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Gashegu M, Gahamanyi N, Ndayambaje FX, Munyemana JB, Ndahindwa V, Lukwago F, Ingabire L, Gambanga F, Gashema P, Tuyishime A, Dzinamarira T, Dukundane D, Muvunyi TZ, Muvunyi CM. Exploring Prescription Practices: Insights from an Antimicrobial Stewardship Program at a Tertiary Healthcare Facility, Rwanda. Antibiotics (Basel) 2024; 13:548. [PMID: 38927214 PMCID: PMC11200619 DOI: 10.3390/antibiotics13060548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 05/25/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024] Open
Abstract
Antimicrobial resistance (AMR) is a major public health threat linked to increased morbidity and mortality. It has the potential to return us to the pre-antibiotic era. Antimicrobial stewardship (AMS) programs are recognized as a key intervention to improve antimicrobial use and combat AMR. However, implementation of AMS remains limited in Africa, particularly in Rwanda. This study aimed to assess prescription practices, identify areas for improvement, and promote adherence to AMS principles. Conducted at King Faisal Hospital in Rwanda, this qualitative study used semi-structured interviews with eight participants until saturation was reached. The interviews were recorded, transcribed, and thematically analyzed, revealing four emerging themes. The first theme was on AMS activities that were working well based on availability of microbiology laboratory results and prescription guidelines as factors influencing antibiotic prescription adjustments. The second theme was related to challenges during the implementation of the AMS program, including the prescription of broad-spectrum antibiotics, limited local data on AMR patterns, and stock-outs of essential antibiotics. The third theme was on the importance of adhering to AMR management guidelines at KFH. The last emerged on recommendations from participants centered on regular training for healthcare workers, widespread dissemination of AMR findings across departments, and the enforcement of antibiotic restriction policies. These actions can improve prescription behaviors, upholding the highest standards of patient care, and strengthening the nascent AMS program.
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Affiliation(s)
- Misbah Gashegu
- Rwanda Biomedical Centre, Kigali P.O. Box 7162, Rwanda; (M.G.); (N.G.); (A.T.)
| | - Noel Gahamanyi
- Rwanda Biomedical Centre, Kigali P.O. Box 7162, Rwanda; (M.G.); (N.G.); (A.T.)
- Biology Department, College of Science and Technology, University of Rwanda, Kigali P.O. Box 3900, Rwanda
| | - François Xavier Ndayambaje
- Department of Microbiology and Parasitology, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali P.O. Box 3286, Rwanda; (F.X.N.); (J.B.M.)
| | - Jean Bosco Munyemana
- Department of Microbiology and Parasitology, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali P.O. Box 3286, Rwanda; (F.X.N.); (J.B.M.)
| | - Vedaste Ndahindwa
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali P.O. Box 3286, Rwanda;
| | - Fredrick Lukwago
- King Faisal Hospital, Kigali P.O Box 2534, Rwanda; (F.L.); (L.I.); (D.D.)
| | - Lambert Ingabire
- King Faisal Hospital, Kigali P.O Box 2534, Rwanda; (F.L.); (L.I.); (D.D.)
| | - Fiona Gambanga
- Clinton Health Access Initiative, Kigali P.O. Box 4062, Rwanda;
| | - Pierre Gashema
- Repolicy Research Centre, Kigali P.O. Box 7584, Rwanda;
- College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh EH8 9YL, UK
| | - Albert Tuyishime
- Rwanda Biomedical Centre, Kigali P.O. Box 7162, Rwanda; (M.G.); (N.G.); (A.T.)
| | - Tafadzwa Dzinamarira
- International Centre for AIDS Care and Treatment Program, ICAP, Lusaka P.O. Box 34358, Zambia;
| | - Damas Dukundane
- King Faisal Hospital, Kigali P.O Box 2534, Rwanda; (F.L.); (L.I.); (D.D.)
| | | | - Claude Mambo Muvunyi
- Rwanda Biomedical Centre, Kigali P.O. Box 7162, Rwanda; (M.G.); (N.G.); (A.T.)
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali P.O. Box 3286, Rwanda;
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Otaigbe II. Achieving universal health coverage in low- and middle-income countries through digital antimicrobial stewardship. Front Digit Health 2023; 5:1298861. [PMID: 38162693 PMCID: PMC10757329 DOI: 10.3389/fdgth.2023.1298861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Affiliation(s)
- Idemudia Imonikhe Otaigbe
- Department of Medical Microbiology, School of Basic Clinical Sciences, Benjamin Carson (Snr) College of Health & Medical Sciences, Babcock University/Babcock University Teaching Hospital, Ilishan Remo, Ogun State, Nigeria
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Villaverde S, Caro JM, Domínguez-Rodríguez S, Orellana MÁ, Rojo P, Epalza C, Blázquez-Gamero D. PACTA-Ped: Antimicrobial stewardship programme in a tertiary care hospital in Spain. An Pediatr (Barc) 2023; 99:312-320. [PMID: 37891136 DOI: 10.1016/j.anpede.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 09/12/2023] [Indexed: 10/29/2023] Open
Abstract
INTRODUCTION Fighting against antimicrobial resistance is a current priority, and further efforts need to be made to improve antimicrobial prescribing and reduce the spread of infections in paediatric care settings. METHODS We conducted a prospective longitudinal study on the use of antimicrobials from the time the antimicrobial stewardship programme (ASP) was introduced in January 2016 to December 2017 (period 2 [P2]) in our children's hospital. We compared the obtained results on antimicrobial prescribing with retrospective data from the period preceding the introduction of the ASP (2014-2015, period 1 [P1]). The sample consisted of paediatric inpatients who received broad-spectrum antimicrobials, antifungals or intravenous antibiotherapy lasting more than 5 days. We compared the use of antimicrobials in P1 versus P2. RESULTS A total of 160 patients were included during P2. The antibiotics for which a recommendation was made most frequently were meropenem (41.6%) and cefotaxime (23.4%). In 45% of care episodes, the consultant recommended "no change" to the prescribed antimicrobial. The final rate of acceptance of received recommendations by the prescribing physicians was 89%. We found average decreases of 27.8% in the days of treatment per 1000 inpatient days and 22.9% in the number of antimicrobial starts per 1000 admissions in P2. The use of carbapenems, cephalosporins and glycopeptides decreased in P2 compared to P1. The average annual cost of antimicrobial treatment decreased from є150 356/year during P1 to є98 478/year in P2. CONCLUSION Our ASP achieved a significant decrease in the use of broad-spectrum antibiotics and antifungals. The costs associated with antimicrobial prescribing decreased following the introduction of the ASP, which was a cost-effective action in this study period.
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Affiliation(s)
- Serena Villaverde
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.
| | - José Manuel Caro
- Department of Pharmacy, Hospital Universitario 12 de Octubre, Madrid, Spain; Antimicrobial Stewardship Programme, Hospital 12 de Octubre, Madrid, Spain
| | - Sara Domínguez-Rodríguez
- Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
| | - María Ángeles Orellana
- Antimicrobial Stewardship Programme, Hospital 12 de Octubre, Madrid, Spain; Department of Microbiology, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Pablo Rojo
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Cristina Epalza
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain; Antimicrobial Stewardship Programme, Hospital 12 de Octubre, Madrid, Spain
| | - Daniel Blázquez-Gamero
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
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Giamarellou H, Galani L, Karavasilis T, Ioannidis K, Karaiskos I. Antimicrobial Stewardship in the Hospital Setting: A Narrative Review. Antibiotics (Basel) 2023; 12:1557. [PMID: 37887258 PMCID: PMC10604258 DOI: 10.3390/antibiotics12101557] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
The increasing global threat of antibiotic resistance, which has resulted in countless fatalities due to untreatable infections, underscores the urgent need for a strategic action plan. The acknowledgment that humanity is perilously approaching the "End of the Miracle Drugs" due to the unjustifiable overuse and misuse of antibiotics has prompted a critical reassessment of their usage. In response, numerous relevant medical societies have initiated a concerted effort to combat resistance by implementing antibiotic stewardship programs within healthcare institutions, grounded in evidence-based guidelines and designed to guide antibiotic utilization. Crucial to this initiative is the establishment of multidisciplinary teams within each hospital, led by a dedicated Infectious Diseases physician. This team includes clinical pharmacists, clinical microbiologists, hospital epidemiologists, infection control experts, and specialized nurses who receive intensive training in the field. These teams have evidence-supported strategies aiming to mitigate resistance, such as conducting prospective audits and providing feedback, including the innovative 'Handshake Stewardship' approach, implementing formulary restrictions and preauthorization protocols, disseminating educational materials, promoting antibiotic de-escalation practices, employing rapid diagnostic techniques, and enhancing infection prevention and control measures. While initial outcomes have demonstrated success in reducing resistance rates, ongoing research is imperative to explore novel stewardship interventions.
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Affiliation(s)
- Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Lamprini Galani
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Theodoros Karavasilis
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Konstantinos Ioannidis
- Clinical Pharmacists, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece;
| | - Ilias Karaiskos
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
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Schinas G, Polyzou E, Spernovasilis N, Gogos C, Dimopoulos G, Akinosoglou K. Preventing Multidrug-Resistant Bacterial Transmission in the Intensive Care Unit with a Comprehensive Approach: A Policymaking Manual. Antibiotics (Basel) 2023; 12:1255. [PMID: 37627675 PMCID: PMC10451180 DOI: 10.3390/antibiotics12081255] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/27/2023] Open
Abstract
Patients referred to intensive care units (ICU) commonly contract infections caused by multidrug-resistant (MDR) bacteria, which are typically linked to complications and high mortality. There are numerous independent factors that are associated with the transmission of these pathogens in the ICU. Preventive multilevel measures that target these factors are of great importance in order to break the chain of transmission. In this review, we aim to provide essential guidance for the development of robust prevention strategies, ultimately ensuring the safety and well-being of patients and healthcare workers in the ICU. We discuss the role of ICU personnel in cross-contamination, existing preventative measures, novel technologies, and strategies employed, along with antimicrobial surveillance and stewardship (AMSS) programs, to construct effective and thoroughly described policy recommendations. By adopting a multifaceted approach that combines targeted interventions with broader preventive strategies, healthcare facilities can create a more coherent line of defense against the spread of MDR pathogens. These recommendations are evidence-based, practical, and aligned with the needs and realities of the ICU setting. In conclusion, this comprehensive review offers a blueprint for mitigating the risk of MDR bacterial transmission in the ICU, advocating for an evidence-based, multifaceted approach.
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Affiliation(s)
- Georgios Schinas
- Department of Medicine, University of Patras, 26504 Patras, Greece; (G.S.); (E.P.); (C.G.); (K.A.)
| | - Elena Polyzou
- Department of Medicine, University of Patras, 26504 Patras, Greece; (G.S.); (E.P.); (C.G.); (K.A.)
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Patras, Greece
| | | | - Charalambos Gogos
- Department of Medicine, University of Patras, 26504 Patras, Greece; (G.S.); (E.P.); (C.G.); (K.A.)
| | - George Dimopoulos
- 3rd Department of Critical Care, Evgenidio Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Karolina Akinosoglou
- Department of Medicine, University of Patras, 26504 Patras, Greece; (G.S.); (E.P.); (C.G.); (K.A.)
