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Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, Todi SK, Mohan A, Hegde A, Jagiasi BG, Krishna B, Rodrigues C, Govil D, Pal D, Divatia JV, Sengar M, Gupta M, Desai M, Rungta N, Prayag PS, Bhattacharya PK, Samavedam S, Dixit SB, Sharma S, Bandopadhyay S, Kola VR, Deswal V, Mehta Y, Singh YP, Myatra SN. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024; 28:S104-S216. [PMID: 39234229 PMCID: PMC11369928 DOI: 10.5005/jp-journals-10071-24677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/20/2024] [Indexed: 09/06/2024] Open
Abstract
How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.
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Affiliation(s)
- Gopi C Khilnani
- Department of Pulmonary, Critical Care and Sleep Medicine, PSRI Hospital, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Dhruva Chaudhry
- Department of Pulmonary and Critical Care Medicine, University of Health Sciences, Rohtak, Haryana, India
| | - Kapil G Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India
| | - Subhash K Todi
- Department of Critical Care, AMRI Hospital, Kolkata, West Bengal, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS, New Delhi, India
| | - Ashit Hegde
- Department of Medicine & Critical Care, P D Hinduja National Hospital, Mumbai, India
| | - Bharat G Jagiasi
- Department of Critical Care, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai, Maharashtra, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St John's Medical College and Hospital, Bengaluru, India
| | - Camila Rodrigues
- Department of Microbiology, P D Hinduja National Hospital, Mumbai, India
| | - Deepak Govil
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Divya Pal
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Jigeeshu V Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Mansi Gupta
- Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mukesh Desai
- Department of Immunology, Pediatric Hematology and Oncology Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Narendra Rungta
- Department of Critical Care & Anaesthesiology, Rajasthan Hospital, Jaipur, India
| | - Parikshit S Prayag
- Department of Transplant Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Pradip K Bhattacharya
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Srinivas Samavedam
- Department of Critical Care, Ramdev Rao Hospital, Hyderabad, Telangana, India
| | - Subhal B Dixit
- Department of Critical Care, Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Sudivya Sharma
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Susruta Bandopadhyay
- Department of Critical Care, AMRI Hospitals Salt Lake, Kolkata, West Bengal, India
| | - Venkat R Kola
- Department of Critical Care Medicine, Yashoda Hospitals, Hyderabad, Telangana, India
| | - Vikas Deswal
- Consultant, Infectious Diseases, Medanta - The Medicity, Gurugram, Haryana, India
| | - Yatin Mehta
- Department of Critical Care and Anesthesia, Medanta – The Medicity, GuruGram, Haryana, India
| | - Yogendra P Singh
- Department of Critical Care, Max Super Speciality Hospital, Patparganj, New Delhi, India
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Abejew AA, Wubetu GY, Fenta TG. Relationship between Antibiotic Consumption and Resistance: A Systematic Review. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2024; 2024:9958678. [PMID: 38476862 PMCID: PMC10932619 DOI: 10.1155/2024/9958678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/20/2023] [Accepted: 02/24/2024] [Indexed: 03/14/2024]
Abstract
Background Unreserved use of antibiotics exerted selective pressure on susceptible bacteria, resulting in the survival of resistant strains. Despite this, the relationship between antibiotic resistance (ABR) and antibiotic consumption (ABC) is rarely studied. This systematic review aims to review the relationship between ABC and ABR from 2016 to 2022. Methods Articles published over 7 years (2016-2022) were searched from December 23 to 31, 2022. The search strategy was developed by using keywords for ABC and ABR. From 3367 articles, 58 eligible articles were included in the final review. Results The pooled ABC was 948017.9 DPDs and 4108.6 DIDs where over 70% of antibiotics were from the Watch and Reserve category based on the WHO AWaRe classification. The average pooled prevalence of ABR was 38.4%. Enterococcus faecium (59.4%), A. baumannii (52.6%), and P. aeruginosa (48.6%) were the most common antibiotic-resistant bacteria. Cephalosporins (76.8%), penicillin (58.3%), and aminoglycosides (52%) were commonly involved antibiotics in ABR. The positive correlation between ABR and consumption accounted for 311 (81%). The correlation between ABR P. aeruginosa and ABC accounted for 87 (22.7%), followed by 78 (20.3%) and 77 (20.1%) for ABR E. coli and K. pneumoniae with ABCs, respectively. Consumption of carbapenems and fluoroquinolones was most commonly correlated with resistance rates of P. aeruginosa, K. pneumoniae, E. coli, and A. baumannii. Conclusion There is a positive correlation between ABC and the rate of ABR. The review also revealed a cross-resistance between the consumption of different antibiotics and ABR. Optimizing antibiotic therapy and reducing unnecessary ABC will prevent the emergence and spread of ABR. Thus, advocating the implementation of stewardship programs plays a pivotal role in containing ABR.
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Affiliation(s)
- Asrat Agalu Abejew
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Pharmacy, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | | | - Teferi Gedif Fenta
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Raglow Z, Advani SD, Aitken SL, Patel PK. Antimicrobial stewardship in solid organ transplant recipients: Current challenges and proposed metrics. Transpl Infect Dis 2022; 24:e13883. [PMID: 36254525 DOI: 10.1111/tid.13883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/03/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Solid organ transplant (SOT) recipients are challenging populations for antimicrobial stewardship interventions due to a variety of reasons, including immunosuppression, consequent risk of opportunistic and donor-derived infections, high rates of infection with multi-drug resistant organisms (MDROs), Clostridioides difficile, and need for prolonged antimicrobial prophylaxis. Despite this, data on stewardship interventions and metrics that address the distinct needs of these patients are limited. METHODS We performed a narrative review of the current state of antimicrobial stewardship in SOT recipients, existing interventions and metrics in this population, and considerations for implementation of transplant-specific stewardship programs. RESULTS Antimicrobial stewardship metrics are evolving even in the general patient population. Data on metrics applicable to the SOT population are even more limited. Standard process, outcomes, and balancing metrics may not always apply to the SOT population. A successful stewardship program for SOT recipients requires reviewing existing data, applying general stewardship principles, and understanding the nuances of SOT patients. CONCLUSION As antimicrobial stewardship interventions are being implemented in SOT recipients; new metrics are needed to assess their impact. In conclusion, SOT patients present a challenging but important opportunity for antimicrobial stewards. ABBREVIATIONS SOT, antimicrobial stewardship program, MDRO, Clostridioides difficile infection, Centers for Disease Control and Prevention, Infectious Diseases Society of America, prospective audit and feedback, hematopoietic cell transplant, cytomegalovirus, trimethoprim-sulfamethoxazole, surgical site infections, nucleic acid amplification testing, days of therapy, defined daily dose, and length of stay.
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Affiliation(s)
- Zoe Raglow
- Department of Internal Medicine Division of Infectious Diseases University of Michigan Ann Arbor Michigan USA
| | - Sonali D. Advani
- Department of Medicine Division of Infectious Diseases Duke University School of Medicine Durham North Carolina USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention Durham North Carolina USA
| | - Samuel L. Aitken
- Department of Pharmacy University of Michigan Ann Arbor Michigan USA
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | - Payal K. Patel
- Department of Internal Medicine Division of Infectious Diseases, Ann Arbor VA Healthcare System Ann Arbor Michigan USA
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Tailoring Antimicrobial Stewardship (AMS) Interventions to the Cultural Context: An Investigation of AMS Programs Operating in Northern Italian Acute-Care Hospitals. Antibiotics (Basel) 2022; 11:antibiotics11091257. [PMID: 36140036 PMCID: PMC9495251 DOI: 10.3390/antibiotics11091257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/06/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Antibiotic misuse and overuse are important contributors to the development of antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) programs are coordinated sets of actions aiming to promote appropriate antibiotic use, improving patient outcomes whilst reducing AMR. Two main organizational models for AMS programs have been described: restrictive strategies (RS) vs. enabling strategies (ES). Evaluating and understanding social and cultural influences on antibiotic decision-making are critical for the development of successful and sustainable context-specific AMS programs. Characteristics and surrogate outcomes of AMS programs operating in acute-care hospitals of Piedmont in north-western Italy were investigated. The aim of this study was assessing whether RS vs. ES operating in our context were associated with different outcomes in terms of total antimicrobial usage and percentage of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant enterobacteria (CRE) over invasive isolates. In total, 24 AMS programs were assessed. ES were more frequently chosen compared to RS, with the latter being implemented only in broader AMS programs involving enabling components (combined strategy, CS). This study found no difference in evaluated outcomes among hospitals implementing ES vs. CS, suggesting both approaches could be equally valid in our context.
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Antimicrobial Stewardship Interventions in Pediatric Oncology: A Systematic Review. J Clin Med 2022; 11:jcm11154545. [PMID: 35956160 PMCID: PMC9369733 DOI: 10.3390/jcm11154545] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 12/28/2022] Open
Abstract
Antimicrobial stewardship programs represent efficacious measures for reducing antibiotic overuse and improving outcomes in different settings. Specific data on pediatric oncology are lacking. We conducted a systematic review on the PubMed and Trip databases according to the PRISMA guidelines, searching for reports regarding antimicrobial stewardship in pediatric oncology and hematology patients. The aim of the study was to summarize the present literature regarding the implementation of antimicrobial stewardship programs or initiatives in this particular population, and provide insights for future investigations. Nine papers were included in the qualitative analysis: three regarding antifungal interventions, five regarding antibacterial interventions, and one regarding both antifungal and antibacterial stewardship interventions. Variable strategies were reported among the included studies. Different parameters were used to evaluate the impact of these interventions, including days of therapy per 1000-patient-days, infections with resistant strains, safety analysis, and costs. We generally observed a reduction in the prescription of broad-spectrum antibiotics and an improved appropriateness, with reduced antibiotic-related side effects and no difference in infection-related mortality. Antibiotic stewardship programs or interventions are effective in reducing antibiotic consumption and improving outcomes in pediatric oncology hematology settings, although stewardship strategies differ substantially in different institutions. A standardized approach needs to be implemented in future studies in order to better elucidate the impact of stewardship programs in this category of patients.
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Yuste JR, Matteo ABD, Gruber F. Impact of Infectious Diseases training in the perception of antibiotic resistance and rational use of antibiotics among Spanish medical students - a cross-sectional study. BMC MEDICAL EDUCATION 2022; 22:550. [PMID: 35840970 PMCID: PMC9287956 DOI: 10.1186/s12909-022-03580-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/22/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Antibiotic resistance is one of the main public health problems worldwide. One key tool to optimize antibiotic prescription is medical training. The aim of this study is to compare the impact of training in infectious diseases on students' knowledge of the antibiotic resistance problem and the rational use of antibiotics. METHODS We performed a cross-sectional study in the medical school of the University of Navarra. We conducted an anonymous in situ survey of students in each year of training. Data were analyzed grouping the students as follows: GROUP 1: first three years of education, no training in Clinical Microbiology (CM) or in Infectious Diseases (ID); GROUP 2: fourth-year students, training in CM but not ID; GROUP 3: Fifth and sixth-year students who have completed the training in CM and ID. Chi-square test (or Fisher's exact test when appropriate) was performed to evaluate potential associations. Wilcoxon's test was used to compare the median correct answers between groups. We used Spearman's test for correlation between year of training and performance in questionnaire. RESULTS A total of 994 students respond to the survey, 80.4% of the eligible students. Almost all students who had completed infectious diseases training perceive antibiotic resistance as an important problem in comparison with students who had not completed the formation (99.5% in group 3 vs 94.5% in group 1, p = 0.02). Knowledge of antibiotic stewardship underwent a statistically significant change after training in infectious diseases (from 9.2% in group 1 to 52.2% in group 3, p < 0.001). In the training questions block we also found an increase in the average number of correct answers (21.4% in group 1 vs 44.7% in group 3, p < 0.001). When comparing the results of subgroups 3A and 3B we found a significant loss of knowledge as we moved away from training (49% vs 40.9%, p < 0.001). CONCLUSIONS The training of medical students is the key to improving both perception and knowledge of infectious diseases. However, we have an opportunity for educational improvement as far as infectious diseases are concerned, regarding both the acquisition of knowledge and its loss as time lapses after training.
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Affiliation(s)
- José Ramón Yuste
- Division of Infectious Diseases, Faculty of Medicine, University of Navarra, Clinica Universidad de Navarra, Pamplona, Spain.
