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Ryan KL, Jeffres M, Hornback KM, Lusardi K, Hirsch EB. Adding Antimicrobial Stewardship Pharmacists to the Infectious Diseases Compensation Discussion: A More Perfect Union? Clin Infect Dis 2024; 79:271-272. [PMID: 38014757 DOI: 10.1093/cid/ciad722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/22/2023] [Accepted: 11/22/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Keenan Levy Ryan
- Inpatient Pharmacy Department, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Meghan Jeffres
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Krutika Mediwala Hornback
- Department of Pharmacy, Medical University of South Carolina (MUSC) Health, Charleston, South Carolina, USA
| | - Katherine Lusardi
- Department of Pharmacy, Baptist Health System, Little Rock, Arkansas, USA
| | - Elizabeth B Hirsch
- Department of Experimental & Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
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2
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Zwerwer LR, Luz CF, Soudis D, Giudice N, Nijsten MWN, Glasner C, Renes MH, Sinha B. Identifying the need for infection-related consultations in intensive care patients using machine learning models. Sci Rep 2024; 14:2317. [PMID: 38282072 PMCID: PMC10822855 DOI: 10.1038/s41598-024-52741-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/23/2024] [Indexed: 01/30/2024] Open
Abstract
Infection-related consultations on intensive care units (ICU) have a positive impact on quality of care and clinical outcome. However, timing of these consultations is essential and to date they are typically event-triggered and reactive. Here, we investigate a proactive approach to identify patients in need for infection-related consultations by machine learning models using routine electronic health records. Data was retrieved from a mixed ICU at a large academic tertiary care hospital including 9684 admissions. Infection-related consultations were predicted using logistic regression, random forest, gradient boosting machines, and long short-term memory neural networks (LSTM). Overall, 7.8% of admitted patients received an infection-related consultation. Time-sensitive modelling approaches performed better than static approaches. Using LSTM resulted in the prediction of infection-related consultations in the next clinical shift (up to eight hours in advance) with an area under the receiver operating curve (AUROC) of 0.921 and an area under the precision recall curve (AUPRC) of 0.541. The successful prediction of infection-related consultations for ICU patients was done without the use of classical triggers, such as (interim) microbiology reports. Predicting this key event can potentially streamline ICU and consultant workflows and improve care as well as outcome for critically ill patients with (suspected) infections.
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Affiliation(s)
- Leslie R Zwerwer
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
- Center for Information Technology, University of Groningen, Nettelbosje 1, 9747 AJ, Groningen, The Netherlands.
| | - Christian F Luz
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Dimitrios Soudis
- Center for Information Technology, University of Groningen, Nettelbosje 1, 9747 AJ, Groningen, The Netherlands
| | - Nicoletta Giudice
- Center for Information Technology, University of Groningen, Nettelbosje 1, 9747 AJ, Groningen, The Netherlands
| | - Maarten W N Nijsten
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Corinna Glasner
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Maurits H Renes
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Bhanu Sinha
- Department of Medical Microbiology and Infection Prevention, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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Kassamali Escobar Z, Shively NR. Health System and Tele-Antimicrobial Stewardship: The Role of Building Networks. Infect Dis Clin North Am 2023; 37:873-900. [PMID: 37657974 DOI: 10.1016/j.idc.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Tele-antimicrobial stewardship programs (tele-ASPs) use technology and remote access to resources and clinical expertise to expand antimicrobial services within and outside of health systems. Models of tele-ASPs are workforce multiplying and workforce extending, depending on how they are structured. Building rapport and strong interpersonal networks are essential for successful ASPs. The available evidence suggests that an optimal model for tele-ASP includes hands-on involvement from remote infectious disease (ID) expertise with implementation by local pharmacists. However, this model remains limited by the available time and cost of ID-trained specialists.
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Affiliation(s)
- Zahra Kassamali Escobar
- University of Washington Center for Stewardship in Medicine, Seattle, WA, USA; Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 825 Eastlake Avenue, Mail Stop G5-900, P.O. Box 19023, Seattle, WA 98109, USA
| | - Nathan R Shively
- Division of Infectious Diseases, Allegheny Health Network, 320 E North Avenue, Fourth Floor, East Wing, Suite 406, Pittsburgh, PA 15212, USA.
