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Szymczak JE, Petty LA, Gandhi TN, Neetz RA, Hersh A, Presson AP, Lindenauer PK, Bernstein SJ, Muller BM, White AT, Horowitz JK, Flanders SA, Smith JD, Vaughn VM. Protocol for a parallel cluster randomized trial of a participatory tailored approach to reduce overuse of antibiotics at hospital discharge: the ROAD home trial. Implement Sci 2024; 19:23. [PMID: 38439076 PMCID: PMC10910678 DOI: 10.1186/s13012-024-01348-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: 01/03/2024] [Accepted: 02/02/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Antibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care. There may be different pathways to improve discharge antibiotic prescribing that vary widely in feasibility. Supporting hospitals in selecting interventions tailored to their context may be an effective approach to feasibly reduce antibiotic overuse at discharge across diverse hospitals. The objective of this study is to evaluate the effectiveness of the Reducing Overuse of Antibiotics at Discharge Home multicomponent implementation strategy ("ROAD Home") on antibiotic overuse at discharge for community-acquired pneumonia and urinary tract infection. METHODS This 4-year two-arm parallel cluster-randomized trial will include three phases: baseline (23 months), intervention (12 months), and postintervention (12 months). Forty hospitals recruited from the Michigan Hospital Medicine Safety Consortium will undergo covariate-constrained randomization with half randomized to the ROAD Home implementation strategy and half to a "stewardship as usual" control. ROAD Home is informed by the integrated-Promoting Action on Research Implementation in Health Services Framework and includes (1) a baseline needs assessment to create a tailored suite of potential stewardship interventions, (2) supported decision-making in selecting interventions to implement, and (3) external facilitation following an implementation blueprint. The primary outcome is baseline-adjusted days of antibiotic overuse at discharge. Secondary outcomes include 30-day patient outcomes and antibiotic-associated adverse events. A mixed-methods concurrent process evaluation will identify contextual factors influencing the implementation of tailored interventions, and assess implementation outcomes including acceptability, feasibility, fidelity, and sustainment. DISCUSSION Reducing antibiotic overuse at discharge across hospitals with varied resources requires tailoring of interventions. This trial will assess whether a multicomponent implementation strategy that supports hospitals in selecting evidence-based stewardship interventions tailored to local context leads to reduced overuse of antibiotics at discharge. Knowledge gained during this study could inform future efforts to implement stewardship in diverse hospitals and promote equity in access to the benefits of quality improvement initiatives. TRIAL REGISTRATION Clinicaltrials.gov NCT06106204 on 10/30/23.
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Affiliation(s)
- Julia E Szymczak
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Lindsay A Petty
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Tejal N Gandhi
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Robert A Neetz
- MyMichigan Medical Center Midland, MyMichigan Health, Midland, MI, USA
| | - Adam Hersh
- Department of Pediatrics, Division of Pediatric Infectious Diseases, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Angela P Presson
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Peter K Lindenauer
- Baystate Medical Center Department of Healthcare Delivery and Population Science, Center for Quality of Care Research, Springfield, MA, USA
| | - Steven J Bernstein
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, Division of General Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Brandi M Muller
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Andrea T White
- Department of Internal Medicine, Division of General Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Jennifer K Horowitz
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Scott A Flanders
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Justin D Smith
- Department of Population Health Sciences, Division of Health System Innovation & Research, University of Utah School of Medicine, Salt Lake City, USA
| | - Valerie M Vaughn
- Department of Internal Medicine, Division of General Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Internal Medicine, Division of General Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Population Health Sciences, Division of Health System Innovation & Research, University of Utah School of Medicine, Salt Lake City, USA.
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Smith J, Frens J, Mehta D, Naik K, Sinclair E, Baumeister T. Optimizing transitions of care antimicrobial prescribing at a community teaching hospital. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e228. [PMID: 38156224 PMCID: PMC10753507 DOI: 10.1017/ash.2023.504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/31/2023] [Accepted: 11/03/2023] [Indexed: 12/30/2023]
Abstract
Objective Antibiotic prescribing at hospital discharge is an important focus for antimicrobial stewardship efforts. This study set out to determine the impact of a pharmacist-led intervention at hospital discharge on appropriate antimicrobial prescribing. Design This was a pre-/post-study evaluating the impact of a pharmacist-led review on antibiotic prescribing at hospital discharge. Pharmacists evaluated antibiotic prescriptions at discharge for appropriate duration, spectrum of activity, frequency, and strength of dose. Each of these criteria needed to be met for an antibiotic regimen to be considered appropriate. Setting Moses Cone Hospital is a 535-bed community teaching hospital in Greensboro, North Carolina. Patients or Participants Patients ≥18 years of age discharged from the hospital with an antibiotic prescription were included. Exclusion criteria included patients discharged against medical advice, discharged to a skilled nursing facility, or prescribed indefinite prophylactic antimicrobial therapy. Interventions A review of patients discharged with antibiotics in 2020 was performed. Patients discharged with antibiotic prescriptions from January 2021 to April 2022 were evaluated prior to discharge by pharmacists. The pharmacist made recommendations to providers based on their evaluations. Results 162 retrospective patients were screened, and 136 patients were screened at discharge from the hospital in the prospective cohort. 76/162 (47%) retrospective patients received appropriate antibiotic therapy at discharge, while 92/136 (68%) of prospective patients received appropriate discharge therapy (p = 0.001). Conclusions In this study examining the efficacy of stewardship pharmacist intervention at hospital discharge, pharmacist review and recommendations were associated with an increased rate of appropriate antimicrobial prescribing. Ethics statement This study was conducted under the approval of the Institutional Review Board of the Moses H. Cone Health System. The approval protocol number was 1483117-1 and took effect on September 2nd, 2019. As the research was either retrospective in nature or part of the standard of care recommendations, the project was granted expedited review.
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Affiliation(s)
- Jordan Smith
- Moses H. Cone Memorial Hospital, Greensboro, NC, USA
- Fred Wilson School of Pharmacy, High Point University, High Point, NC, USA
| | - Jeremy Frens
- Moses H. Cone Memorial Hospital, Greensboro, NC, USA
| | - Dhaval Mehta
- Moses H. Cone Memorial Hospital, Greensboro, NC, USA
- Fred Wilson School of Pharmacy, High Point University, High Point, NC, USA
| | - Kushal Naik
- Moses H. Cone Memorial Hospital, Greensboro, NC, USA
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Dumkow LE, Geyer AC, Davidson LE. Antimicrobial Stewardship at Transitions of Care. Infect Dis Clin North Am 2023; 37:769-791. [PMID: 37580244 DOI: 10.1016/j.idc.2023.06.007] [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: 08/16/2023]
Abstract
Antimicrobial stewardship interventions have historically been siloed in different care settings; recently, a need for stewardship interventions at care transitions has arisen as inappropriate prescribing at care transitions may result in patient harm. There are several care areas that should be considered for optimizing antibiotic prescribing. Interventions can be difficult to implement as they often require the efforts of a multidisciplinary team and are resource intensive. Antimicrobial stewardship programs should prioritize interventions at transitions of care to improve prescribing and patient outcomes.
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Affiliation(s)
- Lisa E Dumkow
- Trinity Health Grand Rapids, 200 Jefferson Avenue, Grand Rapids, MI 49503, USA.
| | - Abigail C Geyer
- Trinity Health Grand Rapids, 200 Jefferson Avenue, Grand Rapids, MI 49503, USA
| | - Lisa E Davidson
- Atrium Health, 1540 Garden Terrace, Suite 211, Charlotte, NC 28203, USA; Wake Forest School of Medicine, 475 Vine Street, Winston-Salem, NC 27101, USA
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Moehring R, Vaughn VM. Development of Inpatient Stewardship Metrics: Is It Time for Public Reporting? Infect Dis Clin North Am 2023; 37:853-871. [PMID: 37661471 DOI: 10.1016/j.idc.2023.07.006] [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: 09/05/2023]
Abstract
Given the complexity and nuance needed to make antimicrobial prescribing decisions, metrics aiming to assess these decisions can be complex in method, require resource investment for measurement, and demand thoughtfulness in how to use data for program implementation and messaging to key partners. Antimicrobial stewardship programs today use several metrics of antimicrobial use in parallel with other clinical data for a multitude of purposes and audiences. Here, we discuss goals for inpatient stewardship metrics, current metrics used by stewardship programs locally and nationally, and future directions for antimicrobial use metric development.
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Affiliation(s)
| | - Valerie M Vaughn
- Division of General Internal Medicine, University of Utah, 30 Mario Capecchi Drive, 3S149, Salt Lake City, UT 84112, USA
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Abbas M, Kashmiri K, Rehman IU, Ali Z, Rahman AU, Khalil A, Ming LC, Shafique M, Khan TM. Evaluation of healthcare professionals' understanding of fluoroquinolones' safety profile, usage, and boxed warnings in Pakistan. J Pharm Policy Pract 2023; 16:154. [PMID: 38012805 PMCID: PMC10680351 DOI: 10.1186/s40545-023-00674-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 11/20/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION Fluoroquinolones (FQs) is a distinct class of antibiotics which are prescribed and used quite frequently worldwide, despite the box warnings (BW) issued by Food and Drug Administration (FDA). Literature has shown in spite of BWs related to FQs there is minimal impact on health care professionals (HCPs) prescribing habits, potentially attributing towards limited and insufficient awareness. In Pakistan, FQs are mostly prescribed antibiotics for microbial treatments, therefore the purpose of this study was to determine the level of knowledge about the safety profile, use, and BW of FQs among HCPs working in Pakistan. METHODS A cross-sectional study was undertaken among the HCPs of Khyber Pakhtunkhwa province of Pakistan from October 2022 to December 2022. A validated questionnaire was used to assess the knowledge of HCPs regarding FQs, its safety profile and BW. A random convenient sample technique was used while recruiting HCPs in this study. As the HCPs comprised physicians, dentists, pharmacist and nurses, all were approached in person and the study objective was fully elaborated and explained to them. The statistic test like: one-way ANOVA, independent-t test, multivariate logistic regression were used keeping the p-value < 0.05 as statistically significant. RESULTS A total of n = 250 HCPs were approached, of which n = 186 HCPs completed the questionnaire with a response rate of 74.4%. FQs prescribing pattern was only assessed among the prescribers, i.e., physicians and dentists (39/186). The mean knowledge score for indications was 5.29 ± 3.05, while for the adverse effects was 7.70 ± 2.61. The highest score for knowledge for indications and adverse effect score was achieved by physicians followed by dentist. The mean knowledge score for the BW was 3.46 ± 2.93 and among the HCPs for the BW of FQs, 20.4% of the HCPs had appropriate knowledge score (score ≥ 50%). The knowledge score was significantly higher in males (p = 0.039), dentists (p = 0.001), HCPs having master/specialization level of education (p = 0.003), HCPs working in government sector hospitals (p = 0.010) and secondary care hospitals (p = 0.001) while the multivariate logistic regression analysis showed that HCPs working in primary care hospital (OR: 6.2) and secondary care hospital (OR: 20.3) were associated with the tendency to achieve 50% or above knowledge score. CONCLUSION Findings of this study reveals the unsatisfactory knowledge of HCPs regarding the safety profile, use, and BW of FQs putting patients at heightened risks of FQs associated AEs. Therefore, it is crucial to implement a national antimicrobial stewardship program, seminars and lectures aimed at continuously updating the knowledge of HCPs, regardless of their specialties, and effectively restrict the misuse of antimicrobial and disseminate FDA BWs in clinical practice.
