Measuring broad-spectrum antibiotic use in hospitals with established versus new indicators

BACKGROUND

The target of a 30 % reduction in the use of broad-spectrum antibiotics in hospitals from 2012 to 2020 was not achieved, measured using the standard indicator of defined daily doses (DDD) per 100 bed days. We wished to investigate the reliability of the standard indicator and of selected alternative indicators for antibiotic use, and to determine the actual reduction in use.

MATERIAL AND METHOD

We included ten DDD-based indicators with adjustment for combinations of activity marker, admission category (inpatient vs. all admissions), and case mix, and evaluated these according to how each indicator correlated with antibiotic resistance in a self-developed model. We then calculated use of broad-spectrum antibiotics in hospitals for the period 2012-20 with indicators deemed valid, and compared these indicators with regard to change in use and ranking of hospitals according to use. We used consumption rate (DDD per 1000 inhabitants per day) as an activity-neutral reference indicator (national and regional).

RESULTS

All the indicators for antibiotic use showed a strong correlation with resistance. For five indicators the correlation was statistically significant. Of these, the indicator that combined adjustment for the total number of admitted patients and case mix accorded best with the consumption rate (35.6 %). The same indicator also showed the largest reduction in use (29.3 %) and gave the most hospitals that achieved a reduction of at least 30 % (13 of 22).

INTERPRETATION

Combined adjustment for number of admitted patients and case mix represents a new, robust indicator for antibiotic use that is suitable for hospitals at all levels. The indicator can be used in parallel with the consumption rate, and consideration should be given to introducing the latter as the new standard indicator at national and regional level.

Antibiotic consumption in Belgian acute care hospitals: analysis of the surveillance methodology, consumption evolution 2003 to 2016 and future perspectives

BackgroundStudies have demonstrated the link between antimicrobial consumption and the development of antimicrobial resistance. Surveillance of antimicrobial consumption is an action point of the European Commission's 'One Health Action Plan Against Antimicrobial Resistance'.AimThis study aims to compare two methodologies for antibiotic consumption surveillance, investigate the 14-year evolution of antibiotic consumption in Belgian acute care hospitals and discuss future perspectives.MethodsWe compared self-reported data (old methodology) and reimbursement data (new methodology) of national antibiotic consumption surveillance in hospitals. Descriptive analyses were performed on the reimbursement data collected per year and per trimester (2003-2016), per hospital and per unit. Antibiotic consumption was compared with European Surveillance of Antimicrobial Consumption Network (ESAC-Net) results.ResultsThe median differences for defined daily doses (DDDs)/1,000 patient days and DDDs/1,000 admissions were 3.09% and 3.94% when comparing the old vs new methodology. Based on reimbursement data, the median antibiotic consumption in 2016 in 102 Belgian acute care hospitals was 577.1 DDDs/1,000 patient days and 3,890.3 DDDs/1,000 admissions with high variation between hospitals (interquartile ranges (IQR): 511.3-655.0 and 3,450.0-4,400.5, respectively), and similar to 2015. Based on DDDs/1,000 patient days, the magnitude of consumption is comparable with the Netherlands, Denmark and Sweden, but is higher when based on DDDs/1,000 admissions.ConclusionAntibiotic consumption in Belgian acute care hospitals has remained overall stable over time. However, the high variation across hospitals should be further investigated. This surveillance data could be used for benchmarking and assessing interventions to improve antibiotic consumption in these hospitals.

Observational Study of Antibiotic Usage at the Children's Clinical University Hospital in Riga, Latvia

