Evaluating a pilot, structured, face-to-face, antimicrobial stewardship, prospective audit-and-feedback program in emergency general surgery service in a community hospital

Background

Prospective audit and feedback (PAF) is an established practice in critical care settings but not in surgical populations. We pilot-tested a structured face-to-face PAF program for our acute-care surgery (ACS) service.

Methods

This was a mixed-methods study. For the quantitative analysis, the structured PAF period was from August 1, 2017, to April 30, 2019. The ad hoc PAF period was from May 1, 2019, to January 31, 2021. Interrupted time-series segmented negative binomial regression analysis was used to evaluate change in antimicrobial usage measured in days of therapy per 1,000 patient days for all systemic and targeted antimicrobials. Secondary outcomes included C. difficile infections, length of stay and readmission within 30 days. Each secondary outcome was analyzed using a logistic regression or negative binomial regression model. For the qualitative analyses, all ACS surgeons and trainees from November 23, 2015, to April 30, 2019, were invited to participate in an email-based anonymous survey developed using implementation science principles. Responses were measured using counts.

Results

In total, 776 ACS patients were included in the structured PAF period and 783 patients were included in the in ad hoc PAF period. No significant changes in level or trend for antimicrobial usage were detected for all and targeted antimicrobials. Similarly, no significant differences were detected for secondary outcomes. The survey response rate was 25% (n = 10). Moreover, 50% agreed that PAF provided them with skills to use antimicrobials more judiciously, and 80% agreed that PAF improved the quality of antimicrobial treatment for their patients.

Conclusion

Structured PAF showed clinical outcomes similar to ad hoc PAF. Structured PAF was well received and was perceived as beneficial by surgical staff.

Pharmacist gender and physician acceptance of antibiotic stewardship recommendations: An analysis of the reducing overuse of antibiotics at discharge home intervention

OBJECTIVE

To assess association of pharmacist gender with acceptance of antibiotic stewardship recommendations.

DESIGN

A retrospective evaluation of the Reducing Overuse of Antibiotics at Discharge (ROAD) Home intervention.

SETTING

The study was conducted from May to October 2019 in a single academic medical center.

PARTICIPANTS

The study included patients receiving antibiotics on a hospitalist service who were nearing discharge.

METHODS

During the intervention, clinical pharmacists (none who had specialist postgraduate infectious disease residency training) reviewed patients on antibiotics and led an antibiotic timeout (ie, structured conversation) prior to discharge to improve discharge antibiotic prescribing. We assessed the association of pharmacist gender with acceptance of timeout recommendations by hospitalists using logistic regression controlling for patient characteristics.

RESULTS

Over 6 months, pharmacists conducted 295 timeouts: 158 timeouts (53.6%) were conducted by 12 women, 137 (46.4%) were conducted by 8 men. Pharmacists recommended an antibiotic change in 82 timeouts (27.8%), of which 51 (62.2%) were accepted. Compared to male pharmacists, female pharmacists were less likely to recommend a discharge antibiotic change: 30 (19.0%) of 158 versus 52 (38.0%) of 137 (P < .001). Female pharmacists were also less likely to have a recommendation accepted: 10 (33.3%) of 30 versus 41 (8.8%) of 52 (P < .001). Thus, timeouts conducted by female versus male pharmacists were less likely to result in an antibiotic change: 10 (6.3%) of 158 versus 41 (29.9%) of 137 (P < .001). After adjustments, pharmacist gender remained significantly associated with whether recommended changes were accepted (adjusted odds ratio [aOR], 0.10; 95%confidence interval [CI], 0.03-0.36 for female versus male pharmacists).

CONCLUSIONS

Antibiotic stewardship recommendations made by female clinical pharmacists were less likely to be accepted by hospitalists. Gender bias may play a role in the acceptance of clinical pharmacist recommendations, which could affect patient care and outcomes.

Sepsis Team Organizational Model to Decrease Mortality for Intra-Abdominal Infections: Is Antibiotic Stewardship Enough?

