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Schuts EC, Boyd A, Natsch S, Veenman A, Prins JM. A national antimicrobial guide with local, customizable versions: how is it used? A two-year analysis. JAC Antimicrob Resist 2023; 5:dlad136. [PMID: 38130702 PMCID: PMC10733808 DOI: 10.1093/jacamr/dlad136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023] Open
Abstract
Objectives Guideline adherence is one of the most important objectives for antibiotic stewardship. The Dutch Working Party on Antibiotic Policy (SWAB) developed an online national guide (SWAB-ID) in 2006. Every Dutch hospital is offered the opportunity to customize the national version to their local context and distribute it through an independent website. We studied user data to see how often the guidelines on therapy, prophylaxis and medication are used. Methods Data on usage between 19 June 2020 and 30 June 2022 were extracted through Google Analytics for the national site and the 53 hospitals using a customized version of the national guide. User data were divided into three main groups: users of the national guide SWAB-ID, and users of the sites of general hospitals and university hospitals. Results A total of 1 837 126 searches were analysed, of which 1 393 681 (75.9%) concerned therapy, 111 774 (6.1%) prophylaxis and 331 671 (18%) medication. Of these searches, 456 854 (24.9%) were performed on the national site, 950 887 (51.8%) by general hospitals and 429 385 (23.4%) by university hospitals. The most commonly searched tracts among all user groups were lower respiratory tract (21.8%), kidney and urinary tract (16.6%) and skin and soft tissues (11.8%). The most commonly searched conditions were community-acquired pneumonia (15.3%), cystitis (13.5%) and sepsis (11.3%). The top ranked pages on medication differed for the three categories of users. Conclusions The SWAB-ID antimicrobial guide is used extensively by both general and university hospitals. The online guide can help in prescribing therapy according to the guideline.
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Affiliation(s)
- Emelie C Schuts
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Anders Boyd
- Department of Infectious Diseases, Public Health Service Amsterdam, Amsterdam, The Netherlands
- Stichting HIV Monitoring, Amsterdam, The Netherlands
| | - Stephanie Natsch
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arjen Veenman
- Integrated Disease Management Corporation (IDMC), Nijmegen, The Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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2
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Villaverde S, Caro JM, Domínguez-Rodríguez S, Orellana MÁ, Rojo P, Epalza C, Blázquez-Gamero D. PACTA-Ped: Antimicrobial stewardship programme in a tertiary care hospital in Spain. An Pediatr (Barc) 2023; 99:312-320. [PMID: 37891136 DOI: 10.1016/j.anpede.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 09/12/2023] [Indexed: 10/29/2023] Open
Abstract
INTRODUCTION Fighting against antimicrobial resistance is a current priority, and further efforts need to be made to improve antimicrobial prescribing and reduce the spread of infections in paediatric care settings. METHODS We conducted a prospective longitudinal study on the use of antimicrobials from the time the antimicrobial stewardship programme (ASP) was introduced in January 2016 to December 2017 (period 2 [P2]) in our children's hospital. We compared the obtained results on antimicrobial prescribing with retrospective data from the period preceding the introduction of the ASP (2014-2015, period 1 [P1]). The sample consisted of paediatric inpatients who received broad-spectrum antimicrobials, antifungals or intravenous antibiotherapy lasting more than 5 days. We compared the use of antimicrobials in P1 versus P2. RESULTS A total of 160 patients were included during P2. The antibiotics for which a recommendation was made most frequently were meropenem (41.6%) and cefotaxime (23.4%). In 45% of care episodes, the consultant recommended "no change" to the prescribed antimicrobial. The final rate of acceptance of received recommendations by the prescribing physicians was 89%. We found average decreases of 27.8% in the days of treatment per 1000 inpatient days and 22.9% in the number of antimicrobial starts per 1000 admissions in P2. The use of carbapenems, cephalosporins and glycopeptides decreased in P2 compared to P1. The average annual cost of antimicrobial treatment decreased from є150 356/year during P1 to є98 478/year in P2. CONCLUSION Our ASP achieved a significant decrease in the use of broad-spectrum antibiotics and antifungals. The costs associated with antimicrobial prescribing decreased following the introduction of the ASP, which was a cost-effective action in this study period.
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Affiliation(s)
- Serena Villaverde
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.
| | - José Manuel Caro
- Department of Pharmacy, Hospital Universitario 12 de Octubre, Madrid, Spain; Antimicrobial Stewardship Programme, Hospital 12 de Octubre, Madrid, Spain
| | - Sara Domínguez-Rodríguez
- Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
| | - María Ángeles Orellana
- Antimicrobial Stewardship Programme, Hospital 12 de Octubre, Madrid, Spain; Department of Microbiology, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Pablo Rojo
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Cristina Epalza
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain; Antimicrobial Stewardship Programme, Hospital 12 de Octubre, Madrid, Spain
| | - Daniel Blázquez-Gamero
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
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3
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Reyes RE, López MJ, Pérez JE, Martínez G. Description of changes in clinical outcomes following the implementation of an antibiotic stewardship program in a level IV hospital. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2023; 43:244-251. [PMID: 37433162 PMCID: PMC10540980 DOI: 10.7705/biomedica.6748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 05/09/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Inadequate prescription of antibiotics has been recognized as a public health problem by the World Health Organization. In this context, antibiotic stewardship programs have been implemented as a tool to mitigate its impact. OBJETIVE To describe the changes in clinical outcomes after the implementation of an antibiotic stewardship program in a level IV hospital. MATERIALS AND METHODS We conducted a unique cohort study of patients hospitalized for infectious pathologies that were treated with antibiotics in an advanced medical facility. We collected the clinical history before the implementation of the antibiotic stewardship program (2013 to 2015) and then we compared it to the records from 2018 to 2019 collected after the implementation of the program. We evaluated changes in clinical outcomes such as overall mortality, and hospital stay, among others. RESULTS We analyzed 1,066 patients: 266 from the preimplementation group and 800 from the post-implementation group. The average age was 59.2 years and 62% of the population was male. Statistically significant differences were found in overall mortality (29% vs 15%; p<0.001), mortality due to infectious causes (25% vs 9%; p<0.001), and average hospital stay (45 days vs 21 days; p<0.001); we also observed a tendency to decrease hospital readmission at 30 days for infectious causes (14% vs 10%; p=0.085). CONCLUSIONS The antibiotic stewardship program implemented was associated with a decrease in overall mortality and mortality due to infectious causes, as well as in average hospital stay. Our results evidenced the importance of interventions aimed at mitigating the impact of inadequate prescription of antibiotics.
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Affiliation(s)
- Raúl Eduardo Reyes
- Servicio de Medicina Interna, Hospital Militar Central, Bogotá, D.C., Colombia.
| | - María José López
- Servicio de Infectología, Hospital Militar Central, Bogotá, D.C., Colombia.
| | | | - Gustavo Martínez
- Servicio de Medicina Interna, Hospital Militar Central, Bogotá, D.C., Colombia.
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4
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Keikha M, Kamali H, Ghazvini K, Karbalaei M. Conceptual framework of antibiotic stewardship programs in reducing ESBL-producing Enterobacteriaceae: a systematic review and meta-analysis. J Chemother 2022; 34:483-491. [PMID: 35706130 DOI: 10.1080/1120009x.2022.2085473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Today, the phenomenon of antibiotic resistance has become one of the main concerns of health system around the world. Antimicrobial stewardship programs (ASPs) are considered as the most important strategy in optimizing antibiotic consumption, which in turn reduce the emergence of multidrug/extensively drug-resistant (MDR/XDR) microorganisms, as well as reducing mortality and healthcare costs. However, the effectiveness of APSs in controlling the spread of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae has not been investigated. The pooled odds ratio for the effectiveness of ASPs in reducing ESBL-producing Enterobacteriaceae was 0.82 (95% CI: 0.70-0.98; P value: 0.03); our results showed that in group with implemented ASPs, the prevalence of infection associated with these bacteria had been reduced by 11.8%. Overall, antimicrobial stewardship strategies are significantly effective in reducing ESBL-producing Enterobacteriaceae infections. The present study concluded that a comprehensive stewardship program will certainly reduce the mortality rate, as well as hospitalization stay and treatment costs. In general, our findings strongly support the performance of ASPs in healthcare centers.
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Affiliation(s)
- Masoud Keikha
- Antimicrobial Resistance Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Kamali
- Department of Pharmaceutics, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kiarash Ghazvini
- Department of Microbiology and Virology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohsen Karbalaei
- Department of Microbiology and Virology, Faculty of Medicine, Jiroft University of Medical Sciences, Jiroft, Iran
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5
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Gerber JS, Jackson MA, Tamma PD, Zaoutis TE. Policy Statement: Antibiotic Stewardship in Pediatrics. J Pediatric Infect Dis Soc 2021; 10:641-649. [PMID: 33595086 DOI: 10.1093/jpids/piab002] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/04/2021] [Indexed: 11/15/2022]
Abstract
Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting the use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy and duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs (ASPs); essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient ASPs are provided.
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Affiliation(s)
- Jeffrey S Gerber
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mary Anne Jackson
- Department of Pediatrics, Section of Infectious Disease, Children's Mercy Hospital, UMKC School of Medicine, Kansas City, Missouri, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Pediatric Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Theoklis E Zaoutis
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Agossa K, Sy K, Mainville T, Gosset M, Jeanne S, Grosgogeat B, Siepmann F, Loingeville F, Dubar M. Antibiotic Use in Periodontal Therapy among French Dentists and Factors Which Influence Prescribing Practices. Antibiotics (Basel) 2021; 10:303. [PMID: 33804145 PMCID: PMC8001084 DOI: 10.3390/antibiotics10030303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 01/21/2023] Open
Abstract
The aim of the present survey is to investigate the use of antibiotics during periodontal therapy among French dentists with a focus on exploring potential differences between various groups of practitioners. A self-administered questionnaire was distributed to different groups of practitioners including members of (i) the French Society of Periodontology and Implantology; (ii) the College of University Teachers in Periodontology and, (iii) private practitioners participating in the French general dental practice-based research network. 272 questionnaires were included in the analysis. Prescription patterns were globally in line with the current recommendations. Systemic antibiotics are most frequently used as a first-line therapy in necrotizing periodontitis (92%) and aggressive periodontitis (53.3% to 66.1%). However, malpractice still exists, including in the management of periodontal abscesses. Antibiotics are prescribed (i) less frequently for periodontal abscesses and (ii) more frequently for generalized aggressive periodontitis by members of the periodontal society and University college (p < 0.05). Amoxicillin (59.9%) and the amoxicillin + metronidazole (59.6%) combination were the most frequently prescribed molecules. Providing a high number of periodontal treatments per week, being more recently graduated, having a post-graduate certificate in periodontology and holding or having held an academic position/hospital practice were all factors associated with a better knowledge of and/or more adequate antibiotic use.
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Affiliation(s)
- Kevimy Agossa
- University of Lille, Inserm, CHU Lille, U1008—Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France; (K.S.); (F.S.)
- Department of Periodontology, School of Dentistry, University of Lille, Place de Verdun, 59000 Lille, France; (T.M.); (M.D.)
| | - Kadiatou Sy
- University of Lille, Inserm, CHU Lille, U1008—Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France; (K.S.); (F.S.)