- Department of Internal Medicine, Faculty of Medicine, University of Navarra, Clinica Universidad de Navarra, Pamplona, Spain.
| | - Andrés Blanco-Di Matteo
- Division of Infectious Diseases, Faculty of Medicine, University of Navarra, Clinica Universidad de Navarra, Pamplona, Spain
- Department of Internal Medicine, Faculty of Medicine, University of Navarra, Clinica Universidad de Navarra, Pamplona, Spain
| | - Fernando Gruber
- Division of Infectious Diseases, Faculty of Medicine, University of Navarra, Clinica Universidad de Navarra, Pamplona, Spain
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Ng TM, Heng ST, Chua BH, Ang LW, Tan SH, Tay HL, Yap MY, Quek J, Teng CB, Young BE, Lin R, Ang B, Lee TH, Lye DC. Sustaining Antimicrobial Stewardship in a High-Antibiotic Resistance Setting. JAMA Netw Open 2022; 5:e2210180. [PMID: 35503216 PMCID: PMC9066280 DOI: 10.1001/jamanetworkopen.2022.10180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE There is a lack of studies comparing the intended and unintended consequences of prospective review and feedback (PRF) with computerized decision support systems (CDSS), especially in the longer term in antimicrobial stewardship. OBJECTIVE To examine the outcomes associated with the sequential implementation of PRF and CDSS and changes to these interventions with long-term use of antibiotics for and incidence of multidrug resistant organisms (MDROs) and other unintended outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study used an interrupted time series with segmented regression analysis of data from January 2007 to December 2018. Data were extracted from the electronic medical records of patients admitted at a large university teaching hospital with high rates of antibiotic resistance in Singapore. Data were analyzed from June 2019 to June 2020. EXPOSURES PRF of piperacillin-tazobactam and carbapenems (intervention 1, April 2009), with the addition of hospital-wide CDSS (intervention 2, April 2011), and lifting of CDSS for half of the hospital wards for 6 months (intervention 3, March 2017). MAIN OUTCOMES AND MEASURES Monthly antimicrobial use was measured in defined daily doses (DDDs) per 1000 patient-days. The monthly incidence of MDROs was calculated as number of clinical isolates detected per 1000 inpatient-days over a 6-month period. Unintended outcomes examined included in-hospital mortality and age-adjusted length of stay (LOS). RESULTS The number of inpatients increased from 56 263 in 2007 to 63 572 in 2018. During the same period, the mean monthly patient days increased from 33 929 in 2007 to 45 603 in 2018, and the proportion of patients older than 65 years increased from 45.5% in 2007 to 56.6% in 2018. After intervention 1, there were 0.33 (95% CI, 0.18 to 0.48) more DDDs per 1000 patient-days per month of piperacillin-tazobactam and carbapenems and -11.05 (95% CI, -15.55 to -6.55) fewer DDDs per 1000 patient-days per month for other broad-spectrum antibiotics. After intervention 2, there were -0.22 (95% CI, -0.33 to -0.10) fewer DDDs per 1000 patient-days per month of piperacillin-tazobactam and carbapenems and -2.10 (95% CI, -3.13 to -1.07) fewer DDDs per 1000 patient-days per month for other broad-spectrum antibiotics. After intervention 3, use of piperacillin-tazobactam and carbapenem increased by 0.28 (95% CI, 0.02 to 0.55) DDDs per 1000 patient-days per month. After intervention 2, incidence of Clostridioides difficile decreased (estimate, -0.02 [95% CI, -0.03 to -0.01] cases per 1000 patient-days per month). CONCLUSIONS AND RELEVANCE In this cohort study, concurrent PRF and CDSS were associated with limiting the use of piperacillin-tazobactam and carbapenems while reducing use of other antibiotics.
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Affiliation(s)
- Tat Ming Ng
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Shi Thong Heng
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Boon Hou Chua
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Li Wei Ang
- National Public Health and Epidemiology Unit, National Centre for Infectious Diseases, Singapore, Singapore
| | - Sock Hoon Tan
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Hui Lin Tay
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Min Yi Yap
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jason Quek
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Christine B. Teng
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Barnaby E. Young
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ray Lin
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Brenda Ang
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tau Hong Lee
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - David C. Lye
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Funaro JR, Moehring RW, Liu B, Lee HJ, Yang S, Sarubbi CB, Anderson DJ, Wrenn RH. Impact of Education and Data Feedback on Guideline-Concordant Prescribing for Urinary Tract Infections in the Outpatient Setting. Open Forum Infect Dis 2022; 9:ofab214. [PMID: 35146036 PMCID: PMC8825625 DOI: 10.1093/ofid/ofab214] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 01/09/2023] Open
Abstract
Background Urinary tract infections (UTIs) are the most common outpatient indication for antibiotics and an important target for antimicrobial stewardship (AS) activities. With The Joint Commission standards now requiring outpatient AS, data supporting effective strategies are needed. Methods We conducted a 2-phase, prospective, quasi-experimental study to estimate the effect of an outpatient AS intervention on guideline-concordant antibiotic prescribing in a primary care (PC) clinic and an urgent care (UC) clinic between August 2017 and July 2019. Phase 1 of the intervention included the development of clinic-specific antibiograms and UTI diagnosis and treatment guidelines, presented during educational sessions with clinic providers. Phase 2, consisting of routine clinic- and provider-specific feedback, began ~12 months after the initial education. The primary outcome was percentage of encounters with first- or second-line antibiotics prescribed according to clinic-specific guidelines and was assessed using an interrupted time series approach. Results Data were collected on 4724 distinct patients seen during 6318 UTI encounters. The percentage of guideline-concordant prescribing increased by 22% (95% CI, 12% to 32%) after Phase 1 education, but decreased by 0.5% every 2 weeks afterwards (95% CI, –0.9% to 0%). Following routine data feedback in Phase 2, guideline concordance stabilized, and significant further decline was not seen (–0.6%; 95% CI, –1.6% to 0.4%). This shift in prescribing patterns resulted in a 52% decrease in fluoroquinolone use. Conclusions Clinicians increased guideline-concordant prescribing, reduced UTI diagnoses, and limited use of high-collateral damage agents following this outpatient AS intervention. Routine data feedback was effective to maintain the response to the initial education.
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Affiliation(s)
- Jason R Funaro
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebekah W Moehring
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Beiyu Liu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Hui-Jie Lee
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Siyun Yang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Christina B Sarubbi
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Deverick J Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Rebekah H Wrenn
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
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Carayon P, Thuemling T, Parmasad V, Bao S, O'Horo J, Bennett NT, Safdar N. Implementation of An Antibiotic Stewardship Intervention to Reduce Prescription of Fluoroquinolones: A Human Factors Analysis in Two Intensive Care Units. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2022; 26:161-171. [PMID: 35146329 DOI: 10.1177/25160435211025417] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antibiotic use is often the target of interventions in health care organizations that aim to decrease healthcare-associated infections (HAI) such as Clostridioides difficile (CDI); this is particularly important for fluoroquinolones (FQ), which are frequently used in critical care settings. In this study, using a multiple case study research approach, we conduct an in-depth analysis of an intervention aimed at limiting ICU prescriber access to FQ in two ICUs of two hospitals. The data collection and analysis were guided by a human factors engineering approach based on the SEIPS (Systems Engineering Initiative for Patient Safety) model and evidence-based implementation principles. Our results show some differences in the implementation of the FQ intervention between the two ICUs, such as level and method of FQ restriction, and training and communication with physicians and pharmacists. In both ICUs, several organizational learning mechanisms helped to quickly identify problems with the intervention and ensure that changes were made in a just-in-time manner (e.g. just-in-time training, removal of FQ in order set for pneumonia). Despite their organizational differences, both sites developed strategies to successfully implement the FQ intervention.
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Affiliation(s)
- Pascale Carayon
- Department of Industrial and Systems Engineering, Wisconsin Institute for Healthcare Systems Engineering; University of Wisconsin-Madison
| | - Teresa Thuemling
- Wisconsin Institute for Healthcare Systems Engineering; University of Wisconsin-Madison
| | | | - Songtao Bao
- School of Journalism and Mass Communication; University of Wisconsin-Madison
| | | | | | - Nasia Safdar
- Department of Medicine; University of Wisconsin-Madison
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Umemura T, Mutoh Y, Ota A, Ito Y, Mizuno T, Oguchi H, Yamada T, Ikeda Y, Ichihara T. Influence of Change of Full-Time Equivalents on Post-prescription Review with Feedback Interventions in an Antimicrobial Stewardship. Biol Pharm Bull 2022; 45:235-239. [PMID: 35110510 DOI: 10.1248/bpb.b21-00856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Few studies have investigated the influence of more full-time equivalents (FTEs) of infectious disease (ID) pharmacists on the likelihood of a post-prescription review with feedback (PPRF) intervention. This study focused on this in community hospitals before and after the Japanese medical reimbursement system was revised to introduce antimicrobial stewardship (AS) fees. We collected data for two periods: before (April 2017 to March 2018) and after (April 2018 to March 2019) AS fee implementation. The efficacy of the PPRF by the ID pharmacist was assessed based on the usage of broad-spectrum antimicrobials in days of therapy (DOT) per 100 patient-days. Further, we generated the susceptibility rate for antimicrobial-resistant organisms. The number of PPRF drugs was 2336 (2596 cases) before AS fee implementation and 2136 (1912 cases) after implementation. The overall monthly FTE for AS for an ID pharmacist increased from [median (interquartile range; IQR)] 0.34 (0.33-0.36) to 0.63 (0.61-0.63) after AS fee implementation. The DOT of the broad-spectrum antibiotics decreased from 10.46 (9.61-12.48) to 8.68 (8.14-9.18). The DOT of carbapenems and quinolones decreased significantly from 4.11 (3.69-4.41) to 3.07 (2.79-3.22) and 0.96 (0.61-1.14) to 0.37 (0.19-0.46), respectively (p < 0.05). Furthermore, the rate of levofloxacin (LVFX)-susceptible Pseudomonas (P.) aeruginosa improved from 71.5 to 84.8% (p < 0.01). We observed that increasing the FTE of ID pharmacists influences the DOTs of broad-spectrum antibiotics; a higher FTE contributes to fewer DOTs. Further, the susceptibility of P. aeruginosa to meropenem and LVFX increased as the FTE increased.
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Affiliation(s)
- Takumi Umemura
- Department of Pharmacy, Tosei General Hospital.,Department of Infection and Prevention, Tosei General Hospital.,College of Pharmacy, Kinjo Gakuin University
| | - Yoshikazu Mutoh
- Department of Infection and Prevention, Tosei General Hospital
| | - Aiko Ota
- Department of Pharmacy, Tosei General Hospital
| | - Yuki Ito
- Department of Pharmacy, Tosei General Hospital
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Wushouer H, Du K, Chen S, Zhou Y, Zheng B, Guan X, Shi L. Outpatient Antibiotic Prescribing Patterns and Appropriateness for Children in Primary Healthcare Settings in Beijing City, China, 2017-2019. Antibiotics (Basel) 2021; 10:antibiotics10101248. [PMID: 34680828 PMCID: PMC8532681 DOI: 10.3390/antibiotics10101248] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 11/20/2022] Open
Abstract
(1) Background: Few studies have focused on antibiotic use and appropriateness in children in primary health institutions (PHIs). This study aimed to identify the patterns and appropriateness of antibiotic use for children in PHIs in Beijing, China. (2) Methods: Outpatient prescriptions of 327 PHIs from 2017 to 2019 for patients <18 years old were collected. Prescriptions were described using quantity indicators. Antibiotics were categorized according to ATC classification J01 and Access, Watch, Reserve grouping. Appropriateness was reviewed by experts using three subtypes of irrational prescriptions (irregular, inappropriate, and abnormal). (3) Results: 20,618 prescriptions were collected in total. The antibiotic prescription rate (APR) was 15.1% (N = 3113). Among antibiotic prescriptions, J01FA Macrolides were the most used (N = 1068, 34.9%). The Watch group constituted 89.0% (N = 2818) of total antibiotic use. Bronchitis (N = 1059, 35.2%) was the most common diagnosis. A total of 292 instances of irrational antibiotic use were identified, with inappropriate prescriptions being the most prevalent subtype (N = 233, 79.8%). (4) Conclusion: Although APR for children in PHIs in Beijing was relatively low, the pattern of antibiotic use differed from other countries. Further studies are needed to optimize antibiotic use for children in PHIs under different levels of economic development.
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Affiliation(s)
- Haishaerjiang Wushouer
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China; (H.W.); (K.D.); (Y.Z.); (L.S.)
- International Research Center for Medicinal Administration (IRCMA), Peking University, Beijing 100191, China
| | - Kexin Du
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China; (H.W.); (K.D.); (Y.Z.); (L.S.)
| | - Shicai Chen
- Department of Pharmacy, Luhe Teaching Hospital of Capital Medical University, Beijing 101100, China;
| | - Yue Zhou
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China; (H.W.); (K.D.); (Y.Z.); (L.S.)
| | - Bo Zheng
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing 100034, China;
| | - Xiaodong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China; (H.W.); (K.D.); (Y.Z.); (L.S.)
- International Research Center for Medicinal Administration (IRCMA), Peking University, Beijing 100191, China
- Correspondence: ; Tel.: +86-10-82805019
| | - Luwen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China; (H.W.); (K.D.); (Y.Z.); (L.S.)
