1
|
Hawes AM, Greene MT, Ratz D, Fowler KE, Kendall RE, Patel PK. Antimicrobial Stewardship Teams in Veterans Affairs and Nonfederal Hospitals in the United States: A National Survey of Antimicrobial Stewardship Practices. Open Forum Infect Dis 2024; 11:ofad620. [PMID: 38213633 PMCID: PMC10783152 DOI: 10.1093/ofid/ofad620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/16/2023] [Indexed: 01/13/2024] Open
Abstract
In a cross-sectional survey of US acute care hospitals, antimicrobial stewardship programs were present in most Veterans Affairs and nonfederal hospitals but varied in team composition, scope, and impact. Diagnostic stewardship was common across hospitals. Veterans Affairs hospitals had increased reach in outpatient settings. Telestewardship remains an opportunity in all hospital systems.
Collapse
Affiliation(s)
- Armani M Hawes
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - M Todd Greene
- Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Department of Internal Medicine, VA/UM Patient Safety Enhancement Program, Ann Arbor, Michigan, USA
| | - David Ratz
- Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, VA/UM Patient Safety Enhancement Program, Ann Arbor, Michigan, USA
| | - Karen E Fowler
- Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Internal Medicine, VA/UM Patient Safety Enhancement Program, Ann Arbor, Michigan, USA
| | - Ronald E Kendall
- Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Payal K Patel
- Department of Internal Medicine, VA/UM Patient Safety Enhancement Program, Ann Arbor, Michigan, USA
- Division of Infectious Diseases, Department of Internal Medicine, Intermountain Health, Salt Lake City, Utah, USA
| |
Collapse
|
2
|
Gopichandran V. Reducing the Ethical Burdens of Antimicrobial Stewardship using a Social Determinants Approach. Asian Bioeth Rev 2022; 14:183-190. [PMID: 35462967 PMCID: PMC8986926 DOI: 10.1007/s41649-022-00202-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/25/2022] Open
Abstract
Antimicrobial resistance is an emerging global health problem. Antimicrobial stewardship interventions attempt at regulating the prescription and use of antimicrobials so that the emergence of resistance is reduced. But antimicrobial stewardship interventions have several ethical issues such as inequity in access to antimicrobials among the poor who need them more, and limitation of the autonomy of prescribers and patients. Several upstream social determinants influence susceptibility to infections, antimicrobial prescription practices, and emergence of antimicrobial resistance. Some of these social determinants impose ethical burdens on the antimicrobial stewardship interventions. Addressing these social determinants with a public health approach will help reduce antimicrobial resistance. This article argues that the social determinants approach helps reduce the ethical burdens of antimicrobial stewardship.
Collapse
Affiliation(s)
- Vijayaprasad Gopichandran
- Department of Community Medicine, ESIC Medical College and Postgraduate Institute of Medical Sciences and Research, Chennai, India
| |
Collapse
|
3
|
Atif M, Ihsan B, Malik I, Ahmad N, Saleem Z, Sehar A, Babar ZUD. Antibiotic stewardship program in Pakistan: a multicenter qualitative study exploring medical doctors' knowledge, perception and practices. BMC Infect Dis 2021; 21:374. [PMID: 33882843 PMCID: PMC8059254 DOI: 10.1186/s12879-021-06043-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/05/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The emerging threat of antibiotic resistance is growing exponentially and antibiotic stewardship programs are cornerstone to fight against this global threat. The study aimed to explore the knowledge, perspectives and practices of physicians regarding various aspects of antibiotic stewardship program including antibiotic stewardship activities, rational use of antibiotics, antibiotic resistance, prescribing practices and factors associated with these practices. METHODS In this qualitative study, a total of 17 semi-structured, in-depth interviews with doctors of three tertiary care public sector hospitals in Bahawalpur and Rahim Yar Khan were conducted. The convenient sampling method was adopted to collect the data and the saturation point criterion was applied to determine the sample size. Thematic analysis approach was used to draw conclusions from the data. RESULTS The analysis of data yielded five themes, 12 subthemes and 26 categories. The themes included, (i) perception about antibiotic use and antibiotic stewardship, (ii) antibiotic prescription practices, (iii) antibiotic resistance, (iv) limited strategies adopted by hospital administration to ensure quality and safe distribution of antibiotics, (v) implementation of antibiotic stewardship program: barriers, suggestion and future benefits. Doctors had misconceptions about the rational use of antibiotics. The perception regarding antibiotic stewardship programs was poor. Moreover, very few activities related to ASP existed. The participants gave many suggestions for successful implementation of ASP in order to reduce the burden of antibiotic resistance, including development of guidelines for the use of antibiotics, strict legislation regarding use of antibiotics, active participation of healthcare professionals and awareness program among general public about the use of antibiotics. CONCLUSION This study concluded that poor knowledge of doctors regarding ASP, non-existence of antibiogram of hospital and lack of rules for the safe use of antibiotics were the main driving factors associated with irrational antibiotic prescription practices and development of AR.
Collapse
Affiliation(s)
- Muhammad Atif
- Department of Pharmacy Practice, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan.
| | - Beenish Ihsan
- Department of Pharmacy Practice, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Iram Malik
- Department of Pharmacy Practice, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Nafees Ahmad
- Department of Pharmacy Practice, Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, Pakistan
| | - Zikria Saleem
- Department of Pharmacy, University of Lahore, Lahore, Pakistan
| | - Azka Sehar
- Department of Pharmacy Practice, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | | |
Collapse
|
4
|
Majumder MAA, Rahman S, Cohall D, Bharatha A, Singh K, Haque M, Gittens-St Hilaire M. Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health. Infect Drug Resist 2020; 13:4713-4738. [PMID: 33402841 PMCID: PMC7778387 DOI: 10.2147/idr.s290835] [Citation(s) in RCA: 182] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/17/2020] [Indexed: 12/18/2022] Open
Abstract
Antimicrobial resistance (AMR) is a serious threat to global public health. It increases morbidity and mortality, and is associated with high economic costs due to its health care burden. Infections with multidrug-resistant (MDR) bacteria also have substantial implications on clinical and economic outcomes. Moreover, increased indiscriminate use of antibiotics during the COVID-19 pandemic will heighten bacterial resistance and ultimately lead to more deaths. This review highlights AMR's scale and consequences, the importance, and implications of an antimicrobial stewardship program (ASP) to fight resistance and protect global health. Antimicrobial stewardship (AMS), an organizational or system-wide health-care strategy, is designed to promote, improve, monitor, and evaluate the rational use of antimicrobials to preserve their future effectiveness, along with the promotion and protection of public health. ASP has been very successful in promoting antimicrobials' appropriate use by implementing evidence-based interventions. The "One Health" approach, a holistic and multisectoral approach, is also needed to address AMR's rising threat. AMS practices, principles, and interventions are critical steps towards containing and mitigating AMR. Evidence-based policies must guide the "One Health" approach, vaccination protocols, health professionals' education, and the public's awareness about AMR.