- Faculté d’Odontologie, Université de Lyon, Université Claude Bernard Lyon 1, 69008 Lyon, France;
- Hospices Civils de Lyon, Service d’Odontologie, 69007 Lyon, France
| | - Théo Mainville
- Department of Periodontology, School of Dentistry, University of Lille, Place de Verdun, 59000 Lille, France; (T.M.); (M.D.)
| | - Marjolaine Gosset
- Laboratory Orofacial Pathologies, Imaging and Biotherapies URP2496, Université de Paris, F-92120 Montrouge, France;
- Service de Médecine Bucco-Dentaire, AP-HP, Hôpital Charles Foix, F-94200 Ivry-sur-Seine, France
- SFPIO—French Society of Periodontology and Oral Implantology, 44000 Nantes, France
| | - Sylvie Jeanne
- UFR d’Odontologie de Rennes, Bâtiment 15, 2 Avenue du Professeur Léon Bernard, Campus Santé, 35043 Rennes, France;
- Pôle Odontologie, CHU Rennes, 2 Rue Henri Le Guilloux, 35000 Rennes, France
- CNEP—French College of Teachers in Periodontology, 35000 Rennes, France
| | - Brigitte Grosgogeat
- Faculté d’Odontologie, Université de Lyon, Université Claude Bernard Lyon 1, 69008 Lyon, France;
- Hospices Civils de Lyon, Service d’Odontologie, 69007 Lyon, France
- Laboratoire des Multimatériaux et Interfaces, Université de Lyon—Claude Bernard Lyon 1, UMR CNRS 5615, F-69622 Villeurbanne, France
- ReCOL—French Private Dental Practice-Based Research Network, 69007 Lyon, France
| | - Florence Siepmann
- University of Lille, Inserm, CHU Lille, U1008—Controlled Drug Delivery Systems and Biomaterials, F-59000 Lille, France; (K.S.); (F.S.)
| | - Florence Loingeville
- University of Lille, CHU Lille, ULR 2694—METRICS: Evaluation of Health Technologies and Medical Practices, F-59000 Lille, France;
| | - Marie Dubar
- Department of Periodontology, School of Dentistry, University of Lille, Place de Verdun, 59000 Lille, France; (T.M.); (M.D.)
- University of Lille, Inserm, CHU Lille, UMR-S 1172 JPArc, F-59000 Lille, France
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7
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Ward MJ, Chavis B, Banerjee R, Katz S, Anders S. User-Centered Design in Pediatric Acute Care Settings Antimicrobial Stewardship. Appl Clin Inform 2021; 12:34-40. [PMID: 33472258 DOI: 10.1055/s-0040-1718757] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Antibiotic prescribing in ambulatory care centers is increasing. Previous research suggests that 20 to 50% of antibiotic prescriptions are either unnecessary or inappropriate. Unnecessary antibiotic consumption can harm patients by increasing antibiotic resistance and drug-associated toxicities, and the reasons for such use are multifactorial. Antimicrobial Stewardship Programs (ASP) were developed to guide better use of antibiotics. A core element of ASP is to provide feedback to clinical providers. To create clinically meaningful feedback, user-center design (UCD) is a robust approach to include end-users in the design process to improve systems. OBJECTIVE The study aimed to take a UCD approach to developing antibiotic prescribing feedback through input from clinicians in two ambulatory care settings. METHODS We conducted two group prototyping sessions with pediatric clinicians who practice in the emergency department and urgent care settings at a tertiary care children's hospital. Participants received background on the problem of antibiotic prescribing and then were interviewed about their information needs, perceived value, and desired incentives for a prescribing feedback system. Sessions concluded with their response and recommendations to sample sections of an antibiotic feedback report including orienting material, report detail, targeted education, and resources. RESULTS A UCD approach was found to be highly valuable in the development of a feedback mechanism that is viewed as desirable by clinicians. Clinicians preferred interpreting the data themselves with aids such as diagrams and charts over the researcher concluded statements about the clinician's behavior. Specific feedback that clinicians considered redundant were removed from the model if preexisting alerts were established. CONCLUSION Integrating a UCD approach in developing ASP feedback identified desirable report characteristics that substantially modified preliminary wireframes for feedback. Future research will evaluate the clinical effectiveness of our feedback reports in outpatient settings.
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Affiliation(s)
- Michael J Ward
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Bryson Chavis
- Clemson University, Clemson, South Carolina, United States
| | - Ritu Banerjee
- Division of Pediatric Infectious Diseases, Department of Pediatrics. Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Sophie Katz
- Division of Pediatric Infectious Diseases, Department of Pediatrics. Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Shilo Anders
- Center for Research & Innovation in Systems Safety, Department of Anesthesiology, Biomedical Informatics, & EECS, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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8
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Abstract
Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy, duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs; essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient antibiotic stewardship programs are provided.
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Affiliation(s)
- Jeffrey S Gerber
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
| | - Mary Anne Jackson
- Section of Infectious Disease, Department of Pediatrics, Children's Mercy Hospital and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; and
| | - Pranita D Tamma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Theoklis E Zaoutis
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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9
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Velasco-Arnaiz E, Simó-Nebot S, Ríos-Barnés M, López Ramos MG, Monsonís M, Urrea-Ayala M, Jordan I, Mas-Comas A, Casadevall-Llandrich R, Ormazábal-Kirchner D, Cuadras-Pallejà D, Pérez-Pérez C, Millet-Elizalde M, Sánchez-Ruiz E, Fortuny C, Noguera-Julian A. Benefits of a Pediatric Antimicrobial Stewardship Program in Antimicrobial Use and Quality of Prescriptions in a Referral Children's Hospital. J Pediatr 2020; 225:222-230.e1. [PMID: 32522527 DOI: 10.1016/j.jpeds.2020.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/11/2020] [Accepted: 06/03/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To evaluate the results of the first 24 months of a postprescription review with feedback-based antimicrobial stewardship program in a European referral children's hospital. STUDY DESIGN We performed a pre-post study comparing antimicrobial use between the control (2015-2016) and the intervention periods (2017-2018) expressed in days of therapy/100 days present. Quality of prescriptions was evaluated by quarterly cross-sectional point-prevalence surveys. Length of stay, readmission rates, in-hospital mortality rates, cost of systemic antimicrobial agents, and antimicrobial resistance rates were included as complementary outcomes. RESULTS Total antimicrobial use and antibacterial use significantly decreased during the intervention period (P = .002 and P = .001 respectively), and total antifungal use remained stable. A significant decline in parenteral antimicrobial use was also observed (P < .001). In 8 quarterly point-prevalence surveys (938 prescriptions evaluated), the mean prevalence of use of any antimicrobial among inpatients was 39%. An increasing trend in the rate of optimal prescriptions was observed after the first point-prevalence survey (P = .0898). Nonoptimal prescriptions were more common in surgical than in medical departments, in antibacterial prescriptions with prophylactic intention, and in empirical more than in targeted treatments. No significant differences were observed in terms of mortality or readmission rates. Only minor changes in antimicrobial resistance rates were noted. CONCLUSIONS Our antimicrobial stewardship program safely decreased antimicrobial use and expenditure, and a trend toward improvement in quality of prescription was also observed.
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Affiliation(s)
- Eneritz Velasco-Arnaiz
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Sant Joan de Déu Hospital Research Foundation, Barcelona, Spain
| | - Silvia Simó-Nebot
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Sant Joan de Déu Hospital Research Foundation, Barcelona, Spain; Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - María Ríos-Barnés
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Sant Joan de Déu Hospital Research Foundation, Barcelona, Spain
| | | | - Manuel Monsonís
- Clinical Microbiology Department, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Mireia Urrea-Ayala
- Infection Control Department, Sant Joan de Déu Hospital, Barcelona, Spain
| | - Iolanda Jordan
- Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Pediatric Intensive Care Unit, Sant Joan de Déu Hospital, Barcelona, Spain; Department of Pediatrics, University of Barcelona, Barcelona, Spain; Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - Anna Mas-Comas
- Pharmacy Department, Sant Joan de Déu Hospital, Barcelona, Spain
| | | | | | | | | | | | - Emilia Sánchez-Ruiz
- Blanquerna School of Health Science, Ramon Llull University, Barcelona, Spain
| | - Clàudia Fortuny
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Sant Joan de Déu Hospital Research Foundation, Barcelona, Spain; Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Pediatrics, University of Barcelona, Barcelona, Spain; Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain
| | - Antoni Noguera-Julian
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Infectious Diseases Unit, Department of Pediatrics, Sant Joan de Déu Hospital Research Foundation, Barcelona, Spain; Center for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Pediatrics, University of Barcelona, Barcelona, Spain; Translational Research Network in Pediatric Infectious Diseases (RITIP), Madrid, Spain.
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10
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Fay MJ, Bryant PA. Antimicrobial stewardship in children: Where to from here? J Paediatr Child Health 2020; 56:1504-1507. [PMID: 33099822 DOI: 10.1111/jpc.15209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/24/2020] [Accepted: 09/11/2020] [Indexed: 12/26/2022]
Abstract
Antimicrobial resistance (AMR) is an ever-developing global threat and children are becoming increasingly affected. In addition to established antimicrobial stewardship (AMS) measures, it is important to recognise the need for a paediatric focus to manage the physiological and pathological differences unique to children. Most studies on paediatric AMS are drawn from resource-rich, hospital settings. They support interventions including AMS programmes, bundled groups of interventions, guidelines and education initiatives. These must be tailored to specific institutions, populations and resources as translating interventions between these may not be effective. There are knowledge gaps in paediatric AMS, which pose challenges to designing both interventions and research in this area. These include quantifying antimicrobial consumption, defining AMS outcomes and understanding the development of AMR. Finding answers to fill these gaps needs urgent attention. There is also a need to think outside the box to improve AMS in children. Potential opportunities include intravenous antibiotics at home via hospital-in-the-home programmes, earlier switching to oral antibiotics, repurposing old antibiotics and re-evaluating children labelled as having antibiotic allergy. Using all of the possibilities available gives us the best chance of staying ahead of the relentless march of AMR in children.
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Affiliation(s)
- Michael-John Fay
- Department of Paediatric Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand
| | - Penelope A Bryant
- Infectious Diseases and Hospital-in-the-Home Departments, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Clinical Paediatrics, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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11
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Ozkaynak M, Metcalf N, Cohen DM, May LS, Dayan PS, Mistry RD. Considerations for Designing EHR-Embedded Clinical Decision Support Systems for Antimicrobial Stewardship in Pediatric Emergency Departments. Appl Clin Inform 2020; 11:589-597. [PMID: 32906153 DOI: 10.1055/s-0040-1715893] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE This study was aimed to explore the intersection between organizational environment, workflow, and technology in pediatric emergency departments (EDs) and how these factors impact antibiotic prescribing decisions. METHODS Semistructured interviews with 17 providers (1 fellow and 16 attending faculty), and observations of 21 providers (1 physician assistant, 5 residents, 3 fellows, and 12 attendings) were conducted at three EDs in the United States. We analyzed interview transcripts and observation notes using thematic analysis. RESULTS Seven themes relating to antibiotic prescribing decisions emerged as follows: (1) professional judgement, (2) cognition as a critical individual resource, (3) decision support as a critical organizational resource, (4) patient management with imperfect information, (5) information-seeking as a primary task, (6) time management, and (7) broad process boundaries of antibiotic prescribing. DISCUSSION The emerging interrelated themes identified in this study can be used as a blueprint to design, implement, and evaluate clinical decision support (CDS) systems that support antibiotic prescribing in EDs. The process boundaries of antibiotic prescribing are broader than the current boundaries covered by existing CDS systems. Incongruities between process boundaries and CDS can under-support clinicians and lead to suboptimal decisions. We identified two incongruities: (1) the lack of acknowledgment that the process boundaries go beyond the physical boundaries of the ED and (2) the lack of integration of information sources (e.g., accessibility to prior cultures on an individual patient outside of the organization). CONCLUSION Significant opportunities exist to improve appropriateness of antibiotic prescribing by considering process boundaries in the design, implementation, and evaluation of CDS systems.