- International Research Center for Medicinal Administration (IRCMA), Peking University, Beijing 100191, China
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12
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Simplified therapeutic guidelines: the main tool of antimicrobial stewardship programs associated with optimal antibiotic therapy V3. Eur J Clin Microbiol Infect Dis 2021; 41:375-383. [PMID: 34643831 DOI: 10.1007/s10096-021-04317-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
Hospitals regularly seek to upgrade their antimicrobial stewardship program (ASP). Our aim was to evaluate the impact of simplified therapeutic guidelines (STGs) compared to various established tools for ASP on the rate of optimal antibiotic therapy (OAT) and antibiotic consumption. Audits of antibiotic prescriptions were carried out over a 24-month period. Feedback information led to STGs (e.g., ≤ 15 drugs). The impact of STGs was based on the rate of OAT, defined as a diagnosis of the infectious disease in the patient's medical records associated with the corresponding therapy indicated in the STGs or in other guidelines. STGs were compared to five other means of ASP: internal or national guidelines, audit, information regarding antibiotic consumption and bacterial resistance, and restricted access to targeted antibiotics. Antibiotic consumption was measured in defined daily doses/1000 days of hospital stay, focusing on third-generation cephalosporins (TGC) and fluoroquinolones (FQ). Twenty-six hospitals were audited from April 2017 to June 2019. A total of 1,028 antibiotic prescriptions were analyzed, including 204 (20%) after STG implementation in seven hospitals. In multivariate analysis, OAT (n = 176, 17%) was associated with STGs, AOR 2.21 [1.51-3.22], and with three tools in place, 1.75 [1.24-2.48]. The relative variations of consumption of TGC and FQ for hospitals with or without STGs were - 13.1 vs. + 9.4% and - 18.5 vs. - 2.7%, respectively, from 2018 to 2019. STGs were more likely than other ASP tools to improve the rate of OAT and to reduce the consumption of antibiotics.
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Chrysou K, Zarkotou O, Kalofolia S, Papagiannakopoulou P, Mamali V, Chrysos G, Themeli-Digalaki K, Sypsas N, Tsakris A, Pournaras S. Impact of a 4-year antimicrobial stewardship program implemented in a Greek tertiary hospital. Eur J Clin Microbiol Infect Dis 2021; 41:127-132. [PMID: 34264401 DOI: 10.1007/s10096-021-04290-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 06/09/2021] [Indexed: 01/22/2023]
Abstract
This study aimed to investigate the effects of a 4-year antibiotic stewardship program (ASP) in a tertiary hospital. We monitored data for 2015 (pre-intervention) and 2016-2019 (post-intervention) about antibiotic consumption (DDD/100 bed days), Clostridioides difficile infections (CDIs), resistance rates, length of stay (LOS), and annual antibiotic costs. Significant reductions were observed for total antibiotics/colistin/carbapenems/quinolones/tigecycline consumption and resistance rates of Pseudomonas aeruginosa, Klebsiella pneumoniae, and vancomycin-resistant enterococci. Considerable reductions occurred for LOS (4.18 [2015]/3.0 [2019] days), CDIs (1.47 [2015]/0.86 [2019] per 1000 patients), antibiotic cost/patient (39.45€ [2015]/23.69€ [2019]). The ASP was successful in reducing antibiotic consumption, antibiotic costs, length of hospital stay, and CDIs.
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Affiliation(s)
- Konstantina Chrysou
- Department of Microbiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Olympia Zarkotou
- Department of Clinical Microbiology, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Sofia Kalofolia
- Hospital Pharmacy, Tzaneio General Hospital of Piraeus, Athens, Greece
| | | | - Vasiliki Mamali
- Department of Clinical Microbiology, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Georgios Chrysos
- 2nd Department of Medicine and Infectious Disease Unit, Tzaneio General Hospital of Piraeus, Athens, Greece
| | | | - Nikolaos Sypsas
- General Hospital of Athens "Laiko", National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Tsakris
- Department of Microbiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyros Pournaras
- Department of Microbiology, National and Kapodistrian University of Athens, Athens, Greece. .,Laboratory of Clinical Microbiology, ATTIKON University Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 12462, Chaidari, Athens, Greece.
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Safdar N, Parmasad V, Brown R, Carayon P, Lepak A, O'Horo JC, Schulz L. Decreasing ICU-associated Clostridioides difficile infection through fluoroquinolone restriction, the FIRST trial: a study protocol. BMJ Open 2021; 11:e046480. [PMID: 34187821 PMCID: PMC8245435 DOI: 10.1136/bmjopen-2020-046480] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 06/16/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is one of the most common healthcare-associated infections in the USA, having high incidence in intensive care units (ICU). Antibiotic use increases risk of CDI, with fluoroquinolones (FQs) particularly implicated. In healthcare settings, antibiotic stewardship (AS) and infection control interventions are effective in CDI control, but there is little evidence regarding the most effective AS interventions. Preprescription authorisation (PPA) restricting FQs is a potentially promising AS intervention to reduce CDI. The FQ Restriction for the Prevention of CDI (FIRST) trial will evaluate the effectiveness of an FQ PPA intervention in reducing CDI rates in adult ICUs compared with preintervention care, and evaluate implementation effectiveness using a human-factors and systems engineering model. METHODS AND ANALYSIS This is a multisite, stepped-wedge, cluster, effectiveness-implementation clinical trial. The trial will take place in 12 adult medical-surgical ICUs with ≥10 beds, using Epic as electronic health record (EHR) and pre-existing AS programmes. Sites will receive facilitated implementation support over the 15-month trial period, succeeded by 9 months of follow-up. The intervention comprises a clinical decision support system for FQ PPA, integrated into the site EHRs. Each ICU will be considered a single site and all ICU admissions included in the analysis. Clinical data will be extracted from EHRs throughout the trial and compared with the corresponding pretrial period, which will constitute the baseline for statistical analysis. Outcomes will include ICU-onset CDI rates, FQ days of therapy (DOT), alternative antibiotic DOT, average length of stay and hospital mortality. The study team will also collect implementation data to assess implementation effectiveness using the Systems Engineering Initiative for Patient Safety model. ETHICS AND DISSEMINATION The trial was approved by the Institutional Review Board at the University of Wisconsin-Madison (2018-0852-CP015). Results will be made available to participating sites, funders, infectious disease societies, critical care societies and other researchers. TRIAL REGISTRATION NUMBER NCT03848689.
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Affiliation(s)
- Nasia Safdar
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Vishala Parmasad
- Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Roger Brown
- School of Nursing, University of Wisconsin-Madison Graduate School, Madison, Wisconsin, USA
| | - Pascale Carayon
- Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Alexander Lepak
- Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Lucas Schulz
- Pharmacy, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Jones G, Amoah J, Klein EY, Leeman H, Smith A, Levin S, Milstone AM, Dzintars K, Cosgrove SE, Fabre V. Development of an Electronic Algorithm to Identify in Real Time Adults Hospitalized With Suspected Community-Acquired Pneumonia. Open Forum Infect Dis 2021; 8:ofab291. [PMID: 34189181 PMCID: PMC8231365 DOI: 10.1093/ofid/ofab291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/01/2021] [Indexed: 11/12/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is a major driver of hospital antibiotic use. Efficient methods to identify patients treated for CAP in real time using the electronic health record (EHR) are needed. Automated identification of these patients could facilitate systematic tracking, intervention, and feedback on CAP-specific metrics such as appropriate antibiotic choice and duration. Methods Using retrospective data, we identified suspected CAP cases by searching for patients who received CAP antibiotics AND had an admitting International Classification of Diseases, Tenth Revision (ICD-10) code for pneumonia OR chest imaging within 24 hours OR bacterial urinary antigen testing within 48 hours of admission (denominator query). We subsequently explored different structured and natural language processing (NLP)–derived data from the EHR to identify CAP cases. We evaluated combinations of these electronic variables through receiver operating characteristic (ROC) curves to assess which best identified CAP cases compared to cases identified by manual chart review. Exclusion criteria were age <18 years, absolute neutrophil count <500 cells/mm3, and admission to an oncology unit. Results Compared to the gold standard of chart review, the area under the ROC curve to detect CAP was 0.63 (95% confidence interval [CI], .55–.72; P < .01) using structured data (ie, laboratory and vital signs) and 0.83 (95% CI, .77–.90; P < .01) when NLP-derived data from radiographic reports were included. The sensitivity and specificity of the latter model were 80% and 81%, respectively. Conclusions Creating an electronic tool that effectively identifies CAP cases in real time is possible, but its accuracy is dependent on NLP-derived radiographic data.
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Affiliation(s)
- George Jones
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joe Amoah
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hannah Leeman
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Scott Levin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kathryn Dzintars
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Valeria Fabre
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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16
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Johnson MD, Lewis RE, Dodds Ashley ES, Ostrosky-Zeichner L, Zaoutis T, Thompson GR, Andes DR, Walsh TJ, Pappas PG, Cornely OA, Perfect JR, Kontoyiannis DP. Core Recommendations for Antifungal Stewardship: A Statement of the Mycoses Study Group Education and Research Consortium. J Infect Dis 2021; 222:S175-S198. [PMID: 32756879 DOI: 10.1093/infdis/jiaa394] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In recent years, the global public health community has increasingly recognized the importance of antimicrobial stewardship (AMS) in the fight to improve outcomes, decrease costs, and curb increases in antimicrobial resistance around the world. However, the subject of antifungal stewardship (AFS) has received less attention. While the principles of AMS guidelines likely apply to stewarding of antifungal agents, there are additional considerations unique to AFS and the complex field of fungal infections that require specific recommendations. In this article, we review the literature on AMS best practices and discuss AFS through the lens of the global core elements of AMS. We offer recommendations for best practices in AFS based on a synthesis of this evidence by an interdisciplinary expert panel of members of the Mycoses Study Group Education and Research Consortium. We also discuss research directions in this rapidly evolving field. AFS is an emerging and important component of AMS, yet requires special considerations in certain areas such as expertise, education, interventions to optimize utilization, therapeutic drug monitoring, and data analysis and reporting.
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Affiliation(s)
- Melissa D Johnson
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Russell E Lewis
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elizabeth S Dodds Ashley
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Luis Ostrosky-Zeichner
- Division of Infectious Diseases, Laboratory of Mycology Research, McGovern Medical School, Houston, Texas, USA
| | - Theoklis Zaoutis
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - George R Thompson
- Division of Infectious Diseases, Department of Internal Medicine, University of California, Davis, Sacramento, California, USA
| | - David R Andes
- Department of Medicine and Department of Medical Microbiology and Immunology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Thomas J Walsh
- Transplantation-Oncology Infectious Diseases, Weill Cornell Medicine of Cornell University, New York, New York, USA
| | - Peter G Pappas
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Oliver A Cornely
- Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany.,German Centre for Infection Research, partner site Bonn-Cologne, Cologne, Germany.,CECAD Cluster of Excellence, University of Cologne, Cologne, Germany.,Clinical Trials Center Cologne, University Hospital of Cologne, Cologne, Germany
| | - John R Perfect
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - Dimitrios P Kontoyiannis
- Department of Infectious Diseases, Infection Control and Employee Health, MD Anderson Cancer Center, Houston, Texas, USA
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17
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Calò F, Onorato L, Macera M, Di Caprio G, Monari C, Russo A, Galdieri A, Giordano A, Cuccaro P, Coppola N. Impact of an Education-Based Antimicrobial Stewardship Program on the Appropriateness of Antibiotic Prescribing: Results of a Multicenter Observational Study. Antibiotics (Basel) 2021; 10:antibiotics10030314. [PMID: 33803069 PMCID: PMC8002962 DOI: 10.3390/antibiotics10030314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/07/2021] [Accepted: 03/16/2021] [Indexed: 12/16/2022] Open
Abstract
To evaluate the effect that an education-based Antimicrobial stewardship program (ASP) implemented in two hospitals in southern Italy had on the quality and appropriateness of antibiotic prescription. We conducted a multicenter observational study in two hospitals in the Campania region. Only some departments of both hospitals were already participating in the ASP. We collected data on all patients admitted on the day of evaluation in antibiotic therapy or prophylaxis through a case report form. The primary outcome was to investigate the difference in the appropriateness of the antibiotic prescriptive practice in the departments that had joined the ASP and in those that had not participated in the project (non-ASP). The total number of patients assessed was 486. Of these, 78 (16.05%) were in antibiotic prophylaxis and 130 (26.7%) in antibiotic therapy. The prescriptive appropriateness was better in the units that had joined ASP than in those that had not, with respectively 65.8% versus 22.7% (p < 0.01). Patients in the non-ASP units more frequently received unnecessary antibiotics (44.9% versus 0%, p = 0.03) and, as surgical prophylaxis, the use of antibiotics not recommended by the guidelines (44.2% versus 0%, p = 0.036). Multivariable analysis of the factors associated with prescriptive appropriateness identified ASP units (p = 0.02) and bloodstream or cardiovascular infections (p = 0.03) as independent predictors of better prescriptive appropriateness. The findings of the present study reinforce the importance of adopting an educational ASP to improve the quality of antimicrobial prescription in clinical practice.
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Affiliation(s)
- Federica Calò
- Department of Mental Health and Public Medicine–Infectious Diseases Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (F.C.); (L.O.); (M.M.); (C.M.); (A.R.)
| | - Lorenzo Onorato
- Department of Mental Health and Public Medicine–Infectious Diseases Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (F.C.); (L.O.); (M.M.); (C.M.); (A.R.)
