Trends in hospital antibiotic prescribing after introduction of an antibiotic policy

Genomic, morphological, and biochemical analyses of a multi-metal resistant but multi-drug susceptible strain of Bordetella petrii from hospital soil

Contamination of soil by antibiotics and heavy metals originating from hospital facilities has emerged as a major cause for the development of resistant microbes. We collected soil samples surrounding a hospital effluent and measured the resistance of bacterial isolates against multiple antibiotics and heavy metals. One strain BMCSI 3 was found to be sensitive to all tested antibiotics. However, it was resistant to many heavy metals and metalloids like cadmium, chromium, copper, mercury, arsenic, and others. This strain was motile and potentially spore-forming. Whole-genome shotgun assembly of BMCSI 3 produced 4.95 Mb genome with 4,638 protein-coding genes. The taxonomic and phylogenetic analysis revealed it, to be a Bordetella petrii strain. Multiple genomic islands carrying mobile genetic elements; coding for heavy metal resistant genes, response regulators or transcription factors, transporters, and multi-drug efflux pumps were identified from the genome. A comparative genomic analysis of BMCSI 3 with annotated genomes of other free-living B. petrii revealed the presence of multiple transposable elements and several genes involved in stress response and metabolism. This study provides insights into how genomic reorganization and plasticity results in evolution of heavy metals resistance by acquiring genes from its natural environment.

Does Fluoroquinolones and Third-Generation Cephalosporins Restriction Reverse Extended-Spectrum β-Lactamases Klebsiella pneumoniae Resistance Rates?

Aim: To decrease the incidence and resistance rates of extended-spectrum β-lactamases (ESBL) Klebsiella pneumoniae (KP) by restriction of the use of third-generation cephalosporins (3GCs) and fluoroquinolones. Methods: Consumption of 3GCs, fluoroquinolones, and carbapenems in association with ertapenem and fluoroquinolone-resistant KP isolates, were analyzed in 21 months by autoregressive integrated moving average models. A follow-up analysis was performed 5 years later. Results: Consumption of 3GCs decreased significantly during the postintervention period. Their restriction was associated with a decrease in ertapenem-resistant KP isolates by 17.5%. Fluoroquinolone, 3GCs, and carbapenem use did not significantly predict the percentage of ertapenem-resistant KP isolates. Fluoroquinolone, but not cephalosporin use, significantly predicted the percentage of fluoroquinolone-resistant isolates, with an increase of 1 defined daily dose (DDD) of fluoroquinolone/100 occupied bed-days (OBDs) corresponding to a 0.32% increase of fluoroquinolone-resistant isolates (p = 0.008). A decrease of 1 DDD of carbapenem/100 OBD was associated with a 16.94% increase of fluoroquinolone-resistant isolates (p = 0.007). Five years later, the consumption of all three antimicrobial classes increased significantly compared with the 2011-2013 period, whereas ertapenem-resistant KP rates significantly decreased. Conclusion: This study may bring a valuable contribution to the understanding of the intricate association between antibiotic consumption and bacterial resistance. Reporting a spectrum of different results could present a useful basis for more profound research of various interventions' effects.

Evaluation of the appropriateness of meropenem prescribing at a tertiary care hospital: A retrospective study in Oman

OBJECTIVES

The aim of this study was to evaluate the use of meropenem in terms of indication and continuation of treatment at Sultan Qaboos University Hospital (SQUH), Muscat, Oman.

METHODS

A retrospective observational study, conducted by reviewing the medical records of 400 adults, admitted patients who received at least one dose of meropenem during the study period (January 2017 to September 2017). The analysis was performed using univariate statistics.

RESULTS

Meropenem was prescribed empirically in 382/400 (96%) of the cases. The majority (315/361 (87%)) of the patients received the proper meropenem dose. The indication for meropenem was considered appropriate in only 196/400 (49%) of the cases. The continuation of treatment was evaluated according to culture and sensitivity results in 202 cases, out of which 112 (55%) were justified. Most of the inappropriate uses were seen in oncology and hematology cases (31/42 (74%) and 61/101 (60%), respectively) and among respiratory and urinary tract infections (126/155 (81%) and 40/46 (87%), respectively).

CONCLUSIONS

Approximately half of the meropenem orders at SQUH in Oman were inappropriate and unjustified by culture-test results. New strategies are needed to optimize the rational use of meropenem and to ensure appropriate de-escalation and discontinuation of meropenem whenever indicated.

Development and evaluation of diffusive gradients in thin films technique for measuring antibiotics in seawater

As coastal waters in many regions of the world have been polluted by organic micro-pollutants such as antibiotics that can promote the development of resistance genes, it is of importance to monitor the levels of antibiotics in coastal waters. For this purpose, a reliable and robust sampling approach based on diffusive gradients in thin films (DGT) was developed in this study. The DGT measurement can provide a time weighted average concentration of pollutants. A binding material (resin XDA-1) with a high adsorption capacity for antibiotics, which can resist the pH and ionic strength of seawaters, was selected. The DGT sampler exhibited linear accumulation for 20 antibiotics during a 12h deployment. The antibiotic measurement by the sampler was not affected by pH in the range of 7.3 to 8.9 and ionic strength in the range of 0.5 to 0.8M. After an 8-hour in situ DGT sampling, 10 antibiotics were detected in Dalian coastal seawaters with the concentrations ranging from 2.6 to 44.8ngL^-1, which was comparable to the results measured by an active sampling method. This study can be a first attempt to construct DGT sampler for determining antibiotics in seawaters.

