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Ashton PM, Chunga Chirambo A, Meiring JE, Patel PD, Mbewe M, Silungwe N, Chizani K, Banda H, Heyderman RS, Dyson ZA, MacPherson P, Henrion MYR, Holt KE, Gordon MA. Evaluating the relationship between ciprofloxacin prescription and non-susceptibility in Salmonella Typhi in Blantyre, Malawi: an observational study. THE LANCET. MICROBE 2024; 5:e226-e234. [PMID: 38387472 PMCID: PMC10914669 DOI: 10.1016/s2666-5247(23)00327-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND Ciprofloxacin is the first-line drug for treating typhoid fever in many countries in Africa with a high disease burden, but the emergence of non-susceptibility poses a challenge to public health programmes. Through enhanced surveillance as part of vaccine evaluation, we investigated the occurrence and potential determinants of ciprofloxacin non-susceptibility in Blantyre, Malawi. METHODS We conducted systematic surveillance of typhoid fever cases and antibiotic prescription in two health centres in Blantyre, Malawi, between Oct 1, 2016, and Oct 31, 2019, as part of the STRATAA and TyVAC studies. In addition, blood cultures were taken from eligible patients presenting at Queen Elizabeth Central Hospital, Blantyre, as part of routine diagnosis. Inclusion criteria were measured or reported fever, or clinical suspicion of sepsis. Microbiologically, we identified Salmonella enterica serotype Typhi (S Typhi) isolates with a ciprofloxacin non-susceptible phenotype from blood cultures, and used whole-genome sequencing to identify drug-resistance mutations and phylogenetic relationships. We constructed generalised linear regression models to investigate associations between the number of ciprofloxacin prescriptions given per month to study participants and the proportion of S Typhi isolates with quinolone resistance-determining region (QRDR) mutations in the following month. FINDINGS From 46 989 blood cultures from Queen Elizabeth Central Hospital, 502 S Typhi isolates were obtained, 30 (6%) of which had either decreased ciprofloxacin susceptibility, or ciprofloxacin resistance. From 11 295 blood cultures from STRATAA and TyVAC studies, 241 microbiologically confirmed cases of typhoid fever were identified, and 198 isolates from 195 participants sequenced (mean age 12·8 years [SD 10·2], 53% female, 47% male). Between Oct 1, 2016, and Aug 31, 2019, of 177 typhoid fever cases confirmed by whole-genome sequencing, four (2%) were caused by S Typhi with QRDR mutations, compared with six (33%) of 18 cases between Sept 1 and Oct 31, 2019. This increase was associated with a preceding spike in ciprofloxacin prescriptions. Every additional prescription of ciprofloxacin given to study participants in the preceding month was associated with a 4·2% increase (95% CI 1·8-7·0) in the relative risk of isolating S Typhi with a QRDR mutation (p=0·0008). Phylogenetic analysis showed that S Typhi isolates with QRDR mutations from September and October, 2019, belonged to two distinct subclades encoding two different QRDR mutations, and were closely related (4-10 single-nucleotide polymorphisms) to susceptible S Typhi endemic to Blantyre. INTERPRETATION We postulate a causal relationship between increased ciprofloxacin prescriptions and an increase in fluoroquinolone non-susceptibility in S Typhi. Decreasing ciprofloxacin use by improving typhoid diagnostics, and reducing typhoid fever cases through the use of an efficacious vaccine, could help to limit the emergence of resistance. FUNDING Wellcome Trust, Bill & Melinda Gates Foundation, and National Institute for Health and Care Research (UK).
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Affiliation(s)
- Philip M Ashton
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi; Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK.
| | - Angeziwa Chunga Chirambo
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi; Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK; Department of Medical Laboratory Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - James E Meiring
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | | | - Maurice Mbewe
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - Niza Silungwe
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | | | - Happy Banda
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi
| | - Robert S Heyderman
- Research Department of Infection, Division of Infection and Immunity, University College London, London, UK
| | - Zoe A Dyson
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, VIC, Australia; Wellcome Sanger Institute, Wellcome Genome Campus, Hinxton, UK
| | - Peter MacPherson
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi; Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; School of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Marc Y R Henrion
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kathryn E Holt
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Melita A Gordon
- Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi; Institute of Infection, Veterinary & Ecological Sciences, University of Liverpool, Liverpool, UK
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Zhang W, Zhu Z, Zhao Y, Li Z, Chen L, Huang J, Li J, Yu G. Analyzing and Forecasting Pediatric Fever Clinic Visits in High Frequency Using Ensemble Time-Series Methods After the COVID-19 Pandemic in Hangzhou, China: Retrospective Study. JMIR Med Inform 2023; 11:e45846. [PMID: 37728972 PMCID: PMC10551790 DOI: 10.2196/45846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 07/20/2023] [Accepted: 08/10/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has significantly altered the global health and medical landscape. In response to the outbreak, Chinese hospitals have established 24-hour fever clinics to serve patients with COVID-19. The emergence of these clinics and the impact of successive epidemics have led to a surge in visits, placing pressure on hospital resource allocation and scheduling. Therefore, accurate prediction of outpatient visits is essential for informed decision-making in hospital management. OBJECTIVE Hourly visits to fever clinics can be characterized as a long-sequence time series in high frequency, which also exhibits distinct patterns due to the particularity of pediatric treatment behavior in an epidemic context. This study aimed to build models to forecast fever clinic visit with outstanding prediction accuracy and robust generalization in forecast horizons. In addition, this study hopes to provide a research paradigm for time-series forecasting problems, which involves an exploratory analysis revealing data patterns before model development. METHODS An exploratory analysis, including graphical analysis, autocorrelation analysis, and seasonal-trend decomposition, was conducted to reveal the seasonality and structural patterns of the retrospective fever clinic visit data. The data were found to exhibit multiseasonality and nonlinearity. On the basis of these results, an ensemble of time-series analysis methods, including individual models and their combinations, was validated on the data set. Root mean square error and mean absolute error were used as accuracy metrics, with the cross-validation of rolling forecasting origin conducted across different forecast horizons. RESULTS Hybrid models generally outperformed individual models across most forecast horizons. A novel model combination, the hybrid neural network autoregressive (NNAR)-seasonal and trend decomposition using Loess forecasting (STLF), was identified as the optimal model for our forecasting task, with the best performance in all accuracy metrics (root mean square error=20.1, mean absolute error=14.3) for the 15-days-ahead forecasts and an overall advantage for forecast horizons that were 1 to 30 days ahead. CONCLUSIONS Although forecast accuracy tends to decline with an increasing forecast horizon, the hybrid NNAR-STLF model is applicable for short-, medium-, and long-term forecasts owing to its ability to fit multiseasonality (captured by the STLF component) and nonlinearity (captured by the NNAR component). The model identified in this study is also applicable to hospitals in other regions with similar epidemic outpatient configurations or forecasting tasks whose data conform to long-sequence time series in high frequency exhibiting multiseasonal and nonlinear patterns. However, as external variables and disruptive events were not accounted for, the model performance declined slightly following changes in the COVID-19 containment policy in China. Future work may seek to improve accuracy by incorporating external variables that characterize moving events or other factors as well as by adding data from different organizations to enhance algorithm generalization.