Collapse
Affiliation(s)
- Md Anwarul Azim Majumder
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Sayeeda Rahman
- School of Medicine, American University of Integrative Sciences, Bridgetown, Barbados
| | - Damian Cohall
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Ambadasu Bharatha
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Keerti Singh
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Mainul Haque
- Faculty of Medicine and Defence Health, Universiti Pertahanan, Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, Malaysia
| | | |
Collapse
|
5
|
James D, Lopez L. Impact of a pharmacist-driven education initiative on treatment of asymptomatic bacteriuria. Am J Health Syst Pharm 2020; 76:S41-S48. [PMID: 30854546 DOI: 10.1093/ajhp/zxy081] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The results and methods of a pharmacist-driven multifaceted educational intervention on the appropriate management of asymptomatic bacteriuria (ABU) within an emergency department (ED) are reported. METHODS A retrospective, single-center cohort study was conducted to evaluate the effects of an educational intervention aimed at reducing the rates of mismanaged ABU within an ED at a Level 1 trauma center. The education involved a multifaceted approach directed by pharmacists and involved a handout and algorithm communicated through in-person discussions, emails, and general distribution. In order to evaluate the effectiveness of this education the preintervention and postintervention rates of inappropriate treatments were determined through a retrospective chart review. The primary outcome was the difference in the frequency of inappropriately treated ABU between the preintervention and postintervention periods. RESULTS A total of 268 patients were included in the study for review (134 in each group). There was a 16.5% reduction in the frequency of patients that had ABU inappropriately treated as a urinary tract infection in the postintervention period compared with the preintervention period (31 [23.1%] versus 53 [39.6%], p = 0.004). CONCLUSION Pharmacist-driven education was effecitive in reducing the rates of inappropriately used antibiotics for ABU within an ED.
Collapse
Affiliation(s)
- Daniel James
- Department of Pharmacy, Grant Medical Center, OhioHealth, Columbus, OH
| | - Lauren Lopez
- Department of Pharmacy, Grant Medical Center, OhioHealth, Columbus, OH
| |
Collapse
|
6
|
Shah PJ, Ike C, Thibeaux M, Rodriguez E, Maddox SE, Daoura N. Impact of Antimicrobial Stewardship Interventions on Antimicrobial Utilization in Asymptomatic Bacteriuria. Hosp Pharm 2019; 56:210-214. [PMID: 34381251 DOI: 10.1177/0018578719888911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Antimicrobial therapy for asymptomatic bacteriuria (ASB) is often unnecessary and is a common reason for inappropriate antimicrobial use in hospitalized patients. Unnecessary ASB treatment leads to collateral damage such as resistance, and Clostridium difficile infections. This study evaluated the impact of interdisciplinary antimicrobial stewardship interventions on antimicrobial utilization in ASB. Methods: This was a quasi-experimental institutional review board (IRB)-approved study evaluating the impact of antimicrobial stewardship on antibiotic utilization for ASB in a pilot medical-surgical unit. The control phase was from August-October 2017 and the postintervention phase was from December-March 2018. In the control phase, electronic medical records of patients with positive urine cultures were retrospectively reviewed. Patients were classified as either having ASB or urinary tract infection (UTI) based on the absence or presence of UTI symptoms documented in the medical record. The intervention phase consisted of educational in-services to providers, nurses, and pharmacists. Clinical pharmacists for the pilot unit utilized an electronic real-time surveillance system to identify patients with positive urine cultures. With nurses' collaboration, clinical pharmacists classified these patients as either having UTI or ASB. Stewardship interventions were made in real-time to discontinue antibiotics in patients with ASB. Results: There were 65 and 77 patients with bacteriuria in the pre- and postintervention phases. Among these, ASB was present in 29 (45%) and 27 (35%) patients, respectively. After excluding those receiving antibiotics for concurrent nonurinary indications, the combination of education with pharmacist and nursing interventions decreased unnecessary ASB treatment from 18 (62%) to 6 (22%) patients (relative risk: 0.36, 95% confidence interval: 0.16-0.72, P = .003). Conclusion: The findings of this study highlight the importance of interdisciplinary interventions in reducing unnecessary antimicrobial therapy for the treatment of ASB. With increasing antimicrobial resistance, healthcare institutions should evaluate the role of these interdisciplinary interventions to reduce unnecessary treatment for ASB.
Collapse
Affiliation(s)
- Punit J Shah
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
| | - Chiamaka Ike
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
| | | | | | - Shermel-Edwards Maddox
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA.,University of Houston, Sugar Land, TX, USA
| | - Nicolas Daoura
- Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
| |
Collapse
|
7
|
Community pharmacists as antibiotic stewards: A qualitative study exploring the current status of Antibiotic Stewardship Program in Bahawalpur, Pakistan. J Infect Public Health 2019; 13:118-124. [PMID: 31548165 DOI: 10.1016/j.jiph.2019.07.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/23/2019] [Accepted: 07/02/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The World Health Organization released a Global Action Plan to overcome the threatening concerns of antibacterial resistance. One of the cornerstones of this plan is the Antibiotic Stewardship Program (ASP). The study aimed to assess the community pharmacists' knowledge, perceptions and current practices regarding ASP. METHODS A qualitative study was conducted in Bahawalpur, Pakistan, in which data were collected from the community pharmacists through in-depth, semi-structured interviews. The convenience sampling technique was used to recruit the study participants. Interview protocol was pilot tested and the sample size was limited by applying the saturation point criteria. All interviews were audio recorded and transcribed verbatim. The thematic analysis approach was used to analyze the data and draw conclusions based on study objectives. RESULTS A total of fifteen community pharmacists were interviewed. Analysis of the data yielded five themes and 16 subthemes. All of the respondents had sound knowledge about the irrational use of antibiotics; however, they were oblivious about the ASP. After explaining the term, the respondents were of the opinion that these strategies could not be implemented in the current healthcare system of the country. According to the findings of the study, prescribing and dispensing practices were not followed. Only a few patients were educated about the antibiotics they were purchasing. CONCLUSION Most of the study participants were unaware of any ASP being offered in the community pharmacy settings. The study participants agreed to be the antibiotic stewards, but a number of obstacles were reported. The training of pharmacists, medication reconciliation, the implementation of the good pharmacy practice guidelines and assurance of pharmacist availability at drug retail outlets were few suggestions given by the study participants to incorporate the ASP in the community settings.