Introduction. Sepsis is an overwhelming reaction to infection with significant morbidity, requiring urgent interventions in order to improve outcomes. The 2016 Sepsis-3 guidelines modified the previous definitions of sepsis and septic shock, and proposed some specific diagnostic and therapeutic measures to define the use of fluid resuscitation and antibiotics. However, some open issues still exist. Methods. A literature research was performed on PubMed and Cochrane using the terms "sepsis" AND "intra-abdominal infections" AND ("antibiotic therapy" OR "antibiotic treatment"). The inclusion criteria were management of intra-abdominal infection (IAI) and effects of antibiotic stewardships programs (ASP) on the outcome of the patients. Discussion. Sepsis-3 definitions represent an added value in the understanding of sepsis mechanisms and in the management of the disease. However, some questions are still open, such as the need for an early identification of sepsis. Sepsis management in the context of IAI is particularly challenging and a prompt diagnosis is essential in order to perform a quick treatment (source control and antibiotic treatment). Antibiotic empirical therapy should be based on the kind of infection (community or hospital acquired), local resistances, and patient's characteristic and comorbidities, and should be adjusted or de-escalated as soon as microbiological information is available. Antibiotic Stewardship Programs (ASP) have demonstrated to improve antimicrobial utilization with reduction of infections, emergence of multi-drug resistant bacteria, and costs. Surgeons should not be alone in the management of IAI but ideally inserted in a sepsis team together with anaesthesiologists, medical physicians, pharmacists, and infectious diseases specialists, meeting periodically to reassess the response to the treatment. Conclusion. The cornerstones of sepsis management are accurate diagnosis, early resuscitation, effective source control, and timely initiation of appropriate antimicrobial therapy. Current evidence shows that optimizing antibiotic use across surgical specialities is imperative to improve outcomes. Ideally every hospital and every emergency surgery department should aim to provide a sepsis team in order to manage IAI.

Factors Associated with Acceptance of Telehealth-based Antimicrobial Stewardship Program Recommendations in a Community Hospital Health System

Background

Telehealth-based antimicrobial stewardship programs (TeleASPs) have led to reduced broad-spectrum antimicrobial utilization. Data on factors associated with acceptance of stewardship recommendations are limited.

Methods

A TeleASP, facilitated by remote infectious disease physicians and local pharmacists, was implemented in 2 community hospitals from February 2018 through July 2020. Variables potentially affecting acceptance of TeleASP recommendations were tracked. Odds ratios of acceptance were determined utilizing multiple logistic regression.

Results

During the 30-month period, 4863 (91.2%) of the total 5333 recommendations were accepted. Factors associated with a higher odds of acceptance in multivariable analysis were recommendations for antimicrobial dose/frequency adjustment (odds ratio [OR], 2.63; 95% CI, 1.6–4.3) and order for labs/tests (OR, 3.30; 95% CI, 2.1–5.2), while recommendations for antimicrobial de-escalation (OR, 0.75; 95% CI, 0.60–0.95) and antimicrobial discontinuation (OR, 0.57; 95% CI, 0.42–0.76) were associated with lower odds of acceptance. Female physicians were more likely to accept recommendations compared with males (93.1% vs 90.3% acceptance; OR, 1.65; 95% CI, 1.3–2.2). Compared with physicians with <3 years of experience, who had the highest acceptance rate (96.3%), physicians with ≥21 years of experience had the lowest (87.1%; OR, 0.26; 95% CI, 0.15–0.45).

Conclusions

TeleASP recommendations were accepted at a high rate. Acceptance rates were higher among female physicians, and recommendations to stop or de-escalate antimicrobials led to lower acceptance. Recommendations made to the most experienced physicians were the least accepted, which may be an important factor for stewardship programs to consider in education and intervention efforts.

Retrospective Cohort Analysis of the Effect of Antimicrobial Stewardship on Postoperative Antibiotic Therapy in Complicated Intra-Abdominal Infections: Short-Course Therapy Does Not Compromise Patients’ Safety

Background: Recent evidence suggests that short-course postoperative antibiotic therapy (PAT) of intra-abdominal infections is non-inferior considering clinical outcomes. The aim of this study was to compare the outcome of short vs. long PAT in complicated intra-abdominal infections (cIAIs) without sepsis. Methods: We performed a single center-quality improvement study at a 1500 bed sized university hospital in Bavaria, Germany, with evaluation of the length of antibiotic therapy after emergency surgery on cIAIs with adequate source control during 2016 to 2018. We reviewed a total of 260 cases (160 short duration vs. 100 long duration). The antibiotic prescribing quality was assessed by our in-house antimicrobial stewardship team (AMS). Results: No significant differences of patient characteristics were observed between short and long PAT. The frequency of long PAT declined during the observation period from 48.1% to 26.3%. Prolongation of PAT was not linked with any clinical benefits, on the contrary clinical outcome of patients receiving longer regimes were associated with higher postoperative morbidity. AMS identified additional educational targets to improve antibiotic prescribing quality on general wards like unnecessary postoperative switches of antibiotic regimes, e.g., unrequired switches to oral antibiotics as well as prolongation of PAT due to elevated CRP. Conclusion: Short-course antibiotic therapy after successful surgical source control in cIAIs is safe, and long-duration PAT has no beneficial effects.

Barriers-enablers-ownership approach: a mixed methods analysis of a social intervention to improve surgical antibiotic prescribing in hospitals

OBJECTIVES

To assess an intervention for surgical antibiotic prophylaxis (SAP) improvement within surgical teams focused on addressing barriers and fostering enablers and ownership of guideline compliance.

