Antimicrobial Use Control Measures to Prevent and Control Antimicrobial Resistance in US Hospitals

Evaluation of three protocols for direct susceptibility testing for gram negative-Enterobacteriaceae from patient samples in Uganda with SMS reporting

In Uganda, the challenge of generating and timely reporting essential antimicrobial resistance (AMR) data has led to overreliance on empirical antibiotic therapy, exacerbating the AMR crisis. To address this issue, this study aimed to adapt a one-step AMR testing protocol alongside an SMS (Short Message Service) result relay system (SRRS), with the potential to reduce the turnaround time for AMR testing and result communication from 4 days or more to 1 day in Ugandan clinical microbiology laboratories. Out of the 377 samples examined, 54 isolates were obtained. Notably, E. coli (61%) and K. pneumoniae (33%) were the most frequently identified, majority testing positive for ESBL. Evaluation of three AMR testing protocols revealed varying sensitivity and specificity, with Protocol A (ChromID ESBL-based) demonstrating high sensitivity (100%) but no calculable specificity, Protocol B (ceftazidime-based) showing high sensitivity (100%) and relatively low specificity (7.1%), and Protocol C (cefotaxime-based) exhibiting high sensitivity (97.8%) but no calculable specificity. ESBL positivity strongly correlated with resistance to specific antibiotics, including cefotaxime, ampicillin, and aztreonam (100%), cefuroxime (96%), ceftriaxone (93%), and trimethoprim sulfamethoxazole (87%). The potential of integrating an SRRS underscored the crucial role this could have in enabling efficient healthcare communication in AMR management. This study underscores the substantial potential of the tested protocols for accurately detecting ESBL production in clinical samples, potentially, providing a critical foundation for predicting and reporting AMR patterns. Although considerations related to specificity warrant careful assessment before widespread clinical adoption.

Unnecessary antimicrobial prescribing for upper respiratory tract infections in children in Pietermaritzburg, South Africa

Background

Acute upper respiratory tract infections (URTIs) are contagious diseases of the upper airways, but they are self-limiting in nature. Therefore, antimicrobial-use for the majority of the URTIs is considered inappropriate. Unfortunately, globally, antimicrobials are still being prescribed for the treatment of URTIs, especially in children. However, there is insufficient evidence on the causes of this phenomenon in South Africa.

Objective

To investigate whether the parents/guardians accompanying children with URTIs expected/influenced physicians and/or nurses to prescribe antibiotics.

Methods

This was a prospective descriptive and explorative questionnaire-based study. Participants were guardians who accompanied children aged five years and below, diagnosed with acute URTIs.

Findings

Three hundred and six parents/guardians participated in this study. Seventy six percent (n=233) of participants received antibiotics for URTIs for their children, and 67% (n=156) of these did not make requests for antimicrobial therapy. On overall, there was a statistically significant (p < 0.0001) chance (with OR of 5.9; 95% CI, 2.4 – 14.2) for receiving antibiotics for URTIs without a request.

Conclusion

Physicians and other healthcare providers need education on rational prescribing of antimicrobials, and to implement evidence-based standard treatment guidelines, to reduce inappropriate use of antibiotics in children with self-limiting URTIs.

Antibiotic consumption and management at Kocani General Hospital – Annual report

The aim of the study was to get detailed insight into the antibiotic consumption trends in the three year period (2016-2018) in Kocani Hospital, to identify the most often prescribed antibiotics and to determine whether the treatment of given diagnosis was in accordance with the official guidelines. The survey covered all pediatric and infant patients admitted to the pediatric ward. Patients’ data included gender, age, diagnosis, antibiotic used and doses. The majority of admitted patients were in the age group of 0-1 (27.48%, 25.94% and 30.77% for 2016, 2017 and 2018, accordingly) followed by age group of 1-2 years (20.86%, 22,0% and 23.83% for 2016, 2017 and 2018, consequently) and 2-3 years (16.06%, 16.1% and 14.63% for 2016, 2017 and 2018, consequently) .The most frequent diagnosis was acute tonsillitis which was determined in ~21% of patients, pneumonia without complications in ~18% and acute bronchitis in ~16% of patients in the period 2016-2018. Results from conducted survey identified high prescription rate and use of antibiotics predominantly ceftriaxone (82.58%, 81.05% and 50.85% in 2016, 2017 and 2018, respectively) contrary to official recommendations and evidences based on clinical data for treatment of the diagnoses in question. So, it is foreseeable to conclude that there is urgent need for restrictive and educational measures i.e. to strength the surveillance and monitoring of antibiotic prescription and usage and hence to promote awareness for rational use of antibiotics on all health-care levels. Key words: antibiotic prescription, antibiotic consumption, pediatric wards, annual report

