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Strazzulla A, Adrien V, Houngnandan SR, Devatine S, Bahmed O, Abroug S, Hamrouni S, Monchi M, Diamantis S. Characteristics of Pseudomonas aeruginosa infection in intensive care unit before (2007-2010) and after (2011-2014) the beginning of an antimicrobial stewardship program. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e60. [PMID: 38698949 PMCID: PMC11062793 DOI: 10.1017/ash.2024.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 05/05/2024]
Abstract
Objectives To investigate the factors associated with Pseudomonas aeruginosa isolates in intensive care unit (ICU) before and after an antimicrobial stewardship program. Materials Monocentric retrospective cohort study. Patients admitted to the ICU in 2007-2014 were included. Characteristics of P. aeruginosa patients were compared to overall ICU population. Clinical and microbiological characteristics of P. aeruginosa patients before (2007-2010) and after (2011-2014) the beginning of the AMP were compared. Results Overall, 5,263 patients were admitted to the ICU, 274/5,263 (5%) had a P. aeruginosa isolate during their staying. In 2011-2014, the percentage P. aeruginosa isolates reduced (7% vs 4%, P ≤ .0001). Patients with P. aeruginosa had higher rates of in-hospital death (43% vs 20%, P < .0001) than overall ICU population. In 2011-2014, rates of multidrug-resistant (11% vs 2%, P = .0020), fluoroquinolone-resistant (35% vs 12%, P < .0001), and ceftazidime-resistant (23% vs 8%, P = .0009) P. aeruginosa reduced. Treatments by fluoroquinolones (36% vs 4%, P ≤ .0001), carbapenems (27% vs 9%, P = .0002), and third-generation cephalosporins (49% vs 12%, P ≤ .0001) before P. aeruginosa isolation reduced while piperacillin (0% vs 13%, P < .0001) and trimethoprim-sulfamethoxazole (8% vs 26%, P = .0023) increased. Endotracheal intubation reduced in 2011-2014 (61% vs 35%, P < .0001). Fluoroquinolone-resistance was higher in patients who received endotracheal intubation (29% vs 17%, P = .0197). Previous treatment by fluoroquinolones (OR = 2.94, P = .0020) and study period (2007-2010) (OR = 2.07, P = .0462) were the factors associated with fluoroquinolone-resistance at the multivariate analysis. Conclusions Antibiotic susceptibility in P. aeruginosa isolates was restored after the reduction of endotracheal intubation, fluoroquinolones, carbapenems, and third-generation cephalosporins and the increased use of molecules with a low ecological footprint, as piperacillin and trimethoprim-sulfamethoxazole.
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Affiliation(s)
- Alessio Strazzulla
- Internal and General Medicine Unit, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Vladimir Adrien
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, Melun, France
- Department of Infectious and Tropical Diseases, Avicenne Hospital, AP-HP, Université Sorbonne Paris Nord, Bobigny, France
| | | | - Sandra Devatine
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Ouerdia Bahmed
- Internal and General Medicine Unit, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Sarra Abroug
- Internal and General Medicine Unit, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Sarra Hamrouni
- Internal and General Medicine Unit, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Mehran Monchi
- Intensive Care Unit, Groupe Hospitalier Sud Ile de France, Melun, France
| | - Sylvain Diamantis
- Internal and General Medicine Unit, Groupe Hospitalier Sud Ile de France, Melun, France
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, Melun, France
- EA 7380 Dynamic, Université Paris Est Créteil, EnvA, USC ANSES, Créteil, France
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Ronda M, Gumucio-Sanguino VD, Shaw E, Granada R, Tubau F, Santafosta E, Sabater J, Esteve F, Tebé C, Mañez R, Carratalà J, Puig-Asensio M, Cobo-Sacristán S, Padullés A. Long-Term Effects of a Stepwise, Multimodal, Non-Restrictive Antimicrobial Stewardship Programme for Reducing Broad-Spectrum Antibiotic Use in the ICU. Antibiotics (Basel) 2024; 13:132. [PMID: 38391518 PMCID: PMC10886276 DOI: 10.3390/antibiotics13020132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 02/24/2024] Open
Abstract
Information on the long-term effects of non-restrictive antimicrobial stewardship (AMS) strategies is scarce. We assessed the effect of a stepwise, multimodal, non-restrictive AMS programme on broad-spectrum antibiotic use in the intensive care unit (ICU) over an 8-year period. Components of the AMS were progressively implemented. Appropriateness of antibiotic prescribing was also assessed by monthly point-prevalence surveys from 2013 onwards. A Poisson regression model was fitted to evaluate trends in the reduction of antibiotic use and in the appropriateness of their prescription. From 2011 to 2019, a total of 12,466 patients were admitted to the ICU. Antibiotic use fell from 185.4 to 141.9 DDD per 100 PD [absolute difference, -43.5 (23%), 95% CI -100.73 to 13.73; p = 0.13] and broad-spectrum antibiotic fell from 41.2 to 36.5 [absolute difference, -4.7 (11%), 95% CI -19.58 to 10.18; p = 0.5]. Appropriateness of antibiotic prescribing rose by 11% per year [IRR: 0.89, 95% CI 0.80 to 1.00; p = 0.048], while broad-spectrum antibiotic use showed a dual trend, rising by 22% until 2015 and then falling by 10% per year since 2016 [IRR: 0.90, 95% CI 0.81 to 0.99; p = 0.03]. This stepwise, multimodal, non-restrictive AMS achieved a sustained reduction in broad-spectrum antibiotic use in the ICU and significantly improved appropriateness of antibiotic prescribing.
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Affiliation(s)
- Mar Ronda
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Victor Daniel Gumucio-Sanguino
- Department of Intensive Care, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Evelyn Shaw
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Rosa Granada
- Department of Intensive Care, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Fe Tubau
- Department of Microbiology, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Eva Santafosta
- Department of Intensive Care, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Joan Sabater
- Department of Intensive Care, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Francisco Esteve
- Department of Intensive Care, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Cristian Tebé
- Biostatistics Support and Research Unit, Germans Trias i Pujol Research Institute and Hospital (IGTP), Carretera de Can Ruti, Camí de les Escoles s/n, 08916 Badalona, Barcelona, Spain
- Department of Clinical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, Campus Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Rafael Mañez
- Department of Intensive Care, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Carratalà
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
- Department of Clinical Sciences, Faculty of Medicine and Health Sciences, University of Barcelona, Campus Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Mireia Puig-Asensio
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
| | - Sara Cobo-Sacristán
- Department of Pharmacy, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Pharmacotherapy, Pharmacogenetics and Pharmaceutical Technology, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ariadna Padullés
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Av. Monforte de Lemos, 3-5, 28029 Madrid, Spain
- Department of Pharmacy, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Pharmacotherapy, Pharmacogenetics and Pharmaceutical Technology, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Av. Gran Via de l'Hospitalet 199, 08908 L'Hospitalet de Llobregat, Barcelona, Spain
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Skally M, Leonard M, O'Halloran PJ, Husien B, Bennett K, Burns K, Dinesh B, Humphreys H, Fitzpatrick F. Clostridioides difficile infection in neurosurgical patients in a national centre over 10 years: less common but associated with longer hospital stays. Acta Neurochir (Wien) 2023; 165:3585-3592. [PMID: 37971621 DOI: 10.1007/s00701-023-05883-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/30/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is a leading cause of healthcare-associated (HA) diarrhoea, contributing to patient morbidity and prolonged length-of-stay (LOS). We retrospectively assessed CDI over a decade in a national neurosurgical centre, with a multi-disciplinary approach to CDI surveillance and antimicrobial stewardship, by comparing CDI patients with other patient groups. METHODS Data on CDI in neurosurgical inpatients between January 2012 and December 2021 were collated. Disease-specific variables were compared to other inpatients with CDI. Rates per 10,000 bed days used were calculated. Patient-specific differences were compared with neurosurgical patients without CDI. CDI rates by patient group were explored using odds ratio (OR) and χ2 analyses. Negative binomial regression was used to investigate CDI rates over time. RESULTS Of 50 neurosurgical patients with CDI, all were HA; the average age was 53 years (standard deviation (SD) 16.3 years), 49 were first-episode CDI, and three had severe CDI. The majority (76.7%) had received recent antimicrobials. Compared with non-neurosurgical CDI patients, neurosurgical CDI rates differed significantly (1.9 versus 3.6 per 10,000 bed days used, p < 0.05), neurosurgical patients were younger (p ≤ 0.01), C. difficile testing was more likely to be requested by neurosurgeons (OR 2.4; p ≤ 0.01), and the proportion of severe CDI was higher (6% versus 2%, OR 3.0, p = 0.07, confidence interval (CI) 0.54 to 11.3). Within the neurosurgical cohort, CDI patients had an average LOS four times that of other patients (CI 15.2 to 35.1; p < 0.01) and were older (53.5 versus 47.8 years, CI 0.1 to 11 years; p < 0.05). Only one CDI outbreak was linked to neurosurgical patients. CONCLUSION CDI in neurosurgery patients differed from the wider hospital, with greater awareness of CDI testing. Longer LOS impacted bed utilisation with limited capacity. Robust surveillance supports proactive antimicrobial stewardship programmes in this vulnerable population.
