1
|
Bassetti S, Tschudin-Sutter S, Egli A, Osthoff M. Optimizing antibiotic therapies to reduce the risk of bacterial resistance. Eur J Intern Med 2022; 99:7-12. [PMID: 35074246 DOI: 10.1016/j.ejim.2022.01.029] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 01/02/2023]
Abstract
The incidence of infections caused by bacteria that are resistant to antibiotics is constantly increasing. In Europe alone, it has been estimated that each year about 33'000 deaths are attributable to such infections. One important driver of antimicrobial resistance is the use and abuse of antibiotics in human medicine. Inappropriate prescribing of antibiotics is still very frequent: up to 50% of all antimicrobials prescribed in humans might be unnecessary and several studies show that at least 50% of antibiotic treatments are inadequate, depending on the setting. Possible strategies to optimize antibiotic use in everyday clinical practice and to reduce the risk of inducing bacterial resistance include: the implementation of rapid microbiological diagnostics for identification and antimicrobial susceptibility testing, the use of inflammation markers to guide initiation and duration of therapies, the reduction of standard durations of antibiotic courses, the individualization of antibiotic therapies and dosing considering pharmacokinetics/pharmacodynamics targets, and avoiding antibiotic classes carrying a higher risk for induction of bacterial resistance. Importantly, measures to improve antibiotic prescribing and antibiotic stewardship programs should focus on facilitating clinical reasoning and improving prescribing environment in order to remove any barriers to good prescribing.
Collapse
Affiliation(s)
- Stefano Bassetti
- Division of Internal Medicine, University Hospital Basel and University of Basel, Switzerland; Department of Clinical Research, University Hospital Basel and University of Basel, Switzerland.
| | - Sarah Tschudin-Sutter
- Department of Clinical Research, University Hospital Basel and University of Basel, Switzerland; Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel and University of Basel, Switzerland
| | - Adrian Egli
- Division of Clinical Bacteriology and Mycology, University Hospital Basel and University of Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Switzerland
| | - Michael Osthoff
- Division of Internal Medicine, University Hospital Basel and University of Basel, Switzerland; Department of Clinical Research, University Hospital Basel and University of Basel, Switzerland
| |
Collapse
|
2
|
Christensen I, Haug JB, Berild D, Bjørnholt JV, Skodvin B, Jelsness-Jørgensen LP. Factors Affecting Antibiotic Prescription among Hospital Physicians in a Low-Antimicrobial-Resistance Country: A Qualitative Study. Antibiotics (Basel) 2022; 11:antibiotics11010098. [PMID: 35052975 PMCID: PMC8773165 DOI: 10.3390/antibiotics11010098] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/05/2022] [Accepted: 01/11/2022] [Indexed: 02/05/2023] Open
Abstract
Antimicrobial resistance (AMR) is a threat to hospital patients. Antimicrobial stewardship programs (ASPs) can counteract AMR. To optimize ASPs, we need to understand what affects physicians’ antibiotic prescription from several contexts. In this study, we aimed to explore the factors affecting hospital physicians’ antibiotic choices in a low-resistance country to identify potential targets for future ASPs. We interviewed 14 physicians involved in antibiotic prescription in a Norwegian hospital. The interviews were audiotaped, transcribed verbatim, and analyzed using thematic analysis. The main factors affecting antibiotic prescription were a high work pressure, insufficient staff resources, and uncertainties regarding clinical decisions. Treatment expectations from patients and next of kin, benevolence towards the patients, suboptimal microbiological testing, and limited time for infectious disease specialists to offer advisory services also affected the antibiotic choices. Future ASP efforts should evaluate the system organization and prioritizations to address and manage potential time-pressure issues. To limit the use of broad-spectrum antibiotics, improving microbiology testing and the routines for consultations with infectious disease specialists seems beneficial. We also identified a need among the prescribing physicians for a debate on ethical antibiotic questions.