Usage Pattern and Serum Level Measurement of Amikacin in the Internal Medicine Ward of the Largest Referral Hospital in the South of Iran: A Pharmacoepidemiological Study

BACKGROUND

The inappropriate use of aminoglycosides has harmful effects such as the development of resistant pathogens and the incidence of nephrotoxicity and ototoxicity. Therefore, drug utilization evaluation of these drugs may improve their usage remarkably. The aim of this study was to assess the usage pattern of amikacin in an internal medicine ward.

METHODS

This cross-sectional study was conducted in the Internal Medicine Ward of Nemazee Teaching Hospital, Shiraz, Iran, in 2011. The guideline for amikacin use was approved by the institutional Pharmacy and Therapeutics Committee, and the study criteria were developed to assess several parameters involved in amikacin therapy such as appropriateness of drug use, dosage, duration of therapy, toxicity monitoring, and serum concentration assay. Serum concentration was assayed using a Cobas Mira AutoAnalyzer. Clinical and paraclinical parameters such as glomerular filtration rate, culture, microbial sensitivity, white blood cell count, and fever were collected.

RESULTS

Sixty-three patients were evaluated. Fifty-seven percent of the patients needed dose readjustment; however, it was not performed for 89% of them. Culture between 48 and 72 hours after amikacin administration was not controlled for 79% of the patients. In 19% of the patients, optimum therapeutic effect was not achieved. The mean±SD of the trough and peak concentrations was 7.63±5.4 μg/mL and 15.67±7.79 μg/mL, respectively. Forty-five percent of the trough and 38% of the peak levels were within the therapeutic range. The overall adherence of amikacin usage to the guideline was only 48%.

CONCLUSION

To achieve appropriate treatment and prevent toxic effects, we recommend that pharmacokinetic dosing methods, amikacin guideline, and serum monitoring be considered.

Evaluation of restricted antibiotic use in a hospital in Romania

BACKGROUND

Antibiotics are the most frequently used drugs among hospitalised patients. Antimicrobial resistance is a major health issue and therefore antibiotic consumption should be under strict surveillance.

OBJECTIVE

To evaluate the use of restricted antibiotics in an academic hospital in Romania.

METHODS

Retrospective evaluation of the use of 11 restricted antibiotics issued based on the antibiotics formularies for the year 2012. Therapeutic guidelines and the summary of product characteristics were used for the evaluation. The appropriateness antibiotics use was verified, according to three main criteria: appropriate indication (type of treatment, localization and type of infection), dose and duration of treatment. Descriptive statistics and multiple logistic regression analysis were performed. Results 664 prescribing formularies were analyzed, of these 319 were from the intensive care unit (48.04 %). The most prescribed antibiotics were vancomycin (171, 25.75 %), imipenem (151, 22.74 %) and meropenem (116, 17.47 %). Overall, 285 prescriptions (42.92 %) were considered inappropriate. Vancomycin, meropenem and imipenem were prescribed inappropriate in 49.71, 46.55 and 44.06 % of such cases. Of the total 285 prescriptions deemed as inappropriate, for 49.82 % the dose was incorrect, 20 % were inadequate in terms of treatment duration and 15.44 % were wrongly indicated. Inappropriate use was significantly higher among empirical prescriptions than the documented ones (69.75 vs. 30.25 %, p < 0.001). Multiple stepwise logistic regression identified that the duration of the treatment was significant for inappropriate antibiotic use (p < 0.05). The risk of inappropriate use in the case of empirical prescriptions is higher than for documented prescriptions (OR 5.78, p < 0.001, CI 3.65-9.15).

CONCLUSIONS

the results suggest the need to intensify the control of the use of restricted antibiotics. The implementation of drug formularies in hospitals and the involvement of the clinical pharmacist may ensure rational antibiotic therapy.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Quality of antibiotic (fluoroquinolons, aminosids and amoxicillin-clavulanic acid) prescription in a French teaching hospital]

OBJECTIVES

To assess the quality of prescription of fluoroquinolons, aminosids and amoxicillin-clavulanic acids in medicine departments.

METHODS

Data on target antibiotic prescription were collected on a given day and confronted to local recommendations and literature guidelines. Evaluation of antibiotic therapy was done by assessing molecule choice, administration conditions (dosages, route and administration schedule, treatment duration), reassessment of treatments 48-72 h later, dose adaptation of aminosids depending on serum monitoring.

