Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals

Investigating the Variability among Indicators for Quantifying Antimicrobial Use in the Intensive Care Units: Analysis of Real-world Evidence

This study investigated variability among four indicators for quantifying antimicrobial use in intensive care units (ICUs): defined daily doses (DDD), prescribed daily doses (PDD), duration of therapy (DOT), and length of therapy (LOT) and recommended the most clinically relevant approach. Retrospective data from patients who had received at least one antimicrobial was analyzed. Patients whose records were incomplete or expired were excluded. Duration of therapy (24433/1000 PDs) and LOTs (12832/1000 PDs) underestimated the overall consumption of antimicrobials compared with DDD of 28391/1000 PDs. Whereas PDD (46699/1000 PDs) overestimated it. Comparison analysis detected % differences of 13.94, 23.92, and 54.80% between DDD and DOT, DDD and PDD, and DDD and LOT, indicators respectively. Linear regression revealed stronger (r 2 = 0.86), moderate (r 2 = 0.50), and moderate (r 2 =0.60) correlation between DDD and DOT, DDD and PDD and DDD and LOT indicators respectively. According to findings, combining DOT and DDD is a more practical method to quantify antimicrobial consumption in hospital ICUs.

How to cite this article

Deshwal PR, Tiwari P. Investigating the Variability among Indicators for Quantifying Antimicrobial Use in the Intensive Care Units: Analysis of Real-world Evidence. Indian J Crit Care Med 2024;28(7):662-676.

The efficacy of systemic antibiotics as an adjunct to surgical treatment of peri-implantitis: a systematic review

BACKGROUND

Microbial biofilm accumulation is the main cause of peri-implantitis. The majority of surgical peri-implantitis treatment protocols suggests adjunctive use of systemic antibiotics to target specific putative bacteria. The aim of this systematic review was to critically evaluate the adjunctive use of systemically administered antibiotics in surgical treatment of peri-implantitis by reviewing previously published systematic reviews and primary studies.

METHODS

A systematic literature search was conducted in four electronic databases (MEDLINE, The Cochrane Library, EMBASE, and Web of Science) for randomised controlled trials, cohort studies, case-control studies, and systematic reviews reporting surgical treatment of peri-implantitis with and without adjunctive systemically administered antibiotic therapy. The included systematic reviews and primary studies were qualitatively assessed using AMSTAR and GRADE, respectively. No restrictions were set for date of publication, journal, or language.

RESULTS

The literature search identified 681 papers. Only seven systematic reviews and two primary studies met the inclusion criteria. Four out of seven included systematic reviews concluded that no evidence exists for use of systemic antibiotics to improve the clinical outcomes in surgical treatment of peri-implantitis. One review did not estimate the level of evidence, one did not clearly state any beneficial effect, whereas one reported a limited adjunctive effect. Further, the two included primary studies did not show a long-term significant benefit of adjunctive use of systemically administrated antibiotics. However, one study reported a short-term adjunctive effect in patients with modified surface implants. Due to heterogeneity in study design, low number of included primary studies, and grade of bias, no meta-analysis was performed.

CONCLUSION

The use of systemically administered antibiotics as an adjunct to surgical interventions of peri-implantitis cannot be justified as a part of a standard treatment protocol. A pervasive problem is the lack of uniform diagnosis criteria for peri-implantitis, deficient information about patient characteristics, absence of high quality long-term randomised controlled trials, and authors' declaration on conflict of interest.

Organization of antibiotic stewardship in Europe: the way to go

It is more than two decades ago that a European Union conference on "The Microbial Threat" hosted by the Danish Government in Copenhagen in September 1998 issued recommendations to encourage good practice in the use of antimicrobial agents and reduce inappropriate prescribing. Essential components of those recommendations were antimicrobial teams in hospitals and the use of feedback to prescribers as well as educational activities. Two decades later, important surveillance systems on both antimicrobial resistance as well as on antibiotic consumption are functioning at the European level and in most European countries; European Committee on Antimicrobial Susceptibility Testing (EUCAST) has thoroughly re-evaluated, standardized and harmonized antibiotic susceptibility testing and breakpoints; there have been educational activities in many countries; and stewardship teams are now included in many guidelines and policy papers and recommendations. Yet, antimicrobial resistance problems in Europe have shifted from methicillin-resistant Staphylococus aureus (MRSA) to vancomycin-resistent Enterococcus faecium (VRE) and to multidrug-resistant gramnegative bacteria, while antibiotic consumption volumes, trends and patterns across countries do not show major and highly significant improvements. The way to go further is to recognize that better prescribing comes at a cost and requires investment in expert personnel, practice guideline drafting, and implementation aids, and, secondly, the setting of clear goals and quantitative targets for prescribing quality.

The efficacy of two doses versus 7 days' course of prophylactic antibiotics following cesarean section: An experience from Aminu Kano Teaching Hospital

Background:

Postcesarean wound infection is a leading cause of prolonged hospital stay. Considerable debates still exist regarding choice of antibiotics, dose, and duration of use.

Objectives:

The objective is to compare the efficacy of 2 doses of amoxicillin-clavulanic acid versus a 7 days combination of amoxicillin-clavulanic acid and metronidazole as prophylactic antibiotics following cesarean section (CS).

Methodology:

It was a randomized controlled trial that was conducted among 160 women undergoing CS at Aminu Kano Teaching Hospital. Women were randomized into two groups. Group I (study group) received 2 doses of 1.2 g amoxicillin-clavulanic acid. Group II (control group) received a 7 days course of amoxicillin-clavulanic acid and metronidazole. The data obtained were analyzed using SPSS version 17. Categorical (qualitative) variables were analyzed using Ch-square test and Fisher’s exact test as appropriate while continuous (quantitative) variables were analyzed using independent sample t-test. P < 0.05 was considered statistically significant.

Results:

There was no statistically significant association in the occurrence of fever (12.8% vs. 15.8%, P = 0.6), wound infection (6.4% vs. 10.5%, P = 0.36), endometritis (7.7% vs. 11.8%, P = 0.38), UTI (6.4% vs. 5.3%, P = 1.00), mean duration of hospital stay (129.7 vs. 134.2 h, P = 0.48), and neonatal outcomes between the two groups. There was statistically significant difference in the mean cost of antibiotics (₦2883/US$9.5 vs. ₦7040/US$23.1, P < 0.001) and maternal side effects (10.3% vs. 26.3%, P < 0.001) between the study and the control groups, respectively.

Conclusion:

This study found no statistically significant difference in infectious morbidity, duration of hospital stay, and neonatal outcomes when two doses of amoxicillin-clavulanic acid was compared with a 7 days course of prophylactic antibiotic following CS. The use of two doses of amoxicillin-clavulanic acid has the advantages of reduced cost and some maternal side effects. The two doses were cheaper with minimal side effects.

Antimicrobial activity of protein-containing fractions isolated from Lactobacillus plantarum NRRL B-4496 culture

The interest in lactic acid bacteria, including Lactobacillus plantarum NRRL B-4496, has increased in recent years as bio-preservatives, due to the production of secondary metabolites capable of inhibiting pathogenic bacteria. The objectives of this study were to evaluate the antimicrobial activity, cytotoxicity and the anti-inflammatory response of L. plantarum NRRL B-4496 cell-free supernatant (CFS). Furthermore, the CFS was fractionated by size exclusion chromatography using Sephadex G-25, and a minimal inhibitory volume test was determined against a panel of pathogenic bacteria. The cytotoxicity and the inflammatory activities of the fractions were evaluated using the human-derived THP-1 cell line. Results of this study indicates that CFS of L. plantarum NRRL B-4496 possesses antimicrobial protein compounds against the pathogen Listeria monocytogenes and showed no toxicity nor a pro-inflammatory response to human macrophages. The obtained results contribute to the development of novel bio-preservatives, L. plantarum cell-free supernatant or its fractions, with a potential use in the food industry.