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Affiliation(s)
- Wang Zhang
- Department of Data and Information, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Sino-Finland Joint AI Laboratory for Child Health of Zhejiang Province, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Zhu Zhu
- Department of Data and Information, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Sino-Finland Joint AI Laboratory for Child Health of Zhejiang Province, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Yonggen Zhao
- Department of Data and Information, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Sino-Finland Joint AI Laboratory for Child Health of Zhejiang Province, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Zheming Li
- Department of Data and Information, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Sino-Finland Joint AI Laboratory for Child Health of Zhejiang Province, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Lingdong Chen
- Department of Data and Information, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Sino-Finland Joint AI Laboratory for Child Health of Zhejiang Province, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Jian Huang
- Department of Data and Information, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Sino-Finland Joint AI Laboratory for Child Health of Zhejiang Province, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Jing Li
- Department of Data and Information, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Sino-Finland Joint AI Laboratory for Child Health of Zhejiang Province, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
| | - Gang Yu
- Department of Data and Information, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Sino-Finland Joint AI Laboratory for Child Health of Zhejiang Province, Hangzhou, China
- National Clinical Research Center for Child Health, Hangzhou, China
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Garwan YM, Alsalloum MA, Thabit AK, Jose J, Eljaaly K. Effectiveness of antimicrobial stewardship interventions on early switch from intravenous-to-oral antimicrobials in hospitalized adults: A systematic review. Am J Infect Control 2023; 51:89-98. [PMID: 35644293 DOI: 10.1016/j.ajic.2022.05.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND This review aimed to summarize the available evidence on the effectiveness and safety of antimicrobial stewardship interventions to improve the practice of IV-to-PO antimicrobial switch therapy in hospitalized adults. METHODS Following the PRISMA guidelines, we searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE/PubMed, and Scopus from inception to September 1, 2020, for original articles investigating any interventions aimed to improve the practice of IV-to-PO antimicrobial switch therapy in hospitalized adults with infectious diseases. We included randomized controlled trials (RCTs) and quasi-experimental studies. Studies were excluded if they evaluated drugs other than antimicrobials, head-to-head comparison of interventions, included pediatrics or oncology patients. RESULTS Of 506 unique citations identified, 36 studies met the inclusion criteria. The 36 included studies reported 92 interventions as a single (n = 10) or a bundle of interventions (n = 26). The most common interventions used were guideline/protocol/pathway (n = 25), audit and feedback (n = 20), and education (n = 17). CONCLUSIONS This review provides health care providers with a comprehensive summary on the interventions to promote IV-to-PO antimicrobial switch. While no one intervention could be identified as the safest and most effective as most of the included studies used a bundle of interventions, all interventions resulted in optimizing antibiotic use and reducing health care expenditures without compromising the clinical outcomes. As such, each hospital should design and utilize interventions that are applicable based on available resources and expertise.
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Affiliation(s)
- Yusuf M Garwan
- Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Muath A Alsalloum
- Department of Pharmacy Practice, College of Clinical Pharmacy, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abrar K Thabit
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Jimmy Jose
- School of Pharmacy, University of Nizwa, Nizwa, Sultanate of Oman
| | - Khalid Eljaaly
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
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Jones KA, Onwubiko UN, Kubes J, Albrecht B, Paciullo K, Howard-Anderson J, Suchindran S, Trible R, Jacob JT, Yi SH, Goodenough D, Fridkin SK, Sexton ME, Wiley Z. Reductions in inpatient fluoroquinolone use and postdischarge Clostridioides difficile infection (CDI) from a systemwide antimicrobial stewardship intervention. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2021; 1:e32. [PMID: 36168449 PMCID: PMC9495417 DOI: 10.1017/ash.2021.197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/09/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022]
Abstract
Objective To determine the impact of an inpatient stewardship intervention targeting fluoroquinolone use on inpatient and postdischarge Clostridioides difficile infection (CDI). Design We used an interrupted time series study design to evaluate the rate of hospital-onset CDI (HO-CDI), postdischarge CDI (PD-CDI) within 12 weeks, and inpatient fluoroquinolone use from 2 years prior to 1 year after a stewardship intervention. Setting An academic healthcare system with 4 hospitals. Patients All inpatients hospitalized between January 2017 and September 2020, excluding those discharged from locations caring for oncology, bone marrow transplant, or solid-organ transplant patients. Intervention Introduction of electronic order sets designed to reduce inpatient fluoroquinolone prescribing. Results Among 163,117 admissions, there were 683 cases of HO-CDI and 1,104 cases of PD-CDI. In the context of a 2% month-to-month decline starting in the preintervention period (P < .01), we observed a reduction in fluoroquinolone days of therapy per 1,000 patient days of 21% after the intervention (level change, P < .05). HO-CDI rates were stable throughout the study period. In contrast, we also detected a change in the trend of PD-CDI rates from a stable monthly rate in the preintervention period to a monthly decrease of 2.5% in the postintervention period (P < .01). Conclusions Our systemwide intervention reduced inpatient fluoroquinolone use immediately, but not HO-CDI. However, a downward trend in PD-CDI occurred. Relying on outcome measures limited to the inpatient setting may not reflect the full impact of inpatient stewardship efforts.
