1
|
Kim KR, Park HJ, Baek SY, Choi SH, Lee BK, Kim S, Kim JM, Kang JM, Kim SJ, Choi SR, Kim D, Choi JS, Yoon Y, Park H, Kim DR, Shin A, Kim S, Kim YJ. The Impact of an Antimicrobial Stewardship Program on Days of Therapy in the Pediatric Center: An Interrupted Time-Series Analysis of a 19-Year Study. J Korean Med Sci 2024; 39:e172. [PMID: 38832477 PMCID: PMC11147790 DOI: 10.3346/jkms.2024.39.e172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/29/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND We aimed to analyze the effects of an antimicrobial stewardship program (ASP) on the proportion of antimicrobial-resistant pathogens in bacteremia, antimicrobial use, and mortality in pediatric patients. METHODS A retrospective single-center study was performed on pediatric inpatients under 19 years old who received systemic antimicrobial treatment from 2001 to 2019. A pediatric infectious disease attending physician started ASP in January 2008. The study period was divided into the pre-intervention (2001-2008) and the post-intervention (2009-2019) periods. The amount of antimicrobial use was defined as days of therapy per 1,000 patient-days, and the differences were compared using delta slope (= changes in slopes) between the two study periods by an interrupted time-series analysis. The proportion of resistant pathogens and the 30-day overall mortality rate were analyzed by the χ². RESULTS The proportion of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae bacteremia increased from 17% (39 of 235) in the pre-intervention period to 35% (189 of 533) in the post-intervention period (P < 0.001). The total amount of antimicrobial use significantly decreased after the introduction of ASP (delta slope value = -16.5; 95% confidence interval [CI], -30.6 to -2.3; P = 0.049). The 30-day overall mortality rate in patients with bacteremia did not increase, being 10% (55 of 564) in the pre-intervention and 10% (94 of 941) in the post-intervention period (P = 0.881). CONCLUSION The introduction of ASP for pediatric patients reduced the delta slope of the total antimicrobial use without increasing the mortality rate despite an increased incidence of ESBL-producing gram-negative bacteremia.
Collapse
Affiliation(s)
- Kyung-Ran Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyo Jung Park
- Department of Pharmacy, Samsung Medical Center, Seoul, Korea
- Sungkyunkwan University School of Pharmacy, Suwon, Korea
| | - Sun-Young Baek
- Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Soo-Han Choi
- Department of Pediatrics, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Byung-Kee Lee
- Department of Pediatrics, Seoulsan Boram Hospital, Ulsan, Korea
| | - SooJin Kim
- Samsung Dream Pediatric Clinic, Suwon, Korea
| | - Jong Min Kim
- Department of Pediatrics, Myongji Hospital, Goyang, Korea
| | - Ji-Man Kang
- Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sun-Ja Kim
- Samsung Dream Pediatric Clinic, Jeju, Korea
| | | | - Dongsub Kim
- Department of Pediatrics, Kyungpook National University Hospital, Kyungpook National University School of Medicine, Daegu, Korea
| | - Joon-Sik Choi
- Department of Pediatrics, Gangnam Severance Hospital, Seoul, Korea
| | - Yoonsun Yoon
- Department of Pediatrics, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Hwanhee Park
- Department of Pediatrics, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Doo Ri Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Areum Shin
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seonwoo Kim
- Academic Research Service Headquarter, LSK Global PS, Seoul, Korea
| | - Yae-Jean Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology, Seoul, Korea.
| |
Collapse
|
2
|
Wojcik G, Ring N, Willis DS, Williams B, Kydonaki K. Improving antibiotic use in hospitals: development of a digital antibiotic review tracking toolkit (DARTT) using the behaviour change wheel. Psychol Health 2023:1-21. [PMID: 36855847 DOI: 10.1080/08870446.2023.2182894] [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: 06/30/2022] [Revised: 12/07/2022] [Accepted: 02/15/2023] [Indexed: 03/02/2023]
Abstract
OBJECTIVE To develop a theory-informed behaviour change intervention to promote appropriate hospital antibiotic use, guided by the Medical Research Council's complex interventions framework. METHODS A phased approach was used, including triangulation of data from meta-ethnography and two qualitative studies. Central to intervention design was the generation of a robust theoretical basis using the Behaviour Change Wheel to identify relevant determinants of behaviour change and intervention components. Intervention content was guided by APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria and coded using a Behaviour Change Technique Taxonomy. Stakeholders were involved throughout. RESULTS From numerous modifiable prescribing behaviours identified, active 'antibiotic time-out' was selected as the target behaviour to help clinicians safely initiate antibiotic reassessment. Prescribers' capability, opportunity, and motivation were potential drivers for changing this behaviour. The design process resulted in the selection of 25 behaviour change techniques subsequently translated into intervention content. Integral to this work was the development and refinement of a Digital Antibiotic Review Tracking Toolkit. CONCLUSION This novel work demonstrates how the Behaviour Change Wheel can be used with the Medical Research Council framework to develop a theory-based behaviour change intervention targeting barriers to timely hospital antibiotic reassessment. Future research will evaluate the Antibiotic Toolkit's feasibility and effectiveness.
Collapse
Affiliation(s)
- Gosha Wojcik
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - N Ring
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - D S Willis
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - B Williams
- School of Health, Social Care & Life Sciences, University of Highlands and Islands, Inverness, UK
| | - K Kydonaki
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| |
Collapse
|
3
|
Núñez-Núñez M, Perez-Galera S, Girón-Ortega JA, Sandoval Fernández-Del-Castillo S, Beltrán-García M, De Cueto M, Suárez-Barrenechea AI, Palacios-Baena ZR, Terol-Barrero P, Oltra-Hostalet F, Arenzana-Seisdedos Á, Rodriguez-Baño J, Retamar-Gentil P. Predictors of inappropriate antimicrobial prescription: Eight-year point prevalence surveys experience in a third level hospital in Spain. Front Pharmacol 2022; 13:1018158. [PMID: 36299899 PMCID: PMC9592087 DOI: 10.3389/fphar.2022.1018158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Antibiotic stewardship programs (ASP) have already demonstrated clinical benefits. We aimed to describe the Point Prevalence Surveys (PPS) methodology implemented in our hospital as an efficient tool to guide ASP strategies. Annually repeated PPS were conducted from 2012 to 2019 at a 750-bed university hospital in South Spain. Key quality indicators and inappropriateness of antimicrobial treatment, defined strictly according to local guidelines, were described. Variables associated with inappropriate treatment were identified by bi/multivariable analysis. A total of 1,600 patients were included. We found that 49% of the prescriptions were inappropriate due to unnecessary treatment (14%), not first line drug recommended (14%), inadequate drug according to microbiological results (9%), unsuitable doses (8%), route (3%) or duration (7%). Samples collection presented a significant protective effect together with sepsis presentation at onset and intensive care unit admission. However, age, receiving an empirical treatment and an unknown or urinary source of the infections treated were independent risk factors for inappropriateness. Site and severity of infection were documented in medical charts by prescribers (75 and 61% respectively). PPS may allow identifying the main risk factors for inappropriateness. This simple methodology may be useful for ASP to select modifiable factors to be prioritized for targeted interventions.
Collapse
Affiliation(s)
- María Núñez-Núñez
- Hospital Pharmacy Department, University Hospital Virgen Macarena, Seville, Spain
- Hospital Pharmacy Department, San Cecilio Clinical University Hospital, Granada, Spain
- Biosanitary Research Institute of Granada (Ibs.Granada), Granada, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain
- *Correspondence: María Núñez-Núñez,
| | | | | | | | | | - Marina De Cueto
- Institute of Biomedicine of Seville (IBiS) and CSIC, Seville, Spain
- Infectious Diseases and Microbiology Clinical Unit, University Hospital Virgen Macarena,Sevilla, Spain
- Department of Microbiology, University of Seville, Seville, Spain
| | | | - Zaira R. Palacios-Baena
- Institute of Biomedicine of Seville (IBiS) and CSIC, Seville, Spain
- Infectious Diseases and Microbiology Clinical Unit, University Hospital Virgen Macarena,Sevilla, Spain
- Consortium for Biomedical Research in Infectious Diseases (CIBERINFEC), Madrid, Spain
| | | | | | | | - Jesús Rodriguez-Baño
- Institute of Biomedicine of Seville (IBiS) and CSIC, Seville, Spain
- Infectious Diseases and Microbiology Clinical Unit, University Hospital Virgen Macarena,Sevilla, Spain
- Consortium for Biomedical Research in Infectious Diseases (CIBERINFEC), Madrid, Spain
- Department of Medicine, University of Seville, Seville, Spain
| | - Pilar Retamar-Gentil
- Institute of Biomedicine of Seville (IBiS) and CSIC, Seville, Spain
- Infectious Diseases and Microbiology Clinical Unit, University Hospital Virgen Macarena,Sevilla, Spain
- Consortium for Biomedical Research in Infectious Diseases (CIBERINFEC), Madrid, Spain
- Department of Medicine, University of Seville, Seville, Spain
| |
Collapse
|
4
|
Lloyd EC, Martin ET, Dillman N, Nagel J, Chang R, Gandhi TN, Tribble AC. Impact of a Best Practice Advisory for Pediatric Patients With Staphylococcus aureus Bacteremia. J Pediatric Infect Dis Soc 2021; 10:282-288. [PMID: 32531048 DOI: 10.1093/jpids/piaa058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 05/12/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND Infectious diseases (ID) consultation and optimal antibiotic therapy improve outcomes in Staphylococcus aureus bacteremia (SAB). Data on strategies to improve adherence to these practices in children are limited. METHODS This was a quasi-experimental study evaluating the impact of an electronic medical record (EMR)-based best practice advisory (BPA) for SAB, recommending ID consult and optimal antibiotic therapy based on rapid mecA gene detection. Inpatients < 21 years old with SAB before (January 2015-July 2017) and after (August 2017-December 2018) BPA implementation were included. Primary outcome was receipt of ID consult. Secondary outcomes included receipt of optimal therapy, time to ID consult and optimal therapy, recurrent SAB, and 30-day all-cause mortality. ID consultation rates pre- and postimplementation were compared using interrupted time series (ITS) analysis. Hazard ratios (HRs) and 95% confidence intervals (CIs) for time to optimal therapy were calculated using Cox regression. RESULTS We included 99 SAB episodes (70 preintervention, 29 postintervention). Preintervention, 48 (68.6%) patients received an ID consult compared to 27 (93.1%) postintervention, but this was not statistically significant on ITS analysis due to a preexisting trend of increasing consultation. Median hours to optimal therapy decreased from 26.1 to 5.5 (P = .03), most notably in patients with methicillin-sensitive S. aureus (MSSA) (42.2 to 10.8; P < .01). On Cox regression, BPA implementation was associated with faster time to optimal therapy (HR, 3.22 [95% CI, 1.04-10.01]). CONCLUSIONS Implementation of an EMR-based BPA for SAB resulted in faster time to optimal antibiotic therapy, particularly for patients with MSSA. ID consultation increased throughout the study period and was not significantly impacted by the BPA.
Collapse
Affiliation(s)
- Elizabeth C Lloyd
- Division of Pediatric Infectious Diseases, University of Michigan, Ann Arbor, Michigan
| | - Emily T Martin
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Nicholas Dillman
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Jerod Nagel
- Department of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Robert Chang
- Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan
| | - Tejal N Gandhi
- Division of Infectious Diseases, University of Michigan, Ann Arbor, Michigan
| | - Alison C Tribble
- Division of Pediatric Infectious Diseases, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
5
|
Lee V, Dunsmuir D, Businge S, Tumusiime R, Karugaba J, Wiens MO, Görges M, Kissoon N, Orach S, Kasyaba R, Ansermino JM. Evaluation of a digital triage platform in Uganda: A quality improvement initiative to reduce the time to antibiotic administration. PLoS One 2020; 15:e0240092. [PMID: 33007047 PMCID: PMC7531789 DOI: 10.1371/journal.pone.0240092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 09/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Sepsis is the leading cause of death in children under five in low- and middle-income countries. The rapid identification of the sickest children and timely antibiotic administration may improve outcomes. We developed and implemented a digital triage platform to rapidly identify critically ill children to facilitate timely intravenous antibiotic administration. Objective This quality improvement initiative sought to reduce the time to antibiotic administration at a dedicated children’s hospital outpatient department in Mbarara, Uganda. Intervention and study design The digital platform consisted of a mobile application that collects clinical signs, symptoms, and vital signs to prioritize children through a combination of emergency triggers and predictive risk algorithms. A computer-based dashboard enabled the prioritization of children by displaying an overview of all children and their triage categories. We evaluated the impact of the digital triage platform over an 11-week pre-implementation phase and an 11-week post-implementation phase. The time from the end of triage to antibiotic administration was compared to evaluate the quality improvement initiative. Results There was a difference of -11 minutes (95% CI, -16.0 to -6.0; p < 0.001; Mann-Whitney U test) in time to antibiotics, from 51 minutes (IQR, 27.0–94.0) pre-implementation to 44 minutes (IQR, 19.0–74.0) post-implementation. Children prioritized as emergency received the greatest time benefit (-34 minutes; 95% CI, -9.0 to -58.0; p < 0.001; Mann-Whitney U test). The proportion of children who waited more than an hour until antibiotics decreased by 21.4% (p = 0.007). Conclusion A data-driven patient prioritization and continuous feedback for healthcare workers enabled by a digital triage platform led to expedited antibiotic therapy for critically ill children with sepsis. This platform may have a more significant impact in facilities without existing triage processes and prioritization of treatments, as is commonly encountered in low resource settings.
Collapse
Affiliation(s)
- Victor Lee
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Dustin Dunsmuir
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | | | | | | | - Matthew O. Wiens
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthias Görges
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Niranjan Kissoon
- Center for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sam Orach
- Uganda Catholic Medical Bureau, Kampala, Uganda
| | | | - J. Mark Ansermino
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, BC Children’s Hospital Research Institute, Vancouver, British Columbia, Canada
- * E-mail:
| |
Collapse
|
6
|
Impact of rapid diagnostics with antimicrobial stewardship support for children with positive blood cultures: A quasi-experimental study with time trend analysis. Infect Control Hosp Epidemiol 2020; 41:883-890. [PMID: 32571440 DOI: 10.1017/ice.2020.191] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Evaluate the clinical impact of the implementation of VERIGENE gram-positive blood culture testing (BC-GP) coupled with antimicrobial stewardship result notification for children with positive blood cultures. DESIGN Quasi-experimental study. SETTING Quaternary children's hospital. PATIENTS Hospitalized children aged 0-21 years with positive blood culture events 1 year before and 1 year after implementation of BC-GP testing. METHODS The primary outcome was time to optimal antibiotic therapy for positive blood cultures, defined as receiving definitive therapy without unnecessary antibiotics (pathogens) or no antibiotics (contaminants). Secondary outcomes were time to effective therapy, time to definitive therapy, and time to stopping vancomycin, length of stay, and 30-day mortality. Time-to-therapy outcomes before and after the intervention were compared using Cox regression models and interrupted time series analyses, adjusting for patient characteristics and trends over time. Gram-negative events were included as a nonequivalent dependent variable. RESULTS We included 264 preintervention events (191 gram-positive, 73 gram-negative) and 257 postintervention events (168 gram-positive, 89 gram-negative). The median age was 2.9 years (interquartile range, 0.3-10.1), and 418 pediatric patients (80.2%) had ≥1 complex chronic condition. For gram-positive isolates, implementation of BC-GP testing was associated with an immediate reduction in time to optimal therapy and time to stopping vancomycin for both analyses. BC-GP testing was associated with decreased time to definitive therapy in interrupted time series analysis but not Cox modeling. No such changes were observed for gram-negative isolates. No changes in time to effective therapy, length of stay, or mortality were associated with BC-GP. CONCLUSIONS The implementation of BC-GP testing coupled with antimicrobial stewardship result notification was associated with decreased time to optimal therapy and time to stopping vancomycin for hospitalized children with gram-positive blood culture isolates.