DESIGN

The Queensland Surgical Antibiotic Prophylaxis (QSAP) study was a multicentre, mixed methods study designed to address barriers and enablers to SAP compliance and facilitate engagement in self-directed audit/feedback and assess the efficacy of the intervention in improving compliance with SAP guidelines. The implementation was assessed using a 24-month interrupted time series design coupled with a qualitative evaluation.

SETTING

The study was undertaken at three hospitals (one regional, two metropolitan) in Australia.

PARTICIPANTS

SAP-prescribing decisions for 1757 patients undergoing general surgical procedures from three health services were included. Six bimonthly time points, pre-implementation and post implementation of the intervention, were measured. Qualitative interviews were performed with 29 clinical team members. SAP improvements varied across site and time periods.

INTERVENTION

QSAP embedded ownership of quality improvement in SAP within surgical teams and used known social influences to address barriers to and enablers of optimal SAP prescribing.

RESULTS

The site that reported senior surgeon engagement showed steady and consistent improvement in prescribing over 24 months (prestudy and poststudy). Multiple factors, including resource issues, influenced engagement and sites/time points where these were present had no improvement in guideline compliance.

CONCLUSIONS

The barriers-enablers-ownership model shows promise in its ability to facilitate prescribing improvements and could be expanded into other areas of antimicrobial stewardship. Senior ownership was a predictor of success (or failure) of the intervention across sites and time periods. The key role of senior leaders in change leadership indicates the critical need to engage other specialties in the stewardship agenda. The influence of contextual factors in limiting engagement clearly identifies issues of resource distributions/inequalities within health systems as limiting antimicrobial optimisation potential.

Defining the Scope of Antimicrobial Stewardship Interventions on the Prescription Quality of Antibiotics for Surgical Intra-Abdominal Infections

Background: The aim of this study was to assess the impact of antimicrobial stewardship interventions on surgical antibiotic prescription behavior in the management of non-elective surgical intra-abdominal infections, focusing on postoperative antibiotic use, including the appropriateness of indications. Methods: A single-center quality improvement study with retrospective evaluation of the impact of antimicrobial stewardship measures on optimizing antibacterial use in intra-abdominal infections requiring emergency surgery was performed. The study was conducted in a tertiary hospital in Germany from January 1, 2016, to January 30, 2020, three years after putting a set of antimicrobial stewardship standards into effect. Results: 767 patients were analyzed (n = 495 in 2016 and 2017, the baseline period; n = 272 in 2018, the antimicrobial stewardship period). The total days of therapy per 100 patient days declined from 47.0 to 42.2 days (p = 0.035). The rate of patients receiving postoperative therapy decreased from 56.8% to 45.2% (p = 0.002), comparing both periods. There was a significant decline in the rate of inappropriate indications (17.4% to 8.1 %, p = 0.015) as well as a significant change from broad-spectrum to narrow-spectrum antibiotic use (28.8% to 6.5%, p ≤ 0.001) for postoperative therapy. The significant decline in antibiotic use did not affect either clinical outcomes or the rate of postoperative wound complications. Conclusions: Postoperative antibiotic use for intra-abdominal infections could be significantly reduced by antimicrobial stewardship interventions. The identification of inappropriate indications remains a key target for antimicrobial stewardship programs.

Collaborative Antimicrobial Stewardship for Surgeons

Antimicrobial stewardship efforts that include surgeons rely on healthy and open communications between surgeons, infectious diseases specialists, and pharmacists. These efforts most frequently are related to surgical prophylaxis, the management of surgical infections, and surgical critical care. Policy should be based on best evidence and timely interactions to develop consensus on how to develop appropriate guidelines and protocols. Flexibility on all sides leads to increasingly strong relationships over time.

Barriers to Adherence to Antimicrobial Stewardship Postprescription Review and Feedback For Broad-Spectrum Antimicrobial Agents: A Nested Case-Control Study

Background

Postprescription review and feedback (PPRF) is one of the most common strategies in antimicrobial stewardship program (ASP) intervention. However, disagreements between the prescribers and ASP personnel can occur. The aim of the present study was to identify the factors associated with nonadherence to PPRF intervention.

Methods

The present retrospective nested case-control study was performed at a tertiary care center, which has been conducting a once-weekly PPRF for carbapenems and piperacillin/tazobactam since 2014. Nonadherence to ASP recommendations was defined as the failure of the primary care team to modify or stop antimicrobial therapy 72 hours after the issuance of PPRF recommendations. Factors associated with nonadherence to PPRF intervention were identified using multivariate logistic regression analysis.

Results

In total, 2466 instances of PPRF in 1714 cases between April 2014 and September 2019 were found. The nonadherence rate was 5.9%, and 44 cases were found in which carbapenems or piperacillin/tazobactam continued to be used against PPRF recommendations. Factors associated with nonadherence to PPRF recommendations were a previous history of hospitalization within 90 days (adjusted odds ratio [aOR], 2.62; 95% confidence interval [CI], 1.18-5.81) and a rapidly fatal McCabe score at the time of PPRF intervention (aOR, 2.87; 95% CI, 1.18-6.98). A review of the narrative comments in the electronic medical records indicated that common reasons for nonadherence were "the patient was sick" (n = 12; 27.3%) and "the antimicrobial seemed to be clinically effective" (n = 9; 20.5%).