Background and objectives: Many pediatric patients have been treated with antibiotics during their hospitalization. There is a need to improve antibiotic prescribing for pediatric patients because many of these prescriptions are inappropriate. Antibiotic consumption analysis was conducted at the Children's Clinical University Hospital to identify targets for quality improvement. Materials and Methods: A one day cross-sectional point prevalence survey (PPS) was conducted in May and November 2011⁻2013 using a previously validated and standardized method. The survey included all inpatient pediatric and neonatal beds and identified all children receiving an antibiotic treatment on the day of survey. Total consumption of systemic antibiotics belonging to the ATC J01 class (except amphenicols (J01B) and a combination of antibacterials (J01R)) was also analyzed by using a defined daily dose (DDD) approach and antibiotic drug utilization (90%DU) for the period 2006⁻2015. Results were compared with results in 2017 using the DDD and 90%DU methodology. Results: The most commonly used antibiotic group in all PPS, except in May and November 2011, was other β-lactam antibiotics (J01D): 42 (40%) prescriptions in May 2013 and 66 (42%) and November 2011. In 2006⁻2015 and also in 2017, the most commonly used antibiotic groups were penicillins (J01C) and other β-lactam antibiotics (J01D)-76% (90%DU) of the total antibiotic consumption registered in 2006, 73% in 2015 and 70% in 2017. Starting in 2008, amoxicillin was the most commonly used antibiotic at the hospital. The usage of ceftriaxone increased from 3% in 2006 to 13% in 2015, but decreased in 2017 (7%). Conclusions: Study results from 2006⁻2015 showed that there was a need to establish a stronger antibiotic prescribing policy in the hospital reducing the use of broad-spectrum antibiotics (especially 3rd generation cephalosporins) and increasing the use of narrower spectrum antibiotics. It was partly achieved in 2017 with some reduction in ceftriaxone use.

Antibiotic consumption and resistance of gram-negative pathogens (collateral damage)

Antibiotics are commonly prescribed in community and hospital care. Overuse and misuse favors emergence and spread of resistant bacteria. The ATC/DDD methodology is commonly used for presenting the drug utilization data. In primary care, the consumption is usually expressed in DDD per 1,000 inhabitants per day, in hospital, preferably in DDD per 100 bed days and DDD per 100 admissions. The alternative metric is days of therapy (DOT), which needs IT support. Antibiotics have ecological adverse effects at individual and population level. Antibiotics select resistant bacteria among pathogens and normal flora. Broad-spectrum antibiotics, low dosage and prolonged antibiotic therapy favor the development of resistance. Although total use of antibiotics in hospital is much less than in the community, the intensity of use magnified by cross infection ensures a multitude of resistant bacteria in today's hospitals. Reversal of resistance is complex and might persist for many years despite the introduction of antimicrobial containment and stewardship programs.

Systematic review of antibiotic consumption in acute care hospitals

Antibiotic consumption is an easily quantifiable performance measure in hospitals and might be used for monitoring. We conducted a review of published studies and online surveillance reports reporting on antibiotic consumption in acute care hospitals between the years 1997 and 2013. A pooled estimate of antibiotic consumption was calculated using a random effects meta-analysis of rates with 95% confidence intervals. Heterogeneity was assessed through subgroup analysis and metaregression. Eighty studies, comprising data from 3130 hospitals, met the inclusion criteria. The pooled rate of hospital-wide consumption was 586 (95% confidence interval 540 to 632) defined daily doses (DDD)/1000 hospital days (HD) for all antibacterials. However, consumption rates were highly heterogeneous. Antibacterial consumption was highest in intensive care units, at 1563 DDD/1000 HD (95% confidence interval 1472 to 1653). Hospital-wide antibacterial consumption was higher in Western Europe and in medium-sized, private and university-affiliated hospitals. The methods of data collection were significantly associated with consumption rates, including data sources, dispensing vs. purchase vs. usage data, counting admission and discharge days and inclusion of low-consumption departments. Heterogeneity remained in all subgroup analyses. Major heterogeneity currently precludes defining acceptable antibiotic consumption ranges in acute care hospitals. Guidelines on antibiotic consumption reporting that will account for case mix and a minimal set of hospital characteristics recommending standardized methods for monitoring and reporting are needed.

Antibiotic consumption among a Swedish cohort of children born in 2006

AIM

It is important to measure antibiotic consumption because it contributes to antimicrobial resistance. Our objective was to follow all children born in 2006 in Sweden and to analyse antibiotic consumption during each month of life for the first two years and thereafter for every year during their third to fifth years of life.

METHODS

This was a register-based, open-cohort study where we used the Swedish Prescribed Drug Register, which covers the whole population, to identify the type and date of purchase of antibiotics for the children in the cohort.