Collapse
|
7
|
Manuel-Vázquez A, Palacios-Ortega F, García-Septiem J, Thuissard IJ, Sanz-Rosa D, Arias-Díaz J, Maríajover-Navalón J, Ramia JM. Antimicrobial Stewardship Programs Are Required in a Department of Surgery: "How" Is the Question A Quasi-Experimental Study: Results after Three Years. Surg Infect (Larchmt) 2020; 21:35-42. [PMID: 31347989 DOI: 10.1089/sur.2018.311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective: Our aim was to describe our antimicrobial stewardship program and the methodology based on the results in a surgical department. Methods: Our study was a quasi-experimental study conducted from January 1, 2009, through September 30, 2017. The site was the General and Digestive Surgery Department in a public primary referral center, the University Hospital of Getafe (Madrid, Spain). We implemented the antimicrobial stewardship program following a prospective audit and feedback model, with a surgeon incorporated into the manaagement group. We studied the deaths and 30-day re-admission rates, length of stay, prevalence of gram-negative bacilli, meropenem resistance, and days of treatment with meropenem. Results: After three years of the program, we recorded a significant decrease in Pseudomonas aeruginosa prevalence, a significant increase in Klebsiella pneumoniae prevalence, a decrease in meropenem resistance, and a reduction in meropenem days of treatment. Conclusions: Antimicrobial stewardship programs have a desirable effect on patients. In our experience, the program team should be led by a staff from the particular department. When human resources are limited, the sustainability, efficiency, and effectiveness of interventions are feasible only with adequate computer support. Finally, but no less important, the necessary feedback between the prescribers and the team must be based on an ad hoc method such as that provided by statistical control charts, a median chart in our study.
Collapse
Affiliation(s)
- Alba Manuel-Vázquez
- General and Digestive Surgery Department, University Hospital of Guadalajara, Guadalajara, Spain
| | | | - Javier García-Septiem
- General and Digestive Surgery Department, University Hospital of Getafe, Getafe, Madrid, Spain
| | - Israel John Thuissard
- School of Doctoral Studies and Research.Universidad Europea de Madrid, Madrid, Spain
| | - David Sanz-Rosa
- School of Doctoral Studies and Research.Universidad Europea de Madrid, Madrid, Spain
| | - Javier Arias-Díaz
- San Carlos Clinical Hospital, General and Digestive Surgery Department, Faculty of Medicine, Universidad Complutense, Madrid, Spain
| | - José Maríajover-Navalón
- General and Digestive Surgery Department, University Hospital of Getafe, Getafe, Madrid, Spain
| | - José Manuel Ramia
- General and Digestive Surgery Department, University Hospital of Guadalajara, Guadalajara, Spain
| |
Collapse
|
8
|
Resman F. Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy Part I: step-wise design of an antimicrobial stewardship program. Ther Adv Infect Dis 2020; 7:2049936120933187. [PMID: 32612826 PMCID: PMC7307277 DOI: 10.1177/2049936120933187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/11/2020] [Indexed: 12/27/2022] Open
Abstract
Regardless of one's opinion of antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and includes not only aspects of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name a few. This review aims to take several of these aspects and the scientific evidence of antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? And which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. This first part is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps: (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. The second part, published separately, formulates ten critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.
Collapse
Affiliation(s)
- Fredrik Resman
- Department of Translational Medicine, Clinical
Infection Medicine, Lund University, Rut Lundskogs Gata 3, Plan 6, Malmö, 20502,
Sweden
| |
Collapse
|
9
|
Schweitzer VA, van Werkhoven CH, Rodríguez Baño J, Bielicki J, Harbarth S, Hulscher M, Huttner B, Islam J, Little P, Pulcini C, Savoldi A, Tacconelli E, Timsit JF, van Smeden M, Wolkewitz M, Bonten MJM, Walker AS, Llewelyn MJ. Optimizing design of research to evaluate antibiotic stewardship interventions: consensus recommendations of a multinational working group. Clin Microbiol Infect 2019; 26:41-50. [PMID: 31493472 DOI: 10.1016/j.cmi.2019.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antimicrobial stewardship interventions and programmes aim to ensure effective treatment while minimizing antimicrobial-associated harms including resistance. Practice in this vital area is undermined by the poor quality of research addressing both what specific antimicrobial use interventions are effective and how antimicrobial use improvement strategies can be implemented into practice. In 2016 we established a working party to identify the key design features that limit translation of existing research into practice and then to make recommendations for how future studies in this field should be optimally designed. The first part of this work has been published as a systematic review. Here we present the working group's final recommendations. METHODS An international working group for design of antimicrobial stewardship intervention evaluations was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). The group comprised clinical and academic specialists in antimicrobial stewardship and clinical trial design from six European countries. Group members completed a structured questionnaire to establish the scope of work and key issues to develop ahead of a first face-to-face meeting that (a) identified the need for a comprehensive systematic review of study designs in the literature and (b) prioritized key areas where research design considerations restrict translation of findings into practice. The working group's initial outputs were reviewed by independent advisors and additional expertise was sought in specific clinical areas. At a second face-to-face meeting the working group developed a theoretical framework and specific recommendations to support optimal study design. These were finalized by the working group co-ordinators and agreed by all working group members. RESULTS We propose a theoretical framework in which consideration of the intervention rationale the intervention setting, intervention features and the intervention aims inform selection and prioritization of outcome measures, whether the research sets out to determine superiority or non-inferiority of the intervention measured by its primary outcome(s), the most appropriate study design (e.g. experimental or quasi- experimental) and the detailed design features. We make 18 specific recommendation in three domains: outcomes, objectives and study design. CONCLUSIONS Researchers, funders and practitioners will be able to draw on our recommendations to most efficiently evaluate antimicrobial stewardship interventions.
Collapse
Affiliation(s)
- V A Schweitzer
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - C H van Werkhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - J Rodríguez Baño
- Unit of Infectious Diseases, Clinical Microbiology and Preventive Medicine, Department of Medicine, Hospital Universitario Virgen Macarena, Universidad de Sevilla and Biomedicine Institute of Sevilla (IBiS), Seville, Spain
| | - J Bielicki
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
| | - S Harbarth
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - M Hulscher
- Scientific Centre for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - B Huttner
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - J Islam
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - P Little
- Department of Primary Care Research, University of Southampton, Southampton, UK
| | - C Pulcini
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, APEMAC, Université de Lorraine, Nancy, France
| | - A Savoldi
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - E Tacconelli
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - J-F Timsit
- Medical and Infectious Diseases ICU, Bichat University Hospital, AP-HP, Paris, France; UMR 1137, Infection Antimicrobials Modelling Evolution, Paris Diderot University, Paris, France
| | - M van Smeden
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Wolkewitz
- Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - A S Walker
- MRC Clinical Trials Unit, University College London, London, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M J Llewelyn
- Department of Primary Care Research, University of Southampton, Southampton, UK.
| | | |
Collapse
|
10
|
Huynh N, Baumann A, Loeb M. Reporting quality of the 2014 Ebola outbreak in Africa: A systematic analysis. PLoS One 2019; 14:e0218170. [PMID: 31237909 PMCID: PMC6592536 DOI: 10.1371/journal.pone.0218170] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 05/28/2019] [Indexed: 11/18/2022] Open
Abstract
The objective of this study was to conduct a systematic analysis of the reporting quality of the Ebola Virus Disease (EVD) outbreak in West Africa from 2014-2018 using the Modified STROBE statement. We included studies on the 2014 EVD outbreak alone, limited to those on human patients in Africa. We searched the following databases (MEDLINE, EMBASE, and Web of Science) for outbreak reports published between 2014-2018. We assessed factors potentially associated with the quality of reporting. A total of 69 of 131 (53%) articles within the full-text review fulfilled our eligibility criteria and underwent the Modified STROBE assessment for analyzing the quality of reporting. The Modified STROBE scores of the included studies ranged from 11-26 points and the mean was found to be 19.54 out of 30 with a standard deviation (SD) of ± 4.30. The top three reported Modified STROBE components were descriptive characteristics of study participants, scientific background and evidence rational, and clinical significance of observations. More than 75% of the studies met a majority of the criteria in the Modified STROBE assessment tool. Information that was commonly missing included addressing potential source of bias, sensitivity analysis, further results/analysis such as risk estimates and odds ratios, presence of a flowchart, and addressing missing data. In multivariable analysis, peer-reviewed publication was the only predictor that remained significantly associated with a higher Modified STROBE score. In conclusion, the large range of Modified STROBE scores observed indicates variability in the quality of outbreak reports for EVD. The review identified strong reporting in some areas, whereas other areas are in need of improvement, in particular providing an important description of the outbreak setting and identifying any external elements (potential biases and confounding factors) that could hinder the credibility of the findings.
Collapse
Affiliation(s)
- Nina Huynh
- Global Health Office, McMaster University, Hamilton, Ontario, Canada
| | - Andrea Baumann
- Global Health Office, McMaster University, Hamilton, Ontario, Canada
| | - Mark Loeb
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Michael G DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Ontario, Canada
- * E-mail:
| |
Collapse
|
11
|
Schweitzer VA, van Heijl I, van Werkhoven CH, Islam J, Hendriks-Spoor KD, Bielicki J, Bonten MJM, Walker AS, Llewelyn MJ. The quality of studies evaluating antimicrobial stewardship interventions: a systematic review. Clin Microbiol Infect 2018; 25:555-561. [PMID: 30472426 DOI: 10.1016/j.cmi.2018.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/25/2018] [Accepted: 11/03/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Antimicrobial stewardship aims to optimize antibiotic use and minimize selection of antimicrobial resistance. The methodological quality of published studies in this field is unknown. AIMS Our objective was to perform a comprehensive systematic review of antimicrobial stewardship research design and identify features which limit validity and translation of research findings into clinical practice. SOURCES The following online database was searched: PubMed. STUDY ELIGIBILITY CRITERIA Studies published between January 1950 and January 2017, evaluating any antimicrobial stewardship intervention in the community or hospital setting, without restriction on study design or outcome. CONTENT We extracted data on pre-specified design quality features and factors that may influence design choices including (1) clinical setting, (2) age group studied, (3) when the study was conducted, (4) geographical region, and (5) financial support received. The initial search yielded 17 382 articles; 1008 were selected for full-text screening, of which 825 were included. Most studies (675/825, 82%) were non-experimental; 104 (15%) used interrupted time series analysis, 41 (6%) used external controls, and 19 (3%) used both. Studies in the community setting fulfilled a median of five out of 10 quality features (IQR 3-7) and 3 (IQR 2-4) in the hospital setting. Community setting studies (25%, 205/825) were significantly more likely to use randomization (OR 5.9; 95% CI 3.8-9.2), external controls (OR 5.6; 95% CI 3.6-8.5), and multiple centres (OR 10.5; 95% CI 7.1-15.7). From all studies, only 48% (398/825) reported clinical and 23% (190/825) reported microbiological outcomes. Quality did not improve over time. IMPLICATIONS Overall quality of antimicrobial stewardship studies is low and has not improved over time. Most studies do not report clinical and microbiological outcome data. Studies conducted in the community setting were associated with better quality. These limitations should inform the design of future stewardship evaluations so that a robust evidence base can be built to guide clinical practice.
Collapse
Affiliation(s)
- V A Schweitzer
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands.
| | - I van Heijl
- Department of Clinical Pharmacy and Medical Microbiology, Tergooi Hospital, Hilversum/Blaricum, The Netherlands
| | - C H van Werkhoven
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands
| | - J Islam
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - K D Hendriks-Spoor
- Department of Clinical Pharmacy and Medical Microbiology, Tergooi Hospital, Hilversum/Blaricum, The Netherlands
| | - J Bielicki
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, The Netherlands
| | - A S Walker
- MRC Clinical Trials Unit, University College London, London, UK
| | - M J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | | |
Collapse
|
12
|
De-escalation and discontinuation strategies in high-risk neutropenic patients: an interrupted time series analyses of antimicrobial consumption and impact on outcome. Eur J Clin Microbiol Infect Dis 2018; 37:1931-1940. [PMID: 30051357 DOI: 10.1007/s10096-018-3328-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/10/2018] [Indexed: 02/06/2023]
Abstract
Febrile neutropenia (FN) is the main reason for antibiotic prescription in hematology wards where, on the other hand, antibiotic stewardship (AS) is poorly explored. The objectives of the present study were to evaluate (1) the impact of an AS intervention on antibiotic consumption and (2) the applicability and acceptance rate of the intervention and its clinical impact. A persuasive AS intervention based on European Conference on Infection in Leukaemia (ECIL) guidelines for FN was implemented in a high-risk hematology ward in a tertiary referral public university hospital. This included the creation and diffusion of flow charts on de-escalation and discontinuation of antibiotics for FN, and the introduction in the team of a doctor dedicated to the implementation of flow charts and to antibiotic prescription revision. All consecutive patients receiving antibiotics during hospitalization were included. A segmented linear regression model was performed for the evaluation of antibiotic consumption, taking into account 1-year pre-intervention period and 6-month intervention period. Overall, 137 consecutive antibiotic prescriptions were re-evaluated, 100 prescriptions were for FN. A significant reduction of the level of carbapenem consumption was observed during the intervention period (level change (estimate coefficient ± standard error) = - 135.28 ± 59.49; p = 0.04). Applicability and acceptability of flow charts were high. No differences in terms of intensive care unit transfers, bacteremia incidence, and mortality were found. A persuasive AS intervention in hematology significantly reduced carbapenem consumption without affecting outcome and was well accepted. This should encourage further applications of ECIL guidelines for FN.
Collapse
|
13
|
Ferrer R, Martínez ML, Gomà G, Suárez D, Álvarez-Rocha L, de la Torre MV, González G, Zaragoza R, Borges M, Blanco J, Herrejón EP, Artigas A. Improved empirical antibiotic treatment of sepsis after an educational intervention: the ABISS-Edusepsis study. CRITICAL CARE (LONDON, ENGLAND) 2018. [PMID: 29933756 DOI: 10.1186/s13054-18-2091-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early appropriate antibiotic treatment is essential in sepsis. We aimed to evaluate the impact of a multifaceted educational intervention to improve antibiotic treatment. We hypothesized that the intervention would hasten and improve the appropriateness of empirical antibiotic administration, favor de-escalation, and decrease mortality. METHODS We prospectively studied all consecutive patients with sepsis/septic shock admitted to 72 intensive care units (ICUs) throughout Spain in two 4-month periods (before and immediately after the 3-month intervention). We compared process-of-care variables (resuscitation bundle and time-to-initiation, appropriateness, and de-escalation of empirical antibiotic treatment) and outcome variables between the two cohorts. The primary outcome was hospital mortality. We analyzed the intervention's long-term impact in a subset of 50 ICUs. RESULTS We included 2628 patients (age 64.1 ± 15.2 years; men 64.0%; Acute Physiology and Chronic Health Evaluation (APACHE) II, 22.0 ± 8.1): 1352 in the preintervention cohort and 1276 in the postintervention cohort. In the postintervention cohort, the mean (SD) time from sepsis onset to empirical antibiotic therapy was lower (2.0 (2.7) vs. 2.5 (3.6) h; p = 0.002), the proportion of inappropriate empirical treatments was lower (6.5% vs. 8.9%; p = 0.024), and the proportion of patients in whom antibiotic treatment was de-escalated was higher (20.1% vs. 16.3%; p = 0.004); the expected reduction in mortality did not reach statistical significance (29.4% in the postintervention cohort vs. 30.5% in the preintervention cohort; p = 0.544). Gains observed after the intervention were maintained in the long-term follow-up period. CONCLUSIONS Despite advances in sepsis treatment, educational interventions can still improve the delivery of care; further improvements might also improve outcomes.