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Affiliation(s)
- Muhammad Abbas
- Department of Pharmacy, Abdul Wali Khan University Mardan, Mardan, Pakistan
| | - Kashif Kashmiri
- Department of Pharmacy, Abdul Wali Khan University Mardan, Mardan, Pakistan
| | - Inayat Ur Rehman
- Department of Pharmacy, Abdul Wali Khan University Mardan, Mardan, Pakistan.
| | - Zahid Ali
- Department of Pharmacy, University of Peshawar, Peshawar, Pakistan
| | - Aziz Ur Rahman
- Department of Urology, North West General Hospital and Research Center, Peshawar, Pakistan
| | - Asad Khalil
- Department of Medicine, Lady Reading Hospital, Peshawar, Pakistan
| | - Long Chiau Ming
- School of Medical and Life Sciences, Sunway University, Jalan Universiti, Bandar Sunway, Malaysia
| | - Muhammad Shafique
- Department of Pharmaceutical Sciences, College of Pharmacy, Shaqra University, Shaqra, Saudi Arabia.
| | - Tahir Mehmood Khan
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
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Lóser MK, Horowitz JK, England P, Esteitie R, Kaatz S, McLaughlin E, Munroe E, Heath M, Posa P, Flanders SA, Prescott HC. Institutional Structures and Processes to Support Sepsis Care: A Multihospital Study. Crit Care Explor 2023; 5:e1004. [PMID: 37954901 PMCID: PMC10637402 DOI: 10.1097/cce.0000000000001004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVES To identify opportunities for improving hospital-based sepsis care and to inform an ongoing statewide quality improvement initiative in Michigan. DESIGN Surveys on hospital sepsis processes, including a self-assessment of practices using a 3-point Likert scale, were administered to 51 hospitals participating in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan, at two time points (2020, 2022). Forty-eight hospitals also submitted sepsis protocols for structured review. SETTING Multicenter quality improvement consortium. SUBJECTS Fifty-one hospitals in Michigan. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the included hospitals, 92.2% (n = 47/51) were nonprofit, 88.2% (n = 45/51) urban, 11.8% (n = 6/51) rural, and 80.4% (n = 41/51) teaching hospitals. One hundred percent (n = 51/51) responded to the survey, and 94.1% (n = 48/51) provided a sepsis policy/protocol. All surveyed hospitals used at least one quality improvement approach, including audit/feedback (98.0%, n = 50/51) and/or clinician education (68.6%, n = 35/51). Protocols included the Sepsis-1 (18.8%, n = 9/48) or Sepsis-2 (31.3%, n = 15/48) definitions; none (n = 0/48) used Sepsis-3. All hospitals (n = 51/51) used at least one process to facilitate rapid sepsis treatment, including order sets (96.1%, n = 49/51) and/or stocking of commonly used antibiotics in at least one clinical setting (92.2%, n = 47/51). Treatment protocols included guidance on antimicrobial therapy (68.8%, n = 33/48), fluid resuscitation (70.8%, n = 34/48), and vasopressor administration (62.5%, n = 30/48). On self-assessment, hospitals reported the lowest scores for peridischarge practices, including screening for cognitive impairment (2.0%, n = 1/51 responded "we are good at this") and providing anticipatory guidance (3.9%, n = 2/51). There were no meaningful associations of the Centers for Medicare and Medicaid Services' Severe Sepsis and Septic Shock: Management Bundle performance with differences in hospital characteristics or sepsis policy document characteristics. CONCLUSIONS Most hospitals used audit/feedback, order sets, and clinician education to facilitate sepsis care. Hospitals did not consistently incorporate organ dysfunction criteria into sepsis definitions. Existing processes focused on early recognition and treatment rather than recovery-based practices.
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Affiliation(s)
- Meghan K Lóser
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | | | - Peter England
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Rania Esteitie
- Division of Pulmonary & Critical Care Medicine, Covenant Healthcare, Saginaw, MI
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI
| | | | - Elizabeth Munroe
- Division of Pulmonary & Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Megan Heath
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Pat Posa
- Quality and Patient Safety Program, University of Michigan, Ann Arbor, MI
| | - Scott A Flanders
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Hallie C Prescott
- Division of Pulmonary & Critical Care Medicine, University of Michigan, Ann Arbor, MI
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI
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Jover-Sáenz A, Santos Rodríguez C, Ramos Gil MÁ, Palomera Fernández M, Invencio da Costa LF, Torres-Puig-Gros J, Castellana Perelló D, Montiu González E, Schoenenberger-Arnaiz JA, Bordalba Gómez JR, Galindo Ortego X, Ramirez-Hidalgo M. Impact of an Antimicrobial Stewardship Strategy on Surgical Hospital Discharge: Improving Antibiotic Prescription in the Transition of Care. Antibiotics (Basel) 2023; 12:antibiotics12050834. [PMID: 37237737 DOI: 10.3390/antibiotics12050834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/27/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
Antimicrobial stewardship programs (AMSPs) are essential elements in reducing the unnecessary overprescription of antibiotics. Most of the actions of these programs have focused on actions during acute hospitalization. However, most prescriptions occur after hospital discharge, which represents a necessary and real opportunity for improvement in these programs. We present an AMSP multifaceted strategy implemented in a surgical department which was carried out by a multidisciplinary team to verify its reliability and effectiveness. Over a 1-year post-implementation period, compared to the pre-intervention period, a significant reduction of around 60% in antibiotic exposure occurred, with lower economic cost and greater safety.
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Affiliation(s)
- Alfredo Jover-Sáenz
- Unidad Territorial Infección Nosocomial (UTIN), Hospital Universitari Arnau de Vilanova de Lleida (HUAV), Institut de Recerca Biomèdica (IRBLleida), 25198 Lleida, Spain
| | - Carlos Santos Rodríguez
- Servicio de Farmacia, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain
| | - Miguel Ángel Ramos Gil
- Servicio de Farmacia, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain
| | | | | | | | - Dolors Castellana Perelló
- Unidad Territorial Infección Nosocomial (UTIN), Hospital Universitari Arnau de Vilanova de Lleida (HUAV), Institut de Recerca Biomèdica (IRBLleida), 25198 Lleida, Spain
| | - Elisa Montiu González
- Unidad Territorial Infección Nosocomial (UTIN), Hospital Universitari Arnau de Vilanova de Lleida (HUAV), Institut de Recerca Biomèdica (IRBLleida), 25198 Lleida, Spain
| | | | | | - Xavier Galindo Ortego
- Servicio de Otorrinolaringología, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain
| | - María Ramirez-Hidalgo
- Unidad Territorial Infección Nosocomial (UTIN), Hospital Universitari Arnau de Vilanova de Lleida (HUAV), Institut de Recerca Biomèdica (IRBLleida), 25198 Lleida, Spain
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Valentine-King M, Van J, Hines-Munson C, Dillon L, Graber CJ, Patel PK, Drekonja D, Lichtenberger P, Shukla B, Kramer J, Ramsey D, Trautner B, Grigoryan L. Identification of novel factors associated with inappropriate treatment of asymptomatic bacteriuria in acute and long-term care. Am J Infect Control 2022; 50:1226-1233. [PMID: 35158007 DOI: 10.1016/j.ajic.2022.02.010] [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: 12/20/2021] [Revised: 02/03/2022] [Accepted: 02/05/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chart reviews often fall short of determining what drove antibiotic treatment of asymptomatic bacteriuria (ASB). To overcome this shortcoming, we searched providers' free-text for documentation of their decision-making and for misleading signs and symptoms that may trigger unnecessary treatment of ASB. METHODS We reviewed a random sample of 10 positive urine cultures per month, per facility, from patients in acute or long-term care wards at 8 Veterans Affairs facilities. Cultures were classified as urinary tract infection (UTI) or ASB, and as treated or untreated. Charts were searched for 13 potentially misleading symptoms, and free-text documentation of providers' decision-making was classified into 5 categories. We used generalized estimating equations logistic regression to identify factors associated with ASB treatment. RESULTS One hundred fifty-eight (27.5%) of 575 ASB cases were inappropriately treated with antibiotics. Significant factors associated with inappropriate treatment included: abdominal pain, falls, decreased urine output, urine characteristics, abnormal vital signs, laboratory values, and voiding issues. Providers prescribed an average of 1.4 antimicrobials to patients with ASB, with cephalosporins (41%) and fluoroquinolones (21%) being the most common classes prescribed. CONCLUSIONS Chart reviews of providers' decision-making highlighted new factors associated with inappropriate ASB treatment. These findings can help design antibiotic stewardship interventions for ASB.