RESULTS

During the first one-year follow-up period, 101 555 children up to one year of age were living in Sweden, of which 50 135 were boys and 49 420 were girls. Children consumed the largest amount of antibiotics during their second year of life. In our cohort, 51% received antibiotics at some point during the second year and 24% received multiple treatments. The consumption then dropped with every year of life during the follow-up.

CONCLUSION

This study suggests that actions against overprescribing of antibiotics to children should be targeted towards the second year of life in order to have the greatest effect on consumption.

Why infectious diseases

Infectious diseases is a broad discipline that is almost unique in contemporary medicine with its ability to cure and prevent disease, to identify specific disease causes (microbes), and to deal with diverse, sometimes massive outbreaks. The value of the infectious disease practitioner is now magnified by the crisis of antibiotic resistance, the expanding consequences of international travel, the introduction of completely new pathogen diagnostics, and healthcare reform with emphasis on infection prevention and cost in dollars and lives. Infectious disease careers have great personal rewards to the practitioner based on these observations. It is unfortunate that we have been so effective in our work, but relatively ineffective in convincing the healthcare system of this value.

Assessment of Antimicrobial Utilization Metrics: Days of Therapy Versus Defined Daily Doses and Pharmacy Dispensing Records Versus Nursing Administration Data

OBJECTIVE

To compare antimicrobial utilization data derived from pharmacy dispensing records and nursing administration record data by 2 commonly used units of measure.

DESIGN, PARTICIPANTS, AND METHODS

Data from nursing administration records and pharmacy dispensing records were obtained for 32 medical wards. From nursing and pharmacy data, defined daily doses (DDD) were calculated, and from the nursing data, days of therapy were derived. Direct comparison of total antimicrobial use was performed by graphical analysis and linear regression. Slope of trend line was used to quantify the difference between pairs of measures. Bland-Altman plots were constructed to determine constant and proportional bias. At the level of individual agents, difference between pairs of measures was calculated and presented graphically and the average (95% CI) for the difference between measures was determined.

RESULTS

Nursing administration record–derived DDD were on average 23% lower than corresponding rates of pharmacy dispensing record–derived DDD. The difference between rates of utilization by days of therapy vs DDD from the same source (nursing) was relatively small. Results from analysis of different individual agents were highly variable with wide 95% CIs.

CONCLUSIONS

In our setting, we found clinically relevant differences in antimicrobial utilization associated with data from different sources. This outweighed the importance of the metric (DDD or days of therapy). However, measurement of use of individual agents was highly variable and sensitive to both metric unit and data sources.

Infect Control Hosp Epidemiol 2015;00(0): 1–7

Hospital- and patient-related factors associated with differences in hospital antibiotic use: analysis of national surveillance results

Background

Surveillance data of antibiotic use are increasingly being used for benchmarking purposes, but there is a lack of studies dealing with how hospital- and patient-related factors affect antibiotic utilization in hospitals. Our objective was to identify factors that may contribute to differences in antibiotic use.

Methods

Based on pharmacy sales data (2006–2011), use of all antibiotics, all penicillins, and broad-spectrum antibiotics was analysed in 22 Health Enterprises (HEs). Antibiotic utilization was measured in World Health Organisation defined daily doses (DDDs) and hospital-adjusted (ha)DDDs, each related to the number of bed days (BDs) and the number of discharges. For each HE, all clinical specialties were included and the aggregated data at the HE level constituted the basis for the analyses. Fourteen variables potentially associated with the observed antibiotic use – extracted from validated national databases – were examined in 12 multiple linear regression models, with four different measurement units: DDD/100 BDs, DDD/100 discharges, haDDD/100 BDs and haDDD/100 discharges.

Results

Six variables were independently associated with antibiotic use, but with a variable pattern depending on the regression model. High levels of nurse staffing, high proportions of short (<2 days) and long (>10 days) hospital stays, infectious diseases being the main ICD-10 diagnostic codes, and surgical diagnosis-related groups were correlated with a high use of all antibiotics. University affiliated HEs had a lower level of antibiotic utilization than other institutions in eight of the 12 models, and carried a high explanatory strength. The use of broad-spectrum antibiotics correlated strongly with short and long hospital stays. There was a residual variance (30%–50% for all antibiotics; 60%–70% for broad-spectrum antibiotics) that our analysis did not explain.