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Affiliation(s)
- Mairead Skally
- Department of Microbiology, Beaumont Hospital, Dublin 9, Ireland.
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland.
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Clostridioides difficile - ESGCD, Basel, Switzerland.
| | - Maeve Leonard
- Department of Microbiology, Beaumont Hospital, Dublin 9, Ireland
| | - Philip J O'Halloran
- Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Department of Physiology & Medical Physics, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Ben Husien
- Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
| | - Kathleen Bennett
- Data Sciences Centre, School of Population Health, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Karen Burns
- Department of Microbiology, Beaumont Hospital, Dublin 9, Ireland
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland
| | - Binu Dinesh
- Department of Microbiology, Beaumont Hospital, Dublin 9, Ireland
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland
| | - Hilary Humphreys
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland
| | - Fidelma Fitzpatrick
- Department of Microbiology, Beaumont Hospital, Dublin 9, Ireland
- Department of Clinical Microbiology, The Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Education and Research Centre, Beaumont Hospital, Dublin 9, Ireland
- European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Clostridioides difficile - ESGCD, Basel, Switzerland
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4
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Neuner EA, Atkinson A, Ilges D, Krekel T, Ritchie DJ, Bewley AF, Durkin MJ, Hsueh K, Sayood S. Mixed methods evaluation of handshake antimicrobial stewardship on adult inpatient medicine floors. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e210. [PMID: 38156212 PMCID: PMC10753471 DOI: 10.1017/ash.2023.465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 12/30/2023]
Abstract
Objective To evaluate the effects of handshake antimicrobial stewardship on medicine floors at a large tertiary care hospital. Design Retrospective observational study. Setting 1,278-bed academic hospital. Patients Adults admitted to non-ICU medicine services. Interventions A handshake stewardship team consisting of an infectious diseases (ID) physician and pharmacist reviewed charts of patients receiving antimicrobials on medicine floors without a formal ID consult. Recommendations were communicated in-person to providers and acceptance rates were examined with descriptive statistics. Additional data regarding program perception among providers were obtained via surveys. Antibiotic usage trends were extracted from National Healthcare Safety Network Antimicrobial Use option data and evaluated using an interrupted time-series analysis pre- and post-intervention. Results The overall acceptance rate of interventions was 80%, the majority being recommendations either to discontinue (37%) or de-escalate therapy (28%). Medical residents and hospitalists rated the intervention favorably with 90% reporting recommendations were helpful all or most of the time. There was a statistically significant decrease in vancomycin (78 vs 70 DOT/1,000 d present (DP), p = 0.002) and meropenem (24 vs 17 DOT/1,000 DP, p = 0.007) usage and a statistically significant increase in amoxicillin-clavulanate usage (11 vs 15 DOT/1,000 DP, p < 0.001). Overall antibiotic usage remained unchanged by the intervention, though pre-intervention there was a nonsignificant overall increasing trend while post-intervention there was a nonsignificant decreasing trend in overall usage. There was no change in in-hospital mortality. Conclusion The addition of handshake stewardship with adult medicine services was favorably viewed by participants and led to shifts in antibiotic usage.
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Affiliation(s)
| | - Andrew Atkinson
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Dan Ilges
- Department of Pharmacy, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Tamara Krekel
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - David J. Ritchie
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Alice F. Bewley
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Michael J. Durkin
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kevin Hsueh
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Sena Sayood
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
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Sligl WI, Chen JZ, Wang X, Boehm C, Fong K, Crick K, Garrido Clua M, Codan C, Dingle TC, Gregson D, Prosser C, Sadrzadeh H, Yan C, Chen G, Tse-Chang A, Garros D, Doig CJ, Zygun D, Opgenorth D, Conly JM, Bagshaw SM. Antimicrobial stewardship, procalcitonin testing, and rapid blood-culture identification to optimize sepsis care in critically ill adult patients: A quality improvement initiative. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e107. [PMID: 37502237 PMCID: PMC10369441 DOI: 10.1017/ash.2023.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 07/29/2023]
Abstract
We examined the effect of an antimicrobial stewardship program (ASP), procalcitonin testing and rapid blood-culture identification on hospital mortality in a prospective quality improvement project in critically ill septic adults. Secondarily, we have reported antimicrobial guideline concordance, acceptance of ASP interventions, and antimicrobial and health-resource utilization.
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Affiliation(s)
- Wendy I. Sligl
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Justin Z. Chen
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Xiaoming Wang
- Health Services Statistical and Analytic Methods, Alberta Health Services, Edmonton, Alberta, Canada
| | - Cheyanne Boehm
- Pharmacy Services, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Karen Fong
- Pharmacy Services, University of Alberta Hospital, Alberta Health Services, Edmonton, Alberta, Canada
| | - Katelynn Crick
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - Míriam Garrido Clua
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - Cassidy Codan
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Tanis C. Dingle
- Division of Diagnostic and Applied Microbiology, Department of Laboratory Medicine and Pathology, University of Alberta, and Alberta Precision Laboratories, Edmonton, Alberta, Canada
| | - Daniel Gregson
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Connie Prosser
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Hossein Sadrzadeh
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Charles Yan
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Guanmin Chen
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alena Tse-Chang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Garros
- Division of Pediatric Critical Care, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher J. Doig
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - David Zygun
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - Dawn Opgenorth
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - John M. Conly
- Department of Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
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Wang YZ, Chen J, Pei SQ, Wang C, Han G, Kan LD, Li LC. Treatment strategies and pharmacist-led medication management for Helicobacter pylori infection. Drug Dev Res 2022; 84:326-336. [PMID: 36567647 DOI: 10.1002/ddr.22025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 12/05/2022] [Accepted: 12/11/2022] [Indexed: 12/27/2022]
Abstract
Half of the world's population is Helicobacter pylori carrier. Updated guidelines and consensus have been issued across regions with the main aim of reducing social transmission and increasing H. pylori eradication rate. Although alternative therapies including traditional Chinese medicine and probiotics have also been used to improve H. pylori eradication rate in clinical practice, current mainstream treatment is still dependent on triple and quadruple therapies that includes antibacterial agents (e.g., amoxicillin and furazolidone) and proton pump inhibitor. Researches also assessed the eradication rate of optimized high-dose dual therapy in treating H. pylori infection. With the increase of antibiotic resistance rate, the treatment strategies for H. pylori infection are constantly adjusted and improved. Besides, low medication compliance is another key influencing factor for H. pylori treatment failure. Emerging studies indicate that pharmacists' intervention and new pharmaceutical care methods can enhance patient medication compliance, reduce adverse drug reactions, and improve H. pylori eradication rate. The purpose of this review is to summarize the advances in treating H. pylori infection and highlight the necessity of developing novel strategies to cope with the increasing challenges and to achieve personalized medication. Also, this review attaches great importance to pharmacists in optimizing H. pylori treatment outcomes as a routine part of therapy.
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Affiliation(s)
- Yu-Zhen Wang
- Department of Pharmacy, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jie Chen
- Department of Pharmacy, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shi-Qin Pei
- School of Pharmacy, Hangzhou Medical College, Hangzhou, China
| | - Chen Wang
- Department of Pharmacy, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Gang Han
- Department of Pharmacy, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lian-Di Kan
- Department of Pharmacy, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Liu-Cheng Li
- Department of Pharmacy, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Patel S, Jhass A, Hopkins S, Shallcross L. Enhancing antimicrobial surveillance in hospitals in England: a RAND-modified Delphi. JAC Antimicrob Resist 2022; 4:dlac092. [PMID: 36105825 PMCID: PMC9465639 DOI: 10.1093/jacamr/dlac092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/12/2022] [Indexed: 11/20/2022] Open
Abstract
Background Optimizing antimicrobial use (AMU) is key to reducing antimicrobial-resistant infections, but current AMU monitoring in hospital provides limited insights for quality improvement. Objectives To understand stakeholders’ priorities for developing national AMU surveillance in English hospitals to serve the needs of national policy makers and front-line practitioners. Methods Characteristics of existing AMU surveillance systems were identified from a previous systematic review and categorized by the Acceptability, Practicability, Effectiveness, Affordability, Side-effects and Equity (APEASE) criteria. Stakeholders prioritized characteristics using a two-round RAND-modified Delphi (rating round 1, telephone panel discussion, rating round 2). Findings informed the design of a framework used to assess the extent to which existing surveillance approaches meet stakeholders’ needs. Results Between 17/09/19 and 01/11/19, 24 stakeholders with national and local roles related to AMU prioritized 23 characteristics of AMU surveillance describing: resource for surveillance, data collection, data availability and pathways to translate information from surveillance into practice. No existing surveillance approaches demonstrated all prioritized characteristics. The most common limitation was failure to facilitate clinician engagement with AMU through delays in data access and/or limited availability of disaggregated metrics of prescribing. Conclusions Current surveillance delivers national public health priorities but improving stewardship demands patient-level data linked to clinical outcomes. This study offers a framework to develop current surveillance to meet the needs of local stakeholders in England. Increased investment in data infrastructure and training is essential to make information held within electronic systems available to front-line clinicians to facilitate quality improvement.
