A point prevalence survey of antibiotic use in four acute-care teaching hospitals utilizing the European Surveillance of Antimicrobial Consumption (ESAC) audit tool

Point prevalence of antibiotic usage in major referral hospital in Turkey

INTRODUCTION

The most important and undesirable consequence of inappropriate antibiotic use is the spread of antibiotic resistance, increased adverse effects, increased mortality and healthcare costs. We aimed to assess antibiotic usage characteristics in inpatient setting in our center.

MATERIALS AND METHODS

A one-day, single center point-prevalence study was carried out on June 9th 2021, in Ankara City Hospital in Turkey. Data of antibiotic consumption, appropriateness of usage and predictors of inappropriate use in adult patients were evaluated.

RESULTS

Out of 2640 adult patients, 893 (33.8%) were receiving at least one antibiotic. A total of 1212 antibiotic prescriptions with an average of 1.44±0.64 were found. Antibiotics were most commonly used for therapeutic purpose (84.7%), followed by surgical prophylaxis (11.6%). Majority of therapeutically used antibiotics were empirical (67.9%). Infectious diseases consultation was present in 68.3% with a compliance rate of 95.7%. Rate of inappropriate use was 20%. The most frequent cause of inappropriateness was unnecessary use (52.5%). Most commonly and most inappropriately used antibiotics were carbapenems (17.5%) and first generation cephalosporins (38.7%), respectively. Most of the inappropriateness observed in first-generation cephalosporins was due to inappropriate longer surgical prophylaxis. While age is an independent risk factor for inappropriate antibiotic use (p = 0.042), COVID-19 unit admission, use for therapeutic purpose and infectious diseases consultation were protective factors (p<0.001, p<0.001, p<0.001).

CONCLUSION

Rate of inappropriate use was low, but inappropriate surgical prophylaxis remains an important problem in surgical units. There is a considerable need to implement an antimicrobial stewardship program that focuses on surgical prophylaxis practices.

Antibiotic use and consumption among medical patients of two hospitals in Sierra Leone: a descriptive report

BACKGROUND

Although one of the main drivers of antimicrobial resistance is inappropriate antibiotic prescribing, there are limited resources to support the surveillance of antibiotic consumption in low-income countries. In this study, we aimed to assess antibiotic use and consumption among medical patients of two hospitals in different geographic regions of Sierra Leone.

METHODS

This is a cross-sectional study of adult (18 years or older) patients receiving medical care at two hospitals (34 Military Hospital-MH and Makeni Government Hospital-MGH) between March 2021 and October 2021. After admission to the medical or intensive care unit, patients were sequentially recruited by a nurse from each hospital. Demographic and clinical characteristics and information on the dose of antibiotics, their routes, and frequency of administration and duration were collected using a questionnaire adapted from previous studies and encrypted in EpiCollect software (Epic, Verona WI). A physician reviews and verifies each completed questionnaire. Data analysis was done using STATA version 16.

RESULTS

The mean age of the 468 patients evaluated in this study was 48.6 years. The majority were women (241, 51.7%) and treated at MGH (245, 52.0%). Clinical diagnosis of bacterial infection was made in only 180 (38.5%) patients. Regardless of the diagnosis, most (442, 94.9%) patients received at least one antibiotic. Of a total 813 doses of antibiotics prescribed by the two hospitals, 424 (52.2%) were administered in MH. Overall, antibiotic consumption was 66.9 defined daily doses (DDDs) per 100 bed-days, with ceftriaxone being the most commonly used antibiotic (277, 34.1%). The ACCESS and WATCH antibiotics accounted for 18.9 DDDs per 100 bed-days (28.2%) and 48.0 DDDs per 100 bed-days (71.7%), respectively. None of the patients were prescribed a RESERVE antibiotics. The antibiotic consumption was lower in MH (61.3 DDDs per 100 bed-days) than MGH (76.5 DDDs per 100 bed-days).