Conclusions

The factors associated with hospital antibiotic use were mostly non-modifiable. By adjusting for these factors, it will be easier to evaluate and understand observed differences in antibiotic use between hospitals. Consequently, the inter-hospital differences can be more confidently acted upon. The residual variation is presumed to largely reflect prescriber-related factors.

Feasibility and impact of an intensified antibiotic stewardship programme targeting cephalosporin and fluoroquinolone use in a tertiary care university medical center

BACKGROUND

Restricted use of third-generation cephalosporins and fluoroquinolones has been linked to a reduced incidence of hospital-acquired infections with multidrug-resistant bacteria. We implemented an intensified antibiotic stewardship (ABS) programme in the medical service of a university hospital center aiming at a reduction by at least 30% in the use of these two drug classes.

METHODS

The ABS programme was focused on the 300-bed medical service. Prescription of third-generation cephalosporins was discouraged, whereas the use of penicillins was encouraged. Monthly drug use density was measured in WHO-ATC defined and locally recommended daily doses (DDD and RDD) per 100 patient days, to evaluate trends before (01/2008 to 10/2011) and after starting the intervention (1/2012 to 3/2013). The effect was analysed using interrupted time-series analysis with six non-intervention departments as controls.

RESULTS

Following initiation of the ABS intervention, overall antibiotic use in the medical service declined (p < 0.001). There was a significant intervention-related decrease in the use of cephalosporins and fluoroquinolones (p < 0.001) outperforming the decreasing baseline trend. Trend changes observed in some of the control departments were smaller, and the difference between trend changes in the medical service and those in control departments were highly significant for overall use and cephalosporin use reductions (p < 0.001) as well as for the increasing use of penicillins (p < 0.001). Mean use density levels (in RDD per 100 patient days) dropped for cephalosporins from 16.3 to 10.3 (-37%) and for fluoroquinolones from 17.7 to 10.1 (-43%), respectively. During the same period, the use of penicillins increased (15.4 to 18.2; 18%). The changes in expenditures for antibiotics in the medical service compared to control services minus programme costs indicated initial net cost savings likely to be associated with the programme.

CONCLUSION

An intensified ABS programme targeting cephalosporin und fluoroquinolone use in the setting of a large academic hospital is feasible and effective. The intervention may serve as a model for other services and hospitals with a similar structure and baseline situation.

Emerging Infectious Diseases, Antimicrobial Resistance and Millennium Development Goals: Resolving the Challenges through One Health

Most emerging infectious diseases are zoonoses, which could severely hamper reaching the targets of millennium development goals (MDG). Five out of the total eight MDG's are strongly associated with the Emerging Infectious Diseases (EIDs). Recent emergence and dissemination of drug-resistant pathogens has accelerated and prevent reaching the targets of MDG, with shrinking of therapeutic arsenal, mostly due to antimicrobial resistance (AMR). World Health Organization (WHO has identified AMR as 1 of the 3 greatest threats to global health. Until now, methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) have been observed in hospital-acquired infections. In India, within a span of three years, New Delhi metallo-β-lactamase prevalence has risen from three percent in hospitals to twenty- fifty percent and is found to be colistin resistant as well. Routine use of antimicrobials in animal husbandry accounts for more than 50% in tonnage of all antimicrobial production to promote growth and prophylaxis. This has consequences to human health and environmental contamination with a profound impact on the environmental microbiome, resulting in resistance. Antibiotic development is now considered a global health crisis. The average time required to receive regulatory approval is 7.2 years. Moreover, the clinical approval success is only 16%. To overcome resistance in antimicrobials, intersectoral partnerships among medical, veterinary, and environmental disciplines, with specific epidemiological, diagnostic, and therapeutic approaches are needed. Joint efforts under "One Health", beyond individual professional boundaries are required to stop antimicrobial resistance against zoonoses (EID) and reach the MDG.