Collapse
Affiliation(s)
- Ricard Ferrer
- Intensive Care Department, Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain. .,CIBER Enfermedades Respiratorias, Madrid, Spain.
| | - María Luisa Martínez
- Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain
| | - Gemma Gomà
- Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - David Suárez
- Epidemiology and Assessment Unit, Fundació Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - Luis Álvarez-Rocha
- Intensive Care Department, Hospital Universitario de la Coruña, A Coruña, Spain
| | | | - Gumersindo González
- Intensive Care Department, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Rafael Zaragoza
- Intensive Care Department, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Marcio Borges
- Intensive Care Department, Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Jesús Blanco
- CIBER Enfermedades Respiratorias, Madrid, Spain.,Intensive Care Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Antonio Artigas
- CIBER Enfermedades Respiratorias, Madrid, Spain.,Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain.,Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | | |
Collapse
|
14
|
Ferrer R, Martínez ML, Gomà G, Suárez D, Álvarez-Rocha L, de la Torre MV, González G, Zaragoza R, Borges M, Blanco J, Herrejón EP, Artigas A. Improved empirical antibiotic treatment of sepsis after an educational intervention: the ABISS-Edusepsis study. Crit Care 2018; 22:167. [PMID: 29933756 PMCID: PMC6013897 DOI: 10.1186/s13054-018-2091-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 06/08/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Early appropriate antibiotic treatment is essential in sepsis. We aimed to evaluate the impact of a multifaceted educational intervention to improve antibiotic treatment. We hypothesized that the intervention would hasten and improve the appropriateness of empirical antibiotic administration, favor de-escalation, and decrease mortality. METHODS We prospectively studied all consecutive patients with sepsis/septic shock admitted to 72 intensive care units (ICUs) throughout Spain in two 4-month periods (before and immediately after the 3-month intervention). We compared process-of-care variables (resuscitation bundle and time-to-initiation, appropriateness, and de-escalation of empirical antibiotic treatment) and outcome variables between the two cohorts. The primary outcome was hospital mortality. We analyzed the intervention's long-term impact in a subset of 50 ICUs. RESULTS We included 2628 patients (age 64.1 ± 15.2 years; men 64.0%; Acute Physiology and Chronic Health Evaluation (APACHE) II, 22.0 ± 8.1): 1352 in the preintervention cohort and 1276 in the postintervention cohort. In the postintervention cohort, the mean (SD) time from sepsis onset to empirical antibiotic therapy was lower (2.0 (2.7) vs. 2.5 (3.6) h; p = 0.002), the proportion of inappropriate empirical treatments was lower (6.5% vs. 8.9%; p = 0.024), and the proportion of patients in whom antibiotic treatment was de-escalated was higher (20.1% vs. 16.3%; p = 0.004); the expected reduction in mortality did not reach statistical significance (29.4% in the postintervention cohort vs. 30.5% in the preintervention cohort; p = 0.544). Gains observed after the intervention were maintained in the long-term follow-up period. CONCLUSIONS Despite advances in sepsis treatment, educational interventions can still improve the delivery of care; further improvements might also improve outcomes.
Collapse
Affiliation(s)
- Ricard Ferrer
- Intensive Care Department, Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain.
- CIBER Enfermedades Respiratorias, Madrid, Spain.
| | - María Luisa Martínez
- Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain
| | - Gemma Gomà
- Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - David Suárez
- Epidemiology and Assessment Unit, Fundació Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| | - Luis Álvarez-Rocha
- Intensive Care Department, Hospital Universitario de la Coruña, A Coruña, Spain
| | | | - Gumersindo González
- Intensive Care Department, Hospital General Universitario Morales Meseguer, Murcia, Spain
| | - Rafael Zaragoza
- Intensive Care Department, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Marcio Borges
- Intensive Care Department, Hospital Son Llatzer, Palma de Mallorca, Spain
| | - Jesús Blanco
- CIBER Enfermedades Respiratorias, Madrid, Spain
- Intensive Care Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - Antonio Artigas
- CIBER Enfermedades Respiratorias, Madrid, Spain
- Intensive Care Department, Hospital Universitario General de Catalunya, Autonomous University of Barcelona, Sant Cugat del Vallés, Spain
- Intensive Care Department, Corporación Sanitaria Universitaria Parc Taulí, Autonomous University of Barcelona, Sabadell, Spain
| |
Collapse
|
15
|
Lo C, Mertz D, Loeb M. Assessing the reporting quality of influenza outbreaks in the community. Influenza Other Respir Viruses 2017; 11:556-563. [PMID: 29054122 PMCID: PMC5705690 DOI: 10.1111/irv.12516] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND High-quality reporting of outbreak characteristics is fundamental to understand the behaviour of various strains of influenza virus and the impact of outbreak management strategies. However, few studies have systematically evaluated the quality of outbreak reporting. OBJECTIVES To conduct a systematic analysis and assessment for reporting quality of influenza outbreaks based on a modified version of the STROBE statement, and to examine characteristics associated with reporting quality. METHODS A literature search was conducted across 3 online databases (PubMed, Web of Science, MEDLINE) for reports of influenza outbreaks (pandemic H1N1, avian, seasonal). The quality of reports meeting our eligibility criteria was assessed using the Modified STROBE criteria and assigned a score of 30. Mean differences (MD) and 95% confidence intervals (CI) were reported for comparisons of study characteristics. RESULTS Sixty-four outbreak reports were available for analyses. The average Modified STROBE score was 20/30. Peer-reviewed articles were associated with a better quality of reporting (MD 2.79, 95% CI 0.79-4.78). Likewise, reports from authors affiliated with public health agencies were associated with better quality than those from academic institutions (MD 1.65, 95% CI-0.27-3.56). CONCLUSIONS The development of explicit reporting guidelines specifically geared towards reporting of outbreak investigations proved to be useful. Providing information on patient characteristics, investigation details in introduction and results, as well as addressing limitations that could have biased the findings, were frequently missing in the published reports.
Collapse
Affiliation(s)
- Calvin Lo
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonONCanada
| | - Dominik Mertz
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonONCanada
- Department of MedicineMcMaster UniversityHamiltonONCanada
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonONCanada
- Michael G. DeGroote Institute for Infectious Diseases ResearchMcMaster UniversityHamiltonONCanada
| | - Mark Loeb
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonONCanada
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonONCanada
- Michael G. DeGroote Institute for Infectious Diseases ResearchMcMaster UniversityHamiltonONCanada
| |
Collapse
|
16
|
Murri R, Taccari F, Spanu T, D'Inzeo T, Mastrorosa I, Giovannenze F, Scoppettuolo G, Ventura G, Palazzolo C, Camici M, Lardo S, Fiori B, Sanguinetti M, Cauda R, Fantoni M. A 72-h intervention for improvement of the rate of optimal antibiotic therapy in patients with bloodstream infections. Eur J Clin Microbiol Infect Dis 2017; 37:167-173. [PMID: 29052092 DOI: 10.1007/s10096-017-3117-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 10/04/2017] [Indexed: 01/05/2023]
Abstract
Antimicrobial stewardship programs are implemented to optimize the use of antibiotics and control the spread of antibiotic resistance. Many antimicrobial stewardship interventions have demonstrated significant efficacy in reducing unnecessary prescriptions of antibiotics, the duration of antimicrobial therapy, and mortality. We evaluated the benefits of a combination of rapid diagnostic tests and an active re-evaluation of antibiotic therapy 72 h after the onset of bloodstream infection (BSI). All patients with BSI from November 2015 to November 2016 in a 1100-bed university hospital in Rome, where an Infectious Disease Consultancy Unit (Unità di Consulenza Infettivologica, UDCI) is available, were re-evaluated at the bedside 72 h after starting antimicrobial therapy and compared to two pre-intervention periods: the UDCI was called by the ward physician for patients with BSI and the UDCI was called directly by the microbiologist immediately after a pathogen was isolated from blood cultures. Recommendations for antibiotic de-escalation or discontinuation significantly increased (54%) from the two pre-intervention periods (32% and 27.2%, p < 0.0001). Appropriate escalation also significantly increased (22.5%) from the pre-intervention periods (8.1% and 8.2%, p < 0.0001). The total duration of antibiotic therapy decreased with intervention (from 21.9 days [standard deviation, SD 15.4] in period 1 to 19.3 days [SD 13.3] in period 2 to 17.7 days in period 3 [SD 11.5]; p = 0.002) and the length of stay was significantly shorter (from 29.7 days [SD 29.3] in period 1 to 26.8 days [SD 24.7] in period 2 to 24.2 days in period 3 [SD 20.7]; p = 0.04) than in the two pre-intervention periods. Mortality was similar among the study periods (31 patients died in period 1 (15.7%), 39 (16.7%) in period 2, and 48 (15.3%) in period 3; p = 0.90). Rapid diagnostic tests and 72 h re-evaluation of empirical therapy for BSI significantly correlated with an improved rate of optimal antibiotic therapy and decreased duration of antibiotic therapy and length of stay.
Collapse
Affiliation(s)
- R Murri
- Department of Infectious Diseases, Catholic University of Rome, Rome, Italy.
| | - F Taccari
- Department of Infectious Diseases, Catholic University of Rome, Rome, Italy
| | - T Spanu
- Department of Microbiology, Catholic University of Rome, Rome, Italy
| | - T D'Inzeo
- Department of Microbiology, Catholic University of Rome, Rome, Italy
| | - I Mastrorosa
- Department of Infectious Diseases, Catholic University of Rome, Rome, Italy
| | - F Giovannenze
- Department of Infectious Diseases, Catholic University of Rome, Rome, Italy
| | - G Scoppettuolo
- Department of Infectious Diseases, Catholic University of Rome, Rome, Italy
| | - G Ventura
- Department of Infectious Diseases, Catholic University of Rome, Rome, Italy
| | - C Palazzolo
- Department of Infectious Diseases, Catholic University of Rome, Rome, Italy
| | - M Camici
- Department of Infectious Diseases, Catholic University of Rome, Rome, Italy
| | - S Lardo
- Department of Infectious Diseases, Catholic University of Rome, Rome, Italy
| | - B Fiori
- Department of Microbiology, Catholic University of Rome, Rome, Italy
| | - M Sanguinetti
- Department of Microbiology, Catholic University of Rome, Rome, Italy
| | - R Cauda
- Department of Infectious Diseases, Catholic University of Rome, Rome, Italy
| | - M Fantoni
- Department of Infectious Diseases, Catholic University of Rome, Rome, Italy
| |
Collapse
|
17
|
Hulscher MEJL, Prins JM. Antibiotic stewardship: does it work in hospital practice? A review of the evidence base. Clin Microbiol Infect 2017; 23:799-805. [PMID: 28750920 DOI: 10.1016/j.cmi.2017.07.017] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 07/13/2017] [Accepted: 07/15/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Guidelines for developing and implementing stewardship programmes include recommendations on appropriate antibiotic use to guide the stewardship team's choice of potential stewardship objectives. They also include recommendations on behavioural change interventions to guide the team's choice of potential interventions to ensure that professionals actually use antibiotics appropriately in daily practice. AIMS To summarize the evidence base of both appropriate antibiotic use recommendations (the 'what') and behavioural change interventions (the 'how') in hospital practice. SOURCES Published systematic reviews/Medline. CONTENT The literature shows low-quality evidence of the positive effects of appropriate antibiotic use in hospital patients. The literature shows that any behavioural change intervention might work to ensure that professionals actually perform appropriate antibiotic use recommendations in daily practice. Although effects were overall positive, there were large differences in improvement between studies that tested similar change interventions. IMPLICATIONS The literature showed a clear need for studies that apply appropriate study designs- (randomized) controlled designs-to test the effectiveness of appropriate antibiotic use on achieving meaningful outcomes. Most current studies used designs prone to confounding by indication. In the process of selecting behavioural change interventions that might work best in a chosen setting, much should be learned from behavioural sciences. The challenge for stewardship teams lies in selecting change interventions on the careful assessment of barriers and facilitators, and on a theoretical base while linking determinants to change interventions. Future studies should apply more robust designs and evaluations when assessing behavioural change interventions.
Collapse
Affiliation(s)
- M E J L Hulscher
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| |
Collapse
|
18
|
de Kraker MEA, Abbas M, Huttner B, Harbarth S. Good epidemiological practice: a narrative review of appropriate scientific methods to evaluate the impact of antimicrobial stewardship interventions. Clin Microbiol Infect 2017; 23:819-825. [PMID: 28571767 DOI: 10.1016/j.cmi.2017.05.019] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/15/2017] [Accepted: 05/17/2017] [Indexed: 12/30/2022]
Abstract
AIMS In this narrative review, we provide a framework for assessing the quality of evidence provided by studies investigating antimicrobial stewardship (AMS) interventions, and inform the design and planning stage for future AMS evaluation studies to determine the best strategies to keep antimicrobial resistance at bay. SOURCES Cochrane/Pubmed. CONTENT As AMS is mostly applied in a complex, real-world setting, bias and random time effects can jeopardize the validity of causal inference. The most important risks include simultaneously implemented infection prevention strategies and regression to the mean. Inclusion of homogeneous intervention and control arms, through randomization of the intervention, can limit these risks. However, contamination can play an important role for AMS; therefore, randomization at cluster-level, instead of randomization at individual-level, is recommended. It can be challenging to identify enough representative clusters, and implementation of a cluster-RCT (cRCT) can be costly. Controlled interrupted time series (ITS) design has a high validity as well, and is relatively straightforward to implement, although time-varying confounding should be considered. Independent of the study design, it is crucial to include multiple process, clinical outcome, microbiological and financial measures, to be able to detect possible, unintended consequences. IMPLICATIONS Future studies assessing the impact of new AMS strategies should produce compelling evidence by opting for cRCTs, or ITS including a control arm. Furthermore, a holistic view of intended and unintended consequences should be reported, and a detailed process evaluation should be provided to adequately inform implementation of successful AMS strategies to battle the rising burden of AMR.
Collapse
Affiliation(s)
- M E A de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | - M Abbas
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - B Huttner
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - S Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| |
Collapse
|
19
|
de With K, Allerberger F, Amann S, Apfalter P, Brodt HR, Eckmanns T, Fellhauer M, Geiss HK, Janata O, Krause R, Lemmen S, Meyer E, Mittermayer H, Porsche U, Presterl E, Reuter S, Sinha B, Strauß R, Wechsler-Fördös A, Wenisch C, Kern WV. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2017; 44:395-439. [PMID: 27066980 PMCID: PMC4889644 DOI: 10.1007/s15010-016-0885-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. Materials and methods A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. Conclusion The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.