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Affiliation(s)
- Marissa Valentine-King
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.
| | - John Van
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Casey Hines-Munson
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Laura Dillon
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Christopher J Graber
- Infectious Diseases Section, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA; Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Payal K Patel
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan Medical School, Ann Arbor, MI; Infectious Diseases Section, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Dimitri Drekonja
- Department of Medicine, University of Minnesota, Minneapolis, MN; Minneapolis Veterans Affairs Health Care System, Minneapolis, MN
| | - Paola Lichtenberger
- Infectious Diseases Section, Veterans Affairs Miami Medical Center, Miami, FL; Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Bhavarth Shukla
- Infectious Diseases Section, Veterans Affairs Miami Medical Center, Miami, FL; Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Jennifer Kramer
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - David Ramsey
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Barbara Trautner
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, TX
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX
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Vaughn VM, Ratz D, Greene MT, Flanders SA, Gandhi TN, Petty LA, Huls S, Feng X, White AT, Hersh AL. Antibiotic Stewardship Strategies and Their Association With Antibiotic Overuse After Hospital Discharge: An Analysis of the Reducing Overuse of Antibiotics at Discharge (Road) Home Framework. Clin Infect Dis 2022; 75:1063-1072. [PMID: 35143638 PMCID: PMC9390953 DOI: 10.1093/cid/ciac104] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Strategies to optimize antibiotic prescribing at discharge are not well understood. METHODS In fall 2019, we surveyed 39 Michigan hospitals on their antibiotic stewardship strategies. The association of reported strategies with discharge antibiotic overuse (unnecessary, excess, suboptimal fluoroquinolones) for community-acquired pneumonia (CAP) and urinary tract infection (UTI) was evaluated in 2 ways: (1) all strategies assumed equal weight and (2) strategies were weighted based on the ROAD (Reducing Overuse of Antibiotics at Discharge) Home Framework (ie, Tier 1-Critical infrastructure, Tier 2-Broad inpatient interventions, Tier 3-Discharge-specific strategies) with Tier 3 strategies receiving the highest weight. RESULTS Between 1 July 2017 and 30 July 2019, 39 hospitals with 20 444 patients (56.5% CAP; 43.5% UTI) were included. Survey response was 100%. Hospitals reported a median (interquartile range [IQR]) 12 (9-14) of 34 possible stewardship strategies. On analyses of individual stewardship strategies, the Tier 3 intervention, review of antibiotics prior to discharge, was the only strategy consistently associated with lower antibiotic overuse at discharge (adjusted incident rate ratio [aIRR] 0.543, 95% confidence interval [CI]: .335-.878). On multivariable analysis, weighting by ROAD Home tier predicted antibiotic overuse at discharge for both CAP and UTI. For diseases combined, having more weighted strategies was associated with lower antibiotic overuse at discharge (aIRR 0.957, 95% CI: .927-.987, per weighted intervention); discharge-specific stewardship strategies were associated with a 12.4% relative decrease in antibiotic overuse days at discharge. CONCLUSIONS The more stewardship strategies a hospital reported, the lower its antibiotic overuse at discharge. However, Tier 3, or discharge-specific strategies, appeared to have the largest effect on antibiotic prescribing at discharge.
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Affiliation(s)
- Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Health System Innovation & Research, Department of Population Health Science, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - David Ratz
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - M Todd Greene
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sean Huls
- Departments of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Xiaomei Feng
- Department of Anesthesiology, University of Utah Health, Salt Lake City, Utah, USA
| | - Andrea T White
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
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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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11
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Mercuro NJ, Medler CJ, Kenney RM, MacDonald NC, Neuhauser MM, Hicks LA, Srinivasan A, Divine G, Beaulac A, Eriksson E, Kendall R, Martinez M, Weinmann A, Zervos M, Davis SL. Pharmacist-Driven Transitions of Care Practice Model for Prescribing Oral Antimicrobials at Hospital Discharge. JAMA Netw Open 2022; 5:e2211331. [PMID: 35536577 PMCID: PMC9092199 DOI: 10.1001/jamanetworkopen.2022.11331] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Although prescribers face numerous patient-centered challenges during transitions of care (TOC) at hospital discharge, prolonged duration of antimicrobial therapy for common infections remains problematic, and resources are needed for antimicrobial stewardship throughout this period. OBJECTIVE To evaluate a pharmacist-driven intervention designed to improve selection and duration of oral antimicrobial therapy prescribed at hospital discharge for common infections. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study used a nonrandomized stepped-wedge design with 3 study phases from September 1, 2018, to August 31, 2019. Seventeen distinct medicine, surgery, and specialty units from a health system in Southeast Michigan participated, including 1 academic tertiary hospital and 4 community hospitals. Hospitalized adults who had urinary, respiratory, skin and/or soft tissue, and intra-abdominal infections and were prescribed antimicrobials at discharge were included in the analysis. Data were analyzed from February 18, 2020, to February 28, 2022. INTERVENTIONS Clinical pharmacists engaged in a new standard of care for antimicrobial stewardship practices during TOC by identifying patients to be discharged with a prescription for oral antimicrobials and collaborating with primary teams to prescribe optimal therapy. Academic and community hospitals used both antimicrobial stewardship and clinical pharmacists in a multidisciplinary rounding model to discuss, document, and facilitate order entry of the antimicrobial prescription at discharge. MAIN OUTCOMES AND MEASURES The primary end point was frequency of optimized antimicrobial prescription at discharge. Health system guidelines developed from national guidelines and best practices for short-course therapies were used to evaluate optimal therapy. RESULTS A total of 800 patients prescribed oral antimicrobials at hospital discharge were included in the analysis (441 women [55.1%]; mean [SD] age, 66.8 [17.3] years): 400 in the preintervention period and 400 in the postintervention period. The most common diagnoses were pneumonia (264 [33.0%]), upper respiratory tract infection and/or acute exacerbation of chronic obstructive pulmonary disease (214 [26.8%]), and urinary tract infection (203 [25.4%]). Patients in the postintervention group were more likely to have an optimal antimicrobial prescription (time-adjusted generalized estimating equation odds ratio, 5.63 [95% CI, 3.69-8.60]). The absolute increase in optimal prescribing in the postintervention group was consistent in both academic (37.4% [95% CI, 27.5%-46.7%]) and community (43.2% [95% CI, 32.4%-52.8%]) TOC models. There were no differences in clinical resolution or mortality. Fewer severe antimicrobial-related adverse effects (time-adjusted generalized estimating equation odds ratio, 0.40 [95% CI, 0.18-0.88]) were identified in the postintervention (13 [3.2%]) compared with the preintervention (36 [9.0%]) groups. CONCLUSIONS AND RELEVANCE The findings of this quality improvement study suggest that targeted antimicrobial stewardship interventions during TOC were associated with increased optimal, guideline-concordant antimicrobial prescriptions at discharge.
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Affiliation(s)
- Nicholas J. Mercuro
- Department of Pharmacy, Henry Ford Health System, Detroit, Michigan
- Eugene Applebaum College of Pharmacy, Wayne State University, Detroit, Michigan
- Department of Pharmacy, Maine Medical Center, Portland
| | - Corey J. Medler
- Department of Pharmacy, Henry Ford Health System, Detroit, Michigan
- Eugene Applebaum College of Pharmacy, Wayne State University, Detroit, Michigan
| | - Rachel M. Kenney
- Department of Pharmacy, Henry Ford Health System, Detroit, Michigan
| | | | - Melinda M. Neuhauser
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion, Atlanta, Georgia
| | - Lauri A. Hicks
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion, Atlanta, Georgia
| | - Arjun Srinivasan
- National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion, Atlanta, Georgia
| | - George Divine
- Division of Public Health Sciences, Henry Ford Health System, Detroit, Michigan
| | - Amy Beaulac
- Department of Pharmacy, Henry Ford Health System, Detroit, Michigan
| | - Erin Eriksson
- Department of Pharmacy, Henry Ford Health System, Detroit, Michigan
| | - Ronald Kendall
- Department of Pharmacy, Henry Ford Health System, Detroit, Michigan
| | - Marilen Martinez
- Department of Pharmacy, Henry Ford Health System, Detroit, Michigan
| | - Allison Weinmann
- Division of Infectious Diseases, Henry Ford Health System, Detroit, Michigan
| | - Marcus Zervos
- Division of Infectious Diseases, Henry Ford Health System, Detroit, Michigan
| | - Susan L. Davis
- Department of Pharmacy, Henry Ford Health System, Detroit, Michigan
- Eugene Applebaum College of Pharmacy, Wayne State University, Detroit, Michigan
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12
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Gupta A, Petty L, Gandhi T, Flanders S, Hsaiky L, Basu T, Zhang Q, Horowitz J, Masood Z, Chopra V, Vaughn VM. Overdiagnosis of urinary tract infection linked to overdiagnosis of pneumonia: a multihospital cohort study. BMJ Qual Saf 2022; 31:383-386. [PMID: 34987084 PMCID: PMC9121367 DOI: 10.1136/bmjqs-2021-013565] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 12/14/2021] [Indexed: 12/11/2022]
Abstract
Urinary tract infection (UTI) and community-acquired pneumonia (CAP) are the most common infections treated in hospitals. UTI and CAP are also commonly overdiagnosed, resulting in unnecessary antibiotic use and diagnostic delays. While much is known individually about overdiagnosis of UTI and CAP, it is not known whether hospitals with higher overdiagnosis of one also have higher overdiagnosis of the other. Correlation of overdiagnosis of these two conditions may indicate underlying hospital-level contributors, which in turn may represent targets for intervention. To evaluate the association of overdiagnosis of UTI and CAP, we first determined the proportion of hospitalised patients treated for CAP or UTI at 46 hospitals in Michigan who were overdiagnosed according to national guideline definitions. Then, we used Pearson's correlation coefficient to compare hospital proportions of overdiagnosis of CAP and UTI. Finally, we assessed for 'diagnostic momentum' (ie, accepting a previous diagnosis without sufficient scepticism) by determining how often overdiagnosed patients remained on antibiotics on day 3 of hospitalisation. We included 14 085 patients treated for CAP (11.4% were overdiagnosed) and 10 398 patients treated for UTI (27.8% were overdiagnosed) across 46 hospitals. Within hospitals, the proportion of patients overdiagnosed with UTI was moderately correlated with the proportion of patients overdiagnosed with CAP (r=0.53, p<0.001). Over 80% (81.8% (n=952/1164) of UTI; 89.9% (n=796/885) of CAP) of overdiagnosed patients started on antibiotics by an emergency medicine clinician remained on antibiotics on day 3 of hospitalisation. In conclusion, we found overdiagnosis of UTI and CAP to be correlated at the hospital level. Reducing overdiagnosis of these two common infections may benefit from systematic interventions.