Decreasing Clostridium difficile-Associated Fatality Rates Among Hospitalized Patients in the United States: 2004-2014

BACKGROUND

Clostridium difficile infection has emerged as a major public health problem in the United States over the last 2 decades. We examined the trends in the C. difficile-associated fatality rate, hospital length of stay, and hospital charges over the last decade.

METHODS

We used data from the National Inpatient Sample to identify patients with a principal diagnosis of C. difficile infection from 2004 to 2014. Outcomes included in-hospital fatality rate, hospital length of stay, and hospital charges. For each outcome, trends were also stratified by age categories because the risk of infection and associated mortality increases with age.

RESULTS

Clostridium difficile infection discharges increased from 19.9 per 100,000 persons in 2004 to 33.8 per 100,000 persons in 2014. Clostridium difficile-associated fatality decreased from 3.6% in 2004 to 1.6% in 2014 (P < .001). Among patients aged 45-64 years, fatality decreased from 1.2% in 2004 to 0.7% in 2014 (P < .001). Among patients aged 65-84 years, fatality decreased from 4.3% in 2004 to 2.0% in 2014 (P < .001). Among patients aged ≥85 years, fatality decreased from 6.9% in 2004 to 3.6% in 2014 (P < .001). The mean length of hospital stay decreased from 6.9 days in 2004 to 5.8 days in 2014 (P < .001). The mean hospital charges increased from 2004 ($24,535) to 2014 ($35,898) (P < .001).

CONCLUSION

In-hospital fatality associated with C. difficile infection in the United States has decreased more than 2-fold in the last decade, despite increasing infection rates.

Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases

Introduction

In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute.

Materials and methods

A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development.

Conclusion

The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.

Bacterial Replication Rate Modulation in Combination with Antimicrobial Therapy: Turning the Microbe against Itself

A major clinical challenge for treating infectious diseases is the duration of antimicrobial therapy required to eradicate the pathogen. We hypothesized that modulation of the bacterial replication rate in the context of an antimicrobial exposure is coupled with the rate and extent of bactericidal effects. Herein we describe results from in vitro infection model (one compartment, 24-h model; hollow fiber, 10-day model) studies designed to probe the relationship between the bacterial replication rate and the rate and extent of bactericidal effects in the context of an effective antibiotic exposure. The bacterial replication rate was modulated by adjusting the sodium chloride concentration (0 to 8%) in the growth media (Mueller-Hinton II broth). The study drug selected was levofloxacin, and the challenge isolate was Staphylococcus aureus ATCC 29213 (levofloxacin MIC, 0.125 mg/liter). Within each in vitro infection model, human levofloxacin concentration-time profiles (half-life, 7 h) were simulated and the challenge isolate was subjected to an effective exposure (free-drug area under the concentration-time curve over 24 h divided by the MIC [AUC/MIC ratio], 65; administered as a single dose or daily for 10 days). Over the course of each study, samples were taken from each model for bacterial density determinations and drug concentration assay using liquid chromatography-tandem mass spectrometry (LC-MS/MS). In the 24-h one-compartment in vitro infection model studies, as the bacterial replication rate increased, so too did the rate (slope, 0 to 4 h) and extent (24-h CFU count per milliliter) of bacterial killing. In the 10-day hollow-fiber infection model studies, the times until a reduction of bacterial density to 1 × 10² CFU/ml occurred were 10 days in the media in which the challenge isolate grew slowly and approximately 2 days in the media in which the challenge isolate grew rapidly. Together, these data provide a proof of concept for new adjunctive therapeutic options with respect to the use of antimicrobial agents alone that reduce treatment durations. Such adjunctive therapies hold promise for marked reductions in the tonnage of antimicrobial agents administered to patient populations and selection pressure toward antimicrobial resistance.