- Infectious Diseases Unit, AORN Sant’Anna and San Sebastiano, 81100 Caserta, Italy;
| | - Margherita Macera
- Department of Mental Health and Public Medicine–Infectious Diseases Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (F.C.); (L.O.); (M.M.); (C.M.); (A.R.)
| | - Giovanni Di Caprio
- Infectious Diseases Unit, AORN Sant’Anna and San Sebastiano, 81100 Caserta, Italy;
| | - Caterina Monari
- Department of Mental Health and Public Medicine–Infectious Diseases Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (F.C.); (L.O.); (M.M.); (C.M.); (A.R.)
| | - Antonio Russo
- Department of Mental Health and Public Medicine–Infectious Diseases Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (F.C.); (L.O.); (M.M.); (C.M.); (A.R.)
| | - Anna Galdieri
- Direzione Sanitaria, AOU Vanvitelli, 80138 Naples, Italy;
| | | | - Patrizia Cuccaro
- Direzione Sanitaria, AORN Sant’Anna and San Sebastiano, 81100 Caserta, Italy;
| | - Nicola Coppola
- Department of Mental Health and Public Medicine–Infectious Diseases Unit, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (F.C.); (L.O.); (M.M.); (C.M.); (A.R.)
- Correspondence: ; Tel.: +39-081-5666223; Fax: +39-081-5666013
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18
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Doctors' Perceptions, Attitudes and Practices towards the Management of Multidrug-Resistant Organism Infections after the Implementation of an Antimicrobial Stewardship Programme during the COVID-19 Pandemic. Trop Med Infect Dis 2021; 6:tropicalmed6010020. [PMID: 33562723 PMCID: PMC7930958 DOI: 10.3390/tropicalmed6010020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Greece is among the European countries with the highest consumption of antibiotics, both in community and hospital settings, including last-line antibiotics, such as carbapenems. We sought to explore doctors’ perceptions, attitudes and practices towards the management of patients with multidrug-resistant organism (MDRO) infections after the implementation of an antimicrobial stewardship programme (ASP) in a tertiary academic hospital during the COVID-19 pandemic. Methods: A self-administered, internet-based questionnaire survey was completed by doctors of the University Hospital of Heraklion in Crete, Greece. Results: In total, 202 (59.1%) hospital doctors fully completed the questionnaire. Most of them agreed that the prospective audit and feedback ASP strategy is more effective and educational than the preauthorization ASP strategy. ASP implementation prompted most respondents to monitor the continuously evolving microbiological data of their patients more closely and affected them towards a multidisciplinary and personalised care of patients with infections caused by MDROs and towards a more rigorous implementation of infection prevention and control measures. The vast majority of participants (98.5%) stated that ASP must be continued and further developed during the COVID-19 pandemic. Conclusion: The ASP implementation in our hospital had a beneficial impact on doctors’ perceptions, attitudes and practices with regard to the management of infections due to MDROs.
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Shafat T, Shimoni O, Nikonov A, Nesher L. The Kinetics of an Antibiotic Stewardship Intervention: A Quasi-Experimental Study. Infect Dis Ther 2021; 10:613-619. [PMID: 33515415 PMCID: PMC7954991 DOI: 10.1007/s40121-021-00403-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Little is known about the kinetics and different phases of a successful antibiotic stewardship program (ASP) intervention. Methods We analyzed the trends of quarterly antibiotic use measured in defined daily dose (DDD)/100 days hospitalization using the Joinpoint Regression Program and interrupted time series analysis to objectively identify shifts in the trends of antibiotic use. We correlated these changes in trends with the introduction of a hospital-wide ASP intervention. Results The ASP intervention reduced the overall antibiotic use by 33%, from a prior steady state of 76.5 DDD/100 days hospitalization to a post-intervention steady state of 51.2 DDD/100 days hospitalization (p < 0.001). We identified four distinct phases in the trends: prior steady state (A), early intervention (B), accelerated phase (C), and post steady state (D). From A to B a change of slope (−1.46) [SE 0.37, 95% CI −2.23, −0.69 (p = 0.002)]; B to C, a further decrease of slope (−4.70) [SE 0.64, 95% CI −6.03, −3.37 (p = 0.001)]; between periods C and D, straightening out of the slope (+ 6.84) [SE 0.55, 95% CI 5.70, 7.98 (p < 0.001)] to a new post-intervention steady state. It took 1.5 years after completion of the intervention to reach the new steady state. Conclusions We demonstrate that ASP interventions require time to achieve the maximal effect. Successful interventions require physicians to adapt new prescribing behaviors and gain confidence in the change; this adaptation can be a prolonged process and might even take years after the introduction of the ASP. These factors should be considered when planning and implementing ASP interventions.
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Affiliation(s)
- Tali Shafat
- Infectious Disease Institute, Soroka University Medical Center, Beer Sheba, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel.,Clinical Research Center, Soroka University Medical Center, Beer Sheba, Israel
| | - Orly Shimoni
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel.,Pharmacy Services, Soroka University Medical Center, Beer Sheba, Israel
| | - Anna Nikonov
- Pharmacy Services, Soroka University Medical Center, Beer Sheba, Israel
| | - Lior Nesher
- Infectious Disease Institute, Soroka University Medical Center, Beer Sheba, Israel. .,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba, Israel.
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Cona A, Iannotti N, Gazzola L, Aldieri C, Viganò O, Bini T, Marchetti G, Monforte AD. Long-term positive effect of an educational antimicrobial stewardship program implemented in an Internal Medicine Department: a prospective analysis and a point prevalence survey on long-term effect. J Chemother 2020; 33:238-244. [PMID: 33375926 DOI: 10.1080/1120009x.2020.1861515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The study aims to evaluate antimicrobial consumption and appropriateness one year after the implementation of an antimicrobial stewardship (AMS) program in an Internal Medicine Department in Milan. AMS program structured in two phases: "AMS phase", 5 months AMS-program based on an "audit-and-feedback model"; the "follow-up phase", 5 months long point prevalence survey conducted one year later. Outcomes of the study: antimicrobial consumption and appropriateness of antimicrobial therapy. Secondary outcomes: in-hospital mortality and length of stay (LOS). During the "AMS phase", we obtained a mean decrease of -11.4% of total antibiotic consumption as compared to the previous year (67.9 defined daily dose (DDD)/100 bed-days (bd) vs. 79.4 DDD/100bd, p = 0.07). Antibiotic consumption remained stable during "follow-up phase" (66.3 DDD/100bd, p = 0.9). Rate of appropriateness during the project increased from 48% to 85% (p < 0.01). No difference in in-hospital mortality and in LOS were observed. The study documents a positive long-term effect of AMS program on consumption and appropriate use of antibiotics.
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Affiliation(s)
- Andrea Cona
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Nathalie Iannotti
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Lidia Gazzola
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Chiara Aldieri
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Ottavia Viganò
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Teresa Bini
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Giulia Marchetti
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Antonella d'Arminio Monforte
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
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21
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Simó S, Velasco-Arnaiz E, Ríos-Barnés M, López-Ramos MG, Monsonís M, Urrea-Ayala M, Jordan I, Casadevall-Llandrich R, Ormazábal-Kirchner D, Cuadras-Pallejà D, Tarrado X, Prat J, Sánchez E, Noguera-Julian A, Fortuny C. Effects of a Paediatric Antimicrobial Stewardship Program on Antimicrobial Use and Quality of Prescriptions in Patients with Appendix-Related Intraabdominal Infections. Antibiotics (Basel) 2020; 10:antibiotics10010005. [PMID: 33374676 PMCID: PMC7822420 DOI: 10.3390/antibiotics10010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 11/16/2022] Open
Abstract
The effectiveness of antimicrobial stewardship programs (ASP) in reducing antimicrobial use (AU) in children has been proved. Many interventions have been described suitable for different institution sizes, priorities, and patients, with surgical wards being one of the areas that may benefit the most. We aimed to describe the results on AU and length of stay (LOS) in a pre-post study during the three years before (2014–2016) and the three years after (2017–2019) implementation of an ASP based on postprescription review with feedback in children and adolescents admitted for appendix-related intraabdominal infections (AR-IAI) in a European Referral Paediatric University Hospital. In the postintervention period, the quality of prescriptions (QP) was also evaluated. Overall, 2021 AR-IAIs admissions were included. Global AU, measured both as days of therapy/100 patient days (DOT/100PD) and length of therapy (LOT), and global LOS remained unchanged in the postintervention period. Phlegmonous appendicitis LOS (p = 0.003) and LOT (p < 0.001) significantly decreased, but not those of other AR-IAI diagnoses. The use of piperacillin–tazobactam decreased by 96% (p = 0.044), with no rebound in the use of other Gram-negative broad-spectrum antimicrobials. A quasisignificant (p = 0.052) increase in QP was observed upon ASP implementation. Readmission and case fatality rates remained stable. ASP interventions were safe, and they reduced LOS and LOT of phlegmonous appendicitis and the use of selected broad-spectrum antimicrobials, while increasing QP in children with AR-IAI.
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Affiliation(s)
- Sílvia Simó
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
- Centre for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain;
| | - Eneritz Velasco-Arnaiz
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
| | - María Ríos-Barnés
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
| | | | - Manuel Monsonís
- Clinical Microbiology Department, Sant Joan de Déu Hospital, 08950 Barcelona, Spain;
| | - Mireia Urrea-Ayala
- Patient Safety Area—Infection Control Unit, Sant Joan de Déu Hospital, 08950 Barcelona, Spain;
| | - Iolanda Jordan
- Centre for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain;
- Pediatric Intensive Care Unit, Sant Joan de Déu Hospital, 08950 Barcelona, Spain
- Department of Paediatrics, University of Barcelona, 08007 Barcelona, Spain
| | | | | | | | - Xavier Tarrado
- Paediatric Surgery Department, Sant Joan de Déu Hospital, 08950 Barcelona, Spain; (X.T.); (J.P.)
| | - Jordi Prat
- Paediatric Surgery Department, Sant Joan de Déu Hospital, 08950 Barcelona, Spain; (X.T.); (J.P.)
| | - Emília Sánchez
- Blanquerna School of Health Science, Ramon Llull University, 08022 Barcelona, Spain;
| | - Antoni Noguera-Julian
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
- Centre for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain;
- Statistics Department, Sant Joan de Déu Research Foundation, 08950 Barcelona, Spain;
- Translational Research Network in Paediatric Infectious Diseases (RITIP), 28009 Madrid, Spain
- Correspondence: ; Tel.: +34-932-804-000 (ext. 80063); Fax: +34-932-033-959
| | - Clàudia Fortuny
- Infectious Diseases and Systemic Inflammatory Response in Paediatrics, Infectious Diseases Unit, Department of Paediatrics, Sant Joan de Déu Hospital Research Foundation, 08950 Barcelona, Spain; (S.S.); (E.V.-A.); (M.R.-B.); (C.F.)
- Centre for Biomedical Network Research on Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain;
- Statistics Department, Sant Joan de Déu Research Foundation, 08950 Barcelona, Spain;
- Translational Research Network in Paediatric Infectious Diseases (RITIP), 28009 Madrid, Spain
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22
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Bouchet F, Le Moing V, Dirand D, Cros F, Lienard A, Reynes J, Giraudon L, Morquin D. Effectiveness and Acceptance of Multimodal Antibiotic Stewardship Program: Considering Progressive Implementation and Complementary Strategies. Antibiotics (Basel) 2020; 9:antibiotics9120848. [PMID: 33260815 PMCID: PMC7760905 DOI: 10.3390/antibiotics9120848] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 11/19/2020] [Accepted: 11/25/2020] [Indexed: 12/19/2022] Open
Abstract
Multiple modes of interventions are available when implementing an antibiotic stewardship program (ASP), however, their complementarity has not yet been assessed. In a 938-bed hospital, we sequentially implemented four combined modes of interventions over one year, centralized by one infectious diseases specialist (IDS): (1) on-request infectious diseases specialist consulting service (IDSCS), (2) participation in intensive care unit meetings, (3) IDS intervention triggered by microbiological laboratory meetings, and (4) IDS intervention triggered by pharmacist alert. We assessed the complementarity of the different cumulative actions through quantitative and qualitative analysis of all interventions traced in the electronic medical record. We observed a quantitative and qualitative complementarity between interventions directly correlating to a decrease in antibiotic use. Quantitatively, the number of interventions has doubled after implementation of IDS intervention triggered by pharmacist alert. Qualitatively, these kinds of interventions led mainly to de-escalation or stopping of antibiotic therapy (63%) as opposed to on-request IDSCS (32%). An overall decrease of 14.6% in antibiotic use was observed (p = 0.03). Progressive implementation of the different interventions showed a concrete complementarity of these actions. Combined actions in ASPs could lead to a significant decrease in antibiotic use, especially regarding critical antibiotic prescriptions, while being well accepted by prescribers.
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Affiliation(s)
- Flavien Bouchet
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Montpellier, Université de Montpellier, 34000 Montpellier, France; (V.L.M.); (J.R.); (D.M.)
- Pôle Appui aux Fonctions Cliniques, Département de la Pharmacie, Hôpitaux du Bassin de Thau, 34200 Sète, France; (D.D.); (L.G.)