Antimicrobial resistance (AMR)

The position paper of the European Association of Hospital Pharmacists (EAHP) highlights the importance of the prudent use of antimicrobial drugs through antibiotic stewardship to ensure efficient therapy for patients with life-threatening infections. EAHP calls on national governments and health system managers to utilise the specialised background and knowledge of the hospital pharmacist in multi-professional antibiotic stewardship teams. In addition, the paper recommends the universal application of infection prevention and control measures among healthcare professionals. Due to the lack of funding, EAHP urges increased investment to support the development of innovative proposals and the encouragement of practice-based research projects to investigate new fields of infectious disease control such as immunotherapy and to optimise the cost-effectiveness of systems for surveillance on antibiotic use and resistance. In relation to the 'One Health approach' of the European Commission, EAHP strongly supports regulatory oversight and proper implementation of measures in the veterinary and agriculture sectors at European, national and local level.

Silver nanoparticles as an effective disinfectant: A review

The paradigm modifications in the metallic crystals from bulky to micro-size to nano-scale have resulted in excellent and amazing properties; which have been the remarkable interests in a wider range of applications. Particularly, Ag NPs have much attention owing to their distinctive optical, chemical, electrical and catalytic properties that can be tuned with surface nature, size, shapes, etc. and hence these crystals have been used in various fields such as catalysis, sensor, electronic components, antimicrobial agents in the health industry etc. Among them, Ag NPs based disinfectants have paid attention due to the practical applications in our daily life. Therefore the Ag NPs have been used in different sectors such as silver-based air/water filters, textile, animal husbandry, biomedical and food packaging etc. In this review, the Ag NPs as a disinfectant in different sectors have been included in detail.

Implementation of the Procalcitonin Assay in a Rural Hospital

Objective: Most positive studies in procalcitonin (PCT) utilization were done in large, tertiary medical centers. Furthermore, there is a paucity of data describing the implementation process. This article is the first to describe in detail the implementation process and initial outcomes after 6 months of PCT testing in a rural, 65-bed, primary hospital. Methods: Education before and during PCT implementation as well as facility rollout are described. Initial outcomes were assessed using a before and after quasi-experimental study design comparing 2 identical 6-month time periods: May to October 2016 and May to October 2017. Antibiotic consumption is described with days of therapy (DOT) per 1000 patient days (PD). Antimicrobial purchasing costs, admission rates, and length of stay (LOS) are also compared. Results: Antimicrobial consumption was variable with the greatest reduction at 6 months: 856 DOT/1000 PD before versus 576 DOT/1000 PD after (P < .0001). Admission rates and LOS were unaffected. There was no associated savings in antibiotic purchasing costs: $114 189.79 before and $139 829.26 after (difference +$25 639.47). Conclusion: Although implementation of PCT testing is feasible in a rural health care facility, after 6 months, it was associated with a marginal decrease in antibiotic consumption with no decrease in admission rates, LOS, or antibiotic cost savings.

Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure

Background

Conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project, this study aimed to identify key elements for a global definition of responsible antibiotic use based on diverse stakeholder input.

Methods

A three-step RAND-modified Delphi method was applied. First, a systematic review of antibiotic stewardship literature and relevant organization web sites identified definitions and synonyms of responsible use. Identified elements of definitions were presented by questionnaire to a multidisciplinary international stakeholder panel for appraisal of their relevance. Finally, questionnaire results were discussed in a consensus meeting.

Results

The systematic review and the web site search identified 17 synonyms (e.g. appropriate, correct) and 22 potential elements to include in a definition of responsible use. Elements were grouped into patient-level (e.g. Indication, Documentation) or societal-level elements (e.g. Education, Future Effectiveness). Forty-eight stakeholders with diverse backgrounds [medical community, public health, patients, antibiotic research and development (R&D), regulators, governments] from 18 countries across all continents participated in the questionnaire. Based on relevance scores, 21 elements were retained, 9 were rephrased and 1 was added. Together, the 22 elements and associated best-practice descriptions comprise an exhaustive list of elements to be considered when defining responsible use.

Conclusions

Combination of concepts from the literature and stakeholder opinion led to an international multidisciplinary consensus on a global definition of responsible antibiotic use. The widely diverging perspectives of stakeholders providing input should ensure the comprehensiveness and relevance of the definition for both individual patients and society. An aspirational goal would be to address all elements.

A Before-and-After Study of the Effectiveness of an Antimicrobial Stewardship Program in Critical Care

We evaluated the use of antimicrobials expressed as defined daily doses (DDDs) per 1,000 patient days and days of therapy (DOT) per 100 occupied bed-days in a intensive care unit (ICU) of a general hospital in Barcelona, Spain, before and after implementation of an antimicrobial stewardship (AMS) program (2007 to 2010 versus 2011 to 2015). The quarterly costs of antimicrobials used in the ICU and its weight in the overall hospital costs of antimicrobials were calculated. The effect of the applied AMS program on DDDs and DOT time series data was analyzed by means of intervention time series analysis. A total of 5,002 patients were included (1,971 for the first [before] period and 3,031 for the second [after] period). The percentage of patients treated with one or more antimicrobials decreased from 88.6 to 77.2% (P < 0.001). DDDs decreased from 246.8 to 192.3 (mean difference, -54.5; P = 0.001) and DOT from 66.7 to 54.6 (mean difference, -12.1; P = 0.066). The mean cost per trimester decreased from €115,543 to €73,477 (mean difference, -42,065.4 euros; P < 0.001), and the percentage of ICU antimicrobials cost with respect to the total cost of hospital antimicrobials decreased from 28.5 to 22.8% (mean difference, -5.59; P = 0.023). Implementation of an AMS program in the ICU was associated with a marked reduction in the use of antimicrobials, with cost savings close to one million euros since its implementation. An AMS program can have a significant impact on optimizing antimicrobial use in critical care practice.

Screening of nasal carriage of methicillin-resistant Staphylococcus aureus during admission of patients to Frantz Fanon Hospital, Blida, Algeria

A study was performed of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) strains isolated from nasal preoperative samples. Of 663 samples assessed, staphylococcus was detected in 143 (21.57%). The disc diffusion method (cefoxitin 30 μg), a screening test (oxacillin 6 μg/mL) and a search for Protein Binding Additional Penicillin 2 (PLP2a) allowed the detection and confirmation of resistance to methicillin for 36 strains, a rate of 5.43% of the total population studied. Eight MRSA carriers received care in the trauma service, 14 in cardiology, five in ear, nose and throat, four in neurosurgery and paediatrics, and one in SCI. Thirty-six methicillin-resistant of the nasal portage strains are in their great majority, 27 of 36, rather limited multi-R character (two to three families namely resistance: tetracyclines, fluoroquinolones, aminoglycosides, macrolides). One of the MRSA strains was found to have intermediate sensitivity to vancomycin.