RESULTS

Sixty-three patients were included and 67 "target" antibiotics were prescribed. Prevalence of antibiotic-treated patients was 24.4%, and 14.6% for "target" antibiotic-treated patients. Antibiotic choice was appropriate in 67% of prescriptions. Dosages were adequates in 94% of case and administration schedule in 97% of cases. The oral route administration as soon as possible was applied to half of patients. Treatment duration were respected for 94% of prescriptions. Reassessment of antibiotic therapy 48-72 h later was realized in 66% of cases. Dose adaptation of aminosids, when necessary, was realized on one third of cases. For all the quality criteria assessed, the overall frequency of prescription conformity was 44%.

CONCLUSION

Large diffusion of protocols, systematic reassessment of treatments at 48-72 h, promotion of training sessions for new prescribers in the institution, reinforcing the function of medical correspondents in antibiotic therapy and infectiologists, periodic evaluation of antibiotic therapy, should improve the quality of antibiotic therapy.

Implementation of antibiotic management teams in Belgian hospitals

In 2002-03, the Belgian government subsidized in part the activities of local Antibiotic Managers (AMs) in 36 hospitals selected based on the presence of an operational multidisciplinary Antibiotic Management Team (AMT). AMs were trained as Internists (28), Microbiologists (13) and Hospital Pharmacists (13). The hospitals were representative of Belgian hospitals in affiliation, regional origin and size. The financing scheme allowed the implementation of 175 antibiotic management interventions, with a mean of 5 interventions/hospital. The activities reported in the first 9-month progress reports were analyzed according to national guidelines for AMTs. All hospitals irrespective of size or affiliation had undertaken a wide range of measures: review of formulary (29), implementation of new clinical guidelines (24), restricted access to selected antibiotics (25), improvement of antibiotic susceptibility testing methods (12), development of antibiotic consumption database (35) and analysis of antibacterial susceptibility data (31). Advertisement type categorization of communication methods showed that education of prescribers was based on multimodal communication. All hospitals used at least one passive method, 39% at least one active method and 55% at least one personalized method. The quality of communication was higher in hospitals with teaching affiliation. In conclusion, hospitals that received a financial incentive under theAMT pilot phase have developed multimodal antibiotic policy interventions independently of the hospital size and teaching status. Extension to all Belgian hospitals appears warranted. The impact of AMTs and AMs on the quality of use of antibiotics and trends of antibiotic resistance and cost will be monitored based on standardized indicators.

The effect of a restriction policy on the antimicrobial consumption in Turkey: a country-wide study

BACKGROUND

The total annual expenditure of antimicrobials in Turkey in 2002 was 24% of all drug spending. In order to reduce the cost of drug expenditure, the Turkish government introduced a new restriction policy on the prescription of antimicrobials in June 2003. This new policy is based on the justification that the physicians specializing in infectious diseases should be primarily responsible for the prescription of antimicrobials.

OBJECTIVES

Compare and contrast the usage of antimicrobials at hospitals before and after the implementation of the new restriction policy.

METHODS

The data was collected from the same departments in two different periods in 2003 at 15 hospitals throughout Turkey. The first set of data was collected a few days before the new policy was implemented in May 2003 and the second data set 6 months after that. Antimicrobial usage was calculated as defined daily doses (DDDs) per 100 patient days according to ATC-DDD index. The change in antimicrobial consumption was determined by comparing the mean DDD values before and after the implementation of the new policy.

RESULTS

Before the intervention, the mean antimicrobial use density was 71.56 DDD/100 patients-day at the hospitals in the study. Six months after the implementation, the mean antimicrobial use density was 52.64 DDD/100 patients-day. There was a 26.4% decrease in the antimicrobial usage between that prior to and that after the intervention (P < 0.025).

CONCLUSIONS

The study shows that the implementation of the new policy resulted in a significant reduction in the prescription of antimicrobials.

L'hygiène hospitalière et le conseil en antibiothérapie : un duo opérationnel face au problème de la diffusion des bactéries multirésistantes aux antibiotiques

OBJECTIVES

The authors had for aim to show that preventing the diffusion of multidrug-resistant organism (MRO) is possible thanks to the coordination of recommended preventive actions and the implementation of a sensible anti-infective prescription policy. They also wanted to highlight the role played by the nursing care staff in enforcing recommendations.

METHOD

We compared the results of two health care facilities having both implemented the same strategy aimed at preventing cross-transmission and prescribing anti-infective drugs.

RESULTS

Audits reported a very variable enforcement of recommendations. The results obtained from microbiological monitoring confirmed the essential impact of protocol enactment by every team, on the control of MRO diffusion. The antibiotherapy specialist has a key role in the suggested strategy, allowing a significant decrease in the number of anti-infective prescriptions and a more rational use.

CONCLUSION

The collaboration of a hygiene specialist with an antibiotherapy specialist has proved operational in the fight against MRO diffusion, as long as the competences of both specialists are acknowledged and their cross-disciplinary activities accepted. For the entire staff, enacting a corporate culture is a crucial asset.

Antimicrobial drug use and methicillin-resistant Staphylococcus aureus, Aberdeen, 1996-2000

Relationships between antimicrobial use and MRSA prevalence are analyzed in Aberdeen, Scotland.