Relationship of various infection control interventions to the prevalence of multidrug-resistant Pseudomonas aeruginosa among U.S. hospitals

BACKGROUND

Health care-associated infections caused by antibiotic-resistant gram-negative bacteria, such as Pseudomonas aeruginosa, are an emerging and increasingly important public health threat. However, there are very few studies that examine the relationships between antimicrobial resistance strategies and interventions and the prevalence of antibiotic-resistant and multidrug-resistant strains of Pseudomonas.

METHODS

The membership of the Association for Professionals in Infection Control and Epidemiology was invited to participate in a Web-based survey of U.S. acute care hospital infection preventionists.

RESULTS

A final sample of 225 completed responses was analyzed using correlational techniques. Resistance to gentamicin (r = 0.17, P = .01), imipenem (r = 0.18, P = .02), ceftazidime (r = 0.20, P = .03), and ciprofloxacin (r = 0.15, P = .03) all showed significant direct associations with epidemiologic investigation using molecular testing. A significant inverse relationship was found between resistance to ceftazidime and effective efforts in the identification and isolation of infected patients (r = -0.18, P = .02).

CONCLUSIONS

The finding of significant direct relationships between antimicrobial resistance and epidemiologic investigations using molecular testing suggests that the increased burden of resistance is associated with molecular testing rather than the intervention driving down rates. Effective identification and isolation of infected patients appeared to be associated with lower resistance rates. Further research is needed to uncover causal relationships.

Antibiotic stewardship in the intensive care unit

The rapid emergence and dissemination of antimicrobial-resistant microorganisms in ICUs worldwide constitute a problem of crisis dimensions. The root causes of this problem are multifactorial, but the core issues are clear. The emergence of antibiotic resistance is highly correlated with selective pressure resulting from inappropriate use of these drugs. Appropriate antibiotic stewardship in ICUs includes not only rapid identification and optimal treatment of bacterial infections in these critically ill patients, based on pharmacokinetic-pharmacodynamic characteristics, but also improving our ability to avoid administering unnecessary broad-spectrum antibiotics, shortening the duration of their administration, and reducing the numbers of patients receiving undue antibiotic therapy. Either we will be able to implement such a policy or we and our patients will face an uncontrollable surge of very difficult-to-treat pathogens.

Antimicrobial stewardship in hospitals: Does it work and can we do it?

Selection of resistant pathogens by antimicrobial use is probably the most important cause of antimicrobial resistance. Antimicrobial stewardship (AMS) refers to a multifaceted approach to optimise prescribing. The benefits of AMS programmes have been widely demonstrated in terms of reductions in antimicrobial use, mortality, Clostridium difficile and other healthcare-associated infections, hospital length of stay and bacterial resistance. Several kinds of interventions (i.e. restriction of drugs, pre-authorisation of certain antimicrobials, joint clinical rounds with prescribers, implementation of guidelines and education) have shown positive results. Regrettably, in most hospitals in Latin America, Asia and Africa as well as in a significant proportion of institutions in Europe and North America, essential human and material resources are scarce or absent, and teams are neither developed nor well functioning. Despite current or potential barriers, we should start or improve our already ongoing initiatives on AMS by considering the main specific problems and act accordingly with the available human and material resources. From supervising the use of specific classes of drugs to implementing more sophisticated decision support programmes, there is a wide range of possible useful interventions.