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Affiliation(s)
- Selina Patel
- Institute of Health Informatics, University College London , London , England
| | - Arnoupe Jhass
- Research Department of Primary Care & Population Health, University College London , London , England
| | | | - Laura Shallcross
- Institute of Health Informatics, University College London , London , England
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8
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Mandelli G, Dore F, Langer M, Garbero E, Alagna L, Bianchin A, Ciceri R, Di Paolo A, Giani T, Giugni A, Gori A, Lefons U, Muscatello A, Olivieri C, Pan A, Pedeferri M, Rossi M, Rossolini GM, Russo E, Silengo D, Viaggi B, Bertolini G, Finazzi S. Effectiveness of a Multifaced Antibiotic Stewardship Program: A Pre-Post Study in Seven Italian ICUs. J Clin Med 2022; 11:jcm11154409. [PMID: 35956026 PMCID: PMC9369193 DOI: 10.3390/jcm11154409] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/14/2022] [Accepted: 07/25/2022] [Indexed: 02/01/2023] Open
Abstract
Multidrug resistance has become a serious threat for health, particularly in hospital-acquired infections. To improve patients’ safety and outcomes while maintaining the efficacy of antimicrobials, complex interventions are needed involving infection control and appropriate pharmacological treatments in antibiotic stewardship programs. We conducted a multicenter pre-post study to assess the impact of a stewardship program in seven Italian intensive care units (ICUs). Each ICU was visited by a multidisciplinary team involving clinicians, microbiologists, pharmacologists, infectious disease specialists, and data scientists. Interventions were targeted according to the characteristics of each unit. The effect of the program was measured with a panel of indicators computed with data from the MargheritaTre electronic health record. The median duration of empirical therapy decreased from 5.6 to 4.6 days and the use of quinolones dropped from 15.3% to 6%, both p < 0.001. The proportion of multi-drug-resistant bacteria (MDR) in ICU-acquired infections fell from 57.7% to 48.8%. ICU mortality and length of stay remained unchanged, indicating that reducing antibiotic administration did not harm patients’ safety. This study shows that our stewardship program successfully improved the management of infections. This suggests that policy makers should tackle multidrug resistance with a multidisciplinary approach based on continuous monitoring and personalised interventions.
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Affiliation(s)
- Giulia Mandelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milano, Italy; (G.M.); (E.G.); (G.B.); (S.F.)
| | - Francesca Dore
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milano, Italy; (G.M.); (E.G.); (G.B.); (S.F.)
- Associazione GiViTI—Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva, 24020 Ranica, Italy; (M.L.); (R.C.); (A.G.); (C.O.); (M.P.); (D.S.); (B.V.)
- Correspondence:
| | - Martin Langer
- Associazione GiViTI—Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva, 24020 Ranica, Italy; (M.L.); (R.C.); (A.G.); (C.O.); (M.P.); (D.S.); (B.V.)
- Emergency-Ong, 20128 Milano, Italy
| | - Elena Garbero
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milano, Italy; (G.M.); (E.G.); (G.B.); (S.F.)
- Associazione GiViTI—Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva, 24020 Ranica, Italy; (M.L.); (R.C.); (A.G.); (C.O.); (M.P.); (D.S.); (B.V.)
| | - Laura Alagna
- Infectious Diseases Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (L.A.); (A.G.); (A.M.)
| | - Andrea Bianchin
- Anesthesia and Intensive Care, Ospedale Civile San Valentino di Montebelluna, 31044 Montebelluna, Italy;
| | - Rita Ciceri
- Associazione GiViTI—Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva, 24020 Ranica, Italy; (M.L.); (R.C.); (A.G.); (C.O.); (M.P.); (D.S.); (B.V.)
- Anesthesia and Intensive Care, Ospedale Alessandro Manzoni di Lecco, 23900 Lecco, Italy
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, Università di Pisa, 56126 Pisa, Italy;
| | - Tommaso Giani
- Department of Experimental and Clinical Medicine, Università di Firenze, 50134 Firenze, Italy; (T.G.); (G.M.R.)
- Clinical Microbiology and Virology Unit, Azienda Ospedaliero Universitaria Careggi, 50134 Firenze, Italy
| | - Aimone Giugni
- Associazione GiViTI—Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva, 24020 Ranica, Italy; (M.L.); (R.C.); (A.G.); (C.O.); (M.P.); (D.S.); (B.V.)
- Department of Intensive Care and Emergency Medical Services, Ospedale Maggiore, 40133 Bologna, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (L.A.); (A.G.); (A.M.)
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
- Centre for Multidisciplinary Research in Health Science (MACH), Università degli Studi di Milano, 20122 Milan, Italy
| | - Ugo Lefons
- Anesthesia and Intensive Care, Ospedale Alta Val d’Elsa di Poggibonsi, 53036 Poggibonsi, Italy;
| | - Antonio Muscatello
- Infectious Diseases Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (L.A.); (A.G.); (A.M.)
| | - Carlo Olivieri
- Associazione GiViTI—Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva, 24020 Ranica, Italy; (M.L.); (R.C.); (A.G.); (C.O.); (M.P.); (D.S.); (B.V.)
- Anesthesia and Intensive Care, Ospedale Sant’Andrea, ASL VC Vercelli, 13100 Vercelli, Italy
| | - Angelo Pan
- Infectious Diseases Unit, Istituti Ospitalieri di Cremona, 26100 Cremona, Italy;
| | - Matteo Pedeferri
- Associazione GiViTI—Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva, 24020 Ranica, Italy; (M.L.); (R.C.); (A.G.); (C.O.); (M.P.); (D.S.); (B.V.)
- Anesthesia and Intensive Care, Presidio Ospedaliero San Leopoldo Mandić, 23807 Merate, Italy
| | - Marianna Rossi
- Division of Infectious Diseases, “San Gerardo” Hospital, University of Milano-Bicocca, 20900 Monza, Italy;
| | - Gian Maria Rossolini
- Department of Experimental and Clinical Medicine, Università di Firenze, 50134 Firenze, Italy; (T.G.); (G.M.R.)
- Clinical Microbiology and Virology Unit, Azienda Ospedaliero Universitaria Careggi, 50134 Firenze, Italy
| | - Emanuele Russo
- Anesthesia and Intensive Care, Ospedale Maurizio Bufalini di Cesena, 47521 Cesena, Italy;
| | - Daniela Silengo
- Associazione GiViTI—Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva, 24020 Ranica, Italy; (M.L.); (R.C.); (A.G.); (C.O.); (M.P.); (D.S.); (B.V.)
- Anesthesia and Intensive Care, Ospedale San Giovanni Bosco, 10154 Turin, Italy
| | - Bruno Viaggi
- Associazione GiViTI—Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva, 24020 Ranica, Italy; (M.L.); (R.C.); (A.G.); (C.O.); (M.P.); (D.S.); (B.V.)
- Neuro Intensive Care Unit, Department of Anesthesiology, Azienda Ospedaliero Universitaria Careggi, 50134 Firenze, Italy
| | - Guido Bertolini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milano, Italy; (G.M.); (E.G.); (G.B.); (S.F.)
| | - Stefano Finazzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milano, Italy; (G.M.); (E.G.); (G.B.); (S.F.)
- Associazione GiViTI—Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva, 24020 Ranica, Italy; (M.L.); (R.C.); (A.G.); (C.O.); (M.P.); (D.S.); (B.V.)
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9
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Hashimoto M, Asai S, Umezawa K, Kohara K, Miyazawa M, Suzuki Y, Miyachi H. Impact of ward pharmacist-led antimicrobial stewardship in intensive care units. J Chemother 2022:1-10. [PMID: 35748502 DOI: 10.1080/1120009x.2022.2087652] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Various outcomes of mortality, medical costs, and antimicrobial usage result from antimicrobial stewardship (AS) programmes. Here, we clarified the effects of AS implementation by a well-trained pharmacist in an open intensive care unit (open ICU) through a retrospective, comparative study of 5123 open ICU patients of Tokai University Hospital. The 12 months before and after AS implementation were considered the control and study periods, respectively. After AS implementation, the number of AS cases increased significantly. The period until the implementation of therapeutic drug monitoring was significantly shortened, and antimicrobial drug usage increased significantly. The methicillin-resistant Staphylococcus aureus (MRSA) detection rate decreased significantly. Earlier and more frequent AS implementation could enhance treatment effects, possibly decreasing the MRSA incidence. Despite active AS implementation, antimicrobial drug usage did not necessarily decrease. ICU pharmacists with experience in AS should take on leadership roles and implement active AS strategies in open ICU settings.