Similar to many hospitals worldwide, Aberdeen Royal Infirmary has had an outbreak of methicillin-resistant Staphylococcus aureus (MRSA). In this setting, the outbreak is attributable to two major clones. The relationships between antimicrobial use and MRSA prevalence were analyzed by time-series analysis. From June 1997 to December 2000, dynamic, temporal relationships were found between monthly %MRSA and previous %MRSA, macrolide use, third-generation cephalosporin use, and fluoroquinolone use. This study suggests that use of antimicrobial drugs to which the MRSA outbreak strains are resistant may be an important factor in perpetuating the outbreak. Moreover, this study confirmed the ecologic effect of antimicrobial drug use (i.e., current antimicrobial use) may have an effect on resistance in future patients. Although these results may not be generalized to other hospitals, they suggest new directions for control of MRSA, which has thus far proved difficult and expensive.

Oral quinolones in hospitalized patients: an evaluation of a computerized decision support intervention

OBJECTIVE

To determine whether a computerized decision support system could increase the proportion of oral quinolone antibiotic orders placed for hospitalized patients.

DESIGN

Prospective, interrupted time-series analysis.

SETTING

University hospital in the south-eastern United States.

SUBJECTS

Inpatient quinolone orders placed from 1 February 2001 to 31 January 2003.

INTERVENTION

A web-based intervention was deployed as part of an existing order entry system at a university hospital on 5 February 2002. Based on an automated query of active medication and diet orders, some users ordering intravenous quinolones were presented with a suggestion to consider choosing an oral formulation.

MAIN OUTCOME MEASURE

The proportion of inpatient quinolone orders placed for oral formulations before and after deployment of the intervention.

RESULTS

There were a total of 15 194 quinolone orders during the study period, of which 8962 (59%) were for oral forms. Orders for oral quinolones increased from 4202 (56%) before the intervention to 4760 (62%) after, without a change in total orders. In the time-series analysis, there was an overall 5.6% increase (95% CI 2.8-8.4%; P < 0.001) in weekly oral quinolone orders due to the intervention, with the greatest effect on nonintensive care medical units.

CONCLUSIONS

A web-based intervention was able to increase oral quinolone orders in hospitalized patients. This is one of the first studies to demonstrate a significant effect of a computerized intervention on dosing route within an antibiotic class. This model could be applied to other antibiotics or other drug classes with good oral bioavailability.

Impact of regular attendance by infectious disease specialists on the management of hospitalised adults with community-acquired febrile syndromes

The impact of attendance by infectious disease specialists (IDS) on hospitalised adults with community-acquired infection was assessed by studying 402 consecutive febrile adults who were admitted randomly to either of two internal medicine wards over a 4-month period and given intravenous antibiotics. In ward 1, patients were attended by IDS, whereas those in ward 2 were attended by physicians from other specialties. In total, 160 patients were treated in ward 1 and 242 in ward 2 (median age 66 years; 49% male). The case-mix was comparable. Only 39% of ward 2 patients underwent minimal fever diagnostic tests compared to 82% in ward 1 (p < 0.001). Ward 1 and 2 patients received 188 and 315 antibiotic courses, respectively, of which 32% and 20% required approval from IDS (p 0.003). Patients in ward 1 were more likely to receive ceftriaxone (7.5% vs. 2%; p 0.002), erythromycin (7% vs. 1.5%; p 0.002) and cefuroxime (48% vs. 26%; p < 0.0001), but were less likely to receive amoxycillin-clavulanate (8% vs. 28%; p < 0.0001). The mean durations of therapy were 3.6 and 3.2 days (not significant), and therapy was deemed to be completely appropriate in 55.5% and 43% of cases, respectively (p 0.012). The crude mortality rates were 6.3% and 7.9%, respectively (not significant), while the medication costs were US dollars 27.4 and US dollars 26.4/patient/antibiotic day, respectively. Regular attendance by IDS resulted in significantly higher rates of accurate diagnosis and appropriate therapy. IDS prescribed more restricted (and expensive) agents, but preferred less expensive agents among unrestricted drugs, thereby offsetting the overall medication costs.

Pneumopathies du sujet âgé

OBJECTIVE

We developed a prescribing guideline containing recommendations for the initial empirical antibiotic therapy in community or nosocomial pneumonia. The aim of the present study was to examine the impact of this measure.

METHOD

The prescribing guideline was implemented in May 1999. We retrospectively reviewed the charts of all patients>65 years with community-, or nursing home- or hospital-acquired pneumonia hospitalised in our department of acute geriatric care between May 1999 and November 2000. The criteria assessed were: consistence with the guideline, clinical effectiveness within 72 hours, adequation with the isolated germs and intra-hospital mortality.