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Affiliation(s)
| | - Udodirim N. Onwubiko
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | | | | | - Jessica Howard-Anderson
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta, Georgia
| | - Sujit Suchindran
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ronald Trible
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jesse T. Jacob
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta, Georgia
| | - Sarah H. Yi
- Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dana Goodenough
- Georgia Emerging Infections Program, Atlanta, Georgia
- Foundation for Atlanta Veterans’ Education & Research, Decatur, Georgia
- Atlanta Veterans’ Affairs Medical Center, Decatur, Georgia
| | - Scott K. Fridkin
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta, Georgia
| | - Mary Elizabeth Sexton
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zanthia Wiley
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Guo L, Yang L, Qi Y, Niyazi G, Zheng J, Xu R, Chen X, Zhang J, Xi W, Liu D, Wang X, Chen H, Kong MG. Low-Temperature Gas Plasma Combined with Antibiotics for the Reduction of Methicillin-Resistant Staphylococcus aureus Biofilm Both In Vitro and In Vivo. Life (Basel) 2021; 11:life11080828. [PMID: 34440572 PMCID: PMC8400093 DOI: 10.3390/life11080828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/05/2021] [Accepted: 08/08/2021] [Indexed: 11/23/2022] Open
Abstract
Biofilm infections in wounds seriously delay the healing process, and methicillin-resistant Staphylococcus aureus is a major cause of wound infections. In addition to inactivating micro-organisms, low-temperature gas plasma can restore the sensitivity of pathogenic microbes to antibiotics. However, the combined treatment has not been applied to infectious diseases. In this study, low-temperature gas plasma treatment promoted the effects of different antibiotics on the reduction of S. aureus biofilms in vitro. Low-temperature gas plasma combined with rifampicin also effectively reduced the S. aureus cells in biofilms in the murine wound infection model. The blood and histochemical analysis demonstrated the biosafety of the combined treatment. Our findings demonstrated that low-temperature gas plasma combined with antibiotics is a promising therapeutic strategy for wound infections.
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Affiliation(s)
- Li Guo
- Center for Plasma Biomedicine, State Key Laboratory of Electrical Insulation and Power Equipment, Xi’an Jiaotong University, Xi’an 710049, China; (L.G.); (Y.Q.); (X.C.); (J.Z.); (W.X.); (X.W.)
| | - Lu Yang
- School of Life Science and Technology, Xi’an Jiaotong University, Xi’an 710049, China; (L.Y.); (G.N.); (R.X.)
| | - Yu Qi
- Center for Plasma Biomedicine, State Key Laboratory of Electrical Insulation and Power Equipment, Xi’an Jiaotong University, Xi’an 710049, China; (L.G.); (Y.Q.); (X.C.); (J.Z.); (W.X.); (X.W.)
| | - Gulimire Niyazi
- School of Life Science and Technology, Xi’an Jiaotong University, Xi’an 710049, China; (L.Y.); (G.N.); (R.X.)
| | - Jianbao Zheng
- Department of General Surgery, First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China
- Correspondence: author: (J.Z.); (D.L.); (M.G.K.)
| | - Ruobing Xu
- School of Life Science and Technology, Xi’an Jiaotong University, Xi’an 710049, China; (L.Y.); (G.N.); (R.X.)
| | - Xusong Chen
- Center for Plasma Biomedicine, State Key Laboratory of Electrical Insulation and Power Equipment, Xi’an Jiaotong University, Xi’an 710049, China; (L.G.); (Y.Q.); (X.C.); (J.Z.); (W.X.); (X.W.)
| | - Jingye Zhang
- Center for Plasma Biomedicine, State Key Laboratory of Electrical Insulation and Power Equipment, Xi’an Jiaotong University, Xi’an 710049, China; (L.G.); (Y.Q.); (X.C.); (J.Z.); (W.X.); (X.W.)
| | - Wang Xi
- Center for Plasma Biomedicine, State Key Laboratory of Electrical Insulation and Power Equipment, Xi’an Jiaotong University, Xi’an 710049, China; (L.G.); (Y.Q.); (X.C.); (J.Z.); (W.X.); (X.W.)
| | - Dingxin Liu
- Center for Plasma Biomedicine, State Key Laboratory of Electrical Insulation and Power Equipment, Xi’an Jiaotong University, Xi’an 710049, China; (L.G.); (Y.Q.); (X.C.); (J.Z.); (W.X.); (X.W.)
- Correspondence: author: (J.Z.); (D.L.); (M.G.K.)
| | - Xiaohua Wang
- Center for Plasma Biomedicine, State Key Laboratory of Electrical Insulation and Power Equipment, Xi’an Jiaotong University, Xi’an 710049, China; (L.G.); (Y.Q.); (X.C.); (J.Z.); (W.X.); (X.W.)
| | - Hailan Chen
- Frank Reidy Center for Bioelectrics, Old Dominion University, Norfolk, VA 23508, USA;
| | - Michael G. Kong
- Center for Plasma Biomedicine, State Key Laboratory of Electrical Insulation and Power Equipment, Xi’an Jiaotong University, Xi’an 710049, China; (L.G.); (Y.Q.); (X.C.); (J.Z.); (W.X.); (X.W.)
- Frank Reidy Center for Bioelectrics, Old Dominion University, Norfolk, VA 23508, USA;
- Department of Electrical and Computer Engineering, Old Dominion University, Norfolk, VA 23529, USA
- Correspondence: author: (J.Z.); (D.L.); (M.G.K.)
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Peragine C, Walker SAN, Simor A, Walker SE, Kiss A, Leis JA. Impact of a Comprehensive Antimicrobial Stewardship Program on Institutional Burden of Antimicrobial Resistance: A 14-Year Controlled Interrupted Time-series Study. Clin Infect Dis 2021; 71:2897-2904. [PMID: 31813967 DOI: 10.1093/cid/ciz1183] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/06/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) constitutes an international public health threat widely believed to result from excessive antimicrobial use (AMU). Numerous authorities have recommended antimicrobial stewardship programs (ASPs) to curb the selection of AMR, but there is a lack of data confirming this benefit. METHODS A controlled interrupted time-series study spanning 14 years was performed to assess impact of a comprehensive hospital-based ASP that included pharmacist-led audit and feedback on institutional AMR. Patient-level microbiologic and AMU data were obtained from October 2002 to September 2016. Poisson regression models were used to identify changes in the incidence and trend of hospital-acquired (HA) antibiotic-resistant organisms (AROs) and multidrug-resistant organisms (MDROs). Changes in community-acquired (CA)-ARO, CA-MDRO, and inpatient AMU were assessed as controls and process outcomes. RESULTS Statistically significant shifts in AMU, HA-ARO, and HA-MDRO trends coinciding with ASP implementation were observed, corresponding with a 9% reduction in HA-ARO burden (incidence rate ratio [IRR], 0.91 [95% confidence interval {CI}, .83-.99]; P = .03) and a 13% reduction in HA-MDRO burden (IRR, 0.87 [95% CI, .73-1.04]; P = .13) in the intervention period. In contrast, CA-ARO and CA-MDRO incidence continued to rise, with 40% (IRR, 1.40 [95% CI, 1.28-1.54]; P < .0001) and 68% (IRR, 1.68 [95% CI, 1.57-1.82]; P < .0001) increases in burden found, respectively. CONCLUSIONS Implementation of a comprehensive ASP resulting in reduced AMU was associated with a significant reduction in institutional AMR, even though community AMR increased during the same period. These results confirm that ASPs play an important role in the fight against AMR.