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Affiliation(s)
- Masayoshi Hashimoto
- Department of Pharmacy, Tokai University Hospital, Isehara, Japan.,Division of Infection control, Tokai University Hospital, Isehara, Japan
| | - Satomi Asai
- Division of Infection control, Tokai University Hospital, Isehara, Japan.,Department of Laboratory Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Kazuo Umezawa
- Division of Infection control, Tokai University Hospital, Isehara, Japan.,Department of Emergency and Critical Care, Tokai University School of Medicine, Isehara, Japan
| | - Kento Kohara
- Department of Pharmacy, Tokai University Hospital, Isehara, Japan
| | - Miki Miyazawa
- Division of Infection control, Tokai University Hospital, Isehara, Japan
| | - Yuji Suzuki
- Department of Pharmacy, Tokai University Hospital, Isehara, Japan
| | - Hayato Miyachi
- Division of Infection control, Tokai University Hospital, Isehara, Japan.,Department of Laboratory Medicine, Tokai University School of Medicine, Isehara, Japan
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10
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Yang Q, Yuan F, Li L, Jin J, He J. Effects of monthly evaluations on the rates of irrational antimicrobial prescription in the outpatient and emergency departments at Ningbo No. 6 Hospital, Ningbo, China. Eur J Med Res 2022; 27:98. [PMID: 35733215 PMCID: PMC9214680 DOI: 10.1186/s40001-022-00728-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic resistance is a major global public health problem. The primary cause of antibiotic resistance is inappropriate antibiotic use. In this study, we aimed to verify whether the monthly evaluation of antibiotic prescription improves clinical antibiotic use in outpatient and emergency departments. METHODS A minimum of 25% of the prescriptions for antibacterial drugs were randomly selected at the outpatient and emergency departments to enter the monthly evaluation system from July 2016 to June 2019. We analysed the rate of irrational prescription of antibiotics, proportion of the use of antibiotics, and consistency between the evaluation and expert groups after implementing the monthly assessment to validate the role of monthly evaluations. RESULTS After 3 years of monthly evaluations of antibiotic prescriptions, the utilisation rate of single antibiotics in the outpatient and emergency departments was found to increase each year. Each year, a decreasing trend was observed for the irrational use of antibiotics, whereas the proportion of antibiotics to the total drugs prescribed gradually decreased in the same period. In addition, the consistency of prescription evaluation results between the evaluation and expert groups increased continuously. CONCLUSIONS Monthly evaluation of antibiotic prescriptions is an effective management tool for the rational use of antibiotics in clinical practice. This practice could help reduce the combinative use of antibiotics, rate of irrational antibiotic prescription, and antibiotic use ratio, and play an important role in safe clinical drug use.
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Affiliation(s)
- Qiong Yang
- Department of Pharmacy, Ningbo No. 6 Hospital, Ningbo, China
| | - Fangfang Yuan
- Department of Rheumatism and Immunology, Ningbo No. 6 Hospital, Ningbo, China
| | - Li Li
- Department of Pharmacy, Ningbo No. 6 Hospital, Ningbo, China
| | - Jianfeng Jin
- Department of Pharmacy, Ningbo No. 6 Hospital, Ningbo, China
| | - Junhong He
- Department of Pharmacy, Ningbo No. 6 Hospital, Ningbo, China.
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11
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Stalteri Mastrangelo R, Hajizadeh A, Piggott T, Loeb M, Wilson M, Lozano LEC, Roldan Y, El-Khechen H, Miroshnychenko A, Thomas P, Schünemann HJ, Nieuwlaat R. In-Hospital Macro-, Meso-, and Micro-Drivers and Interventions for Antibiotic Use and Resistance: A Rapid Evidence Synthesis of Data from Canada and Other OECD Countries. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2022; 2022:5630361. [PMID: 35509517 PMCID: PMC9061047 DOI: 10.1155/2022/5630361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 11/23/2021] [Accepted: 01/07/2022] [Indexed: 06/14/2023]
Abstract
Hospitals continue to face challenges in reducing incorrect antibiotic use due to social and cultural factors at the level of the health system, the care facility, the provider, and the patient. The objective of this paper is to highlight the social and cultural drivers of antimicrobial use and resistance and targeted interventions for secondary and tertiary care settings in Canada and other OECD countries. This paper is an extension of the synthesis conducted for the Public Health Agency of Canada's 2019 Spotlight Report: Preserving Antibiotics Now and Into the Future. We conducted a systematic review with a few modifications to meet rapid timelines. We conducted a search in Ovid MEDLINE and McMaster University's evidence databases for systematic reviews and then for individual Canadian studies. To cast a wider net, we searched OECD organization websites and screened reference lists from systematic reviews. We synthesized the evidence narratively and categorized the evidence into macro-, meso-, and microlevel. A total of 70 studies were (a) from OCED countries and summarized evidence of potential sociocultural antimicrobial resistance and use barriers or facilitators and/or interventions addressing these challenges; (b) systematic reviews with 50% of included studies that are situated in secondary and tertiary settings; and (c) published in Canada's two official languages, English and French. We found that hospital structures and policies may influence antibiotic utilization and variations in antimicrobial management. Microlevel factors may sway inappropriate prescribing among clinicians. The amount and type of antibiotics used may affect resistance rates. Interventions were mainly comprised of antibiotic stewardship and training that modify clinician behavior and that educate patients and carers. This evidence synthesis illustrates the various drivers of, and interventions for, antimicrobial use and resistance at the macro-, meso-, and microlevel in secondary and tertiary settings. We demonstrate that upstream drivers may lead to downstream events that influence antimicrobial resistance.
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Affiliation(s)
- Rosa Stalteri Mastrangelo
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Anisa Hajizadeh
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Thomas Piggott
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Mark Loeb
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Departments of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, ON, Canada
| | - Michael Wilson
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Luis Enrique Colunga Lozano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton, ON, Canada
| | - Yetiani Roldan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton, ON, Canada
| | - Hussein El-Khechen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Anna Miroshnychenko
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Priya Thomas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Holger J. Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton, ON, Canada
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12
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Bashar MA, Miot J, Shoul E, van Zyl RL. Impact of an antibiotic stewardship programme in a surgical setting. S Afr J Infect Dis 2021; 36:307. [PMID: 34917678 PMCID: PMC8661296 DOI: 10.4102/sajid.v36i1.307] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 10/06/2021] [Indexed: 12/20/2022] Open
Abstract
Background Antibiotics are miracles of science and critical for many surgical procedures. However, the emergence of multidrug resistant pathogens resulting from inappropriate antibiotic use is a threat to modern medicine. This study aimed to determine the appropriateness of antibiotic use, cost, consumption and impact of an antibiotic stewardship intervention round in a surgical ward setting. Methods Baseline antibiotic utilisation was determined with a retrospective cross-sectional study in two surgical wards in a tertiary academic hospital in South Africa where medical records of 264 patients who received antibiotics were reviewed. In the second stage of the study, records of 212 patients who received antibiotics were reviewed during a weekly antibiotic stewardship intervention round. The volume of antibiotics consumed was determined using defined daily doses (DDDs)/1000 patients' days, and the appropriateness of the antibiotic prescription for treatment was also determined using a quality-of-use algorithm. Results There was a reduction in the volume of antibiotic consumption from a total 739.30 DDDs/1000 to 564.93 DDDs/1000 patient days, with reduction in inappropriate antibiotic use from 35% to 26% from baseline to antibiotic stewardship programme stages, respectively. There was an overall increase in culture targeted therapy in both wards in the antibiotic stewardship programme stage. Conclusion The implementation of an antibiotic stewardship programme led to a reduction in antibiotic consumption and improvement in appropriate use of antibiotics.
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Affiliation(s)
- Muhammad A Bashar
- Pharmacology Division, Department of Pharmacy and Pharmacology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Pharmacology and Therapeutics, College of Health Sciences, Federal University Birnin Kebbi, Birnin Kebb, Nigeria
| | - Jacqui Miot
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Evan Shoul
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Robyn L van Zyl
- Pharmacology Division, Department of Pharmacy and Pharmacology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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13
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Yoon YK, Kwon KT, Jeong SJ, Moon C, Kim B, Kiem S, Kim HS, Heo E, Kim SW. Guidelines on Implementing Antimicrobial Stewardship Programs in Korea. Infect Chemother 2021; 53:617-659. [PMID: 34623784 PMCID: PMC8511380 DOI: 10.3947/ic.2021.0098] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022] Open
Abstract
These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Korean Society for Antimicrobial Therapy, Seoul, Korea
| | - Ki Tae Kwon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Korean Society of Infectious Diseases, Seoul, Korea
| | - Chisook Moon
- Korean Society of Infectious Diseases, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Bongyoung Kim
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungmin Kiem
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyung-Sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Eunjeong Heo
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Shin-Woo Kim
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
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14
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Seidelman JL, Turner NA, Wrenn RH, Sarubbi C, Anderson DJ, Sexton DJ, Moehring RW. Impact of Antibiotic Stewardship Rounds in the Intensive Care Setting: a prospective cluster-randomized crossover study. Clin Infect Dis 2021; 74:1986-1992. [PMID: 34460904 DOI: 10.1093/cid/ciab747] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Few groups have formally studied the effect of dedicated antibiotic stewardship rounds (ASRs) on antibiotic use (AU) in intensive care units (ICUs). METHODS We implemented weekly ASRs using a two-arm, cluster-randomized, crossover study in 5 ICUs at Duke University Hospital from 11/2017 to 6/2018. We excluded patients without an active antibiotic order, or if they had a marker of high complexity including an existing infectious disease consult, transplant, ventricular assist device, or ECMO. AU during and following ICU stay for patients with ASRs was compared to the controls. We recorded the number of reviews, recommendations delivered, and responses. We evaluated change in ICU-specific AU during and after the study. RESULTS Our analysis included 4,683 patients: 2330 intervention and 2353 controls. Teams performed 761 reviews during ASRs, which excluded 1569 patients: 60% of patients off antibiotics, and 8% complex patients. Exclusions affected 88% the cardiac surgery ICU (CTICU) patients. AU rate ratio (RR) was 0.97 (0.91-1.04). When CTICU was removed, the RR was 0.93 (0.89-0.98). AU in the post-study period decreased by 16% (95% CI 11-24%) compared to the AU in the baseline period. Change in AU was differential among units: largest in the neurology ICU (-28%) and smallest in the CTICU (-2%). CONCLUSION Weekly multi-disciplinary ASRs was a high-resource intervention associated with a small AU reduction. The noticeable ICU AU decline over time is possibly due to indirect effects of ASRs. Effects differed among specialty ICUs, emphasizing the importance of customizing ASRs to match unit-specific population, workflow, and culture.