Surveillance and management of multidrug-resistant microorganisms

Multidrug-resistant organisms are an established and growing worldwide public health problem and few therapeutic options remain available. The traditional antimicrobials (glycopeptides) for multidrug-resistant Gram-positive infections are declining in efficacy. New drugs that are presently available are linezolid, daptomicin and tigecycline, which have well-defined indications for severe infections, and talavancin, which is under Phase III trial for hospital-acquired pneumonia. Unfortunately the therapies available for multidrug-resistant Gram-negatives, including carbapenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae, are limited to only colistin and tigecycline. Both of these drugs are still not registered for severe infections, such as hospital acquired pneumonia. Consequently, as confirmed by scientific evidence, a multidisciplinary approach is needed. Surveillance, infection control procedures, isolation and antimicrobial stewardship should be implemented to reduce multidrug-resistant organism diffusion.

Real-time optical antimicrobial susceptibility testing

Rapid antibiotic susceptibility testing is in high demand in health care fields as antimicrobial-resistant bacterial strains emerge and spread. Here, we describe an optical screening system (oCelloScope) which, based on time-lapse imaging of 96 bacteria-antibiotic combinations at a time, introduces real-time detection of bacterial growth and antimicrobial susceptibility with imaging material to support the automatically generated graphs. Automated antibiotic susceptibility tests of a monoculture showed statistically significant antibiotic effects within 6 min and within 30 min in complex samples from pigs suffering from catheter-associated urinary tract infections. The oCelloScope system provides a fast high-throughput screening method for detecting bacterial susceptibility that might entail an earlier diagnosis and introduction of appropriate targeted therapy and thus combat the threat from multidrug-resistant pathogenic bacteria. The oCelloScope system can be employed for a broad range of applications within bacteriology and might present new vistas as a point-of-care instrument in clinical and veterinary settings.

The state of antimicrobial stewardship programs in California

OBJECTIVE

To assess antimicrobial stewardship programs (ASPs) and strategies in California general acute care hospitals and to describe the effect of state legislation (Senate Bill 739) requiring hospitals to develop processes for evaluating the judicious use of antimicrobials.

DESIGN

Web-based survey of general acute care hospitals.

PARTICIPANTS

All 422 general acute care hospital campuses in California were invited to participate.

RESULTS

Responses from 223 (53%) of California's general acute care hospital campuses were included and were statistically representative of all acute care hospital campuses by region but not bed size or rurality. Community hospitals represented 73% of respondents. Fifty percent of hospitals described a current ASP and 30% reported planning an ASP; of these, 51% reported measuring outcomes. Twenty percent of hospitals reported no planned ASP or uncertainty whether an ASP existed and described barriers including staffing constraints (47%), lack of funding (42%), and lack of initiation of a formal proposal to start an ASP (42%). Of 135 responding hospitals, 22% reported that Senate Bill 739 influenced initiation of their ASP.

CONCLUSIONS

Although many studies have been published that describe hospital-specific ASPs, most have been described within academic centers, and there are limited assessments of ASP strategies across hospital systems. Our study verifies that many ASPs exist in California, particularly in community settings where a scarcity of antimicrobial restriction was thought to exist. Additionally, Senate Bill 739 appears to have played a role in initiating many hospital ASPs, which supports the adoption of similar legislation in other states and nationally.

Antibiotic heterogeneity optimizes antimicrobial prescription and enables resistant pathogen control in the intensive care unit

BACKGROUND

Multi-drug-resistant organisms (MDRO) complicate care increasingly on the general ward and in the emergency department, operating room, and intensive care unit (ICU). Whereas barrier precautions are important in limiting transmission of MDRO between patients, few tactics have been defined that reduce the genesis of MDRO.

METHOD

Review of pertinent English-language literature.

RESULTS

Antibiotic heterogeneity practices, as part of an overall antimicrobial drug stewardship program, offer one readily deployable means to reduce selection pressure for MDRO development in the ICU. The data underpinning this approach and data derived from its use indicate that, especially in surgical ICUs, heterogeneity of antibiotic prescribing can preserve or restore microbial ecology, reduce the prevalence of MDRO and the incidence of infections caused thereby, and facilitate the implementation and effectiveness of other antibiotic-sparing tactics, such as de-escalation.