- Department of Internal Medicine and Infectious Diseases, University General Hospital of Patras, 26504 Patras, Greece
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Trotter NE, Slight SP, Karimi R, Bates DW, Sheikh A, Weir C, Tolley CL. The effect of digital antimicrobial stewardship programmes on antimicrobial usage, length of stay, mortality and cost. INFORMATICS IN MEDICINE UNLOCKED 2023. [DOI: 10.1016/j.imu.2023.101183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Reynolds D, Burnham JP, Vazquez Guillamet C, McCabe M, Yuenger V, Betthauser K, Micek ST, Kollef MH. The threat of multidrug-resistant/extensively drug-resistant Gram-negative respiratory infections: another pandemic. Eur Respir Rev 2022; 31:31/166/220068. [PMID: 36261159 DOI: 10.1183/16000617.0068-2022] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/09/2022] [Indexed: 12/22/2022] Open
Abstract
Antibiotic resistance is recognised as a global threat to human health by national healthcare agencies, governments and medical societies, as well as the World Health Organization. Increasing resistance to available antimicrobial agents is of concern for bacterial, fungal, viral and parasitic pathogens. One of the greatest concerns is the continuing escalation of antimicrobial resistance among Gram-negative bacteria resulting in the endemic presence of multidrug-resistant (MDR) and extremely drug-resistant (XDR) pathogens. This concern is heightened by the identification of such MDR/XDR Gram-negative bacteria in water and food sources, as colonisers of the intestine and other locations in both hospitalised patients and individuals in the community, and as agents of all types of infections. Pneumonia and other types of respiratory infections are among the most common infections caused by MDR/XDR Gram-negative bacteria and are associated with high rates of mortality. Future concerns are already heightened due to emergence of resistance to all existing antimicrobial agents developed in the past decade to treat MDR/XDR Gram-negative bacteria and a scarcity of novel agents in the developmental pipeline. This clinical scenario increases the likelihood of a future pandemic caused by MDR/XDR Gram-negative bacteria.
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Affiliation(s)
- Daniel Reynolds
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jason P Burnham
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Mikaela McCabe
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Valerie Yuenger
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Kevin Betthauser
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Scott T Micek
- Dept of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, MO, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Elsawah H, Samir A, Elrazzaz M, Ramadan A, Elnaggar A, Taema K. Carbapenems consumption and Klebsiella resistance in intensive care units in Egypt: A study to evaluate the effect of an antimicrobial stewardship program. J Infect Prev 2022; 23:142-148. [PMID: 37256159 PMCID: PMC10226057 DOI: 10.1177/17571774211060436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 08/31/2021] [Indexed: 09/20/2023] Open
Abstract
Background The high prevalence of carbapenem-resistant Klebsiella imposes optimizing antibiotic consumption. We aimed to evaluate the impact of antibiotic stewardship program on carbapenem consumption and the Klebsiella resistance. Method We retrospectively evaluated critically ill patients with isolated Klebsiella species from Elaraby hospital, Egypt during the period from April 2017 to January 2019. We collected data related to carbapenems consumption and Klebsiella clinical isolates with their antimicrobial susceptibility. Based on susceptibility, Klebsiella isolates were classified into sensitive, extended spectrum beta-lactamase (ESBL) producer, and carbapenem-resistant Klebsiella (CRK), respectively. Our primary outcome was the change in carbapenems consumption after implementing the program, while the secondary outcomes were the changes in the incidence of CRK. Results The study included 205 patients with isolated Klebsiella species during the study period. The antibiotic stewardship program started in March 2018. Out of the 205 patients, 61 patients (29.8%) represented the pre-intervention sample, and 144 patients (70.2%) represented the post-intervention sample. Applying the antibiotic stewardship program was associated with a significant decrease in the carbapenems consumption from 38.9 to 26.6 defined daily dose/1000 patient-days (p = 0.02). The incidence of CRK was decreased from 85.25% of total Klebsiella isolates to 48.6% (p < 0.001). Klebsiella species were more likely to be in a lower category of resistance after applying the program with an odds ratio of 6.3 (2.88-13.73) using ordinal logistic regression. Conclusion Applying the antibiotic stewardship program could reduce the unnecessary carbapenems use in the ICU with a subsequent decrease in the emergence of the Klebsiella-resistant strains.
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Affiliation(s)
- Hozaifa Elsawah
- Biostatistics Department, High Institute of Public Health, Alexandria University, Egypt
| | | | | | | | | | - Khaled Taema
- Critical Care Department, Kasr Alainy Hospitals, Cairo University, Egypt
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Corbin CK, Sung L, Chattopadhyay A, Noshad M, Chang A, Deresinksi S, Baiocchi M, Chen JH. Personalized antibiograms for machine learning driven antibiotic selection. COMMUNICATIONS MEDICINE 2022; 2:38. [PMID: 35603264 PMCID: PMC9053259 DOI: 10.1038/s43856-022-00094-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 02/25/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Background
The Centers for Disease Control and Prevention identify antibiotic prescribing stewardship as the most important action to combat increasing antibiotic resistance. Clinicians balance broad empiric antibiotic coverage vs. precision coverage targeting only the most likely pathogens. We investigate the utility of machine learning-based clinical decision support for antibiotic prescribing stewardship.
Methods
In this retrospective multi-site study, we developed machine learning models that predict antibiotic susceptibility patterns (personalized antibiograms) using electronic health record data of 8342 infections from Stanford emergency departments and 15,806 uncomplicated urinary tract infections from Massachusetts General Hospital and Brigham & Women’s Hospital in Boston. We assessed the trade-off between broad-spectrum and precise antibiotic prescribing using linear programming.
Results
We find in Stanford data that personalized antibiograms reallocate clinician antibiotic selections with a coverage rate (fraction of infections covered by treatment) of 85.9%; similar to clinician performance (84.3% p = 0.11). In the Boston dataset, the personalized antibiograms coverage rate is 90.4%; a significant improvement over clinicians (88.1% p < 0.0001). Personalized antibiograms achieve similar coverage to the clinician benchmark with narrower antibiotics. With Stanford data, personalized antibiograms maintain clinician coverage rates while narrowing 69% of empiric vancomycin+piperacillin/tazobactam prescriptions to piperacillin/tazobactam. In the Boston dataset, personalized antibiograms maintain clinician coverage rates while narrowing 48% of ciprofloxacin to trimethoprim/sulfamethoxazole.
Conclusions
Precision empiric antibiotic prescribing with personalized antibiograms could improve patient safety and antibiotic stewardship by reducing unnecessary use of broad-spectrum antibiotics that breed a growing tide of resistant organisms.
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Polidori P, Leonardi Vinci D, Adami S, Bianchi S, Faggiano ME, Provenzani A. Role of the hospital pharmacist in an Italian antimicrobial stewardship programme. Eur J Hosp Pharm 2022; 29:95-100. [PMID: 32900820 PMCID: PMC8899682 DOI: 10.1136/ejhpharm-2020-002242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/21/2020] [Accepted: 06/08/2020] [Indexed: 11/04/2022] Open
Abstract
The inappropriate use of antimicrobial agents is contributing to an increasing phenomenon of bacterial resistance. For this reason, there is a growing interest in 'antimicrobial stewardship', a series of coordinated and multidisciplinary interventions aimed to promote the safe and appropriate use of antimicrobials in which the pharmacist's contribution is necessary for the optimal choice of drug, dose, duration of therapy and the implementation of cost containment strategies. AIM OF THE STUDY We wanted to create a reference model and a specific training manual on antibiotic stewardship to introduce the role of the department pharmacist with specific infection disease skills in the Italian health system hospitals. METHODS This study was conducted in six Italian hospitals for 24 months. It was divided into three phases: definition of indicators (as defined daily doses/100 days of hospitalisation, switches from intravenous (IV) to oral and from empirical to targeted therapies, etc) elaboration of research protocol; sharing, application and detection of the indicators and selection of centres involved; analysis and sharing of results and subsequent drafting and distribution of the training manual.Statistical analysis focused on possible differences between the frequencies of the aforementioned switches. Differences were analysed comparing the values recorded in the first quarter with those of the third quarter trough a χ² test. Statistical significance was set at p<0.05. RESULTS The pharmacist's work showed a statistically significant increase in the conversion from IV to oral antibiotic therapy (χ² (1.496)=9112 ; p=0.0025; df=1). It was also detected a 5% improvement in appropriate dosing, 34% reduction in drug stocks, 4% increase in allergy reports and 275% increase in the number of adverse drug reactions reported. CONCLUSIONS In this study, the interventions of the antibiotic stewardship pharmacist led to an improvement in quality of care, resource efficiency and healthcare professional awareness.
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Affiliation(s)
| | | | - Silvia Adami
- Pharmacy Service, AUSL Veneto, Verona, Veneto, Italy
| | - Stefano Bianchi
- U.O. Hospital and Territorial Pharmaceutical Assistance, AUSL Ferrara, Ferrara, Emilia-Romagna, Italy
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Bertolino G, Marras L, Mureddu V, Camboni M, Cadeddu A. Trends of Antimicrobial Consumption in Hospital: Tackling the Hidden Part of the Iceberg with an Electronic Personalised Prescription Software for Antimicrobial Stewardship. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022. [DOI: 10.1007/5584_2022_752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Tartof SY, Chen LH, Tian Y, Wei R, Im T, Yu K, Rieg G, Bider-Canfield Z, Wong F, Takhar HS, Qian L. Do Inpatient Antimicrobial Stewardship Programs Help Us in the Battle Against Antimicrobial Resistance? Clin Infect Dis 2021; 73:e4454-e4462. [PMID: 32667983 PMCID: PMC8673436 DOI: 10.1093/cid/ciaa1004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Antibiotic stewardship programs (ASPs) have demonstrated success at reducing costs, yet there is limited quality evidence of their effectiveness in reducing infections of high-profile drug-resistant organisms. METHODS This retrospective, cohort study included all Kaiser Permanente Southern California (KPSC) members aged ≥18 years hospitalized in 9 KPSC hospitals from 1 January 2008 to 31 December 2016. We measured the impact of staggered ASP implementation on consumption of 18 ASP-targeted antibiotics using generalized linear mixed-effects models. We used multivariable generalized linear mixed-effects models to estimate the adjusted effect of an ASP on rates of infection with drug-resistant organisms. Analyses were adjusted for confounding by time, cluster effects, and patient- and hospital-level characteristics. RESULTS We included 765 111 hospitalizations (288 257 pre-ASP, 476 854 post-ASP). By defined daily dose, we found a 6.1% (-7.5% to -4.7%) overall decrease antibiotic use post-ASP; by days of therapy, we detected a 4.3% (-5.4% to -3.1%) decrease in overall use of antibiotics. The number of prescriptions increased post-ASP (1.04 [1.03-1.05]). In adjusted analyses, we detected an overall increase in vancomycin-resistant enterococci infections post-ASP (1.37 [1.10-1.69]). We did not detect a change in the rates of extended-spectrum beta-lactamase, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa infections post-ASP. CONCLUSIONS ASPs with successful reductions in consumption of targeted antibiotics may not see changes in infection rates with antibiotic-resistant organisms in the 2 to 6 years post-implementation. There are likely differing timescales for reversion to susceptibility across organisms and antibiotics, and unintended consequences from compensatory prescribing may occur.
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Affiliation(s)
- Sara Y Tartof
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Lie Hong Chen
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Yun Tian
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Rong Wei
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Theresa Im
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Kalvin Yu
- Inpatient Pharmacy Department, Kaiser Permanent Fontana Medical Center, Fontana, California, USA
- Department of Infectious Diseases, Southern California Permanente Medical Group, West Hollywood, California, USA
| | - Gunter Rieg
- Inpatient Pharmacy Department, Kaiser Permanent Fontana Medical Center, Fontana, California, USA
- Department of Infectious Diseases, Southern California Permanente Medical Group, South Bay, California, USA
| | - Zoe Bider-Canfield
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Frances Wong
- Inpatient Pharmacy Department, Kaiser Permanent Fontana Medical Center, Fontana, California, USA
| | - Harpreet S Takhar
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
| | - Lei Qian
- Kaiser Permanente Southern California Department of Research & Evaluation, Pasadena, California, USA
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Gursoy G, Uzun O, Metan G, Yildirim M, Bahap M, Demirkan SK, Topeli A, Akinci SB, Topcuoglu MA, Berker M, Hazirolan G, Akova M, Unal S. Does Antimicrobial Stewardship Program Improve the Quality of Care in ICU Patients Consulted to Infectious Diseases? Experience in a Tertiary Care Hospital. Int J Infect Dis 2021; 115:201-207. [PMID: 34883234 DOI: 10.1016/j.ijid.2021.12.315] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/26/2021] [Accepted: 12/02/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND One of the most important public health problems is the ever growing problem of antibiotic resistance. On one hand, the rate of introduction of new molecules into clinical practice has considerably slowed down, on the other hand, rapid emergence of resistance shortens the effective "life-span" of these molecules. OBJECTIVE In this study, the quality of care before and after active intervention and feedback was evaluated in patients diagnosed with sepsis/septic shock or ventilator-associated pneumonia (VAP) in Hacettepe University Adult and Oncology Hospitals ICUs. RESULTS There was a significant increase in total scores. Significant improvements were achieved in the management of these patients in terms of requesting necessary diagnostic tests, and prolonged infusion of beta-lactam agents. CONCLUSION Implementation of an ASP in centers where antimicrobial management of ICU patients is largely controlled by infectious diseases specialists is still a feasible strategy that leads to better patient care.
