Impact of a Systematic Pharmacist-Initiated Antibiotic Time-Out Intervention for Hospitalized Adults

Impact of an Antimicrobial Stewardship Strategy on Surgical Hospital Discharge: Improving Antibiotic Prescription in the Transition of Care

Antimicrobial stewardship programs (AMSPs) are essential elements in reducing the unnecessary overprescription of antibiotics. Most of the actions of these programs have focused on actions during acute hospitalization. However, most prescriptions occur after hospital discharge, which represents a necessary and real opportunity for improvement in these programs. We present an AMSP multifaceted strategy implemented in a surgical department which was carried out by a multidisciplinary team to verify its reliability and effectiveness. Over a 1-year post-implementation period, compared to the pre-intervention period, a significant reduction of around 60% in antibiotic exposure occurred, with lower economic cost and greater safety.

Impact of Antibiotic Time-Outs in Multidisciplinary ICU Rounds for Antimicrobial Stewardship Program on Patient Survival: A Controlled Before-and-After Study

The antimicrobial stewardship program (ASP) is an important quality improvement initiative that is recommended in the ICU. However, the shortage of infectious disease physicians in Japan has led to the need for simpler methods for implementing ASPs. We investigated whether antibiotic time-outs (ATOs) during multidisciplinary rounds as part of an ASP can improve patient survival and reduce the number of days of therapy (DOT) with antibiotics.

DESIGN

Single-center controlled before-and-after study.

SETTING

Medical/surgical ICU in a tertiary university medical center in Tokyo, Japan.

PATIENTS

All patients 16 years old or older admitted consecutively in the ICU between October 2016 and March 2020.

INTERVENTIONS

An intensivist-driven ICU multidisciplinary round was introduced in October 2016, and ATOs with ICU rounds were implemented in June 2018. ATOs were conducted 3, 7, and 14 days after initiation of antibiotics.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the subdistribution hazard ratio (SHR) of survival to hospital discharge compared between multidisciplinary rounds (phase 1) and ATO during multidisciplinary rounds (phase 2) using the multivariable Fine-Gray model. The secondary outcomes were the SHR of survival to ICU discharge and the trends in the DOT with IV antibiotics per 1,000 patient-days between October 2016 and March 2020 by using interrupted time-series analysis. The number of patients in phases 1 and 2 was 777 and 796, respectively. The group that underwent ATO during multidisciplinary rounds showed a significant increase in the survival to hospital discharge in comparison with the multidisciplinary round-only group (SHR, 1.13; 95% CI, 1.02-1.25); however, the SHR of survival to ICU discharge showed no significant intergroup difference. The DOT with total IV antibiotics decreased after ATO implementation (change in intercept, -178.26; 95% CI, -317.74 to -38.78; change in slope, -7.00; 95% CI, -15.77 to 1.78).

CONCLUSIONS

ATOs during multidisciplinary rounds are associated with improved patient survival and reduced DOT.

An overview of the hospitals’ antimicrobial stewardship programs implemented to improve antibiotics’ utilization, cost and resistance patterns

Introduction: The high reliance of the physicians and surgeons on the antibiotics since their discovery has led to an irrational antibiotic utilization which not only has raised the incidence of antimicrobial resistance (AMR) but also increased the cost of treatment with antibiotics as high use of antibiotics has been found related to the occurrence of certain nosocomial infections which need extra antibiotic courses to be cured. In order to overcome these antibiotic utilization related problems an antimicrobial stewardship (AMS) program being the set of various persuasive, restrictive and structural interventions is considered an effective tool to rationalize the in-patient antimicrobial utilization worldwide. Method: The focus of this review is on the interventions that are being implemented during the in-patient AMS programs and have been described effective in controlling the antibiotic utilization, their cost of treatment and an overall infection control. The literature containing the information about various AMS interventions effecting the utilization and cost patterns along with the impact on AMR was searched in various databases such as PubMed, Google Scholar, Science Direct, Ovid (Medline) and Scopus. The categorical sorting of the published data is based on various AMS interventions such as the guideline development, formulary restriction (pre-authorization), educative interventions, clinical pathway development and prospective (post prescription) audit. Considering the objectives of the study such as the goal to curb overutilization of antibiotics, control of their cost of treatment for in-patients and infection control the sorted literature is presented in three different tables describing the AMS impact on the said outcomes. Results: The post AMS changes in utilization patterns are described as fall of antibiotics defined daily doses (DDD) and days of therapy (DOT) which resulted in the reduction of the cost of treatment with antibiotics. The reduction of the cost of treatment with antibiotics also resulted due to the AMS impact on the control of various nosocomial and multi-drug resistant (MDR) infections. Conclusion:  It has been concluded that the AMS program if implemented under the supervision of an expert AMS team mainly comprising of an infectious disease (ID) physician, clinical pharmacists and microbiologists with considerable support by the hospital authorities could be a highly efficient tool of the pharmacovigilance for rationalizing the in-patient antimicrobial practice.

Practice-enhancing publications about the medication-use process in 2020

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2020 that can impact health-system pharmacy daily practice.

SUMMARY

The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles evaluating at least one step of the MUP were assessed for their usefulness in practice improvement. A PubMed search for articles published in calendar year 2020 was conducted in January 2021 using targeted Medical Subject Headings (MeSH) keywords, and the table of contents of selected pharmacy journals was searched, providing a total of 9,433 articles. A thorough review identified 49 potentially practice-enhancing articles: 15 for prescribing/transcribing, 10 for dispensing, 6 for administration, and 18 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why they are important within health-system pharmacy. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article assists in identifying and summarizing the most impactful recently published literature. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the moist significant published studies can assist in changing practice at the institutional level.

Effectiveness of an Electronic Automated Antibiotic Time Out Alert in the Setting of Gram-Negative Bacteremia

To minimize complications associated with over-utilization of antibiotics, many antimicrobial stewardship programs have incorporated an antibiotic time out (ATO); however, limited data are available to support its effectiveness. This was a single-center retrospective cohort study assessing the impact of the automated electronic ATO in the setting of Gram-negative bacteremia. The primary outcome was the proportion of patients who received a modification of therapy within 24 h of final culture results. Secondary outcomes included modification at any point in therapy, time to modification of therapy, time to de-escalation, and days of therapy of broad-spectrum antibiotics. There was a total of 222 patients who met inclusion criteria, 97 patients pre-ATO and 125 patients post-ATO. The primary outcome of modification of therapy within 24 h of final culture results was not significantly different (24% vs. 30%, p = 0.33). The secondary outcome of modification of therapy at any point in therapy was not significantly different between the two groups (65% vs. 67%, p = 0.73). All other secondary outcomes were not significantly different. The ATO alert was not associated with a higher rate of antibiotic modification within 24 h of culture results in patients with GNB. Further efforts are needed to optimize the ATO strategy and antibiotic prescribing practices.