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Affiliation(s)
- Mustafa Ozkaynak
- College of Nursing, University of Colorado-Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Noel Metcalf
- College of Nursing, University of Colorado-Denver, Anschutz Medical Campus, Aurora, Colorado, United States
| | - Daniel M Cohen
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Larissa S May
- Department of Emergency Medicine, UC Davis Health, Davis, California, United States
| | - Peter S Dayan
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, United States
| | - Rakesh D Mistry
- Department of Pediatrics and Emergency Medicine, Section of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, United States
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Goss FR, Bookman K, Barron M, Bickley D, Landgren B, Kroehl M, Williamson K, Zane R, Wiler J. Improved antibiotic prescribing using indication-based clinical decision support in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:214-221. [PMID: 33000036 PMCID: PMC7493549 DOI: 10.1002/emp2.12029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/23/2019] [Accepted: 01/27/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Evaluate an indication-based clinical decision support tool to improve antibiotic prescribing in the emergency department. METHODS Encounters where an antibiotic was prescribed between January 2015 and October 2017 were analyzed before and after the introduction of a clinical decision support tool to improve clinicians' selection of a guideline-approved antibiotic based on clinical indication. Evaluation was conducted on a pre-defined subset of conditions that included skin and soft tissue infections, respiratory infections, and urinary infections. The primary outcome was ordering of a guideline-approved antibiotic prescription at the drug and duration of therapy level. A mixed model following a binomial distribution with a logit link was used to model the difference in proportions of guideline-approved prescriptions before and after the intervention. RESULTS For conditions evaluated, selection rate of a guideline-approved antibiotic for a given indication improved from 67.1% to 72.2% (P < 0.001). When duration of therapy is included as a criterion, selection of a guideline-approved antibiotic was lower and improved from 24.7% to 31.4% (P < 0.001), highlighting that duration of therapy is often missing at the time of prescribing. The most substantial improvements were seen for pneumonia and pyelonephritis with an increase from 87.9% to 97.5% and 62.8% to 82.6%, respectively. Other significant improvements were seen for abscess, cellulitis, and urinary tract infections. CONCLUSION Antibiotic prescribing can be improved both at the drug and duration of therapy level using a non-interruptive and indication based-clinical decision support approach. Future research and quality improvement efforts are needed to incorporate duration of therapy guidelines into the antibiotic prescribing process.
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Affiliation(s)
- Foster R. Goss
- Department of Emergency MedicineUniversity of Colorado HospitalAuroraColorado
- University of Colorado School of MedicineAuroraColorado
| | - Kelly Bookman
- Department of Emergency MedicineUniversity of Colorado HospitalAuroraColorado
- University of Colorado School of MedicineAuroraColorado
| | - Michelle Barron
- University of Colorado School of MedicineAuroraColorado
- Department of Infection Prevention and ControlUniversity of Colorado HospitalAuroraColorado
| | - Daniel Bickley
- Department of Emergency MedicineUniversity of Colorado HospitalAuroraColorado
- University of Colorado School of MedicineAuroraColorado
| | - Brady Landgren
- Department of Emergency MedicineUniversity of Colorado HospitalAuroraColorado
- University of Colorado School of MedicineAuroraColorado
| | | | | | - Richard Zane
- Department of Emergency MedicineUniversity of Colorado HospitalAuroraColorado
- University of Colorado School of MedicineAuroraColorado
| | - Jennifer Wiler
- Department of Emergency MedicineUniversity of Colorado HospitalAuroraColorado
- University of Colorado School of MedicineAuroraColorado
- University of Colorado Denver School of BusinessDenverColorado
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Donà D, Barbieri E, Daverio M, Lundin R, Giaquinto C, Zaoutis T, Sharland M. Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review. Antimicrob Resist Infect Control 2020; 9:3. [PMID: 31911831 PMCID: PMC6942341 DOI: 10.1186/s13756-019-0659-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.
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Affiliation(s)
- D. Donà
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
- Pediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
- Fondazione Penta ONLUS, Padua, Italy
| | - E. Barbieri
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
| | - M. Daverio
- Pediatric intensive care unit, Department for Woman and Child Health, University of Padua, Padua, Italy
| | - R. Lundin
- Fondazione Penta ONLUS, Padua, Italy
| | - C. Giaquinto
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
- Fondazione Penta ONLUS, Padua, Italy
| | - T. Zaoutis
- Fondazione Penta ONLUS, Padua, Italy
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - M. Sharland
- Pediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
- Fondazione Penta ONLUS, Padua, Italy
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The use of survey-driven feedback to improve antimicrobial stewardship efforts at a single center. Infect Control Hosp Epidemiol 2020; 41:252-253. [DOI: 10.1017/ice.2019.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Silva ML, Cargnello C, Aulois-Griot M, Dumartin C. Antibiotic misuse: How to evaluate the costs? Med Mal Infect 2019; 49:485-494. [PMID: 30954321 DOI: 10.1016/j.medmal.2019.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/08/2018] [Accepted: 03/13/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Few studies have assessed the costs associated with the misuse of antibiotics in hospitals in France, despite the value of health economic data to inform antibiotic stewardship activities. We aimed to identify the methodological tools used to assess the cost of antibiotic misuse in hospitals. METHODS We performed a literature review using the major electronic medical databases. An index of relevance was developed to assess the intrinsic quality of selected articles. RESULTS Four hundred and three articles were retrieved, but 35 were selected for analysis. Most studies investigated the inadequate choice of the antibiotic molecule (n=17), the incorrect treatment duration (n=9), and the administration of an inappropriate dosage (n=7). Only three studies were medical/economic evaluations of specific interventions, such as prescription control by pharmacists or the implementation of a new diagnostic test. Considering our aim, the relevance of the studies was limited: few had defined the economic assessment as the primary objective or had detailed the method for calculating costs. Nevertheless, the misuse evaluation was usually better described. CONCLUSIONS Despite these limits, key factors for measuring antibiotic misuse (i.e., molecule choice, dosage) in relation to the costs (i.e., over/under prescription, hospital stay, staff remuneration) might serve as the basis for the development of a reference methodology to value the costs of misuse. The application of this methodology on identified situations of antibiotic misuse would help hospital decision-makers to justify resource allocation for implementing antimicrobial stewardship activities.
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Affiliation(s)
- M L Silva
- Unité Inserm 1219, UFR sciences pharmaceutiques- laboratoire de droit et économie pharmaceutiques, université de Bordeaux, 146, rue Léo-Saignat, case postale 81, 33076 Bordeaux, France.
| | - C Cargnello
- Unité Inserm 1219, UFR sciences pharmaceutiques- laboratoire de droit et économie pharmaceutiques, université de Bordeaux, 146, rue Léo-Saignat, case postale 81, 33076 Bordeaux, France
| | - M Aulois-Griot
- Unité Inserm 1219, UFR sciences pharmaceutiques- laboratoire de droit et économie pharmaceutiques, université de Bordeaux, 146, rue Léo-Saignat, case postale 81, 33076 Bordeaux, France
| | - C Dumartin
- Unité Inserm 1219, UFR sciences pharmaceutiques- laboratoire de droit et économie pharmaceutiques, université de Bordeaux, 146, rue Léo-Saignat, case postale 81, 33076 Bordeaux, France; CHU Bordeaux, CPIAS Nouvelle Aquitaine, hôpital Pellegrin - bâtiment Le Tondu, 33076 Bordeaux, France
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Nathwani D, Varghese D, Stephens J, Ansari W, Martin S, Charbonneau C. Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review. Antimicrob Resist Infect Control 2019; 8:35. [PMID: 30805182 PMCID: PMC6373132 DOI: 10.1186/s13756-019-0471-0] [Citation(s) in RCA: 213] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/11/2019] [Indexed: 12/21/2022] Open
Abstract
Background Hospital antimicrobial stewardship programs (ASPs) aim to promote judicious use of antimicrobials to combat antimicrobial resistance. For ASPs to be developed, adopted, and implemented, an economic value assessment is essential. Few studies demonstrate the cost-effectiveness of ASPs. This systematic review aimed to evaluate the economic and clinical impact of ASPs. Methods An update to the Dik et al. systematic review (2000–2014) was conducted on EMBASE and Medline using PRISMA guidelines. The updated search was limited to primary research studies in English (30 September 2014–31 December 2017) that evaluated patient and/or economic outcomes after implementation of hospital ASPs including length of stay (LOS), antimicrobial use, and total (including operational and implementation) costs. Results One hundred forty-six studies meeting inclusion criteria were included. The majority of these studies were conducted within the last 5 years in North America (49%), Europe (25%), and Asia (14%), with few studies conducted in Africa (3%), South America (3%), and Australia (3%). Most studies were conducted in hospitals with 500–1000 beds and evaluated LOS and change in antibiotic expenditure, the majority of which showed a decrease in LOS (85%) and antibiotic expenditure (92%). The mean cost-savings varied by hospital size and region after implementation of ASPs. Average cost savings in US studies were $732 per patient (range: $2.50 to $2640), with similar trends exhibited in European studies. The key driver of cost savings was from reduction in LOS. Savings were higher among hospitals with comprehensive ASPs which included therapy review and antibiotic restrictions. Conclusions Our data indicates that hospital ASPs have significant value with beneficial clinical and economic impacts. More robust published data is required in terms of implementation, LOS, and overall costs so that decision-makers can make a stronger case for investing in ASPs, considering competing priorities. Such data on ASPs in lower- and middle-income countries is limited and requires urgent attention.