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Wi YM, Kwon KT, Jeon CH, Kim SH, Hwang S, Bae S, Kim Y, Chang HH, Kim SW, Cheong HS, Lee S, Jung DS, Sohn KM, Moon C, Heo ST, Kim B, Lee MS, Hur J, Kim J, Yoon YK. Carbapenem Use in the Last Days of Life: A Nationwide Korean Study. Antibiotics (Basel) 2023; 12:964. [PMID: 37370283 DOI: 10.3390/antibiotics12060964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/09/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023] Open
Abstract
The appropriate use of carbapenem is a critical concern for patient safety and public health, and is a national priority. We investigated the nationwide status of carbapenem prescription in patients within their last 14 days of life to guide judicious-use protocols from the previous study comprised of 1350 decedents. Carbapenem use was universally controlled through computerised authorisation system at all centres during the study period. Carbapenem prescribing patterns and their optimality were evaluated. A total of 1201 patients received antimicrobial agents within the last two weeks of their lives, of whom 533 (44.4%) received at least one carbapenem. The median carbapenem treatment duration was seven days. Of the 533 patients receiving carbapenems, 510 (95.7%) patients had microbiological samples drawn and 196 (36.8%) yielded carbapenem-resistant pathogens. A total of 200 (37.5%) patients were referred to infectious disease (ID) specialists. Of the 333 patients (62.5%) who did not have ID consultations, 194 (58.2%) were assessed as "not optimal", 79 (23.7%) required escalation, 100 (30.0%) required de-escalation, and 15 (4.5%) were discontinued. Notwithstanding the existing antibiotic restriction program system, carbapenems are commonly prescribed to patients in their last days of life.
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Affiliation(s)
- Yu Mi Wi
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu 41404, Republic of Korea
| | - Cheon-Hoo Jeon
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea
| | - Si-Ho Kim
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea
| | - Soyoon Hwang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu 41404, Republic of Korea
| | - Sohyun Bae
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Yoonjung Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Hyun-Ha Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Shin-Woo Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Hae Suk Cheong
- Division of Infectious Diseases, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, Republic of Korea
| | - Shinwon Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, Busan 50612, Republic of Korea
| | - Dong Sik Jung
- Department of Internal Medicine, Dong-A University College of Medicine, Busan 49201, Republic of Korea
| | - Kyung Mok Sohn
- Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon 35015, Republic of Korea
| | - Chisook Moon
- Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan 47392, Republic of Korea
| | - Sang Taek Heo
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Jeju National University, Jeju 63241, Republic of Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Republic of Korea
| | - Mi Suk Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul 02447, Republic of Korea
| | - Jian Hur
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu 42415, Republic of Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Republic of Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, Republic of Korea
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Chorafa E, Komatsiouli V, Iosifidis E, Kourti M, Sdougka M, Roilides E. Antimicrobial Stewardship Programs in PICU Settings: A Systematic Review. Pediatr Crit Care Med 2023; 24:e20-e27. [PMID: 36000864 DOI: 10.1097/pcc.0000000000003069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Development of antimicrobial stewardship programs (ASPs) is strategy for prevention and management of emergence of antimicrobial-resistant organisms. In this study, we systematically reviewed the literature on antimicrobial stewardship interventions in PICUs and analyzed approaches, structure, implementation, and outcomes of the ASPs. DATA SOURCES PubMed and Scopus databases were systematically searched for studies published from January 1, 2007, to December 31, 2020, reporting interventions on judicious use of antimicrobials in PICUs (last search performed February 28, 2021). DATA SELECTION Studies that evaluated an intervention in a PICU setting or both in PICU and other settings and reported separate results for PICU were eligible for full-text review. Studies that had implemented stewardship in the entire hospital, including the PICU, but without presenting dedicated PICU data were excluded from the analysis. DATA EXTRACTION The strategy of intervention, structure of ASP team, implementation, and outcomes were assessed with a checklist tool for all studies included in the analysis. Risk of bias was assessed with the Cochrane Risk-of-Bias in Nonrandomized studies of Interventions tool. DATA SYNTHESIS Thirteen articles were found: 11 that applied ASP in PICUs, and two at hospital level. All PICU-dedicated ASPs applied a multimodal intervention combining strategies simultaneously; audit with feedback (6/11) and facility-specific clinical practice guidelines (7/11) were the most common strategies. A multidisciplinary team was formulated in all ASPs except for three biomarker-based interventions. Six of 11 studies included techniques to enhance behavior change and one implemented a behavior-based intervention. Antibiotic consumption was evaluated in all ASPs, cost in three of 11, antibiotic resistance in one of 11, length of hospitalization in six of 11, and mortality in eight of 11. All hospital-wide ASPs used audit with feedback in addition to facility-specific clinical practice guidelines and assessed antimicrobial consumption, expenditures, length of stay, and mortality. CONCLUSIONS The prevalence of ASPs in PICUs is limited, and few programs follow all of the currently available recommendations.