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Affiliation(s)
- Gamze Gursoy
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Hacettepe, A. Adnan Saygun Street, 06230 Altındag/Ankara.
| | - Omrum Uzun
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Hacettepe, A. Adnan Saygun Street, 06230 Altındag/Ankara
| | - Gokhan Metan
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Hacettepe, A. Adnan Saygun Street, 06230 Altındag/Ankara
| | - Mehmet Yildirim
- Hacettepe University Faculty of Medicine, Department of Internal Medicine, Section of Intensive Care Medicine
| | - Melda Bahap
- Hacettepe University Faculty of Pharmacy, Department of Clinical Pharmacy
| | | | - Arzu Topeli
- Hacettepe University Faculty of Medicine, Department of Internal Medicine, Section of Intensive Care Medicine
| | - Seda Banu Akinci
- Hacettepe University Faculty of Medicine, Department of Anesthesiology and Reanimation, Section of Intensive Care Medicine
| | - Mehmet Akif Topcuoglu
- Hacettepe University Faculty of Medicine, Department of Neurology, Section of Intensive Care Medicine
| | - Mustafa Berker
- Hacettepe University Faculty of Medicine, Department of Neurosurgery, Section of Intensive Care Medicine
| | | | - Murat Akova
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Hacettepe, A. Adnan Saygun Street, 06230 Altındag/Ankara
| | - Serhat Unal
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Hacettepe, A. Adnan Saygun Street, 06230 Altındag/Ankara
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14
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Thursky KA, Hardefeldt LY, Rajkhowa A, Ierano C, Bishop J, Hawes L, Biezen R, Saha SK, Dowson L, Bailey KE, Scarborough R, Little SB, Gotterson F, Hur B, Khanina A, Urbancic K, Crabb HK, Richards S, Sri A, James R, Kong DCM, Marshall C, Mazza D, Peel T, Stuart RL, Manski-Nankervis JA, Friedman ND, Bennett N, Schulz T, Billman-Jacobe H, Buono E, Worth L, Bull A, Richards M, Ayton D, Gilkerson JR, Browning GF, Buising KL. Antimicrobial stewardship in Australia: the role of qualitative research in programme development. JAC Antimicrob Resist 2021; 3:dlab166. [PMID: 34806005 PMCID: PMC8600289 DOI: 10.1093/jacamr/dlab166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.
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Affiliation(s)
- Karin A Thursky
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne and Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Laura Y Hardefeldt
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Arjun Rajkhowa
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Courtney Ierano
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Jaclyn Bishop
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Pharmacy Department, Ballarat Health Services, 1 Drummond Street North, Ballarat, Victoria 3353, Australia
| | - Lesley Hawes
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
| | - Ruby Biezen
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
- Department of General Practice, University of Melbourne, 780 Elizabeth Street, Melbourne, Victoria 3010, Australia
| | - Sajal K Saha
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
| | - Leslie Dowson
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Kirsten E Bailey
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Ri Scarborough
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Stephen B Little
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Fiona Gotterson
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Brian Hur
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Anna Khanina
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne and Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Karen Urbancic
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Helen K Crabb
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Suzanna Richards
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Anna Sri
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Rodney James
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - David C M Kong
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Pharmacy Department, Ballarat Health Services, 1 Drummond Street North, Ballarat, Victoria 3353, Australia
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - Caroline Marshall
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Danielle Mazza
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, Monash University, 1/270 Ferntree Gully Road, Notting Hill, Victoria 3168, Australia
| | - Trisha Peel
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, The Alfred and Central Clinical School, Burnet Institute, Monash University and Alfred Health, 85 Commercial Road, Monash University, Melbourne, Victoria 3004, Australia
| | - Rhonda L Stuart
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Departments of Infectious Diseases and Infection Control and Epidemiology, Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Jo-Anne Manski-Nankervis
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of General Practice, University of Melbourne, 780 Elizabeth Street, Melbourne, Victoria 3010, Australia
| | - N Deborah Friedman
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, University Hospital Geelong, Barwon Health, Bellerine Street, Geelong, Victoria 3220, Australia
| | - Noleen Bennett
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- VICNISS Coordinating Centre, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Thomas Schulz
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
| | - Helen Billman-Jacobe
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Evette Buono
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- New South Wales Clinical Excellence Commission, 1 Reserve Road, St Leonards, New South Wales 2065, Australia
| | - Leon Worth
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne and Peter MacCallum Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia
| | - Ann Bull
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- VICNISS Coordinating Centre, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Michael Richards
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
- VICNISS Coordinating Centre, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
| | - Darshini Ayton
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria 3004, Australia
| | - James R Gilkerson
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Glenn F Browning
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Asia-Pacific Centre for Animal Health, Melbourne Veterinary School, Faculty of Veterinary and Agricultural Sciences, University of Melbourne, Corner Park Drive and Flemington Road, Building 400, Parkville, Victoria 3010, Australia
| | - Kirsty L Buising
- NHMRC National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Department of Infectious Diseases, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne Health, 300 Grattan Street, Parkville, Victoria 3050, Australia
- Guidance Group, Royal Melbourne Hospital, Melbourne Health, 792 Elizabeth Street, Melbourne, Victoria 3000, Australia
- Peter Doherty Institute of Infection and Immunity, 792 Elizabeth Street, Melbourne Victoria, 3000, Australia
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15
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Acceptability and effectiveness of antimicrobial stewardship implementation strategies on fluoroquinolone prescribing. Infect Control Hosp Epidemiol 2021; 42:1361-1368. [PMID: 33843527 PMCID: PMC9999290 DOI: 10.1017/ice.2021.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess the effectiveness and acceptability of antimicrobial stewardship-focused implementation strategies on inpatient fluoroquinolones. METHODS Stewardship champions at 15 hospitals were surveyed regarding the use and acceptability of strategies to improve fluoroquinolone prescribing. Antibiotic days of therapy (DOT) per 1,000 days present (DP) for sites with and without prospective audit and feedback (PAF) and/or prior approval were compared. RESULTS Among all of the sites, 60% had PAF or prior approval implemented for fluoroquinolones. Compared to sites using neither strategy (64.2 ± 34.4 DOT/DP), fluoroquinolone prescribing rates were lower for sites that employed PAF and/or prior approval (35.5 ± 9.8; P = .03) and decreased from 2017 to 2018 (P < .001). This decrease occurred without an increase in advanced-generation cephalosporins. Total antibiotic rates were 13% lower for sites with PAF and/or prior approval, but this difference did not reach statistical significance (P = .20). Sites reporting that PAF and/or prior approval were "completely" accepted had lower fluoroquinolone rates than sites where it was "moderately" accepted (34.2 ± 5.7 vs 48.7 ± 4.5; P < .01). Sites reported that clinical pathways and/or local guidelines (93%), prior approval (93%), and order forms (80%) "would" or "may" be effective in improving fluoroquinolone use. Although most sites (73%) indicated that requiring infectious disease consults would or may be effective in improving fluoroquinolones, 87% perceived implementation to be difficult. CONCLUSIONS PAF and prior approval implementation strategies focused on fluoroquinolones were associated with significantly lower fluoroquinolone prescribing rates and nonsignificant decreases in total antibiotic use, suggesting limited evidence for class substitution. The association of acceptability of strategies with lower rates highlights the importance of culture. These results may indicate increased acceptability of implementation strategies and/or sensitivity to FDA warnings.
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16
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Ilges D, Ritchie DJ, Krekel T, Neuner EA, Hampton N, Kollef MH, Micek S. Assessment of Antibiotic De-escalation by Spectrum Score in Patients With Nosocomial Pneumonia: A Single-Center, Retrospective Cohort Study. Open Forum Infect Dis 2021; 8:ofab508. [PMID: 34805436 PMCID: PMC8600177 DOI: 10.1093/ofid/ofab508] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/11/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Hospital-acquired and ventilator-associated pneumonia (HAP/VAP) cause significant mortality. Guidelines recommend empiric broad-spectrum antibiotics followed by de-escalation (DE). This study sought to assess the impact of DE on treatment failure. METHODS This single-center retrospective cohort study screened all adult patients with a discharge diagnosis code for pneumonia from 2016 to 2019. Patients were enrolled if they met predefined criteria for HAP/VAP ≥48 hours after admission. Date of pneumonia diagnosis was defined as day 0. Spectrum scores were calculated, and DE was defined as a score reduction on day 3 versus day 1. Patients with DE were compared to patients with no de-escalation (NDE). The primary outcome was composite treatment failure, defined as all-cause mortality or readmission for pneumonia within 30 days of diagnosis. RESULTS Of 11860 admissions screened, 1812 unique patient-admissions were included (1102 HAP, 710 VAP). Fewer patients received DE (876 DE vs 1026 NDE). Groups were well matched at baseline, although more patients receiving DE had respiratory cultures ordered (56.6% vs 50.6%, P = .011). There was no difference in composite treatment failure (35.0% DE vs 33.8% NDE, P = .604). De-escalation was not associated with treatment failure on multivariable Cox regression analysis (hazard ratio, 1.13; 95% confidence interval, 0.96-1.33). Patients receiving DE had fewer antibiotic days (median 9 vs 11, P < .0001), episodes of Clostridioides difficile infection (2.2% vs 3.8%, P = .046), and hospital days (median 20 vs 22 days, P = .006). CONCLUSIONS De-escalation and NDE resulted in similar rates of 30-day treatment failure; however, DE was associated with fewer antibiotic days, episodes of C difficile infection, and days of hospitalization.
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Affiliation(s)
- Dan Ilges
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - David J Ritchie
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
| | - Tamara Krekel
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Elizabeth A Neuner
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Nicholas Hampton
- Center for Clinical Excellence, BJC HealthCare, St. Louis, Missouri, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Scott Micek
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri, USA
- Department of Pharmacy Practice, University of Health Sciences and Pharmacy, St. Louis, Missouri, USA
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17
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Blakey J, Chung LP, McDonald VM, Ruane L, Gornall J, Barton C, Bosnic-Anticevich S, Harrington J, Hew M, Holland AE, Hopkins T, Jayaram L, Reddel H, Upham JW, Gibson PG, Bardin P. Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand. Respirology 2021; 26:1112-1130. [PMID: 34587348 PMCID: PMC9291960 DOI: 10.1111/resp.14147] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 08/04/2021] [Accepted: 08/31/2021] [Indexed: 12/13/2022]
Abstract
Oral corticosteroids (OCS) are frequently used for asthma treatment. This medication is highly effective for both acute and chronic diseases, but evidence indicates that indiscriminate OCS use is common, posing a risk of serious side effects and irreversible harm. There is now an urgent need to introduce OCS stewardship approaches, akin to successful initiatives that optimized appropriate antibiotic usage. The aim of this TSANZ (Thoracic Society of Australia and New Zealand) position paper is to review current knowledge pertaining to OCS use in asthma and then delineate principles of OCS stewardship. Recent evidence indicates overuse and over-reliance on OCS for asthma and that doses >1000 mg prednisolone-equivalent cumulatively are likely to have serious side effects and adverse outcomes. Patient perspectives emphasize the detrimental impacts of OCS-related side effects such as weight gain, insomnia, mood disturbances and skin changes. Improvements in asthma control and prevention of exacerbations can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, multidisciplinary review, optimized medications and other strategies. Recently, add-on therapies including novel biological agents and macrolide antibiotics have demonstrated reductions in OCS requirements. Harm reduction may also be achieved through identification and mitigation of predictable adverse effects. OCS stewardship should entail greater awareness of appropriate indications for OCS prescription, risk-benefits of OCS medications, side effects, effective add-on therapies and multidisciplinary review. If implemented, OCS stewardship can ensure that clinicians and patients with asthma are aware that OCS should not be used lightly, while providing reassurance that asthma can be controlled in most people without frequent use of OCS.