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Affiliation(s)
- Dilip Nathwani
- 1Ninewells Hospital and Medical School, Dundee, DD19SY UK
| | - Della Varghese
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
| | - Jennifer Stephens
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
| | | | - Stephan Martin
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
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Antimicrobial stewardship program (ASP): an effective implementing technique for the therapy efficiency of meropenem and vancomycin antibiotics in Iranian pediatric patients. Ann Clin Microbiol Antimicrob 2019; 18:6. [PMID: 30696456 PMCID: PMC6352345 DOI: 10.1186/s12941-019-0305-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 01/21/2019] [Indexed: 11/25/2022] Open
Abstract
Background Antimicrobial stewardship program (ASP) is a distinguished method to improve the prescription and efficacy of antibiotics. Aim The efficacy of ASP and conventional methods was compared to measure the effectiveness of meropenem (MPM) and vancomycin (VMN) antibiotics in pediatric patients. Design In an interventional quasi-experimental study, 135 children admitted in Children’s Hospital affiliated to University of Medical Sciences in time periods of 2014–2015 and 2015–2016 were assessed. Methods The conventional and ASP methods in 2014–2015 and 2015–2016 were respectively utilized to provide the best antimicrobial therapy of MPM and VMN antibiotics in patient children. The data of mortality rate (MR), antibiotic prescription (AP), antibiotic dose (ADe), antibiotic duration (ADn), length of hospital stay (LOHS), and blood cultures (BCs) were compared across the years using the Chi square, independent t test, and Fisher’s exact test. Results The levels of MR, AP, ADe, ADn, LOHS, and positive BCs using the ASP method in 2015–2016 were significantly lower those of in 2014–2015 using the conventional one (p < 0.05). Conclusions The ASP method versus conventional one with a better efficacy can be employed as an antibiotic administration guide for MPM and VMN in the therapy of patients in community-based hospitals.
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Nomura Y, Garcia M, Child J, Hurst AL, Hyman D, Poppy A, Palmer C, Ranade D, Pyle L, Parker SK. Effect of provider-selected order indications on appropriateness of antimicrobial orders in a pediatric hospital. Am J Health Syst Pharm 2018; 75:213-221. [PMID: 29436467 DOI: 10.2146/ajhp160557] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The effect of mandatory provider-selected order indications (PSOIs) on appropriateness of antimicrobial ordering in a tertiary pediatric hospital was evaluated. METHODS Mandatory PSOIs for 14 antimicrobials were implemented in September 2013. Data on initial and final orders in the first 24 hours after ordering were collected from the electronic medical record. Orders from pre-PSOI and post-PSOI implementation were randomly selected and compared with documentation at the time of order to elicit the documentation-determined clinical indication (DDCI). Appropriateness of the order for the DDCI was evaluated and compared between groups using 2-sample t tests, chi-square tests, and logistic regression. RESULTS Among the total 1,304 orders included in the review, 275 (21.1%) were inappropriate based on DDCI. The indications associated with the greatest number of inappropriate orders in both groups were suspected sepsis/bacteremia, meningitis/central nervous system infection, and pneumonia. A total of 128 (18.3%) of 700 initial orders were inappropriate compared with the DDCI in the pre-PSOI period, and 82 (17.8%) of 461 initial orders were inappropriate in the post-PSOI period (p = 0.83). A total of 78 (11.1%) of 700 final orders were inappropriate in the pre-PSOI period, and 29 (6.3%) of 461 final orders were inappropriate in the post-intervention period (p = 0.01). Overall, 84 (12%) of 700 inappropriate orders reached the patient in the pre-PSOI period versus 43 (9.3%) of 461 inappropriate orders in the post-PSOI period (p = 0.15). CONCLUSION PSOIs were effective in reducing inappropriate antimicrobial orders in the first 24 hours after ordering if the correct indication was selected.
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Affiliation(s)
- Yosuke Nomura
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Madeleine Garcia
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Jason Child
- Department of Pharmacy, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Amanda L Hurst
- Department of Pharmacy, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Daniel Hyman
- Department of Quality and Patient Safety and Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Amy Poppy
- Department of Quality and Patient Safety, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Claire Palmer
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Daksha Ranade
- Department of Clinical Informatics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Laura Pyle
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Sarah K Parker
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
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Abstract
Appropriate metrics are needed to measure the quality, clinical, and financial impacts of antimicrobial stewardship programs. Metrics are typically categorized into antibiotic use measures, process measures, quality measures, costs, and clinical outcome measures. Traditionally, antimicrobial stewardship metrics have focused on antibiotic use, antibiotic costs, and process measures. With health care reform, practice should shift to focusing on clinical impact of stewardship programs over financial impact. This article reviews the various antimicrobial stewardship metrics that have been described in the literature, evidence to support these metrics, controversies surrounding metrics, and areas in which future research is necessary.
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Affiliation(s)
- Amy L Brotherton
- Infectious Diseases, Department of Pharmacy, The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906, USA.
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Bertollo LG, Lutkemeyer DS, Levin AS. Are antimicrobial stewardship programs effective strategies for preventing antibiotic resistance? A systematic review. Am J Infect Control 2018; 46:824-836. [PMID: 29472107 DOI: 10.1016/j.ajic.2018.01.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/05/2018] [Accepted: 01/05/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) have been proposed as a solution for the global burden of antibiotic resistance, despite the lack of evidence on the subject. OBJECTIVE To analyze the role of ASPs in reducing bacterial resistance to antibiotics in hospital settings. DATA SOURCES A review in PubMed, Scopus, LILACS, and SciELO databases was performed. The period analyzed was January 1, 2012-January 4, 2017. ELIGIBILITY CRITERIA Studies that related ASPs to bacterial resistance. DATA EXTRACTION All studies that did not focus on ASPs were removed. Antifungal and antiviral programs were excluded. RESULTS Only 8 studies had quasi-experimental designs, and none were controlled trials. ASP strategies and microorganism-antibiotic pairs evaluated varied widely. Seven studies were classified as presenting clearly positive results, 3 had limited positive results, 7 had doubtful results, 4 had negative results, and 5 had noninterpretable results. The implementation of new infection control practices occurred in 7 studies. LIMITATIONS There are yet few studies on this matter, and most of them have inadequate study designs. Great heterogeneity between study features was detrimental to drawing evidence-based conclusions. CONCLUSIONS There is no solid evidence that ASPs are effective in reducing antibiotic resistance in hospital settings. We uphold the need for more studies with appropriate study designs, standardized ASP interventions targeting common microorganism-antibiotic pairs, and avoiding simultaneous implementation of infection control practices.
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Affiliation(s)
- Leandro G Bertollo
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Diego S Lutkemeyer
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Anna S Levin
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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TELE-EXPERTISE SYSTEM BASED ON THE USE OF THE ELECTRONIC PATIENT RECORD TO SUPPORT REAL-TIME ANTIMICROBIAL USE. Int J Technol Assess Health Care 2018; 34:156-162. [PMID: 29490710 DOI: 10.1017/s0266462318000089] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The aims of this study are (i) to present the design of a tele-expertise system, based on the telephone and electronic patient record (EPR), which supports the counseling of the infectious diseases specialist (IDS) for appropriate antimicrobial use, in a French University hospital; and (ii) to assess the diffusion of the system, the users' adherence, and their perceived utility. METHODS A prospective observational study was conducted to measure (i) the number and patterns of telephone calls for tele-expertise council, the number of initial and secondary assessments from the IDS and multidisciplinary meetings; (ii) the clinicians' adherence rate to therapeutic proposals by the IDS and the number of clinical situations for which the IDS decided to move to bedside; and (iii) the perceived utility of the system by the medical managers of the most demanding departments. RESULTS The review of patients' records for 1 year period indicates that 87 percent of the therapeutic recommendations were fully followed. The adherence was high, despite the IDS moving to the bedside only in 6 percent of cases. Medical managers of the most demanding departments considered the system to be useful. Moreover, 6,994 tele-expertise notifications have been recorded into the EPR for 48 months. CONCLUSIONS The tele-expertise system is an original way to design information technology supported antimicrobial stewardship intervention based on the remote access to relevant information by the IDS and on the traceability of the medical counseling for the clinicians.
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Mas-Morey P, Valle M. A systematic review of inpatient antimicrobial stewardship programmes involving clinical pharmacists in small-to-medium-sized hospitals. Eur J Hosp Pharm 2017; 25:e69-e73. [PMID: 31157071 DOI: 10.1136/ejhpharm-2017-001381] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/05/2017] [Accepted: 10/10/2017] [Indexed: 01/22/2023] Open
Abstract
Objective Antimicrobial stewardship programmes (ASPs) have been widely implemented in large hospitals but little is known regarding small-to-medium-sized hospitals. This literature review evaluates outcomes described for ASPs participated in by clinical pharmacists and implemented in small-to-medium-sized hospitals (<500 beds). Methods Following PRISMA principles, PubMed and Cochrane Library databases were searched in early 2016 for English language articles describing implementation and outcomes for inpatient ASPs participated in by clinical pharmacists in small-to-medium-sized hospitals. Each included study was required to include at least one of the following outcomes: microbiological outcomes, quality of care and clinical outcomes or antimicrobial use and cost outcomes. Results We included 28 studies from 26 hospitals, mostly American or Canadian. Most cases (23 studies) consisted of time-series comparisons of pre-and post-intervention periods. Of the 28 studies analysed, 8 reported microbiological outcomes, 21 reported quality of care and clinical outcomes, and 27 reported antimicrobial use and cost outcomes. Interventions were not generally associated with significant changes in mortality or readmission rates but were associated with substantial cost savings, mainly due to reduced use of antibiotics or the use of cheaper antibiotics. Conclusion As far as we are aware, ours is the first systematic review that evaluates ASPs participated in by clinical pharmacists in small-to-medium-sized hospitals. ASPs appear to be an effective strategy for reducing antimicrobial use and cost. However, the limited association with better microbiological, care quality and clinical outcomes would highlight the need for further studies and for standardised methods for evaluating ASP outcomes.
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Affiliation(s)
- Pedro Mas-Morey
- Department of Pharmacy, Hospital Quirónsalud Palmaplanas, Palma de Mallorca, Balearic Islands, Spain.,Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marta Valle
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain.,Pharmacokinetic/Pharmacodynamic Modelling and Simulation, Sant Pau Institute of Biomedical Research (IIB-Sant Pau), Barcelona, Spain
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Snyder M, Pasikhova Y, Baluch A. Early Antimicrobial De-escalation and Stewardship in Adult Hematopoietic Stem Cell Transplantation Recipients: Retrospective Review. Open Forum Infect Dis 2017; 4:ofx226. [PMID: 29255727 PMCID: PMC5726466 DOI: 10.1093/ofid/ofx226] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 11/06/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Antimicrobial stewardship in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients remains underutilized in North America. European guidelines advise de-escalation of broad-spectrum therapy after 72 hours in select patients with neutropenic fever of unknown origin. This is not commonplace in the United States, as current guidelines recommend broad-spectrum therapy until neutrophil engraftment. If de-escalating after at least 5 days of broad-spectrum therapy and defervescence in neutropenic allo-HSCT recipients does not predispose them to recurrent fever or infection, the practice could afford several benefits. METHODS The primary end point was rate of recurrent fever. Secondary outcomes included Clostridium difficile-associated infections, length of stay, intensive care unit (ICU) admission incidence, in-hospital mortality rate, need for re-escalation of therapy, rate of positive blood cultures for patients who had recurrent fevers, overall antimicrobial utilization from neutropenic fever onset, and pharmacoeconomic impact. RESULTS A total of 120 patients were assessed in 2 groups as cohort 1 (n = 46), which received early de-escalation, and cohort 2 (n = 74), which did not. The primary end point met criteria for noninferiority, as 7 patients (15%) in cohort 1 had recurrent fever within the specified time frame compared with 14 (19%) in cohort 2 (90% CI, -0.0878 to 0.1629, P = .026). Patients in cohort 1 received significantly less gram-positive broad-spectrum antimicrobials, with trends toward lower use of broad-spectrum gram-negative agents and lower associated costs and no differences in length of stay, ICU admission incidence, need for re-escalation of therapy, rate of culture-positive bacteremia after de-escalation or discontinuation of broad-spectrum therapy, or in-hospital mortality rate. CONCLUSIONS De-escalating after at least 5 days of broad-spectrum therapy and defervescence did not appear to affect the rate of recurrent fever. This allowed for significant reductions in gram-positive broad-spectrum antimicrobial utilization, with trends toward lower use of broad-spectrum gram-negative agents and associated costs and no difference in clinical outcomes compared with those continuing such therapy until neutrophil engraftment.