CONCLUSION

Heterogeneity of antibiotic prescribing is effective in preventing the dissemination of MDRO pathogens.

Improving antimicrobial stewardship: the evolution of programmatic strategies and barriers

OBJECTIVE

To describe the prevalence and characteristics of antimicrobial stewardship programs (ASPs) in hospitals across the United States and to describe financial support provided for these programs.

DESIGN

Electronic and paper 14-question survey of infectious diseases physician members of the Infectious Diseases Society of America Emerging Infections Network (IDSA EIN).

PARTICIPANTS

All 1,044 IDSA EIN members who care for adult patients were invited to participate.

RESULTS

Five hundred twenty-two (50%) members responded. Seventy-three percent of respondents reported that their institutions had or were planning an ASP, compared with 50% reporting the same thing in an EIN survey 10 years before. A shift was noted from formulary restriction alone to use of a set of tailored strategies designed to provide information and feedback to prescribers, particularly in community hospitals. Lack of funding and lack of personnel were reported as major barriers to implementing a program. Fifty-two percent of respondents with an ASP reported that infectious diseases physicians do not receive direct compensation for their participation in the ASP, compared with 18% 10 years ago.

CONCLUSIONS

The percentage of institutions reporting ASPs has increased over the last decade, although small community hospitals were least likely to have these programs. In addition, ASP strategies have shifted dramatically. Lack of funding remains a key barrier for ASPs, and administrators need additional cost savings data in order to support ASPs. Interestingly, while guidelines and editorials regard compensated participation by an infectious diseases physician in these programs as critical, we found that more than half of the respondents reported no direct compensation for ASP activities.

Antibiotic prescribing in hospitals: a social and behavioural scientific approach

Antibiotics have dramatically changed the prognoses of patients with severe infectious diseases over the past 50 years. However, the emergence and dissemination of resistant organisms has endangered the effectiveness of antibiotics. One possible approach to the resistance problem is the appropriate use of antibiotic drugs for preventing and treating infections. This Review describes how the volume and appropriateness of antibiotic use in hospitals vary between countries, hospitals, and physicians. At each specific level-cultural, contextual, and behavioural-we discuss the determinants that influence hospital antibiotic use and the possible improvement strategies to make it more appropriate. Changing hospital antibiotic use is a challenge of formidable complexity. On each level, many determinants play a part, so that the measures or strategies undertaken to improve antibiotic use need to be equally diverse. Although various strategies for improving antibiotic use are available, a programme with activities at all three levels is needed for hospitals. Evaluating these programme activities in a way that provides external validity of the conclusions is crucial.

Improved susceptibility of Gram-negative bacteria in an intensive care unit following implementation of a computerized antibiotic decision support system

OBJECTIVES

Emergence of multiresistant Gram-negative organisms in intensive care units (ICUs) throughout the world is a concerning problem. Therefore we undertook a study to follow the resistance patterns of the most common clinically isolated Gram-negative organisms within our ICU following an antibiotic stewardship intervention to evaluate whether a reduction in broad-spectrum antibiotics improves local antibiotic resistance patterns.

METHODS

This prospective study was conducted over a 7 year period within an ICU at a tertiary teaching hospital in Melbourne, Australia. All clinically isolated Gram-negative organisms were identified and extracted from the hospital pathology system. Three monthly antibiograms were created. The pre-interventional period occurred between January 2000 and June 2002 (10 quarters) and the post-interventional period was defined from July 2002 to December 2006 (18 quarters). Segmented linear regression was used to analyse for a difference in the rates of change in susceptibility.

RESULTS

A total of 2838 Gram-negative organisms were isolated from clinical sites from ICU patients during the study period. There was significant improvement in susceptibility of Pseudomonas to imipenem 18.3%/year [95% confidence interval (CI): 4.9-31.6; P = 0.009] and gentamicin 11.6%/year (95% CI: 1.8-21.5; P = 0.02) compared with the pre-intervention trend. Significant changes in the rates of gentamicin and ciprofloxacin susceptibility were also observed in the inducible Enterobacteriaceae group although these were less clinically significant.