Impact of Gram stain results on initial treatment selection in patients with ventilator-associated pneumonia: a retrospective analysis of two treatment algorithms

BACKGROUND

Ventilator-associated pneumonia (VAP) is a common and serious problem in intensive care units (ICUs). Several studies have suggested that the Gram stain of endotracheal aspirates is a useful method for accurately diagnosing VAP. However, the usefulness of the Gram stain in predicting which microorganisms cause VAP has not been established. The purpose of this study was to evaluate whether a Gram stain of endotracheal aspirates could be used to determine appropriate initial antimicrobial therapy for VAP.

METHODS

Data on consecutive episodes of microbiologically confirmed VAP were collected from February 2013 to February 2016 in the ICU of a tertiary care hospital in Japan. We constructed two hypothetical empirical antimicrobial treatment algorithms for VAP: a guidelines-based algorithm (GLBA) based on the recommendations of the American Thoracic Society-Infectious Diseases Society of America (ATS-IDSA) guidelines and a Gram stain-based algorithm (GSBA) which limited the choice of initial antimicrobials according to the results of bedside Gram stains. The GLBA and the GSBA were retrospectively reviewed for each VAP episode. The initial coverage rates and the selection of broad-spectrum antimicrobial agents were compared between the two algorithms.

RESULTS

During the study period, 219 suspected VAP episodes were observed and 131 episodes were assessed for analysis. Appropriate antimicrobial coverage rates were not significantly different between the two algorithms (GLBA 95.4% versus GSBA 92.4%; p = 0.134). The number of episodes for which antimethicillin-resistant Staphylococcus aureus agents were selected as an initial treatment was larger in the GLBA than in the GSBA (71.0% versus 31.3%; p < 0.001), as were the number of episodes for which antipseudomonal agents were recommended as an initial treatment (70.2% versus 51.9%; p < 0.001).

CONCLUSIONS

Antimicrobial treatment based on Gram stain results may restrict the administration of broad-spectrum antimicrobial agents without increasing the risk of treatment failure.

TRIAL REGISTRATION

UMIN-CTR, UMIN000026457 . Registered 8 March 2017 (retrospectively registered).

Local Intra-wound Administration of Powdered Antibiotics in Orthopaedic Surgery

Surgical site infection (SSI) is one of the most common complications after orthopaedic surgery, leading to significant morbidity and its associated costs. Surgical guidelines strongly recommend the use of systemic antibiotic prophylaxis to reduce the risk for developing SSI. Locally administered powdered antibiotics have the potential to provide remarkably high intra-wound concentrations without risk for systemic toxicity. However, a paucity of high quality evidence in the orthopaedic literature has prevented widespread adoption of this technique. The majority of clinical studies on local intra-wound antibiotics have evaluated the use of topical powdered vancomycin in spinal surgery, though only a single prospective study currently exists. This review will discuss all the available evidence describing the effectiveness, pharmacokinetics, and potential adverse effects with the use of topical powdered antibiotics in orthopedic surgery.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Steering Evolution with Sequential Therapy to Prevent the Emergence of Bacterial Antibiotic Resistance

The increasing rate of antibiotic resistance and slowing discovery of novel antibiotic treatments presents a growing threat to public health. Here, we consider a simple model of evolution in asexually reproducing populations which considers adaptation as a biased random walk on a fitness landscape. This model associates the global properties of the fitness landscape with the algebraic properties of a Markov chain transition matrix and allows us to derive general results on the non-commutativity and irreversibility of natural selection as well as antibiotic cycling strategies. Using this formalism, we analyze 15 empirical fitness landscapes of E. coli under selection by different β-lactam antibiotics and demonstrate that the emergence of resistance to a given antibiotic can be either hindered or promoted by different sequences of drug application. Specifically, we demonstrate that the majority, approximately 70%, of sequential drug treatments with 2-4 drugs promote resistance to the final antibiotic. Further, we derive optimal drug application sequences with which we can probabilistically 'steer' the population through genotype space to avoid the emergence of resistance. This suggests a new strategy in the war against antibiotic-resistant organisms: drug sequencing to shepherd evolution through genotype space to states from which resistance cannot emerge and by which to maximize the chance of successful therapy.

New Horizons for Pediatric Antibiotic Stewardship

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.

The spread of multi drug resistant infections is leading to an increase in the empirical antibiotic treatment failure in cirrhosis: a prospective survey

Background

The spread of multi-resistant infections represents a continuously growing problem in cirrhosis, particularly in patients in contact with the healthcare environment.

Aim

Our prospective study aimed to analyze epidemiology, prevalence and risk factors of multi-resistant infections, as well as the rate of failure of empirical antibiotic therapy in cirrhotic patients.

Methods

All consecutive cirrhotic patients hospitalized between 2008 and 2013 with a microbiologically-documented infection (MDI) were enrolled. Infections were classified as Community-Acquired (CA), Hospital-Acquired (HA) and Healthcare-Associated (HCA). Bacteria were classified as Multidrug-Resistant (MDR) if resistant to at least three antimicrobial classes, Extensively-Drug-Resistant (XDR) if only sensitive to one/two classes and Pandrug-Resistant (PDR) if resistant to all classes.

Results

One-hundred-twenty-four infections (15% CA, 52% HA, 33% HCA) were observed in 111 patients. Urinary tract infections, pneumonia and spontaneous bacterial peritonitis were the more frequent. Forty-seven percent of infections were caused by Gram-negative bacteria. Fifty-one percent of the isolates were multi-resistant to antibiotic therapy (76% MDR, 21% XDR, 3% PDR): the use of antibiotic prophylaxis (OR = 8.4; 95%CI = 1.03-76; P = 0,05) and current/recent contact with the healthcare-system (OR = 3.7; 95%CI = 1.05-13; P = 0.04) were selected as independent predictors. The failure of the empirical antibiotic therapy was progressively more frequent according to the degree of resistance. The therapy was inappropriate in the majority of HA and HCA infections.

Conclusions

Multi-resistant infections are increasing in hospitalized cirrhotic patients. A better knowledge of the epidemiological characteristics is important to improve the efficacy of empirical antibiotic therapy. The use of preventive measures aimed at reducing the spread of multi-resistant bacteria is also essential.

ACVIM consensus statement on therapeutic antimicrobial use in animals and antimicrobial resistance

The epidemic of antimicrobial resistant infections continues to challenge, compromising animal care, complicating food animal production and posing zoonotic disease risks. While the overall role of therapeutic antimicrobial use in animals in the development AMR in animal and human pathogens is poorly defined, veterinarians must consider the impacts of antimicrobial use in animal and take steps to optimize antimicrobial use, so as to maximize the health benefits to animals while minimizing the likelihood of antimicrobial resistance and other adverse effects. This consensus statement aims to provide guidance on the therapeutic use of antimicrobials in animals, balancing the need for effective therapy with minimizing development of antimicrobial resistance in bacteria from animals and humans.

Impact of Different Methods of Feedback to Clinicians After Postprescription Antimicrobial Review Based on the Centers for Disease Control and Prevention's 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults

Objectives.

To evaluate (1) the framework of the 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults that is part of the Centers for Disease Control and Prevention (CDC) Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, with regard to steps addressing antimicrobial use; and (2) methods of feedback to clinicians regarding antimicrobial use after postprescription review.

Design.

Prospective intervention to identify and modify inappropriate antimicrobial therapy.