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Affiliation(s)
- Matthew Snyder
- Department of Pharmacy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Yanina Pasikhova
- Department of Pharmacy, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Aliyah Baluch
- Department of Infectious Diseases, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
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Reducing antibiotic prescriptions for childhood upper respiratory tract infections. LANCET GLOBAL HEALTH 2017; 5:e1170-e1171. [DOI: 10.1016/s2214-109x(17)30423-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 11/21/2022]
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Baysari MT, Del Gigante J, Moran M, Sandaradura I, Li L, Richardson KL, Sandhu A, Lehnbom EC, Westbrook JI, Day RO. Redesign of computerized decision support to improve antimicrobial prescribing. A controlled before-and-after study. Appl Clin Inform 2017; 8:949-963. [PMID: 28905978 PMCID: PMC6220696 DOI: 10.4338/aci2017040069] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/01/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To determine the impact of the introduction of new pre-written orders for antimicrobials in a computerized provider order entry (CPOE) system on 1) accuracy of documented indications for antimicrobials in the CPOE system, 2) appropriateness of antimicrobial prescribing, and 3) compliance with the hospital's antimicrobial policy. Prescriber opinions of the new decision support were also explored to determine why the redesign was effective or ineffective in altering prescribing practices. METHODS The study comprised two parts: a controlled pre-post study and qualitative interviews. The intervention involved the redesign of pre-written orders for half the antimicrobials so that approved indications were incorporated into pre-written orders. 555 antimicrobials prescribed before (September - October, 2013) and 534 antimicrobials prescribed after (March - April, 2015) the intervention on all general wards of a hospital were audited by study pharmacists. Eleven prescribers participated in semi-structured interviews. RESULTS Redesign of computerized decision support did not result in more appropriate or compliant antimicrobial prescribing, nor did it improve accuracy of indication documentation in the CPOE system (Intervention antimicrobials: appropriateness 49% vs. 50%; compliance 44% vs. 42%; accuracy 58% vs. 38%; all p>0.05). Via our interviews with prescribers we identified five main reasons for this, primarily that indications entered into the CPOE system were not monitored or followed-up, and that the antimicrobial approval process did not align well with prescriber workflow. CONCLUSION Redesign of pre-written orders to incorporate appropriate indications did not improve antimicrobial prescribing. Workarounds are likely when compliance with hospital policy creates additional work for prescribers or when system usability is poor. Implementation of IT, in the absence of support or follow-up, is unlikely to achieve all anticipated benefits.
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Affiliation(s)
- Melissa T Baysari
- Melissa T. Baysari, Australian Institute of Health Innovation, Level 6 75 Talavera Rd, Macquarie University, NSW 2109 Australia, Phone +612 98502416,
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Curtis CE, Al Bahar F, Marriott JF. The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review. PLoS One 2017; 12:e0183062. [PMID: 28837665 PMCID: PMC5570266 DOI: 10.1371/journal.pone.0183062] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/28/2017] [Indexed: 12/18/2022] Open
Abstract
Background Inappropriate antimicrobial use has been shown to be an important determinant of the emergence of antimicrobial resistance (AMR). Health information technology (HIT) in the form of Computerised Decision Support (CDS) represents an option for improving antimicrobial prescribing and containing AMR. Objectives To evaluate the evidence for CDS in improving quantitative and qualitative measures of antibiotic prescribing in inpatient hospital settings. Methods A systematic literature search was conducted of articles published from inception to 20th December 2014 using eight electronic databases: MEDLINE, EMBASE, PUBMED, Web of Science, CINAHL, Cochrane Library, HMIC and PsychINFo. An updated systematic literature search was conducted from January 1st 2015 to October 1st 2016 using PUBMED. The search strategy used combinations of the following terms: (electronic prescribing) OR (clinical decision support) AND (antibiotic or antibacterial or antimicrobial) AND (hospital or secondary care or inpatient). Studies were evaluated for quality using a 10-point rating scale. Results Eighty-one studies were identified matching the inclusion criteria. Seven outcome measures were evaluated: adequacy of antibiotic coverage, mortality, volume of antibiotic usage, length of stay, antibiotic cost, compliance with guidelines, antimicrobial resistance, and CDS implementation and uptake. Meta-analysis of pooled outcomes showed CDS significantly improved the adequacy of antibiotic coverage (n = 13; odds ratio [OR], 2.11 [95% CI, 1.67 to 2.66, p ≤ 0.00001]). Also, CDS was associated with marginally lowered mortality (n = 20; OR, 0.85 [CI, 0.75 to 0.96, p = 0.01]). CDS was associated with lower antibiotic utilisation, increased compliance with antibiotic guidelines and reductions in antimicrobial resistance. Conflicting effects of CDS on length of stay, antibiotic costs and system uptake were also noted. Conclusions CDS has the potential to improve the adequacy of antibiotic coverage and marginally decrease mortality in hospital-related settings.
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Affiliation(s)
- Christopher E. Curtis
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
| | - Fares Al Bahar
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - John F. Marriott
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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Kreitmeyr K, von Both U, Pecar A, Borde JP, Mikolajczyk R, Huebner J. Pediatric antibiotic stewardship: successful interventions to reduce broad-spectrum antibiotic use on general pediatric wards. Infection 2017; 45:493-504. [DOI: 10.1007/s15010-017-1009-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 03/14/2017] [Indexed: 01/07/2023]
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Hoshina T, Yamamoto N, Ogawa M, Nakamoto T, Kusuhara K. The efficacy of the direct clinical intervention for infectious diseases by a pediatric infectious disease specialist in the pediatric ward of a tertiary medical facility without a pediatric antimicrobial stewardship program. Eur J Clin Microbiol Infect Dis 2017; 36:1449-1454. [PMID: 28283829 DOI: 10.1007/s10096-017-2952-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/27/2017] [Indexed: 11/24/2022]
Abstract
Antimicrobial stewardship programs (ASPs) have been introduced in most hospital complexes; however, they are not always useful for pediatric patients. The aim of this study is to investigate the efficacy of direct clinical intervention for infectious diseases by a pediatric infectious disease specialist in a tertiary medical facility without pediatric ASP. This retrospective study included 1,821 patients who were hospitalized in the pediatric ward of a large metropolitan hospital from 2010 to 2015. The clinical course, the use of intravenous antimicrobial agents and the results of a microbiological analysis were compared between the period after the beginning of direct intervention by the specialist (post-intervention period) and the previous period (pre-intervention period). In the post-intervention period, the proportion of the patients who received intravenous antimicrobial agents, the number of antimicrobial agents used for each episode, and the proportion of episodes in which an antimicrobial agent was re-administrated were significantly lower (P = 0.006, P = 0.004, P = 0.036, respectively), and the duration of antimicrobial treatment was significantly shorter (P < 0.001). In addition, narrower spectrum antimicrobial agents were used, and the incidence of meropenem-sensitive Pseudomonas aeruginosa significantly increased (P = 0.037) in the post-intervention period. There was no change of mortality between the two periods. Direct clinical intervention by a pediatric infectious diseases specialist is useful for the treatment of infectious diseases in the pediatric ward of a tertiary medical facility without a pediatric ASP. The creation of a pediatric ASP is recommended in hospital complexes.
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Affiliation(s)
- T Hoshina
- Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan.
| | - N Yamamoto
- Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - M Ogawa
- Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - T Nakamoto
- Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - K Kusuhara
- Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health, Japan, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
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Stenner SP, Chakravarthy R, Johnson KB, Miller WL, Olson J, Wickizer M, Johnson NN, Ohmer R, Uskavitch DR, Bernard GR, Neal EB, Lehmann CU. ePrescribing: Reducing Costs through In-Class Therapeutic Interchange. Appl Clin Inform 2016; 7:1168-1181. [PMID: 27966005 DOI: 10.4338/aci-2016-09-ra-0160] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/27/2016] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Spending on pharmaceuticals in the US reached $373.9 billion in 2014. Therapeutic interchange offers potential medication cost savings by replacing a prescribed drug for an equally efficacious therapeutic alternative. METHODS Hard-stop therapeutic interchange recommendation alerts were developed for four medication classes (HMG-CoA reductase inhibitors, serotonin receptor agonists, intranasal steroid sprays, and proton-pump inhibitors) in an electronic prescription-writing tool for outpatient prescriptions. Using prescription data from January 2012 to June 2015, the Compliance Ratio (CR) was calculated by dividing the number of prescriptions with recommended therapeutic interchange medications by the number of prescriptions with non-recommended medications to measure effectiveness. To explore potential cost savings, prescription data and medication costs were analyzed for the 45,000 Vanderbilt Employee Health Plan members. RESULTS For all medication classes, significant improvements were demonstrated - the CR improved (proton-pump inhibitors 2.8 to 5.32, nasal steroids 2.44 to 8.16, statins 2.06 to 5.51, and serotonin receptor agonists 0.8 to 1.52). Quarterly savings through the four therapeutic interchange interventions combined exceeded $200,000 with an estimated annual savings for the health plan of $800,000, or more than $17 per member. CONCLUSION A therapeutic interchange clinical decision support tool at the point of prescribing resulted in increased compliance with recommendations for outpatient prescriptions while producing substantial cost savings to the Vanderbilt Employee Health Plan - $17.77 per member per year. Therapeutic interchange rules require rational targeting, appropriate governance, and vigilant content updates.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Christoph U Lehmann
- Christoph U. Lehmann, MD, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1475, Nashville, TN 37203, , Tel: 615-322-4071
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Koppel R, Chen Y. Unintended Consequences: New Problems, New Solutions. Contributions From 2015. Yearb Med Inform 2016:87-92. [PMID: 27830235 DOI: 10.15265/iy-2016-048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To select the best of the 2015 published papers on unintended consequences of healthcare information technology (HIT). METHOD Literature searches in several areas of scholarship, including IT, human factors, evaluation studies, medical errors, medical informatics, and implementation science. Also, because the specific terms "unintended consequences" were not often included in abstracts and titles, a more nuanced search algorithm was developed. RESULTS We identified 754 papers that had some empirical research on unintended consequences of HIT. An initial screen of titles and abstracts reduced this to 171 papers of potential interest. We then further filtered out papers that did not meet the following criteria: 1) the paper had to report an original empirical investigation, and 2) the impact reported had to be not negligible, i.e., in quantitative studies, the results related to unintended consequences were statistically significant; and in qualitative studies the relevant themes emerged were prominent. This resulted in 33 papers of which 15 were selected as best paper candidates. Each of these 15 papers was then separately evaluated by four reviewers. The final selection of four papers was made jointly by the external reviewers and the two section editors. CONCLUSIONS There is a growing awareness of the importance of HIT's unintended consequences-be they generated by the HIT vendors, the implementation process, the consultants, the users, or most probably, some combination of the above. There has also been greater creativity in use of data sources, including secondary data (e.g., medical malpractice cases and surveys) and a wider acceptance of mixed methods to identify unintended consequences. Unfortunately, the complexity of causes mitigates the value of recommendations to avoid unwanted outcomes. Suggestions are often contentious rather than obvious, setting-specific, and not universally applicable. "Lessons learned" often take on generalized-and perhaps platitudinous-forms, such as: "plan extra time," "involve all of the stakeholders," "recognize the different needs of different units or disciplines." The greater awareness of these problems, and the increased desire to identify and eliminate them is clearly reflected in the area's growing literature. We are hopeful the topic will receive additional attention and the discipline will improve its ability to identify and address these unexpected and usually adverse outcomes.