CONCLUSION

Antibiotic consumption was highest with ceftriaxone, followed by levofloxacin and metronidazole. Given the high rate of consumption of antibiotics in the WATCH category of the AWaRe classification, there is a need to initiate surveillance of antibiotic consumption and establish hospital-based antibiotic stewardship in these settings.

Documenting the indication for antimicrobial prescribing: a scoping review

BACKGROUND

Documenting an indication when prescribing antimicrobials is considered best practice; however, a better understanding of the evidence is needed to support broader implementation of this practice.

OBJECTIVES

We performed a scoping review to evaluate antimicrobial indication documentation as it pertains to its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in all patient populations.

ELIGIBILITY CRITERIA

Published and unpublished literature evaluating the documentation of an indication for antimicrobial prescribing.

SOURCES OF EVIDENCE

A search was conducted in MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts in addition to a review of the grey literature.

CHARTING AND ANALYSIS

Screening and extraction was performed by two independent reviewers. Studies were categorised inductively and results were presented descriptively.

RESULTS

We identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (109, 89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%-100%). Studies evaluating the impact of indication documentation on prescribing and patient outcomes most commonly examined appropriateness and identified a benefit to prescribing or patient outcomes in 17 of 19 studies. Qualitative studies evaluating healthcare worker perspectives (n=10) noted the common barriers and facilitators to this practice.

CONCLUSION

There is growing interest in the importance of documenting an indication when prescribing antimicrobials. While antimicrobial indication documentation is not uniformly implemented, several studies have shown that multipronged approaches can be used to improve this practice. Emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes both in community and hospital settings. But setting-specific and larger trials are needed to provide a more robust evidence base for this practice.

Point prevalence survey of antibiotic utilization in secondary care hospital in the United Arab Emirates

Objectives

The present study was carried out to identify and report the pattern of antibiotics prescribing to determine the adherence to the international empirical and therapeutic guidelines of antibiotic use.

Methods

A point prevalence survey took place at a selected date of January 26, 2020, in which data collection was performed to all the patients present in the hospital who used at least one systemic antibiotic agent as an inpatient from 00:00 am until midnight of that day. This was performed using European Surveillance of Antimicrobial Consumption (ESAC - audit tool). The participated hospital in this point prevalence study represents a major government hospital in the UAE. Descriptive statistics were used and results were expressed using standard statistical methods.

Results

Out of the 125 hospitalized patients, a total of 41 (32.8%) patients were included in the survey and treated with different trends of antibiotics on the date point prevalence survey. The total number prescribed antibiotics was 54 with a higher percentage of treatment indication (70.4%), compared to prophylaxis indication (29.6%). The combinations of penicillin's win in being the most commonly used agents by a percent of 31.5%, including the use of Amoxicillin-clavulanic acid by 22.2% and Piperacillin-tazobactam with 9.3%. The compliance with local/international guidelines accounts for 78.0% of the treated & prophylaxis patients.

Conclusions

Considerable results have been obtained which can assure the quality improvement of the antibiotic use in the studied hospital.

Antibiotic prescribing practices in general surgery: a mixed methods quality improvement project

Background

A single pre-operative antibiotic dose provides optimal prophylaxis against surgical site infection (SSI), but significant variability persists in adherence to prophylaxis guidelines. We describe a quality improvement project aiming to improve guideline-driven antibiotic prescribing within surgical teams at a tertiary hospital.

Methods

Face-to-face interviews with surgical teams and anonymous surveys of senior surgeons and anaesthetists were used to collect qualitative data on the perceptions and attitudes of prescribers. This informed intervention development, including a daily ward-round checklist using the acronymous ‘ABBDDOMM’, from A (antibiotics) to M (microbiology), combined with education and heightened guideline accessibility. A first audit cycle was performed for patients undergoing intra-abdominal surgery during a two-month period (cycle one). Post-implementation data were collected 12 months later (cycle two).