CONCLUSIONS

This study demonstrates improved antibiotic susceptibility of ICU Gram-negative isolates including Pseudomonas following an intervention aimed at reducing broad-spectrum antibiotics.

Pro/con debate: Should antimicrobial stewardship programs be adopted universally in the intensive care unit?

You are director of a large multi-disciplinary ICU. You have recently read that hospital-wide antibiotic stewardship programs have the potential to improve the quality and safety of care, and to reduce the emergence of multi-drug resistant organisms and overall costs. You are considering starting one of these programs in your ICU, but are concerned about the associated infrastructure costs. You are debating whether it is worth bringing the concept forward to your hospital's administration to consider investing in.

Impact of a restrictive antimicrobial policy on the process and timing of antimicrobial administration

BACKGROUND

In-hospital antimicrobial approval policies are designed to curb the indiscriminant use of antimicrobials. These policies usually require written forms and/or direct requests to an Infectious Disease specialist (or surrogate) prior to release of the antimicrobial. We hypothesized that the approval processes at our institution results in delayed antimicrobial administration.

METHODS

We performed a retrospective cohort study examining the time from order to administration for 25 different antimicrobials ordered "stat." Antimicrobials were classified as restricted (required approval) or unrestricted. We compared these 2 classes to each other both during the daytime (8 AM to 10 PM), when approval is required for restricted antimicrobials, and at night when the first dose of all antimicrobials is exempted. We defined a delay in administration when the medication was given >1 hour from time of order. We separately examined delays of >2 hours.

RESULTS

A higher percentage of >1-hour delays occurred when the antimicrobial was restricted (odds ratio [OR] = 1.49; 95% confidence interval [CI] = 1.23-1.82). Similar results were seen for >2-hour delays (OR = 1.78; 95% CI = 1.39-2.21). During the exempt-from-restriction time period (10 PM to 8 AM), there was no difference between these 2 classes of antimicrobials. Results were unchanged by adjustment for service (medicine vs. surgery vs. other), patient characteristics (age, sex, race), or by weekday vs. weekend.

CONCLUSIONS

Statistically significant delays in stat antimicrobial administration occur in our institution when antimicrobials require preapproval. These findings illustrate the importance of considering clinical efficiency when restrictions are put in place for time-sensitive therapies such as antimicrobials.

Hospital antibiotic stewardship

PURPOSE OF REVIEW

Antibiotic stewardship is designed to optimize antimicrobial therapy administered to hospitalized patients, to ensure cost-effective therapy and improve patients' outcome while containing bacterial resistance. Current data on the development of effective programmes, including guidelines for their implementation, have demonstrated some efficacy and controversies are reviewed.

RECENT FINDINGS

Guidelines have been recently issued for the development and implementation of active antibiotic stewardship programmes in hospitals. A multidisciplinary team including at least an infectious disease physician and a clinical pharmacist is required. Multiple strategies are available, including prospective audit with feedback to the provider, education and antimicrobial restriction. Interventions have shown a positive effect on optimization of antimicrobial use, reduced costs and bacterial resistance, but studies showing improvement in patient outcomes are sparse. Results of studies may be confounded by several factors, mainly due to their before-after design and lack of control for cointerventions.

SUMMARY

Combined with an effective infection control programme, antibiotic stewardship can help contain antimicrobial resistance. Studies demonstrating improvement of patients' outcomes are needed to increase acceptance by a broader audience of physicians. A proactive strategy of prospective auditing with direct counsels and feedback to the prescriber, ensuring systematic reassessment of ongoing therapy, appears most useful.

Antibiotic use in 26 departments of internal medicine in 6 general hospitals in Israel: variability and contributing factors

OBJECTIVES

Increased antibiotic consumption is associated with increased bacterial resistance worldwide. We aimed to analyse antibiotic consumption and potential contributory factors in internal medicine departments in Israel.