Collapse
Affiliation(s)
- K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - F Allerberger
- Division Public Health, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - S Amann
- Hospital Pharmacy, Munich Municipal Hospital, Munich, Germany
| | - P Apfalter
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - H-R Brodt
- Department of Infectious Disease Medical Clinic II, Goethe-University Frankfurt, Frankfurt, Germany
| | - T Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - M Fellhauer
- Hospital Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - H K Geiss
- Department of Hospital Epidemiology and Infectiology, Sana Kliniken AG, Ismaning, Germany
| | - O Janata
- Department for Hygiene and Infection Control, Danube Hospital, Vienna, Austria
| | - R Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
| | - S Lemmen
- Division of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany
| | - E Meyer
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Berlin, Germany
| | - H Mittermayer
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - U Porsche
- Department for Clinical Pharmacy and Drug Information, Landesapotheke, Landeskliniken Salzburg (SALK), Salzburg, Austria
| | - E Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - S Reuter
- Clinic for General Internal Medicine, Infectious Diseases, Pneumology and Osteology, Klinikum Leverkusen, Leverkusen, Germany
| | - B Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Strauß
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Erlangen, Germany
| | - A Wechsler-Fördös
- Department of Antibiotics and Infection Control, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Wenisch
- Medical Department of Infection and Tropical Medicine, Kaiser Franz Josef Hospital, Vienna, Austria
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, Freiburg University Medical Center, Freiburg, Germany
| |
Collapse
|
20
|
Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, Gould IM, Ramsay CR, Michie S. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2:CD003543. [PMID: 28178770 PMCID: PMC6464541 DOI: 10.1002/14651858.cd003543.pub4] [Citation(s) in RCA: 397] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotic resistance is a major public health problem. Infections caused by multidrug-resistant bacteria are associated with prolonged hospital stay and death compared with infections caused by susceptible bacteria. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. We updated this systematic review to evaluate the impact of interventions to improve antibiotic prescribing to hospital inpatients. OBJECTIVES To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and to investigate the effect of two intervention functions: restriction and enablement. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, and Embase. We searched for additional studies using the bibliographies of included articles and personal files. The last search from which records were evaluated and any studies identified incorporated into the review was January 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies (NRS). We included three non-randomised study designs to measure behavioural and clinical outcomes and analyse variation in the effects: non- randomised trials (NRT), controlled before-after (CBA) studies and interrupted time series (ITS) studies. For this update we also included three additional NRS designs (case control, cohort, and qualitative studies) to identify unintended consequences. Interventions included any professional or structural interventions as defined by the Cochrane Effective Practice and Organisation of Care Group. We defined restriction as 'using rules to reduce the opportunity to engage in the target behaviour (or increase the target behaviour by reducing the opportunity to engage in competing behaviours)'. We defined enablement as 'increasing means/reducing barriers to increase capability or opportunity'. The main comparison was between intervention and no intervention. DATA COLLECTION AND ANALYSIS Two review authors extracted data and assessed study risk of bias. We performed meta-analysis and meta-regression of RCTs and meta-regression of ITS studies. We classified behaviour change functions for all interventions in the review, including those studies in the previously published versions. We analysed dichotomous data with a risk difference (RD). We assessed certainty of evidence with GRADE criteria. MAIN RESULTS This review includes 221 studies (58 RCTs, and 163 NRS). Most studies were from North America (96) or Europe (87). The remaining studies were from Asia (19), South America (8), Australia (8), and the East Asia (3). Although 62% of RCTs were at a high risk of bias, the results for the main review outcomes were similar when we restricted the analysis to studies at low risk of bias.More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% confidence interval (CI) 14% to 16%; 23,394 participants; high-certainty evidence). This represents an increase from 43% to 58% .There were high levels of heterogeneity of effect size but the direction consistently favoured intervention.The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67; 14 RCTs; 3318 participants; high-certainty evidence) from 11.0 days. Information from non-randomised studies showed interventions to be associated with improvement in prescribing according to antibiotic policy in routine clinical practice, with 70% of interventions being hospital-wide compared with 31% for RCTs. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs; 15,827 participants; moderate-certainty evidence). Antibiotic stewardship interventions probably reduce length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs; 3834 participants; moderate-certainty evidence). One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence).Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions (high-certainty evidence). Enabling interventions that included feedback were probably more effective than those that did not (moderate-certainty evidence).There was very low-certainty evidence about the effect of the interventions on reducing Clostridium difficile infections (median -48.6%, interquartile range -80.7% to -19.2%; 7 studies). This was also the case for resistant gram-negative bacteria (median -12.9%, interquartile range -35.3% to 25.2%; 11 studies) and resistant gram-positive bacteria (median -19.3%, interquartile range -50.1% to +23.1%; 9 studies). There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use. Heterogeneity of intervention effect on prescribing outcomesWe analysed effect modifiers in 29 RCTs and 91 ITS studies. Enablement and restriction were independently associated with a larger effect size (high-certainty evidence). Feedback was included in 4 (17%) of 23 RCTs and 20 (47%) of 43 ITS studies of enabling interventions and was associated with greater intervention effect. Enablement was included in 13 (45%) of 29 ITS studies with restrictive interventions and enhanced intervention effect. AUTHORS' CONCLUSIONS We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment. Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Additional trials comparing antibiotic stewardship with no intervention are unlikely to change our conclusions. Enablement consistently increased the effect of interventions, including those with a restrictive component. Although feedback further increased intervention effect, it was used in only a minority of enabling interventions. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Consequently, effective dissemination of our findings could have considerable health service and policy impact. Future research should instead focus on targeting treatment and assessing other measures of patient safety, assess different stewardship interventions, and explore the barriers and facilitators to implementation. More research is required on unintended consequences of restrictive interventions.
Collapse
Affiliation(s)
- Peter Davey
- University of DundeePopulation Health SciencesMackenzie BuildingKirsty Semple WayDundeeScotlandUKDD2 4BF
| | - Charis A Marwick
- University of DundeePopulation Health Sciences Division, Medical Research InstituteDundeeUK
| | - Claire L Scott
- NHS Education for ScotlandScottish Dental Clinical Effectiveness ProgrammeDundee Dental Education CentreSmall's WyndDundeeUKDD1 4HN
| | - Esmita Charani
- Imperial College LondonNIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial ResistanceDu Cane RoadLondonUKW12 OHS
| | - Kirsty McNeil
- University of DundeeSchool of Medicine147 Forth CrescentDundeeScotlandUKDD2 4JA
| | - Erwin Brown
- No affiliation31 Park CrescentFrenchayBristolUKBS16 1NZ
| | - Ian M Gould
- Aberdeen Royal InfirmaryDepartment of Medical MicrobiologyForesterhillAberdeenUKAB25 2ZN
| | - Craig R Ramsay
- University of AberdeenHealth Services Research Unit, Division of Applied Health SciencesPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
| | - Susan Michie
- University College LondonResearch Department of Primary Care and Population HealthUpper Floor 3, Royal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | | |
Collapse
|
21
|
Vercheval C, Gillet M, Maes N, Albert A, Frippiat F, Damas P, Van Hees T. Quality of documentation on antibiotic therapy in medical records: evaluation of combined interventions in a teaching hospital by repeated point prevalence survey. Eur J Clin Microbiol Infect Dis 2016; 35:1495-500. [PMID: 27255220 DOI: 10.1007/s10096-016-2690-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/20/2016] [Indexed: 11/29/2022]
Abstract
This study aimed to improve the quality of documentation on antibiotic therapy in the computerized medical records of inpatients. A prospective, uncontrolled, interrupted time series (ITS) study was conducted by repeated point prevalence survey (PPS) to audit the quality of documentation on antibiotic therapy in the medical records before and after a combined intervention strategy (implementation of guidelines, distribution of educational materials, educational outreach visits, group educational interactive sessions) from the antimicrobial stewardship team (AST) in the academic teaching hospital (CHU) of Liège, Belgium. The primary outcome measure was the documentation rate on three quality indicators in the computerized medical records: (1) indication for treatment, (2) antibiotics prescribed, and (3) duration or review date. Segmented regression analysis was used to analyze the ITS. The medical records of 2306 patients receiving antibiotics for an infection (1177 in the pre-intervention period and 1129 in the post-intervention period) were analyzed. A significant increase in mean percentages in the post-intervention period was observed as compared with the pre-intervention period for the three quality indicators (indication documented 83.4 ± 10.4 % vs. 90.3 ± 6.6 %, p = 0.0013; antibiotics documented 87.9 ± 9.0 % vs. 95.6 ± 5.1 %, p < 0.0001; and duration or review date documented 31.9 ± 15.4 % vs. 67.7 ± 15.2 %, p < 0.0001). The study demonstrated the successful implementation of a combined intervention strategy from the AST. This strategy was associated with significant changes in the documentation rate in the computerized medical records for the three quality indicators.
Collapse
Affiliation(s)
- C Vercheval
- Department of Clinical Pharmacy, CIRM (Center for Interdisciplinary Research on Medicines), University Hospital of Liège, Liège, Belgium. .,Service de Pharmacie Clinique, CHU de Liège, Avenue de l'hôpital, 1 - B35, Sart Tilman, 4000, Liège, Belgium.
| | - M Gillet
- Department of Clinical Pharmacy, CIRM (Center for Interdisciplinary Research on Medicines), University Hospital of Liège, Liège, Belgium
| | - N Maes
- Department of Biostatistics and Medico-Economic Information, University Hospital of Liège, Liège, Belgium
| | - A Albert
- Department of Biostatistics and Medico-Economic Information, University Hospital of Liège, Liège, Belgium
| | - F Frippiat
- Department of Infectious Diseases and General Internal Medicine, University Hospital of Liège, Liège, Belgium
| | - P Damas
- Department of Intensive Care Unit, University Hospital of Liège, Liège, Belgium
| | - T Van Hees
- Department of Clinical Pharmacy, CIRM (Center for Interdisciplinary Research on Medicines), University Hospital of Liège, Liège, Belgium
| |
Collapse
|
22
|
Effiong A, Shinn L, Pope TM, Raho JA. Advance care planning for end-stage kidney disease. Hippokratia 2016. [DOI: 10.1002/14651858.cd010687.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Andem Effiong
- United States Department of Health and Human Services; 10903 New Hampshire Avenue Silver Spring Maryland USA 20993
- Georgetown University School of Medicine; Washington DC USA
- Union Graduate College - Icahn School of Medicine at Mount Sinai; Mount Sinai New York USA
| | - Laura Shinn
- Rowan University; Political Science and Economics; Glassboro New Jersey USA
| | - Thaddeus M Pope
- Hamline University School of Law; Health Law Institute; MS-D2017 1536 Hewitt Ave Saint Paul Minnesota USA 55104-1237
| | - Joseph A Raho
- Universita di Pisa; Department of Philosophy; Visa Fabio Filzi, 35 Pisa Italy 56123
| |
Collapse
|
23
|
Boel J, Andreasen V, Jarløv JO, Østergaard C, Gjørup I, Bøggild N, Arpi M. Impact of antibiotic restriction on resistance levels ofEscherichia coli: a controlled interrupted time series study of a hospital-wide antibiotic stewardship programme. J Antimicrob Chemother 2016; 71:2047-51. [DOI: 10.1093/jac/dkw055] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 02/10/2016] [Indexed: 11/12/2022] Open
|
24
|
Høgli JU, Garcia BH, Skjold F, Skogen V, Småbrekke L. An audit and feedback intervention study increased adherence to antibiotic prescribing guidelines at a Norwegian hospital. BMC Infect Dis 2016; 16:96. [PMID: 26920549 PMCID: PMC4769530 DOI: 10.1186/s12879-016-1426-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 02/10/2016] [Indexed: 02/01/2023] Open
Abstract
Background Appropriate antibiotic prescribing is associated with favourable levels of antimicrobial resistance (AMR) and clinical outcomes. Most intervention studies on antibiotic prescribing originate from settings with high level of AMR. In a Norwegian hospital setting with low level of AMR, the literature on interventions for promoting guideline-recommended antibiotic prescribing in hospital is scarce and requested. Preliminary studies have shown improvement potentials regarding antibiotic prescribing according to guidelines. We aimed to promote appropriate antibiotic prescribing in patients with community-acquired pneumonia (CAP) and acute exacerbations of chronic obstructive pulmonary disease (AECOPD) at a respiratory medicine department in a Norwegian University hospital. Our specific objectives were to increase prescribing of appropriate empirical antibiotics, reduce high-dose benzylpenicillin and reduce total treatment duration. Methods We performed an audit and feedback intervention study, combined with distribution of a recently published pocket version of the national clinical practice guideline. We included patients discharged with CAP or AECOPD and prescribed antibiotics during hospital stay, and excluded those presenting with aspiration, nosocomial infection and co-infections. The pre- and post-intervention period was 9 and 6 months, respectively. Feedback was provided orally to the department physicians at an internal-educational meeting. To explore the effect of the intervention on appropriate empirical antibiotics and mean total treatment duration we applied before-after analysis (Student’s t-test) and interrupted time series (ITS). We used Pearson’s χ2 to compare dose changes. Results In the pre-and post-intervention period we included 253 and 155 patients, respectively. Following the intervention, overall mean prescribing of appropriate empirical antibiotics increased from 61.7 to 83.8 % (P < 0.001), overall mean total treatment duration decreased from 11.2 to 10.4 days (P = 0.015), and prescribing of high-dose benzylpenicillin decreased from 48.8 to 38.6 % (P = 0.125). With ITS we found that six months post-intervention, the effect on appropriate empirical antibiotic prescribing had increased and sustained, while the effect on treatment duration was at pre-intervention level. Conclusion The combination of audit and feedback plus distribution of a pocket version of guideline recommendations led to a substantial increase in prescribing of appropriate empirical antibiotics, which is important due to favourable effect on AMR and clinical outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1426-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- June Utnes Høgli
- Department of Pharmacy, Faculty of Health Sciences, UiT - The Arctic University of Norway, N - 9037, Tromsø, Norway.
| | - Beate Hennie Garcia
- Department of Pharmacy, Faculty of Health Sciences, UiT - The Arctic University of Norway, N - 9037, Tromsø, Norway.
| | - Frode Skjold
- Department of Pharmacy, Faculty of Health Sciences, UiT - The Arctic University of Norway, N - 9037, Tromsø, Norway.
| | - Vegard Skogen
- Department of Infectious Diseases, Division of Internal Medicine, University Hospital of North Norway, N - 9038, Tromsø, Norway. .,Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, N - 9037, Tromsø, Norway.
| | - Lars Småbrekke
- Department of Pharmacy, Faculty of Health Sciences, UiT - The Arctic University of Norway, N - 9037, Tromsø, Norway.
| |
Collapse
|
25
|
Sartelli M, Weber DG, Ruppé E, Bassetti M, Wright BJ, Ansaloni L, Catena F, Coccolini F, Abu-Zidan FM, Coimbra R, Moore EE, Moore FA, Maier RV, De Waele JJ, Kirkpatrick AW, Griffiths EA, Eckmann C, Brink AJ, Mazuski JE, May AK, Sawyer RG, Mertz D, Montravers P, Kumar A, Roberts JA, Vincent JL, Watkins RR, Lowman W, Spellberg B, Abbott IJ, Adesunkanmi AK, Al-Dahir S, Al-Hasan MN, Agresta F, Althani AA, Ansari S, Ansumana R, Augustin G, Bala M, Balogh ZJ, Baraket O, Bhangu A, Beltrán MA, Bernhard M, Biffl WL, Boermeester MA, Brecher SM, Cherry-Bukowiec JR, Buyne OR, Cainzos MA, Cairns KA, Camacho-Ortiz A, Chandy SJ, Che Jusoh A, Chichom-Mefire A, Colijn C, Corcione F, Cui Y, Curcio D, Delibegovic S, Demetrashvili Z, De Simone B, Dhingra S, Diaz JJ, Di Carlo I, Dillip A, Di Saverio S, Doyle MP, Dorj G, Dogjani A, Dupont H, Eachempati SR, Enani MA, Egiev VN, Elmangory MM, Ferrada P, Fitchett JR, Fraga GP, Guessennd N, Giamarellou H, Ghnnam W, Gkiokas G, Goldberg SR, Gomes CA, Gomi H, Guzmán-Blanco M, Haque M, Hansen S, Hecker A, Heizmann WR, Herzog T, Hodonou AM, Hong SK, Kafka-Ritsch R, Kaplan LJ, Kapoor G, Karamarkovic A, Kees MG, Kenig J, Kiguba R, Kim PK, Kluger Y, Khokha V, Koike K, Kok KYY, Kong V, Knox MC, Inaba K, Isik A, Iskandar K, Ivatury RR, Labbate M, Labricciosa FM, Laterre PF, Latifi R, Lee JG, Lee YR, Leone M, Leppaniemi A, Li Y, Liang SY, Loho T, Maegele M, Malama S, Marei HE, Martin-Loeches I, Marwah S, Massele A, McFarlane M, Melo RB, Negoi I, Nicolau DP, Nord CE, Ofori-Asenso R, Omari AH, Ordonez CA, Ouadii M, Pereira Júnior GA, Piazza D, Pupelis G, Rawson TM, Rems M, Rizoli S, Rocha C, Sakakhushev B, Sanchez-Garcia M, Sato N, Segovia Lohse HA, Sganga G, Siribumrungwong B, Shelat VG, Soreide K, Soto R, Talving P, Tilsed JV, Timsit JF, Trueba G, Trung NT, Ulrych J, van Goor H, Vereczkei A, Vohra RS, Wani I, Uhl W, Xiao Y, Yuan KC, Zachariah SK, Zahar JR, Zakrison TL, Corcione A, Melotti RM, Viscoli C, Viale P. Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA). World J Emerg Surg 2016; 11:33. [PMID: 27429642 PMCID: PMC4946132 DOI: 10.1186/s13017-016-0089-y] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 07/04/2016] [Indexed: 02/08/2023] Open
Abstract
Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.
