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Ciarkowski C, Vaughn VM. Antibiotic documentation: death by a thousand clicks. BMJ Qual Saf 2022; 31:773-775. [PMID: 38467424 DOI: 10.1136/bmjqs-2022-015020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Claire Ciarkowski
- Internal Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Valerie M Vaughn
- Internal Medicine, University of Utah Health, Salt Lake City, Utah, USA
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Saini S, Leung V, Si E, Ho C, Cheung A, Dalton D, Daneman N, Grindrod K, Ha R, McIsaac W, Oberai A, Schwartz K, Shiamptanis A, Langford BJ. Documenting the indication for antimicrobial prescribing: a scoping review. BMJ Qual Saf 2022; 31:787-799. [PMID: 35552253 DOI: 10.1136/bmjqs-2021-014582] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/05/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Documenting an indication when prescribing antimicrobials is considered best practice; however, a better understanding of the evidence is needed to support broader implementation of this practice. OBJECTIVES We performed a scoping review to evaluate antimicrobial indication documentation as it pertains to its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in all patient populations. ELIGIBILITY CRITERIA Published and unpublished literature evaluating the documentation of an indication for antimicrobial prescribing. SOURCES OF EVIDENCE A search was conducted in MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts in addition to a review of the grey literature. CHARTING AND ANALYSIS Screening and extraction was performed by two independent reviewers. Studies were categorised inductively and results were presented descriptively. RESULTS We identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (109, 89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%-100%). Studies evaluating the impact of indication documentation on prescribing and patient outcomes most commonly examined appropriateness and identified a benefit to prescribing or patient outcomes in 17 of 19 studies. Qualitative studies evaluating healthcare worker perspectives (n=10) noted the common barriers and facilitators to this practice. CONCLUSION There is growing interest in the importance of documenting an indication when prescribing antimicrobials. While antimicrobial indication documentation is not uniformly implemented, several studies have shown that multipronged approaches can be used to improve this practice. Emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes both in community and hospital settings. But setting-specific and larger trials are needed to provide a more robust evidence base for this practice.
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Affiliation(s)
- Sharon Saini
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Valerie Leung
- Public Health Ontario, Toronto, Ontario, Canada
- Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada
| | - Elizabeth Si
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Certina Ho
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Institute for Safe Medication Practices, Toronto, Ontario, Canada
| | - Anne Cheung
- West Park Healthcare Centre, Toronto, Ontario, Canada
| | | | - Nick Daneman
- Public Health Ontario, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Rita Ha
- North York Family Health Team, Toronto, Ontario, Canada
| | - Warren McIsaac
- Sinai Health System, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anjali Oberai
- Wawa Family Health Team, Wawa, Ontario, Canada
- Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Kevin Schwartz
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Bradley J Langford
- Hotel Dieu Shaver Health and Rehabilitation Centre, St. Catharines, Ontario, Canada
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Padigos J, Reid S, Kirby E, Broom J. Knowledge, perceptions and experiences of nurses in antimicrobial optimization or stewardship in the intensive care unit. J Hosp Infect 2020; 109:10-28. [PMID: 33290817 DOI: 10.1016/j.jhin.2020.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 12/13/2022]
Abstract
There is an urgent and recognized need for an interprofessional collaborative approach to support global action in addressing antimicrobial resistance (AMR). Antimicrobial stewardship (AMS) refers to systematic approaches for antimicrobial optimization within healthcare organizations. In areas with high antimicrobial utilization such as intensive care units (ICUs), specific roles for nurses in AMS are not clearly defined. This review aimed to identify and to critically evaluate primary studies that examined knowledge, perspectives and experiences of nurses associated with antimicrobial use and optimization in ICUs. A systematic search of Medline, CINAHL, PsychINFO, EMBASE, PubMed, SCOPUS, Cochrane Library and Web of Science databases for primary studies published from 1st January 2000 to 20th March 2020 was performed. A convergent synthesis design was used to synthesize quantitative and qualitative data. Of the 898 studies initially screened, 26 were included. Most (18/26) studies were quantitative. All qualitative studies (6/26) were of high methodological quality. Studies where interventions were used (10/26) identified significant potential for ICU nurses to reduce antimicrobial use, time-to-antibiotic administration, and error rates. Barriers to nursing engagement included knowledge deficits in antimicrobial use, interprofessional dissonance and the culture of deference to physicians. Enhancing education, technology utilization, strong nursing leadership and robust organizational structures that support nurses were perceived as enablers to strengthen their roles in optimizing antimicrobial use. This review showed that nursing initiatives have significant potential to strengthen antimicrobial optimization in ICUs. Barriers and enablers to active engagement were identified.