Setting.

A 1,000-bed, tertiary care teaching hospital.

Patients.

Inpatients in selected medicine and surgery units receiving broad-spectrum antimicrobials for 48-72 hours.

Interventions.

We created a computer-based clinical-event detection system that automatically identified inpatients taking broad-spectrum and “reserve” antimicrobials for 48-72 hours. Although prior approval was required for initial administration of broad-spectrum and reserve antimicrobials, once approval was obtained, therapy with the antimicrobials could be continued indefinitely at the discretion of the treating clinician. Therapy that was ongoing at 48-72 hours was reviewed by an infectious diseases pharmacist or physician, and when indicated feedback was provided to clinicians to modify or discontinue therapy. Feedback was provided via a direct telephone call, a note on the front of the medical record, or text message sent to the clinician's pager. The acceptance rate of feedback was recorded and recommendations were categorized according to the 12 steps recommended by the CDC.

Results.

Interventions were recommended for 334 (30%) of 1,104 courses of antimicrobial therapy reviewed. A total of 87% of interventions fit into one of the CDC's 12 steps of prevention: 39% into step 3 (“target the pathogen”), 1% into step 4 (“access experts”), 3% into steps 7 and 8 (“treat infection, not colonization or contamination”), 18% into step 9 (“say ‘no’ to vancomycin”), and 26% into step 10 (“stop treatment when no infection”). The rate of compliance with recommendations to improve antimicrobial use was 72%. No differences in compliance were seen with the different methods of feedback.

Conclusions.

Nearly one-third of antimicrobial courses did not follow the CDC's recommended 12 steps for prevention of antimicrobial resistance. Clinicians demonstrated high compliance with following suggestions made after postprescription review, suggesting that it is a useful approach to decreasing and improving antimicrobial use among inpatients.

Infection control strategies for preventing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people

BACKGROUND

Nursing homes for older people provide an environment likely to promote the acquisition and spread of meticillin-resistant Staphylococcus aureus (MRSA), putting residents at increased risk of colonisation and infection. It is recognised that infection prevention and control strategies are important in preventing and controlling MRSA transmission.

OBJECTIVES

To determine the effects of infection prevention and control strategies for preventing the transmission of MRSA in nursing homes for older people.

SEARCH METHODS

In August 2013, for this third update, we searched the Cochrane Wounds Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Database of Abstracts of Reviews of Effects (DARE, The Cochrane Library), Ovid MEDLINE, OVID MEDLINE (In-process and Other Non-Indexed Citations), Ovid EMBASE, EBSCO CINAHL, Web of Science and the Health Technology Assessment (HTA) website. Research in progress was sought through Current Clinical Trials, Gateway to Reseach, and HSRProj (Health Services Research Projects in Progress).

SELECTION CRITERIA

All randomised and controlled clinical trials, controlled before and after studies and interrupted time series studies of infection prevention and control interventions in nursing homes for older people were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the results of the searches. Another review author appraised identified papers and undertook data extraction which was checked by a second review author.

MAIN RESULTS

For this third update only one study was identified, therefore it was not possible to undertake a meta-analysis. A cluster randomised controlled trial in 32 nursing homes evaluated the effect of an infection control education and training programme on MRSA prevalence. The primary outcome was MRSA prevalence in residents and staff, and a change in infection control audit scores which measured adherence to infection control standards. At the end of the 12 month study, there was no change in MRSA prevalence between intervention and control sites, while mean infection control audit scores were significantly higher in the intervention homes compared with control homes.

AUTHORS' CONCLUSIONS

There is a lack of research evaluating the effects on MRSA transmission of infection prevention and control strategies in nursing homes. Rigorous studies should be conducted in nursing homes, involving residents and staff to test interventions that have been specifically designed for this unique environment.

Multidrug resistance in bacteria: a serious patient safety challenge for India

Patient safety is an important issue affecting the delivery of health care in developed, transitional and developing countries. With the advancements in patient care, hitherto unknown issues relating to patient safety are emerging. An important problem endangering patient safety is infections acquired in the health care facilities. Health care associated infections (HCAIs) are no longer a local or regional problem. With the dissemination of multi-drug resistant bacteria across the globe, the problem of HCAIs has become even grimmer. The emergence of pan-resistant bacterial strains, compounded by lack of availability of new antimicrobials foretells a grave future for management of infections acquired in hospitals. Therefore, it is important to frame local policies and measures and take affirmative actions for prevention of HCAIs and reduce the burden of multi drug resistance.

Variation in hospital antibiotic prescribing practices for children with acute lymphoblastic leukemia

Antibiotic variation among pediatric oncology patients has not been well-described. Identification of significant variability in antibiotic use within this population would warrant evaluation of its clinical impact. We conducted a retrospective cohort study of newly diagnosed patients with pediatric acute lymophoblastic leukemia (ALL) hospitalized from 1999 to 2009 in 39 freestanding US children's hospitals within the Pediatric Health Information System. Medication use data were obtained for the first 30 days from each patient's index ALL admission date. Antibiotic exposure rates were reported as antibiotic days/1000 hospital days. Unadjusted composite broad-spectrum antibiotic exposure rates varied from 577 to 1628 antibiotic days/1000 hospital days. This wide range of antibiotic exposure was unaffected by adjustment for age, gender, race and days of severe illness (adjusted range: 532-1635 days of antibiotic therapy/1000 hospital days). Antibiotic use for children with newly diagnosed ALL varies widely across children's hospitals and is not explained by demographics or illness severity.

Extended follow-up of an antibiotic cycling program for the management of febrile neutropenia in a hematologic malignancy and hematopoietic cell transplantation unit

BACKGROUND

Febrile neutropenia is a common complication during treatment of hematological malignancies and hematopoietic cell transplantation. Empiric antibiotic therapy in this setting, while standard of care, commonly leads to microbial resistance. We have previously shown that cycling antibiotics in this patient population is feasible. This report provides long-term follow-up of cycling antibiotics in this patient population.

METHODS

In a prospective cohort of hematological malignancy patients with neutropenic fever, we sought to evaluate the role of empiric antibiotic cycling in preventing antibiotic resistance. Antibiotic cycling was initiated in March 2002 and, until June 2005, antibiotics were cycled every 8 months (Cycling Period A). From July 2005 to December 2009, antibiotics were cycled every 3 months (Cycling Period B). The rates of bacteremia, resistance, and complications were compared to a retrospective cohort (Pre-cycling Period).

RESULTS

The rate of gram-negative bacteremia decreased when compared to Cycling Periods A and B (5.3 vs. 2.1 and 3.3 episodes/1000 patient-days, respectively, P < 0.0001), most likely owing to implementation of quinolone prophylaxis. The resistance profile of the gram-negative organisms isolated remained stable over the 3 time periods, with the exception of an increase in quinolone resistance during the cycling periods. Gram-positive bacteremia rates remained stable, but vancomycin-resistant Enterococcus (VRE) increased significantly (0.1 vs. 1.0 and 1.6 episodes/1000 patient-days, respectively, P = 0.005) during cycling periods. Mortality rates were comparable.

CONCLUSIONS

Antibiotic cycling for neutropenic fever was effectively implemented and followed over an extended time period. Gram-negative resistance remained stable, but there is some concern for selection of resistant gram-positive bacteria, specifically VRE. Although antibiotic cycling did not seem to cause resistance in our study, further study is necessary to clarify the effect of cycling on antibiotic resistance, patient outcomes, and hospital cost.

