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Harvey EJ, McLeod M, De Brún C, Ashiru-Oredope D. Criteria to achieve safe antimicrobial intravenous-to-oral switch in hospitalised adult populations: a systematic rapid review. BMJ Open 2023; 13:e068299. [PMID: 37419640 PMCID: PMC10335582 DOI: 10.1136/bmjopen-2022-068299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 06/04/2023] [Indexed: 07/09/2023] Open
Abstract
OBJECTIVES This rapid review aimed to assess and collate intravenous-to-oral switch (IVOS) criteria from the literature to achieve safe and effective antimicrobial IVOS in the hospital inpatient adult population. DESIGN The rapid review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. DATA SOURCES OVID Embase and Medline databases. ELIGIBILITY CRITERIA Articles of adult populations published globally between 2017 and 2021 were included. DATA EXTRACTION AND SYNTHESIS An Excel spreadsheet was designed with specific column headings. IVOS criteria from UK hospital IVOS policies informed the framework synthesis. RESULTS IVOS criteria from 45/164 (27%) local IVOS policies were categorised into a five-section framework: (1) timing of IV antimicrobial review, (2) clinical signs and symptoms, (3) infection markers, (4) enteral route and (5) infection exclusions. The literature search identified 477 papers, of which 16 were included. The most common timing for review was 48-72 hours from initiation of intravenous antimicrobial (n=5, 30%). Nine studies (56%) stated clinical signs and symptoms must be improving. Temperature was the most frequently mentioned infection marker (n=14, 88%). Endocarditis had the highest mention as an infection exclusion (n=12, 75%). Overall, 33 IVOS criteria were identified to go forward into the Delphi process. CONCLUSION Through the rapid review, 33 IVOS criteria were collated and presented within five distinct and comprehensive sections. The literature highlighted the possibility of reviewing IVOS before 48-72 hours and of presenting heart rate, blood pressure and respiratory rate as a combination early warning score criterion. The criteria identified can serve as a starting point of IVOS criteria review for any institution globally, as no country or region limits were applied. Further research is required to achieve consensus on IVOS criteria from healthcare professionals that manage patients with infections. PROSPERO REGISTRATION NUMBER CRD42022320343.
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Affiliation(s)
- Eleanor J Harvey
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use & Sepsis Division, UK Health Security Agency, London, UK
| | - Monsey McLeod
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
- Antimicrobial Prescribing and Medicines Optimisation, NHS England and NHS Improvement London, London, UK
| | - Caroline De Brún
- Knowledge and Library Services, UK Health Security Agency, London, UK
| | - Diane Ashiru-Oredope
- Healthcare-Associated Infection, Fungal, Antimicrobial Resistance, Antimicrobial Use & Sepsis Division, UK Health Security Agency, London, UK
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK
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Wild J, Siegrist B, Hobohm L, Münzel T, Schwanz T, Sagoschen I. Short and Concise Peer-to-Peer Teaching—Example of a Successful Antibiotic Stewardship Intervention to Increase Iv to Po Conversion. Antibiotics (Basel) 2022; 11:antibiotics11030402. [PMID: 35326866 PMCID: PMC8944614 DOI: 10.3390/antibiotics11030402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 12/05/2022] Open
Abstract
Antibiotic stewardship (ABS) programs aim to combine effective treatment with minimized antibiotic-related harms. Common ABS interventions are simple and effective, but their implementation in daily practice is often difficult. The aim of our study was to investigate if a single, short, peer-to-peer teaching intervention (junior doctor to junior doctor) during clinical routine can successfully improve antibiotic prescriptions. We performed a quasi-experimental before–after study on a regular care cardiology ward at a large academic medical center in Germany. We evaluated antibiotic use metrics retrospectively and calculated defined daily doses (DDD) with the anatomical therapeutic chemical/DDD classification system of the World Health Organization. We hypothesize that the over-representative use of intravenous administration is a potentially modifiable target, which can be proven by antibiotic use metrics analysis. After a single peer-to-peer teaching session with a focus on indications for iv to po conversion, the normalized percentage of intravenous compared to oral administration significantly decreased (from 86.5 ± 50.3% to 41.4 ± 70.3%). Moreover, after the intervention, antibiotics with high oral bioavailability were no longer administered intravenously at all during the following quarter. Our results indicate that even a single peer-to-peer training session is highly effective in improving the iv to po conversion rate in the short term.
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Affiliation(s)
- Johannes Wild
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (L.H.); (T.M.); (I.S.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Correspondence:
| | - Bettina Siegrist
- Department of Pharmacy, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany;
| | - Lukas Hobohm
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (L.H.); (T.M.); (I.S.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (L.H.); (T.M.); (I.S.)
| | - Thomas Schwanz
- Institute of Medical Microbiology and Hygiene, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany;
| | - Ingo Sagoschen
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (L.H.); (T.M.); (I.S.)