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Affiliation(s)
- R Koppel
- Prof. Ross Koppel, Sociology Department, University of Pennsylvania, Philadelphia, PA 19104, USA, E-mail:
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Abstract
BACKGROUND Implementation of an antimicrobial stewardship program is recommended as one solution to combat increasing antimicrobial resistance. Most antimicrobial stewardship programs use preauthorization or restrictive strategies recommended in national guidelines. We describe a unique, rounding-based strategy, handshake stewardship. Handshake stewardship is distinguished by: (1) lack of restriction and preauthorization, (2) review of all prescribed antimicrobials and (3) a rounding-based, in-person approach to feedback by a pharmacist-physician team. METHODS We retrospectively measured antimicrobial use hospital-wide and by unit during preimplementation, planning, and postimplementation phases of the handshake stewardship approach to determine the efficacy of this strategy in decreasing use in a freestanding children's hospital. All antimicrobials prescribed on the inpatient services between October 2010 and September 2014 were included in the review. Monthly antimicrobial use (hospital-wide and by unit) was measured in days of therapy per 1000 patient days (DOT/1000 PD). RESULTS Overall antimicrobial use decreased by 10.9% during the 4 years of the analysis (942 to 839 DOT/1000 PD, P < 0.01), with an impact of 10.3% on antibacterials (750 to 673 DOT/1000 PD, P < 0.01). Vancomycin use decreased by 25.7% (105 to 78 DOT/1000 PD, P < 0.01). Meropenem use decreased by 22.2% (45 to 35 DOT/1000 PD, P = 0.04) without a compensatory increase of other antipseudomonal agents. Decreased usage was observed both hospital-wide and on individual units for most agents. CONCLUSIONS The handshake stewardship approach is an effective strategy for an antimicrobial stewardship program, as demonstrated by the widespread and significant decrease in antimicrobial use after implementation.
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Abstract
BACKGROUND Antibiotics are among the drugs most commonly prescribed to children in hospitals and communities. Unfortunately, a great number of these prescriptions are unnecessary or inappropriate. Antibiotic abuse and misuse have several negative consequences, including drug-related adverse events, the emergence of multidrug resistant bacterial pathogens, the development of Clostridium difficile infection, the negative impact on microbiota, and undertreatment risks. In this paper, the principle of and strategies for paediatric antimicrobial stewardship (AS) programs, the effects of AS interventions and the common barriers to development and implementation of AS programs are discussed. DISCUSSION Over the last few years, there have been significant shortages in the development and availability of new antibiotics; therefore, the implementation of strategies to preserve the activity of existing antimicrobial agents has become an urgent public health priority. AS is one such approach. The need for formal AS programs in paediatrics was officially recognized only recently, considering the widespread use of antibiotics in children and the different antimicrobial resistance patterns that these subjects exhibit in comparison to adult and elderly patients. However, not all problems related to the implementation of AS programs among paediatric patients are solved. The most important remaining problems involve educating paediatricians, creating a multidisciplinary interprofessional AS team able to prepare guidelines, monitoring antibiotic prescriptions and defining corrective measures, and the availability of administrative consensuses with adequate financial support. Additionally, the problem of optimizing the duration of AS programs remains unsolved. Further studies are needed to solve the above mentioned problems. CONCLUSIONS In paediatric patients, as in adults, the successful implementation of AS strategies has had a significant impact on reducing targeted- and nontargeted-antimicrobial use by improving the quality of care for hospitalized patients and preventing the emergence of resistance. Considering that rationalization of antibiotic misuse and abuse is the basis for reducing emergence of bacterial resistance and several clinical problems, all efforts must be made to develop multidisciplinary paediatric AS programs in hospital and community settings.
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Affiliation(s)
- Nicola Principi
- Department of Pathophysiology and Transplantation, Pediatric Highly Intensive Care Unit, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milan, 20122 Italy
| | - Susanna Esposito
- Department of Pathophysiology and Transplantation, Pediatric Highly Intensive Care Unit, Università degli Studi di Milano, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Commenda 9, Milan, 20122 Italy
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The effectiveness of information technology to improve antimicrobial prescribing in hospitals: A systematic review and meta-analysis. Int J Med Inform 2016; 92:15-34. [DOI: 10.1016/j.ijmedinf.2016.04.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 04/06/2016] [Accepted: 04/17/2016] [Indexed: 12/19/2022]
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Systematic Review and Meta-analysis of Clinical and Economic Outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs. Antimicrob Agents Chemother 2016; 60:4840-52. [PMID: 27246783 DOI: 10.1128/aac.00825-16] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 05/26/2016] [Indexed: 12/29/2022] Open
Abstract
The implementation of antimicrobial stewardship programs (ASPs) is a promising strategy to help address the problem of antimicrobial resistance. We sought to determine the efficacy of ASPs and their effect on clinical and economic parameters. We searched PubMed, EMBASE, and Google Scholar looking for studies on the efficacy of ASPs in hospitals. Based on 26 studies (extracted from 24,917 citations) with pre- and postimplementation periods from 6 months to 3 years, the pooled percentage change of total antimicrobial consumption after the implementation of ASPs was -19.1% (95% confidence interval [CI] = -30.1 to -7.5), and the use of restricted antimicrobial agents decreased by -26.6% (95% CI = -52.3 to -0.8). Interestingly, in intensive care units, the decrease in antimicrobial consumption was -39.5% (95% CI = -72.5 to -6.4). The use of broad-spectrum antibiotics (-18.5% [95% CI = -32 to -5.0] for carbapenems and -14.7% [95% CI = -27.7 to -1.7] for glycopeptides), the overall antimicrobial cost (-33.9% [95% CI = -42.0 to -25.9]), and the hospital length of stay (-8.9% [95% CI = -12.8 to -5]) decreased. Among hospital pathogens, the implementation of ASPs was associated with a decrease in infections due to methicillin-resistant Staphylococcus aureus (risk difference [RD] = -0.017 [95% CI = -0.029 to -0.005]), imipenem-resistant Pseudomonas aeruginosa (RD = -0.079 [95% CI = -0.114 to -0.040]), and extended-spectrum beta-lactamase Klebsiella spp. (RD = -0.104 [95% CI = -0.153 to -0.055]). Notably, these improvements were not associated with adverse outcomes, since the all-cause, infection-related 30-day mortality and infection rates were not significantly different after implementation of an ASP (RD = -0.001 [95% CI = -0.009 to 0.006], RD = -0.005 [95% CI = -0.016 to 0.007], and RD = -0.045% [95% CI = -0.241 to 0.150], respectively). Hospital ASPs result in significant decreases in antimicrobial consumption and cost, and the benefit is higher in the critical care setting. Infections due to specific antimicrobial-resistant pathogens and the overall hospital length of stay are improved as well. Future studies should focus on the sustainability of these outcomes and evaluate potential beneficial long-term effects of ASPs in mortality and infection rates.
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Cresswell K, Mozaffar H, Shah S, Sheikh A. Approaches to promoting the appropriate use of antibiotics through hospital electronic prescribing systems: a scoping review. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2016; 25:5-17. [DOI: 10.1111/ijpp.12274] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 04/20/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Kathrin Cresswell
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
| | - Hajar Mozaffar
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
| | | | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics; The University of Edinburgh; UK
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Gong S, Qiu X, Song Y, Sun X, He Y, Chen Y, Li M, Luo R, He L, Wei Q, Shen S, Liu Y, Zhang L, Zhou W, Huang P, Mai J, Liu L, Xu Y, Liang H, Xia H. Effect of Financially Punished Audit and Feedback in a Pediatric Setting in China, within an Antimicrobial Stewardship Program, and as Part of an International Accreditation Process. Front Public Health 2016; 4:99. [PMID: 27242991 PMCID: PMC4870519 DOI: 10.3389/fpubh.2016.00099] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 05/02/2016] [Indexed: 01/21/2023] Open
Abstract
Background Prior authorization, audit and feedback, and pay for performance are the three core “active” strategies of antimicrobial stewardship program (ASP), yet little is known about the individual or combined benefits of such programs, particularly in a pediatric setting. Objectives The aim of this study was to compare these core ASP strategies and determine the incremental effect of financially punished audit and feedback. Methods During the journey to the Joint Commission International accreditation, a tertiary pediatric medical center performed two different hospital-wide stewardship interventions in succession. The first stage without formalized ASPs served as pre-intervention period, January 2011 to April 2011. The ASP used prior authorization alone during the first-intervention period, May 2011 to September 2011. In October 2011, financially punished audit and feedback was introduced, marking the start of the second-intervention period, October 2011 to November 2012. We compared the differences of the change in monthly average use of antibiotics and expenditure on antibiotics before and after the ASP changes by using interrupted time series via dynamic regression. The main end points included the proportions of antibiotic prescriptions and expenditure on antibacterial relative to all medications. Results Before the second-intervention period, neither the proportion of antibiotic prescriptions nor the proportion of expenditure on antibiotics declined significantly in both ambulatory and inpatient settings. However, after the introduction of financially punished audit and feedback, the proportion of both antibiotic prescriptions (β = −6.269, P < 0.001, and reduction = 59.4% for outpatients; β = −1.235, P < 0.001, and reduction = 19.8% for inpatients) and expenditure on antibiotics (β = −7.777, P < 0.001, and reduction = 46.7% for outpatients; β = −4.933, P = 0.001, and reduction = 16.3% for inpatients) dropped immediately. Conclusion The combination of more than one core strategies (prior authorization, audit and feedback, and pay for performance) will be more effective than one strategy alone.
