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Amor-García MÁ, Chamorro-de-Vega E, Rodríguez-González CG, Iglesias-Peinado I, Moreno-Díaz R. Effects of a Pharmacist-Designed Clinical Decision Support System on Antimicrobial Stewardship. Appl Clin Inform 2024; 15:679-688. [PMID: 38857881 PMCID: PMC11324356 DOI: 10.1055/a-2341-8823] [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: 02/23/2024] [Accepted: 06/06/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Clinical decision support systems (CDSSs) are computer applications, which can be applied to give guidance to practitioners in antimicrobial stewardship (AS) activities; however, further information is needed for their optimal use. OBJECTIVES Our objective was to analyze the implementation of a CDSS program in a second-level hospital, describing alerts, recommendations, and the effects on consumption and clinical outcomes. METHODS In October 2020, a pharmacist-driven CDSS designed for AS was implemented in a second-level hospital. The program provides a list of alerts related to antimicrobial treatment and microbiology, which were automatized for revision by the AS professionals. To analyze the implementation of the CDSS, a pre-post-intervention, retrospective study was designed. AS-triggered alerts and recommendations (total number and rate of acceptance) were compiled. The effect of the CDSS was measured using antimicrobial consumption, duration of antimicrobial treatments, in-hospital mortality, and length of stay (LOS) for patients admitted for infectious causes. RESULTS The AS team revised a total of 7,543 alerts and 772 patients had at least one recommendation, with an acceptance rate of 79.3%. Antimicrobial consumption decreased from 691.1 to 656.8 defined daily doses (DDD)/1,000 beds-month (p = 0.04) and the duration of antimicrobial treatment from 3.6 to 3.3 days (p < 0.01). In-hospital mortality decreased from 6.6 to 6.2% (p = 0.46) and mean LOS from 7.2 to 6.2 days (p < 0.01). CONCLUSION The implementation of a CDSS resulted in a significant reduction of antimicrobial DDD, duration of antimicrobial treatments, and hospital LOS. There was no significant difference in mortality.
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Affiliation(s)
| | - Esther Chamorro-de-Vega
- Pharmacy Service, Instituto de Investigación Sanitaria Gregorio Marañón, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Irene Iglesias-Peinado
- Department of Pharmacology, Pharmacognosy and Botany, Faculty of Pharmacy, Complutense University of Madrid, Madrid, Spain
| | - Raquel Moreno-Díaz
- Pharmacy Service, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain
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Yusuf H, Hillman A, Stegeman JA, Cameron A, Badger S. Expanding access to veterinary clinical decision support in resource-limited settings: a scoping review of clinical decision support tools in medicine and antimicrobial stewardship. Front Vet Sci 2024; 11:1349188. [PMID: 38895711 PMCID: PMC11184142 DOI: 10.3389/fvets.2024.1349188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/13/2024] [Indexed: 06/21/2024] Open
Abstract
Introduction Digital clinical decision support (CDS) tools are of growing importance in supporting healthcare professionals in understanding complex clinical problems and arriving at decisions that improve patient outcomes. CDS tools are also increasingly used to improve antimicrobial stewardship (AMS) practices in healthcare settings. However, far fewer CDS tools are available in lowerand middle-income countries (LMICs) and in animal health settings, where their use in improving diagnostic and treatment decision-making is likely to have the greatest impact. The aim of this study was to evaluate digital CDS tools designed as a direct aid to support diagnosis and/or treatment decisionmaking, by reviewing their scope, functions, methodologies, and quality. Recommendations for the development of veterinary CDS tools in LMICs are then provided. Methods The review considered studies and reports published between January 2017 and October 2023 in the English language in peer-reviewed and gray literature. Results A total of 41 studies and reports detailing CDS tools were included in the final review, with 35 CDS tools designed for human healthcare settings and six tools for animal healthcare settings. Of the tools reviewed, the majority were deployed in high-income countries (80.5%). Support for AMS programs was a feature in 12 (29.3%) of the tools, with 10 tools in human healthcare settings. The capabilities of the CDS tools varied when reviewed against the GUIDES checklist. Discussion We recommend a methodological approach for the development of veterinary CDS tools in LMICs predicated on securing sufficient and sustainable funding. Employing a multidisciplinary development team is an important first step. Developing standalone CDS tools using Bayesian algorithms based on local expert knowledge will provide users with rapid and reliable access to quality guidance on diagnoses and treatments. Such tools are likely to contribute to improved disease management on farms and reduce inappropriate antimicrobial use, thus supporting AMS practices in areas of high need.
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Affiliation(s)
| | | | - Jan Arend Stegeman
- Department of Farm Animal Health, Faculty of Veterinary Medicine, Utrecht University, Utrecht, Netherlands
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Notarbartolo V, Badiane BA, Insinga V, Giuffrè M. Antimicrobial Stewardship: A Correct Management to Reduce Sepsis in NICU Settings. Antibiotics (Basel) 2024; 13:520. [PMID: 38927186 PMCID: PMC11200753 DOI: 10.3390/antibiotics13060520] [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: 04/25/2024] [Revised: 05/25/2024] [Accepted: 05/30/2024] [Indexed: 06/28/2024] Open
Abstract
The discovery of antimicrobial drugs has led to a significant increase in survival from infections; however, they are very often prescribed and administered, even when their use is not necessary and appropriate. Newborns are particularly exposed to infections due to the poor effectiveness and the immaturity of their immune systems. For this reason, in Neonatal Intensive Care Units (NICUs), the use of antimicrobial drugs is often decisive and life-saving, and it must be started promptly to ensure its effectiveness in consideration of the possible rapid evolution of the infection towards sepsis. Nevertheless, the misuse of antibiotics in the neonatal period leads not only to an increase in the development and wide spreading of antimicrobial resistance (AMR) but it is also associated with various short-term (e.g., alterations of the microbiota) and long-term (e.g., increased risk of allergic disease and obesity) effects. It appears fundamental to use antibiotics only when strictly necessary; specific decision-making algorithms and electronic calculators can help limit the use of unnecessary antibiotic drugs. The aim of this narrative review is to summarize the right balance between the risks and benefits of antimicrobial therapy in NICUs; for this purpose, specific Antimicrobial Stewardship Programs (ASPs) in neonatal care and the creation of a specific antimicrobial stewardship team are requested.
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Affiliation(s)
- Veronica Notarbartolo
- Neonatology and Neonatal Intensive Care Unit, University Hospital “Paolo Giaccone”, 90127 Palermo, Italy;
| | - Bintu Ayla Badiane
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy; (B.A.B.); (M.G.)
| | - Vincenzo Insinga
- Neonatology and Neonatal Intensive Care Unit, University Hospital “Paolo Giaccone”, 90127 Palermo, Italy;
| | - Mario Giuffrè
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90127 Palermo, Italy; (B.A.B.); (M.G.)
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Suksamai S, Sajak S, Thongphubeth K, Khawcharoenporn T. A Prospective Quasi-Experimental Study of Multifaceted Interventions Including Computerized Drug Utilization Evaluation to Improve an Antibiotic Stewardship Program. J Patient Saf 2024; 20:e9-e17. [PMID: 38372558 DOI: 10.1097/pts.0000000000001211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
OBJECTIVE This study aimed to determine and evaluate interventions that improve an antibiotic stewardship program (ASP) in reduction of the amount of antibiotic use and errors in drug utilization evaluation (DUE) form completion. METHODS A prospective quasi-experimental study was conducted to evaluate the effectiveness of the multifaceted interventions (preauthorization with computerized DUE, self-supervised checklists, and short active reminders of the antibiotic guidelines recommendations) incorporating an ASP among hospitalized internal medicine patients in a Thai tertiary care center. The preintervention period was from January to December 2018, and the postintervention period was from February 2019 to January 2020. RESULTS A total of 9188 and 9787 patient data were analyzed during the preintervention and postintervention periods, respectively. The overall median antibiotic use (defined daily dose/1000 bed-days) was significantly decreased in the postintervention period compared with the preintervention period (867.68 versus 732.33; P < 0.001). The reduction in antibiotic use was predominantly observed among broad-spectrum antibiotics, including cefoperazone/sulbactam (15.35 versus 9.75; P = 0.04), cefepime (13.09 versus 6.37; P = 0.003), ciprofloxacin (32.99 versus 17.83; P < 0.001), piperacillin/tazobactam (99.23 versus 91.93; P = 0.03), meropenem (2.01 versus 0.99; P < 0.001), imipenem/cilastatin (9.53 versus 4.59; P = 0.04), and colistin (74.70 versus 22.34; P < 0.0001). The overall rate of errors in DUE form completion was significantly decreased after the intervention (40% versus 28%; P < 0.001). The incidence of carbapenem-resistant Enterobacteriaceae infections/colonization was significantly lower in the postintervention period (0.27 versus 0.12/1000 bed-days; P = 0.02). CONCLUSIONS The study multifaceted interventions incorporating ASP were associated with significant reduction in the amount of broad-spectrum antibiotic use, DUE form completion errors, and incidence of carbapenem-resistant Enterobacteriaceae infection/colonization.