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Chowdhury K, Haque M, Nusrat N, Adnan N, Islam S, Lutfor AB, Begum D, Rabbany A, Karim E, Malek A, Jahan N, Akter J, Ashraf S, Hasan MN, Hassan M, Akhter N, Mazumder M, Sihan N, Naher N, Akter S, Zaman SU, Chowdhury T, Nesa J, Biswas S, Islam MD, Hossain AM, Rahman H, Biswas PK, Shaheen M, Chowdhury F, Kumar S, Kurdi A, Mustafa ZU, Schellack N, Gowere M, Meyer JC, Opanga S, Godman B. Management of Children Admitted to Hospitals across Bangladesh with Suspected or Confirmed COVID-19 and the Implications for the Future: A Nationwide Cross-Sectional Study. Antibiotics (Basel) 2022; 11:antibiotics11010105. [PMID: 35052982 PMCID: PMC8772946 DOI: 10.3390/antibiotics11010105] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/04/2022] [Accepted: 01/11/2022] [Indexed: 02/07/2023] Open
Abstract
There is an increasing focus on researching children admitted to hospital with new variants of COVID-19, combined with concerns with hyperinflammatory syndromes and the overuse of antimicrobials. Paediatric guidelines have been produced in Bangladesh to improve their care. Consequently, the objective is to document the management of children with COVID-19 among 24 hospitals in Bangladesh. Key outcome measures included the percentage prescribed different antimicrobials, adherence to paediatric guidelines and mortality rates using purposely developed report forms. The majority of 146 admitted children were aged 5 years or under (62.3%) and were boys (58.9%). Reasons for admission included fever, respiratory distress and coughing; 86.3% were prescribed antibiotics, typically parenterally, on the WHO ‘Watch’ list, and empirically (98.4%). There were no differences in antibiotic use whether hospitals followed paediatric guidance or not. There was no prescribing of antimalarials and limited prescribing of antivirals (5.5% of children) and antiparasitic medicines (0.7%). The majority of children (92.5%) made a full recovery. It was encouraging to see the low hospitalisation rates and limited use of antimalarials, antivirals and antiparasitic medicines. However, the high empiric use of antibiotics, alongside limited switching to oral formulations, is a concern that can be addressed by instigating the appropriate programmes.
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Affiliation(s)
- Kona Chowdhury
- Department of Paediatrics, Gonoshasthaya Samaj Vittik Medical College and Hospital, Savar, Dhaka 1344, Bangladesh;
| | - Mainul Haque
- Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Besi, Kuala Lumpur 57000, Malaysia
- Correspondence: (M.H.); (B.G.); Tel.: +60-3-9051-3400 (ext. 2257) (M.H.); +44-141-548-3825 (B.G.)
| | - Nadia Nusrat
- Department of Paediatrics, Delta Medical College and Hospital, 26/2, Principal Abul Kashem Road, Mirpur-1, Dhaka 1216, Bangladesh;
| | - Nihad Adnan
- Department of Microbiology, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh; (N.A.); (S.I.); (S.U.Z.)
| | - Salequl Islam
- Department of Microbiology, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh; (N.A.); (S.I.); (S.U.Z.)
| | - Afzalunnessa Binte Lutfor
- Department of Microbiology, Ad-Din Women’s Medical College, 2 Boro Mogbazar, Dhaka 1217, Bangladesh;
| | - Dilara Begum
- Depatment of Paediatrics, Dhaka Medical College Hospital, 100 Ramna Central Shaheed Minar Area, Bakshi Bazar, Dhaka 1000, Bangladesh;
| | - Arif Rabbany
- Department of Paediatrics, Mymensnigh Medical College Hospital, Dhaka-Mymensingh Road, Mymensingh Sadar, Mymensingh 2200, Bangladesh;
| | - Enamul Karim
- Department of Paediatrics, US-Bangla Medical College, Kornogop, Tarabo, Rupganj, Narayangonj 1460, Bangladesh;
| | - Abdul Malek
- Department of Pediatrics, Green Life Medical College Hospital, Dhaka 1205, Bangladesh;
| | - Nasim Jahan
- Department of Pediatrics, Asgar Ali Hospital, Distillary Road, Ganderia, Dhaka 1204, Bangladesh;
| | - Jesmine Akter
- Department of Pediatrics, Bangladesh Specialized Hospital, Mirpur Road, Dhaka 1207, Bangladesh;
| | - Sumala Ashraf
- Department of Paediatrics, Holy Family Red Crescent Medical College Hospital, 1-Eskaton Garden Road, Dhaka 1000, Bangladesh;
| | - Mohammad Nazmul Hasan
- Department Paediatric Surgery, Cumilla Medical College Hospital, Cumilla 3500, Bangladesh;
| | - Mahmuda Hassan
- Department of Paediatrics, Ad-din Women’s Medical College, 2 Boro Mogbazar, Dhaka 1217, Bangladesh;
| | - Najnin Akhter
- Department of Pediatrics, Cumilla Medical College Hospital, Cumilla 3500, Bangladesh; (N.A.); (N.S.)
| | - Monika Mazumder
- Department of Pediatrics, Rangpur Medical College, Rangpur 5400, Bangladesh;
| | - Nazmus Sihan
- Department of Pediatrics, Cumilla Medical College Hospital, Cumilla 3500, Bangladesh; (N.A.); (N.S.)
| | - Nurun Naher
- Department of Pediatrics, Evercare Hospital, Plot-81, Block-E, Bashundhara Residential Area, Dhaka 1229, Bangladesh;
| | - Shaheen Akter
- Department of Pediatrics, Enam Medical College and Hospital, Savar, Dhaka 1340, Bangladesh;
| | - Sifat Uz Zaman
- Department of Microbiology, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh; (N.A.); (S.I.); (S.U.Z.)