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Affiliation(s)
- Ashwin Gupta
- Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of Hospital Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lindsay Petty
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Tejal Gandhi
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Scott Flanders
- Division of Hospital Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lama Hsaiky
- Department of Pharmacy, Beaumont Hospital, Dearborn, Michigan, USA
| | - Tanima Basu
- Division of Hospital Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Qisu Zhang
- Division of Hospital Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer Horowitz
- Division of Hospital Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Zainab Masood
- Division of Hospital Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Vineet Chopra
- Division of Hospital Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Valerie M Vaughn
- Division of Hospital Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Division of General Internal Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Population Health Science, The University of Utah School of Medicine, Salt Lake City, Utah, USA
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Mallhi TH, Alanazi AS, Khan YH, Alotaibi NH, Salman M, Alzarea AI, Khan SUD, Alruwaili NK, Alenazi AS, Alatawi AD, Iqbal Z, Butt MH, Iqbal MS. Assessment of Knowledge Regarding Safety Profile, Use, and Boxed Warnings of Fluoroquinolones Among Healthcare Professionals in Saudi Arabia: A Potential Implication for Drug Regulatory Authorities. Front Med (Lausanne) 2022; 9:816320. [PMID: 35572979 PMCID: PMC9099140 DOI: 10.3389/fmed.2022.816320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/07/2022] [Indexed: 11/28/2022] Open
Abstract
Background Despite a series of "boxed warnings" (BWs) issued by the US Food and Drug Administration (FDA), fluoroquinolones (FQs) are among the most prescribed antibiotics across the world. Moreover, few studies demonstrated that BW of FQs had less or no impact on prescribing patterns among healthcare professionals (HCPs), which might be attributed to the lack of knowledge toward such warnings. Since FQs contribute to a major proportion of antimicrobial prescriptions in the Kingdom of Saudi Arabia (KSA), this study aimed to ascertain the extent of knowledge toward safety profile, use, and BW of FQs among HCPs working in the KSA. Methods This cross-sectional study (May-August 2021) was conducted among HCPs working in KSA through a validated questionnaire. The HCPs were requested to identify the indications, adverse effects (AEs), and BW of FQs. The knowledge score (out of 40) was estimated among participants, and its association with demographics was ascertained through the chi-square test, Student's t-test, or Mann-Whitney U-test and one-way ANOVA, or Kruskal-Wallis test, where appropriate. Results Of the 573 participants (age: 36.1 ± 10.6 years, men: 59.7%), 262 (45.8%) were prescribers reporting frequent use of ciprofloxacin, levofloxacin, and ofloxacin. One-fourth (25.6%) of the prescribers did not recognize nalidixic acid as an agent from FQs class. About 60% of participants correctly identified the mechanism of action of FQs. The average knowledge score was 14.8 ± 6.4, where only 21.5% of respondents scored ≥50%. The average knowledge score for indications, AEs, and BW domains was 5.29 ± 3.05, 6.17 ± 4.05, and 2.3 ± 1.5, respectively. Only 75 (13.1%) participants recognized half of the BW, and 38.6% of participants identified at least one warning. The HCPs aged >40 years (p = 0.043), having non-Saudi's nationality (p < 0.001), working in Riyadh and Eastern regions (p < 0.001), having pharmacy and medicine disciplines (p < 0.001), practicing in public sectors (p = 0.004), and having more than 10 years of experience (p < 0.001) were significantly associated with high knowledge score. Conclusion This study demonstrates the unsatisfactory knowledge toward safety profile, use, and BW of FQs among HCPs which may put patients at increased risks of AEs. The knowledge score differed among various socio-demographic groups. There is a dire need to initiate the antimicrobial-focused educational campaigns among HCPs regardless of their specialties and methods to improve education and disseminate FDA warnings in practice.
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Affiliation(s)
- Tauqeer Hussain Mallhi
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka, Saudi Arabia
| | - Abdullah Salah Alanazi
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka, Saudi Arabia
- Health Sciences Research Unit, Jouf University, Sakaka, Saudi Arabia
| | - Yusra Habib Khan
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka, Saudi Arabia
| | - Nasser Hadal Alotaibi
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka, Saudi Arabia
| | - Muhammad Salman
- Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | | | - Salah-Ud-Din Khan
- Department of Biochemistry, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Nabil K. Alruwaili
- Department of Pharmaceutics, College of Pharmacy, Jouf University, Sakaka, Saudi Arabia
| | | | - Ahmed D. Alatawi
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka, Saudi Arabia
| | - Zafar Iqbal
- Department of Pharmaceutical Services, Armed Forces Hospital, King Abdulaziz Airbase, Dhahran, Saudi Arabia
| | - Muhammad Hammad Butt
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Central Punjab, Lahore, Pakistan
| | - Muhammad Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam bin Abdulaziz University, Al-Kharj, Saudi Arabia
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Patel N, Davis SL, MacDonald NC, Medler CJ, Kenney RM, Zervos MJ, Mercuro NJ. Transitions of care: an untapped opportunity for antimicrobial stewardship. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Nisha Patel
- Henry Ford Hospital, Department of Pharmacy Detroit Michigan
| | - Susan L. Davis
- Henry Ford Hospital, Department of Pharmacy Detroit Michigan
- Wayne State University, Eugene Applebaum College of Pharmacy and Health Sciences Detroit Michigan
| | | | - Corey J. Medler
- Henry Ford Hospital, Department of Pharmacy Detroit Michigan
- Wayne State University, Eugene Applebaum College of Pharmacy and Health Sciences Detroit Michigan
| | | | - Marcus J. Zervos
- Henry Ford Hospital, Division of Infectious Diseases Detroit Michigan
| | - Nicholas J. Mercuro
- Henry Ford Hospital, Department of Pharmacy Detroit Michigan
- Wayne State University, Eugene Applebaum College of Pharmacy and Health Sciences Detroit Michigan
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Tartof SY, Chen LH, Tian Y, Wei R, Im T, Yu K, Rieg G, Bider-Canfield Z, Wong F, Takhar HS, Qian L. Do Inpatient Antimicrobial Stewardship Programs Help Us in the Battle Against Antimicrobial Resistance? Clin Infect Dis 2021; 73:e4454-e4462. [PMID: 32667983 PMCID: PMC8673436 DOI: 10.1093/cid/ciaa1004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Antibiotic stewardship programs (ASPs) have demonstrated success at reducing costs, yet there is limited quality evidence of their effectiveness in reducing infections of high-profile drug-resistant organisms. METHODS This retrospective, cohort study included all Kaiser Permanente Southern California (KPSC) members aged ≥18 years hospitalized in 9 KPSC hospitals from 1 January 2008 to 31 December 2016. We measured the impact of staggered ASP implementation on consumption of 18 ASP-targeted antibiotics using generalized linear mixed-effects models. We used multivariable generalized linear mixed-effects models to estimate the adjusted effect of an ASP on rates of infection with drug-resistant organisms. Analyses were adjusted for confounding by time, cluster effects, and patient- and hospital-level characteristics. RESULTS We included 765 111 hospitalizations (288 257 pre-ASP, 476 854 post-ASP). By defined daily dose, we found a 6.1% (-7.5% to -4.7%) overall decrease antibiotic use post-ASP; by days of therapy, we detected a 4.3% (-5.4% to -3.1%) decrease in overall use of antibiotics. The number of prescriptions increased post-ASP (1.04 [1.03-1.05]). In adjusted analyses, we detected an overall increase in vancomycin-resistant enterococci infections post-ASP (1.37 [1.10-1.69]). We did not detect a change in the rates of extended-spectrum beta-lactamase, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa infections post-ASP. CONCLUSIONS ASPs with successful reductions in consumption of targeted antibiotics may not see changes in infection rates with antibiotic-resistant organisms in the 2 to 6 years post-implementation. There are likely differing timescales for reversion to susceptibility across organisms and antibiotics, and unintended consequences from compensatory prescribing may occur.
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Affiliation(s)
- Sara Y Tartof
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Lie Hong Chen
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Yun Tian
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Rong Wei
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Theresa Im
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Kalvin Yu
- Inpatient Pharmacy Department, Kaiser Permanent Fontana Medical Center, Fontana, California, USA
- Department of Infectious Diseases, Southern California Permanente Medical Group, West Hollywood, California, USA
| | - Gunter Rieg
- Inpatient Pharmacy Department, Kaiser Permanent Fontana Medical Center, Fontana, California, USA
- Department of Infectious Diseases, Southern California Permanente Medical Group, South Bay, California, USA
| | - Zoe Bider-Canfield
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Frances Wong
- Inpatient Pharmacy Department, Kaiser Permanent Fontana Medical Center, Fontana, California, USA
| | - Harpreet S Takhar
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Lei Qian
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
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16
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Pédeboscq S, Issa N, Lahouati M, Labadie A, Pereyre S, Camou F. Impact of a 5-year antimicrobial stewardship program focusing on fluoroquinolone prescriptions. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2021; 29:616-621. [PMID: 34355739 DOI: 10.1093/ijpp/riab047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 07/02/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Within the context of the wide use of fluoroquinolones (FQs) and the emergence of multidrug-resistant bacteria, French recommendations concerning the appropriate use of systemic FQs in adults were published in 2015. This study assessed the impact of antibiotic stewardship intervention on the use of FQs over a 5-year period. METHODS Five annual audits were performed to evaluate FQ prescriptions. Following the baseline audit, a campaign of appropriate antibiotic use was initiated with courses on antibiotics including FQs. All audits included quantitative and qualitative evaluations to calculate an index of therapeutic adequacy (ITA) with six criteria: indication, molecule type, dosage, duration, route of administration and association. These audits were performed annually from 2015 to 2019. KEY FINDINGS The number of prescriptions decreased substantially from 90 in 2015 to 17 in 2019. This reduction was consistent with consumption data, such that the defined daily dose for 1000 bed days diminished from 67 in 2015 to 42 in 2019. Between 2015 and 2016, the ITA decreased significantly from 3.27 to 1.79 (P = 0.001), corresponding to an improvement in prescription quality. The ITA stabilised between 2016 and 2019. Moreover, improvements were observed in the proportion of entirely conforming prescriptions, conformity of indications, choice of molecule type among FQs and proportion of prescriptions with non-conforming treatment durations. CONCLUSIONS Between 2015 and 2019, we observed quantitative and qualitative improvements in FQ prescriptions within the hospital. Prescription follow-up through annual audits, combined with training courses, contributed to consistent results.