Collapse
Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Dieter G. Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Etienne Ruppé
- Genomic Research Laboratory, Geneva University Hospitals, Geneva, Switzerland
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy
| | - Brian J. Wright
- Department of Emergency Medicine and Surgery, Stony Brook University School of Medicine, Stony Brook, NY USA
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Fausto Catena
- Department of General, Maggiore Hospital, Parma, Italy
| | | | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Raul Coimbra
- Department of Surgery, UC San Diego Medical Center, San Diego, USA
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
| | - Frederick A. Moore
- Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, FL USA
| | - Ronald V. Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Jan J. De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andrew W. Kirkpatrick
- General, Acute Care, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Ewen A. Griffiths
- General and Upper GI Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Christian Eckmann
- Department of General, Visceral, and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Peine, Germany
| | - Adrian J. Brink
- Department of Clinical microbiology, Ampath National Laboratory Services, Milpark Hospital, Johannesburg, South Africa
| | - John E. Mazuski
- Department of Surgery, School of Medicine, Washington University in Saint Louis, Missouri, USA
| | - Addison K. May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN USA
| | - Rob G. Sawyer
- Department of Surgery, University of Virginia Health System, Charlottesville, VA USA
| | - Dominik Mertz
- Departments of Medicine, Clinical Epidemiology and Biostatistics, and Pathology and Molecular Medicine, McMaster University, Hamilton, ON Canada
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | - Anand Kumar
- Section of Critical Care Medicine and Section of Infectious Diseases, Department of Medicine, Medical Microbiology and Pharmacology/Therapeutics, University of Manitoba, Winnipeg, MB Canada
| | - Jason A. Roberts
- Australia Pharmacy Department, Royal Brisbane and Womens’ Hospital; Burns, Trauma, and Critical Care Research Centre, Australia School of Pharmacy, The University of Queensland, Brisbane, QLD Australia
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Richard R. Watkins
- Department of Internal Medicine, Division of Infectious Diseases, Akron General Medical Center, Northeast Ohio Medical University, Akron, OH USA
| | - Warren Lowman
- Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Brad Spellberg
- Division of Infectious Diseases, Los Angeles County-University of Southern California (USC) Medical Center, Keck School of Medicine at USC, Los Angeles, CA USA
| | - Iain J. Abbott
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC Australia
| | | | - Sara Al-Dahir
- Division of Clinical and Administrative Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA USA
| | - Majdi N. Al-Hasan
- Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC USA
| | | | | | - Shamshul Ansari
- Department of Microbiology, Chitwan Medical College, and Department of Environmental and Preventive Medicine, Oita University, Oita, Japan
| | - Rashid Ansumana
- Centre for Neglected Tropical Diseases, Liverpool School of Tropical Medicine, University of Liverpool, and Mercy Hospital Research Laboratory, Njala University, Bo, Sierra Leone
| | - Goran Augustin
- Department of Surgery, University Hospital Center, Zagreb, Croatia
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | | | - Aneel Bhangu
- Academic Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Marcelo A. Beltrán
- Department of General Surgery, Hospital San Juan de Dios de La Serena, La Serena, Chile
| | | | - Walter L. Biffl
- Department of Surgery, University of Colorado, Denver, CO USA
| | | | - Stephen M. Brecher
- Department of Pathology and Laboratory Medicine, VA Boston HealthCare System, and Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA USA
| | - Jill R. Cherry-Bukowiec
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI USA
| | - Otmar R. Buyne
- Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Miguel A. Cainzos
- Department of Surgery, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Kelly A. Cairns
- Pharmacy Department, Alfred Health, Melbourne, VIC Australia
| | - Adrian Camacho-Ortiz
- Hospital Epidemiology and Infectious Diseases, Hospital Universitario Dr Jose Eleuterio Gonzalez, Monterrey, Mexico
| | - Sujith J. Chandy
- Department of Pharmacology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala India
| | - Asri Che Jusoh
- Department of General Surgery, Kuala Krai Hospital, Kuala Krai, Kelantan Malaysia
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Caroline Colijn
- Department of Mathematics, Imperial College London, London, UK
| | - Francesco Corcione
- Department of Laparoscopic and Robotic Surgery, Colli-Monaldi Hospital, Naples, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Daniel Curcio
- Infectología Institucional SRL, Hospital Municipal Chivilcoy, Buenos Aires, Argentina
| | - Samir Delibegovic
- Department of Surgery, University Clinical Center of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Zaza Demetrashvili
- Department General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
| | | | - Sameer Dhingra
- School of Pharmacy, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Eric Williams Medical Sciences Complex, Uriah Butler Highway, Champ Fleurs, Trinidad and Tobago
| | - José J. Diaz
- Division of Acute Care Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - Isidoro Di Carlo
- Department of Surgical Sciences, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Angel Dillip
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Michael P. Doyle
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, Griffin, GA USA
| | - Gereltuya Dorj
- School of Pharmacy and Biomedicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Agron Dogjani
- Department of Surgery, University Hospital of Trauma, Tirana, Albania
| | - Hervé Dupont
- Département d’Anesthésie-Réanimation, CHU Amiens-Picardie, and INSERM U1088, Université de Picardie Jules Verne, Amiens, France
| | - Soumitra R. Eachempati
- Department of Surgery, Division of Burn, Critical Care, and Trauma Surgery (K.P.S., S.R.E.), Weill Cornell Medical College/New York-Presbyterian Hospital, New York, USA
| | - Mushira Abdulaziz Enani
- Department of Medicine, Infectious Disease Division, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Valery N. Egiev
- Department of Surgery, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Mutasim M. Elmangory
- Sudan National Public Health Laboratory, Federal Ministry of Health, Khartoum, Sudan
| | - Paula Ferrada
- Department of Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Joseph R. Fitchett
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA USA
| | - Gustavo P. Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | | | - Helen Giamarellou
- 6th Department of Internal Medicine, Hygeia General Hospital, Athens, Greece
| | - Wagih Ghnnam
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - George Gkiokas
- 2nd Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Carlos Augusto Gomes
- Department of Surgery, Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Juiz de Fora, Brazil
| | - Harumi Gomi
- Center for Global Health, Mito Kyodo General Hospital, University of Tsukuba, Mito, Ibaraki Japan
| | - Manuel Guzmán-Blanco
- Hospital Privado Centro Médico de Caracas and Hospital Vargas de Caracas, Caracas, Venezuela
| | - Mainul Haque
- Unit of Pharmacology, Faculty of Medicine and Defense Health, National Defence University of Malaysia, Kuala Lumpur, Malaysia
| | - Sonja Hansen
- Institute of Hygiene, Charité-Universitätsmedizin Berlin, Hindenburgdamm 27, 12203 Berlin, Germany
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | | | - Torsten Herzog
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Adrien Montcho Hodonou
- Department of Surgery, Faculté de médecine, Université de Parakou, BP 123 Parakou, Bénin
| | - Suk-Kyung Hong
- Division of Trauma and Surgical Critical Care, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Reinhold Kafka-Ritsch
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Lewis J. Kaplan
- Department of Surgery Philadelphia VA Medical Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Garima Kapoor
- Department of Microbiology, Gandhi Medical College, Bhopal, India
| | | | - Martin G. Kees
- Department of Anesthesiology and Intensive Care, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Jakub Kenig
- 3rd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Ronald Kiguba
- Department of Pharmacology and Therapeutics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Peter K. Kim
- Department of Surgery, Albert Einstein College of Medicine and Jacobi Medical Center, Bronx, NY USA
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenneth Y. Y. Kok
- Department of Surgery, The Brunei Cancer Centre, Jerudong Park, Brunei
| | - Victory Kong
- Department of Surgery, Edendale Hospital, Pietermaritzburg, South Africa
| | - Matthew C. Knox
- School of Medicine, Western Sydney University, Campbelltown, NSW Australia
| | - Kenji Inaba
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA USA
| | - Arda Isik
- Department of General Surgery, Erzincan University, Faculty of Medicine, Erzincan, Turkey
| | - Katia Iskandar
- Department of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Rao R. Ivatury
- Department of Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Maurizio Labbate
- School of Life Science and The ithree Institute, University of Technology, Sydney, NSW Australia
| | - Francesco M. Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, UNIVMP, Ancona, Italy
| | - Pierre-François Laterre
- Department of Critical Care Medicine, Cliniques Universitaires Saint Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Rifat Latifi
- Department of Surgery, Division of Trauma, University of Arizona, Tucson, AZ USA
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Ran Lee
- Texas Tech University Health Sciences Center School of Pharmacy, Abilene, TX USA
| | - Marc Leone
- Department of Anaesthesiology and Critical Care, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Yousheng Li
- Department of Surgery, Inling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Stephen Y. Liang
- Division of Infectious Diseases, Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO USA
| | - Tonny Loho
- Division of Infectious Diseases, Department of Clinical Pathology, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Marc Maegele
- Department for Traumatology and Orthopedic Surgery, Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke (UW/H), Cologne, Germany
| | - Sydney Malama
- Health Research Program, Institute of Economic and Social Research, University of Zambia, Lusaka, Zambia
| | - Hany E. Marei
- Biomedical Research Center, Qatar University, Doha, Qatar
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Wellcome Trust-HRB Clinical Research, Department of Clinical Medicine, Trinity Centre for Health Sciences, St James’ University Hospital, Dublin, Ireland
| | - Sanjay Marwah
- Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | - Amos Massele
- Department of Clinical Pharmacology, School of Medicine, University of Botswana, Gaborone, Botswana
| | - Michael McFarlane
- Department of Surgery, Radiology, University Hospital of the West Indies, Kingston, Jamaica
| | - Renato Bessa Melo
- General Surgery Department, Centro Hospitalar de São João, Porto, Portugal
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - David P. Nicolau
- Center of Anti-Infective Research and Development, Hartford, CT USA
| | - Carl Erik Nord
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | | | | | - Carlos A. Ordonez
- Department of Surgery and Critical Care, Universidad del Valle, Fundación Valle del Lili, Cali, Colombia
| | - Mouaqit Ouadii
- Department of Surgery, Hassan II University Hospital, Medical School of Fez, Sidi Mohamed Benabdellah University, Fez, Morocco
| | | | - Diego Piazza
- Division of Surgery, Vittorio Emanuele Hospital, Catania, Italy
| | - Guntars Pupelis
- Department of General and Emergency Surgery, Riga East University Hospital ‘Gailezers’, Riga, Latvia
| | - Timothy Miles Rawson
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
| | - Miran Rems
- Department of General Surgery, Jesenice General Hospital, Jesenice, Slovenia
| | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael’s Hospital, University of Toronto, Toronto, Canada
| | | | - Boris Sakakhushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | | | - Norio Sato
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Helmut A. Segovia Lohse
- II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Gabriele Sganga
- Department of Surgery, Catholic University of Sacred Heart, Policlinico A Gemelli, Rome, Italy
| | - Boonying Siribumrungwong
- Department of Surgery, Faculty of Medicine, Thammasat University Hospital, Thammasat University, Pathum Thani, Thailand
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Tan Tock Seng, Singapore
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Rodolfo Soto
- Department of Emergency Surgery and Critical Care, Centro Medico Imbanaco, Cali, Colombia
| | - Peep Talving
- Department of Surgery, North Estonia Medical Center, Tallinn, Estonia
| | - Jonathan V. Tilsed
- Surgery Health Care Group, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - Gabriel Trueba
- Institute of Microbiology, Biological and Environmental Sciences College, University San Francisco de Quito, Quito, Ecuador
| | - Ngo Tat Trung
- Department of Molecular Biology, Tran Hung Dao Hospital, No 1, Tran Hung Dao Street, Hai Ba Trung Dist, Hanoi, Vietnam
| | - Jan Ulrych
- 1st Department of Surgery - Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Prague, Czech Republic
| | - Harry van Goor
- Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Andras Vereczkei
- Department of Surgery, Medical School University of Pécs, Pécs, Hungary
| | - Ravinder S. Vohra
- Nottingham Oesophago-Gastric Unit, Nottingham University Hospitals, Nottingham, UK
| | - Imtiaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Waldemar Uhl
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affilliated Hospital, Zhejiang University, Zhejiang, China
| | - Kuo-Ching Yuan
- Trauma and Emergency Surgery Department, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | | | - Jean-Ralph Zahar
- Infection Control Unit, Angers University, CHU d’Angers, Angers, France
| | - Tanya L. Zakrison
- Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgry, University of Miami, Miami, FL USA
| | - Antonio Corcione
- Anesthesia and Intensive Care Unit, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Rita M. Melotti
- Anesthesiology and Intensive Care Unit, Sant’Orsola University Hospital, Bologna, Italy
| | - Claudio Viscoli
- Infectious Diseases Unit, University of Genoa (DISSAL) and IRCCS San Martino-IST, Genoa, Italy
| | - Perluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’ Orsola Hospital, University of Bologna, Bologna, Italy
| |
Collapse
|
26
|
Spoorenberg V, Hulscher MEJL, Geskus RB, de Reijke TM, Opmeer BC, Prins JM, Geerlings SE. A Cluster-Randomized Trial of Two Strategies to Improve Antibiotic Use for Patients with a Complicated Urinary Tract Infection. PLoS One 2015; 10:e0142672. [PMID: 26637169 PMCID: PMC4670093 DOI: 10.1371/journal.pone.0142672] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 10/25/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Up to 50% of hospital antibiotic use is inappropriate and therefore improvement strategies are urgently needed. We compared the effectiveness of two strategies to improve the quality of antibiotic use in patients with a complicated urinary tract infection (UTI). METHODS In a multicentre, cluster-randomized trial 19 Dutch hospitals (departments Internal Medicine and Urology) were allocated to either a multi-faceted strategy including feedback, educational sessions, reminders and additional/optional improvement actions, or a competitive feedback strategy, i.e. providing professionals with non-anonymous comparative feedback on the department's appropriateness of antibiotic use. Retrospective baseline- and post-intervention measurements were performed in 2009 and 2012 in 50 patients per department, resulting in 1,964 and 2,027 patients respectively. Principal outcome measures were nine validated guideline-based quality indicators (QIs) that define appropriate antibiotic use in patients with a complicated UTI, and a QI sumscore that summarizes for each patient the appropriateness of antibiotic use. RESULTS Performance scores on several individual QIs showed improvement from baseline to post-intervention measurements, but no significant differences were found between both strategies. The mean patient's QI sum score improved significantly in both strategy groups (multi-faceted: 61.7% to 65.0%, P = 0.04 and competitive feedback: 62.8% to 66.7%, P = 0.01). Compliance with the strategies was suboptimal, but better compliance was associated with more improvement. CONCLUSION The effectiveness of both strategies was comparable and better compliance with the strategies was associated with more improvement. To increase effectiveness, improvement activities should be rigorously applied, preferably by a locally initiated multidisciplinary team. TRIAL REGISTRATION Nederlands Trial Register 1742.
