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Ture Z, Güner R, Alp E. Antimicrobial stewardship in the intensive care unit. JOURNAL OF INTENSIVE MEDICINE 2023; 3:244-253. [PMID: 37533805 PMCID: PMC10391567 DOI: 10.1016/j.jointm.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/03/2022] [Accepted: 10/10/2022] [Indexed: 08/04/2023]
Abstract
High resistance rates to antimicrobials continue to be a global health threat. The incidence of multidrug-resistant (MDR) microorganisms in intensive care units (ICUs) is quite high compared to in the community and other units in the hospital because ICU patients are generally older, have higher numbers of co-morbidities and immune-suppressed; moreover, the typically high rates of invasive procedures performed in the ICU increase the risk of infection by MDR microorganisms. Antimicrobial stewardship (AMS) refers to the implementation of coordinated interventions to improve and track the appropriate use of antibiotics while offering the best possible antibiotic prescription (according to dose, duration, and route of administration). Broad-spectrum antibiotics are frequently preferred in ICUs because of greater infection severity and colonization and infection by MDR microorganisms. For this reason, a number of studies on AMS in ICUs have increased in recent years. Reducing the use of broad-spectrum antibiotics forms the basis of AMS. For this purpose, parameters such as establishing an AMS team, limiting the use of broad-spectrum antimicrobials, terminating treatments early, using early warning systems, pursuing infection control, and providing education and feedback are used. In this review, current AMS practices in ICUs are discussed.
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Affiliation(s)
- Zeynep Ture
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Erciyes University, Kayseri 38039,Turkey
| | - Rahmet Güner
- Department of Infectious Diseases and Clinical Microbiology, Yıldırım Beyazıt University, Ankara 06800, Turkey
| | - Emine Alp
- Department of Infectious Diseases and Clinical Microbiology, Yıldırım Beyazıt University, Ankara 06800, Turkey
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2
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Saatchi A, Yoo JW, Schwartz KL, Silverman M, Morris AM, Patrick DM, McCormack J, Marra F. Quantifying the Gap between Expected and Actual Rates of Antibiotic Prescribing in British Columbia, Canada. Antibiotics (Basel) 2021; 10:1428. [PMID: 34827366 PMCID: PMC8615253 DOI: 10.3390/antibiotics10111428] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/13/2021] [Accepted: 11/19/2021] [Indexed: 11/16/2022] Open
Abstract
Despite decades of stewardship efforts to combat antimicrobial resistance and quantify changes in use, the quality of antibiotic use in British Columbia (BC) remains unknown. As the overuse and misuse of antibiotics drives antibiotic resistance, it is imperative to expand surveillance efforts to examine the quality of antibiotic prescriptions. In late 2019, Canadian expected rates of antibiotic prescribing were developed for common infections. These rates were utilized to quantify the gap between the observed rates of prescribing and Canadian expected rates for antibiotic use for the province of BC. The prescribing data were extracted and matched to physician billing systems using anonymized patient identifiers from 1 January 2000 to 31 December 2018. Outpatient prescribing was further subdivided into community and emergency department settings and stratified by the following age groups: <2 years, 2-18 years, and ≥19 years. The proportions of physician visits that received antibiotic prescription were compared against the Canadian expected rates to quantify the unnecessary use for 18 common indications. Respiratory tract infections (RTI), including acute bronchitis, acute sinusitis, and acute pharyngitis, reported significant levels of overprescribing. Across all ages and health care settings, prescribing for RTI indications occurred at rates 2-8 times higher than the expected rates recommended by a group of expert Canadian physicians. Understanding the magnitude of unnecessary prescribing is a first step in delineating the provincial prescribing quality. The quantification of antibiotic overuse offers concrete targets for provincial stewardship efforts to reduce unnecessary prescribing by an average of 30% across both outpatient and emergency care settings.