| | - Tanjina Chowdhury
- Department of Pediatrics, Sylhet M.A.G. Osmani Medical College Hospital, Medical College Road, Kajolshah, Sylhet 3100, Bangladesh;
| | - Jebun Nesa
- Department of Paediatrics, Center for Women and Child Health, Savar, Dhaka 1349, Bangladesh;
| | - Susmita Biswas
- Department of Paediatrics, Chattogram Medical College Hospital, Panchlaish, Chattogram 4203, Bangladesh; (S.B.); (M.S.)
| | - Mohammod Didarul Islam
- Department of Paediatrics, Shaheed Syed Nazrul Islam Medical College, Kishorganj 2300, Bangladesh;
| | - Al Mamun Hossain
- Department of Paediatrics, Satkhira Medical College Hospital, Baka, Satkhira 9400, Bangladesh;
| | - Habibur Rahman
- Department of Paediatrics, Meherpur District Hospital, Meherpur 7100, Bangladesh;
| | - Palash Kumar Biswas
- Department of Paediatrics, Jashore Medical College Hospital, Jessore 7400, Bangladesh;
| | - Mohammed Shaheen
- Department of Paediatrics, Chattogram Medical College Hospital, Panchlaish, Chattogram 4203, Bangladesh; (S.B.); (M.S.)
| | - Farah Chowdhury
- Department of Paediatrics, Chattogram Ma Shishu Hospital Medical College, Chattogram 4100, Bangladesh;
| | - Santosh Kumar
- Department of Periodontology and Implantology, Karnavati University, Gandhinagar 382422, India;
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, UK;
- Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil 44001, Iraq
- Center of Research and Strategic Studies, Lebanese French University, Erbil 44001, Iraq
| | - Zia Ul Mustafa
- Department of Pharmacy Services, District Headquarter (DHQ) Hospital, Pakpattan 57400, Pakistan;
| | - Natalie Schellack
- Department of Pharmacology, Faculty of Health Sciences, University of Pretoria, Pretoria 0007, South Africa; (N.S.); (M.G.)
| | - Marshall Gowere
- Department of Pharmacology, Faculty of Health Sciences, University of Pretoria, Pretoria 0007, South Africa; (N.S.); (M.G.)
| | - Johanna C. Meyer
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa;
| | - Sylvia Opanga
- Department of Pharmaceutics and Pharmacy Practice, School of Pharmacy, University of Nairobi, Nairobi 00202, Kenya;
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, UK;
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa;
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman P.O. Box 346, United Arab Emirates
- Correspondence: (M.H.); (B.G.); Tel.: +60-3-9051-3400 (ext. 2257) (M.H.); +44-141-548-3825 (B.G.)
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Kallen MC, Hulscher MEJL, Elzer B, Geerlings SE, van der Linden PD, Teerenstra S, Natsch S, Opmeer BC, Prins JM. A multicentre cluster-randomized clinical trial to improve antibiotic use and reduce length of stay in hospitals: comparison of three measurement and feedback methods. J Antimicrob Chemother 2021; 76:1625-1632. [PMID: 33638644 PMCID: PMC8120330 DOI: 10.1093/jac/dkab035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/20/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Various metrics of hospital antibiotic use might assist in guiding antimicrobial stewardship (AMS). OBJECTIVES To compare patient outcomes in association with three methods to measure and feedback information on hospital antibiotic use when used in developing an AMS intervention. METHODS Three methods were randomly allocated to 42 clusters from 21 Dutch hospitals: (1) feedback on quantity of antibiotic use [DDD, days-of-therapy (DOT) from hospital pharmacy data], versus feedback on (2) validated, or (3) non-validated quality indicators from point prevalence studies. Using this feedback together with an implementation tool, stewardship teams systematically developed and performed improvement strategies. The hospital length of stay (LOS) was the primary outcome and secondary outcomes included DOT, ICU stay and hospital mortality. Data were collected before (February-May 2015) and after (February-May 2017) the intervention period. RESULTS The geometric mean hospital LOS decreased from 9.5 days (95% CI 8.9-10.1, 4245 patients) at baseline to 9.0 days (95% CI 8.5-9.6, 4195 patients) after intervention (P < 0.001). No differences in effect on LOS or secondary outcomes were found between methods. Feedback on quality of antibiotic use was used more often to identify improvement targets and was preferred over feedback on quantity of use. Consistent use of the implementation tool seemed to increase effectiveness of the AMS intervention. CONCLUSIONS The decrease in LOS versus baseline likely reflects improvement in the quality of antibiotic use with the stewardship intervention. While the outcomes with the three methods were otherwise similar, stewardship teams preferred data on the quality over the quantity of antibiotic use.