Effectiveness of interventions in reducing antibiotic use for upper respiratory infections in ambulatory care practices

The objective was to evaluate the effect of separate interventions on antimicrobial prescribing for uncomplicated upper respiratory tract infections. The authors conducted a quasi-experimental pre-post study with concurrent control groups for each intervention. Academic detailing led to a significant reduction in unnecessary antibiotic prescribing. However, there was no significant change in antibiotic prescribing in response to educational mailings to providers or to provider involvement in patient mailings. Organizations that seek to reduce inappropriate use of antibiotics should use proven approaches, even when they are more expensive.

Pediatric vancomycin use in 421 hospitals in the United States, 2008

BACKGROUND

Recommendations to prevent the spread of vancomycin resistance have been in place since 1995 and include guidelines for inpatient pediatric use of vancomycin. The emergence of large databases allows us to describe variation in pediatric vancomycin across hospitals. We analyzed a database with hospitalizations for children under 18 at 421 hospitals in 2008.

METHODOLOGY/PRINCIPAL FINDINGS

The Premier hospital 2008 database, consisting of records for 877,201 pediatric hospitalizations in 421 hospitals, was analyzed. Stratified analyses and logistic mixed effects models were used to calculate the probability of vancomycin use while considering random effects of hospital variation, hospital fixed effects and patient effects, and the hierarchical structure of the data. Most hospitals (221) had fewer than 10 hospitalizations with vancomycin use in the study period, and 47 hospitals reported no vancomycin use in 17,271 pediatric hospitalizations. At the other end of the continuum, 21 hospitals (5.6% of hospitals) each had over 200 hospitalizations with vancomycin use, and together, accounted for more than 50% of the pediatric hospitalizations with vancomycin use. The mixed effects modeling showed hospital variation in the probability of vancomycin use that was statistically significant after controlling for teaching status, urban or rural location, size, region of the country, patient ethnic group, payor status, and APR-mortality and severity codes.

CONCLUSIONS/SIGNIFICANCE

The number and percentage of pediatric hospitalizations with vancomycin use varied greatly across hospitals and was not explained by hospital or patient characteristics in our logistic models. Public health efforts to reduce vancomycin use should be intensified at hospitals with highest use.

Pharmacodynamics for predicting therapeutic outcome and countering resistance spread: The cefditoren case

The relationship between pharmacokinetics and pharmacodynamics is a key instrument to improve antimicrobial stewardship and should be aimed to identification of the drug exposure measure that is closely associated not only with the ability to kill organisms but also to suppress the emergence of resistant subpopulations. This article reviews published studies for efficacy prediction with cefditoren and those aimed to explore its potential for countering resistance spread, focusing on the three most prevalent community-acquired isolates from respiratory infections: Streptococcus pneumoniae (S. pneumoniae), Haemophilus influenzae (H. influenzae) and Streptococcus pyogenes (S. pyogenes). Studies for efficacy prediction include in vitro pharmacodynamic simulations (using physiological concentrations of human albumin) and mice models (taking advantage of the same protein binding rate in mice and humans) to determine the value of the pharmacodynamic indices predicting efficacy, and Monte Carlo simulations to explore population pharmacodynamic coverage, as weapons for establishing breakpoints. Studies exploring the potential of cefditoren (free concentrations obtained with 400 mg cefditoren bid administration) for countering spread of resistance showed its capability for countering (1) intra-strain spread of resistance linked to ftsI gene mutations in H. influenzae; (2) the spread of H. influenzae resistant strains (with ftsI gene mutations) in multi-strain H. influenzae niches or of S. pneumoniae strains with multiple resistance traits in multi-strain S. pneumoniae niches; and (3) for overcoming indirect pathogenicity linked to β-lactamase production by H. influenzae that protects S. pyogenes in multibacterial niches. This revision evidences the ecological potential for cefditoren (countering resistance spread among human-adapted commensals) and its adequate pharmacodynamic coverage of respiratory pathogens (including those resistant to previous oral compounds) producing community-acquired infections.

Antimicrobial-resistant Klebsiella species isolated from free-range chicken samples in an informal settlement

INTRODUCTION

Sub-therapeutic doses of antimicrobial agents are administered routinely to poultry to aid growth and to prevent disease, with prolonged exposure often resulting in bacterial resistance. Crossover of antibiotic resistant bacteria from poultry to humans poses a risk to human health.

MATERIAL AND METHODS

In this study, 17 chicken samples collected from a vendor operating in an informal settlement in the Cape Town Metropolitan area, South Africa were screened for antimicrobial-resistant Gram-negative bacilli using the Kirby Bauer disk diffusion assay.

RESULTS

IN TOTAL, SIX ANTIBIOTICS WERE SCREENED: ampicillin, ciprofloxacin, gentamicin, nalidixic acid, tetracycline and trimethoprim. Surprisingly, Klebsiella ozaenae was identified in 96 and K. rhinoscleromatis in 6 (n=102) of the samples tested. Interestingly, ∼40% of the isolated Klebsiella spp. showed multiple resistance to at least three of the six antibiotics tested.

CONCLUSIONS

Klebsiella ozaenae and K. rhinoscleromatis cause clinical chronic rhinitis and are almost exclusively associated with people living in areas of poor hygiene.

Infection control strategies for preventing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people

BACKGROUND

Nursing homes for older people provide an environment likely to promote the acquisition and spread of meticillin-resistant Staphylococcus aureus (MRSA), putting residents at increased risk of colonisation and infection. It is recognised that infection prevention and control strategies are important in preventing and controlling MRSA transmission.

OBJECTIVES

To determine the effects of infection prevention and control strategies for preventing the transmission of MRSA in nursing homes for older people.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2011, Issue 2), the Cochrane Wounds Group Specialised Register (searched May 27th, 2011). We also searched Ovid MEDLINE (from 1950 to April Week 2 2011), OVID MEDLINE (In-process and Other Non-Indexed Citations, April 26th 2011) Ovid EMBASE (1980 to 2011 Week 16), EBSCO CINAHL (1982 to April 21st 2011), DARE (1992 to 2011, week 16), Web of Science (1981 to May 2011), and the Health Technology Assessment (HTA) website (1988 to May 2011). Research in progress was sought through Current Clinical Trials (www.controlled-trials.com), Medical Research Council Research portfolio, and HSRPRoj (current USA projects).

SELECTION CRITERIA

All randomised and controlled clinical trials, controlled before and after studies and interrupted time series studies of infection prevention and control interventions in nursing homes for older people were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed the results of the searches. Another review author appraised identified papers and undertook data extraction which was checked by a second review author.

MAIN RESULTS

For this second update only one study was identified, therefore it was not possible to undertake a meta-analysis. A cluster randomised controlled trial in 32 nursing homes evaluated the effect of an infection control education and training programme on MRSA prevalence. The primary outcome was MRSA prevalence in residents and staff, and a change in infection control audit scores which measured adherence to infection control standards. At the end of the 12 month study, there was no change in MRSA prevalence between intervention and control sites, while mean infection control audit scores were significantly higher in the intervention homes compared with control homes.

AUTHORS' CONCLUSIONS

There is a lack of research evaluating the effects on MRSA transmission of infection prevention and control strategies in nursing homes. Rigorous studies should be conducted in nursing homes, to test interventions that have been specifically designed for this unique environment.