Collapse
Affiliation(s)
- Ingrid Christensen
- Department of Infection Control, Østfold Hospital Trust, Kalnes, 1714 Graalum, Norway; (J.B.H.); (L.-P.J.-J.)
- Faculty of Medicine, Ph.D. Program Medicine and Health Sciences, University of Oslo, 0315 Oslo, Norway
- Correspondence: ; Tel.: +47-9073-3113; Fax: +47-6986-4885
| | - Jon Birger Haug
- Department of Infection Control, Østfold Hospital Trust, Kalnes, 1714 Graalum, Norway; (J.B.H.); (L.-P.J.-J.)
| | - Dag Berild
- Department of Infectious Diseases, Oslo University Hospital, 0424 Oslo, Norway;
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway;
| | - Jørgen Vildershøj Bjørnholt
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway;
- Department of Microbiology, Oslo University Hospital, 0424 Oslo, Norway
| | - Brita Skodvin
- Norwegian Advisory Unit on Antibiotic Use in Hospitals, Department of Research and Development, Haukeland University Hospital, 5021 Bergen, Norway;
| | - Lars-Petter Jelsness-Jørgensen
- Department of Infection Control, Østfold Hospital Trust, Kalnes, 1714 Graalum, Norway; (J.B.H.); (L.-P.J.-J.)
- Faculty of Health and Social Studies, Østfold University College, 1671 Fredrikstad, Norway
| |
Collapse
|
3
|
Furukawa D, Dieringer TD, Wong MD, Tong JT, Cader IA, Wisk LE, Han MA, Gupta SM, Kerbel RB, Uslan DZ, Graber CJ. Evaluation of antibiotic escalation in response to nurse-driven inpatient sepsis screen. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2021; 1:e59. [PMID: 36168494 PMCID: PMC9495422 DOI: 10.1017/ash.2021.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To determine the frequency and predictors of antibiotic escalation in response to the inpatient sepsis screen at our institution. DESIGN Retrospective cohort study. SETTING Two affiliated academic medical centers in Los Angeles, California. PATIENTS Hospitalized patients aged 18 years and older who had their first positive sepsis screen between January 1, 2019, and December 31, 2019, on acute-care wards. METHODS We described the rate and etiology of antibiotic escalation, and we conducted multivariable regression analyses of predictors of antibiotic escalation. RESULTS Of the 576 cases with a positive sepsis screen, antibiotic escalation occurred in 131 cases (22.7%). New infection was the most documented etiology of escalation, with 76 cases (13.2%), followed by known pre-existing infection, with 26 cases (4.5%). Antibiotics were continued past 3 days in 17 cases (3.0%) in which new or existing infection was not apparent. Abnormal temperature (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.91-4.70) and abnormal lactate (aOR, 2.04; 95% CI, 1.28-3.27) were significant predictors of antibiotic escalation. The patient already being on antibiotics (aOR, 0.54; 95% CI, 0.34-0.89) and the positive screen occurred during a nursing shift change (aOR, 0.36; 95% CI, 0.22-0.57) were negative predictors. Pneumonia was the most documented new infection, but only 19 (50%) of 38 pneumonia cases met full clinical diagnostic criteria. CONCLUSIONS Inpatient sepsis screening led to a new infectious diagnosis in 13.2% of all positive sepsis screens, and the risk of prolonged antibiotic exposure without a clear infectious source was low. Pneumonia diagnostics and lactate testing are potential targets for future stewardship efforts.