Collapse
Affiliation(s)
- Veroniek Spoorenberg
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
- * E-mail: (VS); (SG)
| | - Marlies E. J. L. Hulscher
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Ronald B. Geskus
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Theo M. de Reijke
- Department of Urology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Brent C. Opmeer
- Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jan M. Prins
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
| | - Suzanne E. Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands
- * E-mail: (VS); (SG)
| |
Collapse
|
27
|
Dodds Ashley ES, Kaye KS, DePestel DD, Hermsen ED. Antimicrobial stewardship: philosophy versus practice. Clin Infect Dis 2015; 59 Suppl 3:S112-21. [PMID: 25261538 DOI: 10.1093/cid/ciu546] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
To promote the judicious use of antimicrobials and preserve their usefulness in the setting of growing resistance, a number of policy-making bodies and professional societies have advocated the development of antimicrobial stewardship programs. Although these programs have been implemented at many institutions in the United States, their impact has been difficult to measure. Current recommendations advocate the use of both outcome and process measures as metrics for antimicrobial stewardship. Although patient outcome metrics have the greatest impact on the quality of care, the literature shows that antimicrobial use and costs are the indicators measured most frequently by institutions to justify the effectiveness of antimicrobial stewardship programs. The measurement of more meaningful outcomes has been constrained by difficulties inherent to these measures, lack of funding and resources, and inadequate study designs. Antimicrobial stewardship can be made more credible by refocusing the antimicrobial review process to target specific disease states, reassessing the usefulness of current metrics, and integrating antimicrobial stewardship program initiatives into institutional quality and safety efforts.
Collapse
Affiliation(s)
| | - Keith S Kaye
- Division of Infectious Diseases, Wayne State University School of Medicine and Detroit Medical Center, Michigan
| | - Daryl D DePestel
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts
| | - Elizabeth D Hermsen
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha
| |
Collapse
|
28
|
Howard P, Pulcini C, Levy Hara G, West RM, Gould IM, Harbarth S, Nathwani D. An international cross-sectional survey of antimicrobial stewardship programmes in hospitals. J Antimicrob Chemother 2014; 70:1245-55. [PMID: 25527272 DOI: 10.1093/jac/dku497] [Citation(s) in RCA: 165] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To report the extent and components of global efforts in antimicrobial stewardship (AMS) in hospitals. METHODS An Internet-based survey comprising 43 questions was disseminated worldwide in 2012. RESULTS Responses were received from 660 hospitals in 67 countries: Africa, 44; Asia, 50; Europe, 361; North America, 72; Oceania, 30; and South and Central America, 103. National AMS standards existed in 52% of countries, 4% were planning them and 58% had an AMS programme. The main barriers to implementing AMS programmes were perceived to be a lack of funding or personnel, a lack of information technology and prescriber opposition. In hospitals with an existing AMS programme, AMS rounds existed in 64%; 81% restricted antimicrobials (carbapenems, 74.3%; quinolones, 64%; and cephalosporins, 58%); and 85% reported antimicrobial usage, with 55% linking data to resistance rates and 49% linking data to infection rates. Only 20% had electronic prescribing for all patients. A total of 89% of programmes educated their medical, nursing and pharmacy staff on AMS. Of the hospitals, 38% had formally reviewed their AMS programme: reductions were reported by 96% of hospitals for inappropriate prescribing, 86% for broad-spectrum antibiotic use, 80% for expenditure, 71% for healthcare-acquired infections, 65% for length of stay or mortality and 58% for bacterial resistance. CONCLUSIONS The worldwide development and implementation of AMS programmes varies considerably. Our results should inform and encourage the further evaluation of this with a view to promoting a worldwide stewardship framework. The prospective measurement of well-defined outcomes of the impact of these programmes remains a significant challenge.
Collapse
Affiliation(s)
- P Howard
- Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK
| | - C Pulcini
- CHU de Nancy, Service de Maladies Infectieuses, Nancy, France Université de Lorraine, Université Paris Descartes, EA 4360 Apemac, Nancy, France
| | - G Levy Hara
- Infectious Diseases Unit, Hospital Carlos G Durand, Buenos Aires, Argentina
| | - R M West
- Leeds Institute for Health Sciences, University of Leeds, Leeds LS2 9LJ, UK
| | - I M Gould
- Microbiology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK
| | - S Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - D Nathwani
- Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | | | | |
Collapse
|
29
|
van Limburg M, Sinha B, Lo-Ten-Foe JR, van Gemert-Pijnen JE. Evaluation of early implementations of antibiotic stewardship program initiatives in nine Dutch hospitals. Antimicrob Resist Infect Control 2014; 3:33. [PMID: 25392736 PMCID: PMC4228167 DOI: 10.1186/2047-2994-3-33] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 09/10/2014] [Indexed: 11/27/2022] Open
Abstract
Background Antibiotic resistance is a global threat to patient safety and care. In response, hospitals start antibiotic stewardship programs to optimise antibiotic use. Expert-based guidelines recommend strategies to implement such programs, but local implementations may differ per hospital. Earlier published assessments determine maturity of antibiotic stewardship programs based on expert-based structure indicators, but they disregard that there may be valid deviations from these expert-based programs. Aim To analyse the progress and barriers of local implementations of antibiotic stewardship programs with stakeholders in nine Dutch hospitals and to develop a toolkit that guides implementing local antibiotic stewardship programs. Methods An online questionnaire based on published guidelines and recommendations, conducted with seven clinical microbiologists, seven infectious disease physicians and five clinical pharmacists at nine Dutch hospitals. Results Results show local differences in antibiotic stewardship programs and the uptake of interventions in hospitals. Antibiotic guidelines and antibiotic teams are the most extensively implemented interventions. Education, decision support and audit-feedback are deemed important interventions and they are either piloted in implementations at academic hospitals or in preparation for application in non-academic hospitals. Other interventions that are recommended in guidelines - benchmarking, restriction and antibiotic formulary - appear to have a lower priority. Automatic stop-order, pre-authorization, automatic substitution, antibiotic cycling are not deemed to be worthwhile according to respondents. Conclusion There are extensive local differences in the implementation of antibiotic stewardship interventions. These differences suggest a need to further explore the rationale behind the choice of interventions in antibiotic stewardship programs. Rather than reporting this rationale, this study reports where rationale can play a key role in the implementation of antibiotic stewardship programs. A one-size-fits-all solution is unfeasible as there may be barriers or valid reasons for local experts to deviate from expert-based guidelines. Local experts can be supported with a toolkit containing advice based on possible barriers and considerations. These parameters can be used to customise an implementation of antibiotic stewardship programs to local needs (while retaining its expert-based foundation). Electronic supplementary material The online version of this article (doi:10.1186/2047-2994-3-33) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Maarten van Limburg
- Department Psychology Health and Technology, Faculty Behavioral, Management and Social Sciences, University of Twente, Enschede, the Netherlands
| | - Bhanu Sinha
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Jerome R Lo-Ten-Foe
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Julia Ewc van Gemert-Pijnen
- Department Psychology Health and Technology, Faculty Behavioral, Management and Social Sciences, University of Twente, Enschede, the Netherlands
| |
Collapse
|
30
|
Borde JP, Kern WV, Hug M, Steib-Bauert M, de With K, Busch HJ, Kaier K. Implementation of an intensified antibiotic stewardship programme targeting third-generation cephalosporin and fluoroquinolone use in an emergency medicine department. Emerg Med J 2014; 32:509-15. [PMID: 25261006 DOI: 10.1136/emermed-2014-204067] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 08/29/2014] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Early initiation of antimicrobial treatment for acute infection is an important task in the emergency department (ED) with a likely impact on the hospital-wide antibiotic use pattern. We implemented an antibiotic stewardship (ABS) programme focused on non-trauma emergency patients at a large university hospital centre targeting broad-spectrum cephalosporin and fluoroquinolone use. METHODS Guidelines and focused discussion groups emphasised reduced prescription of third-generation cephalosporins and fluoroquinolones and encouraged penicillins. Antibiotic consumption expressed as monthly drug density in WHO-Anatomical Therapeutic Chemical defined and locally recommended daily doses (DDD and RDD) per 100 patient days was analysed before (January 2008 to October 2011) and after starting the intervention (January 2012 to October 2013). We performed a before-and-after uncontrolled interventional study using interrupted time-series (ITS) analysis in one ED to investigate ABS intervention-related effects in a quasiexperimental research setting. RESULTS The mean monthly total antibiotic use density declined from 111 RDD (138 DDD) per 100 patient days before the intervention to 86 RDD (128 DDD) per 100 patient days after starting the intervention. Among the different antibacterial drug classes, the consumption of third-generation cephalosporins showed the largest reduction and dropped significantly by -68% between preintervention and postintervention periods. Using the RDD dataset, ITS confirmed a highly significant postintervention change in level of third-generation cephalosporins (-15.2, 95% CI (-24.08 to -6.311)) and a corresponding increase in the use of aminopenicillin/betalactamase inhibitor formulations (+6.6, 95% CI (4.169 to 9.069)). The drug use densities for fluoroquinolones and for overall antibiotics declined, however, the postinterventional level changes missed statistical significance--overall (95% CI (-39.99 to 0.466), fluoroquinolones 95% CI (-11.72 to 4.333)). CONCLUSIONS An intensified ABS programme using non-restrictive tools targeting third-generation cephalosporin and fluoroquinolone use in the setting of a large academic hospital emergency medicine department is feasible and effective. The intervention may serve as a model for other emergency medicine departments at hospitals with a similar structure and baseline situation.
Collapse
Affiliation(s)
- Johannes P Borde
- Department of Medicine, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany
| | - Winfried V Kern
- Department of Medicine, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany
| | - Martin Hug
- Pharmacy Service, University Medical Center, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany
| | - Michaela Steib-Bauert
- Department of Medicine, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany
| | - Katja de With
- Department of Medicine, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Hans-Jörg Busch
- Department of Medicine, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany Department of Emergency Medicine, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Informatics, Universitätsklinikum Freiburg i.Br., Freiburg i.Br., Germany
| |
Collapse
|
31
|
Wang HY, Chiu CH, Huang CT, Cheng CW, Lin YJ, Hsu YJ, Chen CH, Deng ST, Leu HS. Blood culture-guided de-escalation of empirical antimicrobial regimen for critical patients in an online antimicrobial stewardship programme. Int J Antimicrob Agents 2014; 44:520-7. [PMID: 25306484 DOI: 10.1016/j.ijantimicag.2014.07.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 07/23/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
Abstract
A blood culture-guided review strategy was applied to a hospital-wide computerised antimicrobial approval system (HCAAS) at a medical centre in Taiwan. The study aimed to evaluate the impact of this deployment on prescribers' behaviours, antimicrobial consumption, antimicrobial expenditure and healthcare quality in adult intensive care units (ICUs). The HCAAS automatically identifies patients with positive blood cultures and notifies the pre-assigned infectious diseases (ID) physicians for an online second review of the current antimicrobial regimen. Patients from 16 adult ICUs were selected as a focus group. Descriptive analysis, McNemar's test, interrupted time-series analysis and univariate regression analysis were applied. The number of prescriptions assigned for second review increased from 304 in 2010 to 682 in 2012. The approval rate for the antimicrobial regimen in the second review exceeded 70%. In disapproved cases, prescribers accepted the recommendation from ID physicians in 66.1% of cases in the first year; the acceptance rate increased to 80.6% in 2012. Among the restricted antimicrobial agents, consumption gradients decreased for all eight drug classes. The overall antimicrobial expenditure gradient declined significantly following deployment of the second review strategy. The healthcare-associated infection rate continued to decrease over time, and the mortality and ICU re-admission rates remained stable after deployment. A blood culture-guided review of antimicrobial use based on clinical and microbiological evidence improves accuracy in choosing appropriate antimicrobial agents and encourages de-escalation. Consumption and expenditure gradients of antimicrobial agents decreased after the intervention, and healthcare quality was not compromised.
Collapse
Affiliation(s)
- Hsiu-Yin Wang
- Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Hsun Chiu
- Molecular Infectious Disease Research Centre, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Ching-Tai Huang
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chun-Wen Cheng
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Jr Lin
- Biostatistical Centre for Clinical Research, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ying-Jen Hsu
- Department of Management Information System, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Hua Chen
- Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shin-Tarng Deng
- Department of Pharmacy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsieh-Shong Leu
- Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| |
Collapse
|
32
|
Sood MM, Komenda P, Rigatto C, Hiebert B, Tangri N. The association of eGFR reporting with the timing of dialysis initiation. J Am Soc Nephrol 2014; 25:2097-104. [PMID: 24652801 DOI: 10.1681/asn.2013090953] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Automated reporting of eGFR by laboratories has been widely implemented during the last decade. Over this same period, a steady increase in eGFR at dialysis initiation has been reported. This study examined trends in eGFR at dialysis initiation over time among incident dialysis patient populations before and after eGFR reporting. All patients who initiated dialysis between January of 2001 and December of 2010 in four Canadian provinces that implemented province-wide automated eGFR reporting and had an eGFR measure at dialysis initiation were included in the study (n=22,208). The primary outcome was change over time in eGFR among patients at dialysis initiation. An interrupted time series and adjusted multilevel regression models were used to determine the differences in eGFR at dialysis initiation before and after reporting. We observed a linear increase in the mean eGFR at dialysis initiation from 9.1 to 10.8 ml/min per m(2) during the study period. There was no change in the trajectory of the eGFR at dialysis initiation before or after eGFR reporting in crude or adjusted models accounting for case mix and facility characteristics. These findings were consistent among age and sex strata and when the proportions of patients with an eGFR≥10.5 or ≥12 ml/min per m(2) were examined. In conclusion, automated laboratory-based eGFR reporting did not influence eGFR at dialysis initiation among incident dialysis patient populations. Concerns that widespread eGFR reporting leads to earlier dialysis initiation are not supported by this study.
Collapse
Affiliation(s)
- Manish M Sood
- The Ottawa Hospital Research Institute, The Ottawa Hospital, Civic Campus, University of Ottawa, Ottawa, Ontario, Canada;
| | - Paul Komenda
- Seven Oaks Hospital, University of Manitoba, Winnipeg, Manitoba, Canada; and
| | - Claudio Rigatto
- Seven Oaks Hospital, University of Manitoba, Winnipeg, Manitoba, Canada; and
| | - Brett Hiebert
- Cardiac Sciences, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Seven Oaks Hospital, University of Manitoba, Winnipeg, Manitoba, Canada; and
| |
Collapse
|
33
|
Thursky K. Use of computerized decision support systems to improve antibiotic prescribing. Expert Rev Anti Infect Ther 2014; 4:491-507. [PMID: 16771625 DOI: 10.1586/14787210.4.3.491] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This decade will see the emergence of the electronic medical record, electronic prescribing and computerized decision support in the hospital setting. Current opinion from key infectious diseases bodies supports the use of computerized decision support systems as potentially useful tools in antibiotic stewardship programs. However, although antibiotic decision support systems appear beneficial for improving the quality of prescribing and reducing the costs of antibiotic prescribing, their overall cost-effectiveness, impact on patient outcome and antimicrobial resistance is much less certain. This review describes computerized decision support systems used to assist with antibiotic prescribing, the evidence for their effectiveness and the current and future roles.
Collapse
Affiliation(s)
- Karin Thursky
- Infectious Diseases Physician, Centre for Clinical Research Excellence in Infectious Diseases, Victorian Infectious Diseases Service, Royal Melbourne Hospital, Grattan Street, Parkville, Victoria, 3051, Australia.
| |
Collapse
|
34
|
Boyles TH, Whitelaw A, Bamford C, Moodley M, Bonorchis K, Morris V, Rawoot N, Naicker V, Lusakiewicz I, Black J, Stead D, Lesosky M, Raubenheimer P, Dlamini S, Mendelson M. Antibiotic stewardship ward rounds and a dedicated prescription chart reduce antibiotic consumption and pharmacy costs without affecting inpatient mortality or re-admission rates. PLoS One 2013; 8:e79747. [PMID: 24348995 PMCID: PMC3857167 DOI: 10.1371/journal.pone.0079747] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 09/27/2013] [Indexed: 11/26/2022] Open
Abstract
Background Antibiotic consumption is a major driver of bacterial resistance. To address the increasing burden of multi-drug resistant bacterial infections, antibiotic stewardship programmes are promoted worldwide to rationalize antibiotic prescribing and conserve remaining antibiotics. Few studies have been reported from developing countries and none from Africa that report on an intervention based approach with outcomes that include morbidity and mortality. Methods An antibiotic prescription chart and weekly antibiotic stewardship ward round was introduced into two medical wards of an academic teaching hospital in South Africa between January-December 2012. Electronic pharmacy records were used to collect the volume and cost of antibiotics used, the patient database was analysed to determine inpatient mortality and 30-day re-admission rates, and laboratory records to determine use of infection-related tests. Outcomes were compared to a control period, January-December 2011. Results During the intervention period, 475.8 defined daily doses were prescribed per 1000 inpatient days compared to 592.0 defined daily doses/1000 inpatient days during the control period. This represents a 19.6% decrease in volume with a cost reduction of 35% of the pharmacy’s antibiotic budget. There was a concomitant increase in laboratory tests driven by requests for procalcitonin. There was no difference in inpatient mortality or 30-day readmission rate during the control and intervention periods. Conclusions Introduction of antibiotic stewardship ward rounds and a dedicated prescription chart in a developing country setting can achieve reduction in antibiotic consumption without harm to patients. Increased laboratory costs should be anticipated when introducing an antibiotic stewardship program.