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Affiliation(s)
- M C Kallen
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
| | - M E J L Hulscher
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - B Elzer
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
| | - S E Geerlings
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
| | - P D van der Linden
- Tergooi Hospital, Department of Clinical Pharmacy, Van Riebeeckweg 212, Hilversum, The Netherlands
| | - S Teerenstra
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department for Health Evidence, Group Biostatistics, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - S Natsch
- Radboud University Medical Center, Department of Pharmacy, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - B C Opmeer
- Amsterdam UMC, University of Amsterdam, Clinical Research Unit, Meibergdreef 9, Amsterdam, The Netherlands
| | - J M Prins
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
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Nik Zuraina NMN, Goni MD, Amalina KN, Hasan H, Mohamad S, Suraiya S. Thermostable Heptaplex PCR Assay for the Detection of Six Respiratory Bacterial Pathogens. Diagnostics (Basel) 2021; 11:diagnostics11050753. [PMID: 33922299 PMCID: PMC8146555 DOI: 10.3390/diagnostics11050753] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 01/15/2023] Open
Abstract
A thermostabilized, multiplex polymerase chain reaction (mPCR) assay was developed in this study for the detection of six respiratory bacterial pathogens. Specific primers were designed for an internal amplification control (IAC) and six target sequences from Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, Mycobacterium tuberculosis, and Haemophilus influenzae. The resultant seven-band positive amplification control (PAC) of this heptaplex PCR assay corresponded to 105 base pairs (bp) of IAC, 202 bp of K. pneumoniae, 293 bp of S. aureus, 349 bp of S. pneumoniae, 444 bp of P. aeruginosa, 505 bp of M. tuberculosis, and 582 bp of H. influenzae. Results found that 6% (w/v) of the stabilizer was optimum to preserve the functional conformation of Taq DNA polymerase enzyme. This assay was stable at ambient temperature for at least 6 months. The sensitivity and specificity of this assay were both 100% when testing on the intended target organisms (n = 119) and non-intended species (n = 57). The mPCR assay developed in this study enabled accurate, rapid, and simple detection of six respiratory bacteria.
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Affiliation(s)
- Nik Mohd Noor Nik Zuraina
- Department of Medical Microbiology and Parasitology, Universiti Sains Malaysia, Kota Bharu 16150, Kelantan, Malaysia; (N.M.N.N.Z.); (K.N.A.); (H.H.)
| | - Mohammed Dauda Goni
- Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Kota Bharu 16100, Kelantan, Malaysia;
| | - Khazani Nur Amalina
- Department of Medical Microbiology and Parasitology, Universiti Sains Malaysia, Kota Bharu 16150, Kelantan, Malaysia; (N.M.N.N.Z.); (K.N.A.); (H.H.)
| | - Habsah Hasan
- Department of Medical Microbiology and Parasitology, Universiti Sains Malaysia, Kota Bharu 16150, Kelantan, Malaysia; (N.M.N.N.Z.); (K.N.A.); (H.H.)
| | - Suharni Mohamad
- School of Dental Sciences, Universiti Sains Malaysia, Kota Bharu 16150, Kelantan, Malaysia;
| | - Siti Suraiya
- Department of Medical Microbiology and Parasitology, Universiti Sains Malaysia, Kota Bharu 16150, Kelantan, Malaysia; (N.M.N.N.Z.); (K.N.A.); (H.H.)
- Correspondence:
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Implementation of pharmacist-managed early switch from intravenous to oral therapy using electronic identification at a tertiary academic hospital. Saudi Pharm J 2021; 29:324-336. [PMID: 33994827 PMCID: PMC8093584 DOI: 10.1016/j.jsps.2021.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/06/2021] [Indexed: 11/20/2022] Open
Abstract
Overutilization of intravenous (IV) medications can result in drug shortages, which is one of the major health care crisis, in addition to increasing costs, length of hospital stays (LOS) and the associated complications. We hypothesized that IV therapy was overused at our hospital where oral (PO) was applicable, and that the implementation of IV-PO protocol could result in a cost-effective practice. Hence, we aimed at assessing impact and outcomes of implementing such a protocol. A single center, prospective quasi-interventional study conducted at tertiary academic hospital. A protocol was implemented targeting 17 medications, with educational sessions to medical staff during a 5-month phase. IV orders of 48 h or more, among adult patients at medical or surgical wards with no contraindication to PO route were eligible. Once eligible, pharmacists send interventions using hospital's computerized order entry system, and physicians' responses were monitored on daily basis. Efficacy was estimated by percentage of switch recommendations that resulted in effective switch to PO medication. Cost-minimization analysis was used for course cost between the control phase and intervention phase. Length of hospital stay (LOS), readmissions within 90 days and in-hospital mortality were analyzed as secondary outcomes. During intervention phase, 781 patients had at least one IV order switched to PO. Gastric acid-reducing agents (GARAs) accounted for the most IV prescriptions (50.4%), followed by antibiotics (39.6%). Pharmacists carried out 2677 interventions to which switch recommendations were issued in 1185 (44.3%). Primary switch recommendations (N = 677) led to effective switch in 60.7% cases. These included per protocol switch (8.9%), switch to another PO (2.5%), spontaneous switch by physician (17.6%) and IV discontinuation (31.8%). The overall efficacy was estimated as 62.8%. The intervention was associated with reduced IV consumption from 4,574-18,597 vials in control phase to 3,654-15,546 vials in intervention phase, which resulted in overall cost saving of 50,960.8 SAR ($13,589.5), with an average monthly cost saving of 10,192.2 SAR ($2,717.9). Pharmacist-managed early switch from IV-PO therapy, with physicians' education, showed significant reduction in IV medication use in our hospital. By reducing unnecessary IV use, this strategy enabled considerable cost savings, besides the potential advantages of convenience and safety.