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Affiliation(s)
- Sunudtha Suksamai
- From the Department of Internal Medicine, Faculty of Medicine, Thammasat University
| | | | | | - Thana Khawcharoenporn
- Division of Infectious Diseases, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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Choi UY, Han SB. Antibiotic Use in Korean Children Diagnosed With Acute Bronchiolitis: Analysis of the National Health Insurance Reimbursement Data. J Korean Med Sci 2024; 39:e141. [PMID: 38711315 DOI: 10.3346/jkms.2024.39.e141] [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: 01/14/2024] [Accepted: 04/08/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Acute bronchiolitis, the most common lower respiratory tract infection in infants, is mostly caused by respiratory viruses. However, antibiotics are prescribed to about 25% of children with acute bronchiolitis. This inappropriate use of antibiotics for viral infections induces antibiotic resistance. This study aimed to determine the antibiotic prescription rate and the factors associated with antibiotic use in children with acute bronchiolitis in Korea, where antibiotic use and resistance rates are high. METHODS Healthcare data of children aged < 24 months who were diagnosed with acute bronchiolitis between 2016 and 2019 were acquired from the National Health Insurance system reimbursement claims data. Antibiotic prescription rates and associated factors were evaluated. RESULTS A total of 3,638,424 visits were analyzed. The antibiotic prescription rate was 51.8%, which decreased over time (P < 0.001). In the multivariate analysis, toddlers (vs. infants), non-capital areas (vs. capital areas), primary clinics and non-tertiary hospitals (vs. tertiary hospitals), inpatients (vs. outpatients), and non-pediatricians (vs. pediatricians) showed a significant association with antibiotic prescription (P < 0.001). Fourteen cities and provinces in the non-capital area exhibited a wide range of antibiotic prescription rates ranging from 41.2% to 65.4%, and five (35.7%) of them showed lower antibiotic prescription rates than that of the capital area. CONCLUSION In Korea, the high antibiotic prescription rates for acute bronchiolitis varied by patient age, region, medical facility type, clinical setting, and physician specialty. These factors should be considered when establishing strategies to promote appropriate antibiotic use.
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Affiliation(s)
- Ui Yoon Choi
- Department of Pediatrics, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Beom Han
- Department of Pediatrics, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Korea.
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Broom J, Broom A, Kenny K, Konecny P, Post JJ. Regulating antimicrobial use within hospitals: A qualitative study. Infect Dis Health 2024; 29:81-90. [PMID: 38216402 DOI: 10.1016/j.idh.2023.12.001] [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: 04/03/2023] [Revised: 11/30/2023] [Accepted: 12/06/2023] [Indexed: 01/14/2024]
Abstract
OBJECTIVES To examine how regulatory structures and processes focused on antimicrobial stewardship and antimicrobial resistance are experienced by hospital managers and clinicians. METHODS Forty-two hospital managers and clinicians working within accreditation and antimicrobial stewardship teams in three Australian hospitals participated in individual in-depth interviews. Thematic analysis was performed. RESULTS Thematic analysis revealed participants' experiences of hospital antimicrobial regulation and their perceptions of what would be required for meaningful antimicrobial optimisation. Theme 1: Experience of regulation of antimicrobials within hospitals: Participants described an increased profile of antimicrobial resistance with inclusion in regulatory requirements, but also the risks of bureaucratic manoeuvring to meet standards rather than governance-inducing systemic changes. Theme 2: Growth of accreditation processes and hospitals over time: Both regulatory requirements and hospitals were described as evolving over time, each manoeuvring in response to each other (e.g. development of short notice accreditation). Theme 3: Perceived requirements for change: Participants perceived a need for top-down buy-in, resource prioritisation, complex understanding of power and influence on clinician behaviour, and a critical need for medical engagement. CONCLUSIONS This study around antimicrobials shows the tension and dynamic relationship between regulatory processes and hospital responses, bringing to light the enduring balance of a system that positions itself to meet regulatory requirements and emerging "demands", without necessarily addressing the key underlying concerns. Antimicrobial resistance-related solutions are perceived as likely to require further resourcing and buy-in across multiple levels, engagement across professional streams and require strategies that consider complex systems change in order for regulatory structures to have potency.
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Affiliation(s)
- Jennifer Broom
- Sunshine Coast University Hospital, Sunshine Coast Hospital and Health Service, 6 Doherty Street, Birtinya, QLD, Australia; University of Queensland, Brisbane, QLD, Australia.
| | - Alex Broom
- Sydney Centre for Healthy Societies, School of Social and Political Sciences, The University of Sydney, Camperdown, NSW, Australia.
| | - Katherine Kenny
- Sydney Centre for Healthy Societies, School of Social and Political Sciences, The University of Sydney, Camperdown, NSW, Australia.
| | - Pamela Konecny
- Department of Infectious Diseases, Immunology & Sexual Health, St George Hospital, Kogarah, Sydney, Australia; School of Clinical Medicine, University of New South Wales, Sydney, Australia.
| | - Jeffrey J Post
- School of Clinical Medicine, University of New South Wales, Sydney, Australia; Department of Infectious Diseases, Prince of Wales Hospital and Community Health Services, Randwick, NSW, Australia.
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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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White NM, Carter HE, Kularatna S, Borg DN, Brain DC, Tariq A, Abell B, Blythe R, McPhail SM. Evaluating the costs and consequences of computerized clinical decision support systems in hospitals: a scoping review and recommendations for future practice. J Am Med Inform Assoc 2023; 30:1205-1218. [PMID: 36972263 PMCID: PMC10198542 DOI: 10.1093/jamia/ocad040] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/23/2023] [Accepted: 03/03/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE Sustainable investment in computerized decision support systems (CDSS) requires robust evaluation of their economic impacts compared with current clinical workflows. We reviewed current approaches used to evaluate the costs and consequences of CDSS in hospital settings and presented recommendations to improve the generalizability of future evaluations. MATERIALS AND METHODS A scoping review of peer-reviewed research articles published since 2010. Searches were completed in the PubMed, Ovid Medline, Embase, and Scopus databases (last searched February 14, 2023). All studies reported the costs and consequences of a CDSS-based intervention compared with current hospital workflows. Findings were summarized using narrative synthesis. Individual studies were further appraised against the Consolidated Health Economic Evaluation and Reporting (CHEERS) 2022 checklist. RESULTS Twenty-nine studies published since 2010 were included. Studies evaluated CDSS for adverse event surveillance (5 studies), antimicrobial stewardship (4 studies), blood product management (8 studies), laboratory testing (7 studies), and medication safety (5 studies). All studies evaluated costs from a hospital perspective but varied based on the valuation of resources affected by CDSS implementation, and the measurement of consequences. We recommend future studies follow guidance from the CHEERS checklist; use study designs that adjust for confounders; consider both the costs of CDSS implementation and adherence; evaluate consequences that are directly or indirectly affected by CDSS-initiated behavior change; examine the impacts of uncertainty and differences in outcomes across patient subgroups. DISCUSSION AND CONCLUSION Improving consistency in the conduct and reporting of evaluations will enable detailed comparisons between promising initiatives, and their subsequent uptake by decision-makers.
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Affiliation(s)
- Nicole M White
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - David N Borg
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - David C Brain
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Amina Tariq
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Bridget Abell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Robin Blythe
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Digital Health and Informatics Directorate, Metro South Health, Brisbane, Queensland, Australia
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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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Ewusie J, Beyene J, Thabane L, Straus SE, Hamid JS. An improved method for analysis of interrupted time series (ITS) data: accounting for patient heterogeneity using weighted analysis. Int J Biostat 2022; 18:521-535. [PMID: 34473922 DOI: 10.1515/ijb-2020-0046] [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: 04/07/2020] [Accepted: 08/05/2021] [Indexed: 01/10/2023]
Abstract
Interrupted time series (ITS) design is commonly used to evaluate the impact of interventions in healthcare settings. Segmented regression (SR) is the most commonly used statistical method and has been shown to be useful in practical applications involving ITS designs. Nevertheless, SR is prone to aggregation bias, which leads to imprecision and loss of power to detect clinically meaningful differences. The objective of this article is to present a weighted SR method, where variability across patients within the healthcare facility and across time points is incorporated through weights. We present the methodological framework, provide optimal weights associated with data at each time point and discuss relevant statistical inference. We conduct extensive simulations to evaluate performance of our method and provide comparative analysis with the traditional SR using established performance criteria such as bias, mean square error and statistical power. Illustrations using real data is also provided. In most simulation scenarios considered, the weighted SR method produced estimators that are uniformly more precise and relatively less biased compared to the traditional SR. The weighted approach also associated with higher statistical power in the scenarios considered. The performance difference is much larger for data with high variability across patients within healthcare facilities. The weighted method proposed here allows us to account for the heterogeneity in the patient population, leading to increased accuracy and power across all scenarios. We recommend researchers to carefully design their studies and determine their sample size by incorporating heterogeneity in the patient population.