Findings

Interviews provided insight into common themes and barriers surrounding antibiotic prescribing, whilst surveys explored future solutions to these barriers. In cycle one, 100/205 (48.8%) patients received extended antibiotics beyond the single-dose prophylaxis. Following intervention, only 41/138 (29.7%) patients received extended antibiotic courses, demonstrating a 21.5% reduction in prolonged antibiotics (P<0.0005). In cycle one, 107/205 patients (52.2%) received antibiotics compliant with Trust Guidelines, compared to 80/138 (58.0%) in cycle two.

Conclusion

Our proposed checklist, alongside antimicrobial stewardship education, prompts daily review of important patient parameters and results to significantly reduce inappropriate post-operative antibiotic prescribing. Promoting the sustained use of similar checklists by junior doctors and focusing on measures to improve uptake of pre-operative induction antibiotic guidelines is required to achieve further benefits.

Point prevalence surveys of antimicrobial use: a systematic review and the implications

Introduction: In view of increasing concerns with antimicrobial resistance (AMR), the World Health Organization (WHO) instituted a Global Action Plan (GAP) to address this. Area covered: One of the strategies to achieve the goals of GAP is to conduct regular surveillance of antimicrobial use through point prevalence surveys (PPS). In this review, PubMed, EBSCO, Proquest, Cinahl, and Scopus were searched for PPS of antimicrobial use published in English between January 2000 and December 2019. After systematic database screening of 2,893 articles, 60 PPS met the inclusion criteria and consequently were incorporated in this systematic review. Expert opinion: This review highlighted that most of the PPS were conducted in upper-middle and high-income countries. Prevalence of antimicrobial use was significantly higher in non-European hospitals compared with European hospitals. The domination of third-generation cephalosporin and fluoroquinolones use across all the regions suggests substantial use of broad-spectrum antimicrobials across countries. Among all identified regions around the world, India was the region where the highest use of antimicrobials was observed. Although PPS is a useful tool to assess the pattern of antimicrobial use and provides a robust baseline; however, a standardized surveillance method is needed. In order to optimize antimicrobial use, more efforts are required to improve antimicrobial use.

Antibiotic prescribing in general medical and surgical specialties: a prospective cohort study

Background

Qualitative work has described the differences in prescribing practice across medical and surgical specialties. This study aimed to understand if specialty impacts quantitative measures of prescribing practice.

Methods

We prospectively analysed the antibiotic prescribing across general medical and surgical teams for acutely admitted patients. Over a 12-month period (June 2016 – May 2017) 659 patients (362 medical, 297 surgical) were followed for the duration of their hospital stay. Antibiotic prescribing across these cohorts was assessed using Chi-squared or Wilcoxon rank-sum, depending on normality of data. The t-test was used to compare age and length of stay. A logistic regression model was used to predict escalation of antibiotic therapy.

Results

Surgical patients were younger (p < 0.001) with lower Charlson Comorbidity Index scores (p < 0.001). Antibiotics were prescribed for 45% (162/362) medical and 55% (164/297) surgical patients. Microbiological results were available for 26% (42/164) medical and 29% (48/162) surgical patients, of which 55% (23/42) and 48% (23/48) were positive respectively. There was no difference in the spectrum of antibiotics prescribed between surgery and medicine (p = 0.507). In surgery antibiotics were 1) prescribed more frequently (p = 0.001); 2) for longer (p = 0.016); 3) more likely to be escalated (p = 0.004); 4) less likely to be compliant with local policy (p < 0.001) than medicine.

Conclusions

Across both specialties, microbiology investigation results are not adequately used to diagnose infections and optimise their management. There is significant variation in antibiotic decision-making (including escalation patterns) between general surgical and medical teams. Antibiotic stewardship interventions targeting surgical specialties need to go beyond surgical prophylaxis. It is critical to focus on of review the patients initiated on therapeutic antibiotics in surgical specialties to ensure that escalation and continuation of therapy is justified.