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Affiliation(s)
- Christine Peragine
- Department of Pharmacy, Sunnybrook Health Sciences Centre Bayview Campus, Toronto, Ontario, Canada.,Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Sandra A N Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre Bayview Campus, Toronto, Ontario, Canada.,Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Simor
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Scott E Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre Bayview Campus, Toronto, Ontario, Canada.,Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Alexander Kiss
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jerome A Leis
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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7
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Effect of prospective audit and feedback on inpatient fluoroquinolone use and appropriateness of prescribing. Infect Control Hosp Epidemiol 2020; 41:1458-1460. [PMID: 32762780 DOI: 10.1017/ice.2020.339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We report the effect of prospective audit and feedback (PAF) on inpatient fluoroquinolone (FQN) prescriptions. During the PAF period, FQN use decreased from 39.19 to 29.58 days of therapy per 1,000 patient days (P < .001) and appropriateness improved from 68% to 88% (P < .001). High-yield indications to target included noninfectious urinary tract and respiratory presentations.
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Kinoshita N, Komura M, Tsuzuki S, Shoji K, Miyairi I. The effect of preauthorization and prospective audit and feedback system on oral antimicrobial prescription for outpatients at a children's hospital in Japan. J Infect Chemother 2020; 26:582-587. [PMID: 32088130 DOI: 10.1016/j.jiac.2020.01.013] [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: 10/20/2019] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 11/15/2022]
Abstract
Antimicrobial stewardship programs (ASP) for oral antibiotics is still uncommon, despite the fact that oral antibiotics prescription accounts for 90% of total antibiotic consumption in developed countries. We introduced preauthorization and prospective audit and feedback (PAF) system on broad-spectrum oral antimicrobials as a part of ASP intervention from October 2015 in a tertiary children's hospital in Japan. Antimicrobial consumption and cost of targeted oral antimicrobials decreased from 11.1 days of therapy (DOT) per 1000 outpatient visits and 860,040 yen ($ 7167: 1 $ = 120 yen) to 1.9 DOT per 1000 outpatient visits and 142,200 yen ($ 1185) annually, respectively (p < 0.001). Interrupted time-series analysis showed that prescriptions for targeted antimicrobials decreased rapidly after initiation of preauthorization (p < 0.001). Prescriptions for non-targeted oral antimicrobial increased temporarily (p < 0.001), but a decreasing trend was found after the initiation (p < 0.001). In pre-intervention period, the main indications for using targeted antimicrobials were upper and lower respiratory infection, urinary tract infections, prophylaxis for medical procedures and otitis media, but only 21.4% of them were appropriate prescription. The appropriate prescription rate of post -intervention period increased to 58.5%. During the study period, the susceptibility pattern of major bacteria to these antimicrobials did not change. In conclusion, introduction of the preauthorization and PAF for selected oral antimicrobials decreased the antimicrobial use of both targeted and non-targeted antimicrobials. This intervention may be an effective method of ASP for other children's hospitals.
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Affiliation(s)
- Noriko Kinoshita
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan; Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Makoto Komura
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan.
| | - Shinya Tsuzuki
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
| | - Kensuke Shoji
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.
| | - Isao Miyairi
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan.
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Demoré B, Humbert P, Boschetti E, Bevilacqua S, Clerc-Urmès I, May T, Pulcini C, Thilly N. Evaluation of effects of an operational multidisciplinary team on antibiotic use in the medium to long term at a French university hospital. Int J Clin Pharm 2017; 39:1061-1069. [PMID: 28756579 DOI: 10.1007/s11096-017-0516-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 07/19/2017] [Indexed: 11/30/2022]
Abstract
Background Antibiotic-resistant bacteria are a major public health problem throughout the world. In 2006, in accordance with the national guidelines for antibiotic use, the CHRU of Nancy created an operational multidisciplinary antibiotic team at one of its sites. In 2011, a cluster-controlled trial showed that the operational multidisciplinary antibiotic team (the intervention) had a favourable short-term effect on antibiotic use and costs. Objective Our objective was to determine whether these effects continued over the medium to long term (that is, 2-7 years after creation of the operational multidisciplinary antibiotic team, 2009-2014). Setting The 1800-bed University Hospital of Nancy (France). Method The effect in the medium to long term is measured according to the same criteria and assessed by the same methods as the first study. A cluster controlled trial was performed on the period 2009-2014. The intervention group comprised 11 medical and surgical wards in settings where the operational multidisciplinary antibiotic team was implemented and the control group comprised 6 wards without this operational team. Main outcome measure Consumption of antibiotics overall and by therapeutic class (in defined daily doses per 1000 patient-days) and costs savings (in €). Results The reduction in antibiotic use and costs continued, but at a lower rate than in the short term (11% between 2009 and 2014 compared with 33% between 2007 and 2009) at the site of the intervention. The principal decreases concerned fluoroquinolones and glycopeptides. At the site without an operational multidisciplinary antibiotic team (the control group), total antibiotic use remained stable. Between 2009 and 2014, costs fell 10.5% in the intervention group and 5.7% in the control group. Conclusion This study shows that it is possible to maintain the effectiveness over time of such an intervention and demonstrates its role in defining a hospital's antibiotic policy.
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Affiliation(s)
- Béatrice Demoré
- Pharmacy, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France.
- Faculté de Pharmacie, UMR 7565, SRSMC, CNRS - Lorraine University, Rue Albert Lebrun, 54001, Nancy Cedex, France.