- Correspondence:
| | - Vincent Le Moing
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Montpellier, Université de Montpellier, 34000 Montpellier, France; (V.L.M.); (J.R.); (D.M.)
| | - Delphine Dirand
- Pôle Appui aux Fonctions Cliniques, Département de la Pharmacie, Hôpitaux du Bassin de Thau, 34200 Sète, France; (D.D.); (L.G.)
| | - François Cros
- Département Informatique, Hôpitaux du Bassin de Thau, 34200 Sète, France;
| | - Alexi Lienard
- Département de Biologie Médicale, Hôpitaux du Bassin de Thau, 34200 Sète, France;
| | - Jacques Reynes
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Montpellier, Université de Montpellier, 34000 Montpellier, France; (V.L.M.); (J.R.); (D.M.)
| | - Laurent Giraudon
- Pôle Appui aux Fonctions Cliniques, Département de la Pharmacie, Hôpitaux du Bassin de Thau, 34200 Sète, France; (D.D.); (L.G.)
| | - David Morquin
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier Universitaire de Montpellier, Université de Montpellier, 34000 Montpellier, France; (V.L.M.); (J.R.); (D.M.)
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23
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Wongkamhla T, Khan-Asa B, Tongsai S, Angkasekwinai N. Infectious Disease Team Review Using Antibiotic Switch and Discharge Criteria Shortens the Duration of Intravenous Antibiotic: A Single-Center Cluster-Randomized Controlled Trial in Thailand. Open Forum Infect Dis 2020; 7:ofaa539. [PMID: 33324724 PMCID: PMC7724507 DOI: 10.1093/ofid/ofaa539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/27/2020] [Indexed: 12/29/2022] Open
Abstract
Background Strategies have been recommended to optimize early antibiotic (ATB) switching from intravenous (IV) to oral ATB. This study aimed to determine whether infectious disease (ID) team review using ATB switch and discharge criteria would shorten the duration of IV ATB and length of hospital stay (LOS). Methods This cluster-randomized controlled trial was conducted in 8 general medical wards as cluster units at Siriraj Hospital during January–October 2019. The ID team review with checklist criteria was performed on the third, fifth, and seventh day of IV-ATB treatment to determine (1) the suitability of switching to oral ATB or outpatient parenteral ATB therapy and (2) early discharge for patients receiving IV-ATB versus control. The primary outcomes were LOS and the duration or days of therapy (DOT) or defined daily dose (DDD) of IV-ATB therapy. Results Four wards each were randomly assigned to the intervention and control groups (46 patients/cluster, 184 patients/arm). No significant difference was observed between intervention and controls for median duration of IV-ATB therapy (7 vs 7 days) and LOS (9 vs 10 days). A significantly shorter duration of IV ATB was observed in patients without sepsis in the intervention group when measured by DOT (7 vs 8 days, P = .027) and DDD (7 vs 9, P = .017) in post hoc analysis. Conclusions Infectious disease team review using checklist criteria did not result in a shorter duration of IV-ATB and LOS in overall patients. Further study is needed to determine whether faster culture turnaround time or advanced testing will reduce the duration of IV-ATB therapy.
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Affiliation(s)
- Thanyarak Wongkamhla
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Buddharat Khan-Asa
- Pharmacy Department, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sasima Tongsai
- Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nasikarn Angkasekwinai
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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24
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Claeys KC, Heil EL, Hitchcock S, Johnson JK, Leekha S. Management of Gram-Negative Bloodstream Infections in the Era of Rapid Diagnostic Testing: Impact With and Without Antibiotic Stewardship. Open Forum Infect Dis 2020; 7:ofaa427. [PMID: 33134414 PMCID: PMC7585329 DOI: 10.1093/ofid/ofaa427] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/09/2020] [Indexed: 12/26/2022] Open
Abstract
Background Verigene Blood-Culture Gram-Negative is a rapid diagnostic test (RDT) that detects gram-negatives (GNs) and resistance within hours from gram stain. The majority of the data support the use of RDTs with antimicrobial stewardship (AMS) intervention in gram-positive bloodstream infection (BSI). Less is known about GN BSI. Methods This was a retrospective quasi-experimental (nonrandomized) study of adult patients with RDT-target GN BSI comparing patients pre-RDT/AMS vs post-RDT/pre-AMS vs post-RDT/AMS. Optimal therapy was defined as appropriate coverage with the narrowest spectrum, accounting for source and co-infecting organisms. Time to optimal therapy was analyzed using Kaplan-Meier and multivariable Cox proportional hazards regression. Results Eight-hundred thirty-two patients were included; 237 pre-RDT/AMS vs 308 post-RDT/pre-AMS vs 237 post-RDT/AMS, respectively. The proportion of patients on optimal antibiotic therapy increased with each intervention (66.5% vs 78.9% vs 83.2%; P < .0001). Time to optimal therapy (interquartile range) decreased with introduction of RDT: 47 (7.9–67.7) hours vs 24.9 (12.4–55.2) hours vs 26.5 (10.3–66.5) hours (P = .09). Using multivariable modeling, infectious diseases (ID) consult was an effect modifier. Within the ID consult stratum, controlling for source and ICU stay, compared with the pre-RDT/AMS group, both post-RDT/pre-AMS (adjusted hazard ratio [aHR], 1.34; 95% CI, 1.04–1.72) and post-RDT/AMS (aHR, 1.28; 95% CI, 1.01–1.64), improved time to optimal therapy. This effect was not seen in the stratum without ID consult. Conclusions With the introduction of RDT and AMS, both proportion and time to optimal antibiotic therapy improved, especially among those with an existing ID consult. This study highlights the beneficial role of RDTs in GN BSI.
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Affiliation(s)
- Kimberly C Claeys
- Department Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Emily L Heil
- Department Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | | | | | - Surbhi Leekha
- University of Maryland School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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25
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Antimicrobial de-escalation as part of antimicrobial stewardship in intensive care: no simple answers to simple questions-a viewpoint of experts. Intensive Care Med 2020; 46:236-244. [PMID: 32025778 PMCID: PMC7224113 DOI: 10.1007/s00134-019-05871-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/16/2019] [Indexed: 12/19/2022]
Abstract
Antimicrobial de-escalation (ADE) is defined as the discontinuation of one or more components of combination empirical therapy, and/or the change from a broad-spectrum to a narrower spectrum antimicrobial. It is most commonly recommended in the intensive care unit (ICU) patient who is treated with broad-spectrum antibiotics as a strategy to reduce antimicrobial pressure of empirical broad-spectrum therapy and prevent antimicrobial resistance, yet this has not been convincingly demonstrated in a clinical setting. Even if it appears beneficial, ADE may have some unwanted side effects: it has been associated with prolongation of antimicrobial therapy and could inappropriately be used as a justification for unrestricted broadness of empirical therapy. Also, exposing a patient to multiple, sequential antimicrobials could have unwanted effects on the microbiome. For these reasons, ADE has important shortcomings to be promoted as a quality indicator for appropriate antimicrobial use in the ICU. Despite this, ADE clearly has a role in the management of infections in the ICU. The most appropriate use of ADE is in patients with microbiologically confirmed infections requiring longer antimicrobial therapy. ADE should be used as an integral part of an ICU antimicrobial stewardship approach in which it is guided by optimal specimen quality and relevance. Rapid diagnostics may further assist in avoiding unnecessary initiation of broad-spectrum therapy, which in turn will decrease the need for subsequent ADE.
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26
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Seok H, Jeon JH, Park DW. Antimicrobial Therapy and Antimicrobial Stewardship in Sepsis. Infect Chemother 2020; 52:19-30. [PMID: 32239809 PMCID: PMC7113444 DOI: 10.3947/ic.2020.52.1.19] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Indexed: 12/27/2022] Open
Abstract
Since sepsis was first defined, sepsis management has remained challenging. To improve mortality rates for sepsis and septic shock, an accurate diagnosis and prompt administration of appropriate antibiotics are essential. The goals of antimicrobial stewardship are to achieve optimal clinical outcomes and to ensure cost-effectiveness and minimal unintended consequences, such as toxic effects and development of resistant pathogens. A combination of inadequate diagnostic criteria for sepsis and time pressure to provide broad-spectrum antimicrobial therapy remains an obstacle for antimicrobial stewardship. Efforts such as selection of appropriate empirical antibiotics and de-escalation or determination of whether or not to stop antibiotics may help to improve a patient's clinical prognosis as well as the successful implementation of antimicrobial stewardship.
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Affiliation(s)
- Hyeri Seok
- Division of Infectious Diseases, Korea University Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ji Hoon Jeon
- Division of Infectious Diseases, Korea University Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Dae Won Park
- Division of Infectious Diseases, Korea University Medicine, Korea University Ansan Hospital, Ansan, Korea.
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27
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Jiménez-Jorge S, Palacios-Baena ZR, Rosso-Fernández CM, Girón-Ortega JA, Rodriguez-Baño J, Retamar P. Opportunities for antibiotic optimisation and outcome improvement in patients with negative blood cultures: study protocol for a cluster-randomised crossover trial, the NO-BACT study. BMJ Open 2019; 9:e030062. [PMID: 31857298 PMCID: PMC6937003 DOI: 10.1136/bmjopen-2019-030062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Patients with negative blood cultures (BCx) represent 85%-90% of all patients with BCx taken during hospital admission. This population usually includes a heterogeneous group of patients admitted with infectious diseases or febrile syndromes that require a blood culture. There is very little evidence of the clinical characteristics and antibiotic treatment given to these patients. METHODS AND ANALYSIS In a preliminary exploratory prospective cohort study of patients with BCx taken, the clinical/therapeutic characteristics and outcomes/antimicrobial stewardship opportunities of a population of patients with negative BCx will be analysed. In the second phase, using a cluster randomised crossover design, the implementation of an antimicrobial stewardship intervention targeting patients with negative BCx will be evaluated in terms of quality of antimicrobial use (duration and de-escalation), length of hospital stay and mortality. ETHICS AND DISSEMINATION This study has been and registered with clinicaltrials.gov. The findings of our study may support the implementation in clinical practice of an antimicrobial stewardship intervention to optimise the use of antibiotics in patients with negative BCx. The results of this study will be published in peer-reviewed journals and disseminated at national and international conferences. TRIAL REGISTRATION NUMBER NCT03535324.
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Affiliation(s)
- Silvia Jiménez-Jorge
- Clinical Research and Clinical Trials Unit, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Zaira R Palacios-Baena
- Infectious Diseases and Clinical Microbiology Department, Hospital Universitario Virgen Macarena. Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen Macarena, Seville, Spain
| | - Clara M Rosso-Fernández
- Clinical Research and Clinical Trials Unit, Hospital Universitario Virgen del Rocío, Seville, Spain
- Department of Clinical Pharmacology, Virgen del Rocío University Hospital, Seville, Spain
| | - José A Girón-Ortega
- Internal Medicine Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Jesús Rodriguez-Baño
- Infectious Diseases and Clinical Microbiology Department, Hospital Universitario Virgen Macarena. Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen Macarena, Seville, Spain
| | - Pilar Retamar
- Infectious Diseases and Clinical Microbiology Department, Hospital Universitario Virgen Macarena. Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen Macarena, Seville, Spain
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28
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Akazawa T, Kusama Y, Fukuda H, Hayakawa K, Kutsuna S, Moriyama Y, Ohashi H, Tamura S, Yamamoto K, Hara R, Shigeno A, Ota M, Ishikane M, Tokita S, Terakado H, Ohmagari N. Eight-Year Experience of Antimicrobial Stewardship Program and the Trend of Carbapenem Use at a Tertiary Acute-Care Hospital in Japan-The Impact of Postprescription Review and Feedback. Open Forum Infect Dis 2019; 6:ofz389. [PMID: 31660352 PMCID: PMC6790398 DOI: 10.1093/ofid/ofz389] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/02/2019] [Indexed: 12/14/2022] Open
Abstract
Objective We implemented a stepwise antimicrobial stewardship program (ASP). This study evaluated the effect of each intervention and the overall economic impact on carbapenem (CAR) use. Method Carbapenem days of therapy (CAR-DOT) were calculated to assess the effect of each intervention, and antipseudomonal DOT were calculated to assess changes in use of broad-spectrum antibiotics. We carried out segmented regression analysis of studies with interrupted time series for 3 periods: Phase 1 (infectious disease [ID] consultation service only), Phase 2 (adding monitoring and e-mail feedback), and Phase 3 (adding postprescription review and feedback [PPRF] led by ID specialist doctors and pharmacists). We also estimated cost savings over the study period due to decreased CAR use. Results The median monthly CAR-DOT, per month per 100 patient-days, during Phase 1, Phase 2, and Phase 3 was 5.46, 3.69, and 2.78, respectively. The CAR-DOT decreased significantly immediately after the start of Phase 2, but a major decrease was not observed during this period. Although the immediate change was not apparent after Phase 3 started, CAR-DOT decreased significantly over this period. Furthermore, the monthly DOT of 3 alternative antipseudomonal agents also decreased significantly over the study period, but the incidence of antimicrobial resistance did not decrease. Cost savings over the study period, due to decreased CAR use, was estimated to be US $150 000. Conclusions Adding PPRF on the conventional ASP may accelerate antimicrobial stewardship. Our CAR stewardship program has had positive results, and implementation is ongoing.