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Affiliation(s)
- Elisavet Chorafa
- Infectious Diseases Unit, Third Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Vasiliki Komatsiouli
- Infectious Diseases Unit, Third Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Elias Iosifidis
- Infectious Diseases Unit, Third Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Maria Kourti
- Infectious Diseases Unit, Third Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Maria Sdougka
- Pediatric Intensive Care Unit, Hippokration General Hospital, Thessaloniki, Greece
| | - Emmanuel Roilides
- Infectious Diseases Unit, Third Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
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Abstract
BACKGROUND Antimicrobials are the most commonly prescribed drug class in children. Overuse through inappropriate prescribing is a key driver of antimicrobial resistance and is recognized as one of the top 10 threats to global health by the World Health Organization. METHODS A prospective observational cohort study was performed following implementation of a multifaceted Antimicrobial Stewardship (AMS) program (January 2014 to December 2020). Data were collected on AMS and "handshake" ward rounds from patient information sources and directly from clinicians responsible for patient care. Primary outcomes include appropriateness of therapy (drug, dose, antimicrobial spectrum, duration and route), compliance with prescribing guidelines, antimicrobial expenditure, use of high-priority antimicrobials and duration of hospitalization. We compared outcomes across 3 time periods; January 2014-December 2015, January 2016-December 2017 and January 2018-December 2020. RESULTS The appropriateness of individual antimicrobial orders improved across the study periods from 6111/7040 (79.4%) in the first 2 years following implementation of the AMS program to 17,819/19,229 (92.3%) in the latter period. Guideline compliance increased from 5426/7700 (70.5%) to 17,822/19,316 (92.3%). A reduction in overall antimicrobial expenditure (34% reduction, equivalent to $12.52 per bed day) and a decrease in antifungal expenditure (37% reduction, equivalent to $5.56 per bed day) was observed across the time periods. CONCLUSIONS This study quantifies a comprehensive pediatric AMS program's sustained impact on reducing inappropriate antimicrobial use and expenditure and improving compliance with guidelines. The effectiveness of these interventions has been demonstrated and should be considered by institutions seeking to improve rational antimicrobial use in children.
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Whittington KJ, Ma Y, Butler AM, Hogan PG, Ahmed F, Flowers J, Milburn G, Morelli JJ, Newland JG, Fritz SA. The impact of infectious diseases consultation for children with Staphylococcus aureus bacteremia. Pediatr Res 2022; 92:1598-1605. [PMID: 35982140 PMCID: PMC9789160 DOI: 10.1038/s41390-022-02251-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/14/2022] [Accepted: 07/27/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Despite clear benefit of improved outcomes in adults, the impact of infectious diseases (ID) consultation for Staphylococcus aureus bacteremia in children remains understudied. METHODS To assess the impact of pediatric ID consultation on management and outcomes, we conducted a cohort study of children with S. aureus bacteremia at St. Louis Children's Hospital from 2011 to 2018. We assessed adherence to six established quality-of-care indicators (QCIs). We applied propensity score methodology to examine the impact of ID consultation on risk of treatment failure, a composite of all-cause mortality or hospital readmission within 90 days. RESULTS Of 306 patients with S. aureus bacteremia, 193 (63%) received ID consultation. ID consultation was associated with increased adherence to all QCIs, including proof-of-cure blood cultures, indicated laboratory studies, echocardiography, source control, targeted antibiotic therapy, and antibiotic duration. Obtaining proof-of-cure blood cultures and all indicated laboratory studies were associated with improved outcomes. In propensity score-weighted analyses, risk of treatment failure was similar among patients who did and did not receive ID consultation. However, the number of events was small and risk estimates were imprecise. CONCLUSIONS For children with S. aureus bacteremia, ID consultation improved adherence to QCIs, some of which were associated with improved clinical outcomes. IMPACT In children with Staphylococcus aureus bacteremia, consultation by an infectious diseases (ID) physician improved adherence to established quality-of-care indicators (QCIs). The current literature regarding ID consultation in pediatric S. aureus bacteremia is sparse. Three prior international studies demonstrated improved quality of care with ID consultation, though results were disparate regarding clinical outcomes. This article impacts the current literature by strengthening the evidence that ID consultation in children improves adherence to QCIs, and demonstrates that adherence to QCIs improves clinical outcomes.
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Affiliation(s)
- Kyle J. Whittington
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Yinjiao Ma
- Department of Medicine Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Anne M. Butler
- Department of Medicine Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Patrick G. Hogan
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Faria Ahmed
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - JessieAnn Flowers
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Grace Milburn
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - John J. Morelli
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Jason G. Newland
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Stephanie A. Fritz
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA,Corresponding author: Stephanie A. Fritz, MD, MSCI, 660 S. Euclid Avenue, MSC 8116-43-10, St. Louis, MO 63110-9872, , Phone: (314) 454-6050
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Vento TJ, Veillette JJ, Gelman SS, Adams A, Jones P, Repko K, Stenehjem EA. Implementation of an Infectious Diseases Telehealth Consultation and Antibiotic Stewardship Program for 16 Small Community Hospitals. Open Forum Infect Dis 2021; 8:ofab168. [PMID: 34141816 PMCID: PMC8205263 DOI: 10.1093/ofid/ofab168] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/01/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Telehealth improves access to infectious diseases (ID) and antibiotic stewardship (AS) services in small community hospitals (SCHs), but the optimal model has not been defined. We describe implementation and impact of an integrated ID telehealth (IDt) service for 16 SCHs in the Intermountain Healthcare system. METHODS The Intermountain IDt service included a 24-hour advice line, eConsults, telemedicine consultations (TCs), daily AS surveillance, long-term AS program (ASP) support by an IDt pharmacist, and a monthly telementoring webinar. We evaluated program measures from November 2016 through April 2018. RESULTS A total of 2487 IDt physician interactions with SCHs were recorded: 859 phone calls (35% of interactions), 761 eConsults (30%), and 867 TCs (35%). Of 1628 eConsults and TCs, 1400 (86%) were SCH provider requests, while 228 (14%) were IDt pharmacist generated. Six SCHs accounted for >95% of interactions. Median consultation times for each initial telehealth interaction type were 5 (interquartile range [IQR], 5-10) minutes for phone calls, 20 (IQR, 15-25) minutes for eConsults, and 50 (IQR, 35-60) minutes for TCs. Thirty-two percent of consults led to in-person ID clinic follow-up. Bacteremia was the most common reason for consultation (764/2487 [31%]) and Staphylococcus aureus the most common organism identified. ASPs were established at 16 facilities. Daily AS surveillance led to 2229 SCH pharmacist and 1305 IDt pharmacist recommendations. Eight projects were completed with IDt pharmacist support, leading to significant reductions in meropenem, vancomycin, and fluoroquinolone use. CONCLUSIONS An integrated IDt model led to collaborative ID/ASP interventions and improvements in antibiotic use at 16 SCHs. These findings provide insight into clinical and logistical considerations for IDt program implementation.