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Affiliation(s)
- Joycelyne Ewusie
- School of Epidemiology and Public Health, University of Ottawa Faculty of Medicine, Ottawa, ON, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Joseph Beyene
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jemila S Hamid
- School of Epidemiology and Public Health, University of Ottawa Faculty of Medicine, Ottawa, ON, Canada
- Department of Mathematics and Statistics, University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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Hak F, Guimarães T, Santos M. Towards effective clinical decision support systems: A systematic review. PLoS One 2022; 17:e0272846. [PMID: 35969526 PMCID: PMC9377614 DOI: 10.1371/journal.pone.0272846] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 07/27/2022] [Indexed: 11/21/2022] Open
Abstract
Background Clinical Decision Support Systems (CDSS) are used to assist the decision-making process in the healthcare field. Developing an effective CDSS is an arduous task that can take advantage from prior assessment of the most promising theories, techniques and methods used at the present time. Objective To identify the features of Clinical Decision Support Systems and provide an analysis of their effectiveness. Thus, two research questions were formulated: RQ1—What are the most common trend characteristics in a CDSS? RQ2—What is the maturity level of the CDSS based on the decision-making theory proposed by Simon? Methods AIS e-library, Decision Support Systems journal, Nature, PlosOne and PubMed were selected as information sources to conduct this systematic literature review. Studies from 2000 to 2020 were chosen covering search terms in CDSS, selected according to defined eligibility criteria. The data were extracted and managed in a worksheet, based on the defined criteria. PRISMA statements were used to report the systematic review. Results The outcomes showed that rule-based module was the most used approach regarding knowledge management and representation. The most common technological feature adopted by the CDSS were the recommendations and suggestions. 19,23% of studies adopt the type of system as a web-based application, and 51,92% are standalone CDSS. Temporal evolution was also possible to visualize. This study contributed to the development of a Maturity Staging Model, where it was possible to verify that most CDSS do not exceed level 2 of maturity. Conclusion The trend characteristics addressed in the revised CDSS were identified, compared to the four predefined groups. A maturity stage model was developed based on Simon’s decision-making theory, allowing to assess the level of maturity of the most common features of the CDSS. With the application of the model, it was noticed that the phases of choice and implementation are underrepresented. This constitutes the main gap in the development of an effective CDSS.
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Affiliation(s)
- Francini Hak
- Algoritmi Research Center, University of Minho, Braga, Portugal
- * E-mail:
| | - Tiago Guimarães
- Algoritmi Research Center, University of Minho, Braga, Portugal
| | - Manuel Santos
- Algoritmi Research Center, University of Minho, Braga, Portugal
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Khadem TM, Ergen HJ, Salata HJ, Andrzejewski C, McCreary EK, Abdel Massih RC, Bariola JR. Impact of Clinical Decision Support System Implementation at a Community Hospital with an Existing Tele-Antimicrobial Stewardship Program. Open Forum Infect Dis 2022; 9:ofac235. [PMID: 35836746 PMCID: PMC9274440 DOI: 10.1093/ofid/ofac235] [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: 02/27/2022] [Accepted: 05/06/2022] [Indexed: 11/15/2022] Open
Abstract
Background Lack of on-site antimicrobial stewardship expertise is a barrier to establishing successful programs. Tele-antimicrobial stewardship programs (TASPs) utilizing a clinical decision support system (CDSS) can address these challenges. Methods This interrupted time series study reports the impact of CDSS implementation (February 2020) within an existing TASP on antimicrobial usage in a community hospital. Segmented regression analysis was used to assess differences in antimicrobial usage from January 2018 through December 2021. Pre- and post-CDSS frequencies of intravenous vs oral antimicrobials, time to optimal therapy (TTOT), pharmacist efficiency (number of documented interventions per month), and percentage of hospitalized patients receiving antimicrobials were compared with descriptive statistics. Results Implementation of a CDSS into an existing TASP was associated with an immediate 11% reduction in antimicrobial usage (level change, P < .0001). Antimicrobial usage was already trending down by 0.25% per month (pre-CDSS slope, P < .0001) and continued to trend down at a similar rate after implementation (post-CDSS slope, P = .0129). Frequency of use of select oral agents increased from 38% to 57%. Median TTOT was 1 day faster (2.9 days pre-CDSS vs 1.9 days post-CDSS). On average, pharmacists documented 2.2-fold more interventions per month (198 vs 90) and patients received 1.03 fewer days of antimicrobials per admission post-CDSS. Conclusions Implementation of a CDSS within an established TASP at a community hospital resulted in decreased antimicrobial usage, higher rates of oral usage, faster TTOT, and improved pharmacist efficiency.
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Affiliation(s)
- Tina M. Khadem
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- UPMC Centralized Health-System Antimicrobial Stewardship Efforts, Pittsburgh PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| | | | | | | | - Erin K. McCreary
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| | - Rima C. Abdel Massih
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
| | - J. Ryan Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh, PA USA
- UPMC Centralized Health-System Antimicrobial Stewardship Efforts, Pittsburgh PA USA
- Infectious Disease Connect Inc., Pittsburgh PA USA
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Jenkins JA, Pontefract SK, Cresswell K, Williams R, Sheikh A, Coleman JJ. Antimicrobial stewardship using electronic prescribing systems in hospital settings: a scoping review of interventions and outcome measures. JAC Antimicrob Resist 2022; 4:dlac063. [PMID: 35774070 PMCID: PMC9237448 DOI: 10.1093/jacamr/dlac063] [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] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objectives
To identify interventions implemented in hospital electronic prescribing systems and the outcome measures used to monitor their impact.
Methods
We systematically searched CINAHL, EMBASE, Google Scholar and Medline using keywords in three strands: (i) population: hospital inpatient or emergency department; (ii) intervention: electronic prescribing functionality; and (iii) outcome: antimicrobial stewardship. The interventions were grouped into six themes: alerts, order sets, restriction of access, mandated documentation, embedded guidelines and automatic prescription stop. The outcome measures were organized into those that measure the quality or quantity of prescribing or clinical decision support (CDS) activity. The impact of each intervention reported was grouped into a positive, negative or no change.
Results
A total of 28 studies were eligible for inclusion. There were 28 different interventions grouped into the six themes. Alerts visible to the practitioner in the electronic health record (EHR) were most frequently implemented (n = 11/28). Twenty different outcome measures were identified, divided into quality (n = 13/20) and quantity outcomes (n = 4/20) and CDS activity (n = 3/20). One-third of outcomes reported across the 28 studies showed positive change (34.4%, n = 42/122) and 61.4% (n = 75/122) showed no change.
Conclusions
The most frequently implemented interventions were alerts, the majority of which were to influence behaviour or decision-making of the practitioner within the EHR. Quality outcomes were most frequently selected by researchers. The review supports previous research that larger well-designed randomized studies are needed to investigate the impact of interventions on AMS and outcome measures to be standardized.
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Affiliation(s)
- J A Jenkins
- University Hospitals Birmingham NHS Foundation Trust , Birmingham, B15 2GW , UK
- Institute of Clinical Sciences, University of Birmingham , Birmingham, B15 2TT , UK
| | - S K Pontefract
- University Hospitals Birmingham NHS Foundation Trust , Birmingham, B15 2GW , UK
- Institute of Clinical Sciences, University of Birmingham , Birmingham, B15 2TT , UK
| | - K Cresswell
- Usher Institute, The University of Edinburgh , Edinburgh, EH16 4UX , UK
| | - R Williams
- Usher Institute, The University of Edinburgh , Edinburgh, EH16 4UX , UK
| | - A Sheikh
- Usher Institute, The University of Edinburgh , Edinburgh, EH16 4UX , UK
| | - J J Coleman
- University Hospitals Birmingham NHS Foundation Trust , Birmingham, B15 2GW , UK
- Institute of Clinical Sciences, University of Birmingham , Birmingham, B15 2TT , UK
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14
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Ng TM, Heng ST, Chua BH, Ang LW, Tan SH, Tay HL, Yap MY, Quek J, Teng CB, Young BE, Lin R, Ang B, Lee TH, Lye DC. Sustaining Antimicrobial Stewardship in a High-Antibiotic Resistance Setting. JAMA Netw Open 2022; 5:e2210180. [PMID: 35503216 PMCID: PMC9066280 DOI: 10.1001/jamanetworkopen.2022.10180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE There is a lack of studies comparing the intended and unintended consequences of prospective review and feedback (PRF) with computerized decision support systems (CDSS), especially in the longer term in antimicrobial stewardship. OBJECTIVE To examine the outcomes associated with the sequential implementation of PRF and CDSS and changes to these interventions with long-term use of antibiotics for and incidence of multidrug resistant organisms (MDROs) and other unintended outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study used an interrupted time series with segmented regression analysis of data from January 2007 to December 2018. Data were extracted from the electronic medical records of patients admitted at a large university teaching hospital with high rates of antibiotic resistance in Singapore. Data were analyzed from June 2019 to June 2020. EXPOSURES PRF of piperacillin-tazobactam and carbapenems (intervention 1, April 2009), with the addition of hospital-wide CDSS (intervention 2, April 2011), and lifting of CDSS for half of the hospital wards for 6 months (intervention 3, March 2017). MAIN OUTCOMES AND MEASURES Monthly antimicrobial use was measured in defined daily doses (DDDs) per 1000 patient-days. The monthly incidence of MDROs was calculated as number of clinical isolates detected per 1000 inpatient-days over a 6-month period. Unintended outcomes examined included in-hospital mortality and age-adjusted length of stay (LOS). RESULTS The number of inpatients increased from 56 263 in 2007 to 63 572 in 2018. During the same period, the mean monthly patient days increased from 33 929 in 2007 to 45 603 in 2018, and the proportion of patients older than 65 years increased from 45.5% in 2007 to 56.6% in 2018. After intervention 1, there were 0.33 (95% CI, 0.18 to 0.48) more DDDs per 1000 patient-days per month of piperacillin-tazobactam and carbapenems and -11.05 (95% CI, -15.55 to -6.55) fewer DDDs per 1000 patient-days per month for other broad-spectrum antibiotics. After intervention 2, there were -0.22 (95% CI, -0.33 to -0.10) fewer DDDs per 1000 patient-days per month of piperacillin-tazobactam and carbapenems and -2.10 (95% CI, -3.13 to -1.07) fewer DDDs per 1000 patient-days per month for other broad-spectrum antibiotics. After intervention 3, use of piperacillin-tazobactam and carbapenem increased by 0.28 (95% CI, 0.02 to 0.55) DDDs per 1000 patient-days per month. After intervention 2, incidence of Clostridioides difficile decreased (estimate, -0.02 [95% CI, -0.03 to -0.01] cases per 1000 patient-days per month). CONCLUSIONS AND RELEVANCE In this cohort study, concurrent PRF and CDSS were associated with limiting the use of piperacillin-tazobactam and carbapenems while reducing use of other antibiotics.