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Affiliation(s)
- Stéphane Pédeboscq
- Pharmacy Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Nahema Issa
- Intensive Care and Infectious Disease Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Marin Lahouati
- Pharmacy Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Aurélie Labadie
- Pharmacy Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Sabine Pereyre
- Bacteriology Laboratory, University Hospital of Bordeaux, Bordeaux, France
| | - Fabrice Camou
- Intensive Care and Infectious Disease Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
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17
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Vaughn VM, Gandhi TN, Hofer TP, Petty LA, Malani AN, Osterholzer D, Dumkow LE, Ratz D, Horowitz JK, McLaughlin ES, Czilok T, Flanders SA. A Statewide Collaborative Quality Initiative To Improve Antibiotic Duration And Outcomes Of Patients Hospitalized With Uncomplicated Community-Acquired Pneumonia. Clin Infect Dis 2021; 75:460-467. [PMID: 34791085 PMCID: PMC9427146 DOI: 10.1093/cid/ciab950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Indexed: 12/02/2022] Open
Abstract
Background Community-acquired pneumonia (CAP) is a common cause for hospitalization and antibiotic overuse. We aimed to improve antibiotic duration for CAP across 41 hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS). Methods This prospective collaborative quality initiative included patients hospitalized with uncomplicated CAP who qualified for a 5-day antibiotic duration. Between 23 February 2017 and 5 February 2020, HMS targeted appropriate 5-day antibiotic treatment through benchmarking, sharing best practices, and pay-for-performance incentives. Changes in outcomes, including appropriate receipt of 5 ± 1–day antibiotic treatment and 30-day postdischarge composite adverse events (ie, deaths, readmissions, urgent visits, and antibiotic-associated adverse events), were assessed over time (per 3-month quarter), using logistic regression and controlling for hospital clustering. Results A total of 41 hospitals and 6553 patients were included. The percentage of patients treated with an appropriate 5 ± 1–day duration increased from 22.1% (predicted probability, 20.9% [95% confidence interval: 17.2%–25.0%]) to 45.9% (predicted probability, 43.9% [36.8%–51.2%]; adjusted odds ratio [aOR] per quarter, 1.10 [1.07–1.14]). Thirty-day composite adverse events occurred in 18.5% of patients (1166 of 6319) and decreased over time (aOR per quarter, 0.98 [95% confidence interval: .96–.99]) owing to a decrease in antibiotic-associated adverse events (aOR per quarter, 0.91 [.87–.95]). Conclusions Across diverse hospitals, HMS participation was associated with more appropriate use of short-course therapy and fewer adverse events in hospitalized patients with uncomplicated CAP. Establishment of national or regional collaborative quality initiatives with data collection and benchmarking, sharing of best practices, and pay-for-performance incentives may improve antibiotic use and outcomes for patients hospitalized with uncomplicated CAP.
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Affiliation(s)
- Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Division of Health System Innovation & Research, Department of Population Health Science, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Timothy P Hofer
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA.,Division of General Internal Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Division of Infectious Diseases, Department of Internal Medicine, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA.,Department of Infection Prevention and Control, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Danielle Osterholzer
- Hurley Medical Center, Flint, Michigan, USA.,Michigan State University, College of Human Medicine, East Lansing, Michigan, USA
| | - Lisa E Dumkow
- Department of Clinical Pharmacy Services, Mercy Health Saint Mary's, Grand Rapids, Michigan USA
| | - David Ratz
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Jennifer K Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Elizabeth S McLaughlin
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Tawny Czilok
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
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18
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Vaughn VM, Hersh AL, Spivak ES. Antibiotic Overuse and Stewardship at Hospital Discharge: The Reducing Overuse of Antibiotics at Discharge (ROAD) Home Framework. Clin Infect Dis 2021; 74:1696-1702. [PMID: 34554249 PMCID: PMC9070833 DOI: 10.1093/cid/ciab842] [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: 06/16/2021] [Indexed: 01/19/2023] Open
Abstract
Though opportunities exist to improve antibiotic prescribing across the care spectrum, discharge from acute hospitalization is an increasingly recognized source of antibiotic overuse. Antimicrobials are prescribed to more than 1 in 8 patients at hospital discharge; approximately half of which could be improved. Key targets for antibiotic stewardship at discharge include unnecessary antibiotics, excess duration, avoidable fluoroquinolones, and improving (or avoiding) intravenous antibiotic therapy. Barriers to discharge antibiotic stewardship include the perceived “high stakes” of care transitions during which patients move from intense to infrequent observation, difficulties in antibiotic measurement to guide improvement at discharge, and poor communication across silos, particularly with skilled nursing facilities. In this review, we discuss what is currently known about antibiotic overuse at hospital discharge, key barriers, and targets for improving antibiotic prescribing at discharge and we introduce an evidence-based framework, the Reducing Overuse of Antibiotics at Discharge Home Framework, for conducting discharge antibiotic stewardship.
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Affiliation(s)
- Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Division of Health System Innovation & Research, Department of Population Health Science, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Emily S Spivak
- Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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19
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Roth BM, Laps A, Yamba K, Heil EL, Johnson JK, Stafford K, Hachaambwa LM, Kalumbi M, Mulenga L, Patel DM, Claassen CW. Antibiogram Development in the Setting of a High Frequency of Multi-Drug Resistant Organisms at University Teaching Hospital, Lusaka, Zambia. Antibiotics (Basel) 2021; 10:782. [PMID: 34203126 PMCID: PMC8300684 DOI: 10.3390/antibiotics10070782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 11/24/2022] Open
Abstract
Antimicrobial resistance is a global challenge requiring reliable surveillance data collection and use. Prior studies on resistance in Zambia depended on laboratory methods with limited standardization. Since 2015, the University Teaching Hospital (UTH) microbiology laboratory has used the Vitek 2 Compact (bioMerieux, Inc., Marcy-l'Étoile, France) for standardized identification and susceptibility testing. We conducted a cross-sectional study of 2019 bacterial isolates collected from July 2015 to April 2017 to identify bacterial causes of infections, their susceptibility to commonly used antibiotics at UTH, and develop hospital antibiograms with a multidisciplinary team using World Health Organization guidance. We found high levels of antibiotic resistance among Gram negative bacteria. Escherichia coli and Klebsiella pneumoniae were highly resistant to all antibiotics except amikacin and carbapenems. E. coli had susceptibilities of 42.4% to amoxicillin/clavulanic acid, 41.4% to ceftriaxone, 40.2% to ciprofloxacin, and 10.4% to trimethoprim/sulfamethoxazole (TMP/SMX). K. pneumoniae had susceptibilities of 20.7% to amoxicillin/clavulanic acid, 15.6% to ceftriaxone, 48.5% to ciprofloxacin, and 12.3% to TMP/SMX. The high resistance to 3rd generation cephalosporins indicates high rates of beta-lactamase production. This is information that clinicians need to inform clinical decision making and choice of empiric antibiotics and that UTH requires to inform antimicrobial stewardship such as improvements in antibiotic use.
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Affiliation(s)
- Brenna M. Roth
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (K.S.); (L.M.H.); (C.W.C.)
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Alexandra Laps
- University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Kaunda Yamba
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka 10101, Zambia; (K.Y.); (M.K.)
| | - Emily L. Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA;
| | - J. Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Kristen Stafford
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (K.S.); (L.M.H.); (C.W.C.)
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Lottie M. Hachaambwa
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (K.S.); (L.M.H.); (C.W.C.)
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
- Department of Medicine, University of Zambia School of Medicine, Lusaka 10101, Zambia;
- Infectious Diseases Unit, Department of Internal Medicine, University Teaching Hospital, Lusaka 10101, Zambia
| | - Mox Kalumbi
- Department of Pathology and Microbiology, University Teaching Hospital, Lusaka 10101, Zambia; (K.Y.); (M.K.)
| | - Lloyd Mulenga
- Department of Medicine, University of Zambia School of Medicine, Lusaka 10101, Zambia;
- Infectious Diseases Unit, Department of Internal Medicine, University Teaching Hospital, Lusaka 10101, Zambia
- Ministry of Health, Government of the Republic of Zambia, Lusaka 10101, Zambia
| | - Devang M. Patel
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Cassidy W. Claassen
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (K.S.); (L.M.H.); (C.W.C.)
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
- Department of Medicine, University of Zambia School of Medicine, Lusaka 10101, Zambia;
- Infectious Diseases Unit, Department of Internal Medicine, University Teaching Hospital, Lusaka 10101, Zambia
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20
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Jenkins TC, Tamma PD. Thinking Beyond the "Core" Antibiotic Stewardship Interventions: Shifting the Onus for Appropriate Antibiotic Use from Stewardship Teams to Prescribing Clinicians. Clin Infect Dis 2021; 72:1457-1462. [PMID: 32667974 DOI: 10.1093/cid/ciaa1003] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/10/2020] [Indexed: 01/31/2023] Open
Abstract
United States guidance for hospital antibiotic stewardship has emphasized prospective audit and feedback and prior authorization of select antibiotics as core interventions. These remain the most common interventions implemented by stewardship programs. Although these approaches have been shown to reduce unnecessary antibiotic use, they incorrectly put the onus for appropriate antibiotic use on the stewardship team rather than the prescribing clinician. We propose that a primary focus of stewardship programs should be implementation of broader interventions that engage frontline clinicians and equip them with tools to integrate antibiotic stewardship into their own daily practice, thus reducing the need for day-to-day stewardship team oversite. We discuss a framework of broader interventions and policies that will facilitate this paradigm shift.
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Affiliation(s)
- Timothy C Jenkins
- Department of Medicine and Division of Infectious Diseases, Denver Health, Denver, Colorado, USA.,Department of Patient Safety and Quality, Denver Health, Denver, Colorado, USA.,Department of Medicine and Division of Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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21
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Vaughn VM, Gandhi TN, Petty LA, Patel PK, Prescott HC, Malani AN, Ratz D, McLaughlin E, Chopra V, Flanders SA. Empiric Antibacterial Therapy and Community-onset Bacterial Coinfection in Patients Hospitalized With Coronavirus Disease 2019 (COVID-19): A Multi-hospital Cohort Study. Clin Infect Dis 2021; 72:e533-e541. [PMID: 32820807 PMCID: PMC7499526 DOI: 10.1093/cid/ciaa1239] [Citation(s) in RCA: 249] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Antibacterials may be initiated out of concern for bacterial coinfection in coronavirus disease 2019 (COVID-19). We determined prevalence and predictors of empiric antibacterial therapy and community-onset bacterial coinfections in hospitalized patients with COVID-19. METHODS A randomly sampled cohort of 1705 patients hospitalized with COVID-19 in 38 Michigan hospitals between 3/13/2020 and 6/18/2020. Data were collected on early (within 2 days of hospitalization) empiric antibacterial therapy and community-onset bacterial coinfections (positive microbiologic test ≤3 days). Poisson generalized estimating equation models were used to assess predictors. RESULTS Of 1705 patients with COVID-19, 56.6% were prescribed early empiric antibacterial therapy; 3.5% (59/1705) had a confirmed community-onset bacterial infection. Across hospitals, early empiric antibacterial use varied from 27% to 84%. Patients were more likely to receive early empiric antibacterial therapy if they were older (adjusted rate ratio [ARR]: 1.04 [1.00-1.08] per 10 years); had a lower body mass index (ARR: 0.99 [0.99-1.00] per kg/m2), more severe illness (eg, severe sepsis; ARR: 1.16 [1.07-1.27]), a lobar infiltrate (ARR: 1.21 [1.04-1.42]); or were admitted to a for-profit hospital (ARR: 1.30 [1.15-1.47]). Over time, COVID-19 test turnaround time (returned ≤1 day in March [54.2%, 461/850] vs April [85.2%, 628/737], P < .001) and empiric antibacterial use (ARR: 0.71 [0.63-0.81] April vs March) decreased. CONCLUSIONS The prevalence of confirmed community-onset bacterial coinfections was low. Despite this, half of patients received early empiric antibacterial therapy. Antibacterial use varied widely by hospital. Reducing COVID-19 test turnaround time and supporting stewardship could improve antibacterial use.