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Affiliation(s)
- John Blakey
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Medical School, Curtin University, Perth, Western Australia, Australia
| | - Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, College of Health Medicine and Wellbeing, The University of Newcastle, New Lambton Heights, New South Wales, Australia
| | - Laurence Ruane
- Monash Lung and Sleep, Monash University and Medical Centre, Melbourne, Victoria, Australia
| | - John Gornall
- Centre of Excellence in Severe Asthma, The University of Newcastle, New Lambton Heights, New South Wales, Australia
| | - Chris Barton
- Department of General Practice, Monash University, Melbourne, Victoria, Australia
| | - Sinthia Bosnic-Anticevich
- Sydney Pharmacy School, The University of Sydney AND Quality Use of Respiratory Medicines Group, The Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - John Harrington
- John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia
| | - Anne E Holland
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Trudy Hopkins
- South Eastern Sydney Health Department, Sydney, New South Wales, Australia
| | - Lata Jayaram
- Department of Respiratory Medicine, Western Health and University of Melbourne, Melbourne, Victoria, Australia
| | - Helen Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, New South Wales, Australia
| | - John W Upham
- The University of Queensland, Diamantina Institute AND Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, College of Health Medicine and Wellbeing, The University of Newcastle, New Lambton Heights, New South Wales, Australia.,John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Philip Bardin
- Monash Lung Sleep Allergy & Immunology, Monash University and Medical Centre, Melbourne, Victoria, Australia
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18
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Safdar N, Parmasad V, Brown R, Carayon P, Lepak A, O'Horo JC, Schulz L. Decreasing ICU-associated Clostridioides difficile infection through fluoroquinolone restriction, the FIRST trial: a study protocol. BMJ Open 2021; 11:e046480. [PMID: 34187821 PMCID: PMC8245435 DOI: 10.1136/bmjopen-2020-046480] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 06/16/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is one of the most common healthcare-associated infections in the USA, having high incidence in intensive care units (ICU). Antibiotic use increases risk of CDI, with fluoroquinolones (FQs) particularly implicated. In healthcare settings, antibiotic stewardship (AS) and infection control interventions are effective in CDI control, but there is little evidence regarding the most effective AS interventions. Preprescription authorisation (PPA) restricting FQs is a potentially promising AS intervention to reduce CDI. The FQ Restriction for the Prevention of CDI (FIRST) trial will evaluate the effectiveness of an FQ PPA intervention in reducing CDI rates in adult ICUs compared with preintervention care, and evaluate implementation effectiveness using a human-factors and systems engineering model. METHODS AND ANALYSIS This is a multisite, stepped-wedge, cluster, effectiveness-implementation clinical trial. The trial will take place in 12 adult medical-surgical ICUs with ≥10 beds, using Epic as electronic health record (EHR) and pre-existing AS programmes. Sites will receive facilitated implementation support over the 15-month trial period, succeeded by 9 months of follow-up. The intervention comprises a clinical decision support system for FQ PPA, integrated into the site EHRs. Each ICU will be considered a single site and all ICU admissions included in the analysis. Clinical data will be extracted from EHRs throughout the trial and compared with the corresponding pretrial period, which will constitute the baseline for statistical analysis. Outcomes will include ICU-onset CDI rates, FQ days of therapy (DOT), alternative antibiotic DOT, average length of stay and hospital mortality. The study team will also collect implementation data to assess implementation effectiveness using the Systems Engineering Initiative for Patient Safety model. ETHICS AND DISSEMINATION The trial was approved by the Institutional Review Board at the University of Wisconsin-Madison (2018-0852-CP015). Results will be made available to participating sites, funders, infectious disease societies, critical care societies and other researchers. TRIAL REGISTRATION NUMBER NCT03848689.
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Affiliation(s)
- Nasia Safdar
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Vishala Parmasad
- Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Roger Brown
- School of Nursing, University of Wisconsin-Madison Graduate School, Madison, Wisconsin, USA
| | - Pascale Carayon
- Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Alexander Lepak
- Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Lucas Schulz
- Pharmacy, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Wolf J, Margolis E. Effect of Antimicrobial Stewardship on Outcomes in Patients With Cancer or Undergoing Hematopoietic Stem Cell Transplantation. Clin Infect Dis 2021; 71:968-970. [PMID: 31633164 DOI: 10.1093/cid/ciz903] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/09/2019] [Indexed: 12/18/2022] Open
Affiliation(s)
- Joshua Wolf
- Department of Infectious Diseases, St Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Elisa Margolis
- Department of Infectious Diseases, St Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Short and long term impact of combining restrictive and enabling interventions to reduce aztreonam consumption in a community hospital. Int J Clin Pharm 2021; 43:1345-1351. [PMID: 33677793 PMCID: PMC7937360 DOI: 10.1007/s11096-021-01257-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/22/2021] [Indexed: 10/28/2022]
Abstract
Background Antimicrobial stewardship initiatives combining restrictive and enabling components may be an effective strategy to achieve short- and long-term objectives. Aztreonam, a relatively high-cost antipseudomonal antibiotic, is an appropriate target for stewardship initiatives based on propensity for overuse in penicillin allergy, an activity profile often warranting additional empiric gram-negative and gram-positive coverage, and a unique durability to Ambler class B metallo-beta-lactamases. Objective Analyze the immediate and long-term impact on aztreonam prescribing of combining restrictive and enabling interventions. Setting Single 233-bed community hospital with 45 adult intensive care unit beds in Nashville, Tennessee. Method Retrospective, interrupted time series analysis comparing all patients receiving aztreonam prior to intervention between January 1, 2010 and September 30, 2011 and following intervention between October 1, 2011 and September 30, 2019. Quarterly defined daily doses/1000 adjusted patient days and microbiology laboratory annual surveillance data were utilized for analysis. Main outcome measure Post-intervention change in trend of aztreonam consumption. Results Following intervention, a significant decline in aztreonam consumption was observed (- 1.97 defined daily doses/1000 adjusted patient days; p = 0.003) resulting in a sustained decrease in aztreonam consumption from 2011 (3rd quarter) to 2019 (3rd quarter) from 15.2 to 0.26 defined daily doses/1000 adjusted patient days. Short-term group 2 carbapenem consumption increased (p = 0.044). Pseudomonas aeruginosa susceptibility to aztreonam improved from 2011 to 2018 (72% vs. 84%; p = 0.0004) without deleterious effects to alternative antipseudomonal beta-lactams. Conclusion Combining restrictive and enabling interventions had immediate and sustained impact on aztreonam consumption with P. aeruginosa susceptibility improvement.
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Kim SH, Yoon JG, Park HJ, Won H, Ryoo SS, Choi E, Park EK, Huh K, Park CM. Effects of a comprehensive antimicrobial stewardship program in a surgical intensive care unit. Int J Infect Dis 2021; 108:237-243. [PMID: 33639294 DOI: 10.1016/j.ijid.2021.02.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/14/2021] [Accepted: 02/19/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES We evaluated the effects of a comprehensive antimicrobial stewardship program (ASP) in a surgical intensive care unit (SICU). METHODS The ASP was implemented from March 2018 to February 2019 at an SICU in a teaching hospital. An infectious disease physician and a pharmacist visited the SICU 3 times per week for prospective audit and feedback. Outcomes were compared between the ASP period and the same months in the preceding year (pre-ASP period). The primary outcome measure was the use of anti-pseudomonal beta-lactams (APBL). Appropriate antimicrobial de-escalation and ICU mortality rates were also compared. RESULTS A total of 182 and 149 patients were included in the study for the pre-ASP and ASP periods, respectively. Although disease severity was higher in the ASP group (septic shock 39.0% in pre-ASP vs 65.1% in ASP group, P<0.001), the use of APBL as a definitive treatment was lower during ASP (68.7% vs 57.7%, OR 0.62, 95% CI 0.40-0.98). Appropriate antimicrobial de-escalation improved (63.2% vs 94.6%, P<0.001). ICU mortality was comparable (7.7% vs 7.4%) and significantly lower during the ASP, after adjustment (adjusted OR 0.41, 95% CI 0.18-0.92, P=0.032). CONCLUSIONS A comprehensive ASP decreased the use of APBL and was associated with improved patient outcomes.
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Affiliation(s)
- Si-Ho Kim
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Jin Gu Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyo Jung Park
- Department of Pharmaceutical Services, Samsung Medical Center, Seoul, Republic of Korea
| | - Hojeong Won
- Statistics and Data Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Sung Suk Ryoo
- Nusring Department, Samsung Medical Center, Seoul, Republic of Korea
| | - Eunsil Choi
- Office of Infection Prevention and Control, Samsung Medical Center, Seoul, Republic of Korea
| | - Eun-Kyung Park
- Department of Quality Innovation, Samsung Medical Center, Seoul, Republic of Korea
| | - Kyungmin Huh
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Chi-Min Park
- Department of Critical Care Medicine and Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Taylor M, Liechti S, Palazzi D. Intermittent Education and Audit and Feedback Reduce Inappropriate Prescribing of Oral Third-Generation Cephalosporins for Pediatric Upper Respiratory Tract Infections. Jt Comm J Qual Patient Saf 2021; 47:250-257. [PMID: 33446441 DOI: 10.1016/j.jcjq.2020.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In June 2017, leaders within a pediatric ambulatory care network in Houston approached the antimicrobial stewardship team at Texas Children's Hospital with concerns for high oral third-generation cephalosporin (oTGC) use in their clinics. An outpatient quality improvement (QI) team was formed. The specific aim was to reduce inappropriate oTGC prescribing at one clinic ("Clinic A") by 15% in one year. METHODS Following a benchmark analysis of oTGC use at Clinic A, Plan-Do-Study-Act (PDSA) cycles were designed and conducted over one year: one educational session, three individual audit and feedback sessions, and one group feedback session. The primary outcome was the percentage of oTGCs not aligning with American Academy of Pediatrics (AAP) guidelines for bacterial upper respiratory tract infections. Monthly oTGC prescribing at Clinic A was also compared to four control clinics. RESULTS In June 2017, 72% (231/322) of oTGCs prescriptions at Clinic A did not align with AAP guidelines. The most common diagnosis was primary/nonrecurrent acute otitis media. Following interventions, the mean percentage inappropriate oTGCs decreased from 72% to 45% (absolute reduction 27%, p < 0.001), which was sustained the year following the last PDSA cycle (absolute reduction 26%, p < 0.001). Total monthly oTGC prescribing at Clinic A decreased over time, but not in four control clinics. Provider active participation in stewardship activities decreased over time. CONCLUSION Intermittent education and audit and feedback were associated with reduced oTGC misuse at Clinic A but not at four control clinics. Improvements were maintained despite decreased participation in stewardship activities, suggesting that perceptions of ongoing antibiotic audits can help sustain prescribing improvements.
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Interrupted time-series analysis to evaluate the impact of a behavioral change outpatient antibiotic stewardship intervention. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e37. [PMID: 36168485 PMCID: PMC9495536 DOI: 10.1017/ash.2021.203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 11/30/2022]
Abstract
Objective: We evaluated the effect of a behaviorally enhanced quality improvement intervention in reducing the number of antibiotic prescriptions written for antibiotic nonresponsive acute respiratory infections (ARIs). A secondary objective was identifying whether a reduction in inappropriate antibiotic prescriptions, if present, persisted after the immediate implementation of the intervention. Design: Nonrandomized, quasi-experimental study conducted from January 2017 through February 2020. Setting: University of California, Davis Health outpatient clinics. In total, 21 pediatric, family, and internal medicine practices in 10 cities and towns were included. Patients: Patients evaluated by a participating physician at an enrolled practice site during the study period with diagnoses (primary and secondary) from the International Classification of Diseases, Tenth Revision codes consistent with antibiotic nonresponsive ARI diagnoses. Intervention: A behaviorally enhanced quality improvement intervention to reduce inappropriate prescribing for antibiotic nonresponsive ARI. Results: In total, 63,028 eligible patient visits across 21 locations were included in the analysis. The most frequently prescribed antibiotic for antibiotic nonresponsive ARI was azithromycin (n = 3,551), followed by amoxicillin (n = 924). Overall, the intervention was associated with an immediate 46% reduction in antibiotic prescriptions for antibiotic nonresponsive ARI (P = .001) following the intervention. We detected no significant change in the month-to-month trend after the intervention was implemented (P = .87), indicating that the reduction was sustained throughout the postintervention period. Conclusion: Our findings demonstrate that a behaviorally enhanced quality improvement intervention to reduce inappropriate prescribing for antibiotic nonresponsive ARI in ambulatory care encounters was successful in reducing potentially inappropriate prescriptions for presumed antibiotic nonresponsive ARI.