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Affiliation(s)
- Todd J Vento
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical Center, Murray, Utah, USA
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Intermountain Healthcare TeleHealth Services, Murray, Utah, USA
| | - John J Veillette
- Intermountain Healthcare TeleHealth Services, Murray, Utah, USA
- Department of Pharmacy, Intermountain Medical Center, Murray, Utah, USA
| | - Stephanie S Gelman
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical Center, Murray, Utah, USA
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Intermountain Healthcare TeleHealth Services, Murray, Utah, USA
| | - Angie Adams
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical Center, Murray, Utah, USA
| | - Peter Jones
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical Center, Murray, Utah, USA
| | - Katherine Repko
- Intermountain Healthcare TeleHealth Services, Murray, Utah, USA
| | - Edward A Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Medical Center, Murray, Utah, USA
- Office of Patient Experience, Intermountain Healthcare, Salt Lake City, Utah, USA
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Gerber JS, Jackson MA, Tamma PD, Zaoutis TE. Policy Statement: Antibiotic Stewardship in Pediatrics. J Pediatric Infect Dis Soc 2021; 10:641-649. [PMID: 33595086 DOI: 10.1093/jpids/piab002] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/04/2021] [Indexed: 11/15/2022]
Abstract
Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting the use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy and duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs (ASPs); essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient ASPs are provided.
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Affiliation(s)
- Jeffrey S Gerber
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mary Anne Jackson
- Department of Pediatrics, Section of Infectious Disease, Children's Mercy Hospital, UMKC School of Medicine, Kansas City, Missouri, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Pediatric Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Theoklis E Zaoutis
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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10
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Shively NR, Moffa MA, Paul KT, Wodusky EJ, Schipani BA, Cuccaro SL, Harmanos MS, Cratty MS, Chamovitz BN, Walsh TL. Impact of a Telehealth-Based Antimicrobial Stewardship Program in a Community Hospital Health System. Clin Infect Dis 2021; 71:539-545. [PMID: 31504367 DOI: 10.1093/cid/ciz878] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/03/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Data on antimicrobial stewardship programs (ASPs) facilitated via telehealth in the community hospital setting are limited. METHODS A telehealth-based ASP was implemented in 2 community hospitals (285 and 176 beds). Local pharmacists without residency or prior antimicrobial stewardship training were trained to conduct prospective audit and feedback. For approximately 60 minutes 3 times weekly at the 285-bed hospital and 2 times weekly at the 176-bed hospital, infectious diseases (ID) physicians remotely reviewed patients on broad-spectrum antibiotics and those admitted with lower respiratory tract infections and skin and soft tissue infections with local pharmacists. Recommendations for ASP interventions made by ID physicians were relayed to primary teams and tracked by local pharmacists. Antimicrobial utilization was collected in days of therapy (DOT) per 1000 patient-days (PD) for a 12-month baseline and 6-month intervention period, and analyzed with segmented linear regression analysis. Local ID consultations were tracked and antimicrobial cost savings were estimated. RESULTS During the 6-month intervention period, 1419 recommendations were made, of which 1262 (88.9%) were accepted. Compared to the baseline period, broad-spectrum antibiotic utilization decreased by 24.4% (342.1 vs 258.7 DOT/1000 PD; P < .001) during the intervention period. ID consultations increased by 40.2% (15.4 consultations per 1000 PD vs 21.5 consultations per 1000 PD; P = .001). Estimated annualized savings on antimicrobial expenditures were $142 629.83. CONCLUSIONS An intense ASP model, facilitated in the community hospital setting via telehealth, led to reduced broad-spectrum antimicrobial utilization, increased ID consultations, and reduced antimicrobial expenditures.