Collapse
Affiliation(s)
- Daisuke Furukawa
- Division of Infectious Disease, Department of Medicine, University of California–Los Angeles, California
| | - Thomas D. Dieringer
- Division of Infectious Disease, Department of Medicine, University of California–Los Angeles, California
| | - Mitchell D. Wong
- Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles, California
| | - Julia T. Tong
- Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles, California
| | - Isa A. Cader
- David Geffen School of Medicine, University of California–Los Angeles, California
| | - Lauren E. Wisk
- Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles, California
| | - Maria A. Han
- Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles, California
| | - Summer M. Gupta
- Quality Management Services, UCLA Health, Los Angeles, California
| | - Russell B. Kerbel
- Division of General Internal Medicine, Department of Medicine, University of California, Los Angeles, California
| | - Daniel Z. Uslan
- Division of Infectious Disease, Department of Medicine, University of California–Los Angeles, California
| | - Christopher J. Graber
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, California
| |
Collapse
|
4
|
Broom J, Broom A, Kirby E. The drivers of antimicrobial use across institutions, stakeholders and economic settings: a paradigm shift is required for effective optimization. J Antimicrob Chemother 2020; 74:2803-2809. [PMID: 31169902 DOI: 10.1093/jac/dkz233] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/02/2019] [Accepted: 05/02/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Significant antimicrobial overuse persists worldwide, despite overwhelming evidence of antimicrobial resistance and knowledge that optimization of antimicrobial use will slow the development of resistance. It is critical to understand why this occurs. This study aims to consider the social influences on antimicrobial use within hospitals in Australia, via an in-depth, multisite analysis. METHODS We used a qualitative multisite design, involving 222 individual semi-structured interviews and thematic analysis. Participants (85 doctors, 79 nurses, 31 pharmacists and 27 hospital managers) were recruited from five hospitals in Australia, including four public hospitals (two metropolitan, one regional and one remote) and one private hospital. RESULTS Analysis of the interviews identified social relationships and institutional structures that may have a strong influence on antimicrobial use, which must be addressed concurrently. (i) Social relationships that exist across settings: these include the influence of personal risk, hierarchies, inter- and intraprofessional dynamics and sense of futility in making a difference long term in relation to antimicrobial resistance. (ii) Institutional structures that offer context-specific influences: these include patient population factors (including socioeconomic factors, geographical isolation and local infection patterns), proximity and resource issues. CONCLUSIONS The success of antimicrobial optimization rests on adequate awareness and incorporation of multilevel influences. Analysis of the problem has tended to emphasize individual 'behaviour improvement' in prescribing rather than incorporating the problem of overuse as inherently multidimensional and necessarily incorporating personal, interpersonal and institutional variables. A paradigm shift is urgently needed to incorporate these critical factors in antimicrobial optimization strategies.
Collapse
Affiliation(s)
- J Broom
- Sunshine Coast University Hospital, Birtinya, QLD, Australia.,University of Queensland, Brisbane, QLD, Australia
| | - A Broom
- Practical Justice Initiative, Centre for Social Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - E Kirby
- Practical Justice Initiative, Centre for Social Research in Health, University of New South Wales, Sydney, NSW, Australia
| |
Collapse
|
5
|
van der Voort T, Brinkman DJ, Benemei S, Böttiger Y, Chamontin B, Christiaens T, Likic R, Mačiulaitis R, Marandi T, Monteiro EC, Papaioannidou P, Pers YM, Pontes C, Raskovic A, Regenthal R, Sanz EJ, Wilson K, Tichelaar J, van Agtmael MA. Appropriate antibiotic prescribing among final-year medical students in Europe. Int J Antimicrob Agents 2019; 54:375-379. [PMID: 31075400 DOI: 10.1016/j.ijantimicag.2019.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 04/15/2019] [Accepted: 05/01/2019] [Indexed: 10/26/2022]
Abstract
Little is known about undergraduate education on antibiotic prescribing in Europe and even less about the antibiotic prescribing skills of nearly-graduated medical students. This study aimed to evaluate the antibiotic prescribing skills of final-year medical students across Europe and the education they received during medical training. In a cross-sectional study, final-year medical students from 17 medical schools in 15 European countries were asked to prescribe for two written case reports of infectious diseases (acute bronchitis and community-acquired pneumonia). The appropriateness of antimicrobial therapy was determined using a scoring form based on local guidelines. Teachers from each medical school were asked to complete a standardised questionnaire about the teaching and assessment of undergraduate education on antibiotic use. In total, 856 final-year medical students (95.6%) completed the assessment and 16 teachers (94.1%) completed the questionnaire. Overall, 52.7% (range 26-83%) of the 1.683 therapies prescribed were considered appropriate. The mean number of contact hours for undergraduate education on antimicrobials was 25.6 (range 2-90). Differences in education styles were found to have a significant impact on students' performance, with a problem-based learning style being associated with more appropriate antimicrobial prescribing than a traditional learning style (46.0% vs. 22.9%; P < 0.01). Although there are differences between medical schools, final-year medical students in Europe lack prescribing skills for two common infectious diseases, possibly because of inadequate undergraduate education on antibiotic use and general prescribing. To improve students' skills, interactive teaching methods such as prescribing for simulated and real patients should be used.