Collapse
|
8
|
Hart E, Nguyen M, Allen M, Clark CM, Jacobs DM. A systematic review of the impact of antifungal stewardship interventions in the United States. Ann Clin Microbiol Antimicrob 2019; 18:24. [PMID: 31434563 PMCID: PMC6702721 DOI: 10.1186/s12941-019-0323-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 08/14/2019] [Indexed: 12/19/2022] Open
Abstract
Background Antimicrobial resistance is a widely recognized public health threat, and stewardship interventions to combat this problem are well described. Less is known about antifungal stewardship (AFS) initiatives and their influence within the United States. The purpose of this study was to evaluate evidence on the impact of AFS interventions on clinical and performance measures. Methods A systematic review of English language studies identified in the PubMed and EMBASE databases was performed through November 2017. The review was conducted in accordance with PRISMA. Search terms included antifungal stewardship, antimicrobial stewardship, Candida, candidemia, candiduria, and invasive fungal disease. Eligible studies were those that described an AFS program or intervention occurring in the US and evaluated clinical or performance measures. Results Fifty-four articles were identified and 13 were included. Five studies evaluated AFS interventions and reported clinical outcomes (mortality and length of stay) and performance measures (appropriate antifungal choice and time to therapy). The remaining eight studies evaluated general stewardship interventions and reported data on antifungal consumption. All studies were single center, quasi-experimental with varying interventions across studies. AFS programs had no impact on mortality (3 of 3 studies), with an overall rate of 27% in the intervention group and 23% in the non-intervention group. Length of stay (5 of 5) was also similar between groups (range, 9–25 vs. 11–22). Time to antifungal therapy improved in 2 of 5 studies, and appropriate choice of antifungal increased in 2 of 2 studies. Antifungal consumption was significantly blunted or reduced following stewardship initiation (8 of 8), although a direct comparison between studies was not possible due to a lack of common units. Conclusion The available evidence suggests that AFS interventions can improve performance measures and decrease antifungal consumption. Although this review did not detect improvements in clinical outcomes, significant adverse outcomes were not reported.
Collapse
Affiliation(s)
- Emily Hart
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - Melanie Nguyen
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - Meghan Allen
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - Collin M Clark
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA
| | - David M Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, 316 Pharmacy Building, Buffalo, NY, USA.
| |
Collapse
|
9
|
Fabre V, Cosgrove S. Antimicrobial Stewardship: It Takes a Village. Jt Comm J Qual Patient Saf 2019; 45:587-588. [PMID: 31331859 DOI: 10.1016/j.jcjq.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 06/20/2019] [Accepted: 06/21/2019] [Indexed: 10/26/2022]
|
10
|
Abe FC, Bergamaschi CDC, Figueiró MF, Lopes LC. Resistance profile to antimicrobial agents in the main circulating bacteria isolated from acute periodontal and endodontic infections in Latin America (MICROBE- DENT): A systematic review protocol. Medicine (Baltimore) 2018; 97:e13158. [PMID: 30508894 PMCID: PMC6283129 DOI: 10.1097/md.0000000000013158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 10/16/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Antimicrobial resistance is currently considered the main risk to global health. A variety of microbial species have been isolated from endodontic and periodontal infections. However, clinical endodontic and periodontics bacterial isolates have not been sufficiently characterized with regard to their capacity for antibiotic resistance. We aim to assess the existing evidence to estimate the prevalence of the main antimicrobial resistance and multidrug resistant organisms in endodontics and periodontics and to describe their geographic distribution in Latin America. METHODS All types of designs and will be restricted to Latin American studies will be included in this systematic review. MEDLINE, Embase, CINAHL, BVS (LILACS, BBO - bvsalud.org), IBECS (bases.bireme.br), Google Scholar, Cochrane Central Register of Controlled Trials, and Web of Science databases will be searched from 2013 to December 31, 2018 for all types of study designs that report microbial infection in endodontics and periodontics and their resistance and that define the microbiological methods used to identify microorganisms. The selection of articles for inclusion will be performed by 2 reviewers using predefined eligibility criteria. The Cochrane and ROBINS-I risk of bias assessment tools will be used to assess the methodological quality of randomized control trials. The Newcastle-Ottawa scale will be used to assess the quality of methodology in observational studies. The overall quality of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) using the same principles and domains applied in the quality assessment of prognostic studies. The heterogeneity of the findings will be assessed using both the χ test and the I statistic. Sensitivity analysis will be performed by subgroup analyses and meta-regression to investigate the effect of study-level characteristics, such as age, gender, and methodological quality score, whenever possible. Publication bias across studies will be evaluated by visual inspection of the funnel plots and Begg's test for the results covered in 10 or more studies. RESULTS The evidence derived by this study will inform best practices for patients with endodontic and periodontal problems receiving antimicrobial agents. CONCLUSION Successful completion will significantly impact clinical practice and contribute to improved prescribing competency. PROTOCOL REGISTRATION PROSPERO-CRD42018077810.
Collapse
Affiliation(s)
- Flávia Casale Abe
- Department of Pharmaceutical Sciences, University of Sorocaba, Sorocaba, State of São Paulo
| | | | | | - Luciane Cruz Lopes
- Department of Pharmaceutical Sciences, University of Sorocaba, Sorocaba, State of São Paulo
| |
Collapse
|
11
|
Monnier AA, Eisenstein BI, Hulscher ME, Gyssens IC. Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure. J Antimicrob Chemother 2018; 73:vi3-vi16. [PMID: 29878216 PMCID: PMC5989615 DOI: 10.1093/jac/dky114] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Annelie A Monnier
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
| | | | - Marlies E Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge C Gyssens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
| |
Collapse
|
12
|
Impact of Antimicrobial Stewardship Consultation Service at an Academic Institution. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2017. [DOI: 10.1097/ipc.0000000000000542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
13
|
Mandal J. Significance of Asymptomatic Bacteriuria. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10310957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Since the recognition of asymptomatic bacteriuria (ABU), several studies have questioned its significance. It is a very common condition, observed in many healthy individuals. Current guidelines mandate that ABU should not be treated in all cases, as it does not seem to improve the outcome. Conditional restrictions for treatment of ABU can be relaxed in certain situations, with minimal exceptions to the rule.