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Affiliation(s)
- Nathan R Shively
- Division of Infectious Diseases, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Matthew A Moffa
- Division of Infectious Diseases, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Kathleen T Paul
- Department of Pharmacy, Heritage Valley Health System, Beaver and Sewickley, Pennsylvania, USA
| | - Eric J Wodusky
- Department of Pharmacy, Heritage Valley Health System, Beaver and Sewickley, Pennsylvania, USA
| | - Beth Ann Schipani
- Department of Pharmacy, Heritage Valley Health System, Beaver and Sewickley, Pennsylvania, USA
| | - Susan L Cuccaro
- Department of Pharmacy, Heritage Valley Health System, Beaver and Sewickley, Pennsylvania, USA
| | - Mark S Harmanos
- Department of Pharmacy, Heritage Valley Health System, Beaver and Sewickley, Pennsylvania, USA
| | - Michael S Cratty
- Department of Medicine, Heritage Valley Health System, Beaver and Sewickley, Pennsylvania, USA
| | - Bruce N Chamovitz
- Division of Infectious Diseases, Heritage Valley Health System, Beaver and Sewickley, Pennsylvania, USA
| | - Thomas L Walsh
- Division of Infectious Diseases, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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11
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MacBrayne CE, Williams MC, Levek C, Child J, Pearce K, Birkholz M, Todd JK, Hurst AL, Parker SK. Sustainability of Handshake Stewardship: Extending a Hand Is Effective Years Later. Clin Infect Dis 2021; 70:2325-2332. [PMID: 31584641 DOI: 10.1093/cid/ciz650] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/11/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Children's Hospital Colorado created a unique method of antimicrobial stewardship, called handshake stewardship, that effectively decreased hospital anti-infective use and costs in its pilot year (2013). Handshake stewardship is distinguished by: (1) the lack of prior authorization; (2) a review of all prescribed anti-infectives; (3) a shared review by the physician and the pharmacist; and (4) a daily, rounding-based, in-person approach to supporting providers. We sought to reevaluate the outcomes of the program after 5 years of experience, totaling 8 years of data. METHODS We retrospectively measured anti-infective (antibiotic, antiviral, antifungal) use hospital-wide by unit and by drug for an 8-year period spanning October 2010 to October 2018. Aggregated monthly use was measured in days of therapy per thousand patient days (DOT/1000 PD). The percentage of children admitted ever receiving an anti-infective was also measured, as well as severity-adjusted mortality, readmissions, and lengths of stay. RESULTS Hospital-wide mean anti-infective use significantly decreased, from 891 (95% confidence interval [CI] 859-923) in the pre-implementation phase to 655 (95% CI 637-694) DOT/1000 PD in post-implementation Year 5; in a segmented regression time series analysis, this was a rate of -2.6 DOT/1000 PD (95% CI -4.8 to -0.4). This is largely attributable to decreased antibacterial use, from 704 (95% CI 686-722) to 544 (95% CI 525 -562) DOT/1000 PD. The percentage of children ever receiving an anti-infective during admission likewise declined, from 65% to 52% (95% CI 49-54). There were no detrimental effects on severity adjusted mortality, readmissions, or lengths of stay. CONCLUSIONS The handshake method is an effective and sustainable approach to stewardship.
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Affiliation(s)
- Christine E MacBrayne
- Department of Pharmacy Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Manon C Williams
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Claire Levek
- Department of Pediatrics and Child Health Research Biostatistical Core, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jason Child
- Department of Pharmacy Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Kelly Pearce
- Department of Infection Prevention and Control, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Meghan Birkholz
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - James K Todd
- Department of Pediatrics, Section of Pediatric Infectious Diseases and Department of Infection Prevention and Control, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amanda L Hurst
- Department of Pharmacy Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Sarah K Parker
- Department of Pediatrics, Section of Pediatric Infectious Diseases and Department of Infection Prevention and Control, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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12
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Abstract
Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy, duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs; essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient antibiotic stewardship programs are provided.