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Affiliation(s)
- Tsubasa Akazawa
- Pharmaceutical Department, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoshiki Kusama
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.,Collaborative Chairs Emerging and Reemerging Infectious Diseases, National Center for Global Health and Medicine, Graduate School of Medicine, Tohoku University, Miyagi, Japan
| | - Haruhisa Fukuda
- Department of Health Care Administration and Management, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kayoko Hayakawa
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.,Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Satoshi Kutsuna
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yuki Moriyama
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hirotake Ohashi
- Pharmaceutical Department, National Center for Global Health and Medicine, Tokyo, Japan
| | - Saeko Tamura
- Department of Clinical Laboratory, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kei Yamamoto
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ryohei Hara
- Pharmaceutical Department, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ayako Shigeno
- Pharmaceutical Department, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masayuki Ota
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masahiro Ishikane
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.,Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shunichiro Tokita
- Pharmaceutical Department, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiroyuki Terakado
- Pharmaceutical Department, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Ohmagari
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.,Collaborative Chairs Emerging and Reemerging Infectious Diseases, National Center for Global Health and Medicine, Graduate School of Medicine, Tohoku University, Miyagi, Japan.,Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
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29
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Jones AS, Isaac RE, Price KL, Plunkett AC. Impact of Positive Feedback on Antimicrobial Stewardship in a Pediatric Intensive Care Unit: A Quality Improvement Project. Pediatr Qual Saf 2019; 4:e206. [PMID: 31745509 PMCID: PMC6805100 DOI: 10.1097/pq9.0000000000000206] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 07/31/2019] [Indexed: 11/25/2022] Open
Abstract
We hypothesized that antimicrobial stewardship (AMS) could be enhanced through positive feedback for the behaviors of healthcare professionals. This project aimed to reduce antimicrobial consumption in a Pediatric Intensive Care Unit (PICU) by >5%, with secondary aims to reduce broad-spectrum antimicrobial consumption, and processes related to AMS. Learning from Excellence is a positive feedback initiative conceptualized at our institution. METHODS This project took place over 12 months (April 2017-March 2018) in a 31-bedded PICU. We identified and measured processes about AMS daily. Healthcare professionals, achieving success in these processes, received positive feedback via Learning from Excellence, during a 6 months intervention period. Selected reports were followed with appreciative inquiry interviews to reinforce positive feedback. We calculated antimicrobial consumption data from existing databases (antimicrobial doses dispensed divided by PICU bed-days). Health Care-Associated Infection (HCAI) rates were included as a balancing measure. RESULTS Antimicrobial consumption was 6.5% lower during the intervention period compared with the matching period from the previous year. We reduced broad-spectrum antimicrobial (meropenem) consumption by 17.6%. Improvements in processes were mixed: a daily review of antimicrobials and documentation of antimicrobial prescription and administration significantly improved. Other processes failed to improve. HCAI rates did not change. CONCLUSIONS Positive feedback can be used as a QI intervention to improve processes around AMS. This intervention may contribute to a reduction in antimicrobial consumption. Not all processes are impacted equally, and there may be a "dose-response" effect. Further evaluation would benefit from a trial study design in other settings.
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Affiliation(s)
- Alison S. Jones
- From the Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
| | - Rhian E. Isaac
- From the Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
| | - Katie L. Price
- From the Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
| | - Adrian C. Plunkett
- From the Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
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Direct Measurement of Performance: A New Era in Antimicrobial Stewardship. Antibiotics (Basel) 2019; 8:antibiotics8030127. [PMID: 31450576 PMCID: PMC6784134 DOI: 10.3390/antibiotics8030127] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/20/2019] [Accepted: 08/21/2019] [Indexed: 01/23/2023] Open
Abstract
For decades, the performance of antimicrobial stewardship programs (ASPs) has been measured by incidence rates of hospital-onset Clostridioides difficile and other infections due to multidrug-resistant bacteria. However, these represent indirect and nonspecific ASP metrics. They are often confounded by factors beyond an ASP’s control, such as changes in diagnostic testing methods or algorithms and the potential of patient-to-patient transmission. Whereas these metrics remain useful for global assessment of healthcare systems, antimicrobial use represents a direct metric that separates the performance of an ASP from other safety and quality teams within an institution. The evolution of electronic medical records and healthcare informatics has made measurements of antimicrobial use a reality. The US Centers for Disease Control and Prevention’s initiative for reporting antimicrobial use and standardized antimicrobial administration ratio in hospitals is highly welcomed. Ultimately, ASPs should be evaluated based on what they do best and what they can control, that is, antimicrobial use within their own institution. This narrative review critically appraises existing stewardship metrics and advocates for adopting antimicrobial use as the primary performance measure. It proposes novel formulas to adjust antimicrobial use based on quality of care and microbiological burden at each institution to allow for meaningful inter-network and inter-facility comparisons.
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Anderson DJ, Watson S, Moehring RW, Komarow L, Finnemeyer M, Arias RM, Huvane J, Bova Hill C, Deckard N, Sexton DJ. Feasibility of Core Antimicrobial Stewardship Interventions in Community Hospitals. JAMA Netw Open 2019; 2:e199369. [PMID: 31418804 PMCID: PMC6704742 DOI: 10.1001/jamanetworkopen.2019.9369] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/15/2019] [Indexed: 01/10/2023] Open
Abstract
Importance The feasibility of core Infectious Diseases Society of America-recommended antimicrobial stewardship interventions in community hospitals is unknown. Objective To determine the feasibility and results of implementing 2 core stewardship intervention strategies in community hospitals. Design, Setting, and Participants Three-stage, multicenter, prospective nonrandomized clinical trial with crossover design. The setting was 4 community hospitals in North Carolina (median bed size, 305; range, 102-425). Participants were all patients receiving targeted study antibacterial agents or alternative, nonstudy antibacterial agents. The study dates were October 2014 through October 2015. All statistical analyses were completed as of October 2016. Interventions Two antimicrobial stewardship strategies targeted vancomycin hydrochloride, piperacillin-tazobactam, and the antipseudomonal carbapenems on formulary at the study hospitals: (1) modified preauthorization (PA), in which the prescriber had to receive pharmacist approval for continued use of the antibiotic after the first dose, and (2) postprescription audit and review (PPR), in which the pharmacist would engage the prescriber about antibiotic appropriateness after 72 hours of therapy. Two hospitals performed modified PA for 6 months, then PPR for 6 months after a 1-month washout. The other 2 hospitals performed the reverse. Main Outcomes and Measures The primary outcome was the feasibility of implementing the interventions, determined by (1) approval by hospital administration and committees at each study hospital; (2) completion of pharmacist training; (3) initiation and implementation as determined by number, type, and outcomes of interventions performed; and (4) time required for interventions. Secondary outcomes included antimicrobial use (days of therapy) compared with matched historical periods and length of hospitalization. Results A total of 2692 patients (median age, 65 years; interquartile range, 53-76 years) underwent a study intervention; 1413 (52.5%) were female, 1323 (49.1%) were white, and 1047 (38.9%) were African American. Intervention approvals took a median of 95 days (range, 56-119 days); during these discussions, strict PA was deemed not feasible. Instead, the modified PA intervention was used throughout the study. Pharmacists performed 1456 modified PA interventions (median per hospital, 350 [range, 129-628]) and 1236 PPR interventions (median per hospital, 298 [range, 273-366]). Study antimicrobials were determined to be inappropriate 2 times as often during the PPR period (41.0% [435 of 1060] vs 20.4% [253 of 1243]; P < .001). Pharmacists recommended dose change more often during the modified PA intervention (15.9% [232 of 1456] vs 9.6% [119 of 1236]; P < .001) and de-escalation during PPR (29.1% [360 of 1236] vs 13.0% [190 of 1456]; P < .001). The median time dedicated to the stewardship interventions varied by hospital (range of median hours per week, 5-19). Overall antibiotic use decreased during PPR compared with historical controls (mean [SD] days of therapy per 1000 patient-days, 925.2 [109.8] vs 965.3 [109.4]; mean difference, -40.1; 95% CI, -71.7 to -8.6), but not during modified PA (mean [SD] days of therapy per 1000 patient-days, 931.0 [102.0] vs 926.6 [89.7]; mean difference, 4.4; 95% CI, -55.8 to 64.7). Conclusions and Relevance Strict PA was not feasible in the study hospitals. In contrast, PPR was a feasible and effective strategy for antimicrobial stewardship in settings with limited resources and expertise. Trial Registration ClinicalTrials.gov identifier: NCT02212808.
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Affiliation(s)
- Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Shera Watson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Rebekah W. Moehring
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
| | - Lauren Komarow
- The Biostatistics Center, The George Washington University, Rockville, Maryland
| | - Matthew Finnemeyer
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | | | - Nancie Deckard
- Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel J. Sexton
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina
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Antimicrobial stewardship by academic detailing improves antimicrobial prescribing in solid organ transplant patients. Eur J Clin Microbiol Infect Dis 2019; 38:1915-1923. [PMID: 31325060 DOI: 10.1007/s10096-019-03626-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 06/30/2019] [Indexed: 12/12/2022]
Abstract
We implemented twice-weekly academic detailing rounds in 2015 as an antimicrobial stewardship (AMS) intervention in solid organ transplant (SOT) patients, led by an AMS pharmacist and a transplant infectious diseases physician. They reviewed SOT patients' antimicrobials and made recommendations to prescribers on antimicrobial regimens, diagnostics investigations, and appropriate referrals for transplant infectious diseases consultation. To determine the impact of the intervention, we adjudicated antimicrobials prescriptions using established AMS principles, and compared the proportion of AMS-concordance regimens pre-intervention (2013) with post-intervention (2016) via 4-point-prevalence surveys conducted in each period. All admitted SOT patients who were receiving antimicrobial treatment on survey days were included. Primary outcome was the percentage of antimicrobial regimen adjudicated as AMS concordant. Secondary outcomes were percentage of AMS concordance in patients consulted by transplant infectious diseases; categories of AMS discordance; antimicrobial consumption in defined daily dose/100 patient-days (DDD/100PD); antimicrobial cost in CAD$/PD; and C. difficile infections. Balancing measures were length of stay, 30-day readmission, and in-hospital mortality. We compared outcomes using χ2 test or t-test; significant difference was defined as p < 0.05. Pre-intervention surveys included 139 patients, post-intervention, 179 patients, with 62.3% vs. 56.6% receiving antimicrobials, respectively (p = 0.27). AMS concordance increased from 69% (60/87) to 83.7% (93/111), p = 0.01. Not tailoring antimicrobials was the most common discordance category. AMS concordance under transplant infectious diseases was 82.5% (33/40) pre-intervention vs. 76.6% (36/47) post-intervention, p = 0.5. Antimicrobial consumption increased by 15.3% (140.9 vs.162.4 DDD/100PD, p = 0.001). Antimicrobial cost, C. difficile infection rates and balancing measures remained stable. Academic detailing increased appropriate antimicrobial use in SOT patients without untoward effects.
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Basic, Advanced, and Novel Metrics to Guide Antibiotic Use Assessments. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2019. [DOI: 10.1007/s40506-019-00188-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
While antimicrobial resistance is already a public health crisis in human medicine, therapeutic failure in veterinary medicine due to antimicrobial resistance remains relatively uncommon. However, there are many pathways by which antimicrobial resistance determinants can travel between animals and humans: by close contact, through the food chain, or indirectly via the environment. Antimicrobial stewardship describes measures that can help mitigate the public health crisis and preserve the effectiveness of available antimicrobial agents. Antimicrobial stewardship programs have been principally developed, implemented, and studied in human hospitals but are beginning to be adapted for other applications in human medicine. Key learning from the experiences of antimicrobial stewardship programs in human medicine are summarized in this article-guiding the development of a stewardship framework suitable for adaptation and use in both companion animal and livestock practice. The antimicrobial stewardship program for veterinary use integrates infection prevention and control together with approaches emphasizing avoidance of antimicrobial agents. The 5R framework of continuous improvement that is described recognizes the importance of executive support; highly motivated organizations and teams (responsibility); the need to review the starting position, set objectives, and determine means of measuring progress and success; and a critical focus on reducing, replacing, and refining the use of antimicrobial agents. Significant issues that are currently the focus of intensive research include improved detection and diagnosis of infections, refined dosing regimens that are simultaneously effective while not selecting resistance, searches for alternatives to antimicrobial agents, and development of improved vaccines to enhance immunity and reduce disease.
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35
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Pollara G, Bali S, Marks M, Bates I, Collier S, Balakrishnan I. Time Efficiency Assessment of Antimicrobial Stewardship Strategies. Clin Infect Dis 2019; 64:1463-1464. [PMID: 28329195 DOI: 10.1093/cid/cix220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Gabriele Pollara
- Departments of Microbiology and.,Division of Infection and Immunity, University College London
| | | | - Michael Marks
- Clinical Research Department, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Ian Bates
- University College London School of Pharmacy, and
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Khilnani, GC, Zirpe, K, Hadda, V, Mehta, Y, Madan, K, Kulkarni, A, Mohan, A, Dixit, S, Guleria, R, Bhattacharya, P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian J Crit Care Med 2019; 23:S1-S63. [PMID: 31516211 PMCID: PMC6734471 DOI: 10.5005/jp-journals-10071-23101] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
How to cite this article: Khilnani GC, Zirpe K, Hadda V, Mehta Y, Madan K, Kulkarni A, Mohan A, Dixit S, Guleria R, Bhattacharya P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian Journal of Critical Care Medicine 2019;23 (Suppl 1):1-63.