| | - Pauline Humbert
- Pharmacy, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
| | - Emmanuelle Boschetti
- Pharmacy, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
| | - Sibylle Bevilacqua
- Infectious Diseases Department, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
| | - Isabelle Clerc-Urmès
- Unité ESPRI-BIOBASE, Plateforme d'Aide à la Recherche Clinique, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
| | - Thierry May
- Infectious Diseases Department, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
- Host-Environment Relation, EA 4369, Lorraine University, Nancy, France
| | - Céline Pulcini
- Infectious Diseases Department, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
- EA 4360 Apemac, Lorraine University, Nancy, France
| | - Nathalie Thilly
- Plateforme d'Aide à la Recherche Clinique, Brabois Hospital, University Hospital of Nancy, Allée du Morvan, 54511, Vandoeuvre-lès-Nancy, France
- EA 4360 Apemac, Lorraine University, Nancy, France
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Pitiriga V, Vrioni G, Saroglou G, Tsakris A. The Impact of Antibiotic Stewardship Programs in Combating Quinolone Resistance: A Systematic Review and Recommendations for More Efficient Interventions. Adv Ther 2017; 34:854-865. [PMID: 28303388 DOI: 10.1007/s12325-017-0514-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Indexed: 12/16/2022]
Abstract
Quinolones are among the most commonly prescribed antibiotics worldwide. A clear relationship has been demonstrated between excessive quinolone use and the steady increase in the incidence of quinolone-resistant bacterial pathogens, both in hospital and community sites. In addition, exposure to quinolones has been associated with colonization and infection with healthcare-associated pathogens such as methicillin-resistant Staphylococcus aureus and Clostridium difficile in hospitalized patients. Therefore, the management of quinolone prescribing in hospitals through antibiotic stewardship programs is considered crucial. Although suggestions have been made by previous studies on the positive impact of stewardship programs concerning the emergence and spread of multidrug-resistant bacteria at hospital level, the association of quinolone-targeted interventions with reduction of quinolone resistance is vague. The purpose of this article was to evaluate the impact of stewardship interventions on quinolone resistance rates and healthcare-associated infections, through a literature review using systematic methods to identify and select the appropriate studies. Recommendations for improvements in quinolone-targeted stewardship programs are also proposed. Efforts in battling quinolone resistance should combine various interventions such as restriction formulary policies, prospective audits with feedback to prescribers, infection prevention and control measures, prompt detection of low-level resistance, educational programs, and guidelines for optimal quinolone usage. However, the effectiveness of such strategies should be assessed by properly designed and conducted clinical trials. Finally, novel approaches in diagnostic stewardship for rapidly detecting bacterial resistance, including PCR-based techniques, mass spectrometry, microarrays, and whole-genome sequencing as well as the prompt investigation on the clonality of quinolone-resistant strains, will strengthen our ability to personalize quinolone prescribing to individual patients.
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de With K, Allerberger F, Amann S, Apfalter P, Brodt HR, Eckmanns T, Fellhauer M, Geiss HK, Janata O, Krause R, Lemmen S, Meyer E, Mittermayer H, Porsche U, Presterl E, Reuter S, Sinha B, Strauß R, Wechsler-Fördös A, Wenisch C, Kern WV. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2017; 44:395-439. [PMID: 27066980 PMCID: PMC4889644 DOI: 10.1007/s15010-016-0885-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. Materials and methods A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. Conclusion The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.
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Affiliation(s)
- K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - F Allerberger
- Division Public Health, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - S Amann
- Hospital Pharmacy, Munich Municipal Hospital, Munich, Germany
| | - P Apfalter
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - H-R Brodt
- Department of Infectious Disease Medical Clinic II, Goethe-University Frankfurt, Frankfurt, Germany
| | - T Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - M Fellhauer
- Hospital Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - H K Geiss
- Department of Hospital Epidemiology and Infectiology, Sana Kliniken AG, Ismaning, Germany
| | - O Janata
- Department for Hygiene and Infection Control, Danube Hospital, Vienna, Austria
| | - R Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
| | - S Lemmen
- Division of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany
| | - E Meyer
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Berlin, Germany
| | - H Mittermayer
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - U Porsche
- Department for Clinical Pharmacy and Drug Information, Landesapotheke, Landeskliniken Salzburg (SALK), Salzburg, Austria
| | - E Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - S Reuter
- Clinic for General Internal Medicine, Infectious Diseases, Pneumology and Osteology, Klinikum Leverkusen, Leverkusen, Germany
| | - B Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Strauß
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Erlangen, Germany
| | - A Wechsler-Fördös
- Department of Antibiotics and Infection Control, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Wenisch
- Medical Department of Infection and Tropical Medicine, Kaiser Franz Josef Hospital, Vienna, Austria
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, Freiburg University Medical Center, Freiburg, Germany
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Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, Gould IM, Ramsay CR, Michie S. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2:CD003543. [PMID: 28178770 PMCID: PMC6464541 DOI: 10.1002/14651858.cd003543.pub4] [Citation(s) in RCA: 397] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotic resistance is a major public health problem. Infections caused by multidrug-resistant bacteria are associated with prolonged hospital stay and death compared with infections caused by susceptible bacteria. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. We updated this systematic review to evaluate the impact of interventions to improve antibiotic prescribing to hospital inpatients. OBJECTIVES To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and to investigate the effect of two intervention functions: restriction and enablement. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, and Embase. We searched for additional studies using the bibliographies of included articles and personal files. The last search from which records were evaluated and any studies identified incorporated into the review was January 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies (NRS). We included three non-randomised study designs to measure behavioural and clinical outcomes and analyse variation in the effects: non- randomised trials (NRT), controlled before-after (CBA) studies and interrupted time series (ITS) studies. For this update we also included three additional NRS designs (case control, cohort, and qualitative studies) to identify unintended consequences. Interventions included any professional or structural interventions as defined by the Cochrane Effective Practice and Organisation of Care Group. We defined restriction as 'using rules to reduce the opportunity to engage in the target behaviour (or increase the target behaviour by reducing the opportunity to engage in competing behaviours)'. We defined enablement as 'increasing means/reducing barriers to increase capability or opportunity'. The main comparison was between intervention and no intervention. DATA COLLECTION AND ANALYSIS Two review authors extracted data and assessed study risk of bias. We performed meta-analysis and meta-regression of RCTs and meta-regression of ITS studies. We classified behaviour change functions for all interventions in the review, including those studies in the previously published versions. We analysed dichotomous data with a risk difference (RD). We assessed certainty of evidence with GRADE criteria. MAIN RESULTS This review includes 221 studies (58 RCTs, and 163 NRS). Most studies were from North America (96) or Europe (87). The remaining studies were from Asia (19), South America (8), Australia (8), and the East Asia (3). Although 62% of RCTs were at a high risk of bias, the results for the main review outcomes were similar when we restricted the analysis to studies at low risk of bias.More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% confidence interval (CI) 14% to 16%; 23,394 participants; high-certainty evidence). This represents an increase from 43% to 58% .There were high levels of heterogeneity of effect size but the direction consistently favoured intervention.The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67; 14 RCTs; 3318 participants; high-certainty evidence) from 11.0 days. Information from non-randomised studies showed interventions to be associated with improvement in prescribing according to antibiotic policy in routine clinical practice, with 70% of interventions being hospital-wide compared with 31% for RCTs. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs; 15,827 participants; moderate-certainty evidence). Antibiotic stewardship interventions probably reduce length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs; 3834 participants; moderate-certainty evidence). One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence).Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions (high-certainty evidence). Enabling interventions that included feedback were probably more effective than those that did not (moderate-certainty evidence).There was very low-certainty evidence about the effect of the interventions on reducing Clostridium difficile infections (median -48.6%, interquartile range -80.7% to -19.2%; 7 studies). This was also the case for resistant gram-negative bacteria (median -12.9%, interquartile range -35.3% to 25.2%; 11 studies) and resistant gram-positive bacteria (median -19.3%, interquartile range -50.1% to +23.1%; 9 studies). There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use. Heterogeneity of intervention effect on prescribing outcomesWe analysed effect modifiers in 29 RCTs and 91 ITS studies. Enablement and restriction were independently associated with a larger effect size (high-certainty evidence). Feedback was included in 4 (17%) of 23 RCTs and 20 (47%) of 43 ITS studies of enabling interventions and was associated with greater intervention effect. Enablement was included in 13 (45%) of 29 ITS studies with restrictive interventions and enhanced intervention effect. AUTHORS' CONCLUSIONS We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment. Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Additional trials comparing antibiotic stewardship with no intervention are unlikely to change our conclusions. Enablement consistently increased the effect of interventions, including those with a restrictive component. Although feedback further increased intervention effect, it was used in only a minority of enabling interventions. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Consequently, effective dissemination of our findings could have considerable health service and policy impact. Future research should instead focus on targeting treatment and assessing other measures of patient safety, assess different stewardship interventions, and explore the barriers and facilitators to implementation. More research is required on unintended consequences of restrictive interventions.
