Antibiotic use in an Italian university hospital

Trends of Healthcare-associated Infections in a Tuinisian University Hospital and Impact of COVID-19 Pandemic

BACKGROUND

Although efforts to manage coronavirus disease 2019 (COVID-19) pandemic have understandably taken immediate priority, the impacts on traditional healthcare-associated infection (HAI) surveillance and prevention efforts remain concerning.

AIM

To describe trends in HAIs in a Tunisian university hospital through repeated point prevalence surveys over 9 years, assess the impact of measures implemented for COVID-19 pandemic, and to identify associated factors of HAI.

METHODS

The current study focused on data collected from annual point prevalence surveys conducted from 2012 to 2020. All types of HAIs as defined by the Centers for Disease Control and Prevention (CDC) were included. Data collection was carried out using NosoTun plug. Univariate and multivariate logistic analysis were used to identify HAI risk factors.

RESULTS

Overall, 2729 patients were observed in the 9 surveys; the mean age was 48.3 ± 23.3 years and 57.5% were male. We identified 267 infected patients (9.8%) and 296 HAIs (10.8%). Pneumonia/lower respiratory tract infections were the most frequent HAI (24%), followed by urinary tract infection (20.9%).The prevalence of infected patients increased from 10.6% in 2012 to 14.9% in 2020. However, this increase was not statistically significant. The prevalence of HAIs increased significantly from 12.3% to 15.5% (P =.003). The only decrease involved is bloodstream infections (from 2% to 1%). Independent risk factors significantly associated with HAI were undergoing surgical intervention (aOR = 1.7), the use of antibiotic treatment in previous 6 months (aOR = 1.8), peripheral line (aOR=2), parenteral nutrition (aOR=2.4), urinary tract within 7 days (aOR=2.4), central line (aOR = 6.3), and prosthesis (aOR = 12.8), length of stay (aOR = 3), and the year of the survey. Young age was found as protective factor (aOR = .98).

CONCLUSION

Contrary to what was expected, we noticed an increase in the HAIs rates despite the preventive measures put in place to control the COVID-19 pandemic. This was partly explained by the vulnerability of hospitalized patients during this period.

Benchmarking antimicrobial drug use at university hospitals in five European countries

A point-prevalence survey of five European university hospitals was performed to benchmark antimicrobial drug use in order to identify potential problem areas in prescribing practice and to aid in establishing appropriate and attainable goals. All inpatients at the university hospitals of Rijeka (Croatia), Tartu (Estonia), Riga (Latvia), Vilnius (Lithuania) and Karolinska-Huddinge (Sweden) were surveyed for antimicrobial drug use during a single day. The frequency of antimicrobial drug use was 24% in Rijeka, 30% in Tartu, 26% in Riga, 14% in Vilnius and 32% in Huddinge. Surgical patients were treated with antimicrobial agents more often than medical patients in Riga (53% vs. 31%), Tartu (39% vs. 26%) and Vilnius (54% vs. 25%). Two-thirds of patients in Rijeka, Tartu, Riga and Vilnius, and fewer than half of the patients in Huddinge, received antimicrobial agents intravenously. Broad-spectrum antimicrobial agents were used most commonly in Rijeka. The prevalence of nosocomial infections treated with antibiotics was 9% at Huddinge, and 3-5% at the other centres. Benchmarking antimicrobial drug use at five university hospitals identified differences and problem areas. The high rates of intravenous administration, poor compliance with guidelines, and prolonged surgical prophylaxis were general problems that deserved specific attention at all centres. A change in prescription practices may reduce unnecessary drug use and decrease antimicrobial resistance.

Antibiotic susceptibility and serotype distribution in Streptococcus pneumoniae circulating in Italy: results of the SEMPRE surveillance study (2000-2002)

During 2000-2002, 20 clinical microbiology centres collected 1623 Streptococcus pneumoniae isolates. Susceptibility to penicillin, amoxicillin, amoxicillin/clavulanic acid, cefaclor, cefuroxime, cefotaxime, clarithromycin, ciprofloxacin, levofloxacin, rifampicin and teicoplanin was determined locally by the Etest and/or by the microdilution method by three co-ordinating centres. Total resistance to penicillin increased from 15.2% to 16.1% and macrolide resistance increased from 37.9% to 43.7%. Overall, the most effective drugs (>99% susceptible strains) were amoxicillin, amoxicillin/clavulanic acid, levofloxacin and rifampicin. The most frequent serotypes were: 23F (15.8%), 3 (10.8%) 14 (9.1%), 19F (9.1%), 6B (7.2%), 19A (6.9%) and 6A (4.8%). In conclusion, penicillin and macrolide resistance is increasing in Italy, whilst fluoroquinolone currently remains active. The most common serotypes circulating are included in the heptavalent conjugate vaccine, with the exception of type 3.