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Development of key quality indicators for appropriate antibiotic use in the Republic of Korea: results of a modified Delphi survey. Antimicrob Resist Infect Control 2021; 10:48. [PMID: 33676558 PMCID: PMC7937201 DOI: 10.1186/s13756-021-00913-y] [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: 11/17/2020] [Accepted: 02/19/2021] [Indexed: 12/02/2022] Open
Abstract
Background An effective antibiotic stewardship program relies on the measurement of appropriate antibiotic use, on which there is a lack of consensus. We aimed to develop a set of key quality indicators (QIs) for nationwide point surveillance in the Republic of Korea. Methods A systematic literature search of PubMed, EMBASE, and Cochrane Library (publications until 20th November 2019) was conducted. Potential key QIs were retrieved from the search and then evaluated by a multidisciplinary expert panel using a RAND-modified Delphi procedure comprising two online surveys and a face-to-face meeting. Results The 23 potential key QIs identified from 21 studies were submitted to 25 multidisciplinary expert panels, and 17 key QIs were retained, with a high level of agreement (13 QIs for inpatients, 7 for outpatients, and 3 for surgical prophylaxis). After adding up the importance score and applicability, six key QIs [6 QIs (Q 1–6) for inpatients and 3 (Q 1, 2, and 5) for outpatients] were selected. (1) Prescribe empirical antibiotic therapy according to guideline, (2) change empirical antibiotics to pathogen-directed therapy, (3) obtain culture samples from suspected infection sites, (4) obtain two blood cultures, (5) adapt antibiotic dosage to renal function, and (6) document antibiotic plan. In surgical prophylaxis, the QIs to prescribe antibiotics according to the guideline and initiate antibiotic therapy 1 h before incision were selected. Conclusions We identified key QIs to measure the appropriateness of antibiotic therapy to identify targets for improvement and to evaluate the effects of antibiotic stewardship intervention.
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Lawrence H, Lim WS, McKeever TM. Variation in clinical outcomes and process of care measures in community acquired pneumonia: a systematic review. Pneumonia (Nathan) 2020; 12:10. [PMID: 32999854 PMCID: PMC7517805 DOI: 10.1186/s41479-020-00073-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 08/11/2020] [Indexed: 12/23/2022] Open
Abstract
Background Variation in outcomes of patients with community acquired pneumonia (CAP) has been reported in some, but not all, studies. Although some variation is expected, unwarranted variation in healthcare impacts patient outcomes and equity of care. The aim of this systematic review was to: i) summarise current evidence on regional and inter-hospital variation in the clinical outcomes and process of care measures of patients hospitalised with CAP and ii) assess the strength of this evidence. Methods Databases were systematically searched from inception to February 2018 for relevant studies and data independently extracted by two investigators in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Included studies enrolled adults hospitalised with CAP and reported a measure of variation between two or more units in healthcare outcomes or process of care measures. Outcomes of interest were mortality, length of hospital stay (LOS) and re-admission rates. A structured synthesis of the studies was performed. Results Twenty-two studies were included in the analysis. The median number of units compared across studies was five (IQR 4–15). Evidence for variation in mortality between units was inconsistent; of eleven studies that performed statistical significance testing, five found significant variation. For LOS, of nine relevant studies, all found statistically significant variation. Four studies reported site of admission accounted for 1–24% of the total observed variation in LOS. A shorter LOS was not associated with increased mortality or readmission rates. For readmission, evidence was mixed; of seven studies, 4 found statistically significant variation. There was consistent evidence for variation in the use of intensive care, obtaining blood cultures on admission, receiving antibiotics within 8 h of admission and duration of intravenous antibiotics. Across all outcome measures, only one study accounted for natural variation between units in their analysis. Conclusion There is consistent evidence of moderate quality for significant variation in length of stay and process of care measures but not for in-patient mortality or hospital re-admission. Evidence linking variation in outcomes with variation in process of care measures was limited; where present no difference in mortality was detected despite POC variation. Adjustment for natural variation within studies was lacking; the proportion of observed variation due to chance is not quantified by existing evidence.
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Affiliation(s)
- H Lawrence
- Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, UK.,Division of Epidemiology and Public Health, School of Medicine, Clinical Sciences Building, Nottingham City Hospital, University of Nottingham, Nottingham, UK
| | - W S Lim
- Nottingham University Hospitals NHS Trust, Hucknall Road, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre/Nottingham Clinical Research Facilities, Nottingham, UK
| | - T M McKeever
- Division of Epidemiology and Public Health, School of Medicine, Clinical Sciences Building, Nottingham City Hospital, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre/Nottingham Clinical Research Facilities, Nottingham, UK
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A Propensity Score Matched Study of the Positive Impact of Infectious Diseases Consultation on Antimicrobial Appropriateness in Hospitalized Patients with Antimicrobial Stewardship Oversight. Antimicrob Agents Chemother 2020; 64:AAC.00307-20. [PMID: 32423952 DOI: 10.1128/aac.00307-20] [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: 02/20/2020] [Accepted: 05/02/2020] [Indexed: 12/11/2022] Open
Abstract
Hospital-based antibiotic stewardship (AS) programs provide oversight and guidance for appropriate antimicrobial use in acute care settings. Infectious disease expertise is beneficial in the care of hospitalized patients with infections. The impact of infectious diseases consultation (IDC) on antimicrobial appropriateness in a large tertiary hospital with an established AS program was investigated. This was a cross-sectional study from October 2017 to March 2019 at a large academic hospital with an AS-directed prospective audit and feedback process and multiple IDC services. Antimicrobial appropriateness was adjudicated by an AS team member after antimicrobial start. Antimicrobial appropriateness was compared among antimicrobial orders with and without IDC using propensity score matching and multivariable logistic regression. Analyses were stratified by primary services caring for the patients. There were 10,508 antimicrobial orders from 6,165 unique patient encounters. Overall appropriateness was 92%, with higher appropriateness among patients with IDC versus without IDC (94% versus 84%; P < 0.0001). After propensity score matching and adjustment for certain antibiotics, organisms, syndromes, and locations, IDC was associated with a greater antimicrobial appropriateness odds ratio (OR) of 2.4 (95% confidence interval [CI], 1.9 to 3.0). Stratification by primary service showed an OR of 2.9 (95% CI, 2.1 to 3.8) for surgical specialties and an OR of 1.6 (95% CI, 1.1 to 2.2) for medical specialties. Even with a high overall antimicrobial appropriateness, patients with IDC had greater odds of antimicrobial appropriateness than those without IDC, and this impact was greater in surgical specialties. Infectious diseases consultation can be synergistic with antimicrobial stewardship programs.