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Affiliation(s)
- Jeffrey S Gerber
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
| | - Mary Anne Jackson
- Section of Infectious Disease, Department of Pediatrics, Children's Mercy Hospital and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; and
| | - Pranita D Tamma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Theoklis E Zaoutis
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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13
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Physician experiences implementing antimicrobial stewardship rounds in pediatric hospital medicine: An exploratory, qualitative study. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e11. [PMID: 36168511 PMCID: PMC9495538 DOI: 10.1017/ash.2021.175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/14/2021] [Indexed: 11/30/2022]
Abstract
Objectives: An antimicrobial stewardship intervention was implemented for pediatric medicine units using an in-person rounds-based approach to provide stewardship recommendations and education from an antimicrobial stewardship physician and antimicrobial stewardship pharmacist. Design, Setting, Participants, and Methods: In this exploratory qualitative study, purposeful sampling was used to recruit participants for individual interviews at a tertiary- and quaternary-care referral center. Pediatricians and residents who attended ≥1 stewardship round were included. A semistructured interview guide was created focusing on perceptions of antimicrobial stewardship, personal experiences at stewardship rounds, and perceived impacts on patient care. Using a constant comparative analysis approach, codes were developed and collapsed into themes. Results: Overall, 8 pediatricians and 10 residents completed interviews. Qualitative analysis yielded 3 themes: insights into clinical reasoning, opportunity for growth and learning, and establishing and exploring professional relationships. The handshake-rounds approach encouraged participants to critically evaluate antimicrobial choices and to engage in discussion with the antimicrobial stewardship team. Participants felt validated at stewardship rounds and gained confidence prescribing antimicrobials. Face-to-face interaction reduced reluctance for some participants to consult infectious disease (ID) service; however, others worried that physicians may avoid ID consultation because of stewardship rounds. Conclusions: Participants found stewardship rounds to be an effective strategy for education and development of clinical reasoning skills for optimal antimicrobial prescribing—choosing wisely or choosing rightly. The effects of stewardship rounds on timing and frequency of ID consultation are interesting. Further research into important patient outcomes and consultation practices are needed locally, but our experiences may help others to reflect on the power of conversation and relationships in antimicrobial stewardship.
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14
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Searns JB, Williams MC, MacBrayne CE, Wirtz AL, Leonard JE, Boguniewicz J, Parker SK, Grubenhoff JA. Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. Diagnosis (Berl) 2020; 8:347-352. [PMID: 33112779 DOI: 10.1515/dx-2020-0032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 09/17/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Few studies describe the impact of antimicrobial stewardship programs (ASPs) on recognizing and preventing diagnostic errors. Handshake stewardship (HS-ASP) is a novel ASP model that prospectively reviews hospital-wide antimicrobial usage with recommendations made in person to treatment teams. The purpose of this study was to determine if HS-ASP could identify and intervene on potential diagnostic errors for children hospitalized at a quaternary care children's hospital. METHODS Previously self-identified "Great Catch" (GC) interventions by the Children's Hospital Colorado HS-ASP team from 10/2014 through 5/2018 were retrospectively reviewed. Each GC was categorized based on the types of recommendations from HS-ASP, including if any diagnostic recommendations were made to the treatment team. Each GC was independently scored using the "Safer Dx Instrument" to determine presence of diagnostic error based on a previously determined cut-off score of ≤1.50. Interrater reliability for the instrument was measured using a randomized subset of one third of GCs. RESULTS During the study period, there were 162 GC interventions. Of these, 65 (40%) included diagnostic recommendations by HS-ASP and 19 (12%) had a Safer Dx Score of ≤1.50, (Κ=0.44; moderate agreement). Of those GCs associated with diagnostic errors, the HS-ASP team made a diagnostic recommendation to the primary treatment team 95% of the time. CONCLUSIONS Handshake stewardship has the potential to identify and intervene on diagnostic errors for hospitalized children.
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Affiliation(s)
- Justin B Searns
- Divisions of Hospital Medicine & Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, 13123 E 16th Ave, B302, Aurora, CO 80045, USA
| | - Manon C Williams
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Christine E MacBrayne
- Department of Pharmacy, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Ann L Wirtz
- Department of Pharmacy, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Jan E Leonard
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Juri Boguniewicz
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Sarah K Parker
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Joseph A Grubenhoff
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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15
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The role of multidisciplinary infection prevention teams in identifying community transmission of SARS-CoV-2 in the United States. Infect Control Hosp Epidemiol 2020; 42:780-781. [PMID: 32698916 PMCID: PMC7417973 DOI: 10.1017/ice.2020.360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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16
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Kinoshita N, Komura M, Tsuzuki S, Shoji K, Miyairi I. The effect of preauthorization and prospective audit and feedback system on oral antimicrobial prescription for outpatients at a children's hospital in Japan. J Infect Chemother 2020; 26:582-587. [PMID: 32088130 DOI: 10.1016/j.jiac.2020.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 11/15/2022]
Abstract
Antimicrobial stewardship programs (ASP) for oral antibiotics is still uncommon, despite the fact that oral antibiotics prescription accounts for 90% of total antibiotic consumption in developed countries. We introduced preauthorization and prospective audit and feedback (PAF) system on broad-spectrum oral antimicrobials as a part of ASP intervention from October 2015 in a tertiary children's hospital in Japan. Antimicrobial consumption and cost of targeted oral antimicrobials decreased from 11.1 days of therapy (DOT) per 1000 outpatient visits and 860,040 yen ($ 7167: 1 $ = 120 yen) to 1.9 DOT per 1000 outpatient visits and 142,200 yen ($ 1185) annually, respectively (p < 0.001). Interrupted time-series analysis showed that prescriptions for targeted antimicrobials decreased rapidly after initiation of preauthorization (p < 0.001). Prescriptions for non-targeted oral antimicrobial increased temporarily (p < 0.001), but a decreasing trend was found after the initiation (p < 0.001). In pre-intervention period, the main indications for using targeted antimicrobials were upper and lower respiratory infection, urinary tract infections, prophylaxis for medical procedures and otitis media, but only 21.4% of them were appropriate prescription. The appropriate prescription rate of post -intervention period increased to 58.5%. During the study period, the susceptibility pattern of major bacteria to these antimicrobials did not change. In conclusion, introduction of the preauthorization and PAF for selected oral antimicrobials decreased the antimicrobial use of both targeted and non-targeted antimicrobials. This intervention may be an effective method of ASP for other children's hospitals.