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Affiliation(s)
- Jessica L Seidelman
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Nicholas A Turner
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Rebekah H Wrenn
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | | | - Deverick J Anderson
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Daniel J Sexton
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Rebekah W Moehring
- Duke University Medical Center, Department of Medicine, Division of Infectious Diseases, Durham, North Carolina, USA.,Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
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15
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Cairns KA, Avent M, Buono E, Cheah R, Devchand M, Khumra S, Rawlins M, Roberts JA, Xenos K, Munro C. Standard of practice in infectious diseases for pharmacy services. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2021. [DOI: 10.1002/jppr.1744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Kelly A. Cairns
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Pharmacy Department Alfred Health Melbourne Australia
| | - Minyon Avent
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Queensland State‐Wide Antimicrobial Stewardship Program, Infection and Immunity Theme, UQCCR The University of Queensland Brisbane Australia
| | - Evette Buono
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Clinical Excellence Commission Sydney Australia
- National Centre for Antimicrobial Stewardship Doherty Institute Melbourne Australia
| | - Ron Cheah
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- National Centre for Antimicrobial Stewardship Doherty Institute Melbourne Australia
- Pharmacy Department Monash Health Clayton Australia
| | - Misha Devchand
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Austin Health Heidelberg Australia
| | - Sharmila Khumra
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Austin Health Heidelberg Australia
| | - Matthew Rawlins
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Department of Pharmacy Fiona Stanley Hospital Murdoch Australia
| | - Jason A. Roberts
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- The University of Queensland Centre for Clinical Research Faculty of Medicine & Centre for Translational Anti‐infective Pharmacodynamics School of Pharmacy The University of Queensland Brisbane Australia
- Royal Brisbane and Women’s Hospital Brisbane Australia
- Nîmes University Hospital University of Montpellier Montpellier France
| | - Kristin Xenos
- Infectious Diseases Standard of Practice Working Group The Society of Hospital Pharmacists of Australia Collingwood Australia
- Australian Commission on Safety and Quality in Health Care Sydney Australia
| | - Courtney Munro
- The Society of Hospital Pharmacists of Australia Collingwood Australia
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Gerber JS, Jackson MA, Tamma PD, Zaoutis TE. Policy Statement: Antibiotic Stewardship in Pediatrics. J Pediatric Infect Dis Soc 2021; 10:641-649. [PMID: 33595086 DOI: 10.1093/jpids/piab002] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/04/2021] [Indexed: 11/15/2022]
Abstract
Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting the use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy and duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs (ASPs); essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient ASPs are provided.
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Affiliation(s)
- Jeffrey S Gerber
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mary Anne Jackson
- Department of Pediatrics, Section of Infectious Disease, Children's Mercy Hospital, UMKC School of Medicine, Kansas City, Missouri, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Pediatric Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Theoklis E Zaoutis
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Long-term outcomes of an electronic medical record (EMR)-integrated antimicrobial stewardship (AMS) intensive care unit (ICU) ward round. Infect Control Hosp Epidemiol 2021; 43:670-672. [PMID: 33731236 DOI: 10.1017/ice.2021.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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18
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Haseeb A, Faidah HS, Al-Gethamy M, Iqbal MS, Barnawi AM, Elahe SS, Bukhari DN, Noor Al-Sulaimani TM, Fadaaq M, Alghamdi S, Almalki WH, Saleem Z, Elrggal ME, Khan AH, Algarni MA, Ashgar SS, Hassali MA. Evaluation of a Multidisciplinary Antimicrobial Stewardship Program in a Saudi Critical Care Unit: A Quasi-Experimental Study. Front Pharmacol 2021; 11:570238. [PMID: 33776750 PMCID: PMC7988078 DOI: 10.3389/fphar.2020.570238] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/30/2020] [Indexed: 11/15/2022] Open
Abstract
Background: Antimicrobial stewardship programs (ASPs) are collaborative efforts to optimize antimicrobial use in healthcare institutions through evidence-based quality improvement strategies. With regard to critically ill patients, appropriate antimicrobial usage is of significance, and any delay in therapy increases their risk of mortality. Therefore, the implementation of structured multidisciplinary ASPs in critical care settings is of the utmost importance to promote the judicious use of antimicrobials. Methods: This quasi-experimental study evaluating a multidisciplinary ASP in a 20-bed critical care setting was conducted from January 1, 2016 to July 31, 2017. Outcomes were compared nine months before and after ASP implementation. The national antimicrobial stewardship toolkit by Ministry of health was reviewed and the hospital antibiotic prescribing policy was accordingly modified. The antimicrobial stewardship algorithm (Start Smart and Then Focus) and an ASP toolkit were distributed to all intensive care unit staff. Prospective audit and feedback, in addition to prescribing forms for common infectious diseases and education, were the primary antimicrobial strategies. Results: We found that the mean total monthly antimicrobial consumption measured as defined daily dose per 100 bed days was reduced by 25% (742.86 vs. 555.33; p = 0.110) compared to 7% in the control condition (tracer medications) (35.35 vs. 38.10; p = 0.735). Interestingly, there was a negative impact on cost in the post-intervention phase. Interestingly, the use of intravenous ceftriaxone measured as defined daily dose per 100 bed days was decreased by 82% (94.32 vs. 16.68; p = 0.008), whereas oral levofloxacin use was increased by 84% (26.75 vs. 172.29; p = 0.008) in the intensive care unit. Conclusion: Overall, involvement of higher administration in multidisciplinary ASP committees, daily audit and feedback by clinical pharmacists and physicians with infectious disease training, continuous educational activities about antimicrobial use and resistance, use of local antimicrobial prescribing guidelines based on up-to-date antibiogram, and support from the intensive care team can optimize antibiotic use in Saudi healthcare institutions.
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Affiliation(s)
- Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Al-Abdia Campus, Makkah, Saudi Arabia
| | - Hani Saleh Faidah
- Department of Microbiology, Faculty of Medicine, Umm Al Qura University, Saudi Arabia
| | - Manal Al-Gethamy
- Department of Infection Prevention and Control Program, Alnoor Specialist Hospital Makkah, Makkah, Kingdom of Saudi Arabia
| | - Muhammad Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | | | - Shuruq S Elahe
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, United States
| | - Duha Nabeel Bukhari
- Department of Pharmacy, International Medical Center, Jeddah, Kingdom of Saudi Arabia
| | | | - Mohammad Fadaaq
- Ajyad Emergency Hospital, Ministry of Health, Makkah, Saudi Arabia
| | - Saad Alghamdi
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al Qura University, Makkah, Saudi Arabia
| | - Waleed Hassan Almalki
- Department of Toxicology and Pharmacology, College of Pharmacy, Umm Al Qura University, Makkah, Saudi Arabia
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, New Campus, Lahore, Pakistan
| | - Mahmoud Essam Elrggal
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Al-Abdia Campus, Makkah, Saudi Arabia
| | - Amer Hayat Khan
- Clinical Pharmacy Department, School of Pharmaceutical Sciences, Universiti Science Malaysia, Penang, Malaysia
| | - Mohammed A Algarni
- Microbiology Laboratory, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Sami S Ashgar
- Assistant Professor of Medical Microbiology, College of Medicine, Umm Al Qura University, Makkah, Saudi Arabia
| | - Mohamed Azmi Hassali
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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Use of Prospective Audit and Feedback to Reduce Antibiotic Exposure in a Pediatric Cardiac ICU. Pediatr Crit Care Med 2021; 22:e224-e232. [PMID: 33258575 DOI: 10.1097/pcc.0000000000002608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We sought to determine whether a prospective audit and feedback intervention decreased antibiotic utilization in a pediatric cardiac ICU and to describe the characteristics of prospective audit and feedback audits and recommendations. DESIGN Before-after study. SETTING Pediatric cardiac ICU of a freestanding children's hospital. PATIENTS All patients admitted to the cardiac ICU. INTERVENTIONS A prospective audit and feedback program was established in our hospital's pediatric cardiac ICU on December 7, 2015. The antimicrobial stewardship program audited IV antibiotics, communicated prospective audit and feedback recommendations to the cardiac ICU, and regularly reviewed recommendation adherence. Mean monthly antibiotic utilization 18 months before ("preprospective audit and feedback"; from June 1, 2014 to November 30, 2015) and 24 months after ("prospective audit and feedback"; from January 1, 2016 to December 31, 2017) prospective audit and feedback implementation was compared. Antibiotic audit data during the prospective audit and feedback period were reviewed to capture the characteristics of prospective audit and feedback audits, recommendations, and adherence. MEASUREMENTS AND MAIN RESULTS Mean cardiac ICU IV antibiotic use decreased 20% (701 vs 880 days of therapy per 1,000 patient days, p = 0.001) during the prospective audit and feedback period compared with the preprospective audit and feedback period. There was no difference in mean cardiac ICU length of stay (p = 0.573), mean hospital length of stay (p = 0.722), or the rate of discharge due to death (p = 0.541). There were 988 antibiotic audits and 370 prospective audit and feedback recommendations (37% recommendation rate) during the study period. The most commonly audited antibiotic category was broad-spectrum gram-negative agents and the most common indication for use was sepsis. Broad-spectrum gram-positive agents were more likely to be associated with a recommendation. CONCLUSIONS There was a significant reduction in antibiotic use following implementation of a prospective audit and feedback program in our pediatric cardiac ICU. Over one-third of antibiotics audited in our cardiac ICU were associated with a prospective audit and feedback recommendation, revealing important targets for future antimicrobial stewardship efforts in this population.