Effectiveness of antibiotics versus ibuprofen in relieving symptoms of nosocomial urinary tract infection: A comparative study

BACKGROUND AND PURPOSE

Antibiotic therapy has been the mainstay of treatment in the management of hospitalized patients with nosocomial urinary tract infection (UTI); however, its use is associated with an increase in resistance and high cost. Ibuprofen showed effectiveness in relieving symptoms of UTI, but its superiority is questionable. The goal of this study was to compare the effectiveness of antibiotics against ibuprofen in relieving symptoms of UTI and to identify factors that affect symptom relief.

METHODS

This study was conducted in three public hospitals in Jordan. Patients with nosocomial UTI were assigned to either antibiotics or ibuprofen. Symptoms of UTI were assessed at the time of initiation of treatment and 5 days later.

CONCLUSIONS

Antibiotics were more effective in relieving symptoms of UTI than Ibuprofen. Comorbidity and length of hospitalization affected symptom relief during the treatment of UTI.

IMPLICATION FOR PRACTICE

Nurse practitioners in the clinical settings can take an active role in helping patients with UTI to achieve relief of symptoms by supporting the use of antibiotics over ibuprofen in symptom resolution.

Comparative point prevalence survey of antimicrobial consumption between a hospital in Northern Ireland and a hospital in Jordan

Background

To assess antimicrobial prescribing in a Northern Ireland hospital (Antrim Area Hospital (AAH)) and compare them with those of a hospital in Jordan (Specialty Hospital).

Methods

Using the Global-PPS approach, the present study surveyed patients admitted to the hospital in 2015, the prescribed antibiotics, and a set of quality control indicators related to antibiotics.

Results

Ultimately, 444 and 112 inpatients in the AAH and the Specialty Hospital, respectively, were surveyed. For the medical group, 165 inpatients were prescribed 239 antibiotics in the AAH, while 44 patients in the Specialty Hospital were prescribed 65 antibiotics. In relation to the surgical group, 34 inpatients treated for infection were prescribed 66 antibiotics in the AAH, while 41 patients in the Specialty Hospital treated for infection were prescribed 56 antibiotics. For the medical patients, the most frequently prescribed antibiotics in the AAH were a combination of penicillins (18.8%) and penicillins with extended spectrum (18.8%). For the surgical patients, the most frequently prescribed antibiotics in the AAH were imidazole derivatives (24.2%). For the medical and surgical patients in the Specialty Hospital, the most frequently prescribed antibiotics were third-generation cephalosporins (26.2 and 37.5%, respectively). In medical patients, compliance to guidelines was 92.2% in the Specialty Hospital compared to 72.0% in the AAH (p < 0.001). In surgical patients, compliance to guidelines was 92.7% in the Specialty Hospital compared to 81.8% in the AAH (p = 0.012).

Conclusions

The present study highlighted differences in the utilisation of antimicrobials between two hospitals in two distinct regions and benchmarked antibiotic prescriptions across two hospitals.

Empirical Antibiotic Treatment Does Not Improve Outcomes in Catheter-Associated Urinary Tract Infection: Prospective Cohort Study

Background

Catheter associated urinary tract infection (CAUTI) is the most common healthcare-associated acquired infection. We aimed to describe the short- and long-term survival of patients with CAUTI and the impact of the empirical antibiotic treatment on survival rates.

Methods

In this prospective observational study we included consecutive adult patients with a chronic indwelling catheter-associated UTI and sepsis hospitalized in medical departments. The primary outcomes were 30-days all-cause mortality and long-term survival at end of the follow-up. A multivariate analysis using logistic regression and Cox proportional hazard model was performed to identify independent risk factors for an adverse outcome. A propensity-score model for receiving appropriate empirical antibiotic therapy was constructed and used to match patients.

Results

Overall, 315 consecutive patients with CAUTI were enrolled. The cohort consisted of elderly to very old patients (mean age 79.2 ± 11.5). The crude 30-day all-cause mortality rate was 30.8% (97/315). The median survival time was 82 days (interquartile range [IQR] 22-638). Appropriate early empirical treatment had no statistically significant association with 30-day mortality, propensity score-matched odds ratio (OR) 1.39 (0.76-2.55). Similarly, in the propensity-matched cohort, appropriate empirical treatment was not statistically associated with long-term survival (hazard ratio [HR] = 0.99, 95% confidence interval [CI] 0.75-1.3).