Conclusions

Nonadherence to PPRF recommendations was relatively uncommon at the study institution. However, patients with a severe disease condition frequently continued to receive broad-spectrum antimicrobials against PPRF recommendations. Understanding physicians' cognitive process in nonadherence to ASP recommendations and ASP interventions targeting medical subspecialties caring for severely ill patients is needed to improve ASP.

Who listens and who doesn't? Factors associated with adherence to antibiotic stewardship intervention in a Singaporean tertiary hospital

INTRODUCTION

Antibiotic stewardship programmes (ASPs) can improve patient outcomes by prospective audit and feedback with interventions. However, adherence to ASP interventions is not mandatory. Identifying factors associated with improved adherence may help to enhance ASP recommendations and activities.

METHODS

A retrospective cohort study was conducted, comprising all ASP interventions performed as part of the prospective audit and feedback strategy in our institution (an acute tertiary-care hospital in Singapore) from January 2016 to July 2018. Adherence to ASP intervention was ascertained based on documented compliance with the recommended interventions within 48h. Factors associated with adherence to ASP interventions, such as patient demographics, clinical condition, type of infection, and characteristics of ASP interventions were identified using the χ² test for categorical variables. On multivariate analysis, factors independently associated with adherence to ASP intervention were identified using logistic regression.

RESULTS

Adherence to ASP intervention was 81.9% (5758/7028). On univariate and multivariate analysis, interventions coupled with direct communication via phone call (adjusted odds ratio [aOR] 1.61, 95% CI 1.23-2.08) were associated with higher odds of adherence, whereas admission to a surgical unit, intervention involving carbapenem use, and recommendation to de-escalate or discontinue antibiotics were associated with lower odds of adherence to ASP interventions.

CONCLUSION

Although adherence rates to ASP interventions were relatively high, interventions made to the surgical unit and recommendations related to carbapenem use were not so well received. Interventions communicated verbally via phone call were well received, highlighting the need for a close working relationship between ASP teams and hospital physicians.

A proposal for a comprehensive approach to infections across the surgical pathway

Despite evidence supporting the effectiveness of best practices in infection prevention and management, many healthcare workers fail to implement them and evidence-based practices tend to be underused in routine practice. Prevention and management of infections across the surgical pathway should always focus on collaboration among all healthcare workers sharing knowledge of best practices. To clarify key issues in the prevention and management of infections across the surgical pathway, a multidisciplinary task force of experts convened in Ancona, Italy, on May 31, 2019, for a national meeting. This document represents the executive summary of the final statements approved by the expert panel.

Antimicrobial Stewardship Programs Are Required in a Department of Surgery: "How" Is the Question A Quasi-Experimental Study: Results after Three Years

Objective: Our aim was to describe our antimicrobial stewardship program and the methodology based on the results in a surgical department. Methods: Our study was a quasi-experimental study conducted from January 1, 2009, through September 30, 2017. The site was the General and Digestive Surgery Department in a public primary referral center, the University Hospital of Getafe (Madrid, Spain). We implemented the antimicrobial stewardship program following a prospective audit and feedback model, with a surgeon incorporated into the manaagement group. We studied the deaths and 30-day re-admission rates, length of stay, prevalence of gram-negative bacilli, meropenem resistance, and days of treatment with meropenem. Results: After three years of the program, we recorded a significant decrease in Pseudomonas aeruginosa prevalence, a significant increase in Klebsiella pneumoniae prevalence, a decrease in meropenem resistance, and a reduction in meropenem days of treatment. Conclusions: Antimicrobial stewardship programs have a desirable effect on patients. In our experience, the program team should be led by a staff from the particular department. When human resources are limited, the sustainability, efficiency, and effectiveness of interventions are feasible only with adequate computer support. Finally, but no less important, the necessary feedback between the prescribers and the team must be based on an ad hoc method such as that provided by statistical control charts, a median chart in our study.

The learning hospital: From theory to practice in a hospital infection prevention program

The learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.

Implementation of a Plan-Do-Study-Act framework to reduce unindicated surgical antimicrobial prophylaxis

PURPOSE

The goal of this study was to use a Plan-Do-Study-Act (PDSA) framework to reduce utilization of unindicated surgical antibiotic prophylaxis (SAP) for clean cases without foreign body implantation.