RESULTS

Data were collected on 112 patients (63 women et 49 men; mean age=80 +/- 8 Years). The pneumonia was community-acquired in 52 cases (46%), nursing home acquired in 25 cases (22%) and hospital-acquired in 35 cases (31%). Antibiotic prescription was consistent with the guideline in 64 cases (57%). When the antibiotic therapy was consistent, the patients were more likely to improve within 72 hours (45/64 versus 23/48; p=0.01). Despite a tendency, the number of antimicrobial treatments adapted to the isolated microorganisms was not significantly higher in the consistent group (22/36 adapted treatments versus 10/20). The intra-hospital mortality (25%) was similar in the two groups consistent and not consistent with the guideline. SARM was the most frequent multiresistant bacteria that was isolated.

CONCLUSION

The use of a prescribing guideline might improve the efficiency of empirical probabilistic antibiotic therapies. The impact of the guideline use on overall antibiotic costs and microbiological flora remains to be determined.

Antibiotic use profile at paediatric clinics in two transitional countries

PURPOSE

In this study, we evaluated antibiotic utilisation pattern at two paediatric clinics in different European (transitional) countries: Croatia (Rijeka) and Russia (Smolensk).

METHODS

Antibiotic utilisation during the year 2000 was observed using the ATC/defined daily doses (DDD) methodology (ATC code-J01). Drug-usage data was expressed in numbers of DDD/100 bed-days and the DU90% profile.

RESULTS

In Rijeka, 35 different systemic antibiotics were used and in Smolensk 22. The overall consumption of antibiotic drugs in Rijeka was more than three times higher than in Smolensk (28.96 vs 8.3 DDD/100 bed-days). The top five antibiotic drugs used in Smolensk were amoxicillin, mydecamicin, ampicilin, doxycylin, gentamicin; and in Rijeka cefuroxime axetil, ceftriaxone, azytromycin, ceftibuten and amoxicillin.

CONCLUSION

Differences in antibiotic prescribing patterns are greater than expected. The pattern of antibiotic utilisation in both countries implies that regional control measures and guidelines for antibiotic use in children should be urgently established.

Impact of a multidisciplinary approach to the control of antibiotic prescription in a general hospital

We examined the impact of a rational antibiotic prescription programme based on a multidisciplinary consultative approach in a 600-bed hospital. The programme involved four measures: (1). drawing up of a local prescribing consensus with all prescribers; (2). a restricted prescriptions policy for the most expensive antibiotics; (3.assessment of the prescription of these antibiotics by regular audits; and (4). institutional training and information for prescribers. The impact of the programme was assessed by comparing actual prescriptions with the criteria of the local consensus, compliance with the restrictive prescription policy, changes in the average daily cost of antibiotic therapy per inpatient and changes in the local ecology of methicillin-resistant Staphylococcus aureus (MRSA), Enterobacteriaceae producing extended-spectrum beta-lactamases (EPESB) and ceftazidime-resistant Pseudomonas species (CRP). Using a participatory consensual approach, 182 reference recommendations were established (104 for adults, 78 for children), corresponding to 85% of the clinical settings encountered in the hospital. Six audits, conducted since June 1997, show that the rate of unjustified prescriptions first fell significantly (from 6 to 0%, P<0.001), then increased significantly (from 0 to 3%, P<0.05) before stabilizing at 3%. The cost of antimicrobials per inpatient day fell significantly (from US dollars 13.8 in 1997 to US dollars 11 in 2000, P<0.001). The prevalence of MRSA and CRP remained stable, while that of EPESB fell significantly (P<0.001). This multidisciplinary consultative approach thus reduced antibiotic costs, contributed to infection control, and improved the quality of antibiotic prescription.

Antimicrobial utilization and bacterial resistance at three different hospitals

It has been generally recognized that the prevalence of bacterial resistance among bacteria is an unavoidable consequence of antibiotic use and is positively linked to the overall use of antibacterial drugs. The purpose of this study was to investigate the extent of antimicrobial usage and to evaluate the antimicrobial resistance at three different hospital settings in Croatia: a clinical hospital, a general hospital and a specialized clinic for infectious diseases. In this survey the antimicrobial drug consumption and antimicrobial susceptibility test results were analyzed for the first 6 months of 1997 in three different hospitals in Croatia: the University Hospital Center (UHC), Rijeka, the Clinic for Infectious Diseases 'Dr Fran Mihaljević', Zagreb and the Dubrovnik General Hospital. The data were collected from corresponding hospital pharmacy records and microbiology laboratories. Antimicrobial drug utilization was expressed in number of defined daily doses (DDDs) per 100 bed days. High antimicrobial utilization and high resistance rates were found in all three hospitals. At the Clinic for Infectious Diseases, the most frequently used antimicrobials where those of narrow spectrum while at the UHC Rijeka and the Dubrovnik General Hospital the broad spectrum antimicrobials were mostly used. The highest antimicrobial consumption was noted at the Susak locality of the UHC, Rijeka, where the highest resistance rates of bacteria to antimicrobials were also found. Results of this observational study indicate that attempts should be made to reduce the influence of factors that may lead to emergent resistance. The most effective approach to the prevention of transmission of multidrug-resistant pathogens is preventing the initial emergence of resistance. A rational and strict antibiotic policy is thus of great importance for the optimal use of these agents.