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Affiliation(s)
- Noriko Kinoshita
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan; Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Makoto Komura
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan.
| | - Shinya Tsuzuki
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Kensuke Shoji
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.
| | - Isao Miyairi
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.
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17
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Donà D, Barbieri E, Daverio M, Lundin R, Giaquinto C, Zaoutis T, Sharland M. Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review. Antimicrob Resist Infect Control 2020; 9:3. [PMID: 31911831 PMCID: PMC6942341 DOI: 10.1186/s13756-019-0659-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.
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Affiliation(s)
- D. Donà
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
- Pediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
- Fondazione Penta ONLUS, Padua, Italy
| | - E. Barbieri
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
| | - M. Daverio
- Pediatric intensive care unit, Department for Woman and Child Health, University of Padua, Padua, Italy
| | - R. Lundin
- Fondazione Penta ONLUS, Padua, Italy
| | - C. Giaquinto
- Division of Pediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, Via Giustiniani 3, 35141 Padua, Italy
- Fondazione Penta ONLUS, Padua, Italy
| | - T. Zaoutis
- Fondazione Penta ONLUS, Padua, Italy
- Division of Infectious Diseases and the Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - M. Sharland
- Pediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
- Fondazione Penta ONLUS, Padua, Italy
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18
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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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19
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Hand J. Strategies for Antimicrobial Stewardship in Solid Organ Transplant Recipients. Infect Dis Clin North Am 2018; 32:535-550. [PMID: 30146022 DOI: 10.1016/j.idc.2018.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Complications of antimicrobial therapy, such as multidrug-resistant organisms and Clostridium difficile, commonly affect solid-organ transplant recipients and have been associated with graft loss and mortality. Although opportunities are abundant, antimicrobial stewardship practices guiding appropriate therapy have been infrequently reported in transplant patients. A patient-centered, multidisciplinary structure, using established antimicrobial optimization principles, is needed to create nuanced approaches to protect patients and antimicrobials and improve outcomes.
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Affiliation(s)
- Jonathan Hand
- Department of Infectious Diseases, The University of Queensland School of Medicine, Ochsner Clinical School, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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20
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Kronman MP, Banerjee R, Duchon J, Gerber JS, Green MD, Hersh AL, Hyun D, Maples H, Nash CB, Parker S, Patel SJ, Saiman L, Tamma PD, Newland JG. Expanding Existing Antimicrobial Stewardship Programs in Pediatrics: What Comes Next. J Pediatric Infect Dis Soc 2018; 7:241-248. [PMID: 29267871 PMCID: PMC7107461 DOI: 10.1093/jpids/pix104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/08/2017] [Indexed: 02/06/2023]
Abstract
The prevalence of pediatric antimicrobial stewardship programs (ASPs) is increasing in acute care facilities across the United States. Over the past several years, the evidence base used to inform effective stewardship practices has expanded, and regulatory interest in stewardship programs has increased. Here, we review approaches for established, hospital-based pediatric ASPs to adapt and report standardized metrics, broaden their reach to specialized populations, expand to undertake novel stewardship initiatives, and implement rapid diagnostics to continue their evolution in improving antimicrobial use and patient outcomes.
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Affiliation(s)
- Matthew P Kronman
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Ritu Banerjee
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - Jennifer Duchon
- Division of Infectious Diseases, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael D Green
- Division of Infectious Diseases, Department of Pediatrics, University of Pittsburgh, Pennsylvania
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | - Holly Maples
- Department of Pharmacy, University of Arkansas, Little Rock, Arkansas
| | - Colleen B Nash
- Division of Infectious Diseases, Department of Pediatrics, University of Chicago, Illinois
| | - Sarah Parker
- Division of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Sameer J Patel
- Division of Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lisa Saiman
- Division of Infectious Diseases, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Pranita D Tamma
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jason G Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University, St. Louis, Missouri
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21
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McCarthy MW, Walsh TJ. The rise of hospitalists: an opportunity for infectious diseases investigators. Expert Rev Anti Infect Ther 2018; 16:385-389. [PMID: 29620478 DOI: 10.1080/14787210.2018.1462158] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Despite the essential role played by infectious diseases specialists in patient care, public health, cost-containment, and biomedical research, the field has a substantially higher percentage of vacant positions than other medicine sub-specialties. While much has been written about what this disturbing trend means for patient care, comparatively little attention has been focused on the dire implications for clinical research and the development of novel anti-infective therapy. Areas covered: We examine the ways that hospitalists and infectious disease specialists might collaborate to study emerging diagnostic platforms, novel antimicrobial agents, and strengthen antimicrobial stewardship programs to improve the delivery of high-quality health care. Through the use of PubMed, the manuscript reviews existing collaborations as well as those that might develop in the years to come. Expert commentary: In this paper, we propose potential strategies to confront this emerging problem, focusing on novel collaborations with the hospitalist - the specialist in inpatient medicine - to bolster the pipeline of funding for clinical infectious diseases investigators.