Collapse
Affiliation(s)
- Jharna Mandal
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| |
Collapse
|
14
|
Bonella GF, Fontes AMDS, Jorge MT, Silveira ABMD. Assessment of an intervention aimed at early discontinuation of intravenous antimicrobial therapy in a Brazilian University hospital. Braz J Infect Dis 2016; 20:462-7. [PMID: 27513531 PMCID: PMC9425537 DOI: 10.1016/j.bjid.2016.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/16/2016] [Accepted: 07/03/2016] [Indexed: 11/16/2022] Open
Abstract
Many interventions demonstrate success in adapting the duration of intravenous antibiotic therapy, but few studies have been conducted in developing countries. The aim of this study was to evaluate the effectiveness of an intervention in the induction of early discontinuation of intravenous antimicrobial therapy and/or its switch to oral therapy. The study employed a before–after intervention design that consisted of displaying a message in the computerized prescription on the third day and suspension of the prescription on the fifth day of intravenous antimicrobial therapy. A total of 465 patients were followed during the control period (CP) and 440 in the intervention period (IP). The intravenous therapy was switched to oral therapy for 11 (2.4%) patients during the CP and 25 (5.7%) in the IP (p = 0.011), and was discontinued for 82 (17.6%) patients during the CP and 106 (24.1%) in the IP (p = 0.017). During the IP there was a significant increase of patients who had their antimicrobial treatment discontinued before the seventh day of intravenous treatment, 37.40% (49/131) in the IP and 16.13% (15/93) in the CP (p = 0.0005). The duration of intravenous antimicrobial therapy decreased by one day, but it was not significant (p = 0.136). It is concluded that the proposed intervention is effective in promoting the early discontinuation of antimicrobial treatment and/or switch to oral therapy. As long as a computerized system for prescription already exists, it is easy and inexpensive to be implemented, especially in hospitals in developing countries.
Collapse
|
15
|
Dimopoulou A, Kourlaba G, Psarris A, Coffin S, Spoulou V, Zaoutis T. Perioperative antimicrobial prophylaxis in pediatric patients in Greece: Compliance with guidelines and impact of an educational intervention. J Pediatr Surg 2016; 51:1307-11. [PMID: 26711690 DOI: 10.1016/j.jpedsurg.2015.11.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 11/03/2015] [Accepted: 11/22/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND/PURPOSE Appropriate antimicrobial prophylaxis (PAP) prevents surgical site infections (SSI). The aim of this study was to evaluate the effectiveness of an educational intervention to improve adherence to PAP guidelines in pediatric patients. METHODS A three-phase prospective study with a pre-post design was conducted from April 2013 to December 2014. All patients who underwent one or more surgical procedures were enrolled. A modified Centers for Disease Control's (CDC) Denominator for Procedure form was used to collect clinical and PAP data. The educational intervention was targeted at all pediatric surgeons in the department. Outcomes assessed were the appropriateness of the agent selected for PAP (according to international guidelines) and appropriate termination of PAP within 24h of surgery completion. SSI rates were calculated before and after the intervention. RESULTS During the study period 889 children were enrolled (219 in the preintervention and 670 in the postintervention period). The percentage of patients receiving appropriate PAP improved from 6.2% to 77.1% after the educational intervention (p<0.001). The median duration of PAP was reduced from 5 to 1days in preintervention and postintervention period, respectively. There was no increase in the rate of SSIs (0.93% and 0.92%, p=0.992, in preinterventionand postintervention, respectively). CONCLUSIONS An educational intervention targeted at pediatric surgeons improved the selection of agent and timely discontinuation of PAP.
Collapse
Affiliation(s)
- Anastasia Dimopoulou
- Department of Pediatric Surgery, "Aghia Sophia" Children's Hospital, Athens, Greece.
| | - Georgia Kourlaba
- The Stavros Niarchos Foundation-Collaborative Center for Clinical Epidemiology and Outcomes Research (CLEO), University of Athens School of Medicine, Athens, Greece
| | - Alexandros Psarris
- Department of Pediatric Surgery, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Susan Coffin
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; University of Pennsylvania, Philadelphia, PA, USA
| | - Vasiliki Spoulou
- National Kapodistrian University, Athens, Greece; First Department of Pediatrics, Aghia Sophia" Children's Hospital, Athens, Greece
| | - Theoklis Zaoutis
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| |
Collapse
|
16
|
Falcone M, Concia E, Giusti M, Mazzone A, Santini C, Stefani S, Violi F. Acute bacterial skin and skin structure infections in internal medicine wards: old and new drugs. Intern Emerg Med 2016; 11:637-48. [PMID: 27084183 DOI: 10.1007/s11739-016-1450-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/01/2016] [Indexed: 10/21/2022]
Abstract
Skin and soft tissue infections (SSTIs) are a common cause of hospital admission among elderly patients, and traditionally have been divided into complicated and uncomplicated SSTIs. In 2010, the FDA provided a new classification of these infections, and a new category of disease, named acute bacterial skin and skin structure infections (ABSSSIs), has been proposed as an independent clinical entity. ABSSSIs include three entities: cellulitis and erysipelas, wound infections, and major cutaneous abscesses This paper revises the epidemiology of SSTIs and ABSSSIs with regard to etiologies, diagnostic techniques, and clinical presentation in the hospital settings. Particular attention is owed to frail patients with multiple comorbidities and underlying significant disease states, hospitalized on internal medicine wards or residing in nursing homes, who appear to be at increased risk of infection due to multi-drug resistant pathogens and treatment failures. Management of ABSSSIs and SSTIs, including evaluation of the hemodynamic state, surgical intervention and treatment with appropriate antibiotic therapy are extensively discussed.
Collapse
Affiliation(s)
- Marco Falcone
- Department of Public Health and Infectious Diseases, "Sapienza" University of Rome, Policlinico Umberto I, Viale Dell'Università 37, 00161, Rome, Italy.
| | - Ercole Concia
- Department of Pathology, University of Verona, Verona, Italy
| | | | | | | | - Stefania Stefani
- Department of Biomedical and Biotechnological Sciences, Section of Microbiology, University of Catania, Catania, Italy
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, "Sapienza" University of Rome, Rome, Italy
| |
Collapse
|
17
|
Abstract
Breath testing has enormous potential in the medical diagnostic field. The underlying complexity and perceived availability of adequate specimens, combined with a lack of knowledge of the metabolic pathways that give rise to compounds that are sources of analytes detectable in breath, has greatly slowed development. These real obstacles have recently been largely overcome in the use of breath testing to identify patients with cystic fibrosis associated Pseudomonas aeruginosa infection and tuberculosis. This review summarizes progress made in the characterization of microbial volatiles produced by major lower respiratory tract bacterial pathogens, and their potential use as diagnostic markers in patient breath testing.