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Affiliation(s)
- Ariana Saatchi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (A.S.); (J.-W.Y.); (J.M.)
| | - Ji-Won Yoo
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (A.S.); (J.-W.Y.); (J.M.)
| | - Kevin L. Schwartz
- Public Health Ontario, Toronto, ON M5G 1V2, Canada;
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
| | - Michael Silverman
- Lawson Health Research Institute, London, ON N6A 4V2, Canada;
- Faculty of Medicine, University of Western Ontario, London, ON N6A 5C1, Canada
| | - Andrew M. Morris
- Sinai Health System, University Health Network and University of Toronto, Toronto, ON M5G 1L7, Canada;
| | - David M. Patrick
- British Columbia Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada;
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - James McCormack
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (A.S.); (J.-W.Y.); (J.M.)
| | - Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (A.S.); (J.-W.Y.); (J.M.)
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Cunha CB, Opal SM. Antibiotic Stewardship: Strategies to Minimize Antibiotic Resistance While Maximizing Antibiotic Effectiveness. Med Clin North Am 2018; 102:831-843. [PMID: 30126574 DOI: 10.1016/j.mcna.2018.04.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Empiric therapy of the septic patient in the hospital is challenging. Antibiotic stewardship is concerned with optimizing antibiotic use and minimizing resistance. Clinicians should avoid overcovering and overtreating colonizing organisms in respiratory secretions and urinary catheters. Empiric therapy should take into account the prevalence of multidrug-resistant organisms in the hospital setting. The most effective resistance prevention strategies is to preferentially select a low resistance potential antibiotic, which should be administered in the highest possible dose without toxicity for the shortest duration to eliminate the infection.
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Affiliation(s)
- Cheston B Cunha
- Division of Infectious Disease, Rhode Island Hospital, The Miriam Hospital, Brown University Alpert School of Medicine, 593 Eddy Street, Physicians Office Building, Suite #328, Providence, RI 02903, USA.
| | - Steven M Opal
- Division of Infectious Disease, Rhode Island Hospital, The Miriam Hospital, Brown University Alpert School of Medicine, 593 Eddy Street, Physicians Office Building, Suite #328, Providence, RI 02903, USA
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Dresser LD, Bell CM, Steinberg M, Ferguson ND, Lapinsky S, Lazar N, Murphy P, Singh JM, Morris AM. Use of a structured panel process to define antimicrobial prescribing appropriateness in critical care. J Antimicrob Chemother 2018; 73:246-249. [PMID: 29029170 DOI: 10.1093/jac/dkx341] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/23/2017] [Indexed: 12/19/2022] Open
Abstract
Background Antimicrobial prescribing is frequently reported as appropriate or inappropriate, particularly in the ICU. However, the definitions used are non-standardized and lack validity and reliability. Objectives To develop standardized definitions of appropriateness for antimicrobial prescribing in the critical care setting. Methods We used consensus-based modified Delphi and RAND appropriateness methodology to develop criteria to define appropriateness of antimicrobial prescribing. A multiphased approach with an online questionnaire followed by a facilitated in-person meeting was utilized and included clinicians from a variety of practice areas (e.g. surgeons, infectious diseases specialists, intensivists, transplant specialists and pharmacists). Results There were a total of 23 criteria agreed upon to define the following categories of antimicrobial prescribing: appropriate; effective but unnecessary; inappropriate; and under-treatment. Conclusions These standardized criteria for appropriateness may be generalizable to other patient populations and utilized with other tools to adjudicate prescribing practices.