METHODS

This was a pre-post intervention study conducted at a single children's hospital comparing 6 months of retrospective preintervention data to 10 months of prospectively collected postintervention data. Interventions to reduce unindicated SAP included faculty meetings to review guidelines and establish consensus around inclusion criteria, publicizing guidelines with regular email reminders, and conducting ongoing compliance audits to root cause noncompliance. Early unanticipated noncompliant cases were associated with rotating trainees who prescribed SAP routinely without attending knowledge. A second PDSA cycle then included education-based emails targeting residents with mandatory feedback loop closure.

RESULTS

Preintervention, 40.4% (107/265) of patients received unindicated SAP. Postintervention, the rate of unindicated SAP decreased to 15.4% (6/39) after the first month and 6.2% (20/323) after 10 months, reflecting an 85% reduction across periods (p < 0.01). There was no difference in the rate of surgical site infections between the pre and postintervention cohorts (0.36% vs. 0.67%, p = 1.00).

CONCLUSIONS

Unindicated surgical antibiotic prophylaxis was significantly reduced by implementing a Plan-Do-Study-Act intervention targeting both faculty and trainees.

LEVEL OF EVIDENCE

Prospective comparative treatment study, level II.

Non-adherence to antimicrobial stewardship prospective audit and feedback advice: Risk factors and clinical consequences

Amongst 325 patients receiving restricted antimicrobials whose management was subject to antimicrobial stewardship prospective audit and feedback, adherence to advice was 78%. Non-adherence was associated with diabetic patients, giving more than 1 piece of advice and receipt of piperacillin/tazobactam therapy, and was inversely associated with liver disease. Adherence to advice was associated with a one third reduction in duration of antimicrobial use without adversely impacting other infection-related patient outcomes.

Implementation and Impact of an Antimicrobial Stewardship Program at a Tertiary Care Center in South India

Background

Antimicrobial resistance is a major public health threat internationally but, particularly in India. A primary contributing factor to this rise in resistance includes unregulated access to antimicrobials. Implementing antimicrobial stewardship programs (ASPs) in the acute hospital setting will help curb inappropriate antibiotic use in India. Currently, ASPs are rare in India but are gaining momentum. This study describes ASP implementation in a large, academic, private, tertiary care center in India.

Methods

An ASP was established in February 2016 consisting of an administrative champion, hospitalist, microbiologist, intensivist, and pharmacists. Antimicrobial stewardship program interventions included postprescriptive audit and establishment of institutional guidelines. The ASP tracked appropriate drug selection including loading dose, maintenance dose, frequency, route, duration of therapy, de-escalation, and compliance with ASP recommendations. Defined daily dose (DDD) of drugs and cost of antimicrobials were compared between the pre-implementation phase (February 2015–January 2016) and post-implementation phase (February 2016–January 2017).

Results

Of 48 555 patients admitted during the post-implementation phase, 1020 received 1326 prescriptions for restricted antibiotics. Antibiotic therapy was appropriate in 56% (742) of the total patient prescriptions. A total of 2776 instances of “inappropriate” antimicrobial prescriptions were intervened upon by the ASP. Duration (806, 29%) was the most common reason for inappropriate therapy. Compliance with ASP recommendations was 54% (318). For all major restricted drugs, the DDD/1000 patient days declined, and there was a significant reduction in mean monthly cost by 14.4% in the post-implementation phase.

Conclusions

Implementation of a multidisciplinary antibiotic stewardship program in this academic, large, Indian hospital demonstrated feasibility and economic benefits.

Knowledge, awareness, and attitude towards infection prevention and management among surgeons: identifying the surgeon champion

Despite evidence supporting the effectiveness of best practices of infection prevention and management, many surgeons worldwide fail to implement them. Evidence-based practices tend to be underused in routine practice. Surgeons with knowledge in surgical infections should provide feedback to prescribers and integrate best practices among surgeons and implement changes within their team. Identifying a local opinion leader to serve as a champion within the surgical department may be important. The “surgeon champion” can integrate best clinical practices of infection prevention and management, drive behavior change in their colleagues, and interact with both infection control teams in promoting antimicrobial stewardship.

[Perception of surgeons on the use of antimicrobial stewardships programs]

INTRODUCTION

The misuse and overuse of antimicrobials can contribute to an increase in antimicrobial resistance, increasing the risk of infections caused by drug-resistant bacteria. Most common surgical pathologies are infectious (either primary or as a complication), often being over-treated. Exploring the perception of surgeons on the use of implementing Antimicrobial stewardship programs (ASPs) is relevant in order to adapt the program to local context.

OBJECTIVE

To determine the perception of surgeons on the management of infections and antibiotic (AB) prescription in a General Surgery Department (GSD).

METHODS

A cross-sectional and descriptive study was conducted using an anonymous questionnaire that was distributed to assess the aspects related to AB management.