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Affiliation(s)
- J Padigos
- Intensive Care Unit, Sunshine Coast University Hospital, Birtinya, Queensland, 4551, Australia; Faculty of Medicine, The University of Queensland, Herston, Queensland, 4006, Australia.
| | - S Reid
- Faculty of Medicine, The University of Queensland, Herston, Queensland, 4006, Australia
| | - E Kirby
- Centre for Social Research in Health, University of New South Wales, Sydney 2052, New South Wales, Australia
| | - J Broom
- Faculty of Medicine, The University of Queensland, Herston, Queensland, 4006, Australia; Department of Infectious Diseases, Sunshine Coast University Hospital, Birtinya, Queensland 4551, Australia
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Maher D, Larcombe R, Potts SD, Wiersema UF. Antimicrobial stewardship in intensive care: identifying areas for improvement. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2020. [DOI: 10.1002/jppr.1667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Dorsa Maher
- Pharmacist Flinders Medical Centre SA Pharmacy Bedford Park Australia
- PhD Candidate Clinical and Health Sciences University of South Australia Adelaide Australia
| | - Rebecca Larcombe
- Deputy Director Pharmacy Flinders Medical Centre SA Pharmacy Bedford Park Australia
| | - Simon D. Potts
- Senior Pharmacist, Intensive and Critical Care Unit Flinders Medical Centre SA Pharmacy Bedford Park Australia
| | - Ubbo F. Wiersema
- Consultant, Intensive and Critical Care Unit Flinders Medical Centre Bedford Park Australia
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Peña-López Y, Ramirez-Estrada S, Eshwara VK, Rello J. Limiting ventilator-associated complications in ICU intubated subjects: strategies to prevent ventilator-associated events and improve outcomes. Expert Rev Respir Med 2018; 12:1037-1050. [PMID: 30460868 DOI: 10.1080/17476348.2018.1549492] [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: 12/13/2022]
Abstract
Introduction: Intubation is required to maintain the airways in comatose patients and enhance oxygenation in hypoxemic or ventilation in hypercapnic subjects. Recently, the Centers of Disease Control (CDC) created new surveillance definitions designed to identify complications associated with poor outcomes. Areas covered: The new framework proposed by CDC, Ventilator-Associated Events (VAE), has a range of definitions encompassing Ventilator-Associated Conditions (VAC), Infection-related Ventilator-Associated Complications (IVAC), or Possible Ventilator-Associated Pneumonia - suggesting replacing the traditional definitions of Ventilator-Associated Tracheobronchitis (VAT) and Ventilator-Associated Pneumonia (VAP). They focused more on oxygenation variations than on Chest-X rays or inflammatory biomarkers. This article will review the spectrum of infectious (VAP & VAT) complications, as well as the main non-infectious complications, namely pulmonary edema, acute respiratory distress syndrome (ARDS) and atelectasis. Strategies to limit these complications and improve outcomes will be presented. Expert commentary: Improving outcomes should be the objective of implementing bundles of prevention, based on risk factors amenable of intervention. Promotion of measures that reduce the exposition or duration of intubation should be a priority.
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Affiliation(s)
- Yolanda Peña-López
- a Pediatric Critical Care Department , Vall d'Hebron Barcelona Hospital Campus , Barcelona , Spain
| | | | - Vandana Kalwaje Eshwara
- c Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education , Manipal University , Manipal , India
| | - Jordi Rello
- d Clinical Research/epidemiology In Pneumonia & Sepsis , Vall d'Hebron Institut of Research & Centro de Investigacion Biomedica en Red (CIBERES) , Barcelona , Spain
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Honda H, Ohmagari N, Tokuda Y, Mattar C, Warren DK. Antimicrobial Stewardship in Inpatient Settings in the Asia Pacific Region: A Systematic Review and Meta-analysis. Clin Infect Dis 2017; 64:S119-S126. [DOI: 10.1093/cid/cix017] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Vercheval C, Gillet M, Maes N, Albert A, Frippiat F, Damas P, Van Hees T. Quality of documentation on antibiotic therapy in medical records: evaluation of combined interventions in a teaching hospital by repeated point prevalence survey. Eur J Clin Microbiol Infect Dis 2016; 35:1495-500. [PMID: 27255220 DOI: 10.1007/s10096-016-2690-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/20/2016] [Indexed: 11/29/2022]
Abstract
This study aimed to improve the quality of documentation on antibiotic therapy in the computerized medical records of inpatients. A prospective, uncontrolled, interrupted time series (ITS) study was conducted by repeated point prevalence survey (PPS) to audit the quality of documentation on antibiotic therapy in the medical records before and after a combined intervention strategy (implementation of guidelines, distribution of educational materials, educational outreach visits, group educational interactive sessions) from the antimicrobial stewardship team (AST) in the academic teaching hospital (CHU) of Liège, Belgium. The primary outcome measure was the documentation rate on three quality indicators in the computerized medical records: (1) indication for treatment, (2) antibiotics prescribed, and (3) duration or review date. Segmented regression analysis was used to analyze the ITS. The medical records of 2306 patients receiving antibiotics for an infection (1177 in the pre-intervention period and 1129 in the post-intervention period) were analyzed. A significant increase in mean percentages in the post-intervention period was observed as compared with the pre-intervention period for the three quality indicators (indication documented 83.4 ± 10.4 % vs. 90.3 ± 6.6 %, p = 0.0013; antibiotics documented 87.9 ± 9.0 % vs. 95.6 ± 5.1 %, p < 0.0001; and duration or review date documented 31.9 ± 15.4 % vs. 67.7 ± 15.2 %, p < 0.0001). The study demonstrated the successful implementation of a combined intervention strategy from the AST. This strategy was associated with significant changes in the documentation rate in the computerized medical records for the three quality indicators.