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Affiliation(s)
- Linda D Dresser
- University Health Network, 101 College St., Toronto, Ontario M5G 1L7, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St., Toronto, Ontario M5S 3M2, Canada
| | - Chaim M Bell
- University Health Network, 101 College St., Toronto, Ontario M5G 1L7, Canada.,Sinai Health System, 600 University Ave., Toronto, Ontario M5G 1X5, Canada.,Department of Medicine, University of Toronto, 200 Elizabeth St., Suite RFE 3-805, Toronto, Ontario M5G 2C4, Canada.,Institute for Clinical Evaluative Sciences, 2075 Bayview Ave., G1-06, Toronto, Ontario M4N 3M5, Canada
| | - Marilyn Steinberg
- Sinai Health System, 600 University Ave., Toronto, Ontario M5G 1X5, Canada
| | - Niall D Ferguson
- University Health Network, 101 College St., Toronto, Ontario M5G 1L7, Canada.,Sinai Health System, 600 University Ave., Toronto, Ontario M5G 1X5, Canada.,Department of Medicine, University of Toronto, 200 Elizabeth St., Suite RFE 3-805, Toronto, Ontario M5G 2C4, Canada
| | - Stephen Lapinsky
- Sinai Health System, 600 University Ave., Toronto, Ontario M5G 1X5, Canada.,Department of Medicine, University of Toronto, 200 Elizabeth St., Suite RFE 3-805, Toronto, Ontario M5G 2C4, Canada
| | - Neil Lazar
- University Health Network, 101 College St., Toronto, Ontario M5G 1L7, Canada.,Department of Medicine, University of Toronto, 200 Elizabeth St., Suite RFE 3-805, Toronto, Ontario M5G 2C4, Canada
| | - Patricia Murphy
- University Health Network, 101 College St., Toronto, Ontario M5G 1L7, Canada.,Department of Anesthesia, University of Toronto, 123 Edward St., Room 1200, Toronto, Ontario M5G 1E2, Canada
| | - Jeffrey M Singh
- University Health Network, 101 College St., Toronto, Ontario M5G 1L7, Canada.,Department of Medicine, University of Toronto, 200 Elizabeth St., Suite RFE 3-805, Toronto, Ontario M5G 2C4, Canada
| | - Andrew M Morris
- University Health Network, 101 College St., Toronto, Ontario M5G 1L7, Canada.,Sinai Health System, 600 University Ave., Toronto, Ontario M5G 1X5, Canada.,Department of Medicine, University of Toronto, 200 Elizabeth St., Suite RFE 3-805, Toronto, Ontario M5G 2C4, Canada
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Monnier AA, Eisenstein BI, Hulscher ME, Gyssens IC. Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure. J Antimicrob Chemother 2018; 73:vi3-vi16. [PMID: 29878216 PMCID: PMC5989615 DOI: 10.1093/jac/dky114] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project, this study aimed to identify key elements for a global definition of responsible antibiotic use based on diverse stakeholder input. Methods A three-step RAND-modified Delphi method was applied. First, a systematic review of antibiotic stewardship literature and relevant organization web sites identified definitions and synonyms of responsible use. Identified elements of definitions were presented by questionnaire to a multidisciplinary international stakeholder panel for appraisal of their relevance. Finally, questionnaire results were discussed in a consensus meeting. Results The systematic review and the web site search identified 17 synonyms (e.g. appropriate, correct) and 22 potential elements to include in a definition of responsible use. Elements were grouped into patient-level (e.g. Indication, Documentation) or societal-level elements (e.g. Education, Future Effectiveness). Forty-eight stakeholders with diverse backgrounds [medical community, public health, patients, antibiotic research and development (R&D), regulators, governments] from 18 countries across all continents participated in the questionnaire. Based on relevance scores, 21 elements were retained, 9 were rephrased and 1 was added. Together, the 22 elements and associated best-practice descriptions comprise an exhaustive list of elements to be considered when defining responsible use. Conclusions Combination of concepts from the literature and stakeholder opinion led to an international multidisciplinary consensus on a global definition of responsible antibiotic use. The widely diverging perspectives of stakeholders providing input should ensure the comprehensiveness and relevance of the definition for both individual patients and society. An aspirational goal would be to address all elements.