RESULTS

A total of 42 questionnaires were completed, with a 65% response rate. The large majority (75%) considered that antimicrobial resistance was an important problem. The main situations considered with medium/high margin of improvement were: time from taking the specimen to receiving the results (70%), use of a wide spectrum AB, and excessive duration (88% and 89%), dose adjustment according to renal function (81%), unnecessary prolongation of intravenous AB treatment (87%) and excessive duration of it (89%), preference for intravenous AB administration until discharge of the patient (73%). There were also difficulties in ASP implementation, as well as established and solid AB patterns (84%) and the heterogeneity of the GSD (84%).

CONCLUSIONS

Organisational aspects of the GSD constitute one of the problems to implement the ASPs. A specific multidisciplinary team has been constituted to address different training aspects. This will also serve as a forum of discussion of certain complex patients with difficulties in antibiotic management.

Reducing Antimicrobial Use in an Academic Pediatric Institution: Evaluation of the Effectiveness of a Prospective Audit With Real-Time Feedback

INTRODUCTION

Antimicrobial use is decreasing across freestanding children's hospitals, predominantly in institutions with antimicrobial stewardship programs (ASPs) in place. A highly effective ASP should effect a greater decrease in use than predicted by existing trends. Antimicrobial stewardship programs depend on clinician adherence to program recommendations, but little is known about factors associated with adherence.

METHODS

Parenteral antimicrobial-use data for our institution and 43 additional freestanding children's hospitals were obtained and normalized for patient census. Segmental linear regression was used to compare rates of change of parenteral antimicrobial use before and after ASP implementation. Time-series models were developed to predict use in the absence of intervention. The odds of adherence to ASP recommendations were determined based on provider characteristics and recommendation type.

RESULTS

In the 38 months before ASP implementation, parenteral antimicrobial use was decreasing at our hospital by 3.7%/year, similar to the 3.4%/year found across children's hospitals. The rate of change after implementation of the ASP at our hospital was 11.1%/year, compared to 5.6%/year for other hospitals over the same period. Of 643 interventions, teams adhered with recommendations in 495 cases (77.0%). According to adjusted analysis, primary service was not associated with adherence (P = .356). There was an association between adherence and the role of the clinician receiving a recommendation (P = .009) and the recommendation type (P = .009).

CONCLUSIONS

Understanding factors associated with adherence to ASP recommendations can help those who administer such programs to strategize interventions for maximizing efficacy. Our findings reveal the value of a formal ASP in reducing use when controlling for secular trends.

Antimicrobial stewardship programmes: bedside rationing by another name?

Antimicrobial therapy is a cornerstone of therapy in critically ill patients; however, the wide use of antibiotics has resulted in increased antimicrobial resistance and outbreaks of resistant disease. To counter this, many hospitals have instituted antimicrobial stewardship programmes as a way to reduce the inappropriate use of antibiotics. However, uptake of antimicrobial stewardship programmes has been variable, as many clinicians fear that they may put individual patients at risk of treatment failure. In this paper, I argue that antimicrobial stewardship programmes are indeed a form of bedside rationing, and explore the risks and benefits of such programmes for individual patients in the intensive care unit, and the critically ill population in general. Using Norman Daniels' Accountability for Reasonableness as a framework for evaluating resource allocation policies, I conclude that antimicrobial stewardship programmes are an ethically sound form of bedside rationing.

Optimizing adherence to advice from antimicrobial stewardship audit and feedback rounds

We examined adherence to antimicrobial stewardship prospective audit and feedback rounds in a rehabilitation service compared with the remainder of the acute hospital, and explored the reasons for this. Between October 2014 and December 2015, we retrospectively assessed the rate of non-adherence to advice from antimicrobial stewardship prospective audit and feedback rounds between the rehabilitation service and the acute hospital, along with the source of the patient referral. Compared with the rehabilitation service, acute hospital medical staff were almost twice as likely to not adhere to advice provided on antimicrobial stewardship prospective audit and feedback rounds (13.8% vs. 7.6%, p < 0.0001, relative risk 1.8 [95% confidence interval 1.3, 2.5]). In the rehabilitation service, referrals were more likely to come from medical staff (61.9% vs. 16.3%, p < 0.0001). These findings may be explained by regular, direct engagement of the antimicrobial stewardship team with the rehabilitation service clinical team, a model potentially applicable to other settings.

Every antibiotic, every day: Maximizing the impact of prospective audit and feedback on total antibiotic use

Background

The success of antimicrobial stewardship is dependent on how often it is completed and which antimicrobials are targeted. We evaluated the impact of an antimicrobial stewardship program (ASP) in three non-ICU settings where all systemic antibiotics, regardless of spectrum, were targeted on the first weekday after initiation.

Methods

Prospective audit and feedback (PAAF) was initiated on the surgical, respiratory, and medical wards of a community hospital on July 1, 2010, October 1, 2010, and April 1, 2012, respectively. We evaluated rates of total antibiotic use, measured in days on therapy (DOTs), among all patients admitted to the wards before and after PAAF initiation using an interrupted time series analysis. Changes in antibiotic costs, rates of C. difficile infection (CDI), mortality, readmission, and length of stay were evaluated using univariate analyses.