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10
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Berrevoets MAH, Ten Oever J, Hoogerwerf J, Kullberg BJ, Atsma F, Hulscher ME, Schouten JA. Appropriate empirical antibiotic use in the emergency department: full compliance matters! JAC Antimicrob Resist 2019; 1:dlz061. [PMID: 34222935 PMCID: PMC8210121 DOI: 10.1093/jacamr/dlz061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/18/2019] [Accepted: 10/03/2019] [Indexed: 12/29/2022] Open
Abstract
Background Little is known about determinants of appropriate antibiotic use in the emergency department (ED). We measured appropriateness of antibiotic use for seven quality indicators (QIs) and studied patient-related factors that determine their variation. Patients and methods A retrospective analysis of 948 patients presumptively diagnosed as having an infection needing empirical antibiotic treatment in the ED was performed. Outcomes of seven previously validated QIs were calculated using computerized algorithms. We used logistic regression analysis to identify patient-related factors of QI performance and evaluated whether more appropriate antibiotic use in the ED results in better patient outcomes (length-of-stay, in-hospital mortality, 30 day readmission). Results QI performance ranged from 57.3% for guideline-adherent empirical therapy to 97.3% for appropriate route of administration in patients with sepsis. QI performance was positively associated with patients’ disease severity on admission (presence of fever, tachycardia and hypotension). Overall, the clinical diagnosis and thus the guidelines followed influenced QI performance. The difference in complexity between the guidelines was a possible explanation for the variation in QI performance. A QI performance sum score of 100% was associated with reduced in-hospital mortality. QI performance was not associated with readmission rates. Conclusions We gained insights into factors that determine quality of antibiotic prescription in the ED. Adherence to the full bundle of QIs was associated with reduced in-hospital mortality. These findings suggest that future stewardship interventions in the ED should focus on the entire process of antibiotic prescribing in the ED and not on a single metric only.
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Affiliation(s)
- Marvin A H Berrevoets
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Ten Oever
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jacobien Hoogerwerf
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bart Jan Kullberg
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Femke Atsma
- Scientific Center for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marlies E Hulscher
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.,Scientific Center for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen A Schouten
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.,Scientific Center for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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11
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Datta R, Zhu M, Han L, Allore H, Quagliarello V, Juthani-Mehta M. Increased Length of Stay Associated With Antibiotic Use in Older Adults With Advanced Cancer Transitioned to Comfort Measures. Am J Hosp Palliat Care 2019; 37:27-33. [PMID: 31185722 DOI: 10.1177/1049909119855617] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Antibiotic use may increase hospital length of stay (LOS) among older patients with advanced cancer who are transitioned to comfort measures. METHODS We studied a cohort of patients with advanced cancer aged ≥65 years who were transitioned to comfort measures during admission from July 1, 2014, through November 30, 2016. We evaluated the association between antibiotic exposure and LOS using a Poisson regression model adjusted for age, gender, cancer type, comorbidities, infection, and intensive care unit admission. RESULTS Among 461 patients with advanced cancer, median age was 74 years (range: 65-99), 49.0% (n = 226) were female, and 20.6% (n = 95) had liquid tumors. Overall, 82.9% (n = 382) received ≥1 antibiotic and 64.6% (n = 298) had ≥1 infection diagnosis during hospitalization. Infection diagnoses commonly included sepsis (35%, n = 161/461), pneumonia (25%, n = 117/461), and urinary tract infection (14%, n = 66/461). Among those receiving antibiotics, the most common choices included vancomycin (79%, n = 300/382), cephalosporins (63%, n = 241/382), and penicillins (45%, n = 172/382). In a multivariable Poisson regression model, LOS was 34% longer (count ratio = 1.34, [95% confidence interval: 1.20-1.51]) among those exposed versus unexposed to antibiotics. CONCLUSIONS Antibiotic use among patients with advanced cancer who are transitioned to comfort measures is associated with longer LOS. These data illustrate the importance of tradeoffs associated with antibiotic use, such as unintended increased LOS, when striving for goal-concordant care near the end of life.