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Affiliation(s)
- Tat Ming Ng
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Shi Thong Heng
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Boon Hou Chua
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Li Wei Ang
- National Public Health and Epidemiology Unit, National Centre for Infectious Diseases, Singapore, Singapore
| | - Sock Hoon Tan
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Hui Lin Tay
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Min Yi Yap
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jason Quek
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Christine B. Teng
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Barnaby E. Young
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ray Lin
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Brenda Ang
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tau Hong Lee
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - David C. Lye
- Department of Infectious Diseases, National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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15
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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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16
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Feihl S, Querbach C, Hapfelmeier A, Busch DH, von Eisenhart-Rothe R, Gebhardt F, Pohlig F, Mühlhofer HML. Effect of an Intensified Antibiotic Stewardship Program at an Orthopedic Surgery Department. Surg Infect (Larchmt) 2021; 23:105-112. [PMID: 34762545 DOI: 10.1089/sur.2021.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Institutional programs such as antibiotic stewardship (ABS) programs offer possibilities to monitor and modify antibiotic usage with the aim of reducing antibiotic resistance. In orthopedic units that treat peri-prosthetic joint infections (PJIs), ABS programs are still rare, however, there is extensive use of high-risk antibiotic agents and an increased risk for the occurrence of Clostridium difficile infections (CDIs). Patients and Methods: An ABS program was implemented at the Department of Orthopedic Surgery at a university hospital. Quarterly antibiotic consumption was measured in defined daily doses (DDDs) per 100 patient-days (PDs) at 10 quarters before the intervention and seven quarters after the intervention. The effect of the new antibiotic policy on drug use rates was evaluated using an interrupted time-series analysis. Estimated changes over time in the incidence of CDIs (cases per 1,000 PDs) were analyzed. Results: A remarkable percentual reduction in second-generation cephalosporin use of 83% (p < 0.001; pre-intervention level, 81.486 DDDs/100 patient-days; post-intervention level, 13.751 DDDs/100 PDs) and clindamycin administration of 78% (p < 0.001; pre-intervention level, 18.982 DDDs/100 PDs; post-intervention level, 4.216 DDDs/100 PDs) was observed after implementation of ABS interventions. Total antibiotic use declined by 25% (p < 0.001; pre-intervention level, 129.078 DDDs/100 PDs; post-intervention level, 96.826 DDDs/100 PDs). Conclusions: This research assessed the positive impact of an intensified ABS program at an orthopedic department specializing in PJIs. Antibiotic stewardship program interventions encourage the reduction of total antibiotic usage and especially high-risk antibiotic agents, associated with the development of antimicrobial resistance.
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Affiliation(s)
- Susanne Feihl
- Institute for Medical Microbiology, Immunology and Hygiene, Statistics, Epidemiology, Technical University Munich, School of Medicine, Munich, Germany
| | - Christiane Querbach
- Pharmacy Department, University Hospital Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics, Epidemiology, Technical University Munich, School of Medicine, Munich, Germany
| | - Dirk H Busch
- Institute for Medical Microbiology, Immunology and Hygiene, Statistics, Epidemiology, Technical University Munich, School of Medicine, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopedic Surgery, University Hospital Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | - Friedemann Gebhardt
- Institute for Medical Microbiology, Immunology and Hygiene, Statistics, Epidemiology, Technical University Munich, School of Medicine, Munich, Germany
| | - Florian Pohlig
- Department of Orthopedic Surgery, University Hospital Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | - Heinrich M L Mühlhofer
- Department of Orthopedic Surgery, University Hospital Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
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17
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Andrzejewski C, McCreary EK, Khadem T, Abdel‐Massih RC, Bariola JR. Tele‐antimicrobial
stewardship programs: A review of the literature and the role of the pharmacist. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1489] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
| | - Erin K. McCreary
- Infectious Disease Connect, Incorporated Pittsburgh Pennsylvania USA
- Division of Infectious Diseases, Department of Medicine UPMC Pittsburgh Pennsylvania USA
- University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Tina Khadem
- Infectious Disease Connect, Incorporated Pittsburgh Pennsylvania USA
- Division of Infectious Diseases, Department of Medicine UPMC Pittsburgh Pennsylvania USA
- UPMC Community Hospital Antimicrobial Stewardship Efforts Pittsburgh Pennsylvania USA
| | - Rima C. Abdel‐Massih
- Infectious Disease Connect, Incorporated Pittsburgh Pennsylvania USA
- Division of Infectious Diseases, Department of Medicine UPMC Pittsburgh Pennsylvania USA
- University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - J. Ryan Bariola
- Infectious Disease Connect, Incorporated Pittsburgh Pennsylvania USA
- Division of Infectious Diseases, Department of Medicine UPMC Pittsburgh Pennsylvania USA
- UPMC Community Hospital Antimicrobial Stewardship Efforts Pittsburgh Pennsylvania USA
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18
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Cairns KA, Avent M, Buono E, Cheah R, Devchand M, Khumra S, Rawlins M, Roberts JA, Xenos K, Munro C. Standard of practice in infectious diseases for pharmacy services. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2021. [DOI: 10.1002/jppr.1744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Kelly A. Cairns
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Pharmacy Department Alfred Health Melbourne Australia
| | - Minyon Avent
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Queensland State‐Wide Antimicrobial Stewardship Program, Infection and Immunity Theme, UQCCR The University of Queensland Brisbane Australia
| | - Evette Buono
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Clinical Excellence Commission Sydney Australia
- National Centre for Antimicrobial Stewardship Doherty Institute Melbourne Australia
| | - Ron Cheah
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- National Centre for Antimicrobial Stewardship Doherty Institute Melbourne Australia
- Pharmacy Department Monash Health Clayton Australia
| | - Misha Devchand
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Austin Health Heidelberg Australia
| | - Sharmila Khumra
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Austin Health Heidelberg Australia
| | - Matthew Rawlins
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Department of Pharmacy Fiona Stanley Hospital Murdoch Australia
| | - Jason A. Roberts
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- The University of Queensland Centre for Clinical Research Faculty of Medicine & Centre for Translational Anti‐infective Pharmacodynamics School of Pharmacy The University of Queensland Brisbane Australia
- Royal Brisbane and Women’s Hospital Brisbane Australia
- Nîmes University Hospital University of Montpellier Montpellier France
| | - Kristin Xenos
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Australian Commission on Safety and Quality in Health Care Sydney Australia
| | - Courtney Munro
- The Society of Hospital Pharmacists of Australia Collingwood Australia
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Nadeau E, Mercier A, Perron J, Gilbert M, Nault V, Beaudoin M, Abou Chakra C, Valiquette L, Carignan A. Clinical impact of accepting or rejecting a recommendation from a clinical decision support system-assisted antibiotic stewardship program. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2021; 6:85-93. [PMID: 36341037 PMCID: PMC9608694 DOI: 10.3138/jammi-2020-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/04/2020] [Indexed: 06/16/2023]
Abstract
BACKGROUND Outcomes associated with physician responses to recommendations from an antimicrobial stewardship program (ASP) at an individual patient level have not yet been assessed. We aimed to compare clinical characteristics and mortality risk among patients for whom recommendations from an ASP were accepted or refused. METHODS A prospective cohort study was performed with hospitalized adults who received intravenous or oral antimicrobials at a 677-bed academic centre in Canada in 2014-2017. We included patients with an alert produced by a clinical decision support system (CDSS) for whom a recommendation was made by the pharmacist to the attending physician. The outcome was 90-day in-hospital all-cause mortality. RESULTS We identified 3,197 recommendations throughout the study period, of which 2,885 (90.2%) were accepted. The median length of antimicrobial treatment was significantly shorter when a recommendation was accepted (0.26 versus 1.78 d; p < 0.001). Refusal of a recommendation was not associated with mortality (odds ratio 1.32; 95% confidence interval, 0.93 to 1.89; p = 0.12). The independent risk factors associated with in-hospital mortality were age, Charlson Comorbidity Index score, admission to a critical care unit, duration between admission and recommendation, and issuance of a recommendation on a carbapenem. CONCLUSIONS The duration of antimicrobial treatment was significantly shorter when a recommendation originating from a CDSS-assisted ASP program was accepted. Future prospective studies including potential residual confounding variables, such as the source of infection or physiological derangement, might help in understanding whether CDSS-assisted ASP will have a direct impact on patient mortality.
