.09) and ICU (12.85 DOT/1000 patient-days per month, 95%CI 2.32-23.38).

CONCLUSIONS

After discontinuation of the ASP, antibiotic usage patterns rapidly returned to the patterns prior to the implementation of the programme.

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

OBJECTIVES

This study aimed to identify the status of antimicrobial stewardship programmes (ASPs) in small to medium-sized Korean hospitals as well as the awareness and demands about ASPs of physicians.

METHODS

A questionnaire was designed based on a questionnaire from a previous nationwide survey in 2018 targeting large hospitals in Korea and modified to reflect the results of in-depth interviews with non-infectious diseases (IDs) physicians at secondary care hospitals. The survey targeted all hospitals with ≥150 beds in South Korea and was performed in May-June 2020. Only one ASP-associated physician per hospital participated in the survey.

RESULTS

The survey response rate was 31.9% (217/680). ID specialists comprised the majority of medical personnel participating in ASPs in tertiary care hospitals. Conversely, in secondary and primary care hospitals there was no predominant medical personnel for ASPs and the median full-time equivalent was 0 for all types of medical personnel. Tertiary care hospitals, more than secondary and primary care hospitals, tended to perform ASP activities more actively. 'Workforce for ASPs', 'Establishment of healthcare fees for ASPs' and 'Development of tools for ASPs' were the most important required support for ASP improvement.

CONCLUSION

The level of ASP establishment was more limited in primary care hospitals than in secondary and tertiary care hospitals in Korea. To improve ASPs in Korean hospitals, a supporting workforce and the establishment of a healthcare fee for ASPs appear to be necessary.

Rapid diagnostic testing for antimicrobial stewardship: Utility in Asia Pacific

Rapid diagnostic testing (RDT) can provide prompt, accurate identification of infectious organisms and be a key component of antimicrobial stewardship (AMS) programs. However, their use is less widespread in Asia Pacific than western countries. Cost can be prohibitive, particularly in less resource-replete settings. A selective approach is required, possibly focusing on the initiation of antimicrobials, for differentiating bacterial versus viral infections and identifying locally relevant tropical diseases. Across Asia Pacific, more data are needed on RDT use within AMS, focusing on the impact on antimicrobial usage, patient morbidity and mortality, and cost effectiveness. Moreover, in the absence of formal guidelines, regional consensus statements to guide clinical practice are warranted. These will provide a regionally relevant definition for RDT; greater consensus on its role in managing infections; advice on implementation and overcoming barriers; and guidance on optimizing human resource capacity. By addressing these issues, the outcomes of AMS programs should improve.

Infectious Diseases Physician Workforce in Korea

This study aimed to evaluate the infectious disease (ID) physician workforce in Korea. We investigated the acquisition of ID physicians from 1992 to 2019 with their current working place in the Health Care System. We defined ID physicians working at general or tertiary-care hospitals as active ID physicians. A total 275 physicians acquired ID as a sub-specialty. Among the 275, 242 were active ID physicians. The density of active ID physicians was 0.47 per 100,000 population. Of all the 17 administrative districts, 11 (64.7%) fell short of 0.47, and 131 medical institutions employed the service of ID physicians. The median number of beds per adult ID physician was 372 (interquartile range, 280-507). It is essential to secure human resources to respond to emerging infectious diseases and perform the inherent work of ID physicians.