[Evaluation of an advisory program in antibiotic therapy]

BACKGROUND

Increases in microbial resistance and pharmaceutical costs have prompted an interest in antibiotic control programs (ACP). Nevertheless, there is controversy on the optimal ACP design and implementation. An ACP based on the infectious diseases' specialist recommendations was evaluated.

METHODS

Interventional study of two hospital departments (medical and surgical). Antibiotic costs, mortality rate, readmissions following an infectious disease, and incidence of MRSA and Clostridium difficile between the intervention period and the same period in the previous year were compared. An anonymous survey among health care workers in both departments was conducted.

RESULTS

One-hundred and one antimicrobial therapy courses administered to 80 patients were evaluated. A total of 77 recommendations were issued, which consisted of therapy discontinuation (39%), switch to oral antibiotics (31%), decrease in the antimicrobial spectrum (24%) or enhancing the antimicrobial spectrum (6%). Eighty-five percent of the recommendations were accepted. The antimicrobial use remained stabilized, but the oral administration increased from 12.5 to 18.6 DDD/100 patient-days and parenteral use decreased from 25.9 to 22.3 DDD/100 patient-days. Antimicrobial costs decreased by 19.4% (901,794 pesetas). No changes, either in the mortality rate or in readmission rate due to infectious diseases was observed. In contrast, a decrease in the incidence of both MRSA (3.7% to 0.8%; p < 0.05) and Clostridium difficile (1.2% to 0%; p = 0.05) was observed. All health care workers that responded to the survey thought that ACP should be extended to the rest of the hospital.

CONCLUSIONS

Our ACP, based on the advice of an infectious diseases specialist, was very well accepted and allows for a decrease in antibiotic costs by simplified therapy. The ACP did not cause a negative impact on patients' outcomes and would probably help reducing the incidence of some nosocomial pathogens.

Multicentre evaluation of prescribing concurrence with anti-infective guidelines: epidemiological assessment of indicators

PURPOSE

To assess indicators for anti-infective prescribing not concurrent with regional pharmacotherapeutic treatment guidelines (PTGs) on infectious diseases.

METHODS

A retrospective explorative cohort study based on hospital-wide anti-infective prescription data of a 2-month cross-sectional period (n = 1037). Risk rates (absolute risks: AR), risk rate ratios (relative risks: RR) and odds ratios (OR) with 95% confidence intervals (95%CI) were estimated for patient, disease, drug, and prescriber variables considered to be potential indicators. Univariable and multivariable logistic regression analyses were performed.

FINDINGS

Non-concurrence existed of non-indicated prescribing of (particular) anti-infectives (24.3%) and prescribing of non-first choice anti-infectives (55.2%). Non-concurrent durations of treatment and dosing issues accounted for 17.2% and 16.2% respectively. Non-concurrence was associated with empirical therapy, with certain diagnoses, such as skin and soft tissue, urinary, and osteoarthrological infections, and with prescriptions involving topical dosage forms, cephalosporins, macrolides and lincosamides, and quinolones. There was also an association with certain hospitals and with prescribing by geriatricians, surgeons, pulmonologists, and urologists and, in general, junior clinicians in training.

CONCLUSIONS

Other hospitals could use our epidemiological framework to identify their own indicators for non-concurrent prescribing. Our findings suggest tailor-made enforcement of PTG adherence for certain prescribers while conversely, adaptation of the PTGs will be required for some infectious diseases.

[Economic impact of rationalized antibiotic therapy in a general hospital]

PURPOSE

To evaluate the economic impact and the bacterial resistance rates after 2 years of a rationalized antibiotic prescription program in a 502-bed hospital.

CURRENT KNOWLEDGE AND KEY POINTS

Prescribing protocols were established by consensus in 1998 and were reinforced a year later by nominative dispensing of the most costly antibiotics. The impact of the program was assessed in terms of changes in the overall cost of antibiotics and in the pattern of bacterial resistance among pathogens isolated in the institution, during the period prior to the onset of the program (1997) and its realization (1998 and 1999).

FUTURE AND PROJECTS

The expenses for antibiotic drugs decreased by 46% in 2 years. Resistance rates among the different pathogens studied have remained stable. No increase of mortality was observed. Our rational policy in antibiotic therapy had a positive economic impact. However, new additional measures should be encouraged to prevent antimicrobial resistance.

Quality measures of antimicrobial drug use

Antimicrobial use is the major determinant in the development of resistance. Many parameters of importance for optimal quality of antimicrobial therapy have already been defined. Maximal efficacy of the treatment should be combined with minimal toxicity at the lowest cost. Quality of antimicrobial drug use is dependent on knowledge of many aspects of infectious diseases. Considering efficacy, many of our indications for antimicrobial use need critical evaluation. Irrational use should be discouraged. Avoidance of the development of resistance is a quality parameter that will need increasing attention. This paper reviews the well-established factors that may influence the appropriateness of pharmacotherapy with antimicrobial drugs. It cites recent evidence supporting principles of prudent prescribing and gives an overview of audits that have addressed these parameters. Measures relating to resistance are discussed.