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Affiliation(s)
- Esther Nadeau
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Adam Mercier
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Julie Perron
- Department of Pharmacy, Centre Intégré Universitaire de Santé et des Services Sociaux de l’Estrie, Sherbrooke, Quebec, Canada
| | - Mélanie Gilbert
- Department of Pharmacy, Centre Intégré Universitaire de Santé et des Services Sociaux de l’Estrie, Sherbrooke, Quebec, Canada
| | - Vincent Nault
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mathieu Beaudoin
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Claire Nour Abou Chakra
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Louis Valiquette
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alex Carignan
- Department of Microbiology and Infectious Diseases, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Dzintars K, Fabre VM, Avdic E, Smith J, Adams-Sommer V, Townsend J, Jenh Hsu A, Cosgrove SE. Development of an antimicrobial stewardship module in an electronic health record: Options to enhance daily antimicrobial stewardship activities. Am J Health Syst Pharm 2021; 78:1968-1976. [PMID: 34043746 PMCID: PMC8194800 DOI: 10.1093/ajhp/zxab222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose The purpose of this manuscript is to describe our experience developing an antimicrobial stewardship (AS) module as a clinical decision support tool in the Epic electronic health record (EHR). Summary Clinical decision support systems within the EHR can be used to decrease use of broad-spectrum antibiotics, improve antibiotic selection and dosing, decrease adverse effects, reduce antibiotic costs, and reduce the development of antibiotic resistance. The Johns Hopkins Hospital constructed an AS module within Epic. Customized stewardship alerts and scoring systems were developed to triage patients requiring stewardship intervention. This required a multidisciplinary approach with a team comprising AS physicians and pharmacists and Epic information technology personnel, with assistance from clinical microbiology and infection control when necessary. In addition, an intervention database was enhanced with stewardship-specific interventions, and workbench reports were developed specific to AS needs. We herein review the process, advantages, and challenges associated with the development of the Epic AS module. Conclusion Customizing an AS module in an EHR requires significant time and expertise in antimicrobials; however, AS modules have the potential to improve the efficiency of AS personnel in performing daily stewardship activities and reporting through a single system.
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Affiliation(s)
- Kathryn Dzintars
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Valeria M Fabre
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edina Avdic
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Janessa Smith
- Department of Pharmacy, Orlando Regional Medical Center, Orlando, FL, USA
| | | | - Jennifer Townsend
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Alice Jenh Hsu
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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van Gulik N, Hutchinson A, Considine J, Driscoll A, Malathum K, Botti M. Perceived roles and barriers to nurses' engagement in antimicrobial stewardship: A Thai qualitative case study. Infect Dis Health 2021; 26:218-227. [PMID: 33994163 DOI: 10.1016/j.idh.2021.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Antimicrobial stewardship is the practice of ensuring the optimal use of antibiotics to prevent antimicrobial resistance. A multidisciplinary approach is considered best practice; however, little is known about nurses' contribution. OBJECTIVES To explore how organisational multidisciplinary leaders and clinical nurses perceive nurses' roles in AMS in a single organisational site case study based in Thailand, within the current governance, educational and practice context, and the barriers to nurses' engagement in AMS. METHODS A qualitative descriptive study using thematic analysis approach was conducted in a 1000-bed university hospital in Bangkok, Thailand. The combined number of organisational leaders and nurses was 33 including 15 individual organisational leader interviews and three focus groups involving 18 nurses. RESULTS Nurses currently participate in AMS by supporting system processes, monitoring safety and optimal antibiotic use and patient education. A lack of clear articulation of nurses' role and traditional professional hierarchies limits active participation. Inconsistent engagement was perceived as due to a failure to prioritise AMS activities, a lack of formal policies and a need for further education. CONCLUSION Nurses do engage in AMS but there are significant governance, hierarchical and educational impediments. These gaps need to be addressed before clearly defined nurse roles in AMS can be developed and embedded into clinical practice.
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Affiliation(s)
- Nantanit van Gulik
- Ramathibodi School of Nursing, Mahidol University, Bangkok 10400, Thailand; Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand.
| | - Ana Hutchinson
- Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC 3220, Australia; Centre for Quality and Patient Safety Research - Epworth HealthCare Partnership, Richmond, VIC 3121, Australia
| | - Julie Considine
- Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC 3220, Australia; Centre for Quality and Patient Safety Research - Eastern Health Partnership, Box Hill, VIC 3128, Australia
| | - Andrea Driscoll
- Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC 3220, Australia; Austin Health, Heidelberg, VIC 3084, Australia
| | - Kumthorn Malathum
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Mari Botti
- Centre for Quality and Patient Safety Research, Deakin University, Geelong, VIC 3220, Australia; Centre for Quality and Patient Safety Research - Epworth HealthCare Partnership, Richmond, VIC 3121, Australia
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Bishop JL, Schulz TR, Kong DCM, Buising KL. Sustainability of antimicrobial stewardship programs in Australian rural hospitals: a qualitative study. AUST HEALTH REV 2021; 44:415-420. [PMID: 32492364 DOI: 10.1071/ah19097] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 08/08/2019] [Indexed: 11/23/2022]
Abstract
Objective The aim of this study was to explore the features of sustainable antimicrobial stewardship (AMS) programs in Australian rural hospitals and develop recommendations on incorporating these features into rural hospitals' AMS programs. Methods Lead AMS clinicians with knowledge of at least one AMS program sustained for >2 years in a health service in rural Australia were recruited to the study. A series of interviews was conducted and the transcripts analysed thematically using a framework method. Results Fifteen participants from various professional disciplines were interviewed. Key features that positively affected the sustainability of AMS programs in rural hospitals included a hospital executive who provided strong governance and accountability, dedicated resources, passionate local champions, area-wide arrangements and adaptability to engage in new partnerships. Challenges to building AMS programs with these features were identified, particularly in engaging hospital executive to allocate AMS resources, managing the burn out of passionate champions and formalising network arrangements. Conclusions Strategies to increase the sustainability of AMS programs in rural hospitals include using accreditation as a mechanism to drive direct resource allocation, explicit staffing recommendations for rural hospitals, greater support to develop formal network arrangements and a framework for integrated AMS programs across primary, aged and acute care. What is known about the topic? AMS programs facilitate the responsible use of antimicrobials. Implementation challenges have been identified for rural hospitals, but the sustainability of AMS programs has not been explored. What does this paper add? Factors that positively affected the sustainability of AMS programs in rural hospitals were a hospital executive that provided strong governance and accountability, dedicated resources, network or area-wide arrangements and adaptability. Challenges to building AMS programs with these features were identified. What are the implications for practitioners? Recommended actions to boost the sustainability of AMS programs in rural hospitals are required. These include using accreditation as a mechanism to drive direct resource allocation, explicit staffing recommendations for rural hospitals, greater support to develop network arrangements and support to create integrated AMS programs across acute, aged and primary care.
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Affiliation(s)
- Jaclyn L Bishop
- National Centre for Antimicrobial Stewardship, Peter Doherty Research Institute for Infection and Immunity, Level 5, 792 Elizabeth Street, Melbourne, Vic. 3000, Australia. ; ; ; and Department of Medicine - Royal Melbourne Hospital, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Royal Parade, Melbourne, Vic. 3050, Australia; and Pharmacy Department, Ballarat Health Services, Drummond Street, Ballarat, Vic. 3350, Australia; and Corresponding author.