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Affiliation(s)
- Rupak Datta
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Mojun Zhu
- Department of Hematology and Oncology, Mayo Clinic, Rochester, MN, USA
| | - Ling Han
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA
| | - Heather Allore
- Department of Internal Medicine, Section of Geriatrics, Yale School of Medicine, New Haven, CT, USA.,Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Vincent Quagliarello
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Manisha Juthani-Mehta
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA.,Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
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12
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Bogers SJ, van Daalen FV, Kuil SD, de Jong MD, Geerlings SE. Barriers and facilitators and the need for a clinical guideline for microbiological diagnostic testing in the hospital: a qualitative and quantitative study. Eur J Clin Microbiol Infect Dis 2019; 38:913-920. [PMID: 30843123 PMCID: PMC6469673 DOI: 10.1007/s10096-019-03516-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/15/2019] [Indexed: 02/06/2023]
Abstract
The appropriate use of microbiological investigations is an important cornerstone of antibiotic stewardship programmes, but receives relatively limited attention. This study aimed to identify influencing factors in performing microbiological diagnostic tests and to assess the need for a clinical guideline. We performed a qualitative (focus group) and quantitative (online questionnaire survey) study among medical specialists and residents to identify physicians' considerations in performing microbiological diagnostic tests and to assess the need for a diagnostic guideline. The questionnaire consisted of 14 statements, divided into three categories: knowledge, influencing factors and presence of guidelines. The questionnaire was sent to physicians of the departments of internal medicine, intensive care, paediatrics and pulmonology in five hospitals in the Netherlands. Sub-analyses for medical specialists versus residents and for paediatric versus non-paediatric departments were performed. We included 187 completed questionnaires in our analyses. The physicians reported having adequate knowledge on methods, time-to-result and accuracy, but inadequate knowledge on costs of the tests. Patients' clinical condition, comorbidity, local guidelines and accuracy of tests were appraised as the four most important influencing factors to perform tests. Over 70% (132/187) of physicians reported being interested in a guideline for microbiological diagnostic testing. Fifteen physicians (8.0%) provided additional comments. This study identifies the influencing factors to microbiological testing and shows the demand for a clinical guideline among physicians. IMPORTANCE: Microbiological diagnostic tests are an important cornerstone within antibiotic stewardship programmes [1-5]. These programmes aim to ameliorate the appropriate use of antibiotics and thus improve clinical outcomes of infectious diseases, whilst reducing the emergence of antimicrobial resistance [6]. However, inappropriate microbiological testing is a widely recognised problem [7-12], and influencing factors to testing have not been studied in the past. Our research shows the demand for a clinical guideline among physicians, and it identifies their influencing factors to testing. These results can be used to create a clinical guideline for microbiological diagnostic testing, thus supporting antibiotic stewardship programmes and reducing antimicrobial resistance.
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Affiliation(s)
- Saskia J Bogers
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Frederike V van Daalen
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sacha D Kuil
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Menno D de Jong
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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13
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Assessment of Quality Indicators for Appropriate Antibiotic Use. Antimicrob Agents Chemother 2018; 62:AAC.00875-18. [PMID: 30249698 DOI: 10.1128/aac.00875-18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 08/23/2018] [Indexed: 01/10/2023] Open
Abstract
One of the critical elements of antimicrobial stewardship programs is the ability to measure the quality of antibiotic prescriptions. The aims of the present study were to evaluate the performance properties of a set of previously developed quality indicators (QIs) and to identify the potential room for improvement in antibiotic use in our setting. A monthly cross-sectional point prevalence survey was conducted in a 400-bed acute care teaching hospital, from June to November 2015. All adult patients treated for ≥24 hours with antibiotic therapy for a suspected hospital- or community-acquired bacterial infection were included. Performance scores (adherence, room for improvement, interobserver reliability, and applicability) were calculated for 8 QIs. A total of 362 patients were evaluated. Adherence to the whole set of QIs was accomplished for 14.1% of evaluable patients. The QIs with greater room for improvement were adequate request for blood cultures (60.6%), therapeutic drug monitoring (TDM) (59.1%), sequential antibiotic therapy within 72 hours (48.2%), and empirical antibiotic therapy according to local guidelines (30.4%). The percentage of patients receiving unnecessary antibiotic treatment in the absence of clinical or microbiological evidence of infection after 5 days was 12.2%. All indicators scored kappa values of ≥0.6, suggesting good interobserver reliability. Low applicability (6.1% of reviewed patients) was found only for the TDM QI. The QIs analyzed were found to be applicable, showed good interobserver reliability, and were useful tools to identify areas with potential room for improvement in antibiotic use.