Conclusions

In our setting, patients with CAUTI had poor short- and long-term prognosis regardless of appropriate empirical antibiotic treatment. Avoiding empirical antibiotics for CAUTI might be an important antibiotic stewardship intervention in hospitals.

Longitudinal point prevalence survey of antibacterial use in Northern Ireland using the European Surveillance of Antimicrobial Consumption (ESAC) PPS and Global-PPS tool

Antimicrobial resistance is a limiting factor for the success of the treatment of infectious diseases and is associated with increased morbidity and cost. The present study aims to evaluate prescribing patterns of antimicrobials and quantify progress in relation to targets for quality improvement in the prescription of antimicrobials in Northern Ireland's secondary care sector using three repetitive point prevalence surveys (PPS) over a 6-year period: the European Surveillance of Antimicrobial Consumption (ESAC-PPS) in 2009 and 2011 and the Global-PPS on Antimicrobial Consumption and Resistance in 2015. Out of 3605 patients surveyed over the three time points, 1239 (34.4%) were treated with an antibiotic, the most frequently prescribed antibiotic groups were a combination of penicillins, including β-lactamase inhibitors. Compliance with hospital antibiotic policies in 2009, 2011 and 2015 were 54.5%, 71.5% and 79.9%, respectively. Likewise, an indication for treatment was recorded in patient notes 88.5%, 87.7% and 90.6% in 2009, 2011 and 2015, respectively, and surgical prophylactic antibiotic prescriptions for >24 h was 3.9%, 3.2% and 0.7% in 2009, 2011 and 2015, respectively. Treatment based on biomarker data was used in 61.5% of cases. In conclusion, a general trend in the improvement of key antimicrobial-related quality indicators was noted. The PPS tool provided a convenient, inexpensive surveillance system of antimicrobial consumption and should be considered an essential component to establish and maintain informed antibiotic stewardship in hospitals.

Antibiotic prescribing knowledge, attitudes, and practice among physicians in teaching hospitals in South India

BACKGROUND

Antibiotic overuse is a major public health challenge worldwide. Data from India related to physician antibiotic prescribing patterns are limited.

AIMS

We assessed antibiotic prescribing knowledge, attitudes, and practices among physicians in Mangalore, South India.

MATERIALS AND METHODS

Using a cross-sectional descriptive study design, physicians at academic tertiary hospitals completed an anonymous on-site survey. The survey items incorporated Likert scales, and data were analyzed using SPSS version 15.0.

RESULTS

Of the 350 physicians approached using a convenient sampling method, 230 (66%) consented and interviewed. The physician's knowledge of resistance patterns of common bacteria was related to receiving periodic updates on resistance patterns of bacteria (P = 0.019) and participation in courses on antibiotics (P = 0.026). Individuals with more number of years of experience (mean of 11 years) were less likely to justify antibiotic use for uncomplicated bronchitis (P = 0.015) and acute gastroenteritis (P = 0.001). Most respondents (n = 204, 89%) believed that physicians overprescribed antibiotics in routine clinical practice. Forty-five percent (n = 104) stated that their hospitals did not have an infection control policy in place.

CONCLUSIONS

This study provides some understanding of physician's antibiotic prescribing patterns from teaching hospitals in India. Judicious antimicrobial use through educational and antimicrobial stewardship programs remains critical to control the spread of antibiotic resistance.