Collapse
Affiliation(s)
- James E Graham
- Department of Microbiology and Immunology, and Department of Biology, University of Louisville, Louisville, KY, USA; E-mail:
| |
Collapse
|
18
|
Ison MG. Empiric treatment of nosocomial spontaneous bacterial peritonitis: One size does not fit all. Hepatology 2016; 63:1083-5. [PMID: 26836032 DOI: 10.1002/hep.28476] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 01/27/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Michael G Ison
- Divisions of Infectious Diseases and of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
19
|
Treatment for Positive Urine Cultures in Hospitalized Adults: A Survey of Prevalence and Risk Factors in 3 Medical Centers. Infect Control Hosp Epidemiol 2015; 37:319-26. [PMID: 26607408 DOI: 10.1017/ice.2015.281] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Antibiotic treatment for asymptomatic bacteriuria (ASB) is prevalent but often contrary to published guidelines. OBJECTIVE To evaluate risk factors for treatment of ASB. DESIGN Retrospective observational study. SETTING A tertiary academic hospital, county hospital, and community hospital. PATIENTS Hospitalized adults with bacteriuria. METHODS Patients without documented symptoms of urinary tract infection per Infectious Diseases Society of America (IDSA) criteria were classified as ASB. We examined ASB treatment risk factors as well as broad-spectrum antibiotic usage and quantified diagnostic concordance between IDSA and National Healthcare Safety Network criteria. RESULTS Among 300 patients with bacteriuria, ASB was present in 71% by IDSA criteria. By National Healthcare Safety Network criteria, 71% of patients had ASB; within-patient diagnostic concordance with IDSA was moderate (kappa, 0.52). After excluding those given antibiotics for nonurinary indications, antibiotics were given to 38% (62/164) with ASB. Factors significantly associated with ASB treatment were elevated urine white cell count (65 vs 24 white blood cells per high-powered field, P<.01), hospital identity (hospital C vs A, odds ratio, 0.34 [95% CI, 0.14-0.80], P =.01), presence of leukocyte esterase (5.48 [2.35-12.79], P<.01), presence of nitrites (2.45 [1.11-5.41], P=.03), and Escherichia coli on culture (2.4 [1.2-4.7], P=.01). Of patients treated for ASB, broad-spectrum antibiotics were used in 84%. CONCLUSIONS ASB treatment was prevalent across settings and contributed to broad-spectrum antibiotic use. Associating abnormal urinalysis results with the need for antibiotic treatment regardless of symptoms may drive unnecessary antibiotic use.
Collapse
|
20
|
Abstract
Overuse of urinalysis in older adults to investigate vague changes in condition such as confusion, lethargy, and anorexia, has led to overtreatment of asymptomatic bacteriuria and associated antibiotic resistance.
Collapse
Affiliation(s)
- Joan M Nelson
- Joan M. Nelson University of Colorado at Anshutz Medical Campus College of Nursing, Aurora, Colo. Elliot Good is an adult-geriatric NP at Physician Housecalls, Wheat Ridge, Colo
| | | |
Collapse
|
21
|
Lee MJ, Kim M, Kim NH, Kim CJ, Song KH, Choe PG, Park WB, Bang JH, Kim ES, Park SW, Kim NJ, Oh MD, Kim HB. Why is asymptomatic bacteriuria overtreated?: A tertiary care institutional survey of resident physicians. BMC Infect Dis 2015. [PMID: 26209977 PMCID: PMC4514993 DOI: 10.1186/s12879-015-1044-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Asymptomatic bacteriuria (ABU) is common and often leads to unnecessary antimicrobial use. Reducing antibiotic overuse for ABU is therefore an important issue for antimicrobial stewardship. We performed this study to investigate the appropriateness of ABU management and to evaluate physicians’ knowledge and practice regarding ABU. Methods We reviewed all urine cultures of ≥105 cfu/mL of bacteria among inpatients in a 900-bed hospital in 2011. Each episode of bacteriuria was classified into ABU or urinary tract infection (UTI). ABU was defined as a positive urine culture (≥105 cfu/mL) without symptoms or signs suggesting UTI. In October 2012 a cross-sectional survey of resident physicians was undertaken using an anonymous, self-administered questionnaire. Results We identified 219 ABU cases among 1167 positive urine cultures, of which 70 (32.0 %) were inappropriately treated. Female gender, old age, pyuria, hematuria, and positive nitrite on urinalysis were associated with inappropriate ABU treatment in a multivariate analysis (P < 0.05). The response rate to the survey was 74.2 % (95/128). The mean knowledge score was 37.3 %, and 33.7 % of respondents were able to distinguish ABU from UTI, but less than half knew the indications for treating ABU. Even after ABU was correctly diagnosed, concerns about postoperative infections (38.6 %), UTI (9.1 %), and abnormal urinalysis (29.5 %) prevented proper management. About half of the respondents reported to prescribing antibiotics for ABU despite knowing they were not indicated. Conclusions About one third of ABUs were inappropriately managed. Lack of knowledge and discrepancies between knowledge and practice, contributed to antimicrobial overuse for ABU. Our findings highlight the importance of developing interventions, including education, audit and feedback, to tackle the problem of inappropriate treatment of ABU. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1044-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Myung Jin Lee
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Moonsuk Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Nak-Hyun Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Chung-Jong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea. .,Department of Internal Medicine, Seoul National University Bundang Hospital, 173 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 463-707, Republic of Korea.
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea. .,Department of Internal Medicine, Seoul National University Bundang Hospital, 173 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 463-707, Republic of Korea.
| | - Pyoeng Gyun Choe
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Ji Hwan Bang
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Eu Suk Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea. .,Department of Internal Medicine, Seoul National University Bundang Hospital, 173 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 463-707, Republic of Korea.
| | - Sang Won Park
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Myoung-Don Oh
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea. .,Department of Internal Medicine, Seoul National University Bundang Hospital, 173 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 463-707, Republic of Korea.
| |
Collapse
|
22
|
Bishop BM. Antimicrobial Stewardship in the Emergency Department: Challenges, Opportunities, and a Call to Action for Pharmacists. J Pharm Pract 2015; 29:556-563. [PMID: 26033791 DOI: 10.1177/0897190015585762] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Antimicrobial resistance is a national public health concern. Misuse of antimicrobials for conditions such as upper respiratory infection, urinary tract infections, and cellulitis has led to increased resistance to antimicrobials commonly utilized to treat those infections, such as sulfamethoxazole/trimethoprim and flouroquinolones. The emergency department (ED) is a site where these infections are commonly encountered both in ambulatory patients and in patients requiring admission to a hospital. The ED is uniquely positioned to affect the antimicrobial use and resistance patterns in both ambulatory settings and inpatient settings. However, implementing antimicrobial stewardship programs in the ED is fraught with challenges including diagnostic uncertainty, distractions secondary to patient or clinician turnover, and concerns with patient satisfaction to name just a few. However, this review article highlights successful interventions that have stemmed inappropriate antimicrobial use in the ED setting and warrant further study. This article also proposes other, yet to be validated proposals. Finally, this article serves as a call to action for pharmacists working in antimicrobial stewardship programs and in emergency medicine settings. There needs to be further research on the implementation of these and other interventions to reduce inappropriate antimicrobial use to prevent patient harm and curb the development of antimicrobial resistance.