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Affiliation(s)
- Peter Davey
- University of DundeePopulation Health SciencesMackenzie BuildingKirsty Semple WayDundeeScotlandUKDD2 4BF
| | - Charis A Marwick
- University of DundeePopulation Health Sciences Division, Medical Research InstituteDundeeUK
| | - Claire L Scott
- NHS Education for ScotlandScottish Dental Clinical Effectiveness ProgrammeDundee Dental Education CentreSmall's WyndDundeeUKDD1 4HN
| | - Esmita Charani
- Imperial College LondonNIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial ResistanceDu Cane RoadLondonUKW12 OHS
| | - Kirsty McNeil
- University of DundeeSchool of Medicine147 Forth CrescentDundeeScotlandUKDD2 4JA
| | - Erwin Brown
- No affiliation31 Park CrescentFrenchayBristolUKBS16 1NZ
| | - Ian M Gould
- Aberdeen Royal InfirmaryDepartment of Medical MicrobiologyForesterhillAberdeenUKAB25 2ZN
| | - Craig R Ramsay
- University of AberdeenHealth Services Research Unit, Division of Applied Health SciencesPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
| | - Susan Michie
- University College LondonResearch Department of Primary Care and Population HealthUpper Floor 3, Royal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Yosef I, Manor M, Qimron U. Counteracting selection for antibiotic-resistant bacteria. BACTERIOPHAGE 2016; 6:e1096996. [PMID: 27144084 DOI: 10.1080/21597081.2015.1096996] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 09/13/2015] [Accepted: 09/15/2015] [Indexed: 12/29/2022]
Abstract
The occurrence of antibiotic-resistant bacterial pathogens is on the rise because antibiotics exert selection pressure that kills only the antibiotic-sensitive pathogens. Sanitation and cleansing of hospital surfaces and the skin of medical personnel do not counteract this selective pressure, but rather indiscriminately reduce total pathogens on treated surfaces. Here, we discuss two recently introduced genetic strategies, based on temperate bacteriophages as DNA-delivery vehicles, that aim to sensitize bacteria to antibiotics and selectively kill the antibiotic-resistant ones. Outlooks for rendering one such approach more efficient and applicable are proposed. We believe that using an end product designed according to the provided principles on hospital surfaces and in hand-sanitizers will facilitate substitution of antibiotic-resistant pathogens with sensitive ones.
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Affiliation(s)
- Ido Yosef
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Miriam Manor
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Udi Qimron
- Department of Clinical Microbiology and Immunology, Sackler School of Medicine, Tel Aviv University , Tel Aviv , Israel
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Grignon O, Montassier E, Corvec S, Lepelletier D, Hardouin JB, Caillon J, Batard E. Escherichia coli antibiotic resistance in emergency departments. Do local resistance rates matter? Eur J Clin Microbiol Infect Dis 2014; 34:571-7. [DOI: 10.1007/s10096-014-2264-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 10/07/2014] [Indexed: 11/28/2022]
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García-San Miguel L, Cobo J, Martínez JA, Arnau JM, Murillas J, Peña C, Segura F, Gurguí M, Gálvez J, Giménez M, Gudiol F. ['Third day intervention': an analysis of the factors associated with following the recommendations on the prescribing of antibiotics]. Enferm Infecc Microbiol Clin 2014; 32:654-61. [PMID: 24813928 DOI: 10.1016/j.eimc.2013.09.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 09/10/2013] [Accepted: 09/23/2013] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Stewardship programs on the use of antibiotics usually include interventions based on non-compulsory recommendations for the prescribers. Factors related to the adherence to expert recommendations, and the implementation of these programmes in daily practice, are of interest. METHODS A randomized, controlled, multicentre intervention study was performed in 32 hospitalization units. Antibiotic prescriptions were evaluated by an infectious disease specialist on the third day. We describe the implementation of the intervention, the factors associated with adherence to recommendations, and the impact of the intervention. RESULTS A total of 3,192 interventions were carried out. Information sources used to prepare the recommendations varied significantly between centres. A modification was recommended in 65% of cases: withdrawal (47%), change in administration route (26%), change of drugs or number of antibiotics (27%), and change in dose (5%). Simplification of treatment accounted for 75% of all recommendations. Adherence was 68%, with significant differences between hospitals, and higher when the recommendations consisted of a dose adjustment or change of route, during the first intervention period, and also when recommendations were personally commented on, in addition to writing a note in the clinical chart. We did not find any reduction in antibiotic consumption or variation in the incidence of resistant pathogens. CONCLUSIONS An important proportion of antibiotic prescriptions may be susceptible to improvement, most of them towards simplification. The adherence to the intervention was high, but significant variations at different centres were observed, depending on the type of recommendation, and the study period. Those recommendations that were personally commented on were more followed more than those only written.