Collapse
Affiliation(s)
- Tim van der Voort
- Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Research and Expertise Center in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands.
| | - David J Brinkman
- Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Research and Expertise Center in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Silvia Benemei
- Unit of Clinical Pharmacology, Careggi University Hospital, University of Florence, Firenze, Italy
| | - Ylva Böttiger
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Bernard Chamontin
- Department of Internal Medicine and Hypertension, University of Toulouse, Toulouse, France
| | | | - Robert Likic
- Unit of Clinical Pharmacology, Department of Internal Medicine, University Hospital Centre Zagreb and University of Zagreb School of Medicine, Zagreb, Croatia
| | - Romaldas Mačiulaitis
- Faculty of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Toomas Marandi
- Department of Cardiology, University of Tartu, Tartu, Estonia
| | | | - Paraskevi Papaioannidou
- Department of Pharmacology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Yves M Pers
- Clinical Immunology and Osteoarticular Diseases Unit, Department of Rheumatology, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Caridad Pontes
- Department of Pharmacology, Autonomous University of Barcelona, Barcelona, Spain
| | - Aleksandar Raskovic
- Department of Pharmacology, Toxicology and Clinical Pharmacology, University of Novi Sad, Novi Sad, Serbia
| | - Ralf Regenthal
- Department of Clinical Pharmacology, Leipzig University, Leipzig, Germany
| | - Emilio J Sanz
- School of Medicine, Universidad de La Laguna, Tenerife, Spain
| | - Kurt Wilson
- Faculty of Medicine, University of Manchester, Manchester, UK
| | - Jelle Tichelaar
- Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Research and Expertise Center in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | - Michiel A van Agtmael
- Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Research and Expertise Center in Pharmacotherapy Education (RECIPE), Amsterdam, The Netherlands
| | | |
Collapse
|
6
|
Coenen S, Bartholomeeusen S, Remmen R, Van Royen P, Morreel S, Philips H. Comment on: The 'morning dip' in antimicrobial appropriateness: circumstances determining appropriateness of antimicrobial prescribing. J Antimicrob Chemother 2019; 74:277-278. [PMID: 30169647 DOI: 10.1093/jac/dky355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Samuel Coenen
- Centre for General Practice, Department of Primary and Interdisciplinary Care (ELIZA), University of Antwerp, Antwerp, Belgium.,Department of Epidemiology and Social Medicine (ESOC), University of Antwerp, Antwerp, Belgium.,Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Stephaan Bartholomeeusen
- Centre for General Practice, Department of Primary and Interdisciplinary Care (ELIZA), University of Antwerp, Antwerp, Belgium
| | - Roy Remmen
- Centre for General Practice, Department of Primary and Interdisciplinary Care (ELIZA), University of Antwerp, Antwerp, Belgium
| | - Paul Van Royen
- Centre for General Practice, Department of Primary and Interdisciplinary Care (ELIZA), University of Antwerp, Antwerp, Belgium
| | - Stefan Morreel
- Centre for General Practice, Department of Primary and Interdisciplinary Care (ELIZA), University of Antwerp, Antwerp, Belgium
| | - Hilde Philips
- Centre for General Practice, Department of Primary and Interdisciplinary Care (ELIZA), University of Antwerp, Antwerp, Belgium
| | | |
Collapse
|
7
|