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Affiliation(s)
- Sitang Gong
- Department of Gastroenterology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Xiu Qiu
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Yanyan Song
- Department of Medical Administration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Xin Sun
- Department of Medical Administration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Yanling He
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Yilu Chen
- Department of Pharmacy, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Minqing Li
- Department of Medical Administration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Rui Luo
- Department of Medical Administration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Liya He
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Qing Wei
- Department of Medical Administration, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Songying Shen
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Yu Liu
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Lian Zhang
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Wei Zhou
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Ping Huang
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Jianning Mai
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Li Liu
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Yi Xu
- Department of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
| | - Huiying Liang
- Guangzhou Women and Children's Medical Center, Institute of Pediatrics, Guangzhou Medical University , Guangzhou , China
| | - Huimin Xia
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University , Guangzhou , China
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Smith KL, Tran D, Westra BL. Sinusitis Treatment Guideline Adherence in the E-Visit Setting: A Performance Improvement Project. Appl Clin Inform 2016; 7:299-307. [PMID: 27437042 DOI: 10.4338/aci-2015-10-cr-0143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 02/15/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Studies demonstrate poor guideline adherence by health care providers for the treatment of upper respiratory infections, particularly acute bacterial rhinosinusitis (ABRS), in the appropriate prescribing of antibiotic medications. OBJECTIVE The purpose of this quality improvement project was to evaluate the effect of implementing interventions for improving adherence to a clinical practice guideline for the management of ABRS for patients treated in the e-visit setting. Interventions included: providing a report to providers of their adherence to the ABRS clinical guideline prior to the intervention, providing updated education on the ABRS guideline, and implementing a clinical decision support system reminder. METHODS A pre and post intervention evaluation design was used. Data were obtained from a retrospective electronic health record (EHR) data extract of all 316 diagnoses for ABRS in the pre-intervention 2-month time period and all 368 diagnoses of ABRS in the post-intervention 2-month time period. A review of the structured clinical data elements was performed to determine whether the provider adhered to the clinical guideline, meaning that only patients meeting the criteria for ABRS were to receive an antibiotic prescription. RESULTS AND CONCLUSION The interventions resulted in a 3.3% improvement in adherence to the ABRS clinical guideline from 95.25% adherence pre-intervention to 98.4% post-intervention. These results demonstrated that the use of an educational intervention and clinical decision support resulted in improved adherence to the ABRS clinical guideline in the e-visit setting. The implications for practice could be significant in that these quality improvement interventions improve guideline adherence and reduce unnecessary prescribing of antibiotics.
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Affiliation(s)
| | - Dang Tran
- Fairview Health System , Minneapolis, Minnesota, United States
| | - Bonnie L Westra
- University of Minnesota, School of Nursing , Minneapolis, Minnesota, United States
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Newland JG, Gerber JS, Weissman SJ, Shah SS, Turgeon C, Hedican EB, Thurm C, Hall M, Courter J, Brogan TV, Maples H, Lee BR, Hersh AL. Prevalence and Characteristics of Antimicrobial Stewardship Programs at Freestanding Children's Hospitals in the United States. Infect Control Hosp Epidemiol 2016; 35:265-71. [DOI: 10.1086/675277] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background and Objective.Antimicrobial stewardship programs (ASPs) are a mechanism to ensure the appropriate use of antimicrobials. The extent to which ASPs are formally implemented in freestanding children's hospitals is unknown. The objective of this study was to determine the prevalence and characteristics of ASPs in freestanding children's hospitals.Methods.We conducted an electronic survey of 42 freestanding children's hospitals that are members of the Children's Hospital Association to determine the presence and characteristics of their ASPs. For hospitals without an ASP, we determined whether stewardship strategies were in place and whether there were barriers to implementing a formal ASP.Results.We received responses from 38 (91%) of 42. Among responding institutions, 16 (38%) had a formal ASP, and 15 (36%) were in the process of implementing a program. Most ASPs (13 [81%] of 16) were started after 2007. The median number of full-time equivalents dedicated to ASPs was 0.63 (range, 0.1–1.8). The most common antimicrobials monitored by ASPs were linezolid, vancomycin, and carbapenems. Many hospitals without a formal ASP were performing stewardship activities, including elements of prospective audit and feedback (9 [41%] of 22), formulary restriction (9 [41%] of 22), and use of clinical guidelines (17 [77%] of 22). Antimicrobial outcomes were more likely to be monitored by hospitals with ASPs (100% vs 68%; P = .01), although only 1 program provided support for a data analyst.Conclusions.Most freestanding children's hospitals have implemented or are developing an ASP. These programs differ in structure and function, and more data are needed to identify program characteristics that have the greatest impact.
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Costs of Antimicrobial Stewardship Programs at US Children's Hospitals. Infect Control Hosp Epidemiol 2016; 37:852-4. [PMID: 27020133 DOI: 10.1017/ice.2016.62] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The costs of antimicrobial stewardship programs (ASPs) in children's hospitals have not been described previously. We assessed ASP costs using an online survey administered to ASP leaders at U.S. children's hospitals. ASP costs varied from $17,000 to $388,500 annually (median, $187,400). Overall costs were not correlated with hospital size. Infect Control Hosp Epidemiol 2016;37:852-854.
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Broom J, Broom A, Plage S, Adams K, Post JJ. Barriers to uptake of antimicrobial advice in a UK hospital: a qualitative study. J Hosp Infect 2016; 93:418-22. [PMID: 27130526 DOI: 10.1016/j.jhin.2016.03.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 03/03/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The role of infectious diseases (ID) and clinical microbiology (CM) in hospital settings has expanded in response to increasing antimicrobial resistance, leading to widespread development of hospital antimicrobial stewardship (AMS) programmes, the majority of which include antibiotic approval systems. However, inappropriate antibiotic use in hospitals continues, suggesting potential disjunctions between technical advice and the logics of antibiotic use within hospitals. AIM To examine the experiences of doctors in a UK hospital with respect to AMS guidance of antibiotic prescribing, and experiences of a verbal postprescription antibiotic approval process. METHODS Twenty doctors in a teaching hospital in the UK participated in semi-structured interviews about their experiences of antibiotic use and governance. NVivo10 software was used to conduct a thematic content analysis systematically. FINDINGS This study identified three key themes regarding doctors' relationships with ID/CM clinicians that shaped their antibiotic practices: (1) competing hierarchical influences limiting active consultation with ID/CM; (2) non-ID/CM consultants' sense of ownership over clinical decision-making and concerns about challenges to clinical autonomy; and (3) tensions between evidence-based practice and experiential-style learning. CONCLUSIONS This study illustrates the importance of examining relations between ID/CM and non-ID/CM clinicians in the hospital context, indicating that AMS models that focus exclusively on delivering advice rather than managing interprofessional relationships may be limited in their capacity to optimize antibiotic use. AMS and, specifically, antibiotic approval systems would likely be more effective if they incorporated time and resources for fostering and maintaining professional relationships.
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Affiliation(s)
- J Broom
- Department of Medicine, Sunshine Coast Hospital and Health Service, Nambour, QLD, Australia; School of Medicine, The University of Queensland, QLD, Australia.
| | - A Broom
- School of Social Sciences, The University of New South Wales, Sydney, NSW, Australia
| | - S Plage
- School of Social Sciences, The University of New South Wales, Sydney, NSW, Australia
| | - K Adams
- Department of Infectious Diseases, Hull and East Yorkshire NHS Trust, Kingston upon Hull, UK
| | - J J Post
- Department of Infectious Diseases, Prince of Wales Hospital and Prince of Wales Clinical School, The University of New South Wales, Sydney, NSW, Australia
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Smith MJ, Gerber JS, Hersh AL. Inpatient Antimicrobial Stewardship in Pediatrics: A Systematic Review. J Pediatric Infect Dis Soc 2015; 4:e127-35. [PMID: 26582880 DOI: 10.1093/jpids/piu141] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 12/12/2014] [Indexed: 11/13/2022]
Abstract
BACKGROUND The clinical and economic outcomes associated with pediatric antimicrobial stewardship programs (ASPs) and other supplemental antimicrobial stewardship (AS) interventions have not been well described or reviewed. METHODS We performed a systematic review using PubMed to identify studies with any of the following terms in the title or abstract: "antimicrobial stewardship," "antimicrobial control," "antibiotic control," or "antibiotic stewardship." Studies were further limited to inpatient studies in the United States that contained the terms: "child," "children," "pediatric*" ("*" includes all terms with the same stem), "paediatric,*" "newborn," "infant," or "neonat,*" in the title or abstract. Clinical and economic outcomes from each relevant study were summarized. RESULTS Nine original studies reported outcomes related to formal pediatric ASPs. An additional 8 studies focused on specific AS interventions; 3 on management of community-acquired pneumonia, 2 on vancomycin-specific initiatives, and 1 each on clinical support, antibiotic restriction, and antibiotic rotation. Reported outcomes include decreases in antimicrobial utilization (11 studies), prescribing errors (3 studies), and drug costs (3 studies). Five studies assessed the potential adverse effects of AS interventions on patient safety and found none. Data to support an association between pediatric AS interventions and antimicrobial resistance are limited. CONCLUSIONS A small number of pediatric studies evaluating ASPs or other AS strategies have been published. These studies demonstrate reductions in antimicrobial utilization, cost, and prescribing errors with no apparent negative impact on patient safety. Although the studies are promising, the current evidence base is limited. Additional studies focusing on the appropriateness and outcomes of antimicrobial prescribing practices as well as more formalized economic evaluations are needed.
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Affiliation(s)
- Michael J Smith
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Jeffrey S Gerber
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Magsarili HK, Girotto JE, Bennett NJ, Nicolau DP. Making a Case for Pediatric Antimicrobial Stewardship Programs. Pharmacotherapy 2015; 35:1026-36. [PMID: 26598095 DOI: 10.1002/phar.1647] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although antimicrobials are commonly used in children, it is important to remember that they can have a profound impact on this unique patient population. Inadvertent consequences of antiinfective use in children include antimicrobial resistance, infection caused by Clostridium difficile, increased risk of obesity, and adverse drug events. In addition, compared with adults, children have different dosing requirements, antimicrobial formulation needs, pharmacokinetics, and antimicrobial susceptibility profiles. Therefore, pediatric-specific antimicrobial stewardship efforts are needed to promote appropriate use of antimicrobials in children. The primary purposes of this review article are to provide a rationale behind pediatric-focused antimicrobial stewardship and to describe currently available evidence regarding the initiatives of pediatric antimicrobial stewardship programs (ASPs). A literature search of the Medline database was performed (from inception through March 2015). The studies included in this review focus on antimicrobial stewardship interventions in inpatient pediatric settings. Ten inpatient studies involving pediatric-focused antimicrobial stewardship interventions were identified from the published literature. Four studies used the core strategy of prospective audit with feedback; two used prior approval. The remaining four used supplemental antimicrobial stewardship strategies (guidelines, clinical pathways, and computerized decision support tools). In general, the interventions resulted in decreased antimicrobial use, reduced antimicrobial costs, and fewer prescribing errors. Children have unique medical needs related to antimicrobials and deserve focused ASP efforts. The literature regarding pediatric antimicrobial stewardship interventions is limited, but published interventions may serve as paradigms for developing pediatric ASPs as demonstrated by the general success of these interventions.
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Affiliation(s)
- Heather K Magsarili
- Department of Pharmacy, Connecticut Children's Medical Center, Hartford, Connecticut
| | - Jennifer E Girotto
- Department of Pharmacy, Connecticut Children's Medical Center, Hartford, Connecticut.,Division of Infectious Diseases and Immunology, Connecticut Children's Medical Center, Hartford, Connecticut.,Department of Pharmacy Practice, University of Connecticut, School of Pharmacy, Storrs, Connecticut
| | - Nicholas J Bennett
- Division of Infectious Diseases and Immunology, Connecticut Children's Medical Center, Hartford, Connecticut
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut
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Abstract
Antibiotic resistance remains a major health threat and the overuse of antimicrobials contributes to this serious problem. Antimicrobial stewardship programs (ASPs) are effective in decreasing the inappropriate use of antimicrobials. The development of pediatric ASPs is increasing and these programs have proven effective in optimizing antimicrobial use in children. The value of ASPs is gaining recognition and the expansion of stewardship into additional health care settings is expected. Collaborative efforts are underway among pediatric ASPs to enhance best practices and develop efficient and effective strategies to minimize unnecessary antimicrobial use in children.