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Affiliation(s)
- GC Khilnani,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Kapil Zirpe,
- Neuro-Trauma Unit, Grant Medical Foundation, Ruby Hall Clinic, Pune, Maharashtra, India
| | - Vijay Hadda,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Yatin Mehta,
- Indian Society of Critical Care Medicine, Medanta Institute of Critical Care and Anesthesiology, Gurugram, Haryana, India
| | - Karan Madan,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Kulkarni,
- Department of Anaesthesiology, Division of Critical Care Medicine, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Anant Mohan,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Subhal Dixit,
- Sanjeevan and MJM Hospital, Pune, Maharashtra, India
| | - Randeep Guleria,
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Pradeep Bhattacharya,
- Department of Anaesthesiology, Critical Care and Emergency Services, Bhopal, Madhya Pradesh, India
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Honda H, Murakami S, Tagashira Y, Uenoyama Y, Goto K, Takamatsu A, Hasegawa S, Tokuda Y. Efficacy of a Postprescription Review of Broad-Spectrum Antimicrobial Agents With Feedback: A 4-Year Experience of Antimicrobial Stewardship at a Tertiary Care Center. Open Forum Infect Dis 2018; 5:ofy314. [PMID: 30555853 PMCID: PMC6289023 DOI: 10.1093/ofid/ofy314] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/16/2018] [Indexed: 12/21/2022] Open
Abstract
Background An inpatient antimicrobial stewardship program is vital for judicious antimicrobial use. We began a hospital-wide, postprescription review with feedback (PPRF) in 2014; the present study evaluated its impact on antimicrobial consumption and clinical outcomes over 4 years. Methods Once-weekly PPRF for carbapenems and piperacillin/tazobactam was implemented. We tracked the data on each antimicrobial use as days of therapy (DOT) per 1000 patient-days (PD). Changes in the incidence of drug-resistant organisms, in-hospital mortality, and length of hospital stay per month were analyzed by an interrupted time series. Results Carbapenem use continued to decline in the preintervention and intervention periods (−0.73 and −0.003 DOT/1000 PD, respectively), and although monthly average use remained low in the intervention period (8.3 DOT/1000 PD), more importantly, the postintervention change in the slope diminished significantly. Piperacillin/tazobactam use showed a steeper decline in the intervention period, but the change in the slope was not statistically significant (change in slope: −0.20 DOT/1000 PD per month [P = .16]). Postintervention use of narrower-spectrum antimicrobials including ampicillin/sulbactam (change in slope: +0.58 DOT/1000 PD per month [P < .001]) increased. The antimicrobial cost and the monthly average length of hospital stay also declined (−37.4 USD/1000 PD per month [P < .001] and −0.04 days per month [P < .001], respectively), whereas few postintervention changes in the incidence of drug-resistant organisms were observed. Conclusions In our study, the 4-year PPRF for broad-spectrum antimicrobials coincided with a reduction in the use of targeted antimicrobials and resulted in an improvement in 1 patient-centered outcome, thus conferring the additional benefit of reducing expenditures for antimicrobials.
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Affiliation(s)
- Hitoshi Honda
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Center, Replace Fuchu, Tokyo.,Department of Infection Control, Tokyo Metropolitan Tama Medical Center, Replace Fuchu, Tokyo
| | - Shutaro Murakami
- Department of Infection Control, Tokyo Metropolitan Tama Medical Center, Replace Fuchu, Tokyo
| | - Yasuaki Tagashira
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Center, Replace Fuchu, Tokyo.,Department of Infection Control, Tokyo Metropolitan Tama Medical Center, Replace Fuchu, Tokyo
| | - Yuki Uenoyama
- Department of Infection Control, Tokyo Metropolitan Tama Medical Center, Replace Fuchu, Tokyo
| | - Kaoru Goto
- Department of Infection Control, Tokyo Metropolitan Tama Medical Center, Replace Fuchu, Tokyo
| | - Akane Takamatsu
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Center, Replace Fuchu, Tokyo.,Department of Infection Control, Tokyo Metropolitan Tama Medical Center, Replace Fuchu, Tokyo
| | - Shinya Hasegawa
- Division of Infectious Diseases, Tokyo Metropolitan Tama Medical Center, Replace Fuchu, Tokyo.,Department of Infection Control, Tokyo Metropolitan Tama Medical Center, Replace Fuchu, Tokyo
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Hwang H, Kim B. Impact of an infectious diseases specialist-led antimicrobial stewardship programmes on antibiotic use and antimicrobial resistance in a large Korean hospital. Sci Rep 2018; 8:14757. [PMID: 30283084 PMCID: PMC6170479 DOI: 10.1038/s41598-018-33201-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 09/25/2018] [Indexed: 01/18/2023] Open
Abstract
The aim of this study was to evaluate the impact of an infectious diseases specialist (IDS)-led antimicrobial stewardship programmes (ASPs) in a large Korean hospital. An interrupted time series analysis assessing the trends in antibiotic use and antimicrobial resistance rate of major pathogens between September 2015 and August 2017 was performed in an 859-bed university-affiliated hospital in Korea. The restrictive measure for designated antibiotics led by an IDS reduced carbapenems usage by -4.57 days of therapy (DOT)/1,000 patient-days per month in general wards (GWs) (95% confidence interval [CI], -6.69 to -2.46; P < 0.001), and by -41.50 DOT/1,000 patient-days per month in intensive care units (ICUs) (95% CI, -57.91 to -25.10; P < 0.001). Similarly, glycopeptides usage decreased by -2.61 DOT/1,000 patient-days per month in GWs (95% CI, -4.43 to -0.79; P = 0.007), and -27.41 DOT/1,000 patient-days per month in ICUs (95% CI, -47.03 to -7.79; P = 0.009). Use of 3rd generation cephalosporins, beta-lactam/beta-lactamase inhibitors, and fluoroquinolones in GWs showed change comparable with that of carbapenems or glycopeptides use. Furthermore, trends of antimicrobial resistance rate of Staphylococcus aureus to gentamicin in GWs, Staphylococcus aureus to ciprofloxacin and oxacillin in ICUs, and Pseudomonas aeruginosa to imipenem in ICUs decreased in slope in the intervention period. The in-hospital mortality rate per 1,000 patient-days among ICU patients remained stable between the pre-intervention and intervention periods. In conclusion, an IDS-led ASPs could enact a meaningful reduction in antibiotic use, and a decrease in antibiotic resistance rate, without changing mortality rates in a large Korean hospital.
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Affiliation(s)
- Hyeonjun Hwang
- School of Economic Sciences, Washington State University, Pullman, USA
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea.
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Emberger J, Tassone D, Stevens MP, Markley JD. The Current State of Antimicrobial Stewardship: Challenges, Successes, and Future Directions. Curr Infect Dis Rep 2018; 20:31. [PMID: 29959545 DOI: 10.1007/s11908-018-0637-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The aim of this study is to examine the current state of the field of antimicrobial stewardship (AS) by highlighting key challenges and successes, as well as exciting future directions. RECENT FINDINGS AS mandates from the Centers for Medicare and Medicaid (CMS) and the Joint Commission (TJC) will stimulate increased compliance with current AS standards, but overall compliance is currently poor. Key challenges to progress in the field of AS include insufficient workforce and monetary resources, poorly defined AS metrics, and much needed expansion beyond the inpatient hospital setting. Despite these challenges, massive progress has been made in the last two and a half decades since the field of AS emerged. AS metrics are rapidly evolving and transforming the way antimicrobial stewardship programs (ASPs) measure success. Rapid diagnostics and diagnostic test stewardship are proving to be extremely effective when coupled with an ASP. Telehealth may improve access to ASP expertise in resource poor settings, and the role of bedside nurses as ASP team members has the potential to greatly augment ASP efforts. Allergy testing as an ASP strategy remains largely underutilized. ASPs have made significant gains in the battle against antimicrobial resistance (AR), but considerable advancement is still needed. Awareness of current challenges is critical to ensure progress in the field. The field of AS is expanding and transforming rapidly through integration, technology, and improved processes.
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Affiliation(s)
- Jennifer Emberger
- Virginia Commonwealth University Medical Center, VMI Building, 2nd Floor, Room 204, Richmond, VA, 23298, USA.
| | - Dan Tassone
- Hunter Holmes McGuire Veterans Affairs Medical Center, Virginia Commonwealth University School of Pharmacy, Richmond, VA, USA
| | - Michael P Stevens
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - J Daniel Markley
- Department of Internal Medicine, Division of Infectious Diseases, Hunter Holmes McGuire Veterans Affairs Medical Center, Virginia Commonwealth University Medical Center, Richmond, VA, USA
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40
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Howell CK, Jacob J, Mok S. Remote Antimicrobial Stewardship: A Solution for Meeting The Joint Commission Stewardship Standard? Hosp Pharm 2018; 54:51-56. [PMID: 30718935 DOI: 10.1177/0018578718769240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: The purpose of this study was to determine the time required for antimicrobial stewardship (AS) activities at a small community hospital (SCH) as well as barriers to remote AS to satisfy The Joint Commission (TJC)'s AS standard. Methods: This was a prospective chart review and time study conducted in patients identified by a clinical decision support application as potential opportunities for antimicrobial therapy modification at a SCH between December 12, 2016, and March 31, 2017. Potential interventions were communicated electronically to the clinical pharmacy specialist, who would then communicate the recommendations to the patient's provider. The primary endpoint was a time study for stewardship activities. Secondary endpoints included describing barriers encountered to remote AS as well as a cost-benefit analysis of remote AS. Results: The time study revealed an average of 11 alerts per day, 9 chart reviews per day, 8 interventions per day, and 5 minutes per chart. Seven hundred twenty-four alerts were evaluated with the most common alerts constituting opportunities for de-escalation (29%), targeted drugs (22%), positive blood cultures (18%), Intravenous (IV) to oral (PO) (17%), and antimicrobial renal monitoring (8%).Interventions were accepted (11%), accepted modified (6%), rejected (35%), or undetermined (48%). Barriers to implementation included workflow and indirect communication. For patients with accepted interventions, there was an average savings of $279.82 per patient in pharmacy charges. Conclusion: Through remote AS, a SCH can have an antimicrobial stewardship program that is in compliance with the basic elements of the TJC standard MM.09.01.01, performs daily chart review by an infectious diseases trained pharmacist to increase the quality of patient care, and achieves a mean savings of $279.82 in pharmacy charges and $1,126.26 in hospital charges per patient with accepted interventions.
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Affiliation(s)
- C K Howell
- University of North Texas Health Science Center, Fort Worth, USA.,Medical City Dallas, TX, USA
| | | | - Steve Mok
- Emory University Hospital Midtown, Atlanta, GA, USA
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Claeys KC, Hopkins TL, Vega AD, Heil EL. Fluoroquinolone Restriction as an Effective Antimicrobial Stewardship Intervention. Curr Infect Dis Rep 2018; 20:7. [PMID: 29572691 DOI: 10.1007/s11908-018-0615-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Fluoroquinolones are a commonly prescribed antibiotic class that has come under scrutiny in recent years due to mounting evidence of association between adverse drug events, C. difficile infection and isolation of antibiotic-resistant bacteria. RECENT FINDINGS Inpatient antimicrobial stewardship (AMS) programs have a toolbox of potential interventions to curb inappropriate antibiotic use, prevent antibiotic-associated adverse drug events, and avoid unnecessary costs of care. Fluoroquinolone restriction policies in the acute care setting have demonstrated beneficial effects, including decreased rates of C. difficile infection and ESBL-producing Enterobacteriaceae. However, a simple blanket restriction policy may "squeeze the antibiotic balloon" and will likely be insufficient if not implemented in conjunction with other AMS interventions. There is a growing body of evidence to support formulary restriction of fluoroquinolones in the acute care setting to decrease rates of C. difficile infection and development of ESBL-producing organisms. Data on how to best implement these restrictions or how to implement outside of acute care settings is limited.