Collapse
Affiliation(s)
- Tom H. Boyles
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Andrew Whitelaw
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
- Division of Medical Microbiology, University of Stellenbosch, Cape Town, South Africa
| | - Colleen Bamford
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Mischka Moodley
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Kim Bonorchis
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Vida Morris
- Quality Assurance, Groote Schuur Hospital, Cape Town, South Africa
| | | | | | | | - John Black
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - David Stead
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Maia Lesosky
- Department of General Medicine, University of Cape Town, Cape Town, South Africa
| | - Peter Raubenheimer
- Division of General Internal Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sipho Dlamini
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
- * E-mail:
| |
Collapse
|
35
|
Brett A, Bielicki J, Newland JG, Rodrigues F, Schaad UB, Sharland M. Neonatal and pediatric antimicrobial stewardship programs in Europe-defining the research agenda. Pediatr Infect Dis J 2013; 32:e456-65. [PMID: 23958812 DOI: 10.1097/inf.0b013e31829f0460] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The relationship between suboptimal use of antimicrobials and antimicrobial resistance has become increasingly clear. Despite significant international effort aimed at reducing inappropriate antimicrobial prescribing in hospitals, antimicrobial resistance remains a major public health threat. Antimicrobial Stewardship Programs (ASPs) comprise a series of measures aimed at optimizing the use of antimicrobials, while improving the quality of patient care and promoting cost-effectiveness. This discussion article aims to summarize some of the approaches that have been used in neonatal and pediatric ASPs, with a particular focus on the European healthcare setting. Current evidence demonstrates neonatal and pediatric ASPs to be safe, practical to implement, generally cost-effective and possibly associated with a reduction in antimicrobial resistance rates. This review identified that, despite the recognized need for additional evidence and information on implementation, published data on pediatric ASPs derives mainly from the United States, with very few published reports on formal ASPs in European children's hospitals. Consequently, the optimal method of implementation remains unknown within a European setting. Future research needs to include novel study designs on how best to introduce ASPs, monitoring of clinically relevant outcomes and cost-effectiveness with improved measurement of the impact on antimicrobial resistance.
Collapse
Affiliation(s)
- Ana Brett
- From the *Infectious Diseases Unit and Emergency Service, Hospital Pediátrico, Centro, Hospitalar e Universitário de Coimbra, Coimbra, Portugal; †Paediatric Infectious Diseases Research Group, St George's University London, London, United Kingdom; ‡Division of Pediatric Infectious Diseases, Children's Mercy Hospital and Clinics, University of Missouri-Kansas City, MO; and §Paediatric Infectious Diseases Division, University Children's Hospital, Basel, Switzerland
| | | | | | | | | | | |
Collapse
|
36
|
Impact of a program combining pre-authorization requirement and post-prescription review of carbapenems: an interrupted time-series analysis. Eur J Clin Microbiol Infect Dis 2013; 32:1599-604. [PMID: 23839593 DOI: 10.1007/s10096-013-1918-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 06/23/2013] [Indexed: 10/26/2022]
Abstract
The objective of this study was to assess the impact on carbapenems use of a program combining pre-authorization requirement and systematic post-prescription review of carbapenems prescriptions. The program was implemented in a 1,230-bed teaching tertiary hospital. Monthly carbapenems consumption was analyzed using a controlled interrupted time-series method and compared to that of vancomycin before and after implementation of the intervention. Compared to the pre-intervention period (14 monthly points), a significant and sustained decrease of carbapenems consumption [1.66 defined daily doses (DDD)/1,000 patient-days; p = 0.048] was observed during the intervention period (12 monthly points), despite an increasing trend in incidence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) isolates (0.02/1,000 patient-days per month; p = 0.093). As expected, vancomycin consumption was unaffected by the intervention. A total of 337 prescriptions were reviewed in the intervention period; most were microbiologically documented (81.3%; ESBL-PE: 39.2%). Three of four (76.6%) carbapenems prescriptions were modified within a median [interquartile range] of 2 [1; 4] days, either after infectious disease physician (IDP) advice (48.4%) or by ward physicians (28.2%). Most changes included de-escalating (52.2%) or reducing the planned duration (22.2%), which resulted in a median duration of treatment of only 3 [2; 7] days. The median length of stay and mortality rate were not influenced by the intervention. This reasonably practicable antimicrobial stewardship program including controlled delivery and systematic reevaluation of carbapenems prescriptions was able to reduce their use in our hospital, despite a rising ESBL-PE incidence.
Collapse
|
37
|
Schulz LT, Fox BC, Polk RE. Can the antibiogram be used to assess microbiologic outcomes after antimicrobial stewardship interventions? A critical review of the literature. Pharmacotherapy 2013; 32:668-76. [PMID: 23307516 DOI: 10.1002/j.1875-9114.2012.01163.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Hospitals are implementing antimicrobial stewardship programs (ASPs) in response to national guidelines to improve the use and to extend the utility of antiinfective drugs. An often implied purpose of ASPs is to curb or reverse the emergence of resistant bacteria. Because antibiotic use causes antibiotic resistance, there is a natural tendency to link local measures of antibiotic use to local measures of bacterial resistance, and the hospital antibiogram is a readily available measure of resistance. We performed a literature review to identify published reports that used hospitalwide and unit-specific antibiograms to assess the relationship of ASP interventions to changes in resistance. Eight studies were identified and reviewed. The relationship between hospital antibiotic use and resistance is complex, and the existing literature has several limitations. Furthermore, the antibiogram itself is neither designed nor well suited to reflect changes in hospital antimicrobial drug use. The literature on the effectiveness of ASPs in reducing resistance continues to emerge, but at this time the antibiogram bears an inconsistent relationship with changes in hospital antibiotic use and cannot be recommended to reliably evaluate an ASP intervention. Interrupted time series analysis is a superior strategy to assess the effect of an ASP intervention on bacterial resistance, but it is not widely used because of its complexity and greater data requirements. Nevertheless, before ASP efforts can be convincingly demonstrated to have a favorable impact on resistance, a more sophisticated approach that links drug use to resistance should become a priority, at least for hospitals that have sufficient resources.
Collapse
Affiliation(s)
- Lucas T Schulz
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, USA
| | | | | |
Collapse
|
38
|
Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ, Wilcox M. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013:CD003543. [PMID: 23633313 DOI: 10.1002/14651858.cd003543.pub3] [Citation(s) in RCA: 351] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The first publication of this review in Issue 3, 2005 included studies up to November 2003. This update adds studies to December 2006 and focuses on application of a new method for meta-analysis of interrupted time series studies and application of new Cochrane Effective Practice and Organisation of Care (EPOC) Risk of Bias criteria to all studies in the review, including those studies in the previously published version. The aim of the review is to evaluate the impact of interventions from the perspective of antibiotic stewardship. The two objectives of antibiotic stewardship are first to ensure effective treatment for patients with bacterial infection and second support professionals and patients to reduce unnecessary use and minimize collateral damage. OBJECTIVES To estimate the effectiveness of professional interventions that, alone or in combination, are effective in antibiotic stewardship for hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial-resistant pathogens or Clostridium difficile infection and their impact on clinical outcome. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE from 1980 to December 2006 and the EPOC specialized register in July 2007 and February 2009 and bibliographies of retrieved articles. The main comparison is between interventions that had a restrictive element and those that were purely persuasive. Restrictive interventions were implemented through restriction of the freedom of prescribers to select some antibiotics. Persuasive interventions used one or more of the following methods for changing professional behaviour: dissemination of educational resources, reminders, audit and feedback, or educational outreach. Restrictive interventions could contain persuasive elements. SELECTION CRITERIA We included randomized clinical trials (RCTs), controlled clinical trials (CCT), controlled before-after (CBA) and interrupted time series studies (ITS). Interventions included any professional or structural interventions as defined by EPOC. The intervention had to include a component that aimed to improve antibiotic prescribing to hospital inpatients, either by increasing effective treatment or by reducing unnecessary treatment. The results had to include interpretable data about the effect of the intervention on antibiotic prescribing or microbial outcomes or relevant clinical outcomes. DATA COLLECTION AND ANALYSIS Two authors extracted data and assessed quality. We performed meta-regression of ITS studies to compare the results of persuasive and restrictive interventions. Persuasive interventions advised physicians about how to prescribe or gave them feedback about how they prescribed. Restrictive interventions put a limit on how they prescribed; for example, physicians had to have approval from an infection specialist in order to prescribe an antibiotic. We standardized the results of some ITS studies so that they are on the same scale (percent change in outcome), thereby facilitating comparisons of different interventions. To do this, we used the change in level and change in slope to estimate the effect size with increasing time after the intervention (one month, six months, one year, etc) as the percent change in level at each time point. We did not extrapolate beyond the end of data collection after the intervention. The meta-regression was performed using standard weighted linear regression with the standard errors of the coefficients adjusted where necessary. MAIN RESULTS For this update we included 89 studies that reported 95 interventions. Of the 89 studies, 56 were ITSs (of which 4 were controlled ITSs), 25 were RCT (of which 5 were cluster-RCTs), 5 were CBAs and 3 were CCTs (of which 1 was a cluster-CCT).Most (80/95, 84%) of the interventions targeted the antibiotic prescribed (choice of antibiotic, timing of first dose and route of administration). The remaining 15 interventions aimed to change exposure of patients to antibiotics by targeting the decision to treat or the duration of treatment. Reliable data about impact on antibiotic prescribing data were available for 76 interventions (44 persuasive, 24 restrictive and 8 structural). For the persuasive interventions, the median change in antibiotic prescribing was 42.3% for the ITSs, 31.6% for the controlled ITSs, 17.7% for the CBAs, 3.5% for the cluster-RCTs and 24.7% for the RCTs. The restrictive interventions had a median effect size of 34.7% for the ITSs, 17.1% for the CBAs and 40.5% for the RCTs. The structural interventions had a median effect of 13.3% for the RCTs and 23.6% for the cluster-RCTs. Data about impact on microbial outcomes were available for 21 interventions but only 6 of these also had reliable data about impact on antibiotic prescribing.Meta-analysis of 52 ITS studies was used to compare restrictive versus purely persuasive interventions. Restrictive interventions had significantly greater impact on prescribing outcomes at one month (32%, 95% confidence interval (CI) 2% to 61%, P = 0.03) and on microbial outcomes at 6 months (53%, 95% CI 31% to 75%, P = 0.001) but there were no significant differences at 12 or 24 months. Interventions intended to decrease excessive prescribing were associated with reduction in Clostridium difficile infections and colonization or infection with aminoglycoside- or cephalosporin-resistant gram-negative bacteria, methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis. Meta-analysis of clinical outcomes showed that four interventions intended to increase effective prescribing for pneumonia were associated with significant reduction in mortality (risk ratio 0.89, 95% CI 0.82 to 0.97), whereas nine interventions intended to decrease excessive prescribing were not associated with significant increase in mortality (risk ratio 0.92, 95% CI 0.81 to 1.06). AUTHORS' CONCLUSIONS The results show that interventions to reduce excessive antibiotic prescribing to hospital inpatients can reduce antimicrobial resistance or hospital-acquired infections, and interventions to increase effective prescribing can improve clinical outcome. This update provides more evidence about unintended clinical consequences of interventions and about the effect of interventions to reduce exposure of patients to antibiotics. The meta-analysis supports the use of restrictive interventions when the need is urgent, but suggests that persuasive and restrictive interventions are equally effective after six months.
Collapse
Affiliation(s)
- Peter Davey
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK.
| | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Antoniadou A, Kanellakopoulou K, Kanellopoulou M, Polemis M, Koratzanis G, Papademetriou E, Poulakou G, Giannitsioti E, Souli M, Vatopoulos A, Giamarellou H. Impact of a hospital-wide antibiotic restriction policy program on the resistance rates of nosocomial Gram-negative bacteria. ACTA ACUST UNITED AC 2013; 45:438-45. [PMID: 23336730 DOI: 10.3109/00365548.2012.760845] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND To evaluate the impact of an antibiotic restriction policy on antibiotic consumption and Gram-negative resistance rates, in an environment of antibiotic overconsumption and increasing resistance rates for nosocomial pathogens. METHODS The study was a 'before and after' trial of 18-month duration; the antibiotic restriction policy program was implemented in 1998-2000 and was based on a government program addressed by the Ministry of Health to public hospitals on a national basis. This included prescribing of all newer antibiotics on an order form, auditing of the order forms and consultation with infectious diseases (ID) specialists, dispensing of treatment and prophylaxis guidelines, feedback, and face-to-face education. Antibiotic consumption and Gram-negative resistance rates were recorded before and after the intervention. RESULTS Despite the addition of a new 40-bed ID department in the hospital during the 'after' period, the consumption of restricted antibiotics was significantly reduced by 42% (and their cost by 31%). Gram-negative resistance rates for Pseudomonas, Klebsiella, and Enterobacter, serving as index microorganisms for Gram-negative nosocomial pathogens, were significantly reduced during the 'after' period, even against antibiotics for which there was an increase in consumption. CONCLUSIONS Multidisciplinary restriction programs can reduce antibiotic consumption and Gram-negative resistance rates in the hospital setting.
Collapse
Affiliation(s)
- Anastasia Antoniadou
- Fourth Department of Internal Medicine, University General Hospital Attikon, Greece
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Lesprit P, Landelle C, Brun-Buisson C. Clinical impact of unsolicited post-prescription antibiotic review in surgical and medical wards: a randomized controlled trial. Clin Microbiol Infect 2012; 19:E91-7. [PMID: 23153410 DOI: 10.1111/1469-0691.12062] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 09/11/2012] [Accepted: 09/29/2012] [Indexed: 12/29/2022]
Abstract
This study aimed to determine the clinical course of patients and the quality of antibiotic use using a systematic and unsolicited post-prescription antibiotic review. Seven hundred and fifty-three adult patients receiving antibiotic therapy for 3-5 days were randomized to receive either a post-prescription review by the infectious disease physician (IDP), followed by a recommendation to the attending physician to modify the prescription when appropriate, or no systematic review of the prescription. In the intervention group, 63.3% of prescriptions prompted IDP recommendations, which were mostly followed by ward physicians (90.3%). Early antibiotic modifications were more frequent in the intervention group (57.1% vs. 25.7%, p <0.0001), including stopping therapy, shortening duration and de-escalating broad-spectrum antibiotics. IDP intervention led to a significant reduction of the median [IQR] duration of antibiotic therapy (6 [4-9] vs. 7 days [5-9], p <0.0001). In-hospital mortality, ICU admission and new course of antibiotic therapy rates did not differ between the two groups. Fewer patients in the intervention group were readmitted for relapsing infection (3.4% vs. 7.9%, p 0.01). There was a trend for a shorter length of hospital stay in patients suffering from community-acquired infections in the intervention group (5 days [3-10] vs. 6 days [3-14], p 0.06). This study provides clinical evidence that a post-prescription antibiotic review followed by unsolicited IDP advice is effective in reducing antibiotic exposure of patients and increasing the quality of antibiotic use, and may reduce hospital stay and relapsing infection rates, with no adverse effects on other patient outcomes.