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Viala B, Villiet M, Redor A, Didelot MN, Makinson A, Reynes J, Le Moing V, Morquin D. Using the clinical information system and self-supervision to rationalize the need for antibiotic stewardship: An interventional study in a 2000-bed university hospital. Int J Antimicrob Agents 2020; 57:106233. [PMID: 33232732 DOI: 10.1016/j.ijantimicag.2020.106233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/24/2020] [Accepted: 11/14/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To describe the usefulness of electronic medical records (EMRs) and a computerized physician order entry (CPOE) system to support and assess an antimicrobial stewardship programme (ASP). METHODS At the study hospital, infectious diseases specialists supervise antimicrobial prescription when solicited by physicians in charge of patients. From January to October 2015, treatment days of antibiotic prescription, supervised or unsupervised by infectious disease specialists (SAP or UAP, respectively) in all wards, except intensive care units emergency department, bone marrow transplantation units, and paediatric units, were calculated. Embedding recommendations on carbapenem indications as a checklist into the CPOE system, a self-administered ASP was implemented in 2017. EMRs were reviewed to determine global compliance with carbapenem prescription guidelines (combining introduction of therapy and 72-h assessment) before and after implementation of a self-administered ASP in departments with a low SAP rate for these antibiotics. RESULTS Among 16 090 prescriptions extracted, 19.9% were SAPs. Three patterns of prescription were identified. The first pattern (amoxicillin-clavulanate, ceftriaxone) was characterized by a high UAP rate in every department, the second pattern (cloxacillin, rifampin) was characterized by a high SAP rate in every department, and the third pattern (broad-spectrum beta-lactams) was characterized by heterogeneous distribution of SAP/UAP among departments. Carbapenem prescription was reviewed in five departments with a low SAP rate for carbapenems over 6 months: 94 before and 107 after implementation of the self-administered ASP. Global compliance with guidelines increased significantly from 22% to 37% (risk difference 15%, 95% confidence interval 2.3-28.5%; P=0.02). CONCLUSION A clinical information system may help to rationalize antibiotic stewardship in a context of scarce medical resources. Mapping of antibiotic prescriptions and self-supervision are efficient, complementary and easy-to-implement tools.
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Affiliation(s)
- Benjamin Viala
- Infectious and Tropical Diseases Department, CHU Montpellier, Montpellier, France.
| | - Maxime Villiet
- Clinical Pharmacy Department, CHU Montpellier, Montpellier, France
| | - Alexis Redor
- Infectious and Tropical Diseases Department, CHU Montpellier, Montpellier, France
| | | | - Alain Makinson
- Infectious and Tropical Diseases Department, CHU Montpellier, Montpellier, France
| | - Jacques Reynes
- Infectious and Tropical Diseases Department, CHU Montpellier, Montpellier, France
| | - Vincent Le Moing
- Infectious and Tropical Diseases Department, CHU Montpellier, Montpellier, France
| | - David Morquin
- Infectious and Tropical Diseases Department, CHU Montpellier, Montpellier, France
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Thabit AK, Shea KM, Guzman OE, Garey KW. Antibiotic utilization within 18 community hospitals in the United States: A 5-year analysis. Pharmacoepidemiol Drug Saf 2020; 30:403-408. [PMID: 33094502 DOI: 10.1002/pds.5156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/12/2020] [Accepted: 10/18/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antibiotic overuse is associated with antibiotic resistance. We evaluated antibiotic utilization defined by days of therapy/1000 patient days (DOT/1000 PD) in various community hospitals across the United States. METHODS Community hospitals within the Cardinal Health Drug Cost Opportunity Analytics database were evaluated for the availability of DOT/1000 PD data between 2012 to 2016 for overall and specific antibiotic use and the following classes: narrow-spectrum β-lactams (ampicillin, nafcillin, oxacillin, cefazolin, and cephalexin), non-carbapenem antipseudomonal β-lactams (piperacillin/tazobactam, ceftazidime, and cefepime), carbapenems, anti-methicillin-resistant Staphylococcus aureus agents (vancomycin, linezolid, daptomycin, and tigecycline), and fluoroquinolones. Antibiotic utilization and change in utilization during the study period was calculated using linear regression (β coefficient). RESULTS Eighteen hospitals had antibiotic utilization data available. Hospitals were primarily urban (72%) with an average of 209 total beds and 22 intensive care unit beds. Mean number of pharmacists in these hospitals was nine with a mean pharmacist: bed ratio of 0.05. While all hospitals had antimicrobial stewardship programs established during the study period, only 78% and 22% had infectious diseases (ID) physician and ID pharmacist on staff, respectively. A decrease in antipseudomonal β-lactams (excluding carbapenems) and fluoroquinolones was observed (β coefficients = -1.2 and -2.6, respectively), all other antibiotic classes had increased utilization. CONCLUSION Overall antibiotic utilization increased over 5 years. The increase in narrow-spectrum β-lactams utilization along with the reduction in the use of antipseudomonal β-lactams and fluoroquinolones indicate appropriate antimicrobial stewardship. Institutional antibiotic utilization should be evaluated for appropriateness to limit the overuse of broad-spectrum antibiotics in an effort to reduce resistance development.
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Affiliation(s)
- Abrar K Thabit
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.,Cardinal Health, Houston, Texas, USA.,University of Houston College of Pharmacy, Houston, Texas, USA
| | | | | | - Kevin W Garey
- University of Houston College of Pharmacy, Houston, Texas, USA
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Bauer KA, Kullar R, Gilchrist M, File TM. Antibiotics and adverse events: the role of antimicrobial stewardship programs in 'doing no harm'. Curr Opin Infect Dis 2020; 32:553-558. [PMID: 31567566 DOI: 10.1097/qco.0000000000000604] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Antimicrobial resistance (AMR) is a global threat worldwide, with deaths associated with AMR infections projected to exceed 10 million per year by the year 2050. The overuse and misuse of antibiotics is the primary driver of this resistance, with up to 50% of antibiotics prescribed in the hospital setting being either unnecessary or inappropriate. Antimicrobial stewardship (AMS) programs (ASPs) can mitigate some of this resistance, with the benefits well recognized; however, if we are to truly advance the state of AMS, the principles and practices should align with patient safety. RECENT FINDINGS In a recent evaluation, among 1488 adult patients receiving systemic antibiotic therapy, 298 (20%) experienced at least one antibiotic-associated adverse drug event (ADE). Fifty-six (20%) nonclinically indicated antibiotic regimens were associated with an ADE. It is also well recognized that besides ADEs, the inappropriate use of antibiotics is associated the development of multidrug-resistant infections and Clostridium difficile infection. SUMMARY Currently, there is a significant gap in ASPs correlating initiatives with patient safety goals, including reductions in antibiotic-associated ADEs and multidrug-resistant infections. Therefore, in this article, we provide the rationale for why ASPs are best suited to lead a collaborative effort to prevent antibiotic-associated ADEs and multidrug-resistant infections.
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Affiliation(s)
| | | | - Mark Gilchrist
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Thomas M File
- Department of Internal Medicine, Northeast Ohio Medical University, Rootstown.,Division of Infectious Diseases, Summa Health, Akron, Ohio, USA
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Pierce J, Apisarnthanarak A, Schellack N, Cornistein W, Maani AA, Adnan S, Stevens MP. Global Antimicrobial Stewardship with a Focus on Low- and Middle-Income Countries. Int J Infect Dis 2020; 96:621-629. [PMID: 32505875 PMCID: PMC7271868 DOI: 10.1016/j.ijid.2020.05.126] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Antimicrobial resistance is a global public health crisis. Antimicrobial Stewardship involves adopting systematic measures to optimize antimicrobial use, decrease unnecessary antimicrobial exposure and to decrease the emergence and spread of resistance. Low- and middle-income countries (LMICs) face a disproportionate burden of antimicrobial resistance and also face challenges related to resource availability. Although challenges exist, the World Health Organization has created a practical toolkit for developing Antimicrobial Stewardship Programs (ASPs) that will be summarized in this article.
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Affiliation(s)
- Jacob Pierce
- Virginia Commonwealth University School of Medicine, Department of Internal Medicine, Division of Infectious Diseases, 1000 E Marshall St. Richmond, VA, USA, 23298.
| | - Anucha Apisarnthanarak
- Thammasart University Hospital, 8 95 Phahonyothin Rd, Khlong Nueng, Khlong Luang District, Pathum Thani 12120
| | - Natalie Schellack
- Sefako-Makgatho Health Sciences University, School of Pharmacy, Pretoria. Motlegi St, Ga-Rankuwa Zone 1, Ga-Rankuwa, 0208, South Africa
| | - Wanda Cornistein
- Hospital Universitario Austral Av. Juan Domingo Perón 1500, Pilar Centro, Buenos Aires, Argentina
| | - Amal Al Maani
- Directorate General for Disease Surveillance & Control, MOH. P.O Box: 393, PC 100 Muscat, Oman
| | - Syamhanin Adnan
- Hospital Sungai Buloh (Infectious Disease center) Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia
| | - Michael P Stevens
- Virginia Commonwealth University School of Medicine, Department of Internal Medicine, Division of Infectious Diseases, 1000 E Marshall St. Richmond, VA, USA, 23298
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Goss FR, Bookman K, Barron M, Bickley D, Landgren B, Kroehl M, Williamson K, Zane R, Wiler J. Improved antibiotic prescribing using indication-based clinical decision support in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:214-221. [PMID: 33000036 PMCID: PMC7493549 DOI: 10.1002/emp2.12029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/23/2019] [Accepted: 01/27/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Evaluate an indication-based clinical decision support tool to improve antibiotic prescribing in the emergency department. METHODS Encounters where an antibiotic was prescribed between January 2015 and October 2017 were analyzed before and after the introduction of a clinical decision support tool to improve clinicians' selection of a guideline-approved antibiotic based on clinical indication. Evaluation was conducted on a pre-defined subset of conditions that included skin and soft tissue infections, respiratory infections, and urinary infections. The primary outcome was ordering of a guideline-approved antibiotic prescription at the drug and duration of therapy level. A mixed model following a binomial distribution with a logit link was used to model the difference in proportions of guideline-approved prescriptions before and after the intervention. RESULTS For conditions evaluated, selection rate of a guideline-approved antibiotic for a given indication improved from 67.1% to 72.2% (P < 0.001). When duration of therapy is included as a criterion, selection of a guideline-approved antibiotic was lower and improved from 24.7% to 31.4% (P < 0.001), highlighting that duration of therapy is often missing at the time of prescribing. The most substantial improvements were seen for pneumonia and pyelonephritis with an increase from 87.9% to 97.5% and 62.8% to 82.6%, respectively. Other significant improvements were seen for abscess, cellulitis, and urinary tract infections. CONCLUSION Antibiotic prescribing can be improved both at the drug and duration of therapy level using a non-interruptive and indication based-clinical decision support approach. Future research and quality improvement efforts are needed to incorporate duration of therapy guidelines into the antibiotic prescribing process.