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Kim SH, Yoon JG, Park HJ, Won H, Ryoo SS, Choi E, Park EK, Huh K, Park CM. Effects of a comprehensive antimicrobial stewardship program in a surgical intensive care unit. Int J Infect Dis 2021; 108:237-243. [PMID: 33639294 DOI: 10.1016/j.ijid.2021.02.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/14/2021] [Accepted: 02/19/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES We evaluated the effects of a comprehensive antimicrobial stewardship program (ASP) in a surgical intensive care unit (SICU). METHODS The ASP was implemented from March 2018 to February 2019 at an SICU in a teaching hospital. An infectious disease physician and a pharmacist visited the SICU 3 times per week for prospective audit and feedback. Outcomes were compared between the ASP period and the same months in the preceding year (pre-ASP period). The primary outcome measure was the use of anti-pseudomonal beta-lactams (APBL). Appropriate antimicrobial de-escalation and ICU mortality rates were also compared. RESULTS A total of 182 and 149 patients were included in the study for the pre-ASP and ASP periods, respectively. Although disease severity was higher in the ASP group (septic shock 39.0% in pre-ASP vs 65.1% in ASP group, P<0.001), the use of APBL as a definitive treatment was lower during ASP (68.7% vs 57.7%, OR 0.62, 95% CI 0.40-0.98). Appropriate antimicrobial de-escalation improved (63.2% vs 94.6%, P<0.001). ICU mortality was comparable (7.7% vs 7.4%) and significantly lower during the ASP, after adjustment (adjusted OR 0.41, 95% CI 0.18-0.92, P=0.032). CONCLUSIONS A comprehensive ASP decreased the use of APBL and was associated with improved patient outcomes.
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Affiliation(s)
- Si-Ho Kim
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Division of Infectious Diseases, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Jin Gu Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyo Jung Park
- Department of Pharmaceutical Services, Samsung Medical Center, Seoul, Republic of Korea
| | - Hojeong Won
- Statistics and Data Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Sung Suk Ryoo
- Nusring Department, Samsung Medical Center, Seoul, Republic of Korea
| | - Eunsil Choi
- Office of Infection Prevention and Control, Samsung Medical Center, Seoul, Republic of Korea
| | - Eun-Kyung Park
- Department of Quality Innovation, Samsung Medical Center, Seoul, Republic of Korea
| | - Kyungmin Huh
- Division of Infectious Diseases, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Chi-Min Park
- Department of Critical Care Medicine and Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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21
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Liu J, Zhang S, Huang S, Chen Y, Zhang L, Du H, Wang T, Liu Y, Xu Y, Chen D. Rationality of Time-Dependent Antimicrobial Use in Intensive Care Units in China: A Nationwide Cross-Sectional Survey. Front Med (Lausanne) 2021; 8:584813. [PMID: 33681240 PMCID: PMC7925833 DOI: 10.3389/fmed.2021.584813] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 01/07/2021] [Indexed: 01/04/2023] Open
Abstract
Background: Extended/continuous infusion and therapeutic drug monitoring (TDM) of time-dependent antimicrobials are recommended for optimizing drug exposure for patients in intensive care units (ICUs), although practical application of these measures remains uncertain. We surveyed current practices in infusion and monitoring of commonly prescribed time-dependent antimicrobials in ICUs across China. Methods: From December 2019 to January 2020, we sent online questionnaires about various aspects of infusion and monitoring of time-dependent antimicrobials to intensivists across China. Responses from clinicians were matched with their professional titles using the Sankey diagram. Univariate and multivariate logistic regression analyses were performed to find factors associated with TDM. Results: A total of 3,687 ICU specialists from 31 provincial administrative regions of China responded to our questionnaires. Antibiotic stewardship (ABS) teams were available in hospitals as reported by 3,243 (88.0%) intensivists, including 1,308 (35.5%) who were ABS team members. Although most intensivists (3,490, 94.7%) were acquainted with the concept of prolonged/continuous infusion, nearly half of them (1,634, 44.3%) commonly administered β-lactam antibiotics intermittently. Nearly two-thirds of the respondents reported that their hospitals could not perform TDM. Our multivariable logistic regression analysis revealed that at the hospital level, knowledge of drug sample timing and attitude toward monitoring treatment effects, and drug trough or peak concentration influenced the decision to conduct TDM. Conclusions: We found great variability in prescribing practices, from drug administration to TDM, for several time-dependent antibiotics commonly used for patients with severe infections. Further studies are necessary to effectively evaluate strategies to promote consistent prescribing behavior.
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Affiliation(s)
- Jiao Liu
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sheng Zhang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Sisi Huang
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yizhu Chen
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lidi Zhang
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hangxiang Du
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tao Wang
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yongan Liu
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Xu
- Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Critical Care Medicine, Ruijin Hospital North, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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22
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Abstract
Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy, duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs; essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient antibiotic stewardship programs are provided.
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Affiliation(s)
- Jeffrey S Gerber
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
| | - Mary Anne Jackson
- Section of Infectious Disease, Department of Pediatrics, Children's Mercy Hospital and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; and
| | - Pranita D Tamma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Theoklis E Zaoutis
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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23
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Heil EL, Bork JT. It Is a Marathon, Not a Sprint-Sustainability of Stewardship in ICUs. Crit Care Med 2021; 49:159-161. [PMID: 33337745 DOI: 10.1097/ccm.0000000000004714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Emily L Heil
- Division of Infectious Diseases, Department of Medicine, University of School of Maryland Medicine, Baltimore, MD
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24
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Chatzopoulou M, Kyriakaki A, Reynolds L. Review of antimicrobial resistance control strategies: low impact of prospective audit with feedback on bacterial antibiotic resistance within hospital settings. Infect Dis (Lond) 2020; 53:159-168. [PMID: 33300825 DOI: 10.1080/23744235.2020.1846777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Antimicrobial stewardship constitutes an essential element of any concerted effort to tackle bacterial resistance, a rising public health threat both in community as well as hospital settings. The term comprises variable strategies which aim to optimise prescribing practices through either antibiotic restrictions or prospective audits of prescriptions with subsequent feedback to clinicians. Although highly debated, the actual effects of the latter on the antimicrobial susceptibility patterns of hospital flora are uncertain. The present study aims to review and evaluate the literature concerning the impact of persuasive stewardship strategies on antimicrobial resistance within hospitals. MATERIALS AND METHODS A literature review covering the period to 1st April 2020 was conducted using the PubMed/Medline, Embase, Global Health and CINAHL Plus databases. RESULTS Fifteen studies were retrieved, including twelve simple before-and-after, and three interrupted time-series studies. Audit frequency and compliance rates varied broadly. The rationale of treatment optimisation is not clear in most cases. Overall, surveillance of sentinel microorganisms through antibiograms indicates ambiguous results, with uncertainty as to whether the few successes are due to a causal effect, random incidence fluctuations, or confounding. The most informative approach targeted solely fluoroquinolones, reporting improvements in relevant Pseudomonas susceptibilities and MRSA, but without sufficient data on other effects of the strategy to assess its overall utility in clinical practice. CONCLUSION Higher standard research is needed to address the actual effects of persuasive stewardship strategies on antimicrobial susceptibility patterns. At present, they seem inadequate to play a decisive role in bacterial resistance control within hospitals.