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Affiliation(s)
| | - Javier Cobo
- Servicio de Enfermedades Infecciosas, Hospital Ramón y Cajal, Madrid, España
| | | | - Josep Maria Arnau
- Servicio de Farmacología Clínica, Hospital Vall d'Hebron, Barcelona, España
| | - Javier Murillas
- Servicio de Medicina Interna, Hospital Son Espases, Palma de Mallorca, España
| | - Carmen Peña
- Servicio de Enfermedades Infecciosas, Hospital de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - Ferran Segura
- Servicio de Medicina Interna, Hospital Parc Taulí, Sabadell, Barcelona, España
| | - Montserrat Gurguí
- Servicio de Medicina Interna, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Juan Gálvez
- Servicio de Enfermedades Infecciosas, Hospital Virgen Macarena, Sevilla, España
| | - Montserrat Giménez
- Servicio de Microbiología, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - Francesc Gudiol
- Servicio de Enfermedades Infecciosas, Hospital de Bellvitge, Hospitalet de Llobregat, Barcelona, España
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Elsaid K, Truong T, Monckeberg M, McCarthy H, Butera J, Collins C. Impact of electronic chemotherapy order forms on prescribing errors at an urban medical center: results from an interrupted time-series analysis. Int J Qual Health Care 2013; 25:656-63. [PMID: 24132956 DOI: 10.1093/intqhc/mzt067] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To evaluate the impact of electronic standardized chemotherapy templates on incidence and types of prescribing errors. DESIGN A quasi-experimental interrupted time series with segmented regression. SETTING A 700-bed multidisciplinary tertiary care hospital with an ambulatory cancer center. PARTICIPANTS A multidisciplinary team including oncology physicians, nurses, pharmacists and information technologists. INTERVENTION(S) Standardized, regimen-specific, chemotherapy prescribing forms were developed and implemented over a 32-month period. MAIN OUTCOME MEASURE(S) Trend of monthly prevented prescribing errors per 1000 chemotherapy doses during the pre-implementation phase (30 months), immediate change in the error rate from pre-implementation to implementation and trend of errors during the implementation phase. Errors were analyzed according to their types: errors in communication or transcription, errors in dosing calculation and errors in regimen frequency or treatment duration. Relative risk (RR) of errors in the post-implementation phase (28 months) compared with the pre-implementation phase was computed with 95% confidence interval (CI). RESULTS Baseline monthly error rate was stable with 16.7 prevented errors per 1000 chemotherapy doses. A 30% reduction in prescribing errors was observed with initiating the intervention. With implementation, a negative change in the slope of prescribing errors was observed (coefficient = -0.338; 95% CI: -0.612 to -0.064). The estimated RR of transcription errors was 0.74; 95% CI (0.59-0.92). The estimated RR of dosing calculation errors was 0.06; 95% CI (0.03-0.10). The estimated RR of chemotherapy frequency/duration errors was 0.51; 95% CI (0.42-0.62). CONCLUSIONS Implementing standardized chemotherapy-prescribing templates significantly reduced all types of prescribing errors and improved chemotherapy safety.
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Affiliation(s)
- K Elsaid
- Department of Pharmaceutical Sciences, MCPHS University, 179 Longwood Ave, Boston, MA 02115, USA.
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Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ, Wilcox M. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013:CD003543. [PMID: 23633313 DOI: 10.1002/14651858.cd003543.pub3] [Citation(s) in RCA: 351] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The first publication of this review in Issue 3, 2005 included studies up to November 2003. This update adds studies to December 2006 and focuses on application of a new method for meta-analysis of interrupted time series studies and application of new Cochrane Effective Practice and Organisation of Care (EPOC) Risk of Bias criteria to all studies in the review, including those studies in the previously published version. The aim of the review is to evaluate the impact of interventions from the perspective of antibiotic stewardship. The two objectives of antibiotic stewardship are first to ensure effective treatment for patients with bacterial infection and second support professionals and patients to reduce unnecessary use and minimize collateral damage. OBJECTIVES To estimate the effectiveness of professional interventions that, alone or in combination, are effective in antibiotic stewardship for hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial-resistant pathogens or Clostridium difficile infection and their impact on clinical outcome. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE from 1980 to December 2006 and the EPOC specialized register in July 2007 and February 2009 and bibliographies of retrieved articles. The main comparison is between interventions that had a restrictive element and those that were purely persuasive. Restrictive interventions were implemented through restriction of the freedom of prescribers to select some antibiotics. Persuasive interventions used one or more of the following methods for changing professional behaviour: dissemination of educational resources, reminders, audit and feedback, or educational outreach. Restrictive interventions could contain persuasive elements. SELECTION CRITERIA We included randomized clinical trials (RCTs), controlled clinical trials (CCT), controlled before-after (CBA) and interrupted time series studies (ITS). Interventions included any professional or structural interventions as defined by EPOC. The intervention had to include a component that aimed to improve antibiotic prescribing to hospital inpatients, either by increasing effective treatment or by reducing unnecessary treatment. The results had to include interpretable data about the effect of the intervention on antibiotic prescribing or microbial outcomes or relevant clinical outcomes. DATA COLLECTION AND ANALYSIS Two authors extracted data and assessed quality. We performed meta-regression of ITS studies to compare the results of persuasive and restrictive interventions. Persuasive interventions advised physicians about how to prescribe or gave them feedback about how they prescribed. Restrictive interventions put a limit on how they prescribed; for example, physicians had to have approval from an infection specialist in order to prescribe an antibiotic. We standardized the results of some ITS studies so that they are on the same scale (percent change in outcome), thereby facilitating comparisons of different interventions. To do this, we used the change in level and change in slope to estimate the effect size with increasing time after the intervention (one month, six months, one year, etc) as the percent change in level at each time point. We did not extrapolate beyond the end of data collection after the intervention. The meta-regression was performed using standard weighted linear regression with the standard errors of the coefficients adjusted where necessary. MAIN RESULTS For this update we included 89 studies that reported 95 interventions. Of the 89 studies, 56 were ITSs (of which 4 were controlled ITSs), 25 were RCT (of which 5 were cluster-RCTs), 5 were CBAs and 3 were CCTs (of which 1 was a cluster-CCT).Most (80/95, 84%) of the interventions targeted the antibiotic prescribed (choice of antibiotic, timing of first dose and route of administration). The remaining 15 interventions aimed to change exposure of patients to antibiotics by targeting the decision to treat or the duration of treatment. Reliable data about impact on antibiotic prescribing data were available for 76 interventions (44 persuasive, 24 restrictive and 8 structural). For the persuasive interventions, the median change in antibiotic prescribing was 42.3% for the ITSs, 31.6% for the controlled ITSs, 17.7% for the CBAs, 3.5% for the cluster-RCTs and 24.7% for the RCTs. The restrictive interventions had a median effect size of 34.7% for the ITSs, 17.1% for the CBAs and 40.5% for the RCTs. The structural interventions had a median effect of 13.3% for the RCTs and 23.6% for the cluster-RCTs. Data about impact on microbial outcomes were available for 21 interventions but only 6 of these also had reliable data about impact on antibiotic prescribing.Meta-analysis of 52 ITS studies was used to compare restrictive versus purely persuasive interventions. Restrictive interventions had significantly greater impact on prescribing outcomes at one month (32%, 95% confidence interval (CI) 2% to 61%, P = 0.03) and on microbial outcomes at 6 months (53%, 95% CI 31% to 75%, P = 0.001) but there were no significant differences at 12 or 24 months. Interventions intended to decrease excessive prescribing were associated with reduction in Clostridium difficile infections and colonization or infection with aminoglycoside- or cephalosporin-resistant gram-negative bacteria, methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis. Meta-analysis of clinical outcomes showed that four interventions intended to increase effective prescribing for pneumonia were associated with significant reduction in mortality (risk ratio 0.89, 95% CI 0.82 to 0.97), whereas nine interventions intended to decrease excessive prescribing were not associated with significant increase in mortality (risk ratio 0.92, 95% CI 0.81 to 1.06). AUTHORS' CONCLUSIONS The results show that interventions to reduce excessive antibiotic prescribing to hospital inpatients can reduce antimicrobial resistance or hospital-acquired infections, and interventions to increase effective prescribing can improve clinical outcome. This update provides more evidence about unintended clinical consequences of interventions and about the effect of interventions to reduce exposure of patients to antibiotics. The meta-analysis supports the use of restrictive interventions when the need is urgent, but suggests that persuasive and restrictive interventions are equally effective after six months.