Results

Time series modelling demonstrated that total antibiotic use decreased (± standard error) by 100 ± 51 DOTs/1,000 patient-days on the surgical wards (p = 0.049), 100 ± 46 DOTs/1,000 patient-days on the respiratory ward (p = 0.029), and 91 ± 33 DOTs/1,000 patient-days on the medical wards (p = 0.006) immediately following PAAF initiation. Reductions in antibiotic use were sustained up to 50 months after intervention initiation, and were accompanied by decreases in antibiotic costs. There were no significant changes to patient outcomes on the surgical and respiratory wards following intervention initiation. On the medical wards, however, readmission increased from 4.6 to 5.6 per 1,000 patient-days (p = 0.043), while mortality decreased from 7.4 to 5.0 per 1,000 patient-days (p = 0.001). CDI rates showed a non-significant declining trend after PAAF initiation.

Conclusions

ASPs can lead to cost-effective, sustained reductions in total antibiotic use when interventions are conducted early in the course of therapy and target all antibiotics. Shifting to such a model may help strengthen the effectiveness of ASPs in non-ICU settings.

The Global Alliance for Infections in Surgery: defining a model for antimicrobial stewardship-results from an international cross-sectional survey

BACKGROUND

Antimicrobial Stewardship Programs (ASPs) have been promoted to optimize antimicrobial usage and patient outcomes, and to reduce the emergence of antimicrobial-resistant organisms. However, the best strategies for an ASP are not definitively established and are likely to vary based on local culture, policy, and routine clinical practice, and probably limited resources in middle-income countries. The aim of this study is to evaluate structures and resources of antimicrobial stewardship teams (ASTs) in surgical departments from different regions of the world.

METHODS

A cross-sectional web-based survey was conducted in 2016 on 173 physicians who participated in the AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections) project and on 658 international experts in the fields of ASPs, infection control, and infections in surgery.

RESULTS

The response rate was 19.4%. One hundred fifty-six (98.7%) participants stated their hospital had a multidisciplinary AST. The median number of physicians working inside the team was five [interquartile range 4-6]. An infectious disease specialist, a microbiologist and an infection control specialist were, respectively, present in 80.1, 76.3, and 67.9% of the ASTs. A surgeon was a component in 59.0% of cases and was significantly more likely to be present in university hospitals (89.5%, p < 0.05) compared to community teaching (83.3%) and community hospitals (66.7%). Protocols for pre-operative prophylaxis and for antimicrobial treatment of surgical infections were respectively implemented in 96.2 and 82.3% of the hospitals. The majority of the surgical departments implemented both persuasive and restrictive interventions (72.8%). The most common types of interventions in surgical departments were dissemination of educational materials (62.5%), expert approval (61.0%), audit and feedback (55.1%), educational outreach (53.7%), and compulsory order forms (51.5%).

CONCLUSION

The survey showed a heterogeneous organization of ASPs worldwide, demonstrating the necessity of a multidisciplinary and collaborative approach in the battle against antimicrobial resistance in surgical infections, and the importance of educational efforts towards this goal.

Antimicrobial Stewardship: A Call to Action for Surgeons

Despite current antimicrobial stewardship programs (ASPs) being advocated by infectious disease specialists and discussed by national and international policy makers, ASPs coverage remains limited to only certain hospitals as well as specific service lines within hospitals. The ASPs incorporate a variety of strategies to optimize antimicrobial agent use in the hospital, yet the exact set of interventions essential to ASP success remains unknown. Promotion of ASPs across clinical practice is crucial to their success to ensure standardization of antimicrobial agent use within an institution. To effectively accomplish this standardization, providers who actively engage in antimicrobial agent prescribing should participate in the establishment and support of these programs. Hence, surgeons need to play a major role in these collaborations. Surgeons must be aware that judicious antibiotic utilization is an integral part of any stewardship program and necessary to maximize clinical cure and minimize emergence of antimicrobial resistance. The battle against antibiotic resistance should be fought by all healthcare professionals. If surgeons around the world participate in this global fight and demonstrate awareness of the major problem of antimicrobial resistance, they will be pivotal leaders. If surgeons fail to actively engage and use antibiotics judiciously, they will find themselves deprived of the autonomy to treat their patients.

Identifying Antimicrobial Stewardship Targets for Pediatric Surgical Patients

BACKGROUND

More than 80% of surgical inpatients at US children's hospitals receive antibiotics, accounting for >40% of all inpatient pediatric antibiotic use. We aimed to examine the collective pool of all systemic antibiotics prescribed to children hospitalized for surgical conditions and identify common surgical conditions with highly variable and potentially unnecessary antibiotic use, because these conditions may represent antimicrobial stewardship priorities.