| | - Thomas R Schulz
- National Centre for Antimicrobial Stewardship, Peter Doherty Research Institute for Infection and Immunity, Level 5, 792 Elizabeth Street, Melbourne, Vic. 3000, Australia. ; ; ; and Department of Medicine - Royal Melbourne Hospital, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Royal Parade, Melbourne, Vic. 3050, Australia; and Victorian Infectious Diseases Service, Royal Melbourne Hospital, 300 Grattan Street, Melbourne, Vic. 3050, Australia
| | - David C M Kong
- National Centre for Antimicrobial Stewardship, Peter Doherty Research Institute for Infection and Immunity, Level 5, 792 Elizabeth Street, Melbourne, Vic. 3000, Australia. ; ; ; and Department of Medicine - Royal Melbourne Hospital, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Royal Parade, Melbourne, Vic. 3050, Australia; and Pharmacy Department, Ballarat Health Services, Drummond Street, Ballarat, Vic. 3350, Australia; and Centre for Medicine Use and Safety, Monash University, 381 Royal Parade, Parkville, Vic. 3052, Australia
| | - Kirsty L Buising
- National Centre for Antimicrobial Stewardship, Peter Doherty Research Institute for Infection and Immunity, Level 5, 792 Elizabeth Street, Melbourne, Vic. 3000, Australia. ; ; ; and Department of Medicine - Royal Melbourne Hospital, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Royal Parade, Melbourne, Vic. 3050, Australia; and Victorian Infectious Diseases Service, Royal Melbourne Hospital, 300 Grattan Street, Melbourne, Vic. 3050, Australia
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Hashad N, Perumal D, Stewart D, Tonna AP. Mapping hospital antimicrobial stewardship programmes in the Gulf Cooperation Council states against international standards: a systematic review. J Hosp Infect 2020; 106:404-418. [PMID: 32911008 DOI: 10.1016/j.jhin.2020.09.004] [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: 06/24/2020] [Accepted: 09/01/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND While there is evidence of implementation of antimicrobial stewardship programmes (ASPs) in the Gulf Cooperation Council (GCC) states, there has been limited benchmarking and mapping to international standards and frameworks. AIM To critically appraise and synthesize the evidence of ASP implementation in GCC hospitals with reference to the framework of the Centers for Disease Control and Prevention (CDC), identifying key facilitators and barriers. METHODS A systematic review protocol was developed based on Preferred Reporting Items for Systematic Reviews and Meta-analyses for Protocols guidelines. Five electronic databases were searched for studies published in English from 2010 onwards. Study selection, quality assessment and data extraction were performed independently by two reviewers. A narrative synthesis was conducted with ASP interventions mapped to CDC core elements. FINDINGS Seventeen studies were identified, most of which (N=11) were from Saudi Arabia. Mapping to the CDC framework identified key areas of strengths and weaknesses in reporting implementation. Studies more commonly reported core elements of pharmacy expertise, selected aspects of implementation actions, tracking, antibiotic use and resistance, and education. Little emphasis was placed on the reporting of leadership and accountability. Key implementation facilitators were physician and organization support, information systems and education, and barriers were dedicated staff, workload and funding. CONCLUSION There is a need to enhance the reporting of ASP implementation in GCC hospitals. The CDC framework should be used as a guide during the development, implementation and reporting of ASP interventions. Action is required to identify facilitators and overcome barriers, where possible.
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Affiliation(s)
- N Hashad
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - D Perumal
- Commission of Academic Accreditation, Ministry of Education, IPIC Tower, Abu Dhabi, UAE
| | - D Stewart
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - A P Tonna
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK.
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Cipko K, Cuenca J, Wales E, Harris J, Bond S, Newton P, Miyakis S. Implementation of an antimicrobial stewardship programme and reduction in carbapenemase-producing Enterobacterales in an Australian local health district. JAC Antimicrob Resist 2020; 2:dlaa041. [PMID: 34223004 PMCID: PMC8210183 DOI: 10.1093/jacamr/dlaa041] [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: 08/25/2019] [Revised: 03/09/2020] [Accepted: 04/05/2020] [Indexed: 11/14/2022] Open
Abstract
Background Carbapenemase-producing Enterobacterales (CPE) are increasingly seen in Australian hospitals. Antimicrobial stewardship (AMS) interventions have been shown to reduce rates of carbapenem-resistant organisms; data on their effect on CPE rates are limited. Objectives To explore the effect of a multi-site computer-supported AMS programme on the rates of CPE in an Australian local health district. Methods All laboratory CPE isolates between 2008 and 2018 were identified. Microbiological and demographic data, CPE risk factors and outcomes were collected. Monthly carbapenem use was expressed as DDD per 1000 occupied bed days (OBD). Hand hygiene compliance rates among healthcare workers were analysed. A computer-supported AMS programme was implemented district-wide in 2012. Bivariate relationships were examined using Pearson's r and predictors of CPE isolates using time series linear regression. Results We identified 120 isolates from 110 patients. Numbers of CPE isolates and carbapenem use both showed a strong downward trend during the study period; the decreases were strongly correlated (r = 0.80, P = 0.006). The positive relationship between carbapenem use and CPE isolation was maintained while adjusting for time (b = 0.05, P < 0.001). Average yearly consumption of carbapenems fell by 20%, from 18.4 to 14.7 DDD/1000 OBD following implementation of the AMS programme. Hand hygiene compliance rates remained high throughout. Conclusions We demonstrated a reduction of CPE isolates in conjunction with reduced carbapenem use, longitudinally consolidated by a formal AMS programme. Prospective studies are needed to validate the effect of AMS on carbapenem resistance, especially in high-prevalence settings.
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Affiliation(s)
- Kimberly Cipko
- Department of Infectious Diseases, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Crown Street, Wollongong, New South Wales 2500, Australia.,Graduate School of Medicine, University of Wollongong, Northfields Avenue, Wollongong, New South Wales 2522, Australia
| | - Jose Cuenca
- Research Central, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Crown Street, Wollongong, New South Wales 2500, Australia
| | - Erica Wales
- Department of Pharmacy, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Crown Street, Wollongong, New South Wales 2500, Australia
| | - Joanna Harris
- Infection Management and Control Service, Illawarra Shoalhaven Local Health District, Crown Street, Wollongong, New South Wales 2500, Australia
| | - Stuart Bond
- Graduate School of Medicine, University of Wollongong, Northfields Avenue, Wollongong, New South Wales 2522, Australia.,Department of Pharmacy, Pinderfields Hospital, Mid Yorkshire Hospitals NHS Trust, Aberford Road, Wakefield WF1 4DG, UK
| | - Peter Newton
- Graduate School of Medicine, University of Wollongong, Northfields Avenue, Wollongong, New South Wales 2522, Australia.,NSW Health Pathology, Microbiology, Wollongong Hospital, Crown Street, Wollongong, New South Wales 2500, Australia
| | - Spiros Miyakis
- Department of Infectious Diseases, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Crown Street, Wollongong, New South Wales 2500, Australia.,Graduate School of Medicine, University of Wollongong, Northfields Avenue, Wollongong, New South Wales 2522, Australia
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Liu H, Wilton SB, Southern DA, Knudtson ML, Maitland A, Hauer T, Arena R, Rouleau C, James MT, Stone J, Aggarwal S. Automated Referral to Cardiac Rehabilitation After Coronary Artery Bypass Grafting Is Associated With Modest Improvement in Program Completion. Can J Cardiol 2019; 35:1491-1498. [PMID: 31604671 DOI: 10.1016/j.cjca.2019.08.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 08/01/2019] [Accepted: 08/12/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cardiac rehabilitation (CR) is a guideline-indicated modality for reducing residual cardiovascular risk among patients undergoing coronary artery bypass grafting (CABG) surgery. However, many referred patients do not initiate or complete a CR program; even more patients are never even referred. METHODS All post-CABG patients in Calgary, Alberta, Canada, from January 1, 1996, to March 31, 2016, were included. Data were obtained from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and TotalCardiology Rehabilitation databases. Automated referral to CR at discharge after CABG was instituted on July 1, 2007. We used interrupted time series analysis to evaluate the impact of automated referral on CR referral and completion rates and studied the association of these CR process markers with mortality. RESULTS A total of 8,118 patients underwent CABG surgery during the study period: 5,103 before automation and 3,015 after automation. Automation increased referral rates from 39.5% to 75.0% (P < 0.001). Automated referral was associated with a 7.2% increase in CR completion in the overall population (33.3% vs 26.1%; P < 0.001). In adjusted models, CR referral alone was not associated with reduced mortality (hazard ratio [HR] 0.84, 95% CI 0.64-1.11), but CR completion was (HR 0.43, 95% CI 0.31-0.61). CONCLUSION Automated referral in post-CABG patients resulted in modest improvement in CR program completion. Therefore, even when CR referral is automated to include all eligible patients, additional strategies to support CR program enrollment and completion remain necessary to achieve the desired health benefits.