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Affiliation(s)
- Jennifer L Goldman
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA; Division of Clinical Pharmacology, Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Jason G Newland
- Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA
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Evans RS, Olson JA, Stenehjem E, Buckel WR, Thorell EA, Howe S, Wu X, Jones PS, Lloyd JF. Use of computer decision support in an antimicrobial stewardship program (ASP). Appl Clin Inform 2015; 6:120-35. [PMID: 25848418 DOI: 10.4338/aci-2014-11-ra-0102] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/20/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Document information needs, gaps within the current electronic applications and reports, and workflow interruptions requiring manual information searches that decreased the ability of our antimicrobial stewardship program (ASP) at Intermountain Healthcare (IH) to prospectively audit and provide feedback to clinicians to improve antimicrobial use. METHODS A framework was used to provide access to patient information contained in the electronic medical record, the enterprise-wide data warehouse, the data-driven alert file and the enterprise-wide encounter file to generate alerts and reports via pagers, emails and through the Centers for Diseases and Control's National Healthcare Surveillance Network. RESULTS Four new applications were developed and used by ASPs at Intermountain Medical Center (IMC) and Primary Children's Hospital (PCH) based on the design and input from the pharmacists and infectious diseases physicians and the new Center for Diseases Control and Prevention/National Healthcare Safety Network (NHSN) antibiotic utilization specifications. Data from IMC and PCH now show a general decrease in the use of drugs initially targeted by the ASP at both facilities. CONCLUSIONS To be effective, ASPs need an enormous amount of "timely" information. Members of the ASP at IH report these new applications help them improve antibiotic use by allowing efficient, timely review and effective prioritization of patients receiving antimicrobials in order to optimize patient care.
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Affiliation(s)
- R S Evans
- Medical Informatics, Intermountain Healthcare, University of Utah , Salt Lake City, Utah ; Biomedical Informatics, University of Utah, University of Utah , Salt Lake City, Utah
| | - J A Olson
- Pharmacy, Primary Children's Medical Center, University of Utah , Salt Lake City, Utah
| | - E Stenehjem
- Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, University of Utah , Salt Lake City, Utah
| | - W R Buckel
- Pharmacy, Intermountain Medical Center, University of Utah , Salt Lake City, Utah
| | - E A Thorell
- Pediatric Infectious Diseases, University of Utah , Salt Lake City, Utah
| | - S Howe
- Medical Informatics, Intermountain Healthcare, University of Utah , Salt Lake City, Utah
| | - X Wu
- Medical Informatics, Intermountain Healthcare, University of Utah , Salt Lake City, Utah
| | - P S Jones
- Clinical Epidemiology and Infectious Diseases, Intermountain Medical Center, University of Utah , Salt Lake City, Utah
| | - J F Lloyd
- Medical Informatics, Intermountain Healthcare, University of Utah , Salt Lake City, Utah
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Abstract
In the past 3 years, the Health Information Technology for Economic and Clinical Health Act accelerated the adoption of electronic health records (EHRs) with providers and hospitals, who can claim incentive monies related to meaningful use. Despite the increase in adoption of commercial EHRs in pediatric settings, there has been little support for EHR tools and functionalities that promote pediatric quality improvement and patient safety, and children remain at higher risk than adults for medical errors in inpatient environments. Health information technology (HIT) tailored to the needs of pediatric health care providers can improve care by reducing the likelihood of errors through information assurance and minimizing the harm that results from errors. This technical report outlines pediatric-specific concepts, child health needs and their data elements, and required functionalities in inpatient clinical information systems that may be missing in adult-oriented HIT systems with negative consequences for pediatric inpatient care. It is imperative that inpatient (and outpatient) HIT systems be adapted to improve their ability to properly support safe health care delivery for children.
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Hersh AL, De Lurgio SA, Thurm C, Lee BR, Weissman SJ, Courter JD, Brogan TV, Shah SS, Kronman MP, Gerber JS, Newland JG. Antimicrobial stewardship programs in freestanding children's hospitals. Pediatrics 2015; 135:33-9. [PMID: 25489018 DOI: 10.1542/peds.2014-2579] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Single-center evaluations of pediatric antimicrobial stewardship programs (ASPs) suggest that ASPs are effective in reducing and improving antibiotic prescribing, but studies are limited. Our objective was to compare antibiotic prescribing rates in a group of pediatric hospitals with formalized ASPs (ASP+) to a group of concurrent control hospitals without formalized stewardship programs (ASP-). METHODS We evaluated the impact of ASPs on antibiotic prescribing over time measured by days of therapy/1000 patient-days in a group of 31 freestanding children's hospitals (9 ASP+, 22 ASP-). We compared differences in average antibiotic use for all ASP+ and ASP- hospitals from 2004 to 2012 before and after release of 2007 Infectious Diseases Society of America guidelines for developing ASPs. Antibiotic use was compared for both all antibacterials and for a select subset (vancomycin, carbapenems, linezolid). For each ASP+ hospital, we determined differences in the average monthly changes in antibiotic use before and after the program was started by using interrupted time series via dynamic regression. RESULTS In aggregate, as compared with those years preceding the guidelines, there was a larger decline in average antibiotic use in ASP+ hospitals than in ASP- hospitals from 2007 to 2012, the years after the release of Infectious Diseases Society of America guidelines (11% vs 8%, P = .04). When examined individually, relative to preimplementation trends, 8 of 9 ASP+ hospitals revealed declines in antibiotic use, with an average monthly decline in days of therapy/1000 patient-days of 5.7%. For the select subset of antibiotics, the average monthly decline was 8.2%. CONCLUSIONS Formalized ASPs in children's hospitals are effective in reducing antibiotic prescribing.
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Affiliation(s)
- Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah;
| | - Stephen A De Lurgio
- Children's Mercy Hospitals and Clinics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Cary Thurm
- Children's Hospital Association, Overland Park, Kansas City, Kansas
| | - Brian R Lee
- Children's Mercy Hospitals and Clinics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Scott J Weissman
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | | | - Thomas V Brogan
- Division of Critical Care, Department of Pediatrics, Seattle Children's Hospital, Seattle, Washington; and
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Matthew P Kronman
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Jeffrey S Gerber
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jason G Newland
- Children's Mercy Hospitals and Clinics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
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Roque F, Herdeiro MT, Soares S, Teixeira Rodrigues A, Breitenfeld L, Figueiras A. Educational interventions to improve prescription and dispensing of antibiotics: a systematic review. BMC Public Health 2014; 14:1276. [PMID: 25511932 PMCID: PMC4302109 DOI: 10.1186/1471-2458-14-1276] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/08/2014] [Indexed: 11/10/2022] Open
Abstract
Background Excessive and inappropriate antibiotic use contributes to growing antibiotic resistance, an important public-health problem. Strategies must be developed to improve antibiotic-prescribing. Our purpose is to review of educational programs aimed at improving antibiotic-prescribing by physicians and/or antibiotic-dispensing by pharmacists, in both primary-care and hospital settings. Methods We conducted a critical systematic search and review of the relevant literature on educational programs aimed at improving antibiotic prescribing and dispensing practice in primary-care and hospital settings, published in January 2001 through December 2011. Results We identified 78 studies for analysis, 47 in primary-care and 31 in hospital settings. The studies differed widely in design but mostly reported positive results. Outcomes measured in the reviewed studies were adherence to guidelines, total of antibiotics prescribed, or both, attitudes and behavior related to antibiotic prescribing and quality of pharmacy practice related to antibiotics. Twenty-nine studies (62%) in primary care and twenty-four (78%) in hospital setting reported positive results for all measured outcomes; fourteen studies (30%) in primary care and six (20%) in hospital setting reported positive results for some outcomes and results that were not statistically influenced by the intervention for others; only four studies in primary care and one study in hospital setting failed to report significant post-intervention improvements for all outcomes. Improvement in adherence to guidelines and decrease of total of antibiotics prescribed, after educational interventions, were observed, respectively, in 46% and 41% of all the reviewed studies. Changes in behaviour related to antibiotic-prescribing and improvement in quality of pharmacy practice was observed, respectively, in four studies and one study respectively. Conclusion The results show that antibiotic use could be improved by educational interventions, being mostly used multifaceted interventions. Electronic supplementary material The online version of this article (doi:10.1186/1471-2458-14-1276) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Maria Teresa Herdeiro
- Centre for Cell Biology, University of Aveiro (Centro de Biologia Celular - CBC/UA); Campus Universitário de Santiago, 3810-193 Aveiro, Portugal.
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Systemic antifungal prescribing in neonates and children: outcomes from the Antibiotic Resistance and Prescribing in European Children (ARPEC) Study. Antimicrob Agents Chemother 2014; 59:782-9. [PMID: 25403672 DOI: 10.1128/aac.04109-14] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The appropriate use of systemic antifungals is vital in the prevention and treatment of invasive fungal infection (IFI) in immunosuppressed children and neonates. This multicenter observational study describes the inpatient prescribing practice of antifungal drugs for children and neonates and identifies factors associated with prescribing variability. A single-day point prevalence study of antimicrobial use in hospitalized neonates and children was performed between October and December 2012. The data were entered through a study-specific Web-based portal using a standardized data entry protocol. Data were recorded from 17,693 patients from 226 centers. A total of 136 centers recorded data from 1,092 children and 380 neonates receiving at least one antifungal agent. The most frequently prescribed systemic antifungals were fluconazole (n=355) and amphotericin B deoxycholate (n=195). The most common indications for antifungal administration in children were medical prophylaxis (n=325), empirical treatment of febrile neutropenia (n=122), and treatment of confirmed or suspected IFI (n=100 [14%]). The treatment of suspected IFI in low-birthweight neonates accounted for the majority of prescriptions in the neonatal units (n=103). An analysis of variance (ANOVA) demonstrated no significant effect of clinical indication (prophylaxis or treatment of systemic or localized infection) on the total daily dose (TDD). Fewer than one-half of the patients (n=371) received a TDD within the dosing range recommended in the current guidelines. Subtherapeutic doses were prescribed in 416 cases (47%). The predominance of fluconazole and high incidence of subtherapeutic doses in participating hospitals may contribute to suboptimal clinical outcomes and an increased predominance of resistant pathogenic fungi. A global consensus on antifungal dosing and coordinated stewardship programs are needed to promote the consistent and appropriate use of antifungal drugs in neonates and children.
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Abstract
Antimicrobial stewardship programs (ASPs) are aimed to improve patient care and health care outcomes. It is encouraging to find ASP interventions to be cost-saving in many cost-minimization analyses in literature. Nevertheless, the cost-effectiveness of ASP interventions, measured in cost per quality-adjusted life-years, is less well-established. This Editorial aims to explore the barriers in assessing clinical effectiveness of ASPs and provide suggestions to conduct cost-effectiveness analysis of ASPs.
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Affiliation(s)
- Joyce You
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong , Shatin, NT , Hong Kong
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