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Affiliation(s)
- C Vercheval
- Department of Clinical Pharmacy, CIRM (Center for Interdisciplinary Research on Medicines), University Hospital of Liège, Liège, Belgium. .,Service de Pharmacie Clinique, CHU de Liège, Avenue de l'hôpital, 1 - B35, Sart Tilman, 4000, Liège, Belgium.
| | - M Gillet
- Department of Clinical Pharmacy, CIRM (Center for Interdisciplinary Research on Medicines), University Hospital of Liège, Liège, Belgium
| | - N Maes
- Department of Biostatistics and Medico-Economic Information, University Hospital of Liège, Liège, Belgium
| | - A Albert
- Department of Biostatistics and Medico-Economic Information, University Hospital of Liège, Liège, Belgium
| | - F Frippiat
- Department of Infectious Diseases and General Internal Medicine, University Hospital of Liège, Liège, Belgium
| | - P Damas
- Department of Intensive Care Unit, University Hospital of Liège, Liège, Belgium
| | - T Van Hees
- Department of Clinical Pharmacy, CIRM (Center for Interdisciplinary Research on Medicines), University Hospital of Liège, Liège, Belgium
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Worth LJ, Spelman T, Bull AL, Brett JA, Richards MJ. Epidemiology of Clostridium difficile infections in Australia: enhanced surveillance to evaluate time trends and severity of illness in Victoria, 2010-2014. J Hosp Infect 2016; 93:280-5. [PMID: 27107622 DOI: 10.1016/j.jhin.2016.03.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 03/08/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND With epidemic strains of Clostridium difficile posing a substantial healthcare burden internationally, there is a need for longitudinal evaluation of Clostridium difficile infection (CDI) events in Australia. AIM To evaluate time trends and severity of illness for CDI events in Australian healthcare facilities. METHODS All CDI events in patients admitted to Victorian public hospitals between 1(st) October 2010 and 31(st) December 2014 were reported to the Victorian Healthcare Associated Infection Surveillance System. CDI was defined as the isolation of a toxin-producing C. difficile organism in a diarrhoeal specimen, and classified as community-associated (CA-CDI) or healthcare-associated (HA-CDI). Severe disease was defined as admission to an intensive care unit, requirement for surgery and/or death due to infection. Time trends were examined using a mixed-effects Poisson regression model, and the Walter and Edward test of seasonality was applied to evaluate potential cyclical patterns. FINDINGS In total, 6736 CDI events were reported across 89 healthcare facilities. Of these, 4826 (71.6%) were HA-CDI, corresponding to a rate of 2.49/10,000 occupied bed days (OBDs). The incidence of HA-CDI was highest in the fifth quarter of surveillance (3.6/10,000 OBDs), followed by a reduction. Severe disease was reported in 1.66% of events, with the proportion being significantly higher for CA-CDI compared with HA-CDI (2.21 vs 1.45%, P = 0.03). The highest and lowest incidence of HA-CDI occurred in March and October, respectively. CONCLUSIONS A low incidence of HA-CDI was reported in Victoria compared with US/European surveillance reports. Seasonality was evident, together with diminishing HA-CDI rates in 2012-2014. Severe infections were more common in CA-CDI, supporting future enhanced surveillance in community settings.
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Affiliation(s)
- L J Worth
- Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Victoria, Australia; Department of Medicine, University of Melbourne, Victoria, Australia.
| | - T Spelman
- Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Victoria, Australia
| | - A L Bull
- Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Victoria, Australia
| | - J A Brett
- Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Victoria, Australia
| | - M J Richards
- Victorian Healthcare Associated Infection Surveillance System Coordinating Centre, Victoria, Australia; Department of Medicine, University of Melbourne, Victoria, Australia
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