Hospital-based intensive monitoring of antibiotic-induced adverse events in a university hospital

Hospital-based monitoring is one of the methods used to collect data about drug prescriptions and adverse events. The aim of this 20-day observational prospective study was to evaluate the frequency and type of adverse reaction to antibiotics, and predisposing risk factors in inpatients in six departments of a university hospital (ophthalmology, paediatrics, internal medicine, general surgery, infectious diseases, anaesthesiology and intensive care). The data on all inpatients undergoing antibiotic treatment were collected by physicians trained by our team and validated by an expert panel. Data were recorded on pre-formatted confidential cards (MIO-card). In the 171 inpatients evaluated (125 adults: 39.5% male, mean age 61.6 years, range 21-93; and 46 children: 50% male; mean age 4.75 years, range 3 months-12 years), cefazolin (19.9%), chloramphenicol (18.6%), ceftriaxone (15.4%) and netilmicin (12.9%) were the most frequently used antibiotics. Adverse events occurred in four adults and three children: one had leucopenia (trimethoprim/sulfamethoxazole), one nephrotoxicity (netilmicin+teicoplanin) and one nephrotoxicity (cefotaxime), one diarrhoea (ceftriaxone), one neurotoxicity (isoniazid), one angioneurotic oedema (piperacillin) and one skin rashes (ceftriaxone). A number of strategies (educative and persuasive, facilitative and restrictive) have been proposed to improve antibiotic use. Our study suggests that hospital-based monitoring is a good method with which to detect links between drug exposure and adverse drug reactions in children and adults.

Oral quinolones in hospitalized patients: an evaluation of a computerized decision support intervention

OBJECTIVE

To determine whether a computerized decision support system could increase the proportion of oral quinolone antibiotic orders placed for hospitalized patients.

DESIGN

Prospective, interrupted time-series analysis.

SETTING

University hospital in the south-eastern United States.

SUBJECTS

Inpatient quinolone orders placed from 1 February 2001 to 31 January 2003.

INTERVENTION

A web-based intervention was deployed as part of an existing order entry system at a university hospital on 5 February 2002. Based on an automated query of active medication and diet orders, some users ordering intravenous quinolones were presented with a suggestion to consider choosing an oral formulation.

MAIN OUTCOME MEASURE

The proportion of inpatient quinolone orders placed for oral formulations before and after deployment of the intervention.

RESULTS

There were a total of 15 194 quinolone orders during the study period, of which 8962 (59%) were for oral forms. Orders for oral quinolones increased from 4202 (56%) before the intervention to 4760 (62%) after, without a change in total orders. In the time-series analysis, there was an overall 5.6% increase (95% CI 2.8-8.4%; P < 0.001) in weekly oral quinolone orders due to the intervention, with the greatest effect on nonintensive care medical units.

CONCLUSIONS

A web-based intervention was able to increase oral quinolone orders in hospitalized patients. This is one of the first studies to demonstrate a significant effect of a computerized intervention on dosing route within an antibiotic class. This model could be applied to other antibiotics or other drug classes with good oral bioavailability.

Public drug procurement: the lessons from a drug tender in a teaching hospital of a transition country

INTRODUCTION

There are scarce descriptions of hospital drug procurement in the primary literature. The aim of this study was to analyse the drug tender led by a clinical pharmacologist in a 1200-bed university hospital in Serbia, a developing country in socio-economic transition, and to give recommendations for future steps in hospital drug policy.

PROCEDURE AND OUTCOMES

Drug tendering was conducted according to the public procurement law from January to April 2003. Analysis included the method of defined daily doses and anatomical therapeutic chemical classification, as well as minimal tender prices, free market prices, essential drugs and domestic and foreign manufacturers. The drug tender list consisted of 548 products, 1,315,501 pharmaceutical units and 312 drug entities, among which 164 were essential. For purchasing purposes, 479 drug formulations were selected, costing approximately 1.4 million Euros (approximately 10% of hospital budget). Three-quarters of the expenditure consisted of antimicrobials (29.1%), cytotoxics (28.8%) and intravenous infusions (17.7%). The top 20 drugs consumed 62.2% of the total drug expenditure. Competition for the most expensive and/or most used drugs was the key for financial success of applicants, even when they offered a limited number of drugs. The tender achieved 4.6% and 17.2% cost savings in comparison with minimal tender price and free-market price, respectively. The tender did not provide a fair balance between domestic and foreign manufacturers.

CONCLUSION

The drug tender is resource-consuming, laborious, and risky job. Aggregation of individual tenders, on a national level and/or regional ones, is probably the best choice for hospitals in transition countries at this time.