METHODS

We conducted a retrospective cross-sectional study of surgical inpatients discharged in 2012 at 37 freestanding children's hospitals. We captured all systemic antibiotic use as days of therapy (DOT), and we reported surgical conditions by frequency and contribution to overall antibiotic use. We used multivariable logistic and Poisson regression with marginal standardization to estimate (1) the standardized proportion and (2) DOT of condition-specific targeted antibiotic use among top surgical condition patients.

RESULTS

Among 151 345 surgical inpatients, 82.9% received antimicrobials for a median 2 DOT per subject (interquartile range, 1-5; range, 1-958). The most commonly received antibiotics were cefazolin (16.7% of all DOT), vancomycin (12.5%), and piperacillin/tazobactam (6.9%). The top 10 conditions contributing most to antibiotic use accounted for 51.3% of all antibiotic use. Among these, adjusted use of postoperative and perioperative vancomycin varied across hospitals among craniotomy and cardiothoracic surgery subjects (all P < .001); adjusted use of broad-spectrum antipseudomonal agents varied across hospitals among gastrointestinal surgery subjects (all P < .001).

CONCLUSIONS

Use of (1) vancomycin for pediatric cardiothoracic and neurosurgical patients and (2) broad-spectrum antipseudomonal agents for gastrointestinal surgery patients represent potentially high-yield targets for stewardship efforts to reduce unnecessary antimicrobial use.

Mortality Benefits of Antibiotic Computerised Decision Support System: Modifying Effects of Age

Antibiotic computerised decision support systems (CDSSs) are shown to improve antibiotic prescribing, but evidence of beneficial patient outcomes is limited. We conducted a prospective cohort study in a 1500-bed tertiary-care hospital in Singapore, to evaluate the effectiveness of the hospital’s antibiotic CDSS on patients’ clinical outcomes, and the modification of these effects by patient factors. To account for clustering, we used multilevel logistic regression models. One-quarter of 1886 eligible inpatients received CDSS-recommended antibiotics. Receipt of antibiotics according to CDSS’s recommendations seemed to halve mortality risk of patients (OR 0.54, 95% CI 0.26–1.10, P = 0.09). Patients aged ≤65 years had greater mortality benefit (OR 0.45, 95% CI 0.20–1.00, P = 0.05) than patients that were older than 65 (OR 1.28, 95% CI 0.91–1.82, P = 0.16). No effect was observed on incidence of Clostridium difficile (OR 1.02, 95% CI 0.34–3.01), and multidrug-resistant organism (OR 1.06, 95% CI 0.42–2.71) infections. No increase in infection-related readmission (OR 1.16, 95% CI 0.48–2.79) was found in survivors. Receipt of CDSS-recommended antibiotics reduced mortality risk in patients aged 65 years or younger and did not increase the risk in older patients. Physicians should be informed of the benefits to increase their acceptance of CDSS recommendations.

Patient and physician predictors of patient receipt of therapies recommended by a computerized decision support system when initially prescribed broad-spectrum antibiotics: a cohort study

OBJECTIVE

Antibiotic computerized decision support systems (CDSSs) were developed to guide antibiotic decisions, yet prescriptions of CDSS-recommended antibiotics have remained low. Our aim was to identify predictors of patients' receipt of empiric antibiotic therapies recommended by a CDSS when the prescribing physician had an initial preference for using broad-spectrum antibiotics.

METHODS

We conducted a prospective cohort study in a 1 500-bed tertiary-care hospital in Singapore. We included all patients admitted from October 1, 2011 through September 30, 2012, who were prescribed piperacillin-tazobactam or carbapenem for empiric therapy and auto-triggered to receive antibiotic recommendations by the in-house antibiotic CDSS. Relevant data on the patient, prescribing and attending physicians were collected via electronic linkages of medical records and administrative databases. To account for clustering, we used multilevel logistic regression models to explore factors associated with receipt of CDSS-recommended antibiotic therapy.

RESULTS

One-quarter of the 1 886 patients received CDSS-recommended antibiotics. More patients treated for pneumonia (33.2%) than sepsis (12.1%) and urinary tract infections (7.1%) received CDSS-recommended antibiotic therapies. The prescribing physician - but not the attending physician or clinical specialty - accounted for some (13.3%) of the variation. Prior hospitalization (odds ratio [OR] 1.32, 95% CI, 1.01-1.71), presumed pneumonia (OR 6.77, 95% CI, 3.28-13.99), intensive care unit (ICU) admission (OR 0.38, 95% CI, 0.21-0.66), and renal impairment (OR 0.70, 95% CI, 0.52-0.93) were factors associated with patients' receipt of CDSS-recommended antibiotic therapies.

CONCLUSIONS

We observed that ICU admission and renal impairment were negative predictors of patients' receipt of CDSS-recommended antibiotic therapies. Patients admitted to ICU and those with renal impairment might have more complex clinical conditions that require a physician's assessment in addition to antibiotic CDSS.