WHO defined daily doses versus hospital-adjusted defined daily doses: impact on results of antibiotic use surveillance

OBJECTIVES

To investigate effects on surveillance results of hospital antibiotic use when WHO defined daily doses (WHO DDDs) are adjusted to doses recommended for hospitalized patients [hospital-adjusted defined daily doses (haDDDs)].

METHODS

Data for antibiotic use in 2006-11 for all 22 Norwegian Health Enterprises were analysed with both WHO DDDs and haDDDs as numerators. The haDDDs were determined from recommendations given in regional and national guidelines on antibiotic use in hospitals. The two ways of calculating the amount of antibiotic use were compared, with either the number of bed days (BDs) or the number of discharges as the denominator. The drug utilization 90% methodology was applied for ranking the use of the various antibiotics.

RESULTS

DDD adjustments altered the figures for total antibiotic use from 67.1 WHO DDDs/100 BDs to 49.3 haDDDs/100 BDs (-26.4%). The most marked difference was found for penicillins: 31.1 WHO DDDs/100 BDs versus 13.4 haDDDs/100 BDs (-56.8%). The corresponding figures for broad-spectrum antibiotics were 17.3 and 15.5 (-10.4%), respectively; for these antibiotics, the conversion changes varied significantly between institutions, from -16.7% to -3.3%. Ranking antibiotic use based on haDDDs resulted in higher positions for metronidazole, cefuroxime, cefotaxime and cefalotin/cefalexin compared with the WHO DDD-based ranking, where the penicillins dominated.

CONCLUSIONS

The low-set WHO DDDs for penicillins caused skewed surveillance results that concealed the real magnitude of broad-spectrum antibiotic use and distorted interhospital comparisons. For surveillance of antibiotic use in hospitals, WHO DDDs should be supplemented with haDDDs.

Seven ways to preserve the miracle of antibiotics

Antibiotic resistance is a well-acknowledged crisis with no clearly defined comprehensive, national corrective plan. We propose a number of interventions that, collectively, could make a large difference. These include collection of data to inform decisions, efforts to reduce antibiotic abuse in people and animals, great emphasis on antibiotic stewardship, performance incentives, optimal use of newer diagnostics, better support for clinical and basic resistance-related research, and novel methods to foster new antibiotic development.

Implementation of an antimicrobial stewardship program on the medical-surgical service of a 100-bed community hospital

Background

Antimicrobial stewardship has been promoted as a key strategy for coping with the problems of antimicrobial resistance and Clostridium difficile. Despite the current call for stewardship in community hospitals, including smaller community hospitals, practical examples of stewardship programs are scarce in the reported literature. The purpose of the current report is to describe the implementation of an antimicrobial stewardship program on the medical-surgical service of a 100-bed community hospital employing a core strategy of post-prescriptive audit with intervention and feedback.

Methods

For one hour twice weekly, an infectious diseases physician and a clinical pharmacist audited medical records of inpatients receiving systemic antimicrobial therapy and made non-binding, written recommendations that were subsequently scored for implementation. Defined daily doses (DDDs; World Health Organization Center for Drug Statistics Methodology) and acquisition costs per admission and per patient-day were calculated monthly for all administered antimicrobial agents.

Results

The antimicrobial stewardship team (AST) made one or more recommendations for 313 of 367 audits during a 16-month intervention period (September 2009 – December 2010). Physicians implemented recommendation(s) from each of 234 (75%) audits, including from 85 of 115 for which discontinuation of all antimicrobial therapy was recommended. In comparison to an 8-month baseline period (January 2009 – August 2009), there was a 22% decrease in defined daily doses per 100 admissions (P = .006) and a 16% reduction per 1000 patient-days (P = .013). There was a 32% reduction in antimicrobial acquisition cost per admission (P = .013) and a 25% acquisition cost reduction per patient-day (P = .022).

Conclusions

An effective antimicrobial stewardship program was implemented with limited resources on the medical-surgical service of a 100-bed community hospital.

Surveillance of broad-spectrum antibiotic prescription in Singaporean hospitals: a 5-year longitudinal study

BACKGROUND

Inappropriate prescription of antibiotics may contribute towards higher levels antimicrobial resistance. A key intervention for improving appropriate antibiotic prescription is surveillance of prescription. This paper presents the results of a longitudinal surveillance of broad-spectrum antibiotic prescription in 5 public-sector hospitals in Singapore from 2006 to 2010.