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Affiliation(s)
- Matthew W McCarthy
- a Medicine, Weill Cornell Medical College, Division of General Internal Medicine , New York-Presbyterian Hospital , New York , NY , USA
| | - Thomas J Walsh
- b Transplantation-Oncology Infectious Diseases Program, Medical Mycology Research Laboratory, Medicine, Pediatrics, and Microbiology & Immunology, Weill Cornell Medical Center, Henry Schueler Foundation Scholar , Sharpe Family Foundation Scholar in Pediatric Infectious Diseases , New York , NY , USA
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22
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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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23
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Horikoshi Y, Suwa J, Higuchi H, Kaneko T, Furuichi M, Aizawa Y, Fukuoka K, Okazaki K, Ito K, Shoji T. Sustained pediatric antimicrobial stewardship program with consultation to infectious diseases reduced carbapenem resistance and infection-related mortality. Int J Infect Dis 2017; 64:69-73. [PMID: 28941633 DOI: 10.1016/j.ijid.2017.09.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/04/2017] [Accepted: 09/08/2017] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The impact of pediatric antimicrobial stewardship programs (ASP) on antimicrobial resistance (AMR) remains largely unknown. This study aimed to evaluate the AMR for carbapenem of Gram-negative bacilli (GNB) and carbapenem use with infectious diseases consultation after the implementation of an ASP. METHODS This quasi-experimental study was conducted at Tokyo Metropolitan Children's Medical Center in Japan. The pre- and post-intervention periods were April 2010 to September 2011 and October 2011 to March 2017, respectively. The pre-intervention phase consisted of consultations with the infectious diseases service alone. The ASP was implemented during the post-intervention phase. The carbapenem resistance rates of GNB were calculated. The correlation between carbapenem resistance rates and carbapenem day of therapy (DOT) was examined. The outcome metrics were compared by average length of hospitalization, all-cause mortality, and infection-related mortality. RESULTS A positive correlation was observed between the carbapenem resistance rate in Pseudomonas aeruginosa and DOT (0.76, p=0.04). The carbapenem resistance rate in P. aeruginosa (p<0.01) and DOT (p<0.01) decreased significantly in the post-intervention period. The length of hospitalization (p<0.01) and infection-related mortality (p=0.05) decreased in the post-intervention period. CONCLUSIONS A sustained ASP with additional consultation with the infectious disease service reduced carbapenem use and resistance in P. aeruginosa, leading to favorable outcomes in terms of length of hospitalization and infection-related mortality.
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Affiliation(s)
- Yuho Horikoshi
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu City, Tokyo, 183-8561, Japan.
| | - Junichi Suwa
- Department of Pharmacy, Tokyo Metropolitan Children's Medical Center, Fuchu City, Tokyo, Japan
| | - Hiroshi Higuchi
- Division of Microbiology, Department of Laboratory, Tokyo Metropolitan Children's Medical Center, Fuchu City, Tokyo, Japan
| | - Tetsuji Kaneko
- Clinical Research Support Center, Tokyo Metropolitan Children's Medical Center, Fuchu City, Tokyo, Japan
| | - Mihoko Furuichi
- Division of Infectious Diseases and Allergy, Saitama Children's Medical Center, Saitama City, Saitama, Japan
| | - Yuta Aizawa
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu City, Tokyo, 183-8561, Japan
| | - Kahoru Fukuoka
- Division of Infectious Diseases, Department of Pediatrics, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu City, Tokyo, 183-8561, Japan
| | - Kaoru Okazaki
- Division of Neonatology, Tokyo Metropolitan Children's Medical Center, Fuchu City, Tokyo, Japan
| | - Kenta Ito
- Division of General Pediatrics, Aichi Children's Health and Medical Center, Ohfu City, Aichi, Japan
| | - Takayo Shoji
- Division of Pediatric Infectious Diseases, Shizuoka Children's Hospital, Shizuoka City, Shizuoka, Japan
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24
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Fantoni M, Murri R, Cauda R. Antibiotic stewardship from toolkit to local implementation: the ‘gutta cavat lapidem’ strategy. Future Microbiol 2017; 12:935-938. [DOI: 10.2217/fmb-2017-0110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Massimo Fantoni
- Department of Infectious Diseases, Catholic University of Rome, Italy
| | - Rita Murri
- Department of Infectious Diseases, Catholic University of Rome, Italy
| | - Roberto Cauda
- Department of Infectious Diseases, Catholic University of Rome, Italy
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