Applicability of generic quality indicators for appropriate antibiotic use in daily hospital practice: a cross-sectional point-prevalence multicenter study

The ability to monitor the appropriateness of hospital antibiotic use is a key element of an effective antibiotic stewardship program. A set of 11 generic quality indicators (QIs) was previously developed to assess the quality of antibiotic use in hospitalized adults treated for a bacterial infection. The primary aim of the current study was to assess the clinimetric properties of these QIs (nine process and two structure indicators) in daily clinical practice. In a cross-sectional point-prevalence survey, performed in 2011 and 2012, 1890 inpatients from 22 hospitals in the Netherlands treated with antibiotics for a suspected bacterial infection were included, and data were extracted from medical records. In this cohort we tested the measurability, applicability, reliability, room for improvement and case mix stability of the previously developed QIs. Low applicability (≤10% of reviewed patients) was found for the QIs 'therapeutic drug monitoring', 'adapting antibiotics to renal function' and 'discontinue empirical therapy in case of lack of clinical and/or microbiological evidence of infection'. For the latter, we also found a low inter-observer agreement (kappa <0.4). One QI showed low improvement potential. The remaining seven QIs had sound clinimetric properties. Case-mix correction was necessary for most process QIs. For all QIs, we found ample room for improvement and large variation between hospitals. Establishing the clinimetric properties was essential, as four of the 11 previously selected QIs showed unsatisfactory properties in this practice test. Since the quality of antibiotic use and the process of documenting data is changing over time and may vary per country, QIs should always be tested in practice first.

Quality of documentation on antibiotic therapy in medical records: evaluation of combined interventions in a teaching hospital by repeated point prevalence survey

This study aimed to improve the quality of documentation on antibiotic therapy in the computerized medical records of inpatients. A prospective, uncontrolled, interrupted time series (ITS) study was conducted by repeated point prevalence survey (PPS) to audit the quality of documentation on antibiotic therapy in the medical records before and after a combined intervention strategy (implementation of guidelines, distribution of educational materials, educational outreach visits, group educational interactive sessions) from the antimicrobial stewardship team (AST) in the academic teaching hospital (CHU) of Liège, Belgium. The primary outcome measure was the documentation rate on three quality indicators in the computerized medical records: (1) indication for treatment, (2) antibiotics prescribed, and (3) duration or review date. Segmented regression analysis was used to analyze the ITS. The medical records of 2306 patients receiving antibiotics for an infection (1177 in the pre-intervention period and 1129 in the post-intervention period) were analyzed. A significant increase in mean percentages in the post-intervention period was observed as compared with the pre-intervention period for the three quality indicators (indication documented 83.4 ± 10.4 % vs. 90.3 ± 6.6 %, p = 0.0013; antibiotics documented 87.9 ± 9.0 % vs. 95.6 ± 5.1 %, p < 0.0001; and duration or review date documented 31.9 ± 15.4 % vs. 67.7 ± 15.2 %, p < 0.0001). The study demonstrated the successful implementation of a combined intervention strategy from the AST. This strategy was associated with significant changes in the documentation rate in the computerized medical records for the three quality indicators.

Point prevalence survey of antimicrobial utilization in a Canadian tertiary-care teaching hospital

Objectives: Inappropriate antimicrobial use can promote antimicrobial resistance, which is associated with increased patient morbidity and mortality. Identifying the pattern of antimicrobial use can provide data from which targeted antimicrobial stewardship interventions can be made. The primary objective was to identify the prevalence of antimicrobial use at a tertiary care teaching hospital with both acute and long-term care patients.

Methods: A point prevalence study was conducted on July 19th, 2012. Data on antimicrobial utilization, indication for prescribing, duration of therapy, and frequency of infectious disease or antimicrobial stewardship consultations were collected using a customized integrated stewardship database (SPIRIT) and prospective chart review.

Results: One or more antimicrobial agents were ordered in 31% and 4% of acute care and long-term care patients, respectively. Respiratory and urinary tract infections were the most common indication for antimicrobial therapy in both acute and long-term care. About 25% of surgical prophylaxis orders were prescribed for greater than 24 h.

Conclusion: This prospective point prevalence survey provided important baseline information on antimicrobial use within a large tertiary care teaching hospital and identified potential targets for future antimicrobial stewardship initiatives. A multi-center point prevalence survey should be considered to identify patterns of antimicrobial use in Canada and to establish the first steps toward international antimicrobial surveillance.