Collapse
Affiliation(s)
- P Lesprit
- Université Paris EST Créteil, Unité de Contrôle, Epidémiologie et Prévention de l'Infection, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Henri Mondor, Créteil, France.
| | | | | |
Collapse
|
41
|
Lépée C, Klaber RE, Benn J, Fletcher PJ, Cortoos PJ, Jacklin A, Franklin BD. The use of a consultant-led ward round checklist to improve paediatric prescribing: an interrupted time series study. Eur J Pediatr 2012; 171:1239-45. [PMID: 22628136 DOI: 10.1007/s00431-012-1751-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 05/02/2012] [Indexed: 11/28/2022]
Abstract
UNLABELLED A Check and Correct checklist has previously been developed to increase feedback on prescribing quality and enhance physicians' focus on patients' drug charts during ward rounds. Our objective was to assess the impact of introducing such a prescribing checklist on the quality and safety of inpatient prescribing in two paediatric wards in a London teaching hospital. Between 15 March 2011 and 15 May 2011 (pre-intervention) and between 23 May 2011 and 23 July 2011 (post-intervention), we recorded rates of both technical prescription writing errors and clinical prescribing errors twice a week. During the pre-intervention period, the overall technical error rate was 10.8 % (95 % confidence interval 10.3 %-11.2 %); the clinical error rate was 4.7 % (3.4 %-6.6 %). The most common errors were absence of prescriber's contact details and dose omissions. After the implementation of Check and Correct, error rates were 7.3 % (6.9 %-7.8 %) and 5.5 % (3.9 %-7.9 %), respectively. Segmented regression analysis revealed a significant decrease of -5.0 % in the technical error rate (-7.1 to -2.9 %; -37.7 % relative decrease; R (2) = 0.604) following the intervention, independent of changes in overall medical records' documentation quality. Regarding clinical errors, no significant impact of the intervention could be detected. CONCLUSION Implementing a Check and Correct checklist led to an improvement in the quality of prescription writing. Although a change in culture may be needed to maximise its potential, we would recommend its more widespread use and evaluation.
Collapse
Affiliation(s)
- Carole Lépée
- Sciences du Risque dans le domaine de la Santé, Faculté de Pharmacie, Université d'Auvergne, Clermont-Ferrand, France
| | | | | | | | | | | | | |
Collapse
|
42
|
Ashiru-Oredope D, Sharland M, Charani E, McNulty C, Cooke J. Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: Start Smart--Then Focus. J Antimicrob Chemother 2012; 67 Suppl 1:i51-63. [DOI: 10.1093/jac/dks202] [Citation(s) in RCA: 172] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
|
43
|
Piening S, Haaijer-Ruskamp FM, de Vries JT, van der Elst ME, de Graeff PA, Straus SM, Mol PG. Impact of Safety-Related Regulatory Action on Clinical Practice. Drug Saf 2012; 35:373-85. [DOI: 10.2165/11599100-000000000-00000] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
|
44
|
Rodríguez-Baño J, Paño-Pardo JR, Alvarez-Rocha L, Asensio Á, Calbo E, Cercenado E, Cisneros JM, Cobo J, Delgado O, Garnacho-Montero J, Grau S, Horcajada JP, Hornero A, Murillas-Angoiti J, Oliver A, Padilla B, Pasquau J, Pujol M, Ruiz-Garbajosa P, San Juan R, Sierra R. Programas de optimización de uso de antimicrobianos (PROA) en hospitales españoles: documento de consenso GEIH-SEIMC, SEFH y SEMPSPH. Enferm Infecc Microbiol Clin 2012; 30:22.e1-22.e23. [DOI: 10.1016/j.eimc.2011.09.018] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 09/22/2011] [Accepted: 09/27/2011] [Indexed: 01/12/2023]
|
45
|
Rodríguez-Baño J, Paño-Pardo JR, Alvarez-Rocha L, Asensio Á, Calbo E, Cercenado E, Cisneros JM, Cobo J, Delgado O, Garnacho-Montero J, Grau S, Horcajada JP, Hornero A, Murillas-Angoiti J, Oliver A, Padilla B, Pasquau J, Pujol M, Ruiz-Garbajosa P, San Juan R, Sierra R. [Programs for optimizing the use of antibiotics (PROA) in Spanish hospitals: GEIH-SEIMC, SEFH and SEMPSPH consensus document]. FARMACIA HOSPITALARIA 2011; 36:33.e1-30. [PMID: 22137161 DOI: 10.1016/j.farma.2011.10.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Accepted: 10/18/2011] [Indexed: 11/28/2022] Open
Abstract
The antimicrobial agents are unique drugs for several reasons. First, their efficacy is higher than other drugs in terms of reduction of morbidity and mortality. Also, antibiotics are the only group of drugs associated with ecological effects, because their administration may contribute to the emergence and spread of microbial resistance. Finally, they are used by almost all medical specialties. Appropriate use of antimicrobials is very complex because of the important advances in the management of infectious diseases and the spread of antibiotic resistance. Thus, the implementation of programs for optimizing the use of antibiotics in hospitals (called PROA in this document) is necessary. This consensus document defines the objectives of the PROA (namely, to improve the clinical results of patients with infections, to minimise the adverse events associated to the use of antimicrobials including the emergence and spread of antibiotic resistance, and to ensure the use of the most cost-efficacious treatments), and provides recommendations for the implementation of these programs in Spanish hospitals. The key aspects of the recommendations are as follows. Multidisciplinary antibiotic teams should be formed, under the auspices of the Infection Committees. The PROA need to be considered as part of institutional programs and the strategic objectives of the hospital. The PROA should include specific objectives based on measurable indicators, and activities aimed at improving the use of antimicrobials, mainly through educational activities and interventions based more on training activities directed to prescribers than just on restrictive measures.
Collapse
Affiliation(s)
- J Rodríguez-Baño
- Unidad Clínica de Enfermedades Infecciosas y Microbiología, Hospital Universitario Virgen Macarena, Departamento de Medicina, Universidad de Sevilla, Sevilla, España.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
A large sustained endemic outbreak of multiresistant Pseudomonas aeruginosa: a new epidemiological scenario for nosocomial acquisition. BMC Infect Dis 2011; 11:272. [PMID: 21995287 PMCID: PMC3203071 DOI: 10.1186/1471-2334-11-272] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 10/13/2011] [Indexed: 11/16/2022] Open
Abstract
Background Studies of recent hospital outbreaks caused by multiresistant P.aeruginosa (MRPA) have often failed to identify a specific environmental reservoir. We describe an outbreak due to a single clone of multiresistant (MR) Pseudomonas aeruginosa (PA) and evaluate the effectiveness of the surveillance procedures and control measures applied. Methods Patients with MRPA isolates were prospectively identified (January 2006-May 2008). A combined surveillance procedure (environmental survey, and active surveillance program in intensive care units [ICUs]) and an infection control strategy (closure of ICU and urology wards for decontamination, strict compliance with cross-transmission prevention protocols, and a program restricting the use of carbapenems in the ICUs) was designed and implemented. Results Three hundred and ninety patients were identified. ICU patients were the most numerous group (22%) followed by urology patients (18%). Environmental surveillance found that 3/19 (16%) non-ICU environmental samples and 4/63 (6%) ICU samples were positive for the MRPA clonal strain. In addition, active surveillance found that 19% of patients were fecal carriers of MRPA. Significant changes in the trends of incidence rates were noted after intervention 1 (reinforcement of cleaning procedures): -1.16 cases/1,000 patient-days (95%CI -1.86 to -0.46; p = 0.003) and intervention 2 (extensive decontamination): -1.36 cases/1,000 patient-days (95%CI -1.88 to -0.84; p < 0.001) in urology wards. In addition, restricted use of carbapenems was initiated in ICUs (January 2007), and their administration decreased from 190-170 DDD/1,000 patient-days (October-December 2006) to 40-60 DDD/1,000 patient-days (January-April 2007), with a reduction from 3.1 cases/1,000 patient-days in December 2006 to 2.0 cases/1,000 patient-days in May 2007. The level of initial carbapenem use rose again during 2008, and the incidence of MRPA increased progressively once more. Conclusions In the setting of sustained MRPA outbreaks, epidemiological findings suggest that patients may be a reservoir for further environmental contamination and cross-transmission. Although our control program was not successful in ending the outbreak, we think that our experience provides useful guidance for future approaches to this problem.
Collapse
|
47
|
Chan YY, Lin TY, Huang CT, Deng ST, Wu TL, Leu HS, Chiu CH. Implementation and outcomes of a hospital-wide computerised antimicrobial stewardship programme in a large medical centre in Taiwan. Int J Antimicrob Agents 2011; 38:486-92. [PMID: 21982143 DOI: 10.1016/j.ijantimicag.2011.08.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Revised: 07/05/2011] [Accepted: 08/08/2011] [Indexed: 10/16/2022]
Abstract
Antibiotic stewardship is important to address the problem of antimicrobial resistance, but a practical and sustainable strategy to provide stewardship in a large hospital setting is lacking. We developed a hospital-wide computerised antimicrobial approval system (HCAAS) to guide the use of antimicrobial agents in late 2004 in a 3500-bed medical centre in Taiwan. The objective of this study was to evaluate the impacts of HCAAS on the hospital from 2003 to 2009. Following HCAAS deployment, the gradients of consumption over time during the study period of third- and fourth-generation cephalosporins, fluoroquinolones and glycopeptides fell significantly, whilst that of carbapenems increased. The amount and expenditure of antimicrobial use did not increase with the overall healthcare-associated infection rate, and inpatient mortality rate remained stable with a slight decreasing trend. The rate of meticillin-resistant Staphylococcus aureus started to decline in 2002 and continued after HCAAS deployment. There was an increasing isolation of extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae, presumably leading to the increased use of carbapenems. The isolation rate of Clostridium difficile from patients who developed diarrhoea after antimicrobial therapy did not change over the years, with a mean annual rate of 10.0% after the implementation of HCAAS. HCAAS along with strict infection control measures is necessary to reduce the spread of resistant organisms within the hospital. HCAAS is a sustainable system for providing antibiotic stewardship and exerts a positive impact on the hospital by reducing antimicrobial consumption and expenditure whilst not compromising healthcare quality.
Collapse
Affiliation(s)
- Yuk-Ying Chan
- Department of Pharmacy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | | | | | | | | | | | | |
Collapse
|
48
|
Pulcini C, Dellamonica J, Bernardin G, Molinari N, Sotto A. Impact of an intervention designed to improve the documentation of the reassessment of antibiotic therapies in an intensive care unit. Med Mal Infect 2011; 41:546-52. [PMID: 21855239 DOI: 10.1016/j.medmal.2011.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 03/19/2011] [Accepted: 07/06/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The study objectives were: (i) to design an intervention to improve the written documentation of empiric antibiotic prescriptions' reassessment; (ii) and to assess the impact of this intervention on the quality of prescriptions. PATIENTS AND METHODS A prospective before and after 7-month intervention study in a medical ICU in a French teaching hospital, using interrupted time-series analysis. The intervention was made to improve the documentation of four process measures in medical records: antibiotic plan, reviewing the diagnosis, adapting to positive microbiological results, and IV-per os switch. RESULTS One hundred and fourteen antibiotic prescriptions were assessed, 62 before and 52 after the intervention. The reassessment of antibiotic prescriptions was more often documented in the ICU after the intervention (P=0.03 for sudden change). The prevalence of appropriate antibiotic prescriptions was not statistically different before and after the intervention, either for sudden change and/or linear trend. CONCLUSION A better documentation of antibiotic prescriptions' reassessment was achieved in this ICU, but it did not improve the quality of antibiotic prescriptions.
Collapse
Affiliation(s)
- C Pulcini
- Service d'infectiologie, hôpital l'Archet-1, centre hospitalier universitaire de Nice, 151 route Saint-Antoine-de-Ginestière, Nice cedex 3, France.
| | | | | | | | | |
Collapse
|
49
|
Benko R, Matuz M, Peto Z, Bogár L, Viola R, Doró P, Soós G, Hajdú E. Variations and determinants of antibiotic consumption in Hungarian adult intensive care units. Pharmacoepidemiol Drug Saf 2011; 21:104-9. [PMID: 21796720 DOI: 10.1002/pds.2192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 04/18/2011] [Accepted: 05/25/2011] [Indexed: 01/18/2023]
Abstract
PURPOSE The aim of this work was to study the use of systemic antibacterials and its possible determinants in Hungarian intensive care units (ICUs). METHODS Hospital pharmacy. departments provided package level dispensing data for their corresponding ICU (2006). Data were converted into defined daily doses (DDDs) and expressed as DDD per 100 patient-days and DDD per 100 admissions. Antibiotics were ranked by volume of DDDs, and the agents responsible for 90% of total use (DU90%) were noted. To explore differences and relationships between antibiotic use and antibiotic policy elements/ICU characteristics, the analysis of variances or the Pearson correlation analysis was performed. RESULTS Valid data were obtained for 44 ICUs. Antibiotic use varied widely (from 27.9 to 167.8 DDD per 100 patient-days and from 104.7 to 1784.6 DDD per 100 admissions). In total, 11-34 different antibacterials per ICUs were used, of which, 5-15 were in the DU90% segment. The proportional use of parenteral agents ranged from 46.2 to 98.3%. The mean of overall antibiotic use was highest for penicillins with beta-lactamase inhibitors, followed by quinolones and third-generation cephalosporins. Of the studied factors, only the ICU category (i.e., level of care) showed significant association with total antibacterial use. CONCLUSIONS The striking differences in total antibiotic use and the extensive use of the oral agents in some ICUs may indicate room for improvement. As none of the antibiotic policy elements were accompanied by lower antibiotic use in the pooled analysis, it suggests that--beside the ICU category--other unrevealed factors determine antibiotic use.
Collapse
Affiliation(s)
- Ria Benko
- Department of Clinical Pharmacy, University of Szeged, Szeged, Hungary.
| | | | | | | | | | | | | | | |
Collapse
|
50
|
Bornard L, Dellamonica J, Hyvernat H, Girard-Pipau F, Molinari N, Sotto A, Roger PM, Bernardin G, Pulcini C. Impact of an assisted reassessment of antibiotic therapies on the quality of prescriptions in an intensive care unit. Med Mal Infect 2011; 41:480-5. [PMID: 21778026 DOI: 10.1016/j.medmal.2010.12.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2010] [Revised: 12/01/2010] [Accepted: 12/10/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The study's objective was to assess the impact of a professional multifaceted intervention designed to improve the quality of inpatient empirical therapeutic antibiotic courses at the time of their reassessment, i.e. 24 to 96 hours after treatment initiation. DESIGN We conducted a 5-month prospective pre- and post-intervention study in a medical Intensive Care Unit (ICU) in a teaching hospital, using time-series analysis. The intervention was a multifaceted professional intervention combining systematic 3-weekly visits of an infectious diseases specialist to discuss all antibiotic therapies, interactive teaching courses, and daily contact with a microbiologist. RESULTS Eighty-one antibiotic prescriptions were assessed, 37 before and 44 after the intervention. The prevalence of adequate antibiotic prescriptions was high and not statistically different before and after the intervention (73% vs. 80%, P=0.31), both for sudden change (P=0.67) and linear trend (P=0.055), using interrupted time-series analysis. The intervention triggered a more frequent reassessment of the diagnosis between day 2 and day 4 (11% vs. 32%, P=0.02) and slightly improved the adaptation of antibiotic therapies to positive microbiology (25% before vs. 50% after, P=0.18). CONCLUSIONS Our multifaceted intervention may have improved the quality of antibiotic therapies around day 3 of prescription, but the difference did not reach statistical significance, possibly because of a ceiling effect.
Collapse
Affiliation(s)
- L Bornard
- Service de réanimation médicale, hôpital l'Archet-1, CHU de Nice, 151 route Saint-Antoine-de-Ginestière, Nice cedex 3, France
| | | | | | | | | | | | | | | | | |
Collapse
|