Impact of an antibiotic restriction program on antibiotic utilization in the treatment of community-acquired pneumonia in a Veterans Affairs Medical Center

PURPOSE

The impact of an antibiotic restriction program (ARP) on the patterns of antibiotic use in the treatment of community-acquired pneumonia (CAP) was examined. We also evaluated the association between the ARP and the length of hospital stay in regard to CAP treatment and cost savings associated with the implementation of the ARP.

METHODS

A retrospective cohort study of patients admitted with CAP was conducted during two 6-month periods, one prior to the ARP and one after the ARP. The health system's computerized patient record system (CPRS) was used to obtain demographics, length of hospital stays, readmission rates, blood culture results, co-morbidities, antibiotic use, and durations of therapy. A total of 130 patients met the inclusion criteria for the final analyses. Average drug costs, employee salaries, and the cost of laboratory procedures were used to assess cost savings associated with the ARP.

RESULTS

From a total of 132 antibiotics that were ordered to treat CAP in the pre-ARP period, 28 were restricted (21.2%). However, the number of restricted antibiotics ordered was significantly reduced to 12 out of 114 (10.2%) antibiotics ordered in the post-ARP period (P = 0.024). In post-ARP implementation, the mean length of hospital stay was also significantly reduced from 7.6 to 5.8 days (P = 0.017), and although not statistically significant, the 30-day readmission rates declined from 16.9 to 6.2% (P = 0.097). The ARP was also associated with a saving of $943 per patient treated for CAP.

CONCLUSIONS

In addition to a decrease in the antibiotic utilization and the mean length of hospital stay, the ARP may have yielded cost savings and reduced the readmission rates for those patients admitted and treated for CAP.

High prevalence of extended-spectrum beta-lactamases and plasmid-mediated AmpC beta-lactamases in Enterobacteriaceae isolated from long-term care facilities in Korea

The aim of this study was to investigate for the first time the prevalence and types of extended-spectrum beta-lactamase (ESBL) and plasmid-mediated AmpC beta-lactamase (PABL) in Enterobacteriaceae in Korean long-term care facilities (LTCFs). ESBL rates were 45.3% (72/159) in Escherichia coli and 42.7% (50/117) in Klebsiella pneumoniae. In E. coli, CTX-M-28, the most prevalent ESBLs, was identified for the first time in Korea in 44 isolates. In K. pneumoniae, SHV-12 was found in 27 isolates (52.9% of ESBLs), among which 25 isolates also contained SHV-11. Twenty-seven isolates had SHV and CTX-M beta-lactamase simultaneously. PABL genes were detected in 39.3% (46/117) of K. pneumoniae and 3.1% (5/159) E. coli. In E. coli, DHA-1(3), CMY-2(1), and CMY-6(1) were detected, whereas in K. pneumoniae, only DHA-1 was detected. Among the PABL-producing organisms, 80.0% (E. coli) and 52.2% (K. pneumoniae) simultaneously produced ESBLs. In conclusion, LTCF residents in Korea have a very high prevalence of E. coli and K. pneumoniae producing ESBLs, PABLs, or both, and the genotypes of ESBL and PABL were identical with those found in general hospitals.

Effect of utilization policies for fluoroquinolones: a pilot study in nova scotia hospitals

BACKGROUND

Antimicrobial resistance results in increased morbidity, mortality, and costs to the health care system. Evidence suggests an association between the use of antimicrobials in hospitals and the development of antimicrobial resistance. Fluoroquinolones constitute one group of antimicrobials that are effective against a variety of bacterial infections, yet they may be subject to misuse. Many hospitals in Nova Scotia have implemented policies to improve antimicrobial prescribing, but the impact of these policies on utilization is unknown.

OBJECTIVES

To evaluate the use of fluoroquinolones in Nova Scotia hospitals using the World Health Organization's Anatomical Therapeutic Chemical classification system with defined daily doses (ATC/DDD) and to examine the influence of hospital policies for utilization of fluoroquinolones in community-acquired pneumonia.

METHODS

During the study period (April 1, 1997, to March 31, 2003), fluoroquinolones were administered at 31 of the 37 hospitals in Nova Scotia's 9 district health authorities. Hospital administrative data, hospital characteristics, and pharmaceutical purchasing data related to use of these drugs were aggregated using the ATC/DDD methodology for the fiscal years 1997/1998 to 2002/2003. District pharmacy directors were surveyed to obtain information about district and individual hospital antibiotic policies. Descriptive statistics were calculated, and univariable regression and multilevel analyses were performed.

RESULTS

Mean overall fluoroquinolone use increased over the study period, from 47.2 DDD/1000 bed-days per year in fiscal year 1997/1998 to 163.8 DDD/1000 bed-days per year in fiscal year 2002/2003 (p < 0.001). Multilevel analysis showed that utilization policies aimed at appropriate prescribing did not affect the use of fluoroquinolones.

CONCLUSION

This study revealed that drug purchasing, hospital administrative, and diagnostic data could be combined to compare the utilization of fluoroquinolones among different hospitals and district health authorities. Utilization policies had little effect on the amount, type, or route of fluoroquinolone use.

Epidemiologically relevant antimicrobial resistance phenotypes in pathogens isolated from critically ill patients in a Brazilian Universitary Hospital

Antimicrobial resistance is a threat to public health worldwide and is associated with higher mortality and morbidity. Despite the extensive knowledge about this problem, drug resistance has continued to emerge, especially in intensive care units (ICUs). The objective of this study was to evaluate the frequencies of epidemiologically relevant resistance phenotypes in pathogens isolated from ventilator-associated pneumonia (VAP), bloodstream infections (BSI) and urinary tract infections (UTI) in patients admitted in the adult intensive care unit (AICU) of the Clinical Hospital of Federal University of Uberlândia, during an one year period. Additionally, at the period of the study, the antibiotic consumption in AICU was verified. Coagulase-negative staphylococci and S. aureus were the main agents of BSI (43.9%), with 60.0% of oxacilin-resistance for both microorganisms, Klebsiella-Enterobacter group predominated in UTI (23.4%), with resistance to third generation cephalosporins in 58.0% of the isolates; and, Pseudomonas aeruginosa in VAP (42.0%), with 72.0% of resistance to imipenem. Cephalosporins (49.6%), vancomycin (37.4%) and carbapenems (26.6%) were the most prescribed antibiotics in the unit. The comparison of the results with a publication of the NNIS program evidenced a worse situation in the studied hospital, mainly between Gram-negative, that had surpassed the percentile 90% elaborated by that system. Based on these results a reconsideration on the empirical use of antibiotics and on prevention and control of nosocomial infections practices is recommended.

Infection control strategies for preventing the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people

BACKGROUND

Nursing homes for older people provide an environment likely to promote the acquisition and spread of meticillin-resistant Staphylococcus aureus (MRSA), putting residents at increased risk of colonisation and infection. It is recognised that infection control strategies are important in preventing and controlling MRSA transmission.