Towards a European strategy for controlling antibiotic resistance Nijmegen, Holland August 29-31, 1999

A group of experts met under the auspices of the European Science Foundation, the European Medical Research Council and the European Society of Clinical Microbiology and Infectious Diseases to discuss formulation of a European strategy on the control of antibiotic resistance in Europe. This is a report of the meeting which was used as the basis for a European Commission grant application. The need for a common strategy to make best use of scarce resources was agreed and it was concluded that the first stage (discussed in this article) is to collate existing data on resistance rates, antibiotic consumption, antibiotic stewardship, infection control and molecular typing methods. Consensus reached from analysis of these data can direct us to the most appropriate controlled trials. While it is accepted that there is a widely held perception that the medical profession has been slow to react to the problem of antibiotic resistance, much more work still needs to be carried out before we can recommend, implement and trial definitive control measures. In the meantime, however, all reasonable efforts should be made to reduce antibiotic consumption without compromising patient care, establish cost-effective surveillance systems using existing laboratory generated data, improve hygiene in our hospitals and better define the molecular basis of antibiotic resistance.

Trends in hospital antimicrobial prescribing after 9 years of stewardship

Trends in antibiotic prescribing in Grampian have been monitored prospectively for 11 years from 1986 using computerized ward stock lists and laboratory data relating to all in-patient and out-patient treatments in all Grampian hospitals. The main outcome measures were the number of antibiotics available for routine and restricted use, annual expenditure and defined daily doses (DDDs) of high expenditure antimicrobial agents. An antibiotic committee introduced a policy and formulary in the third year of the study which has had only limited success in controlling prescribing. This report updates the audit from 1992/3 to 1996/7. During this period 22 new antibiotics were considered for inclusion in the hospital formulary. Seventeen, including seven antiretroviral agents, were incorporated, all for restricted use only. Despite this, expenditure on antibiotics has more than trebled since 1986/7 and increased 50% since 1992/3, two-thirds of the latter increase being due to the use of new drugs, namely anti-HIV drugs, lipid amphotericin derivatives and teicoplanin. Big increases in the use of co-amoxiclav, acyclovir, ciprofloxacin and cefotaxime account for the remainder of the increased expenditure. There was an overall increase of 16.9% in DDDs between 1992/3 and 96/7 to 424.0 DDDs/1000 patient days (393.4 DDDs for antibacterials). These findings highlight the current difficulty in controlling prescribing budgets, the increasing use of antibiotics and the consequent increase of antimicrobial-resistant microorganisms.

Antibiotic use in Dutch hospitals 1991-1996

The use of antibiotics in Dutch hospitals between 1991 and 1996 was investigated. A total of 54 hospitals responded to the enquiry, representing over 70% of all hospital beds in The Netherlands. The use of antibiotics in Dutch hospitals, expressed as defined daily doses (DDD) per hundred bed days, gradually increased from 37.2 DDD per 100 bed days in 1991 to 42.5 DDD per 100 bed days in 1996. The antibiotic that showed the largest increase in use was co-amoxiclav. Its use increased more than three-fold from 3.93 DDD per 100 bed days in 1991 to 12.5 DDD per 100 bed days in 1996. The increase in use of co-amoxiclav exceeded the increase in total antibiotic consumption. The use of cephalosporins remained fairly constant during the study period, but there were changes in the relative use of the different cephalosporin groups. The use of earlier cephalosporins gradually decreased, whereas the use of the more recently developed cephalosporins increased between 1991 and 1996. Ciprofloxacin and norfloxacin were the most commonly used fluoroquinolones throughout the study period. The use of ofloxacin increased significantly between 1991 and 1996, approaching the levels of use of ciprofloxacin and norfloxacin. There may be complex reasons for the increases, which need further analysis, but they mirror those few data available from elsewhere in the world. Possible explanations include more intensive treatment to expedite patient discharges, sicker patients with more serious infections and more resistant organisms.

Stewardship of antibiotic use and resistance surveillance: the international scene

Audit is all about education and changing practice. It is well known that doctors are both difficult to target with educational initiatives and those who need educating are the most difficult to target! Changing established practice is even harder and maintaining change in practice is often considered just a dream. This emphasises the importance of the cycle of audit, feedback (education), re-audit etc. This process has been developed over a twelve-year period in Aberdeen while the antibiotic policy has evolved from a 15-page booklet on hospital antibiotic prescribing into a 90-page book combining both hospital and general practice prescribing. Both successes and failures of the audit process will be described in the context of Strategic Goals. The next phase is assessment of performance against other policies in Europe to establish the best methods of antibiotic stewardship. A European group has recently been formed to begin this process. Parameters that can be used to assess the comparative performance of policies will be discussed and include antibiotic resistance rates. Several international resistance surveillance and quality of antibiotic use programmes are highlighted.