Collapse
Affiliation(s)
- Bryan M Bishop
- Department of Pharmacy, St. Rita's Medical Center, Lima, OH, USA .,Department of Pharmacy Practice, Ohio Northern University, Ada, OH, USA
| |
Collapse
|
23
|
McGregor JC, Furuno JP. Optimizing research methods used for the evaluation of antimicrobial stewardship programs. Clin Infect Dis 2015; 59 Suppl 3:S185-92. [PMID: 25261546 DOI: 10.1093/cid/ciu540] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Antimicrobial stewardship programs (ASPs) are an increasingly common intervention for optimizing antimicrobial therapy in healthcare settings. These programs aim to improve patient care and limit the emergence and spread of multidrug-resistant organisms by supporting prudent antimicrobial use. However, pressure from the current reimbursement climate necessitates that ASPs operate as cost-cutting programs rather than focus on patient outcomes. This has forced the research that is evaluating ASP interventions to concentrate heavily on economic outcomes. As the science of antimicrobial stewardship advances, it is essential that well-conducted evaluations, focused on patient and microbial outcomes, serve as the evidence base that directs optimal ASP intervention design and implementation. In this review, we provide guidance and recommendations for the design of studies to evaluate the impact of ASP interventions on patient and microbial outcomes.
Collapse
Affiliation(s)
- Jessina C McGregor
- Department of Pharmacy Practice, Oregon State University/Oregon Health and Science University College of Pharmacy, Portland
| | - Jon P Furuno
- Department of Pharmacy Practice, Oregon State University/Oregon Health and Science University College of Pharmacy, Portland
| |
Collapse
|
24
|
Keeping patients safe: antibiotic resistance and the role of nurse executives in antibiotic stewardship. J Nurs Adm 2015; 45:67-9. [PMID: 25621747 DOI: 10.1097/nna.0000000000000159] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In this column, the authors discuss the issue of antibiotic resistance, components of a program of antibiotic stewardship, and the role of the nurse executive in leading and supporting these efforts.
Collapse
|
25
|
James R, Upjohn L, Cotta M, Luu S, Marshall C, Buising K, Thursky K. Measuring antimicrobial prescribing quality in Australian hospitals: development and evaluation of a national antimicrobial prescribing survey tool. J Antimicrob Chemother 2015; 70:1912-8. [PMID: 25724986 DOI: 10.1093/jac/dkv047] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/04/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Antimicrobial stewardship (AMS) programmes have been developed with the intention of reducing inappropriate and unnecessary use of antimicrobials, while improving the quality of patient care and locally helping prevent the development of antimicrobial resistance. An important aspect of AMS programmes is the qualitative assessment of prescribing through antimicrobial prescribing surveys (APS), which are able to provide information about the prescribing behaviour within institutions. Owing to lack of standardization of audit tools and the resources required, qualitative methods for the assessment of antimicrobial use are not often performed. The aim of this study was to design an audit tool that was appropriate for use in all Australian hospitals, suited to local user requirements and included an assessment of the overall appropriateness of the prescription. METHODS In November 2011, a pilot APS was conducted across 32 hospitals to assess the usability and generalizability of a newly designed audit tool. Following participant feedback, this tool was revised to reflect the requirements of the respondents. A second pilot study was then performed in November 2012 across 85 hospitals. RESULTS These surveys identified several areas that can be targets for quality improvement at a national level, including: documentation of indication; surgical prophylaxis prescribed for >24 h; compliance with prescribing guidelines; and the appropriateness of the prescription. CONCLUSIONS By involving the end users in the design and evaluation, we have been able to provide a practical and relevant APS tool for quantitative and qualitative data collection in a wide range of Australian hospital settings.
Collapse
Affiliation(s)
- Rodney James
- Department of Medicine, University of Melbourne, Melbourne, Victoria 3010, Australia Victorian Infectious Disease Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3010, Australia
| | - Lydia Upjohn
- Victorian Infectious Disease Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3010, Australia
| | - Menino Cotta
- Department of Medicine, University of Melbourne, Melbourne, Victoria 3010, Australia Victorian Infectious Disease Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3010, Australia
| | - Susan Luu
- Victorian Infectious Disease Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3010, Australia
| | - Caroline Marshall
- Department of Medicine, University of Melbourne, Melbourne, Victoria 3010, Australia Victorian Infectious Disease Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3010, Australia
| | - Kirsty Buising
- Victorian Infectious Disease Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3010, Australia
| | - Karin Thursky
- Victorian Infectious Disease Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3010, Australia
| |
Collapse
|
26
|
Bartlett JM, Siola PL. Implementation and first-year results of an antimicrobial stewardship program at a community hospital. Am J Health Syst Pharm 2015; 71:943-9. [PMID: 24830998 DOI: 10.2146/ajhp130602] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE The implementation of an antimicrobial stewardship program (ASP) at a small community hospital affiliated with an accountable care organization (ACO) is described, including a report on first-year program outcomes. SUMMARY With no infectious diseases (ID)-trained pharmacists on staff, a 155-bed hospital formed an ASP by restructuring its clinical pharmacy services. One full-time pharmacist led the program; nine full- or part-time pharmacists-none of whom had residency training-shared ASP responsibilities on a weekly rotation. Under a contract with a private medical group, an ID physician reviewed cases with ASP pharmacists for up to two hours each weekday. ASP interventions and tracking and reporting of outcomes were done primarily by pharmacists. Monitoring of pharmacy purchases in the first year of the program indicated an annualized 26% decrease in overall antimicrobial expenditures from prior-year spending, with a nearly 18% decrease in defined daily doses per 1000 patient-days. Total first-year direct cost savings attributed to the ASP were estimated at $145,353. Pharmacist-initiated conversions of patients from i.v. to oral antimicrobial therapy increased by 688% (p < 0.0001). Overall, the rate of ID physician acceptance of ASP-recommended interventions (mainly streamlining of therapy, limiting the duration of therapy to a specific stop date, and discontinuation of nonindicated drugs) was 74%. CONCLUSION An ASP was implemented at a small ACO-affiliated community hospital by a team of pharmacists without specialized ID training. During the first year of the program, antimicrobial expenditures were reduced and there was a significant increase in pharmacist-initiated i.v.-to-oral conversions.