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Affiliation(s)
- Foster R. Goss
- Department of Emergency MedicineUniversity of Colorado HospitalAuroraColorado
- University of Colorado School of MedicineAuroraColorado
| | - Kelly Bookman
- Department of Emergency MedicineUniversity of Colorado HospitalAuroraColorado
- University of Colorado School of MedicineAuroraColorado
| | - Michelle Barron
- University of Colorado School of MedicineAuroraColorado
- Department of Infection Prevention and ControlUniversity of Colorado HospitalAuroraColorado
| | - Daniel Bickley
- Department of Emergency MedicineUniversity of Colorado HospitalAuroraColorado
- University of Colorado School of MedicineAuroraColorado
| | - Brady Landgren
- Department of Emergency MedicineUniversity of Colorado HospitalAuroraColorado
- University of Colorado School of MedicineAuroraColorado
| | | | | | - Richard Zane
- Department of Emergency MedicineUniversity of Colorado HospitalAuroraColorado
- University of Colorado School of MedicineAuroraColorado
| | - Jennifer Wiler
- Department of Emergency MedicineUniversity of Colorado HospitalAuroraColorado
- University of Colorado School of MedicineAuroraColorado
- University of Colorado Denver School of BusinessDenverColorado
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Michelangeli C, Girard-Lamoulere D, Assi A, Della Guardia M, Roger PM. Antibiotic guidelines coupled with selective reporting of antibiograms. Infect Dis Now 2020; 51:61-66. [PMID: 32360395 DOI: 10.1016/j.medmal.2020.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 01/22/2020] [Accepted: 04/23/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We reported the impact of internal guidelines coupled with selective reporting of antibiotic susceptibility tests (srAST) on antibiotic adequacy in healthcare facilities. METHODS This prospective study involved clinicians from three clinics with medical and surgical activities employing a full-time infectious disease (ID) specialist. Internal guidelines were updated in 2016. The clinics were working with the same laboratory, which delivered the srAST introduced in March 2017. Two weeks per month over a 6-month period, all isolated bacterial specimens, empirical antibiotic therapies (EAT) and the documented ones were analyzed. An EAT listed in the guidelines and a documented therapy mentioned in the srAST defined their adequacy. RESULTS A total of 257 positive bacterial samples were analyzed in 199 patients, for which 106 infections were studied. Of these, 32% were urinary tract infections, 15% were primary bloodstream infections, 11% were bone infections, and 42% were other types of infection. The three main bacteria were Escherichia coli (27%), Staphylococcus aureus (24%), and Enterococcus faecalis (14%). The total number of antibiotic prescriptions was 168, with 75 (45%) EATs and 93 (55%) documented therapies. There were 35/75 (47%) adequate EATs and 86/93 (92%) adequate documented therapies. The ID specialist was not involved in 90/168 (53.5%) prescriptions, of which 43/90 (48%) were adequate, with 21/35 (60%) EATs and 22/86 (25%) documented therapies. There was a statistical correlation between compliance of the EATs with guidelines and of the documented therapy with srAST (p=0.02). CONCLUSION Combining internal guidelines and srAST led to a high rate of antibiotic adequacy.
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Affiliation(s)
- C Michelangeli
- Réso-Infectio-PACA-Est, Nice, France; Faculté de médecine, université Côte d'Azur, Nice, France
| | | | - A Assi
- Polyclinique Les Fleurs, avenue Frédéric-Mistral, 83190 Ollioules, France
| | - M Della Guardia
- Polyclinique Les Fleurs, avenue Frédéric-Mistral, 83190 Ollioules, France
| | - P-M Roger
- Réso-Infectio-PACA-Est, Nice, France; Faculté de médecine, université Côte d'Azur, Nice, France; Polyclinique Les Fleurs, avenue Frédéric-Mistral, 83190 Ollioules, France.
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Kinoshita N, Komura M, Tsuzuki S, Shoji K, Miyairi I. The effect of preauthorization and prospective audit and feedback system on oral antimicrobial prescription for outpatients at a children's hospital in Japan. J Infect Chemother 2020; 26:582-587. [PMID: 32088130 DOI: 10.1016/j.jiac.2020.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 11/15/2022]
Abstract
Antimicrobial stewardship programs (ASP) for oral antibiotics is still uncommon, despite the fact that oral antibiotics prescription accounts for 90% of total antibiotic consumption in developed countries. We introduced preauthorization and prospective audit and feedback (PAF) system on broad-spectrum oral antimicrobials as a part of ASP intervention from October 2015 in a tertiary children's hospital in Japan. Antimicrobial consumption and cost of targeted oral antimicrobials decreased from 11.1 days of therapy (DOT) per 1000 outpatient visits and 860,040 yen ($ 7167: 1 $ = 120 yen) to 1.9 DOT per 1000 outpatient visits and 142,200 yen ($ 1185) annually, respectively (p < 0.001). Interrupted time-series analysis showed that prescriptions for targeted antimicrobials decreased rapidly after initiation of preauthorization (p < 0.001). Prescriptions for non-targeted oral antimicrobial increased temporarily (p < 0.001), but a decreasing trend was found after the initiation (p < 0.001). In pre-intervention period, the main indications for using targeted antimicrobials were upper and lower respiratory infection, urinary tract infections, prophylaxis for medical procedures and otitis media, but only 21.4% of them were appropriate prescription. The appropriate prescription rate of post -intervention period increased to 58.5%. During the study period, the susceptibility pattern of major bacteria to these antimicrobials did not change. In conclusion, introduction of the preauthorization and PAF for selected oral antimicrobials decreased the antimicrobial use of both targeted and non-targeted antimicrobials. This intervention may be an effective method of ASP for other children's hospitals.
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Affiliation(s)
- Noriko Kinoshita
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan; Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Makoto Komura
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan.
| | - Shinya Tsuzuki
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Kensuke Shoji
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.
| | - Isao Miyairi
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.
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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.
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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
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Pillinger KE, Bouchard J, Withers ST, Mediwala K, McGee EU, Gibson GM, Bland CM, Bookstaver PB. Inpatient Antibiotic Stewardship Interventions in the Adult Oncology and Hematopoietic Stem Cell Transplant Population: A Review of the Literature. Ann Pharmacother 2019; 54:594-610. [PMID: 31771337 DOI: 10.1177/1060028019890886] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective: To review the use of antibiotic stewardship interventions in the adult oncology and hematopoietic cell transplantation (HCT) populations. Data Sources: A literature search of PubMed was performed from inception to October 31, 2019. The general search terms used were oncology, cancer, hematologic malignancy, antimicrobial stewardship, antibiotic stewardship, febrile neutropenia, neutropenic fever, de-escalation, discontinuation, prophylaxis, practice guidelines, clinical pathway, rapid diagnostics, Filmarray, Verigene, MALDI-TOF, antibiotic allergy, and antimicrobial resistance. Study Selection and Data Extraction: Relevant English-language studies describing interventions supported by the Infectious Diseases Society of America guidelines on "Implementing an Antibiotic Stewardship Program" were included. Data Synthesis: Antibiotic stewardship publications in the oncology population have increased in recent years. Studies have described the impact of stewardship interventions, including preauthorization, prospective audit and feedback, implementation of clinical pathways, de-escalation of empirical antibiotics for febrile neutropenia (FN) prior to neutrophil recovery, allergy assessments, and use of rapid diagnostic testing. Many of these interventions have been shown to decrease antibiotic use without increased negative consequences, such as affecting length of stay or mortality. Relevance to Patient Care and Clinical Practice: This review synthesizes available evidence for implementing antibiotic stewardship interventions, particularly de-escalation of antibiotics for FN and implementation of clinical pathways for FN and sepsis, in oncology patients and HCT recipients. Summary tables highlight studies and specific research needs for clinicians. Conclusions: Immunocompromised populations, including oncology patients, have often been excluded from stewardship studies. Antibiotic stewardship is effective in reducing antibiotic consumption and improving outcomes in this patient population, although more quality data are needed.
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Pharmacists' role in antimicrobial stewardship and relationship with antibiotic consumption in hospitals: An observational multicentre study. J Glob Antimicrob Resist 2019; 20:131-134. [PMID: 31323427 DOI: 10.1016/j.jgar.2019.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/03/2019] [Accepted: 07/07/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Antimicrobial stewardship (AMS) teams around the world include pharmacists; however, their impact is relatively unknown. This study aimed to explore the relationship between pharmacists' actions and antibiotic consumption. METHODS Hospital pharmacists involved in the French antibiotic consumption surveillance network (ATB-Raisin) were invited to participate in a retrospective observational multicentre study. Collected data were: the previous year's (2016) antibiotic consumption expressed in daily defined dose per 1000 patient-days; AMS measures, including pharmacist-specific actions; and use of a computerised prescription order entry (CPOE) system. Associations between antibiotic consumption and AMS measures were assessed by linear regression, after adjustment for hospital activities. RESULTS Annual data for 2016 from 77 hospitals (7260000 bed-days in 24000 beds) were analysed. Pharmacists were involved in AMS programs in 73% of hospitals, and were the antibiotic advisor in 25%. Pharmaceutical review of prescriptions was organised in almost all hospitals (97%). The univariable analysis identified five measures associated with lower overall antibiotic consumption: CPOE use (if >80% of prescriptions or 100%), pharmaceutical review (if >80% of beds or 100%) and the antibiotic advisor being a pharmacist (P=0.04, P=0.004 and P=0.003, respectively). In the multivariable analysis, two explanatory variables were significantly and independently associated with a lower overall antibiotic consumption: the antibiotic advisor being a pharmacist and a pharmaceutical review covering all beds (-19.9% [-31.6%; -8.1%], P=0.002 and -18.3% [-34.0%; -2.6%], P=0.03, respectively). CONCLUSIONS Antibiotic consumption was lower when the antibiotic advisor was a pharmacist and when the pharmaceutical team reviewed all prescriptions. These results highlight that actions initiated by pharmacists have a positive impact and should be supported.
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Remtulla S, Zurek K, Cervera C, Hernandez C, Lee MC, Hoang HL. Impact of an Unsolicited, Standardized Form-Based Antimicrobial Stewardship Intervention to Improve Guideline Adherence in the Management of Staphylococcus aureus Bacteremia. Open Forum Infect Dis 2019; 6:ofz098. [PMID: 30949538 PMCID: PMC6441557 DOI: 10.1093/ofid/ofz098] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/22/2019] [Indexed: 01/21/2023] Open
Abstract
Background Antimicrobial stewardship programs (ASPs) improve Staphylococcus aureus bacteremia (SAB) management. The objective of the current study was to evaluate the effect of unsolicited prospective audit and feedback (PAF) using a standardized SAB bundle form on the management of SAB. Methods Multicenter, pre-post quasi-experimental study of inpatients with SAB. The ASP developed an evidence-based SAB management bundle that included recommendations for infectious diseases consultation, blood culture clearance, appropriate empiric and definitive therapy, echocardiography, adequate treatment duration, and source control where applicable. ASP pharmacists performed PAF using a standardized form outlining bundle components. The primary outcome was bundle component adherence. Secondary outcomes were length of stay, 30-day readmission rate, and in-hospital and 30-day mortality rates. Results A total of 199 patients were included (preintervention group, 62; intervention group, 137). Bundle implementation with PAF resulted in significant improvements in infectious diseases consultation (56.5% in preintervention vs 93.4% in intervention group), appropriate definitive antibiotic therapy (83.9% vs 99.3%), ordering echocardiography (72.6% vs 95.6%), and adequate treatment duration (87.0% vs 100%) (all P < .001). Overall bundle adherence increased by 43.8% (P < .001). Readmission and 30-day mortality rates decreased, but this difference did not reach statistical significance. Conclusions Unsolicited PAF using a standardized SAB management bundle significantly improved adherence to evidence-based recommendations. This simple yet effective ASP-driven intervention can ensure consistent management of a highly morbid infection.