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Affiliation(s)
- Annelie A Monnier
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
| | | | - Marlies E Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge C Gyssens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
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Paño-Pardo JR, Schüffelmann-Gutiérrez C, Escosa-García L, Laplaza-González M, Moreno-Ramos F, Gómez-Gil R, López JD, Jordán I, Téllez C, de la Oliva P. Opportunities to improve antimicrobial use in paediatric intensive care units: a nationwide survey in Spain. Clin Microbiol Infect 2015; 22:171-177. [PMID: 26498852 DOI: 10.1016/j.cmi.2015.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 10/04/2015] [Accepted: 10/11/2015] [Indexed: 02/06/2023]
Abstract
Improving antimicrobial use is a complex process that requires an accurate assessment of ongoing problems and barriers. Paediatric intensive care units (PICU) have seldom been assessed from this perspective. Two Internet-based, self-administered surveys were conducted nationwide in Spain between January and February 2014. The first survey aimed to assess those characteristics of Spanish PICUs that could influence antimicrobial prescribing or antimicrobial stewardship. The second survey targeted Spanish PICU physicians and pursued to assess their attitudes and perceptions regarding antimicrobial resistance and antimicrobial use. Information about 29/39 contacted PICUs was obtained. A total of 114/206 (55.3%) paediatric intensivists responded. PICUs were heterogeneous regarding years since foundation, number of beds, type of patients admitted and staffing. Only 11 (37.9%) PICUs had available e-prescribing systems. Procalcitonin was available in 24 (89.1%) PICUs, but there were no procalcitonin-based protocols in 14 (60.9%) of them. Half of surveyed PICUs had implemented antimicrobial stewardship activities. Ninety-eight of the 114 PICU physicians (86%) who participated considered that antimicrobial resistance was a significantly relevant problem for their daily and that improving antimicrobial use in their PICU should be a priority (103; 90.4%). The main perceived problems regarding antimicrobial use were the excessive use of antimicrobials in patients with nonconfirmed infections and excessive use of broad-spectrum antimicrobials. The most valued antimicrobial stewardship interventions were the implementation of protocols to guide antimicrobial therapy. Spanish PICU doctors are aware of the relevance of the problem of antimicrobial resistance and the need to improve antimicrobial use. Targeted interventions should take into account their difficulties and preferences when feasible.
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Affiliation(s)
- J R Paño-Pardo
- Division of Infectious Diseases, Hospital Clínico Universitario "Lozano Blesa", Zaragoza, Spain; Instituto de Investigación Sanitaria (IIS) de Aragón, Aragón, Spain
| | | | - L Escosa-García
- Paediatric Tropical and Infectious Diseases, Department of Paediatrics, Hospital Universitario La Paz, Madrid, Spain
| | - M Laplaza-González
- Paediatric Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
| | - F Moreno-Ramos
- Pharmacy Department, Hospital Universitario La Paz, Madrid, Spain
| | - R Gómez-Gil
- Department of Microbiology, Hospital Universitario La Paz, Madrid, Spain
| | - J D López
- Paediatric Intensive Care Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - I Jordán
- Paediatric Intensive Care Unit, Hospital Sant Joan de Deu, Barcelona, Spain
| | - C Téllez
- Paediatric Intensive Care Unit, Hospital Virgen de la Arrixaca, Murcia, Spain
| | - P de la Oliva
- Paediatric Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain; Department of Paediatrics, Medical School, Universidad Autónoma, Madrid, Spain
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Lewis GJ, Fang X, Gooch M, Cook PP. Decreased Resistance of Pseudomonas aeruginosa with Restriction of Ciprofloxacin in a Large Teaching Hospital's Intensive Care and Intermediate Care Units. Infect Control Hosp Epidemiol 2015; 33:368-73. [DOI: 10.1086/664763] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective.To examine the effect of restricting ciprofloxacin on the resistance of nosocomial gram-negative bacilli, including Pseudomonas aeruginosa, to antipseudomonal carbapenems.Design.Interrupted time-series analysis.Setting.Tertiary care teaching hospital with 11 intensive care and intermediate care units with a total of 295 beds.Patients.All nosocomial isolates of P. aeruginosa.Intervention.Restriction of ciprofloxacin.Results.There was a significant decreasing trend observed in the percentage (P = .0351) and the rate (P = .0006) of isolates of P. aeruginosa that were resistant to antipseudomonal carbapenems following the restriction of ciprofloxacin. There was also a significant decreasing trend observed in the percentage (P = .0017) and the rate (P = .0001) of isolates of ciprofloxacin-resistant P. aeruginosa. The rate of cefepime-resistant P. aeruginosa isolates declined (P = .004 ) but the percentage of cefepime-resistant P. aeruginosa isolates did not change. There were no significant changes observed in the rate or the percentage of piperacillin-tazobactam-resistant P. aeruginosa isolates. There were no significant changes observed in the susceptibilities of nosocomial Enterobacteriaciae or Acinetobacter baumannii isolates that were resistant to carbapenems. Over the study period there was a significant increase in the use of carbapenems (P = .0134); the use of ciprofloxacin decreased significantly (P = .0027). There were no significant changes in the use of piperacillin-tazobactam or cefepime.Conclusion.Restriction of ciprofloxacin was associated with a decreased resistance of P. aeruginosa isolates to antipseudomonal carbapenems and ciprofloxacin in our hospital's intermediate care and intensive care units. There were no changes observed in the susceptibilities of nosocomial Enterobacteriaciae or A. baumannii to carbapenems, despite increased carbapenem use. Reducing ciprofloxacin use may be a means of controlling multidrug-resistant P. aeruginosa.