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Affiliation(s)
- Valerie M Vaughn
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Payal K Patel
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Division of Infectious Diseases, Department of Internal Medicine, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
- Department of Infection Prevention and Control, St Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - David Ratz
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Elizabeth McLaughlin
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vineet Chopra
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Scott A Flanders
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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22
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Suzuki H, Perencevich EN, Alexander B, Beck BF, Goto M, Lund BC, Nair R, Livorsi DJ. Inpatient Fluoroquinolone Stewardship Improves the Quantity and Quality of Fluoroquinolone Prescribing at Hospital Discharge: A Retrospective Analysis Among 122 Veterans Health Administration Hospitals. Clin Infect Dis 2021; 71:1232-1239. [PMID: 31562815 DOI: 10.1093/cid/ciz967] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 09/26/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite increasing awareness of harms, fluoroquinolones are still frequently prescribed to inpatients and at hospital discharge. Our goal was to describe fluoroquinolone prescribing at hospital discharge across the Veterans Health Administration (VHA) and to contrast the volume and appropriateness of fluoroquinolone prescribing across 3 antimicrobial stewardship strategy types. METHODS We analyzed a retrospective cohort of patients hospitalized at 122 VHA acute-care hospitals during 2014-2016. Data from a mandatory VHA survey were used to identify 9 hospitals that self-reported 1 of 3 strategies for optimizing fluoroquinolone prescribing: prospective audit and feedback (PAF), restrictive policies (RP), and no strategy. Manual chart reviews to assess fluoroquinolone appropriateness at hospital discharge (ie, postdischarge) were performed across the 9 hospitals (3 hospitals and 125 cases per strategy type). RESULTS There were 1.7 million patient admissions. Overall, there were 1 727 478 fluoroquinolone days of therapy (DOTs), with 674 918 (39.1%) DOTs prescribed for inpatients and 1 052 560 (60.9%) DOTs prescribed postdischarge. Among the 9 reviewed hospitals, postdischarge fluoroquinolone exposure was lower at hospitals using RP, compared to no strategy (3.8% vs 9.3%, respectively; P = .012). Postdischarge fluoroquinolones were deemed inappropriate in 154 of 375 (41.1%) patients. Fluoroquinolones were more likely to be inappropriate at hospitals without a strategy (52.8%) versus those using either RP or PAF (35.2%; P = .001). CONCLUSIONS In this retrospective cohort, the majority of fluoroquinolone DOTs occurred after hospital discharge. A large proportion of postdischarge fluoroquinolone prescriptions were inappropriate, especially in hospitals without a strategy to manage fluoroquinolone prescribing. Our findings suggest that stewardship efforts to minimize and improve fluoroquinolone prescribing should also focus on antimicrobial prescribing at hospital discharge.
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Affiliation(s)
- Hiroyuki Suzuki
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Eli N Perencevich
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Bruce Alexander
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Brice F Beck
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Michihiko Goto
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Brian C Lund
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Rajeshwari Nair
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Daniel J Livorsi
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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23
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Nelson GE. Another Key Moment for Antimicrobial Stewardship: Hospital Discharge. Clin Infect Dis 2021; 71:1240-1242. [PMID: 31562813 DOI: 10.1093/cid/ciz969] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 09/26/2019] [Indexed: 12/11/2022] Open
Affiliation(s)
- George E Nelson
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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24
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Graber CJ, Jones MM, Goetz MB, Madaras-Kelly K, Zhang Y, Butler JM, Weir C, Chou AF, Youn SY, Samore MH, Glassman PA. Decreases in Antimicrobial Use Associated With Multihospital Implementation of Electronic Antimicrobial Stewardship Tools. Clin Infect Dis 2021; 71:1168-1176. [PMID: 31673709 DOI: 10.1093/cid/ciz941] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 10/02/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Antimicrobial stewards may benefit from comparative data to inform interventions that promote optimal inpatient antimicrobial use. METHODS Antimicrobial stewards from 8 geographically dispersed Veterans Affairs (VA) inpatient facilities participated in the development of antimicrobial use visualization tools that allowed for comparison to facilities of similar complexity. The visualization tools consisted of an interactive web-based antimicrobial dashboard and, later, a standardized antimicrobial usage report updated at user-selected intervals. Stewards participated in monthly learning collaboratives. The percent change in average monthly antimicrobial use (all antimicrobial agents, anti-methicillin-resistant Staphylococcus aureus [anti-MRSA] agents, and antipseudomonal agents) was analyzed using a pre-post (January 2014-January 2016 vs July 2016-January 2018) design with segmented regression and external comparison with uninvolved control facilities (n = 118). RESULTS Intervention sites demonstrated a 2.1% decrease (95% confidence interval [CI], -5.7% to 1.6%) in total antimicrobial use pre-post intervention vs a 2.5% increase (95% CI, 0.8% to 4.1%) in nonintervention sites (absolute difference, 4.6%; P = .025). Anti-MRSA antimicrobial use decreased 11.3% (95% CI, -16.0% to -6.3%) at intervention sites vs a 6.6% decrease (95% CI, -9.1% to -3.9%) at nonintervention sites (absolute difference, 4.7%; P = .092). Antipseudomonal antimicrobial use decreased 3.4% (95% CI, -8.2% to 1.7%) at intervention sites vs a 3.6% increase (95% CI, 0.8% to 6.5%) at nonintervention sites (absolute difference, 7.0%; P = .018). CONCLUSIONS Comparative data visualization tool use by stewards at 8 VA facilities was associated with significant reductions in overall antimicrobial and antipseudomonal use relative to uninvolved facilities.
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Affiliation(s)
- Christopher J Graber
- Department of Medicine, David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, California, USA.,Center for Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Makoto M Jones
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA.,Department of Medicine, University of Utah, Salt Lake City, Utah, USA.,Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Matthew Bidwell Goetz
- Department of Medicine, David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, California, USA.,Center for Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Karl Madaras-Kelly
- Department of Pharmacy Boise VA Medical Center, Boise, Idaho.,College of Pharmacy, Idaho State University, Meridian, Idaho
| | - Yue Zhang
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA.,Department of Medicine, University of Utah, Salt Lake City, Utah, USA.,Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Jorie M Butler
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA.,Department of Medicine, University of Utah, Salt Lake City, Utah, USA.,Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Charlene Weir
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA.,Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Ann F Chou
- Department of Family and Preventive Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Sarah Y Youn
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Matthew H Samore
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA.,Department of Medicine, University of Utah, Salt Lake City, Utah, USA.,Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
| | - Peter A Glassman
- Center for Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA.,VA Pharmacy Benefits Management Services, Veterans Health Administration, Washington, D.C., USA
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25
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Antibiotic stewardship teams and Clostridioides difficile practices in United States hospitals: A national survey in The Joint Commission antibiotic stewardship standard era. Infect Control Hosp Epidemiol 2021; 41:143-148. [PMID: 31806059 DOI: 10.1017/ice.2019.313] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship. METHODS Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression. RESULTS Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies. CONCLUSIONS Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non-ID-trained pharmacists and clinicians in antibiotic stewardship.
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26
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Antibiotic assessment at hospital discharge-Room for stewardship intervention. Infect Control Hosp Epidemiol 2021; 41:209-211. [PMID: 31779728 DOI: 10.1017/ice.2019.332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Our stewardship team evaluated 19 months of discharge antibiotic prescriptions to determine prescribing appropriateness and to characterize the interventions made. Intervention occurred in 9.7% of patients, with a 58% acceptance rate. Most interventions were educational (antibiotic course was complete at time of intervention). Discharge antibiotic review is a potential stewardship tool.
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27
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Paulson CM, Handley JF, Dilworth TJ, Persells D, Prusi RY, Brummitt CF, Torres KM, Skrupky LP. Impact of a Systematic Pharmacist-Initiated Antibiotic Time-Out Intervention for Hospitalized Adults. J Pharm Pract 2020; 35:388-395. [PMID: 33353452 DOI: 10.1177/0897190020980616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Antibiotic time-outs (ATO) are a recommended antimicrobial stewardship action, but data assessing their impact are lacking. This study investigated the impact of a systematic, pharmacist initiated ATO intervention. METHODS This pre-post study included inpatients on hospitalist and intensivist services receiving empiric antibiotics for ≥48 hours. The ATO was initiated by pharmacists after 48 hours of empiric therapy and the outcome was documented including antibiotic indication, plan, and duration. An electronic medical record (EMR) alert facilitated ATO completion and pharmacists and prescribers received education prior to implementation. The primary outcome was EMR documentation of an antibiotic plan by 72 hours. Secondary outcomes included antibiotic utilization and antibiotic therapy modifications by 2 hours. RESULTS 399 patients were included, 199 pre- and 200 post-intervention. The most common indications were pneumonia (32%), intra-abdominal infection (20%) and urinary tract infection (19%), with no between-group differences. EMR documentation of an antibiotic plan significantly improved in the post-intervention group (19% vs. 79%, p<0.0001) as did modifications to antibiotic therapy. The median duration of in-hospital antibiotic therapy was similar between groups (4.0 vs. 4.0 days, p = 0.2499). Approximately 45% of patients in each group received discharge antibiotics and median duration of discharge antibiotic therapy prescribed was reduced (7 vs. 5 days in the pre- and post-intervention groups, respectively; p = 0.0140). DISCUSSION Implementation of pharmacist initiated ATO was associated with improvements in supporting EMR documentation and antibiotic therapy modifications. These findings highlight an important role in which pharmacists can serve as part of a collaborative antibiotic stewardship team.