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Affiliation(s)
| | | | | | | | | | - Holly L Hoang
- Covenant Health, Edmonton, Canada.,University of Alberta, Edmonton, Canada
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Eljaaly K, Elarabi S, Alshehri S, Nix DE. Impact of requiring re-authorization of restricted antibiotics on day 3 of therapy. J Antimicrob Chemother 2019; 73:527-530. [PMID: 29077862 DOI: 10.1093/jac/dkx384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 09/21/2017] [Indexed: 12/15/2022] Open
Abstract
Background Pre-authorization of restricted antibiotics is a core component of an antibiotic stewardship programme (ASP). On day 3, information about culture results and clinical status is typically available. Our objective was to compare an ASP that requires initial authorization alone with one requiring initial authorization and re-authorization on day 3 of therapy. Methods A single-centre, retrospective, before and after study was conducted. Randomly selected adults were eligible if receiving a restricted antibiotic for ≥3 days during April to June in 2012 (pre-intervention) and during the same months in 2013 (post-intervention). The target sample size was 166 patients. The intervention required re-authorization of restricted antibiotics that were continuing on day 3. The days of therapy of restricted antibiotic(s), length of hospital stay (LOS) and hospital mortality were compared between pre- and post-intervention periods. Results The ASP intervention was associated with a decrease in median days of therapy from 5 (4-9) to 4 (3-5) days (P < 0.001) for all restricted agents, from 5 (3-6) to 3 (3-5) days for broad-spectrum Gram-negative agents (P < 0.001) and from 6.5 (6-7) to 3 (3-4.5) days for oral vancomycin. The proportion of subjects receiving restricted agents for >4 days decreased from 57.8% to 30.1% (P < 0.001). LOS decreased from 8 (5-17) to 6 (5-9) days (P = 0.005) without a significant change in hospital mortality. Conclusions Requiring re-authorization of restricted antibiotics on day 3 of therapy in addition to initial authorization was associated with reduction in overall consumption of restricted antibiotics and LOS without adversely affecting hospital mortality.
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Affiliation(s)
- Khalid Eljaaly
- Department of Clinical Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Pharmacy Services, St. Elizabeth's Medical Center, Brighton, MA, USA.,Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA.,Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | - Salwa Elarabi
- Department of Pharmacy Services, St. Elizabeth's Medical Center, Brighton, MA, USA
| | - Samah Alshehri
- Department of Clinical Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Pharmacy Services, St. Elizabeth's Medical Center, Brighton, MA, USA.,Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, USA.,Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | - David E Nix
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA.,Department of Medicine, Division of Infectious Diseases, University of Arizona, Tucson, AZ, USA
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Downie SP, Wood PJ, Summers RJ, McDonough M, Wong GOY. Hospital discharge opioid guidelines and policies: a Victorian survey. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Shane P. Downie
- Department of Pharmacy and Applied Science; La Trobe University; Bendigo Australia
| | - Penelope J. Wood
- Department of Pharmacy and Applied Science; La Trobe University; Bendigo Australia
| | - Richard J. Summers
- Department of Pharmacy and Applied Science; La Trobe University; Bendigo Australia
| | - Michael McDonough
- Department of Drug Health Service; Western Health; Melbourne Australia
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Pickens CI, Wunderink RG. Principles and Practice of Antibiotic Stewardship in the ICU. Chest 2019; 156:163-171. [PMID: 30689983 DOI: 10.1016/j.chest.2019.01.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/29/2018] [Accepted: 01/11/2019] [Indexed: 12/29/2022] Open
Abstract
In the face of emerging drug-resistant pathogens and a decrease in the development of new antimicrobial agents, antibiotic stewardship should be practiced in all critical care units. Antibiotic stewardship should be a core competency of all critical care practitioners in conjunction with a formal antibiotic stewardship program (ASP). Prospective audit and feedback, and antibiotic time-outs, are effective components of an ASP in the ICU. As rapid diagnostics are introduced in the ICU, assessment of performance and effect on outcomes will clearly be needed. Disease-specific stewardship for community-acquired pneumonia that relies on clinical pathways may be particularly high-yield. Computerized decision support has the potential to individualize stewardship for specific patients. Finally, infection control and prevention is the cornerstone of every ASP.
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Affiliation(s)
- Chiagozie I Pickens
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Rawlins MDM, Raby E, Sanfilippo FM, Douglass R, Chambers J, McLellan D, Dyer JR. Adaptation of a hospital electronic referral system for antimicrobial stewardship prospective audit and feedback rounds. Int J Qual Health Care 2019; 30:637-641. [PMID: 29733352 DOI: 10.1093/intqhc/mzy088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 04/09/2018] [Indexed: 01/04/2023] Open
Abstract
Objective To evaluate the impact of the adaptation of an existing electronic referral application for use in antimicrobial stewardship prospective audit and feedback rounds (antimicrobial rounds). Design Retrospective, single-centre observational study between March 2015 and February 2016. Setting A new quaternary referral centre. Study Participants Adults referred for antimicrobial rounds outside of the intensive care and haematology units. Intervention Adaptation of an electronic referral application used by medical and allied health staff. A questionnaire-style referral form was designed to capture patient clinical details using a combination of free text and dropdown menus. Clinical pharmacists were educated and granted access to the system. Main Outcome Measures The proportion of completed electronic referrals of total round reviews by month for the 12 months after implementation. The time from request to completion of reviews. The impact on adherence to advice provided on rounds. The impact on the institutional usage of broad-spectrum antibiotics: glycopeptides, carbapenems, third and fourth generation cephalosporins, fluoroquinolones and piperacillin/tazobactam. Results Over the study period, the proportion of electronic referrals of completed antimicrobial round reviews increased from 59% to 88% (P < 0.001); 75.7% of accepted electronic referrals were seen within 48 h of request. The proportion of advice ignored fell from 18% to 8.5% (P < 0.001). Piperacillin/tazobactam, fluoroquinolone and glycopeptide usage decreased. Conclusions The adaptation of an electronic referral application for antimicrobial rounds was associated with increased adherence to advice and reduction in use in target antibiotics. Our model is now used at other institutions.
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Affiliation(s)
- Matthew D M Rawlins
- Department of Pharmacy, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA, Australia
| | - Edward Raby
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Frank M Sanfilippo
- Department of Pharmacy, Royal Perth Perth Hospital, Wellington St, Perth, WA, Australia.,School of Population and Global Health, University of Western Australiam, Hackett Drive, Crawley, WA, Australia
| | - Rae Douglass
- Health Support Services, St Georges Terrace, Perth, WA, Australia
| | - Jonathan Chambers
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Duncan McLellan
- Western Diagnostic Pathology, McCoy Road, Myaree, WA, Australia
| | - John R Dyer
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
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Reali S, Najib EY, Treuerné Balázs KE, Chern Hui Tan A, Váradi L, Hibbs DE, Groundwater PW. Novel diagnostics for point-of-care bacterial detection and identification. RSC Adv 2019; 9:21486-21497. [PMID: 35521339 PMCID: PMC9066158 DOI: 10.1039/c9ra03118a] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/30/2019] [Indexed: 12/20/2022] Open
Abstract
In addition to limiting the effectiveness of antimicrobial agents, antimicrobial resistance (AMR) is a significant global health concern as it is responsible for significant mortality/morbidity and increased economic burdens on healthcare systems. Diagnostic tests have been suggested as a means of prolonging the effectiveness of current antimicrobials; culture and other conventional diagnostics are hindered in their practicality as they are time- and labour intensive to perform. Point-of-care (POC) testing is performed near where the patient is being treated and can provide timely results that allow evidence based clinical interventions to be made. This review aims to outline the chemical principles behind some novel and emerging diagnostic techniques which have the required speed, simplicity, effectiveness and low-cost for incorporation into POC devices which can be used to inform and optimize antimicrobial use. The WHO global action plan on antimicrobial resistance outlines the need for new diagnostic tools. Point-of-care testing for bacterial infections would enable clinically meaningful interventions using methods that are rapid, low-cost, easy-to-operate, and portable.![]()
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Affiliation(s)
- Savannah Reali
- The University of Sydney School of Pharmacy
- Camperdown Campus
- Sydney
- Australia
| | - Elias Y. Najib
- The University of Sydney School of Pharmacy
- Camperdown Campus
- Sydney
- Australia
| | | | | | | | - David E. Hibbs
- The University of Sydney School of Pharmacy
- Camperdown Campus
- Sydney
- Australia
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Systematic review of the use of time series data in the study of antimicrobial consumption and Pseudomonas aeruginosa resistance. J Glob Antimicrob Resist 2018; 15:69-73. [DOI: 10.1016/j.jgar.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/30/2018] [Accepted: 06/05/2018] [Indexed: 11/22/2022] Open
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Simões AS, Maia MR, Gregório J, Couto I, Asfeldt AM, Simonsen GS, Póvoa P, Viveiros M, Lapão LV. Participatory implementation of an antibiotic stewardship programme supported by an innovative surveillance and clinical decision-support system. J Hosp Infect 2018; 100:257-264. [PMID: 30071264 DOI: 10.1016/j.jhin.2018.07.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Antibiotic resistance will cause about 10 million deaths per year by 2050. Fighting antimicrobial resistance is a health priority. Interventions aimed to reduce antimicrobial resistance, such as antibiotic stewardship programmes (ASPs), must be implemented. To be effective, those interventions, and the implementation process, should be matched with social-cultural context. The complexity of ASPs can no longer be developed without considering both organizational and information systems. AIM To support ASPs through the co-design and implementation, in collaboration with healthcare workers, of a surveillance and clinical decision-support system to monitor antibiotic resistance and improve antibiotic prescription. METHODS The surveillance and clinical decision-support system was designed and implemented in three Portuguese hospitals, using a participatory approach between researchers and healthcare workers following the Design Science Research Methodology. FINDINGS Based on healthcare workers' requirements, we developed HAITooL, a real-time surveillance and clinical decision-support system that integrates visualizations of patient, microbiology, and pharmacy data, facilitating clinical decision. HAITooL monitors antibiotic usage and rates of antibiotic-resistant bacteria, allowing early identification of outbreaks. It is a clinical decision-support tool that integrates evidence-based algorithms to support proper antibiotic prescription. HAITooL was considered valuable to support monitoring of antibiotic resistant infections and an important tool for ASP sustainability. CONCLUSION ASP implementation can be leveraged through a surveillance and clinical decision-support system such as HAITooL that allows antibiotic resistance monitoring and supports antibiotic prescription, once it has been adapted to the context and specific needs of healthcare workers and hospitals.
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Affiliation(s)
- A S Simões
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - M R Maia
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - J Gregório
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - I Couto
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - A M Asfeldt
- University Hospital of North Norway and UiT - Arctic University of Norway, Tromsø, Norway
| | - G S Simonsen
- University Hospital of North Norway and UiT - Arctic University of Norway, Tromsø, Norway
| | - P Póvoa
- NOVA Medical School, CEDOC, Universidade Nova de Lisboa, Lisbon, Portugal; Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - M Viveiros
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal
| | - L V Lapão
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisbon, Portugal.
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Johnk SR, Grindeland CJ, Leedahl DD, Carson PJ, Leedahl ND. Impact of a multicenter stewardship-targeted carbapenem justification requirement on the use of carbapenems in 23 hospitals. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2018. [DOI: 10.1002/jac5.1021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Sydney R. Johnk
- Department of Pharmacy Services; Sanford Medical Center; Fargo North Dakota
| | | | - David D. Leedahl
- Department of Pharmacy Services; Sanford Medical Center; Fargo North Dakota
| | - Paul J. Carson
- Department of Infectious Diseases; Sanford Medical Center; Fargo North Dakota
| | - Nathan D. Leedahl
- Department of Enterprise Pharmacy; Sanford Medical Center; Fargo North Dakota
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43
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Antimicrobial Stewardship in the Treatment of Infections Among Patients With Cystic Fibrosis. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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44
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Review of the epidemiological data regarding antimicrobial resistance in Gram-negative bacteria in Australia. Infect Dis Health 2017. [DOI: 10.1016/j.idh.2017.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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45
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Chavada R, Walker HN, Tong D, Murray A. Changes in antimicrobial prescribing behavior after the introduction of the antimicrobial stewardship program: A pre- and post-intervention survey. Infect Dis Rep 2017; 9:7268. [PMID: 29071048 PMCID: PMC5641660 DOI: 10.4081/idr.2017.7268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/23/2017] [Accepted: 08/25/2017] [Indexed: 12/02/2022] Open
Abstract
The introduction of an antimicrobial stewardship (AMS) program is associated with a change in antimicrobial prescribing behavior. A proposed mechanism for this change is by impacting the prescribing etiquette described in qualitative studies. This study sought to detect a change in prescribing attitudes 12 months after the introduction of AMS and gauge utility of various AMS interventions. Surveys were distributed to doctors in two regional Australian hospitals on a convenience basis 6 months before, and 12 months after, the introduction of AMS. Agreement with 20 statements describing attitudes (cultural, behavioral and knowledge) towards antimicrobial prescribing was assessed on a 4-point Likert scale. Mean response scores were compared using the Wilcoxon Rank sum test. 155 responses were collected before the introduction of AMS, and 144 afterwards. After the introduction of AMS, an increase was observed in knowledge about available resources such as electronic decision support systems (EDSS) and therapeutic guidelines, with raised awareness about the support available through AMS rounds and the process to be followed when prescribing restricted antimicrobials. Additionally, doctors were less likely to rely on pharmacy to ascertain when an antimicrobial was restricted, depend on infectious diseases consultant advice and use past experience to guide antimicrobial prescribing. Responses to this survey indicate that positive changes to the antimicrobial prescribing etiquette may be achieved with the introduction of an AMS program. Use of EDSS and other resources such as evidence-based guidelines are perceived to be important to drive rational antimicrobial prescribing within AMS programs.