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14
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van Daalen FV, Hulscher MEJL, Minderhoud C, Prins JM, Geerlings SE. The antibiotic checklist: an observational study of the discrepancy between reported and actually performed checklist items. BMC Infect Dis 2018; 18:16. [PMID: 29310569 PMCID: PMC5759243 DOI: 10.1186/s12879-017-2878-7] [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: 08/08/2017] [Accepted: 12/03/2017] [Indexed: 11/29/2022] Open
Abstract
Background Checklists are increasingly used to measure quality of care. Recently we implemented an antibiotic checklist in nine Dutch hospitals and showed that use of the checklist resulted in more appropriate antibiotic use. While more appropriate antibiotic use was associated with a reduction in length of stay, use of the checklist in itself was not. In the current study we explored discrepancies between reported and actually performed checklist items at the patient level to test the validity of checklist answers, to evaluate whether discrepancies between reported and actually performed checklist items could explain the lack of effect of checklist use on length of stay, and to identify missed opportunities for performance per checklist item. Methods Checklist answers represented reported performance. Actual performance was assessed by data from the patients’ medical files. Reported and actually performed checklist items could be ‘both YES’; ‘both NO’; ‘YES reported, NOT actually performed’; or ‘NO reported, YES actually performed’. We determined an overall ‘both YES’ score per checklist, and used mixed models to evaluate whether an association existed between this overall score and patient’s length of hospital stay. Finally, we analysed whether the items that were not actually performed, could have been performed. Results Between January and October 2015 physicians filled in 1207 checklists. In total 7881 items were checked. Most items were ‘both YES’ (3392/7881, 43.0%) or ‘both NO’ (2601/7881, 33.0%). The number of ‘YES reported, NOT actually performed’ items was 1628/7881 (20.7%) compared to 260/7881 (3.3%) ‘NO reported, YES actually performed’ items. The level of discrepancy between reported and actually performed items differed per checklist item. The item ‘prescribe antibiotic treatment according to the local guideline’ had the highest percentage of ‘YES reported, NOT actually performed’ items, namely 45.1%. A higher overall ‘both YES’ score of the checklist was significantly associated with a shorter length of hospital stay. Of all checklist items 21.8% were not performed while they could have been performed. Conclusions Checklist answers do not accurately assess actual provided care. As actual performance of the antibiotic checklist items is associated with length of stay, efforts to increase actual performance appear to be justified. Electronic supplementary material The online version of this article (10.1186/s12879-017-2878-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Frederike V van Daalen
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Room F4-132, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Marlies E J L Hulscher
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Cas Minderhoud
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Room F4-132, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Room F4-132, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Room F4-132, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
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15
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van Daalen FV, Prins JM, Opmeer BC, Boermeester MA, Visser CE, van Hest RM, Branger J, Mattsson E, van de Broek MFM, Roeleveld TC, Karimbeg AA, Haak EAF, van den Hout HC, van Agtmael MA, Hulscher MEJL, Geerlings SE. Effect of an antibiotic checklist on length of hospital stay and appropriate antibiotic use in adult patients treated with intravenous antibiotics: a stepped wedge cluster randomized trial. Clin Microbiol Infect 2017; 23:485.e1-485.e8. [PMID: 28159671 DOI: 10.1016/j.cmi.2017.01.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/24/2017] [Accepted: 01/25/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Quality indicators (QIs) have been developed to define appropriate antibiotic use in hospitalized patients. We evaluated whether a checklist based on these QIs affects appropriate antibiotic use and length of hospital stay. METHODS An antibiotic checklist for patients treated with intravenous antibiotics was introduced in nine Dutch hospitals in a stepped wedge cluster randomized trial. Prophylaxis was excluded. We included a random sample before (baseline), and all eligible patients after (intervention) checklist introduction. Baseline and intervention outcomes were compared. Primary endpoint was length of stay (LOS), analysed by intention to treat. Secondary endpoints, including QI performances, QI sum score (performance on all QIs per patient), and quality of checklist use, were analysed per protocol. RESULTS Between 1 November 2014 and 1 October 2015 we included 853 baseline and 5354 intervention patients, of whom 993 (19%) had a completed checklist. The LOS did not change (baseline geometric mean 10.0 days (95% CI 8.6-11.5) versus intervention 10.1 days (95% CI 8.9-11.5), p 0.8). QI performances increased between +3.0% and +23.9% per QI, and the percentage of patients with a QI sum score above 50% increased significantly (OR 2.4 (95% CI 2.0-3.0), p<0.001). Higher QI sum scores were significantly associated with shorter LOS. Discordance existed between checklist-answers and actual performance. CONCLUSIONS Use of an antibiotic checklist resulted in a significant increase in appropriateness of antibiotic use, but not in a reduction of LOS. Low overall checklist completion rates and discordance between checklist-answers and actual provided care might have attenuated the impact of the checklist.
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Affiliation(s)
- F V van Daalen
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, The Netherlands.
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, The Netherlands
| | - B C Opmeer
- Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - C E Visser
- Department of Microbiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - R M van Hest
- Department of Pharmacy, Academic Medical Centre, Amsterdam, The Netherlands
| | - J Branger
- Department of Internal Medicine, Flevoziekenhuis, Almere, The Netherlands
| | - E Mattsson
- Department of Medical Microbiology, Reinier de Graaf, Delft, The Netherlands
| | - M F M van de Broek
- Department of Internal Medicine, Antoniusziekenhuis, Nieuwegein, The Netherlands
| | - T C Roeleveld
- Department of Internal Medicine, Spaarnegasthuis, Hoofddorp, The Netherlands
| | - A A Karimbeg
- Department of Internal Medicine, Westfriesgasthuis, Hoorn, The Netherlands
| | - E A F Haak
- Department of Hospital Pharmacy, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - H C van den Hout
- Department of Internal Medicine, Spaarnegasthuis, Haarlem, The Netherlands
| | - M A van Agtmael
- Department of Internal Medicine, Division of Infectious Diseases, VU Medical Centre, Amsterdam, The Netherlands
| | - M E J L Hulscher
- Department of Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, The Netherlands
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