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Affiliation(s)
- Calley M Paulson
- Department of Pharmacy Services, 577980Advocate Aurora Health, Aurora BayCare Medical Center, Green Bay, WI, USA
| | - Jillian F Handley
- Department of Pharmacy Services, 577980Advocate Aurora Health, Milwaukee, WI, USA
| | - Thomas J Dilworth
- Department of Pharmacy Services, 577980Advocate Aurora Health, Milwaukee, WI, USA
| | - Dan Persells
- Department of Pharmacy Services, 577980Advocate Aurora Health, Milwaukee, WI, USA
| | - Rachael Y Prusi
- Department of Education, University of Chicago Medicine, Chicago, IL, USA
| | | | - Katherine M Torres
- Department of Infectious Disease, Aurora Medical Group, Green Bay, WI, USA
| | - Lee P Skrupky
- Department of Education, 6915Mayo Clinic, Rochester, Minnesota, USA
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28
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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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29
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Nachtigall I, Tafelski S, Heucke E, Witzke O, Staack A, Recknagel-Friese S, Geffers C, Bonsignore M. Time and personnel requirements for antimicrobial stewardship in small hospitals in a rural area in Germany. J Infect Public Health 2020; 13:1946-1950. [PMID: 33121907 DOI: 10.1016/j.jiph.2020.10.001] [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: 06/17/2020] [Revised: 09/02/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND In order to control their anti-infectives consumption, hospitals are required to provide multidisciplinary teams comprising among others an infectiologist, a microbiologist and a pharmacist. Small hospitals though often do not dispose of the defaulted personnel. This study illustrates a solution for an antimicrobial stewardship program (ASP) in small community hospitals in a rural area in Germany. METHODS Four hospitals of ca. 200 beds each, jointly hired an antimicrobial stewardship expert to start a common ASP. This expert did rounds on every ward once a week, mostly as chard reviews with the physician in charge. Outside the rounds, he could be consulted by mail. Working time and number of visited patients were documented. Anti-infectives consumption, incidence of Clostridioides difficile infections (CDI) and mortality rates were retrieved from routinely collected data. The intervention period (01/2018-12/2018) was compared to the preintervention period (01/2017-12/2017). RESULTS 3321 patients were visited in the intervention period. In average, 20 patients were seen per day and 20 min were needed per patient/ chard. About 65% of the expert's working time was needed for rounds, 15% for driving between the hospitals. The anti-infectives consumption of the 4 hospitals in the preintervention period amounted to 50 defined daily doses per 100 occupied bed days. The total consumption was reduced by 10% and of quinolones by 36%. The incidence of hospital-acquired CDI receded from 0.14 to 0.07 cases per 100 patient days (-50%, p = 0.001). The overall in-hospital mortality did not change. CONCLUSIONS A single expert was able to implement a successfull ASP in 4 hospitals. While multidisciplinary antimicrobial stewardship teams are ideal for tertiary care hospitals, small hospitals need a more practical solution. This survey shows that one expert can be sufficient for several small hospitals even with the distances in a rural setting.
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Affiliation(s)
- Irit Nachtigall
- Department for Hygiene, Helios Kliniken Ost and Bad Saarow, Pieskower Str. 33, 15526 Bad Saarow, Germany; Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt Operative Intensivmedizin, Campus Charité Mitte, Charitéplatz 1, 10115 Berlin, Germany.
| | - Sascha Tafelski
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Klinik für Anästhesiologie mit Schwerpunkt Operative Intensivmedizin, Campus Charité Mitte, Charitéplatz 1, 10115 Berlin, Germany
| | - Edwin Heucke
- Helios Cluster Saxony-Anhalt, Helios Bördeklinik, Kreiskrankenhaus 4, 39387 Oschersleben, Germany
| | - Oliver Witzke
- Universitätsmedizin Essen, Department of Infectious Diseases, West German Centre of Infectious Diseases, University Duisburg-Essen, Hufelandstraße 55, 45147 Essen, Germany
| | - Annedore Staack
- Helios Klinik Jerichower Land, August-Bebel-Str. 55a, 39288 Burg, Germany
| | | | - Christine Geffers
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Hygiene und Umweltmedizin, Hindenburgdamm 27, 12203 Berlin, Germany
| | - Marzia Bonsignore
- Zentrum für Hygiene, Evangelische Kliniken Gelsenkirchen, Munckelstr. 27, 45879 Gelsenkirchen, Germany.
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30
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Vaughn VM, Gandhi TN, Chopra V, Petty LA, Giesler DL, Malani AN, Bernstein SJ, Hsaiky LM, Pogue JM, Dumkow L, Ratz D, McLaughlin ES, Flanders SA. Antibiotic Overuse after Hospital Discharge: A Multi-Hospital Cohort Study. Clin Infect Dis 2020; 73:e4499-e4506. [PMID: 32918077 PMCID: PMC7947015 DOI: 10.1093/cid/ciaa1372] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 09/09/2020] [Indexed: 12/19/2022] Open
Abstract
Background Antibiotics are commonly prescribed to patients as they leave the hospital. We aimed to create a comprehensive metric to characterize antibiotic overuse after discharge among hospitalized patients treated for pneumonia or urinary tract infection (UTI), and to determine whether overuse varied across hospitals and conditions. Methods In a retrospective cohort study of hospitalized patients treated for pneumonia or UTI in 46 hospitals between 1 July 2017–30 July 2019, we quantified the proportion of patients discharged with antibiotic overuse, defined as unnecessary antibiotic use, excess antibiotic duration, or suboptimal fluoroquinolone use. Using linear regression, we assessed hospital-level associations between antibiotic overuse after discharge in patients treated for pneumonia versus a UTI. Results Of 21 825 patients treated for infection (12 445 with pneumonia; 9380 with a UTI), nearly half (49.1%) had antibiotic overuse after discharge (56.9% with pneumonia; 38.7% with a UTI). For pneumonia, 63.1% of overuse days after discharge were due to excess duration; for UTIs, 43.9% were due to treatment of asymptomatic bacteriuria. The percentage of patients discharged with antibiotic overuse varied 5-fold among hospitals (from 15.9% [95% confidence interval, 8.7%–24.6%] to 80.6% [95% confidence interval, 69.4%–88.1%]) and was strongly correlated between conditions (regression coefficient = 0.85; P < .001). Conclusions Antibiotic overuse after discharge was common and varied widely between hospitals. Antibiotic overuse after discharge was associated between conditions, suggesting that the prescribing culture, physician behavior, or organizational processes contribute to overprescribing at discharge. Multifaceted efforts focusing on all 3 types of overuse and multiple conditions should be considered to improve antibiotic prescribing at discharge.
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Affiliation(s)
- Valerie M Vaughn
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Vineet Chopra
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Daniel L Giesler
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Division of Infectious Diseases, Department of Internal Medicine, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Anurag N Malani
- Department of Infection Prevention and Control, St. Joseph Mercy Health System, Ann Arbor, Michigan, USA
| | - Steven J Bernstein
- Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA.,Division of General Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Lama M Hsaiky
- Department of Pharmaceutical Services, Beaumont Hospital Dearborn, Dearborn, Michigan
| | - Jason M Pogue
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Lisa Dumkow
- Department of Clinical Pharmacy Services, Mercy Health Saint Mary's, Grand Rapids, USA
| | - David Ratz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA.,Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Elizabeth S McLaughlin
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
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31
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Interventions to improve antibiotic prescribing at hospital discharge: A systematic review. Infect Control Hosp Epidemiol 2020; 42:96-99. [PMID: 32867878 DOI: 10.1017/ice.2020.367] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
A large proportion of antibiotic use associated with hospitalization occurs immediately after discharge, representing an important focus for antimicrobial stewardship programs. This review identified few studies evaluating the effect of interventions aimed at improving discharge antibiotic prescribing. Antimicrobial stewardship to improve postdischarge antibiotic prescribing is an unmet need warranting further study.
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32
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Effect of prospective audit and feedback on inpatient fluoroquinolone use and appropriateness of prescribing. Infect Control Hosp Epidemiol 2020; 41:1458-1460. [PMID: 32762780 DOI: 10.1017/ice.2020.339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We report the effect of prospective audit and feedback (PAF) on inpatient fluoroquinolone (FQN) prescriptions. During the PAF period, FQN use decreased from 39.19 to 29.58 days of therapy per 1,000 patient days (P < .001) and appropriateness improved from 68% to 88% (P < .001). High-yield indications to target included noninfectious urinary tract and respiratory presentations.
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33
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Queen J, Zhang J, Sears CL. Oral antibiotic use and chronic disease: long-term health impact beyond antimicrobial resistance and Clostridioides difficile. Gut Microbes 2020; 11:1092-1103. [PMID: 32037950 PMCID: PMC7524332 DOI: 10.1080/19490976.2019.1706425] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
We recently reported an increased colon cancer risk associated with oral antibiotic use in a large United Kingdom population. This association between antibiotic exposure and cancer risk adds to a growing body of evidence that antibiotic use has unintended off-target long-term health consequences. This addendum highlights major studies linking antibiotic use and chronic disease in pediatric and adult populations. Microbiota dysbiosis is the key proposed mechanism underlying antibiotic:disease associations, resulting in alterations in gene expression, epigenetic modification, colonization by pathogenic bacteria, instigation of biofilms, and immune regulation and inflammation. These adverse outcomes of antibiotic exposure underscore the need for diagnostic and antibiotic stewardship, as well as the urgency for further development of non-antibiotic therapies for bacterial infections.
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Affiliation(s)
- Jessica Queen
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA,CONTACT Cynthia Sears The Johns Hopkins University School of Medicine, 1550Orleans Street, CRB 2 Bldg., Suite 1M-05, Baltimore, MD21287, USA
| | - Jiajia Zhang
- The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA,The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia L Sears
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA,The Bloomberg-Kimmel Institute for Cancer Immunotherapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA,The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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34
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Prescriber perceptions of fluoroquinolones, extended-spectrum cephalosporins, and Clostridioides difficile infection. Infect Control Hosp Epidemiol 2020; 41:914-920. [PMID: 32468967 DOI: 10.1017/ice.2020.183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Fluoroquinolones (FQs) and extended-spectrum cephalosporins (ESCs) are associated with higher risk of Clostridioides difficile infection (CDI). Decreasing the unnecessary use of FQs and ESCs is a goal of antimicrobial stewardship. Understanding how prescribers perceive the risks and benefits of FQs and ESCs is needed. METHODS We conducted interviews with clinicians from 4 hospitals. Interviews elicited respondent perceptions about the risk of ESCs, FQs, and CDI. Interviews were audio recorded, transcribed, and analyzed using a flexible coding approach. RESULTS Interviews were conducted with 64 respondents (38 physicians, 7 nurses, 6 advance practice providers, and 13 pharmacists). ESCs and FQs were perceived to have many benefits, including infrequent dosing, breadth of coverage, and greater patient adherence after hospital discharge. Prescribers stated that it was easy to make decisions about these drugs, so they were especially appealing to use in the context of time pressures. They described having difficulty discontinuing these drugs when prescribed by others due to inertia and fear. Prescribers were skeptical about targeting specific drugs as a stewardship approach and felt that the risk of a negative outcome from under treatment of a suspected bacterial infection was a higher priority than the prevention of CDI. CONCLUSIONS Prescribers in this study perceived many advantages to using ESCs and FQs, especially under conditions of time pressure and uncertainty. In making decisions about these drugs, prescribers balance risk and benefit, and they believed that the risk of CDI was acceptable in compared with the risk of undertreatment.