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Affiliation(s)
| | - Argyrw Kyriakaki
- Department of Haematology and Transfusion Medicine, Nikaia Peiraia Agios Panteleimon, Athens, Greece
| | - Lucy Reynolds
- London School of Hygiene and Tropical Medicine, University of London, London, UK
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25
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Maher D, Larcombe R, Potts SD, Wiersema UF. Antimicrobial stewardship in intensive care: identifying areas for improvement. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2020. [DOI: 10.1002/jppr.1667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Dorsa Maher
- Pharmacist Flinders Medical Centre SA Pharmacy Bedford Park Australia
- PhD Candidate Clinical and Health Sciences University of South Australia Adelaide Australia
| | - Rebecca Larcombe
- Deputy Director Pharmacy Flinders Medical Centre SA Pharmacy Bedford Park Australia
| | - Simon D. Potts
- Senior Pharmacist, Intensive and Critical Care Unit Flinders Medical Centre SA Pharmacy Bedford Park Australia
| | - Ubbo F. Wiersema
- Consultant, Intensive and Critical Care Unit Flinders Medical Centre Bedford Park Australia
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26
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Díaz-Madriz JP, Cordero-García E, Chaverri-Fernández JM, Zavaleta-Monestel E, Murillo-Cubero J, Piedra-Navarro H, Hernández-Guillén M, Jiménez-Méndez T. Impact of a pharmacist-driven antimicrobial stewardship program in a private hospital in Costa Rica. Rev Panam Salud Publica 2020; 44:e57. [PMID: 32973905 PMCID: PMC7498282 DOI: 10.26633/rpsp.2020.57] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/02/2020] [Indexed: 12/20/2022] Open
Abstract
Objective. To measure the impact generated by the implementation of the pharmacy-driven antimicrobial stewardship program of the Clínica Bíblica Hospital. Methods. This is a retrospective observational study that evaluates the consumption of antibiotics for the periods before and during implementation of the Clínica Bíblica Hospital antimicrobial stewardship program, calculated by means of defined daily dose per 1 000 patient-days and days of therapy per 1 000 patient-days. In addition, bacterial resistance patterns for the periods 2014–2015 and 2016–2017 were compared. Results. Consumption of most-used antibiotics was calculated, looking for trends that might be associated with the activities implemented by the Clínica Bíblica Hospital antimicrobial stewardship program. Comparing some of the antibiotics with the highest consumption in periods I and II, use of levofloxacin and ceftriaxone showed a decrease of 54.0% (p < 0.001) and 14.6% (p = 0.003), respectively, whereas there was an increase in the use of cefazolin of 4 539.3% (p < 0.001). Regarding percentage of bacterial resistance, in most bacterial isolates no statistically significant changes were observed between the two periods. Conclusions. A reduction in the overall consumption of antibiotics has been achieved over time, most likely attributable to the antimicrobial stewardship program. However, this trend was not observed for all the antibiotics studied. The pattern of resistance among the commonly isolated microorganisms did not vary greatly between the periods studied, which suggests that either the antimicrobial stewardship program may have prevented an increase in bacterial resistance since its implementation, or that it is too soon to see impact on bacterial resistance.
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Affiliation(s)
- José Pablo Díaz-Madriz
- Hospital Clínica Bíblica San José Costa Rica Hospital Clínica Bíblica, San José, Costa Rica
| | - Eugenia Cordero-García
- CUniversity of Costa Rica, San Pedro San Pedro Costa Rica University of Costa Rica, San Pedro, Costa Rica
| | | | | | - Josué Murillo-Cubero
- Universidad de Ciencias Médicas (UCIMED) San José Costa Rica Universidad de Ciencias Médicas (UCIMED), San José, Costa Rica
| | - Hellen Piedra-Navarro
- CUniversity of Costa Rica, San Pedro San Pedro Costa Rica University of Costa Rica, San Pedro, Costa Rica
| | - Marian Hernández-Guillén
- CUniversity of Costa Rica, San Pedro San Pedro Costa Rica University of Costa Rica, San Pedro, Costa Rica
| | - Tiffany Jiménez-Méndez
- CUniversity of Costa Rica, San Pedro San Pedro Costa Rica University of Costa Rica, San Pedro, Costa Rica
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27
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Teixeira Rodrigues A, Roque F, Piñeiro-Lamas M, Falcão A, Figueiras A, Herdeiro MT. Effectiveness of an intervention to improve antibiotic-prescribing behaviour in primary care: a controlled, interrupted time-series study. J Antimicrob Chemother 2020; 74:2788-2796. [PMID: 31257435 DOI: 10.1093/jac/dkz244] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND High rates of antibiotic misprescribing in primary care, with alarming clinical and economic consequences, highlight the urgent need for interventions to improve antibiotic prescribing in this setting. OBJECTIVES To assess the effectiveness on antibiotic prescribing quality indicators of a multifaceted intervention targeting health professionals' and patients' behaviour regarding antibiotic use. METHODS We conducted a pragmatic cluster-randomized controlled trial in the catchment area covered by Portugal's Central Regional Health Administration. The intervention consisted of a multidisciplinary, multifaceted programme involving physicians, pharmacists and patients, and comprising outreach visits for physicians and pharmacists, and educational materials for health professionals and patients. The following were assessed: relative ratios of prescription of penicillins sensitive to β-lactamase, penicillin combinations including β-lactamase inhibitors, third- and fourth-generation cephalosporins and fluoroquinolones; and the ratio of broad- to narrow-spectrum antibiotics. An interrupted time-series analysis for multiple-group comparisons was performed. The study protocol was registered on Clinical.trials.gov (NCT02173509). RESULTS The participation rate in the educational intervention was 64% (197/309 GPs) in a total of 25 counties. Statistically significant improvements were obtained, not only in the relative prescription of penicillins sensitive to β-lactamase (overall relative change of +896%) and penicillin combinations including β-lactamase inhibitors (-161%), but also in the ratio of broad- to narrow-spectrum antibiotics (-200%). Statistically significant results were also obtained for third- and fourth-generation cephalosporins, though only in the immediate term. CONCLUSIONS This study showed that quality indicators of antibiotic prescribing can be improved by tackling influences on behaviour including knowledge and attitudes surrounding physicians' clinical practice. Accordingly, these determinants must be considered when implementing interventions aimed at improving antibiotic prescribing.
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Affiliation(s)
- António Teixeira Rodrigues
- Institute of Biomedicine - iBiMED, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal.,Faculty of Pharmacy, University of Coimbra (FFUC), Coimbra, Portugal.,Centre for Health Evaluation and Research (CEFAR), National Association of Pharmacies, Lisbon, Portugal
| | - Fátima Roque
- Institute of Biomedicine - iBiMED, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal.,Research Unit for Inland Development, Polytechnic of Guarda (UDI/IPG), Guarda, Portugal.,Health Science Research Centre, University of Beira Interior (CICS/UBI), Covilhã, Portugal
| | - Maria Piñeiro-Lamas
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública-CIBERESP), University of Santiago de Compostela, Santiago de Compostela, Spain.,Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Amílcar Falcão
- Faculty of Pharmacy, University of Coimbra (FFUC), Coimbra, Portugal
| | - Adolfo Figueiras
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiología y Salud Pública-CIBERESP), University of Santiago de Compostela, Santiago de Compostela, Spain.,Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Maria Teresa Herdeiro
- Institute of Biomedicine - iBiMED, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
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28
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Al-Omari A, Al Mutair A, Alhumaid S, Salih S, Alanazi A, Albarsan H, Abourayan M, Al Subaie M. The impact of antimicrobial stewardship program implementation at four tertiary private hospitals: results of a five-years pre-post analysis. Antimicrob Resist Infect Control 2020; 9:95. [PMID: 32600391 PMCID: PMC7322716 DOI: 10.1186/s13756-020-00751-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/04/2020] [Indexed: 11/23/2022] Open
Abstract
Background Antimicrobial stewardship (AMS) programs have shown to reduce the emergence of antimicrobial resistance (AMR) and health-care-associated infections (HAIs), and save health-care costs associated with an inappropriate antimicrobial use. The primary objective of this study was to compare the consumption and cost of antimicrobial agents using defined daily dose (DDD) and direct cost of antibiotics before and after the AMS program implementation. Secondary objective was to determine the rate of HAIs [Clostridium difficile (C. difficile), ventilator-associated pneumonia (VAP), and central line-associated bloodstream infection (CLABSI) before and after the AMS program implementation. Methods This is a pre-post quasi-experimental study. Adult inpatients were enrolled in a prospective fashion under the active AMS arm and compared with historical inpatients who were admitted to the same units before the AMS implementation. Study was conducted at four tertiary private hospitals located in two cities in Saudi Arabia. Adult inpatients were enrolled under the pre- AMS arm and post- AMS arm if they were on any of the ten selected restricted broad-spectrum antibiotics (imipenem/cilastatin, piperacillin/tazobactam, colistin, tigecycline, cefepime, meropenem, ciprofloxacin, moxifloxacin, teicoplanin and linezolid). Results A total of 409,403 subjects were recruited, 79,369 in the pre- AMS control and 330,034 in the post- AMS arm. Average DDDs consumption of all targeted broad-spectrum antimicrobials from January 2016 to June 2019 post- AMS launch was lower than the DDDs use of these agents pre- AMS (233 vs 320 DDDs per 1000 patient-days, p = 0.689). Antimicrobial expenditures decreased by 28.45% in the first year of the program and remained relatively stable in subsequent years, with overall cumulative cost savings estimated at S.R. 6,286,929 and negligible expenses of S.R. 505,115 (p = 0.648). Rates of healthcare associated infections involving C. difficile, VAP, and CLABSI all decreased significantly after AMS implementation (incidence of HAIs in 2015 compared to 2019: for C. difficile, 94 vs 13, p = 0.024; for VAP, 24 vs 6, p = 0.001; for CLABSI, 17 vs 1, p = 0.000; respectively). Conclusion Implementation of AMS program at HMG healthcare facilities resulted in reduced antimicrobials use and cost, and lowered incidence of healthcare associated infections.