METHODS

Data (2003-04) from 26 departments in 6 hospitals were retrieved. Defined daily doses (DDD)/100 bed-days were calculated for total antibiotic use and by antibiotic class. Patterns identified were correlated with 15 patients' and departmental variables by univariate and multivariate analyses.

RESULTS

Total antibiotic consumption differed by a factor of 2.3 (115 DDD/100 bed-days to 49.1 DDD/100 bed-days) between the highest and lowest consuming departments. Antibiotic classes differed by a factor of 22.8 for macrolides, a factor of 20 for piperacillin/tazobactam, a factor of 17 for carbapenems, a factor of 13.3 for quinolones, a factor of 9 for vancomycin, a factor of 6.8 for amoxicillin/clavulanate, a factor of 6.6 for aminoglycosides, a factor of 5.3 for penicillins and a factor of 2.8 for cephalosporins. Even among departments within hospitals, there was a difference of up to 1.5-fold for total use and antibiotic class differences ranged between 2.5- and 7.2-fold for third- and fourth-generation cephalosporins, despite similar Charlson scores and other patient variables. In the multivariate analysis, hospital affiliation and rate of 1 day hospitalization were the only significant variables predicting total antibiotic use, contributing 43% and 7.3%, respectively, to the variance. By antibiotic class, controlling for hospital affiliation, patients with neutropenia, lower respiratory tract infections and assisted ventilation were the most common significant contributors, ranging from 3.5% for quinolones to 7.7% for piperacillin/tazobactam.

CONCLUSIONS

Patterns of antibiotic use vary widely among internal medicine departments in Israel, which cannot be explained by objective parameters related either to patients or wards. Ongoing monitoring and guideline formulation are needed to regulate antibiotic prescription.

Antimicrobial resistance prevention initiative--an update: proceedings of an expert panel on resistance

Antimicrobial resistance is a growing problem that complicates the treatment of important nosocomial and community-acquired infections. It is a worldwide problem that spans the range of human pathogens, including bacteria, fungi, and viruses. This update from the Antimicrobial Resistance Prevention Initiative (ARPI) provides a review of some important trends in antibiotic, antifungal, and antiviral resistance. Areas of focus include multidrug-resistant bacteria in the hospital setting; the growing problem of community-acquired methicillin-resistant Staphylococcus aureus; triazole and polyene resistance in nosocomial infections caused by non-Candida albicans or Aspergillus species, and the utility of in vitro susceptibility testing for these fungal infections; antiviral resistance in alpha- or beta-herpesviruses causing genital herpes or cytomegalovirus infection in immunocompromised hosts; and concerns about a possible pandemic involving avian influenza A and the importance of minimizing emergence of resistant strains of this highly pathogenic virus. The challenges in each area are different, but the general keys to addressing the growing problem of antimicrobial resistance continue to be responsible antimicrobial stewardship and the development of newer antimicrobial agents.

Principles of Antibiotic Therapy in Severe Infections: Optimizing the Therapeutic Approach by Use of Laboratory and Clinical Data

The increasingly daunting problem of antimicrobial resistance has led to an intense focus on optimization of antibiotic therapy, with simultaneous goals of improving patient outcomes and minimizing the contribution of that therapy to making the available antibiotics obsolete. Although even appropriate antibiotic therapy drives resistance, inappropriate therapy may also have adverse effects on the individual patient, as well as on the bacterial ecology. Recent research has validated the benefit of intelligent utilization of both microbiological data and clinical assessment in the empirical selection of initial broad-spectrum therapy and in further guidance of therapeutic decisions throughout the course of illness by use of a systems approach. Thus, the optimal approach to the critically ill patient with infection involves the initiation of aggressive broad-spectrum empirical therapy followed by timely responses to microbiological and clinical results as they become available. An appropriate response to this information often involves de-escalation of therapy or even its discontinuation.

Community-acquired pneumonia: doctors do not follow national guidelines

OBJECTIVES

Appropriate assessment of community-acquired pneumonia (CAP) allows accurate severity scoring and hence optimal management, leading to reduced morbidity and mortality. British Thoracic Society (BTS) guidelines provide an appropriate score. Adherence to BTS guidelines was assessed in our medical assessment unit (MAU) in 2001/2 and again in 2005/6, 3 years after introducing an educational programme.