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35
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Bratsman A, Mathias K, Laubscher R, Grigoryan L, Rose S. Outpatient fluoroquinolone prescribing patterns before and after US FDA boxed warning. Pharmacoepidemiol Drug Saf 2020; 29:701-707. [PMID: 32390266 DOI: 10.1002/pds.5018] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/02/2020] [Accepted: 04/09/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Fluoroquinolones are routinely overprescribed for uncomplicated urinary tract infection (uUTI), acute sinusitis, and acute bronchitis. In 2016, the United States (US) Food and Drug Administration (FDA) updated the boxed warning on fluoroquinolones, recommending against their use as first-line agents for the routine pharmacologic management of uUTI, acute sinusitis, and acute bronchitis in patients who have other treatment options. The primary objective of this study was to determine if the 2016 expanded boxed warning was associated with decreased fluoroquinolone prescription rates for these three diagnoses. METHODS We retrospectively reviewed antibiotics prescribed at a single, large, academic outpatient center for these three diagnoses between January 2013 and May 2018. Interrupted time series analysis was used to compare the rate of fluoroquinolone prescriptions before and after the May 2016 FDA boxed warning. RESULTS A total of 10 087 antibiotic prescriptions for these three diagnoses were examined. There was no significant change in fluoroquinolone prescription rates after the FDA boxed warning. The majority of inappropriate fluoroquinolone prescriptions were given for the management of uUTI. CONCLUSION The 2016 US FDA boxed warning against fluoroquinolone use for uUTI, acute sinusitis, and acute bronchitis was not associated with a statistically significant reduction in the rate of fluoroquinolone prescriptions for these diagnoses. Additional research is needed to define how US FDA boxed warnings may be incorporated into broader antibiotic stewardship programs to decrease overuse of fluoroquinolones and avoid adverse effects of the drug class, including Clostridioides difficile infections and emergence of resistant organisms.
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Affiliation(s)
- Andrew Bratsman
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kristen Mathias
- Department of Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | - Rory Laubscher
- Office of Information Technology (OIT) Data Services, Baylor College of Medicine, Houston, Texas, USA
| | - Larissa Grigoryan
- Department of Family and Community, Baylor College of Medicine, Houston, Texas, USA
| | - Stacey Rose
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
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Gatti M, Bianchin M, Raschi E, De Ponti F. Assessing the association between fluoroquinolones and emerging adverse drug reactions raised by regulatory agencies: An umbrella review. Eur J Intern Med 2020; 75:60-70. [PMID: 31983604 DOI: 10.1016/j.ejim.2020.01.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 01/11/2020] [Accepted: 01/15/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Regulatory agencies warned against fluoroquinolones for the management of minor infections because of the risk of emerging adverse events (collagen-associated adverse events, neuropsychiatric toxicity and long-term disability). We aimed to assess quality and credibility of evidence as well as causality regarding these putative associations. METHODS MEDLINE, Scopus, Web of Science and PROSPERO were searched, from inception to August 2019, for systematic reviews with meta-analyses investigating emerging adverse events. Two investigators extracted data to grade quality (through validated AMSTAR-2 tool), rank credibility of the evidence (convincing, highly suggestive, suggestive, weak) through adapted criteria including E-value calculation, and assess causality (Hill's criteria). RESULTS Seven systematic reviews of observational studies providing 16 risk estimates [seven, five and four, respectively, for aortic aneurysm/dissection (AAD), retinal detachment (RD) and any tendon disorders (ATD)] met inclusion criteria. No systematic reviews with meta-analysis investigating the risk of neuropsychiatric toxicity or long-term disability were found. The associations between fluoroquinolones and AAD/ATD showed highly suggestive credibility and were supported by strong evidence of causality (double increased risk, especially within first 2 months of treatment). Conflicting data concerning the emergence of RD were retrieved, resulting in weak evidence of causality. Quality of the evidence ranged from high to low for AAD, from moderate to critically low for RD, and it was moderate for ATD. CONCLUSION Our analysis supports credible, plausible and highly suggestive associations with AAD (rare occurrence but strong causality) and ATD. Limitations of both umbrella reviews and observational evidence should be considered.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
| | - Matteo Bianchin
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
| | - Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy.
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, Italy
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Vaughn VM, Seelye SM, Wang XQ, Wiitala WL, Rubin MA, Prescott HC. Inpatient and Discharge Fluoroquinolone Prescribing in Veterans Affairs Hospitals Between 2014 and 2017. Open Forum Infect Dis 2020; 7:ofaa149. [PMID: 32500088 DOI: 10.1093/ofid/ofaa149] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/23/2020] [Indexed: 11/13/2022] Open
Abstract
Background Between 2007 and 2015, inpatient fluoroquinolone use declined in US Veterans Affairs (VA) hospitals. Whether fluoroquinolone use at discharge also declined, in particular since antibiotic stewardship programs became mandated at VA hospitals in 2014, is unknown. Methods In this retrospective cohort study of hospitalizations with infection between January 1, 2014, and December 31, 2017, at 125 VA hospitals, we assessed inpatient and discharge fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) use as (a) proportion of hospitalizations with a fluoroquinolone prescribed and (b) fluoroquinolone-days per 1000 hospitalizations. After adjusting for illness severity, comorbidities, and age, we used multilevel logit and negative binomial models to assess for hospital-level variation and longitudinal prescribing trends. Results Of 560219 hospitalizations meeting inclusion criteria as hospitalizations with infection, 37.4% (209602/560219) had a fluoroquinolone prescribed either during hospitalization (32.5%, 182337/560219) or at discharge (19.6%, 110003/560219). Hospitals varied appreciably in inpatient, discharge, and total fluoroquinolone use, with 71% of hospitals in the highest prescribing quartile located in the Southern United States. Nearly all measures of fluoroquinolone use decreased between 2014 and 2017, with the largest decreases found in inpatient fluoroquinolone and ciprofloxacin use. In contrast, there was minimal decline in fluoroquinolone use at discharge, which accounted for a growing percentage of hospitalization-related fluoroquinolone-days (52.0% in 2014; 61.3% by 2017). Conclusions Between 2014 and 2017, fluoroquinolone use decreased in VA hospitals, largely driven by decreased inpatient fluoroquinolone (especially ciprofloxacin) use. Fluoroquinolone prescribing at discharge, as well as levofloxacin prescribing overall, is a growing target for stewardship.
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Affiliation(s)
- Valerie M Vaughn
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sarah M Seelye
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Xiao Qing Wang
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Wyndy L Wiitala
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Michael A Rubin
- VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Hallie C Prescott
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
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Truong WR, Hsu DI, Yamaki J. Oral Antibiotic Prescribing in Healthcare-associated Pneumonia Patients at Hospital Discharge. Clin Infect Dis 2019; 69:2042-2043. [PMID: 31211833 DOI: 10.1093/cid/ciz340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Donald I Hsu
- Department of Pharmacy Practice and Administration, Western University of Health Sciences College of Pharmacy, Pomona
| | - Jason Yamaki
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, California
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Vaughn VM, Gandhi T, Chopra V, Malani AN, Flanders SA. Reply to Truong, Hsu, and Yamaki. Clin Infect Dis 2019; 69:2043-2044. [PMID: 31211840 DOI: 10.1093/cid/ciz342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Valerie M Vaughn
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Michigan
- Center for Clinical Management Research, VA Ann Arbor Health System, Michigan
| | - Tejal Gandhi
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, Michigan
| | - Vineet Chopra
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Michigan
- Center for Clinical Management Research, VA Ann Arbor Health System, Michigan
| | - Anurag N Malani
- Division of Infectious Diseases, Department of Internal Medicine, St. Joseph Mercy Health System, Michigan
- Department of Infection Prevention and Control, St. Joseph Mercy Health System, Ann Arbor, Michigan
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Michigan
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Houchens N, Meddings J, Gupta A. Quality and safety in the literature: September 2019. BMJ Qual Saf 2019; 28:769-774. [PMID: 31253735 DOI: 10.1136/bmjqs-2019-009918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 06/12/2019] [Indexed: 01/30/2023]
Affiliation(s)
- Nathan Houchens
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States .,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Jennifer Meddings
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States.,Departmentof Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Ashwin Gupta
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, United States
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41
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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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Total duration of antimicrobial therapy resulting from inpatient hospitalization. Infect Control Hosp Epidemiol 2019; 40:847-854. [DOI: 10.1017/ice.2019.118] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AbstractObjective:To assess the feasibility of electronic data capture of postdischarge durations and evaluate total durations of antimicrobial exposure related to inpatient hospital stays.Design:Multicenter, retrospective cohort study.Setting:Two community hospitals and 1 academic medical center.Patients:Hospitalized patients who received ≥1 dose of a systemic antimicrobial agent.Methods:We collected and reviewed electronic data on inpatient and discharge antimicrobial prescribing from April to September 2016 in 3 pilot hospitals. Inpatient antimicrobial use was obtained from electronic medication administration records. Postdischarge antimicrobial use was calculated from electronic discharge prescriptions. We completed a manual validation to evaluate the ability of electronic prescriptions to capture intended postdischarge antibiotics. Inpatient, postdischarge, and total lengths of therapy (LOT) per admission were calculated to assess durations of antimicrobial therapy attributed to hospitalization.Results:A total of 45,693 inpatient admissions were evaluated. Antimicrobials were given during 23,447 admissions (51%), and electronic discharge prescriptions were captured in 7,442 admissions (16%). Manual validation revealed incomplete data capture in scenarios in which prescribers avoided the electronic system. The postdischarge LOT among admissions with discharge antimicrobials was median 8 days (range, 1–360) with peaks at 5, 7, 10, and 14 days. Postdischarge days accounted for 38% of antimicrobial exposure days.Conclusion:Discharge antimicrobial therapy accounted for a large portion of antimicrobial exposure related to inpatient hospital stays. Discharge prescription data can feasibly be captured through electronic prescribing records and may aid in designing stewardship interventions at transitions of care.
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