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Affiliation(s)
- Hongwei Liu
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
| | - Stephen B Wilton
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; TotalCardiology Research Network, Calgary, Alberta, Canada
| | - Danielle A Southern
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Merril L Knudtson
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Maitland
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Trina Hauer
- TotalCardiology Research Network, Calgary, Alberta, Canada; TotalCardiology Rehabilitation, Calgary, Alberta, Canada
| | - Ross Arena
- TotalCardiology Research Network, Calgary, Alberta, Canada; Department of Physical Therapy, College of Applied Health Sciences, University of Illinois, Chicago, Illinois, USA
| | - Codie Rouleau
- TotalCardiology Research Network, Calgary, Alberta, Canada; TotalCardiology Rehabilitation, Calgary, Alberta, Canada; Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T James
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - James Stone
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; TotalCardiology Research Network, Calgary, Alberta, Canada
| | - Sandeep Aggarwal
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada; TotalCardiology Research Network, Calgary, Alberta, Canada; TotalCardiology Rehabilitation, Calgary, Alberta, Canada
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Rittmann B, Stevens MP. Clinical Decision Support Systems and Their Role in Antibiotic Stewardship: a Systematic Review. Curr Infect Dis Rep 2019; 21:29. [PMID: 31342180 DOI: 10.1007/s11908-019-0683-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW The purpose of this article is to perform a systematic review over the past 5 years on the role and effectiveness of clinical decision support systems (CDSSs) on antibiotic stewardship. RECENT FINDINGS CDDS interventions found a significant impact on multiple outcomes relevant to antibiotic stewardship. There are various types of CDSS implementations, both active and passive (provider initiated). Passive interventions were associated with more significant outcomes; however, both interventions appeared effective. In the reviewed literature, CDSSs were consistently associated with decreasing antibiotic consumption and narrowing the spectrum of antibiotic usage. Generally, guideline adherence was improved with CDSS, although this was not universal. The effect on other outcomes, such as mortality, Clostridiodes difficile infections, length of stay, and cost, inconsistently showed a significant difference. Overall, CDDS implementation has effectively decreased antibiotic consumption and improved guideline adherence across the various types of CDSS. Other positive outcomes were noted in certain settings, but were not universal. When creating a new intervention, it is important to identify the optimal structure and deployment of a CDSS for a specific setting.
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Affiliation(s)
- Barry Rittmann
- Virginia Commonwealth University Health Systems, Richmond, USA. .,, 825 Fairfax Avenue, 4th Floor, Norfolk, VA, 23507, USA.
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The role of electronic health record and "add-on" clinical decision support systems to enhance antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2019; 40:501-511. [PMID: 31020944 DOI: 10.1017/ice.2019.51] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Increasingly, demands are placed on healthcare systems to meet antimicrobial stewardship standards and reporting requirements. This trend, combined with reduced financial and personnel resources, has created a need to adopt information technology (IT) to help ease these burdens and facilitate action. The incorporation of IT into an antimicrobial stewardship program can help improve stewardship intervention efficiencies and facilitate the tracking and reporting of key metrics, including outcomes. This paper provides a review of the stewardship-related functionality within these IT systems, describes how these platforms can be used to improve antimicrobial use, and identifies how they can support current and potential future antimicrobial stewardship regulatory and accreditation standards. Finally, recommendations to help close the gaps in existing systems are provided and suggestions for future areas of development within these programs are delineated.
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El-Lababidi RM, Mooty M, Bonilla MF, Nusair A, Alatoom A, Mohamed S. Implementation and outcomes of an advanced antimicrobial stewardship program at a quaternary care hospital in the United Arab Emirates. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Rania Mohammad El-Lababidi
- Pharmacy Education and Training, Department of Pharmacy Services; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
- Antimicrobial Stewardship Program; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| | - Mohammad Mooty
- Infectious Diseases; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| | | | - Ahmad Nusair
- Infectious Diseases; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| | - Adnan Alatoom
- Pathology and Laboratory Medicine Institute, Clinical Microbiology Section; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
| | - Shafii Mohamed
- Infection Prevention and Control; Cleveland Clinic Abu Dhabi; Abu Dhabi United Arab Emirates
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Mostaghim M, Snelling T, McMullan B, Ewe YH, Bajorek B. Impact of clinical decision support on empirical antibiotic prescribing for children with community-acquired pneumonia. J Paediatr Child Health 2019; 55:305-311. [PMID: 30161269 DOI: 10.1111/jpc.14191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 06/08/2018] [Accepted: 07/08/2018] [Indexed: 12/13/2022]
Abstract
AIM To assess the impact of a computerised clinical decision support system (CDSS) on antibiotic use in hospitalised children with a presumptive diagnosis of uncomplicated community-acquired pneumonia (CAP). METHODS Codes associated with lower respiratory tract infection were used to identify cases of presumed uncomplicated CAP requiring admission to a tertiary paediatric hospital. Random sampling of the periods between 1 October 2010 and 30 September 2012 (pre-CDSS) and 1 October 2012 and 30 September 2014 (post-CDSS) determined the sequence of case assessment by two independent investigators. Initial antibiotic therapy, associated CDSS approvals and documented signs of clinical deterioration prior to antibiotic decision-making were recorded. RESULTS Statistically significant differences between cases pre- and post-CDSS implementation were minimal. High fever was observed in 57.5% (77/134) cases pre-CDSS and 45.8% (49/107) cases post-CDSS (P = 0.07). Supplemental oxygen was used in 30.6% pre-CDSS and 54.2% post-CDSS cases (P < 0.001). Narrow-spectrum penicillins were prescribed most often, with no statistically significant change post-CDSS implementation (81.3% pre-CDSS, 77.6% post-CDSS, P = 0.47). Macrolides were used consistently throughout the study period (53.7% pre-CDSS, 61.7% post-CDSS; P = 0.21). CONCLUSION CDSS implementation did not reduce already low rates of broad-spectrum antibiotic use for uncomplicated CAP.
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Affiliation(s)
- Mona Mostaghim
- Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia.,Pharmacy Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Tom Snelling
- Department of Infectious Diseases, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Brendan McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Yean H Ewe
- Junior Medical Unit, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Beata Bajorek
- Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
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Alghamdi S, Atef-Shebl N, Aslanpour Z, Berrou I. Barriers to implementing antimicrobial stewardship programmes in three Saudi hospitals: Evidence from a qualitative study. J Glob Antimicrob Resist 2019; 18:284-290. [PMID: 30797087 PMCID: PMC7104169 DOI: 10.1016/j.jgar.2019.01.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 01/09/2019] [Accepted: 01/25/2019] [Indexed: 11/17/2022] Open
Abstract
Adoption of ASPs in Saudi hospitals remains low despite a national implementation strategy. Lack of enforcement of policies and guidelines is a main contributor to inappropriate antimicrobial prescribing. Barriers to ASP adoption in Saudi hospitals are mainly organisational. Physicians’ fears and concerns inhibit their adoption of antimicrobial stewardship practices.
Objectives This study explored antimicrobial stewardship programme (ASP) team members’ perspectives regarding factors influencing the adoption and implementation of these programmes in Saudi hospitals. Methods This was a qualitative study based on face-to-face semistructured interviews with healthcare professionals involved in ASPs and activities across three Ministry of Health (MoH) hospitals in Saudi Arabia (n = 18). Interviews were also conducted with two representatives of a General Directorate of Health Affairs in a Saudi region and two representatives of the Saudi MoH (n = 4) between January–February 2017. Results Despite the existence of a national strategy to implement ASPs in Saudi MoH hospitals, their adoption and implementation remains low. Hospitals have their own antimicrobial stewardship policies, but adherence to these is poor. ASP team members highlight that lack of enforcement of policies and guidelines from the MoH and hospital administration is a significant barrier to ASP adoption and implementation. Other barriers include disintegration of teams, poor communication, lack of recruitment/shortage of ASP team members, lack of education and training, and lack of health information technology (IT). Physicians’ fears and concerns in relation to liability are also a barrier to their adoption of ASPs. Conclusion This is the first qualitative study exploring barriers to ASP adoption and implementation in Saudi hospitals from the perspective of ASP team members. Formal endorsement of ASPs from the MoH as well as hospital enforcement of policies and provision of human and health IT resources would improve the adoption and implementation of ASPs in Saudi hospitals.
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Affiliation(s)
- Saleh Alghamdi
- Department of Clinical & Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK; Department of Clinical Pharmacy, Faculty of Clinical Pharmacy, Albaha University, Albaha, Saudi Arabia
| | - Nada Atef-Shebl
- Department of Clinical & Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Zoe Aslanpour
- Department of Clinical & Pharmaceutical Sciences, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Ilhem Berrou
- Faculty of Health & Applied Sciences, University of the West of England, Staple Hill, Bristol BS16 1DD, UK.
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Patton A, Davey P, Harbarth S, Nathwani D, Sneddon J, Marwick CA. Impact of antimicrobial stewardship interventions on Clostridium difficile infection and clinical outcomes: segmented regression analyses. J Antimicrob Chemother 2019; 73:517-526. [PMID: 29177477 DOI: 10.1093/jac/dkx413] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 10/10/2017] [Indexed: 12/12/2022] Open
Abstract
Background Antimicrobial exposure is associated with increased risk of Clostridium difficile infection (CDI), but the impact of prescribing interventions on CDI and other outcomes is less clear. Objectives To evaluate the effect of an antimicrobial stewardship intervention targeting high-risk antimicrobials (HRA), implemented in October 2008, and to compare the findings with similar studies from a systematic review. Methods All patients admitted to Medicine and Surgery in Ninewells Hospital from October 2006 to September 2010 were included. Intervention effects on HRA use (dispensed DDD), CDI cases and mortality rates, per 1000 admissions per month, were analysed separately in Medicine and Surgery using segmented regression of interrupted time series (ITS) data. Data from comparable published studies were reanalysed using the same method. Results Six months post-intervention, there were relative reductions in HRA use of 33% (95% CI 11-56) in Medicine and 32% (95% CI 19-46) in Surgery. At 12 months, there was an estimated reduction in CDI of 7.0 cases/1000 admissions [relative change -24% (95% CI - 55 to 6)] in Medicine, but no change in Surgery {estimated 0.1 fewer cases/1000 admissions [-2% (95% CI - 116 to 112)]}. Mortality reduced throughout the study period, unaffected by the intervention. In all six comparable studies, HRA use reduced significantly, but reductions in CDI rates were only statistically significant in two and none measured mortality. Pre-intervention CDI rates and trends influenced the intervention effect. Conclusions Despite large reductions in HRA prescribing and reductions in CDI, demonstrating real-world impact of stewardship interventions remains challenging.