METHODOLOGY/PRINCIPAL FINDINGS

Quarterly antibiotic prescription data were obtained and converted to defined daily doses (DDDs) per 1,000 inpatient-days. The presence of significant trends in antibiotic prescription over time for both individual and combined hospitals was tested by regression analysis and corrected for autocorrelation between time-points. Excluding fluoroquinolones, there was a significant increase in prescription of all monitored antibiotics from an average of 233.12 defined daily doses (DDD)/1,000 inpatient-days in 2006 to 254.38 DDD/1,000 inpatient-days in 2010 (Coefficient = 1.13, 95%CI: 0.16-2.09, p = 0.025). Increasing utilization of carbapenems, piperacillin/tazobactam, and Gram-positive agents were seen in the majority of the hospitals, while cephalosporins were less prescribed over time. The combined expenditure for 5 hospitals increased from USD9.9 million in 2006 to USD16.7 million in 2010.

CONCLUSIONS/SIGNIFICANCE

The rate of prescription of broad-spectrum antibiotics in Singaporean hospitals is much higher compared to those of European hospitals. This may be due to high rates of antimicrobial resistance. The increase in expenditure on monitored antibiotics over the past 5 years outstripped the actual increase in DDD/1,000 inpatient-days of antibiotics prescribed. Longitudinal surveillance of antibiotic prescription on a hospital and countrywide level is important for detecting trends for formulating interventions or policies. Further research is needed to understand the causes for the various prescription trends and to act on these where necessary.

European Surveillance of Antimicrobial Consumption (ESAC): value of a point-prevalence survey of antimicrobial use across Europe

All 27 EU member states and another seven countries participate in the European Surveillance of Antimicrobial Consumption (ESAC) project. ESAC carried out three hospital point-prevalence surveys on antimicrobial use. Point-prevalence surveys linked antimicrobial use to indication and also assessed dosing using a standardized methodology for data collection and online data submission with feedback capability using a dedicated web-based tool. The objectives of the ESAC hospital point-prevalence surveys were to first determine the feasibility of a pan-European survey and identify targets for quality improvement. Hospitals were voluntarily selected by the lead national or hospital representatives for each country. The WHO Anatomical Therapeutic Chemical Classification of drugs was used for classification of antimicrobials. The three surveys were carried out during a maximum of 2 weeks in the second quarter of 2006, 2008 and 2009. Each department had to be surveyed in 1 day. All systemic antibacterials (J01), rifampicin (J04AB), oral vancomycin (A07AA) and oral/rectal metronidazole (P01AB) were the antimicrobials surveyed, including the prescribed regimen. The number of participating hospitals increased from 20 to 172 from 2006 to 2009. The patient demographics and indications for treatment were similar throughout the three point-prevalence surveys. 'Reason in notes' and 'surgical prophylaxis >24 hours' were also similar. Guideline compliance (51%) was only introduced in the 2009 point-prevalence survey, replacing 'sample for culture and sensitivity' (<50% in 2006 and 2008) since samples were either not taken or no information was available for the majority (>50%) of patients. The use of combination therapy, although exhibiting a wide range within each category, was related to hospital type, with teaching and tertiary hospitals having a significantly higher use of combination therapy (teaching : non-teaching hospitals [p < 0.0001]; and primary : tertiary hospitals [p < 0.0001]). Point-prevalence surveys are useful when time and resources do not allow for continuous surveillance. Repeated point-prevalence surveys within the same institution(s) can be used to monitor trends and effectiveness of antimicrobial-stewardship initiatives. Targets should be set as quality indicators for the individual hospital(s) and effectiveness of any intervention monitored through repeated point-prevalence surveys. Spin-off initiatives, such as the Antibiotic Resistance and Prescribing in European Children, and the European Centre for Disease Prevention and Control point-prevalence survey on healthcare-associated infections and antimicrobial use, will utilize adapted versions of WebPPS, the point-prevalence survey software developed by ESAC. WebPPS will also be made available for non-commercial use to third parties. Interest has been shown from three continents outside Europe, namely North America, Australia and Africa.