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Affiliation(s)
- Ruchir Chavada
- Department of Microbiology and Infectious Diseases, Pathology North Central Coast
| | - Harry N Walker
- Division of Medicine, Central Coast Local Health District
| | - Deborah Tong
- Pharmacy Department, Central Coast Local Health District, NSW, Australia
| | - Amy Murray
- Pharmacy Department, Central Coast Local Health District, NSW, Australia
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Hand KS, Cumming D, Hopkins S, Ewings S, Fox A, Theminimulle S, Porter RJ, Parker N, Munns J, Sheikh A, Keyser T, Puleston R. Electronic prescribing system design priorities for antimicrobial stewardship: a cross-sectional survey of 142 UK infection specialists. J Antimicrob Chemother 2017; 72:1206-1216. [PMID: 27999065 DOI: 10.1093/jac/dkw524] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 11/07/2016] [Indexed: 01/27/2023] Open
Abstract
Background The implementation of electronic prescribing and medication administration (EPMA) systems is a priority for hospitals and a potential component of antimicrobial stewardship (AMS). Objectives To identify software features within EPMA systems that could potentially facilitate AMS and to survey practising UK infection specialist healthcare professionals in order to assign priority to these software features. Methods A questionnaire was developed using nominal group technique and transmitted via email links through professional networks. The questionnaire collected demographic data, information on priority areas and anticipated impact of EPMA. Responses from different respondent groups were compared using the Mann-Whitney U -test. Results Responses were received from 164 individuals (142 analysable). Respondents were predominantly specialist infection pharmacists (48%) or medical microbiologists (37%). Of the pharmacists, 59% had experience of EPMA in their hospitals compared with 35% of microbiologists. Pharmacists assigned higher priority to indication prompt ( P < 0.001), allergy checker ( P = 0.003), treatment protocols ( P = 0.003), drug-indication mismatch alerts ( P = 0.031) and prolonged course alerts ( P = 0.041) and lower priority to a dose checker for adults ( P = 0.02) and an interaction checker ( P < 0.05) than microbiologists. A 'soft stop' functionality was rated essential or high priority by 89% of respondents. Potential EPMA software features were expected to have the greatest impact on stewardship, treatment efficacy and patient safety outcomes with lowest impact on Clostridium difficile infection, antimicrobial resistance and drug expenditure. Conclusions The survey demonstrates key differences in health professionals' opinions of potential healthcare benefits of EPMA, but a consensus of anticipated positive impact on patient safety and AMS.
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Affiliation(s)
- Kieran S Hand
- Southampton Pharmacy Research Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK.,Faculty of Health Sciences, University of Southampton, Southampton SO17 1BJ, UK
| | - Debbie Cumming
- Pharmacy Department, St Mary's Hospital, Parkhurst Road, Newport, Isle of Wight PO31 7QJ, UK
| | - Susan Hopkins
- Department of Infectious Diseases & Microbiology, Royal Free London NHS Foundation Trust, Pond St, London NW3 2QG, UK
| | - Sean Ewings
- Southampton Statistical Sciences Research Institute, University of Southampton, University Road, Southampton SO17 1BJ, UK
| | - Andy Fox
- Southampton Pharmacy Research Centre, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK.,Faculty of Health Sciences, University of Southampton, Southampton SO17 1BJ, UK
| | - Sandya Theminimulle
- Microbiology Department, St Mary's Hospital, Parkhurst Road, Newport, Isle of Wight PO31 7QJ, UK
| | - Robert J Porter
- Department of Microbiology, Royal Devon and Exeter NHS Foundation Trust, Church Lane, Heavitree, Exeter EX2 5AD, UK
| | - Natalie Parker
- Pharmacy Department, Hampshire Hospitals NHS Foundation Trust, Royal Hampshire County Hospital, Romsey Road, Winchester SO22 5DG, UK
| | - Joanne Munns
- Pharmacy Department, Western Sussex Hospitals NHS Foundation Trust, St Richards Hospital, Chichester PO19 6SE, UK
| | - Adel Sheikh
- Pharmacy Department, Queen Alexandra Hospital, Southwick Hill Road, Portsmouth Hospitals' NHS Trust, Portsmouth PO6 3LY, UK
| | - Taryn Keyser
- Pharmacy Department, Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Aldermaston Road, Basingstoke RG24 9NA, UK
| | - Richard Puleston
- City Hospital, Institute of Public Health, Nottingham NG5 1PB, UK
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Curtis CE, Al Bahar F, Marriott JF. The effectiveness of computerised decision support on antibiotic use in hospitals: A systematic review. PLoS One 2017; 12:e0183062. [PMID: 28837665 PMCID: PMC5570266 DOI: 10.1371/journal.pone.0183062] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/28/2017] [Indexed: 12/18/2022] Open
Abstract
Background Inappropriate antimicrobial use has been shown to be an important determinant of the emergence of antimicrobial resistance (AMR). Health information technology (HIT) in the form of Computerised Decision Support (CDS) represents an option for improving antimicrobial prescribing and containing AMR. Objectives To evaluate the evidence for CDS in improving quantitative and qualitative measures of antibiotic prescribing in inpatient hospital settings. Methods A systematic literature search was conducted of articles published from inception to 20th December 2014 using eight electronic databases: MEDLINE, EMBASE, PUBMED, Web of Science, CINAHL, Cochrane Library, HMIC and PsychINFo. An updated systematic literature search was conducted from January 1st 2015 to October 1st 2016 using PUBMED. The search strategy used combinations of the following terms: (electronic prescribing) OR (clinical decision support) AND (antibiotic or antibacterial or antimicrobial) AND (hospital or secondary care or inpatient). Studies were evaluated for quality using a 10-point rating scale. Results Eighty-one studies were identified matching the inclusion criteria. Seven outcome measures were evaluated: adequacy of antibiotic coverage, mortality, volume of antibiotic usage, length of stay, antibiotic cost, compliance with guidelines, antimicrobial resistance, and CDS implementation and uptake. Meta-analysis of pooled outcomes showed CDS significantly improved the adequacy of antibiotic coverage (n = 13; odds ratio [OR], 2.11 [95% CI, 1.67 to 2.66, p ≤ 0.00001]). Also, CDS was associated with marginally lowered mortality (n = 20; OR, 0.85 [CI, 0.75 to 0.96, p = 0.01]). CDS was associated with lower antibiotic utilisation, increased compliance with antibiotic guidelines and reductions in antimicrobial resistance. Conflicting effects of CDS on length of stay, antibiotic costs and system uptake were also noted. Conclusions CDS has the potential to improve the adequacy of antibiotic coverage and marginally decrease mortality in hospital-related settings.
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Affiliation(s)
- Christopher E. Curtis
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- * E-mail:
| | - Fares Al Bahar
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, United Kingdom
| | - John F. Marriott
- School of Pharmacy, College of Medical & Dental Sciences, University of Birmingham, Birmingham, United Kingdom
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Abstract
Vancomycin is a glycopeptide antibiotic that is active against Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus. Nephrotoxicity, which is usually reversible, is the most serious common adverse effect of vancomycin. Vancomycin-associated nephrotoxicity prolongs hospital stays, imposes a need for additional antibiotics and, in rare circumstances, dialysis treatment, and increases medical costs and mortality. Risk factors for nephrotoxicity include the dose and duration of vancomycin treatment, serum trough concentration, patient characteristics, and concomitant receipt of nephrotoxins. Contemporary guidelines recommend targeting vancomycin trough concentrations of ≥10 mg/L to prevent resistance and trough concentrations of 15-20 mg/L to optimize outcomes. There is significant correlation between vancomycin trough serum concentrations and the incidence of vancomycin-associated nephrotoxicity; however, evidence of an association between trough concentrations and efficacy is less convincing. Routine monitoring of serum vancomycin concentrations consumes time and limited healthcare resources and may not be cost effective. The use of alternative antibacterial agents that do not require monitoring would free up pharmacy resources. This time could then be devoted to initiatives such as pharmacist-led antibiotic stewardship programs that are known to reduce antibiotic use and promote improved patient outcomes.
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Affiliation(s)
- Meghan N Jeffres
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, 12850 E. Montview Blvd. V20-1212, Aurora, CO, 80045, USA.
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Doernberg SB, Chambers HF. Antimicrobial Stewardship Approaches in the Intensive Care Unit. Infect Dis Clin North Am 2017; 31:513-534. [PMID: 28687210 DOI: 10.1016/j.idc.2017.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antimicrobial stewardship programs aim to monitor, improve, and measure responsible antibiotic use. The intensive care unit (ICU), with its critically ill patients and prevalence of multiple drug-resistant pathogens, presents unique challenges. This article reviews approaches to stewardship with application to the ICU, including the value of diagnostics, principles of empirical and definitive therapy, and measures of effectiveness. There is good evidence that antimicrobial stewardship results in more appropriate antimicrobial use, shorter therapy durations, and lower resistance rates. Data demonstrating hard clinical outcomes, such as adverse events and mortality, are more limited but encouraging; further studies are needed.
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Affiliation(s)
- Sarah B Doernberg
- Division of Infectious Diseases, Department of Medicine, University of California, 513 Parnassus Avenue, Box 0654, San Francisco, CA 94143, USA.
| | - Henry F Chambers
- Division of Infectious Diseases, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, Room 3400, Building 30, 1001 Potrero Avenue, San Francisco, CA 94110, USA
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Evaluating the Impact of Antibiotic Exposures as Time-Dependent Variables on the Acquisition of Carbapenem-Resistant Acinetobacter baumannii. Crit Care Med 2017; 44:e949-56. [PMID: 27167999 DOI: 10.1097/ccm.0000000000001848] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the time-dependent effect of antibiotics on the initial acquisition of carbapenem-resistant Acinetobacter baumannii. DESIGN Retrospective cohort study. SETTING Forty-bed trauma ICU in Miami, FL. PATIENTS All consecutive patients admitted to the unit from November 1, 2010, to November 30, 2011. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients underwent surveillance cultures at admission to the unit and weekly thereafter. The primary outcome was the acquisition of carbapenem-resistant A. baumannii on surveillance cultures. Daily antibiotic exposures during the time of observation were used to construct time-dependent variables, including cumulative exposures (in grams and daily observed doses [defined daily doses]). Among 360 patients, 45 (12.5%) became colonized with carbapenem-resistant A. baumannii. Adjusted Cox models showed that each additional point in the Acute Physiologic and Chronic Health Evaluation score increased the hazard by 4.8% (hazard ratio, 1.048; 95% CI, 1.010-1.087; p = 0.0124) and time-dependent exposure to carbapenems quadrupled the hazard (hazard ratio, 4.087; 95% CI, 1.873-8.920; p = 0.0004) of acquiring carbapenem-resistant A. baumannii. Additionally, adjusted Cox models determined that every additional carbapenem defined daily dose increased the hazard of acquiring carbapenem-resistant A. baumannii by 5.1% (hazard ratio, 1.051; 95% CI, 1.007-1.093; p = 0.0243). CONCLUSIONS Carbapenem exposure quadrupled the hazards of acquiring A. baumannii even after controlling for severity of illness.
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