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Affiliation(s)
- Andrea Patton
- Population Health Sciences, School of Medicine, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK.,Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Delta House, West Nile Street, Glasgow G1 2NP, UK
| | - Peter Davey
- Population Health Sciences, School of Medicine, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Dilip Nathwani
- Department of Infection and Immunodeficiency, East Block, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Delta House, West Nile Street, Glasgow G1 2NP, UK
| | - Charis A Marwick
- Population Health Sciences, School of Medicine, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK.,Department of Infection and Immunodeficiency, East Block, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
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Mostaghim M, Snelling T, Bajorek B. Factors associated with adherence to antimicrobial stewardship after-hours. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2018; 27:180-190. [PMID: 30281178 DOI: 10.1111/ijpp.12486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 08/08/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Assess restricted antimicrobials acquired after standard working hours for adherence to antimicrobial stewardship (AMS) and identify factors associated with increased likelihood of adherence at the time of acquisition, and the next standard working day. METHODS All documented antimicrobials acquired from a paediatric hospital after-hours drug room from 1 July 2014 to 30 June 2015 were reconciled with records of AMS approval, and documented AMS review in the medical record. KEY FINDINGS Of the 758 antimicrobial acquisitions from the after-hours drug room, 62.3% were restricted. Only 29% were AMS adherent at the time of acquisition, 15% took place despite documented request for approval by a pharmacist. Antimicrobials for respiratory patients (OR 3.10, 95% CI 1.68-5.5) and antifungals (2.48, 95% CI 1.43-4.30) were more likely to be AMS adherent. Half of the acquisitions that required review the next standard working day were adherent to AMS (51.8%, 129/249). Weekday acquisitions (2.10, 95% CI 1.20-3.69) and those for patients in paediatric intensive care (2.26, 95% CI 1.07-4.79) were associated with AMS adherence. Interactions with pharmacists prior to acquisition did not change the likelihood of AMS adherence the next standard working day. Access to restricted antimicrobial held as routine ward stock did not change the likelihood of AMS adherence at the time of acquisition, or the next standard working day. CONCLUSION Restricted antimicrobials acquired after-hours are not routinely AMS adherent at the time of acquisition or the next standard working day, limiting opportunities for AMS involvement.
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Affiliation(s)
- Mona Mostaghim
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia.,Department of Pharmacy, Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - Thomas Snelling
- Department of Infectious Diseases, Princess Margaret Hospital for Children, Perth, WA, Australia.,Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - Beata Bajorek
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
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A new carbapenem drug dosage metric for carbapenem usage and correlation with carbapenem resistance of Pseudomonas aeruginosa. J Infect Chemother 2018; 24:949-953. [PMID: 30268412 DOI: 10.1016/j.jiac.2018.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/24/2018] [Accepted: 08/03/2018] [Indexed: 12/24/2022]
Abstract
The emergence and dissemination of antimicrobial resistance is a worldwide problem. Inappropriate antimicrobial use contributes to this resistance, and several metrics of drug usage have been used to monitor their consumption and rational use. We examined several existing drug metrics, and developed a new one, dose/duration-density (D/d2), for a the best correlation between carbapenem usage and carbapenem resistance of Pseudomonas aeruginosa. The annual changes of antimicrobial use density (AUD), days of therapy (DOT), daily dose (DD) and D/d2 for meropenem, imipenem and total carbapenems was analyzed for a correlation with carbapenem susceptibility of P. aeruginosa from 2006 through 2015 at a university hospital. The substitution of meropenem for imipenem usage, and an approximate 10% increase in carbapenem susceptibility of P. aeruginosa occurred over the study period. There were significant correlations of the meropenem susceptibility of P. aeruginosa and meropenem usage as measured by the meropenem DD, of imipenem susceptibility and imipenem AUD and DOT, and overall carbapenem susceptibility and imipenem DOT. The D/d2 for meropenem, imipenem and total carbapenems had significant correlations with individual and all carbapenem susceptibility of P. aeruginosa. These D/d2 is the best single carbapenem use metric for correlating carbapenem usage with P. aeruginosa resistance. Further studies are warranted to consider the value of D/d2 for other antimicrobials and bacteria.
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Howell CK, Jacob J, Mok S. Remote Antimicrobial Stewardship: A Solution for Meeting The Joint Commission Stewardship Standard? Hosp Pharm 2018; 54:51-56. [PMID: 30718935 DOI: 10.1177/0018578718769240] [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] [Indexed: 11/16/2022]
Abstract
Purpose: The purpose of this study was to determine the time required for antimicrobial stewardship (AS) activities at a small community hospital (SCH) as well as barriers to remote AS to satisfy The Joint Commission (TJC)'s AS standard. Methods: This was a prospective chart review and time study conducted in patients identified by a clinical decision support application as potential opportunities for antimicrobial therapy modification at a SCH between December 12, 2016, and March 31, 2017. Potential interventions were communicated electronically to the clinical pharmacy specialist, who would then communicate the recommendations to the patient's provider. The primary endpoint was a time study for stewardship activities. Secondary endpoints included describing barriers encountered to remote AS as well as a cost-benefit analysis of remote AS. Results: The time study revealed an average of 11 alerts per day, 9 chart reviews per day, 8 interventions per day, and 5 minutes per chart. Seven hundred twenty-four alerts were evaluated with the most common alerts constituting opportunities for de-escalation (29%), targeted drugs (22%), positive blood cultures (18%), Intravenous (IV) to oral (PO) (17%), and antimicrobial renal monitoring (8%).Interventions were accepted (11%), accepted modified (6%), rejected (35%), or undetermined (48%). Barriers to implementation included workflow and indirect communication. For patients with accepted interventions, there was an average savings of $279.82 per patient in pharmacy charges. Conclusion: Through remote AS, a SCH can have an antimicrobial stewardship program that is in compliance with the basic elements of the TJC standard MM.09.01.01, performs daily chart review by an infectious diseases trained pharmacist to increase the quality of patient care, and achieves a mean savings of $279.82 in pharmacy charges and $1,126.26 in hospital charges per patient with accepted interventions.
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Affiliation(s)
- C K Howell
- University of North Texas Health Science Center, Fort Worth, USA.,Medical City Dallas, TX, USA
| | | | - Steve Mok
- Emory University Hospital Midtown, Atlanta, GA, USA
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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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A Role for Antimicrobial Stewardship in Clinical Sepsis Pathways: a Prospective Interventional Study. Infect Control Hosp Epidemiol 2017; 38:1032-1038. [PMID: 28693625 DOI: 10.1017/ice.2017.139] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To evaluate the impact of early infectious diseases (ID) antimicrobial stewardship (AMS) intervention on inpatient sepsis antibiotic management. DESIGN Interventional, nonrandomized, controlled study. SETTING Tertiary-care referral hospital, Sydney, Australia. PATIENTS Consecutive, adult, non-intensive care unit (non-ICU) inpatients triggering an institutional clinical sepsis pathway from May to August 2015. INTERVENTION All patients reviewed by an ID Fellow within 24 hours of sepsis pathway trigger underwent case review and clinic file documentation of recommendations. Those not reviewed by an ID Fellow were considered controls and received standard sepsis pathway care. The primary outcome was antibiotic appropriateness 48 hours after sepsis trigger. RESULTS In total, 164 patients triggered the sepsis pathway: 6 patients were excluded (previous sepsis trigger); 158 patients were eligible; 106 had ID intervention; and 52 were control cases. Of these 158 patients, 91 (58%) had sepsis, and 15 of these 158 (9.5%) had severe sepsis. Initial antibiotic appropriateness, assessable in 152 of 158 patients, was appropriate in 80 (53%) of these 152 patients and inappropriate in 72 (47%) of these patients. In the intervention arm, 93% of ID Fellow recommendations were followed or partially followed, including 53% of cases in which antibiotics were de-escalated. ID Fellow intervention improved antibiotic appropriateness at 48 hours by 24% (adjusted risk ratio, 1.24; 95% confidence interval, 1.04-1.47; P=.035). The appropriateness agreement among 3 blinded ID staff opinions was 95%. Differences in intervention and control group mortality (13% vs 17%) and median length of stay (13 vs 17.5 days) were not statistically significant. CONCLUSION Sepsis overdiagnosis and delayed antibiotic optimization may reduce sepsis pathway effectiveness. Early ID AMS improved antibiotic management of non-ICU inpatients with suspected sepsis, predominantly by de-escalation. Further studies are needed to evaluate clinical outcomes. Infect Control Hosp Epidemiol 2017;38:1032-1038.
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