METHODS

A retrospective case-note study, comparing diagnosis, documentation of severity, management and outcome of CAP during admission to MAU during 3 months of each winter in 2001/2 and 2005/6.

RESULTS

In 2001/2, 65/165 patients were wrongly coded as CAP and 100 were included in the study. In 2005/6 43/130 were excluded and 87 enrolled. In 2005/6, 87% did not receive a severity score, a significant increase from 48% in 2001/2 (p<0.0001). Parenteral antibiotics were given to 79% of patients in 2001/2 and 77% in 2005/6, and third generation cephalosporins were given to 63% in 2001/2 and 54% in 2005/6 (p = NS). In 2001, 15 different antibiotic regimens were prescribed, increasing to 19 in 2005/6.

CONCLUSIONS

Coding remains poor. Adherence to CAP management guidelines was poor and has significantly worsened. Educational programmes, alone, do not improve adherence. Restriction of antibiotic prescribing should be considered.

Development and validation of measures to assess prevention and control of AMR in hospitals

BACKGROUND

The rapid spread of antimicrobial resistance (AMR) in the US hospitals poses serious quality and safety problems. Expert panels, identifying strategies for optimizing antibiotic use and preventing AMR spread, have recommended hospitals undertake efforts to implement specific evidence-based practices.

OBJECTIVE

To develop and validate a measurement scale for assessing hospitals' efforts to implement recommended AMR prevention and control measures.

STUDY DESIGN

Surveys were mailed to infection control professionals in a national sample of 670 US hospitals stratified by geographic region, bedsize, teaching status, and VA affiliation.

SUBJECTS

: Four hundred forty-eight infection control professionals participated (67% response rate).

METHODS

Survey items measured implementation of guideline recommendations, practices for AMR monitoring and feedback, AMR-related outcomes (methicillin-resistant Staphylococcus aureus prevalence and outbreaks [MRSA]), and organizational features. "Derivation" and "validation" samples were randomly selected. Exploratory factor analysis was performed to identify factors underlying AMR prevention and control efforts. Multiple methods were used for validation.

RESULTS

We identified 4 empirically distinct factors in AMR prevention and control: (1) practices for antimicrobial prescription/use, (2) information/resources for AMR control, (3) practices for isolating infected patients, and (4) organizational support for infection control policies. The Prevention and Control of Antimicrobial Resistance scale was reliable and had content and construct validity. MRSA prevalence was significantly lower in hospitals with higher resource/information availability and broader organizational support.

CONCLUSIONS

The Prevention and Control of Antimicrobial Resistance scale offers a simple yet discriminating assessment of AMR prevention and control efforts. Use should complement assessment methods based exclusively on AMR outcomes.

Antimicrobial resistance prevention initiative--an update: proceedings of an expert panel on resistance

Antimicrobial resistance is a growing problem that complicates the treatment of important nosocomial and community-acquired infections. It is a worldwide problem that spans the range of human pathogens, including bacteria, fungi, and viruses. This update from the Antimicrobial Resistance Prevention Initiative (ARPI) provides a review of some important trends in antibiotic, antifungal, and antiviral resistance. Areas of focus include multidrug-resistant bacteria in the hospital setting; the growing problem of community-acquired methicillin-resistant Staphylococcus aureus; triazole and polyene resistance in nosocomial infections caused by non-Candida albicans or Aspergillus species, and the utility of in vitro susceptibility testing for these fungal infections; antiviral resistance in alpha- or beta-herpesviruses causing genital herpes or cytomegalovirus infection in immunocompromised hosts; and concerns about a possible pandemic involving avian influenza A and the importance of minimizing emergence of resistant strains of this highly pathogenic virus. The challenges in each area are different, but the general keys to addressing the growing problem of antimicrobial resistance continue to be responsible antimicrobial stewardship and the development of newer antimicrobial agents.