OBJECTIVES

The objective of this review was to determine the effects of infection control strategies for preventing the transmission of MRSA in nursing homes for older people.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2007, Issue 1), the Cochrane Wounds Group Specialised Register (searched April 2007); the Infectious Diseases Group and EPOC also searched their Specialised Registers for this review (both May 2006). We also searched MEDLINE (from 1966 to March Week 3 2007), EMBASE (1980 to 2007 Week 13), CINAHL (1982 to March Week 3 2007), British Nursing Index (1985 to March 2007), DARE (1992 to March 2007), Web of Science (1981 to March 2007), and the Health Technology Assessment (HTA) database (1988 to March 2007). Research in progress was identified through the National Research Register, Current Clinical Trials (www.controlled-trials.com), Medical Research Council Register, Current Research in Britain (CRIB), and HSRPRoj (current USA projects). SIGLE was also searched in order to identify atypical material which was not accessible through more conventional sources.

SELECTION CRITERIA

All randomised and controlled clinical trials, controlled before and after studies and interrupted time series studies of infection control interventions in nursing homes for older people were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the results of the searches.

MAIN RESULTS

Since no studies met the selection criteria, neither a meta-analysis nor a narrative description of studies was possible.

AUTHORS' CONCLUSIONS

The lack of studies in this field is surprising. Nursing homes for older people provide an environment likely to promote the acquisition and spread of infection, with observational studies repeatedly reporting that being a resident of a nursing home increases the risk of MRSA colonisation. Much of the evidence for recently-issued United Kingdom guidelines for the control and prevention of MRSA in health care facilities was generated in the acute care setting. It may not be possible to transfer such strategies directly to the nursing home environment, which serves as both a healthcare setting and a resident's home. Rigorous studies should be conducted in nursing homes, to test interventions that have been specifically designed for this unique environment.

Relationship between rates of antimicrobial consumption and the incidence of antimicrobial resistance in Staphylococcus aureus and Pseudomonas aeruginosa isolates from 47 French hospitals

OBJECTIVE

To investigate relationships between rates of antimicrobial consumption and the incidence of antimicrobial resistance in Staphylococcus aureus and Pseudomonas aeruginosa isolates from hospitals.

METHODS

We conducted an observational study that used retrospective data from 2002 and linear regression to model relationships. Hospitals were asked to collect data on consecutive S. aureus and P. aeruginosa isolates, consumption rates for antibiotics (ie, anti-infectives for systemic use as defined by Anatomical Therapeutic Chemical class J01), and hospital characteristics, including infection control policies. Rates of methicillin resistance in S. aureus and rates of ceftazidime and ciprofloxacin resistance in P. aeruginosa were expressed as the percentage of isolates that were nonsusceptible (ie, either resistant or intermediately susceptible) and as the incidence of nonsuceptible isolates (ie, the number of nonsuceptible isolates recovered per 1,000 patient-days). The rate of antimicrobial consumption was expressed as the number of defined daily doses per 1,000 patient-days.

SETTING

Data were obtained from 47 French hospitals, and a total of 12,188 S. aureus isolates and 6,370 P. aeruginosa isolates were tested.

RESULTS

In the multivariate analysis, fewer antimicrobials showed a significant association between the consumption rate and the percentage of isolates that were resistant than an association between the consumption rate and the incidence of resistance. The overall rate of antibiotic consumption, not including the antibiotics used to treat methicillin-resistant S. aureus infection, explained 13% of the variance between hospitals in the incidence of methicillin resistance among S. aureus isolates. The incidence of methicillin resistance in S. aureus isolates increased with the use of ciprofloxacin and levofloxacin and with the percentage of the hospital's beds located in intensive care units (adjusted multivariate coefficient of determination [aR(2)], 0.30). For P. aeruginosa, the incidence of ceftazidime resistance was greater in hospitals with higher consumption rates for ceftazidime, levofloxacin, and gentamicin (aR(2), 0.37). The incidence of ciprofloxacin resistance increased with the use of fluoroquinolones and with the percentage of a hospital's beds located in intensive care ( aR(2), 0.28).

CONCLUSIONS

A statistically significant relationship existed between the rate of fluoroquinolone use and the rate of antimicrobial resistance among S. aureus and P. aeruginosa isolates. The incidence of resistant isolates showed a stronger association with the rate of antimicrobial use than did the percentage of isolates with resistance.

Effect of communication errors during calls to an antimicrobial stewardship program

OBJECTIVE

To determine how inaccurate communication of patient data by clinicians in telephone calls to the prior-approval antimicrobial stewardship program (ASP) staff affects the incidence of inappropriate antimicrobial recommendations made by ASP practitioners.

DESIGN

A retrospective cohort design was used. The accuracy of the patient data communicated was evaluated against patients' medical records to identify predetermined, clinically significant inaccuracies. Inappropriate antimicrobial recommendations were defined having been made if an expert panel unanimously rated the actual recommendations as inappropriate after reviewing vignettes derived from inpatients' medical records.

SETTING

The setting was an academic medical center with a prior-approval ASP.

PATIENTS

All inpatient subjects of ASP prior-approval calls were eligible for inclusion.

RESULTS

Of 200 ASP telephone calls, the panel agreed about whether or not antimicrobial recommendations were inappropriate for 163 calls (82%); these 163 calls were then used as the basis for further analyses. After controlling for confounders, inaccurate communication was found to be associated with inappropriate antimicrobial recommendations (odds ratio [OR], of 2.2; P=.03). In secondary analyses of specific data types, only inaccuracies in microbiological data were associated with the study outcome (OR, 7.5; P=.002). The most common reason panelists gave for rating a recommendation as inappropriate was that antimicrobial therapy was not indicated.

CONCLUSIONS

Inaccurate communication of patient data, particularly microbiological data, during prior-approval calls is associated with an increased risk of inappropriate antimicrobial recommendations from the ASP. Clinicians and ASP practitioners should work to confirm that critical data has been communicated accurately prior to use of that data in prescribing decisions.

[Consultations with infectious disease specialists for patients in a teaching hospital: Adherence in 174 cases]

OBJECTIVES

In a teaching hospital where infectious disease specialists were routinely consulted for infections in patients in other departments, we sought to assess adherence to the specialists' recommendations, identify the factors influencing adherence, and measure the proportion of nosocomial infections among these consultations.

METHODS

We collected data from intrahospital consultations with infectious disease specialists over a 4-week period. Afterwards (48 hours later), a physician and pharmacist collected all prescriptions for anti-infectious agents (dose, drug, combinations) and other orders (laboratory tests, radiology examination, isolation) for each patient.

RESULTS

There were 174 infectious disease consultations requested for 143 inpatients during the study period. Anti-infectious agents were prescribed for 52.4% of patients, modified for 22.4%, and stopped for 9.1%; 16.1% neither had nor required such treatment. The rate of adherence to the specialists' recommendations was 84.6% for anti-infectious prescriptions and 77.4% for other orders. The factors associated with adherence were a bedside consultation (p = 0.04) and a recommendation to stop rather than modify anti-infectious treatment (p = 0.02). Roughly 40% of the patients (n = 57) had a nosocomial infection, most often during hospitalization for surgery (53.1% versus 29.1%, p < 0.01). Consultations were requested for 20% of the nosocomial infections observed at Grenoble University Hospital (based on annual prevalence in 2005).

CONCLUSIONS

The specialist's presence at the patient's bedside has an impact on staff adherence to recommendations. These specialists play a vital role in managing nosocomial infections, which account for more than a third of these intrahospital' consultations.