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Affiliation(s)
- Kimberly C Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, N423, Baltimore, MD, 21201, USA. .,Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA.
| | - Teri L Hopkins
- Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Ana D Vega
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, N423, Baltimore, MD, 21201, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, N423, Baltimore, MD, 21201, USA.,Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
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Kaye KS, Bhowmick T, Metallidis S, Bleasdale SC, Sagan OS, Stus V, Vazquez J, Zaitsev V, Bidair M, Chorvat E, Dragoescu PO, Fedosiuk E, Horcajada JP, Murta C, Sarychev Y, Stoev V, Morgan E, Fusaro K, Griffith D, Lomovskaya O, Alexander EL, Loutit J, Dudley MN, Giamarellos-Bourboulis EJ. Effect of Meropenem-Vaborbactam vs Piperacillin-Tazobactam on Clinical Cure or Improvement and Microbial Eradication in Complicated Urinary Tract Infection: The TANGO I Randomized Clinical Trial. JAMA 2018; 319:788-799. [PMID: 29486041 PMCID: PMC5838656 DOI: 10.1001/jama.2018.0438] [Citation(s) in RCA: 222] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Meropenem-vaborbactam is a combination carbapenem/beta-lactamase inhibitor and a potential treatment for severe drug-resistant gram-negative infections. OBJECTIVE To evaluate efficacy and adverse events of meropenem-vaborbactam in complicated urinary tract infection (UTI), including acute pyelonephritis. DESIGN, SETTING, AND PARTICIPANTS Phase 3, multicenter, multinational, randomized clinical trial (TANGO I) conducted November 2014 to April 2016 and enrolling patients (≥18 years) with complicated UTI, stratified by infection type and geographic region. INTERVENTIONS Eligible patients were randomized 1:1 to receive meropenem-vaborbactam (2g/2g over 3 hours; n = 274) or piperacillin-tazobactam (4g/0.5g over 30 minutes; n = 276) every 8 hours. After 15 or more doses, patients could be switched to oral levofloxacin if they met prespecified criteria for improvement, to complete 10 days of total treatment. MAIN OUTCOMES AND MEASURES Primary end point for FDA criteria was overall success (clinical cure or improvement and microbial eradication composite) at end of intravenous treatment in the microbiologic modified intent-to-treat (ITT) population. Primary end point for European Medicines Agency (EMA) criteria was microbial eradication at test-of-cure visit in the microbiologic modified ITT and microbiologic evaluable populations. Prespecified noninferiority margin was -15%. Because the protocol prespecified superiority testing in the event of noninferiority, 2-sided 95% CIs were calculated. RESULTS Among 550 patients randomized, 545 received study drug (mean age, 52.8 years; 361 [66.2%] women; 374 [68.6%] in the microbiologic modified ITT population; 347 [63.7%] in the microbiologic evaluable population; 508 [93.2%] completed the trial). For the FDA primary end point, overall success occurred in 189 of 192 (98.4%) with meropenem-vaborbactam vs 171 of 182 (94.0%) with piperacillin-tazobactam (difference, 4.5% [95% CI, 0.7% to 9.1%]; P < .001 for noninferiority). For the EMA primary end point, microbial eradication in the microbiologic modified ITT population occurred in 128 of 192 (66.7%) with meropenem-vaborbactam vs 105 of 182 (57.7%) with piperacillin-tazobactam (difference, 9.0% [95% CI, -0.9% to 18.7%]; P < .001 for noninferiority); microbial eradication in the microbiologic evaluable population occurred in 118 of 178 (66.3%) vs 102 of 169 (60.4%) (difference, 5.9% [95% CI, -4.2% to 16.0%]; P < .001 for noninferiority). Adverse events were reported in 106 of 272 (39.0%) with meropenem-vaborbactam vs 97 of 273 (35.5%) with piperacillin-tazobactam. CONCLUSIONS AND RELEVANCE Among patients with complicated UTI, including acute pyelonephritis and growth of a baseline pathogen, meropenem-vaborbactam vs piperacillin-tazobactam resulted in a composite outcome of complete resolution or improvement of symptoms along with microbial eradication that met the noninferiority criterion. Further research is needed to understand the spectrum of patients in whom meropenem-vaborbactam offers a clinical advantage. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02166476.
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Affiliation(s)
- Keith S. Kaye
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Tanaya Bhowmick
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Symeon Metallidis
- Department of First Internal Medicine, AHEPA Hospital, Medical School, Aristotle University, Thessaloniki, Greece
| | - Susan C. Bleasdale
- Department of Medicine, University of Illinois College of Medicine, Chicago
| | - Olexiy S. Sagan
- Department of Urology, Regional Clinical Hospital of Zaporizhizhia, Zaporizhizhia, Ukraine
| | - Viktor Stus
- Department of Urology, Dnipropetrovsk Medical Academy of Ministry of Health of Ukraine, Dnipro
| | - Jose Vazquez
- Division of Infectious Diseases, Medical College of Georgia, Augusta University, Augusta
| | - Valerii Zaitsev
- Clinical Studies Department, Bucovinian State Medical University, Chernivtsi, Ukraine
| | | | - Erik Chorvat
- Department of Urology, Urologicke Oddelenie NSP, Poprad, Slovak Republic
| | | | - Elena Fedosiuk
- Department of Anesthesiology and Intensive Care, Nephrology and Hemocorrection, Brest Regional Hospital, Brest, State Republic of Belarus
| | - Juan P. Horcajada
- Hospital del Mar, Infectious Pathology and Antimicrobials Resaearch Group (IPAR)—Institut Hospital del Mar d’Investigaciones Mèdiques (IMIM), Barcelona, Spain
| | - Claudia Murta
- Department of Infection Control Service, Santa Casa de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
| | - Yaroslav Sarychev
- Department of Urology with Forensic Medicine, Ukrainian Medical Stomatological Academy, Poltava, Ukraine
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Kimura T, Uda A, Sakaue T, Yamashita K, Nishioka T, Nishimura S, Ebisawa K, Nagata M, Ohji G, Nakamura T, Koike C, Kusuki M, Ioroi T, Mukai A, Abe Y, Yoshida H, Hirai M, Arakawa S, Yano I, Iwata K, Tokimatsu I. Long-term efficacy of comprehensive multidisciplinary antibiotic stewardship programs centered on weekly prospective audit and feedback. Infection 2017; 46:215-224. [PMID: 29134582 DOI: 10.1007/s15010-017-1099-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/03/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the long-term effects of comprehensive antibiotic stewardship programs (ASPs) on antibiotic use, antimicrobial-resistant bacteria, and clinical outcomes. DESIGN Before-after study. SETTING National university hospital with 934 beds. INTERVENTION Implementation in March 2010 of a comprehensive ASPs including, among other strategies, weekly prospective audit and feedback with multidisciplinary collaboration. METHODS The primary outcome was the use of antipseudomonal antibiotics as measured by the monthly mean days of therapy per 1000 patient days each year. Secondary outcomes included overall antibiotic use and that of each antibiotic class, susceptibility of Pseudomonas aeruginosa, the proportion of patients isolated methicillin-resistant Staphylococcus aureus (MRSA) among all patients isolated S. aureus, the incidence of MRSA, and the 30-day mortality attributable to bacteremia. RESULTS The mean monthly use of antipseudomonal antibiotics significantly decreased in 2011 and after as compared with 2009. Susceptibility to levofloxacin was significantly increased from 2009 to 2016 (P = 0.01 for trend). Its susceptibility to other antibiotics remained over 84% and did not change significantly during the study period. The proportion of patients isolated MRSA and the incidence of MRSA decreased significantly from 2009 to 2016 (P < 0.001 and = 0.02 for trend, respectively). There were no significant changes in the 30-day mortality attributable to bacteremia during the study period (P = 0.57 for trend). CONCLUSION The comprehensive ASPs had long-term efficacy for reducing the use of the targeted broad-spectrum antibiotics, maintaining the antibiotic susceptibility of P. aeruginosa, and decreasing the prevalence of MRSA, without adversely affecting clinical outcome.
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Affiliation(s)
- Takeshi Kimura
- Department of Pharmacy, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan. .,Department of Infection Control and Prevention, Kobe University Hospital, Kobe, Hyogo, Japan.
| | - Atsushi Uda
- Department of Pharmacy, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.,Department of Infection Control and Prevention, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Tomoyuki Sakaue
- Department of Pharmacy, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kazuhiko Yamashita
- Department of Pharmacy, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Tatsuya Nishioka
- Department of Pharmacy, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.,Department of Infection Control and Prevention, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Sho Nishimura
- Department of Infection Control and Prevention, Kobe University Hospital, Kobe, Hyogo, Japan.,Department of Infectious Disease, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Kei Ebisawa
- Department of Infection Control and Prevention, Kobe University Hospital, Kobe, Hyogo, Japan.,Department of Infectious Disease, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Manabu Nagata
- Department of Infection Control and Prevention, Kobe University Hospital, Kobe, Hyogo, Japan.,Department of Infectious Disease, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Goh Ohji
- Department of Infection Control and Prevention, Kobe University Hospital, Kobe, Hyogo, Japan.,Department of Infectious Disease, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Tatsuya Nakamura
- Department of Infection Control and Prevention, Kobe University Hospital, Kobe, Hyogo, Japan.,Department of Clinical Laboratory, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Chihiro Koike
- Department of Infection Control and Prevention, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Mari Kusuki
- Department of Infection Control and Prevention, Kobe University Hospital, Kobe, Hyogo, Japan.,Department of Clinical Laboratory, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Takeshi Ioroi
- Department of Pharmacy, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Akira Mukai
- Faculty of Pharmaceutical Sciences, Setsunan University, Osaka, Japan
| | - Yasuhisa Abe
- Abe Internal Medicine Clinic, Kobe, Hyogo, Japan
| | | | - Midori Hirai
- Department of Pharmacy, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | | | - Ikuko Yano
- Department of Pharmacy, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kentaro Iwata
- Department of Infectious Disease, Kobe University Hospital, Kobe, Hyogo, Japan
| | - Issei Tokimatsu
- Department of Infection Control and Prevention, Kobe University Hospital, Kobe, Hyogo, Japan
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Chavada R, Walker HN, Tong D, Murray A. Changes in antimicrobial prescribing behavior after the introduction of the antimicrobial stewardship program: A pre- and post-intervention survey. Infect Dis Rep 2017; 9:7268. [PMID: 29071048 PMCID: PMC5641660 DOI: 10.4081/idr.2017.7268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/23/2017] [Accepted: 08/25/2017] [Indexed: 12/02/2022] Open
Abstract
The introduction of an antimicrobial stewardship (AMS) program is associated with a change in antimicrobial prescribing behavior. A proposed mechanism for this change is by impacting the prescribing etiquette described in qualitative studies. This study sought to detect a change in prescribing attitudes 12 months after the introduction of AMS and gauge utility of various AMS interventions. Surveys were distributed to doctors in two regional Australian hospitals on a convenience basis 6 months before, and 12 months after, the introduction of AMS. Agreement with 20 statements describing attitudes (cultural, behavioral and knowledge) towards antimicrobial prescribing was assessed on a 4-point Likert scale. Mean response scores were compared using the Wilcoxon Rank sum test. 155 responses were collected before the introduction of AMS, and 144 afterwards. After the introduction of AMS, an increase was observed in knowledge about available resources such as electronic decision support systems (EDSS) and therapeutic guidelines, with raised awareness about the support available through AMS rounds and the process to be followed when prescribing restricted antimicrobials. Additionally, doctors were less likely to rely on pharmacy to ascertain when an antimicrobial was restricted, depend on infectious diseases consultant advice and use past experience to guide antimicrobial prescribing. Responses to this survey indicate that positive changes to the antimicrobial prescribing etiquette may be achieved with the introduction of an AMS program. Use of EDSS and other resources such as evidence-based guidelines are perceived to be important to drive rational antimicrobial prescribing within AMS programs.
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Affiliation(s)
- Ruchir Chavada
- Department of Microbiology and Infectious Diseases, Pathology North Central Coast
| | - Harry N Walker
- Division of Medicine, Central Coast Local Health District
| | - Deborah Tong
- Pharmacy Department, Central Coast Local Health District, NSW, Australia
| | - Amy Murray
- Pharmacy Department, Central Coast Local Health District, NSW, Australia
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45
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Tamma PD, Avdic E, Li DX, Dzintars K, Cosgrove SE. Association of Adverse Events With Antibiotic Use in Hospitalized Patients. JAMA Intern Med 2017; 177:1308-1315. [PMID: 28604925 PMCID: PMC5710569 DOI: 10.1001/jamainternmed.2017.1938] [Citation(s) in RCA: 436] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Estimates of the incidence of overall antibiotic-associated adverse drug events (ADEs) in hospitalized patients are generally unavailable. OBJECTIVE To describe the incidence of antibiotic-associated ADEs for adult inpatients receiving systemic antibiotic therapy. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort of adult inpatients admitted to general medicine wards at an academic medical center. EXPOSURES At least 24 hours of any parenteral or oral antibiotic therapy. MAIN OUTCOMES AND MEASURES Medical records of 1488 patients were examined for 30 days after antibiotic initiation for the development of the following antibiotic-associated ADEs: gastrointestinal, dermatologic, musculoskeletal, hematologic, hepatobiliary, renal, cardiac, and neurologic; and 90 days for the development of Clostridium difficile infection or incident multidrug-resistant organism infection, based on adjudication by 2 infectious diseases trained clinicians. RESULTS In 1488 patients, the median age was 59 years (interquartile range, 49-69 years), and 758 (51%) participants were female. A total of 298 (20%) patients experienced at least 1 antibiotic-associated ADE. Furthermore, 56 (20%) non-clinically indicated antibiotic regimens were associated with an ADE, including 7 cases of C difficile infection. Every additional 10 days of antibiotic therapy conferred a 3% increased risk of an ADE. The most common ADEs were gastrointestinal, renal, and hematologic abnormalities, accounting for 78 (42%), 45 (24%), and 28 (15%) 30-day ADEs, respectively. Notable differences were identified between the incidence of ADEs associated with specific antibiotics. CONCLUSIONS AND RELEVANCE Although antibiotics may play a critical role when used appropriately, our findings underscore the importance of judicious antibiotic prescribing to reduce the harm that can result from antibiotic-associated ADEs.
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Affiliation(s)
- Pranita D Tamma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edina Avdic
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - David X Li
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kathryn Dzintars
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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