Singh S, Menon VP, Mohamed ZU, Kumar VA, Nampoothiri V, Sudhir S, Moni M, Dipu TS, Dutt A, Edathadathil F, Keerthivasan G, Kaye KS, Patel PK. Implementation and Impact of an Antimicrobial Stewardship Program at a Tertiary Care Center in South India. Open Forum Infect Dis 2018; 6:ofy290. [PMID: 31024967 PMCID: PMC6475722 DOI: 10.1093/ofid/ofy290] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/07/2018] [Indexed: 12/16/2022] Open
Abstract
Background Antimicrobial resistance is a major public health threat internationally but, particularly in India. A primary contributing factor to this rise in resistance includes unregulated access to antimicrobials. Implementing antimicrobial stewardship programs (ASPs) in the acute hospital setting will help curb inappropriate antibiotic use in India. Currently, ASPs are rare in India but are gaining momentum. This study describes ASP implementation in a large, academic, private, tertiary care center in India. Methods An ASP was established in February 2016 consisting of an administrative champion, hospitalist, microbiologist, intensivist, and pharmacists. Antimicrobial stewardship program interventions included postprescriptive audit and establishment of institutional guidelines. The ASP tracked appropriate drug selection including loading dose, maintenance dose, frequency, route, duration of therapy, de-escalation, and compliance with ASP recommendations. Defined daily dose (DDD) of drugs and cost of antimicrobials were compared between the pre-implementation phase (February 2015–January 2016) and post-implementation phase (February 2016–January 2017). Results Of 48 555 patients admitted during the post-implementation phase, 1020 received 1326 prescriptions for restricted antibiotics. Antibiotic therapy was appropriate in 56% (742) of the total patient prescriptions. A total of 2776 instances of “inappropriate” antimicrobial prescriptions were intervened upon by the ASP. Duration (806, 29%) was the most common reason for inappropriate therapy. Compliance with ASP recommendations was 54% (318). For all major restricted drugs, the DDD/1000 patient days declined, and there was a significant reduction in mean monthly cost by 14.4% in the post-implementation phase. Conclusions Implementation of a multidisciplinary antibiotic stewardship program in this academic, large, Indian hospital demonstrated feasibility and economic benefits.
Collapse
Affiliation(s)
- Sanjeev Singh
- Department of Medical Administration, Amrita Institute of Medical Sciences, Kochi, India
| | - Vidya P Menon
- Department of Internal Medicine, Amrita Institute of Medical Sciences, Kochi, India
| | - Zubair U Mohamed
- Department of Anaesthesiology and Critical Care Medicine, Amrita Institute of Medical Sciences, Kochi, India
| | - V Anil Kumar
- Department of Microbiology, Amrita Institute of Medical Sciences, Kochi, India
| | - Vrinda Nampoothiri
- Department of Medical Administration, Amrita Institute of Medical Sciences, Kochi, India
| | - Sangita Sudhir
- Department of Medical Administration, Amrita Institute of Medical Sciences, Kochi, India
| | - Merlin Moni
- Department of Internal Medicine, Amrita Institute of Medical Sciences, Kochi, India
| | - T S Dipu
- Department of Internal Medicine, Amrita Institute of Medical Sciences, Kochi, India
| | - Ananya Dutt
- Department of Medical Administration, Amrita Institute of Medical Sciences, Kochi, India
| | - Fabia Edathadathil
- Department of Allied Health Sciences, Amrita Institute of Medical Sciences, Kochi, India
| | - G Keerthivasan
- Department of Microbiology, Amrita Institute of Medical Sciences, Kochi, India
| | - Keith S Kaye
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor
| | - Payal K Patel
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor.,Division of Infectious Diseases, Department of Internal Medicine, Veterans Affairs Ann Arbor Healthcare System, Michigan
| |
Collapse
|