Patterns of antimicrobial resistance in a surgical intensive care unit of a university hospital in Turkey

Background

Several studies have reported higher rates of antimicrobial resistance among isolates from intensive care units than among isolates from general patient-care areas. The aims of this study were to review the pathogens associated with nosocomial infections in a surgical intensive care unit of a university hospital in Turkey and to summarize rates of antimicrobial resistance in the most common pathogens. The survey was conducted over a period of twelve months in a tertiary-care teaching hospital located in the south-eastern part of Turkey, Gaziantep. A total of 871 clinical specimens from 615 adult patients were collected. From 871 clinical specimens 771 bacterial and fungal isolates were identified.

Results

Most commonly isolated microorganisms were: Pseudomonas aeruginosa (20.3%), Candida species (15%) and Staphylococcus aureus (12.9%). Among the Gram-negative microorganisms P. aeruginosa were mostly resistant to third-generation cephalosporins (71.3–98.1%), while Acinetobacter baumannii were resistant in all cases to piperacillin, ceftazidime and ceftriaxone. Isolates of S. aureus were mostly resistant to penicillin, ampicillin, and methicillin (82–95%), whereas coagulase-negative staphylococci were 98.6% resistant to methicillin and in all cases resistant to ampicillin and tetracycline.

Conclusion

In order to reduce the emergence and spread of antimicrobial-resistant pathogens in ICUs, monitoring and optimization of antimicrobial use in hospitals are strictly recommended. Therefore local resistance surveillance programs are of most value in developing appropriate therapeutic guidelines for specific infections and patient types.

Impact of a computerized clinical decision support system on reducing inappropriate antimicrobial use: a randomized controlled trial

OBJECTIVE

Many hospitals utilize antimicrobial management teams (AMTs) to improve patient care. However, most function with minimal computer support. We evaluated the effectiveness and cost-effectiveness of a computerized clinical decision support system for the management of antimicrobial utilization.

DESIGN

A randomized controlled trial in adult inpatients between May 10 and August 3, 2004. Antimicrobial utilization was managed by an existing AMT using the system in the intervention arm and without the system in the control arm. The system was developed to alert the AMT of potentially inadequate antimicrobial therapy.

MEASUREMENTS

Outcomes assessed were hospital antimicrobial expenditures, mortality, length of hospitalization, and time spent managing antimicrobial utilization.

RESULTS

The AMT intervened on 359 (16%) of 2,237 patients in the intervention arm and 180 (8%) of 2,270 in the control arm, while spending approximately one hour less each day on the intervention arm. Hospital antimicrobial expenditures were $285,812 in the intervention arm and $370,006 in the control arm, for a savings of $84,194 (23%), or $37.64 per patient. No significant difference was observed in mortality (3.26% vs. 2.95%, p = 0.55) or length of hospitalization (3.84 vs. 3.99 days, p = 0.38).

CONCLUSION

Use of the system facilitated the management of antimicrobial utilization by allowing the AMT to intervene on more patients receiving inadequate antimicrobial therapy and to achieve substantial time and cost savings for the hospital. This is the first study that demonstrates in a patient-randomized controlled trial that computerized clinical decision support systems can improve existing antimicrobial management programs.

Medidas de control de Staphylococcus aureus resistente a meticilina en hospitales españoles. Encuesta del proyecto SARM 2003 GEIH/GEMARA/REIPI

INTRODUCTION

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the main nosocomial pathogens. The incidence of MRSA infections is increasing in Spain. The objective of this study was to investigate the measures used for surveillance and control of MRSA in a sample of Spanish hospitals.

METHODS

A questionnaire survey was done, including data on the incidence of MRSA infection/colonization for 2002, the microbiological methods used to study S. aureus susceptibility, and the use of control measures based on published guidelines.

RESULTS

Sixty-one hospitals with a catchment population of 16 million inhabitants participated. Automatic methods were most frequently used for routine susceptibility testing. The median incidence was 0.45 cases/100 admissions; this data could be obtained from only 70% of the centers. In 59%, the incidence was indicative of high transmission. Isolation precautions were indicated for all patients with MRSA in 95% of the hospitals; screening of carriers among patients was performed in 18% to 72%, depending on the circumstances. Health care workers from at least one unit had been screened in 52% of the hospitals during 2002. Mupirocin was used for the treatment of 90% of colonized persons.

CONCLUSION

There is considerable variation in the application of control measures in the hospitals surveyed. National guidelines with recommendations for MRSA control are needed in Spain.

Preventing antimicrobial-resistant bacterial infections among older adults in long-term care facilities

For older adults in long-term care facilities (LTCFs), the rate of infections caused by antimicrobial resistant strains of bacteria has increased and is prompting renewed interest in investing health care resources for prevention and control of these pathogens. This document offers a simple framework to combat infections due to antimicrobial resistant bacteria in LTCF residents by providing a multi-step approach consisting of four major strategies: prevent infection, diagnose and treat infection effectively, use antimicrobials wisely, and prevent transmission. Recommendations from this multi-step approach are directed at LTCF medical directors and practicing clinicians involved with the medical care of older adult LTCF residents.

Appropriateness of glycopeptide use in a hospital in Italy

The aims of this study were to quantify the rate of inappropriate glycopeptide use. The study was carried out by reviewing all medical records of patients who received a glycopeptide in a hospital located in Italy. A total of 452 patients received glycopeptides, with a rate of inappropriate use of 90.9%. Appropriateness of glycopeptide prescriptions was significantly higher in Intensive Care Units compared with surgical wards (odds ratio (OR) = 0.03; 95% confidence interval (CI) = 0.01-0.14), in younger patients (OR = 0.97; 95% CI = 0.95-0.99) and in those patients who received the prescription for therapy rather than prophylaxis (OR = 0.2; 95% CI = 0.06-0.66). Models were also developed to predict appropriateness of glycopeptide indications for therapy and prophylaxis. The information obtained in our audit may enable development of strategies to improve physician prescribing patterns.

Vancomycin and home health care

Microbiologic diagnosis before hospital discharge and physician education may limit inappropriate vancomycin use in homecare patients.

The Hospital Infection Control Practices Advisory Committee published guidelines for prudent use of vancomycin to combat increasing resistance to antimicrobial drugs. Studies examining compliance with these guidelines primarily involve hospitalized patients. The growing practice of home use of antimicrobial drugs led to this retrospective cohort study that evaluated parenteral vancomycin use in patients receiving it through a homecare agency. We found that 39.2% of outpatients received vancomycin outside the guidelines, mainly because of prolonged empiric therapy, dosing convenience, and prolonged use after surgery. Patients were more likely to receive vancomycin appropriately if they were >65 years of age, had a history of malignancy, or were discharged from a medical service. In addition, obtaining wound cultures and attempting a microbiologic diagnosis led to more appropriate vancomycin use. Recommendations for prudent vancomycin use are often overlooked when selecting antimicrobial drugs for home infusion. The public health impact of this practice remains unknown.

Decreasing antibiotic overuse in neonatal intensive care units: quality improvement research

Overutilization of antibiotics and emergence of resistant bacteria are important problems, particularly in intensive care units. To date, reproducible interventions to improve antibiotic utilization in hospitals have not been proven to be effective or safe. Evidence-based medicine, clinical practice guidelines, and health information technology are frequently promoted as means to cross the "quality chasm" described by the Institute of Medicine. This article outlines how these approaches intersect in a strategy for quality improvement research evaluating the safety and effectiveness of clinical practice guidelines designed to improve antibiotic use in neonatal intensive care units.