A randomized, prospective study measuring outcomes after antibiotic therapy intervention by a multidisciplinary consult team

Our aim was to identify financial and outcome benefits of therapeutic intervention by a multidisciplinary antimicrobial treatment team composed of pharmacists, a clinical microbiologist, and an infectious disease specialist. Of 252 consecutive inpatients receiving suboptimal intravenous antibiotics identified by the clinical pharmacist, 127 were prospectively randomized to intervention and 125 to a control group. The groups were similar with regard to severity of illness, infection type, and time from admission to randomization. Physicians received timely, detailed reviews of relevant microbiologic and clinical data with recommendations of possible optimal antibiotic choices, dosages, and rationales. Median length of stay after randomization for control and intervention groups was 9.0 days and 5.7 days, respectively (3.3-day difference, p=0.0001). Fifteen (12.0%) and eight patients (6.3%), respectively, died, although the time-specific mortality risk was not significantly different when length of postrandomization follow-up and time to death were taken into account. Physician acceptance of suggestions was 89%. Median patient charges for radiology, laboratory, pharmacy, and room were reduced by $4404/intervention, and median hospital costs were reduced by $2642/intervention. A multidisciplinary antimicrobial therapy team can be a useful information source for physicians, improve outcomes in hospitalized patients receiving intravenous antimicrobials, and result in substantial cost savings.

Antibiotic policies in Central/Eastern Europe (CEE) after 1990

Significant political and social changes in Eastern Europe have caused dramatic changes in healthcare: Centralized state drug policies were decentralized, vaccination strategies in some countries changed and directed financing of healthcare replaced by one or multiple health management organisations (HMO). Centralized Infectious Diseases and/or Antibiotic Resistance surveillance were stopped after 1990 in four of six countries but resurrected after 1996 in Hungary, Poland and Slovakia. According to antibiotic (ATB) resistance and nosocomial infection rates, there are some differences in comparison to Western and Northern Europe e.g., a higher incidence of penicillin resistant pneumococci, ampicillin resistant H. influenzae and methicillin resistant Staphylococcus aureus. Because of increasing consumption of ATB before 1991, due to the free market, pharmaceutical marketing and reimbursement policies, several strategies to decrease consumption and/or resistance were implemented such as restriction of outpatient use, national and hospital formularies and Health Management Organizations-based restrictions. Probably due to the short time scale, no significant reduction in resistance has been documented although antibiotic consumption has declined.

Strategies to rationalize sepsis management--a review of 4 years' experience in Dundee

Hospitals worldwide are facing an unprecedented crisis of rising cost of antibacterials due to the increasing rapid emergence and dissemination of antibiotic-resistant organisms, improper use of antibiotics and the use of broad spectrum parenteral agents. The last 25 years has seen the introduction of many measures to improve the quality of sepsis management, and specifically antimicrobial use. The present paper reviews the development, implementation and evaluation of some of the key strategies employed within the Dundee Teaching Hospitals NHS Trust (DTHT) to enhance recognition and assessment of sepsis and to rationalize the early and often empiric antibiotic treatment of patients in hospital with infection. Particular emphasis is given to optimizing the use of expensive parenteral agents in conjunction with promotion of oral switch therapy where appropriate.

Programs promoting timely sequential antimicrobial therapy: an American perspective

Interventional programs promoting the timely conversion of intravenous to oral antimicrobial therapy have been reported from several hospitals in the U.S.A. and elsewhere. Factors influencing the initiation and conduct of these programs include technological advances, changes in health care delivery or reimbursement, publication of supportive clinical data and growth of clinical pharmacy services. Successful programs employ comprehensive, multidisciplinary strategies to contain antimicrobial-related expenditures using interventions based on structured criteria. Future emphasis on cost-effective drug therapy, advances in computer-based information technology and development of care maps can have favourable influences on the growth of these programs in the U.S.A.

A multidisciplinary approach to hospital-based drug cost containment

OBJECTIVE

To develop and implement a range of strategies to control rising drug expenditure in a teaching hospital.

METHOD

A multidisciplinary team was established to survey drug use and to identify areas where drug wastage was occurring. Once target areas were identified, strategies were developed and implemented and drug expenditure monitored prospectively.

RESULTS

Communication and education about optimum drug use, efficient drug handling and therapeutic drug substitution were identified as areas for action. Antibiotic prescribing, outpatient prescribing and expenditure on new drugs were identified as target areas for cost savings. Compared to previous years, the rate of increase in drug expenditure on antibiotics was reduced by over 5000 pound sterling, from a baseline of 552 278 pound sterling over the study period compared to an increase of 65 984 pound sterling for the previous corresponding period.

CONCLUSION

We believe that despite the short-coming of the study, which adopted an open design without a control group, it demonstrates that effective cost-containment strategies can be implemented by multidisciplinary teams if they are given sufficient support by senior management.

A review of methods of drug cost management in hospitals

To stem the ever-increasing cost of health-care various strategies are being introduced by health authorities world-wide. Methods to control drug costs are reviewed with a particular emphasis on hospital-centred strategies and the role of the pharmacist. The literature suggests that no one single strategy is consistently successful and that better results are obtained by using a combination of strategies.