Collapse
Affiliation(s)
- James M Bartlett
- James M. Bartlett, Pharm.D., is Clinical Pharmacist, Kenmore Mercy Hospital, Kenmore, NY; at the time of writing, he was a clinical pharmacy consultant for Trinity Medical of Western New York, Buffalo. Patricia L. Siola, B.S.Pharm., M.B.A., Ph.D., FASHP, FACHE, is Director of Pharmacy, Catholic Health System-Northtowns, Buffalo.
| | - Patricia L Siola
- James M. Bartlett, Pharm.D., is Clinical Pharmacist, Kenmore Mercy Hospital, Kenmore, NY; at the time of writing, he was a clinical pharmacy consultant for Trinity Medical of Western New York, Buffalo. Patricia L. Siola, B.S.Pharm., M.B.A., Ph.D., FASHP, FACHE, is Director of Pharmacy, Catholic Health System-Northtowns, Buffalo
| |
Collapse
|
27
|
Antibiotic stewardship programmes and the surgeon's role. J Hosp Infect 2015; 89:264-6. [PMID: 25744279 DOI: 10.1016/j.jhin.2015.01.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 01/06/2015] [Indexed: 11/23/2022]
Abstract
Inappropriate antibiotic use is a frequent occurrence, especially in surgical units. Among the unnecessary costs of such usage are unfavourable outcomes for patients and the emergence and spread of resistant bacteria. Antibiotic stewardship programmes aim to limit the spread of antibiotic resistance by promoting thoughtful prescribing of antibiotics. Such programmes usually try to control inappropriate use of antibiotics; to optimize the choice of drug, dosing, route, and duration of therapy; to maximize clinical cure or prevention of infection; and to limit unwanted effects and excess cost. In this paper, I discuss the impact of improper use of antibiotics and outline why I believe that antibiotic stewardship is likely to be the best way of dealing with it. Engagement of surgeons in antibiotic stewardship programmes is crucial to their success.
Collapse
|
28
|
Abstract
Inappropriate antimicrobial use and antimicrobial resistance persist across the healthcare continuum. Antimicrobial stewardship guidelines assist healthcare institutions in establishing antimicrobial stewardship programs but rely on infectious diseases expertise and leadership, which are not available in all settings. Despite this, many institutions have found ways to use available resources to perform stewardship activities, with improvements in antimicrobial use and reductions in resistance and cost. This article highlights success stories in nonuniversity hospital settings and proposes antimicrobial stewardship strategies that may be more feasible in settings with limited infectious diseases expertise, information technology, or financial resources.
Collapse
Affiliation(s)
- Kavita K Trivedi
- Trivedi Consults, LLC, 1020 Curtis Street, Albany, CA 94706, USA.
| | - Kristi Kuper
- VHA Performance Services, 521 East Morehead Street, Suite 300, Charlotte, NC 28202, USA
| |
Collapse
|
29
|
Filice GA, Drekonja DM, Thurn JR, Rector TS, Hamann GM, Masoud BT, Leuck AM, Nordgaard CL, Eilertson MK, Johnson JR. Use of a Computer Decision Support System and Antimicrobial Therapy Appropriateness. Infect Control Hosp Epidemiol 2015; 34:558-65. [DOI: 10.1086/670627] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.To determine whether antimicrobial (AM) courses ordered with an antimicrobial computer decision support system (CDSS) were more likely to be appropriate than courses ordered without the CDSS.Design.Retrospective cohort study. Blinded expert reviewers judged whether AM courses were appropriate, considering drug selection, route, dose, and duration.Setting.A 279-bed university-affiliated Department of Veterans Affairs (VA) hospital.Patients.A 500-patient random sample of inpatients who received a therapeutic AM course between October 2007 and September 2008.Intervention.An optional CDSS, available at the point of order entry in the VA computerized patient record system.Results.CDSS courses were significantly more likely to be appropriate (111/254, 44%) compared with non-CDSS courses (81/246, 33%, P = .013). Courses were more likely to be appropriate when the initial provider diagnosis of the condition being treated was correct (168/273, 62%) than when it was incorrect, uncertain, or a sign or symptom rather than a disease (24/227, 11%, P< .001). In multivariable analysis, CDSS-ordered courses were more likely to be appropriate than non-CDSS-ordered courses (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.13–2.98). Courses were also more likely to be judged appropriate when the initial provider diagnosis of the condition being treated was correct than when it was incorrect, uncertain, or a sign or symptom rather than a disease (OR, 3.56; 95% CI, 1.4-9.0).Conclusions.Use of the CDSS was associated with more appropriate AM use. To achieve greater improvements, strategies are needed to improve provider diagnoses of syndromes that are infectious or possibly infectious.
Collapse
|
30
|
File TM, Srinivasan A, Bartlett JG. Antimicrobial stewardship: importance for patient and public health. Clin Infect Dis 2014; 59 Suppl 3:S93-6. [PMID: 25261547 PMCID: PMC6487653 DOI: 10.1093/cid/ciu543] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
| | - Arjun Srinivasan
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John G. Bartlett
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
31
|
Cantón R, Horcajada JP, Oliver A, Garbajosa PR, Vila J. Inappropriate use of antibiotics in hospitals: the complex relationship between antibiotic use and antimicrobial resistance. Enferm Infecc Microbiol Clin 2014; 31 Suppl 4:3-11. [PMID: 24129283 DOI: 10.1016/s0213-005x(13)70126-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hospitals are considered an excellent compartment for the selection of resistant and multi-drug resistant (MDR) bacteria. The overuse and misuse of antimicrobial agents are considered key points fuelling this situation. Antimicrobial stewardship programs have been designed for better use of these compounds to prevent the emergence of resistant microorganisms and to diminish the upward trend in resistance. Nevertheless, the relationship between antibiotic use and antimicrobial resistance is complex, and the desired objectives are difficult to reach. Various factors affecting this relationship have been advocated including, among others, antibiotic exposure and mutant selection windows, antimicrobial pharmacodynamics, the nature of the resistance (natural or acquired, including mutational and that associated with horizontal gene transfer) and the definition of resistance. Moreover, antimicrobial policies to promote better use of these drugs should be implemented not only in the hospital setting coupled with infection control programs, but also in the community, which should also include animal and environmental compartments. Within hospitals, the restriction of antimicrobials, cycling and mixing strategies and the use of combination therapies have been used to avoid resistance. Nevertheless, the results have not always been favorable and resistant bacteria have persisted despite the theoretical benefits of these strategies. Mathematical models as well as microbiological knowledge can explain this failure, which is mainly related to the current scenario involving MDR bacteria and overcoming the fitness associated with resistance. New antimicrobials, rapid diagnostic and antimicrobial susceptibility testing and biomarkers will be useful for future antimicrobial stewardship interventions.