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Hermsen ED, VanSchooneveld TC, Sayles H, Rupp ME. Implementation of a Clinical Decision Support System for Antimicrobial Stewardship. Infect Control Hosp Epidemiol 2015; 33:412-5. [DOI: 10.1086/664762] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Clinical decision support systems (CDSSs) for antimicrobial stewardship require considerable human resources and financial investments. This pre-/postimplementation study evaluated the effect of a CDSS on performance of prospective audit with intervention and feedback and demonstrated an increase in interventions and recommendation acceptance countered by a substantial number of non-actionable alerts.
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Risk Factors of Carbapenem-resistant Acinetobacter baumannii Infection among Hospitalized Patients. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.jecm.2014.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Amer MR, Akhras NS, Mahmood WA, Al-Jazairi AS. Antimicrobial stewardship program implementation in a medical intensive care unit at a tertiary care hospital in Saudi Arabia. Ann Saudi Med 2013; 33:547-54. [PMID: 24413857 PMCID: PMC6074906 DOI: 10.5144/0256-4947.2013.547] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Antimicrobial stewardship programs (ASPs) have shown to prevent the emergence of antimicrobial resistance associated with an inappropriate antimicrobial use. The primary objective of this study was to compare the prescribing appropriateness rate of the empirical antibiotic therapy before and after the ASP implementation in a tertiary care hospital. Secondary objectives include the rate of Clostridium difficile-associated diarrhea (CDAD), physicians' acceptance rate, patient's intensive care unit (ICU) course, total utilization using defined daily dose, and total direct cost of antibiotics. DESIGN AND SETTINGS This is a comparative, historically controlled study. Adult medical ICU patients were enrolled in a prospective fashion under the active ASP arm and compared with historical patients who were admitted to the same unit before the ASP implementation. This study was approved by the institutional review board, and the need for informed consent was waived because the interventions and recommendations were evidence based and considered the standard of care. The study was conducted at KFSHRC, Riyadh. METHODS Adult medical ICU patients were enrolled under the active ASP arm if they were on any of the 5 targeted antibiotics (piperacillin/tazobactam, imipenem/cilastatin, meropenem, vancomycin, tigecycline), and had no official infectious disease consultation. The interventions were conducted via prospective audit and feedback. RESULTS A total of 73 subjects were recruited, 49 in historical control and 24 in the active arm. The appropriateness of empirical antibiotics was improved from 30.6% (15/49) in the historical control arm to 100% (24/24) in the proactive ASP arm (P value < .05). For the ASP group, initially 79.1% (19/24) of the antibiotic uses were inappropriate and diminished by ASPs to 0% on the recommendations implementation. A total of 27 interventions were made with an acceptance rate of 96.3%. The rate of CDAD did not differ between the groups. A reduction in antibiotics utilization and direct cost were also noticed in the ASP arm. CONCLUSION A proactive ASP is a vital approach in optimizing the appropriate empirical antibiotics utilization in an ICU setting in tertiary care hospitals. This study highlights the importance of such a program and may serve as a foundation for further ASP initiatives particularly in our region.
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Affiliation(s)
| | | | | | - Abdulrazaq S Al-Jazairi
- Dr. Abdulrazaq S. Al-Jazairi, Head, Medical/Critical Pharmacy Department,, Division of Pharmacy Services,, King Faisal Specialist Hospital and Research Centre,, PO Box 3354, MBC-11, Riyadh 11211,, Saudi Arabia, T: +966-11-4427603, F: +966-11-4427608,
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