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Affiliation(s)
- Peter Davey
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK.
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Emergence of colistin resistance in Enterobacteriaceae after the introduction of selective digestive tract decontamination in an intensive care unit. Antimicrob Agents Chemother 2013; 57:3224-9. [PMID: 23629703 DOI: 10.1128/aac.02634-12] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Selective decontamination of the digestive tract (SDD) selectively eradicates aerobic Gram-negative bacteria (AGNB) by the enteral administration of oral nonabsorbable antimicrobial agents, i.e., colistin and tobramycin. We retrospectively investigated the impact of SDD, applied for 5 years as part of an infection control program for the control of an outbreak with extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae in an intensive care unit (ICU), on resistance among AGNB. Colistin MICs were determined on stored ESBL-producing K. pneumoniae isolates using the Etest. The occurrence of both tobramycin resistance among pathogens intrinsically resistant to colistin (CIR) and bacteremia caused by ESBL-producing K. pneumoniae and CIR were investigated. Of the 134 retested ESBL-producing K. pneumoniae isolates, 28 were isolated before SDD was started, and all had MICs of <1.5 mg/liter. For the remaining 106 isolated after starting SDD, MICs ranged between 0.5 and 24 mg/liter. Tobramycin-resistant CIR isolates were found sporadically before the introduction of SDD, but their prevalence increased immediately afterward. Segmented regression analysis showed a highly significant relationship between SDD and resistance to tobramycin. Five patients were identified with bacteremia caused by ESBL-producing K. pneumoniae before SDD and 9 patients thereafter. No bacteremia caused by CIR was found before SDD, but its occurrence increased to 26 after the introduction of SDD. In conclusion, colistin resistance among ESBL-producing K. pneumoniae isolates emerged rapidly after SDD. In addition, both the occurrence and the proportion of tobramycin resistance among CIR increased under the use of SDD. SDD should not be applied in outbreak settings when resistant bacteria are prevalent.
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Relationship between hospital antibiotic use and quinolone resistance in Escherichia coli. Int J Infect Dis 2012. [PMID: 23183232 DOI: 10.1016/j.ijid.2012.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The relationship between the hospital use of various classes of antibiotics and resistance of Escherichia coli to quinolones remains debated. Our aim was to study the relationship between the hospital use of 16 classes of antibacterial agents and the incidence of quinolone-resistant E. coli isolates. METHODS Antibiotic use and resistance data were collected from 36 hospitals. Incident rate ratios (IRR) were assessed using negative binomial regression. RESULTS The incidence of quinolone-resistant isolates was independently associated with the consumption of tetracyclines (IRR 1.139, 95% CI 1.030-1.259), first- and second-generation cephalosporins (IRR 1.007, 95% CI 1.002-1.013), third-generation cephalosporins (IRR 1.029, 95% CI 1.010-1.048), and quinolones (IRR 1.007, 95% CI 1.000-1.014). These associations were independent from the type of patient served. CONCLUSIONS The level of hospital use of quinolones influences the incidence of quinolone resistance in E. coli hospital isolates. The consumption of two other classes of antibiotics, cephalosporins and tetracyclines, is also associated with quinolone resistance.
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Harris PNA, Ferguson JK. Antibiotic therapy for inducible AmpC β-lactamase-producing Gram-negative bacilli: what are the alternatives to carbapenems, quinolones and aminoglycosides? Int J Antimicrob Agents 2012; 40:297-305. [PMID: 22824371 DOI: 10.1016/j.ijantimicag.2012.06.004] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 06/06/2012] [Accepted: 06/07/2012] [Indexed: 01/15/2023]
Abstract
Some bacteria that possess chromosomally determined AmpC β-lactamases may express these enzymes at a high level following exposure to β-lactams, either by induction or selection for derepressed mutants. This may lead to clinical failure even if an isolate initially tests susceptible in vitro, a phenomenon best characterised by third-generation cephalosporin therapy for Enterobacter bacteraemia or meningitis. Several other Enterobacteriaceae, such as Serratia marcescens, Citrobacter freundii, Providencia spp. and Morganella morganii (often termed the 'ESCPM' group), may also express high levels of AmpC. However, the risk of clinical failure with β-lactams that test susceptible in vitro is less clear in these species than for Enterobacter. Laboratories frequently do not report β-lactam or β-lactamase inhibitor combination drug susceptibilities for ESCPM organisms, encouraging alternative therapy with quinolones, aminoglycosides or carbapenems. However, quinolones and carbapenems present problems with selective pressure for multiresistant organisms, and aminoglycosides with potential toxicity. The risk of emergent AmpC-mediated resistance for non-Enterobacter spp. appears rare in clinical studies. Piperacillin/tazobactam may remain effective and may be less selective for AmpC derepressed mutants than cephalosporins. The potential roles for agents such as cefepime or trimethoprim/sulfamethoxazole are also discussed. Clinical studies that better define optimal treatment for this group of bacteria are required.
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Affiliation(s)
- P N A Harris
- Hunter Area Pathology, Pathology North, John Hunter Hospital, New Lambton, NSW, Australia.
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Dumartin C, Rogues AM, Amadéo B, Péfau M, Venier AG, Parneix P, Maurain C. Antibiotic usage in south-western French hospitals: trends and association with antibiotic stewardship measures. J Antimicrob Chemother 2011; 66:1631-7. [DOI: 10.1093/jac/dkr179] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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