Collapse
Affiliation(s)
- Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; Red Española de Investigación en Patología Infecciosa (REIPI), Instituto de Salud Carlos III, Madrid, Spain; Unidad de Resistencia a Antibióticos y Virulencia Bacteriana, Consejo Superior de Investigaciones Científicas, Madrid, Spain.
| | | | | | | | | |
Collapse
|
32
|
Halpape K, Sulz L, Schuster B, Taylor R. Audit and Feedback-Focused approach to Evidence-based Care in Treating patients with pneumonia in hospital (AFFECT Study). Can J Hosp Pharm 2014; 67:17-27. [PMID: 24634522 DOI: 10.4212/cjhp.v67i1.1317] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Pneumonia is the eighth leading cause of death in Canada. Use of guideline-concordant therapy tempers the development of resistance, decreases health care costs, and reduces morbidity and mortality. OBJECTIVES The purpose of this study was to optimize the treatment of patients with pneumonia under hospitalist care by focusing on best practice and local antibiogram data. The objectives were to collaborate with a hospitalist representative to optimize in-hospital treatment of patients with community-acquired, hospital-acquired, and health care-associated pneumonia; to complete a baseline audit to determine the proportion of antibiotic orders adhering to the strategy; to present the strategy and baseline audit findings to the hospitalists; to perform a post-intervention audit, with comparison to baseline, and to present results to the hospitalists; to expedite de-escalation to a narrower-spectrum antibiotic; to expedite parenteral-to-oral step-down therapy and promote appropriate duration of therapy; and to determine if a pneumonia scoring system was used. METHODS An audit and feedback intervention focusing on pre- and post-intervention retrospective chart audits was completed. Review of pneumonia guidelines and the local antibiogram assisted in identifying the study strategy. A presentation to the hospitalists outlined antimicrobial stewardship principles and described the findings of the baseline audit. Pre- and post-intervention audit results were compared. RESULTS Local best-practice treatment algorithms were developed for community-acquired pneumonia and for hospital-acquired and health care-associated pneumonia. The pre-intervention audit covered the period December 2011 to January 2012, with subsequent education and audit results presented to the hospitalists in November 2012. The post-intervention audit covered the period December 2012 to January 2013. Adherence to the treatment algorithms increased from 10% (2/21) in the pre-intervention audit to 38% (5/13) in the post-intervention audit. There was a trend to reduced duration of therapy in the post-intervention group. CONCLUSION An audit and feedback intervention related to hospitalists' prescribing for pneumonia increased adherence to local best practice.
Collapse
Affiliation(s)
- Katelyn Halpape
- , BSP, ACPR, is a PharmD student in the Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia. She completed her pharmacy practice residency with the Regina Qu'Appelle Health Region, Regina, Saskatchewan, in 2012/2013
| | - Linda Sulz
- , BSP, PharmD, is with Regina Qu'Appelle Health Region, Regina, Saskatchewan
| | - Brenda Schuster
- , BSP, ACPR, PharmD, FCSHP, is with Regina Qu'Appelle Health Region, and the Department of Academic Family Medicine, University of Saskatchewan, Regina, Saskatchewan
| | - Ron Taylor
- , MD, CCFP(EM), is with Regina Qu'Appelle Health Region, Regina, Saskatchewan
| |
Collapse
|
33
|
Koning SI, Rhodes J, Rofe OC, Sundararajan V, O'Reilly M, Koning SI. Antimicrobial Prescribing in a Rapid Assessment Medical Unit - A Multi-Phase Pilot Study. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2013. [DOI: 10.1002/j.2055-2335.2013.tb00270.x] [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]
Affiliation(s)
| | - Jessica Rhodes
- Faculty of Pharmacy and Pharmaceutical Sciences; Monash University
| | | | - Vijaya Sundararajan
- Department of Medicine, St Vincent's Hospital, Department of Medicine, Southern Clinical School; University of Melbourne, Monash University
| | - Mary O'Reilly
- Infectious Diseases and Infection Prevention and Control, Eastern Health, Faculty of Medicine, Nursing and Health Sciences; Monash University; Clayton Victoria
| | | |
Collapse
|
34
|
Marschall J, Carpenter CR, Fowler S, Trautner BW. Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter: meta-analysis. BMJ 2013; 346:f3147. [PMID: 23757735 PMCID: PMC3678514 DOI: 10.1136/bmj.f3147] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine whether antibiotic prophylaxis at the time of removal of a urinary catheter reduces the risk of subsequent symptomatic urinary tract infection.: DESIGN Systematic review and meta-analysis of studies published before November 2012 identified through PubMed, Embase, Scopus, and the Cochrane Library; conference abstracts for 2006-12 were also reviewed. INCLUSION CRITERIA Studies were included if they examined antibiotic prophylaxis administered to prevent symptomatic urinary tract infection after removal of a short term (≤ 14 days) urinary catheter. RESULTS Seven controlled studies had symptomatic urinary tract infection after catheter removal as an endpoint; six were randomized controlled trials (five published; one in abstract form) and one was a non-randomized controlled intervention study. Five of these seven studies were in surgical patients. Studies were heterogeneous in the type and duration of antimicrobial prophylaxis and the period of observation. Overall, antibiotic prophylaxis was associated with benefit to the patient, with an absolute reduction in risk of urinary tract infection of 5.8% between intervention and control groups. The risk ratio was 0.45 (95% confidence interval 0.28 to 0.72). The number needed to treat to prevent one urinary tract infection was 17 (12 to 30). CONCLUSIONS Patients admitted to hospital who undergo short term urinary catheterization might benefit from antimicrobial prophylaxis when the catheter is removed as they experience fewer subsequent urinary tract infections. Potential disadvantages of more widespread antimicrobial prophylaxis (side effects and cost of antibiotics, development of antimicrobial resistance) might be mitigated by the identification of which patients are most likely to benefit from this approach.
Collapse
Affiliation(s)
- Jonas Marschall
- Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO 63110, USA.
| | | | | | | |
Collapse
|
35
|
Kwon JH, Fausone MK, Du H, Robicsek A, Peterson LR. Impact of laboratory-reported urine culture colony counts on the diagnosis and treatment of urinary tract infection for hospitalized patients. Am J Clin Pathol 2012; 137:778-84. [PMID: 22523217 DOI: 10.1309/ajcp4kvgqzeg1ydm] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Reducing health care-associated urinary tract infection (UTI) is a National Patient Safety Goal. The purpose of this investigation was to establish a colony count threshold to predict clinically significant UTIs that develop in hospitalized patients. A total of 185 cases were reviewed sequentially by 2 physicians. The information extracted included subjective complaints, presence of an indwelling urinary catheter, clinical signs and symptoms, WBC count, urinalysis, and urine culture results. The first reviewer recorded whether the patient was diagnosed and treated for a UTI by the clinician. The second reviewer determined if the patient met National Healthcare Safety Network guidelines for nosocomial UTI. Compared with patients with colony counts less than 100,000 colony-forming units per milliliter (CFU/mL), patients with colony counts 100,000 CFU/mL or more were 73.86 times more likely to have a clinically significant UTI (odds ratio, 73.86; 95% confidence interval, 24.23 ∼ 225.15; P < .0001; c-statistic, 0.859). Reporting positive results only for patients with 100,000 CFU/mL or more would have reduced the number of positive cultures by 38%. These data suggest that reporting colony counts less than 100,000 CFU/mL encourages treatment of non-clinically significant UTIs in hospitalized patients, causing inappropriate antibiotic use.
Collapse
|