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Affiliation(s)
- Awad Al-Omari
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia.,Alfaisal University, Riyadh, Saudi Arabia
| | - Abbas Al Mutair
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia. .,Alfaisal University, Riyadh, Saudi Arabia. .,School of Nursing, Wollongong University, Wollongong, Australia.
| | | | - Samer Salih
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Ahmed Alanazi
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Hesham Albarsan
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Maha Abourayan
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Maha Al Subaie
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
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Impact of implementing a non-restrictive antibiotic stewardship program in an emergency department: a four-year quasi-experimental prospective study. Sci Rep 2020; 10:8194. [PMID: 32424172 PMCID: PMC7235006 DOI: 10.1038/s41598-020-65222-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/27/2020] [Indexed: 11/08/2022] Open
Abstract
Antibiotic resistance is increasing worldwide. The implementation of antibiotic stewardship programmes (ASPs) is of utmost importance to optimize antibiotic use in order to prevent resistance development without harming patients. The emergency department (ED), cornerstone between hospital and community, represents a crucial setting for addressing ASP implementation; however, evidence data on ASP in ED are poor. In this study, a 4-year, non-restrictive, multi-faceted ASP was implemented in a general ED with the aim to evaluate its impact on antibiotic use and costs. Secondly, the study focused on assessing the impact on length of hospital stay (LOS), Clostridioides difficile infection (CDI) incidence rate, and mortality in the patients' group admitted from ED to medical wards. The ASP implementation was associated with a reduction of antibiotic use and costs. A mild but sustained LOS decrease in all medical wards and a significant downward trend of CDI incidence rate were observed, while mortality did not significantly change. In conclusion, the implementation of our ED-based ASP has demonstrated to be feasible and safe and might clinically benefit the hospital admitted patients' group. Further research is needed to identify the most suitable ASP design for ED and the key outcome measures to reliably assess its effectiveness.
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Effect of a prospective audit with intervention and feedback on Clostridioides difficile infection management. Int J Clin Pharm 2020; 42:923-930. [PMID: 32410207 DOI: 10.1007/s11096-020-01050-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
Background Clostridioides difficile infections are associated with morbidity and mortality in several countries. Their increasing incidence and frequent recurrence make them an urgent public health threat. The lack of adherence to international treatment guidelines for Clostridioides difficile infections is a proven mortality risk factor. Objective To evaluate long-term prescribers' adherence to recommendations on the management of Clostridioides difficile infections and its impact on clinical outcomes after an educational and Clostridioides difficile-prospective audit with intervention and feedback period. Setting All patients admitted to a 1500-bed university hospital with positive Clostridioides difficile tests identified were included. Methods Data were collected retrospectively over a baseline period (May-November 2014) and prospectively over a Clostridioides difficile-prospective audit with intervention and feedback period (November 2015-May 2016) and an observation period (November 2017-September 2018). All Clostridioides difficile cases were reviewed by a Clostridioides difficile-prospective audit with intervention and feedback team composed of pharmacists, an infectious diseases specialist and a microbiologist to obtain a complete overview of patient records in each area of expertise. Main outcome measures Percentage of conformity to the protocol, percentage of recovery at 10 days and percentage of relapse, as well as Clostridioides difficile incidence and percentage of Fidaxomicin use. Results A total of 183 patients were included over the three periods. A significant improvement in conformity to the local protocol was observed between the intervention period (23.9%) and the observation period (67.3%) (P < 10-3). Fidaxomicin prescriptions increased significantly (P = 0.006). Clinical outcomes improved significantly with an increase in the percentage of recovery at 10 days (P = 0.001) and a decrease in the percentage of relapse (P = 0.016). The Clostridioides difficile incidence rate improved significantly to 1.3 per 10,000 patient-days during the observation period. Conclusion This study shows the lasting effect of an educational and Clostridioides difficile-prospective audit with intervention and feedback period on prescribers' adherence to recommendations and a significant impact on clinical outcomes.
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Rocha-Pereira N, Figueiredo Dias P, Correia S, Shahriari S, Neves J, Teixeira J, Paiva JA, Lima Alves C, Azevedo A. Persuasive antimicrobial stewardship intervention in the context of a KPC outbreak: a controlled interrupted time series analysis. Antimicrob Resist Infect Control 2020; 9:55. [PMID: 32317012 PMCID: PMC7175563 DOI: 10.1186/s13756-020-00718-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/07/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Antimicrobial resistance is a major public health threat. Antimicrobial stewardship (AMS) is one of the key strategies to overcome resistance, but robust evidence on the effect of specific interventions is lacking. We report an interrupted time series (ITS) analysis of a persuasive AMS intervention implemented during a KPC producing Klebsiella pneumoniae outbreak. METHODS A controlled ITS for carbapenem consumption, total antibiotic consumption and antibiotic-free days, between January 2012 and May 2018 was performed, using segmented regression analysis. The AMS intervention was implemented in the Vascular Surgery ward starting on April 2016 in the context of a KPC outbreak. The General Surgery ward was taken as a control group. Data were aggregated by month for both wards, including 51 pre-intervention and 26 intervention points. RESULTS The AMS intervention produced a level change in carbapenem consumption of - 11.14 DDDs/100 patient-days accompanied by a decreasing trend of total antibiotic consumption and stable rate of antibiotic-free days in Vascular Surgery ward. These differences were not apparent in the control group. No differences in mortality or readmission rates between pre-intervention and intervention periods were noticed in any of the groups. CONCLUSION Persuasive AMS interventions on top of previously implemented restrictive interventions can reduce carbapenem consumption without increasing total antibiotic consumption. Starting persuasive AMS interventions in an outbreak setting does not compromise the sustainability of the intervention.
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Affiliation(s)
- Nuno Rocha-Pereira
- Infection and Antimicrobial Resistance Control and Prevention Unit, Hospital Epidemiology Centre, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal. .,Infectious Diseases Department, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal. .,Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal. .,UPCIRA, Centro de Epidemiologia Hospitalar, Centro Hospitalar Universitário de São João EPE, Porto, Portugal.
| | - Paulo Figueiredo Dias
- Infectious Diseases Department, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal.,Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Sofia Correia
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal.,Department of Public Health and Forensic Sciences, and Medical Education, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Shirin Shahriari
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal
| | - João Neves
- Angiology and Vascular Surgery Department, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal
| | - José Teixeira
- Angiology and Vascular Surgery Department, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal
| | - José Artur Paiva
- Department of Medicine, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Intensive Care Medicine Department, Centro Hospitalar Universitário São João, EPE, Porto, Portugal.,Grupo de Infecção e Sépsis, Porto, Portugal
| | - Carlos Lima Alves
- Infection and Antimicrobial Resistance Control and Prevention Unit, Hospital Epidemiology Centre, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal.,Infectious Diseases Department, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal
| | - Ana Azevedo
- EPIUnit, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal.,Department of Public Health and Forensic Sciences, and Medical Education, Faculdade de Medicina da Universidade do Porto, Porto, Portugal.,Hospital Epidemiology Centre, Centro Hospitalar Universitário de São João, EPE, Porto, Portugal
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Lindsay PJ, Rohailla S, Taggart LR, Lightfoot D, Havey T, Daneman N, Lowe C, Muller MP. Antimicrobial Stewardship and Intensive Care Unit Mortality: A Systematic Review. Clin Infect Dis 2020; 68:748-756. [PMID: 29982376 DOI: 10.1093/cid/ciy550] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 06/29/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) using audit and feedback in the intensive care unit (ICU) setting can reduce harms related to inappropriate antibiotic use. However, inappropriate discontinuation or narrowing of antibiotic treatment could increase infection-related mortality in this population. Individual ASP studies are underpowered to detect differences in mortality. METHODS We conducted a systematic review and meta-analysis of audit and feedback in the ICU setting, using mortality as our outcome. RESULTS Of 2447 citations, 11 studies met our inclusion criteria. Although a variety of study designs were used to assess reductions in antibiotic use, mortality was analyzed using an uncontrolled before-after study design in all studies. Five studies directed audit and feedback to all or most ICU patients receiving antibiotics and measured overall ICU mortality. In the meta-analysis of these studies, the pooled relative risk of ICU mortality was 1.03 (95% confidence interval, .93-1.14). A second meta-analysis of 3 smaller studies that evaluated mortality only in patients directly assessed by the ASP found a pooled relative risk of ICU mortality of 1.06 (95% confidence interval, .80 to 1.4). Three studies were not appropriate for meta-analysis, but their results were consistent with our overall findings. CONCLUSIONS Our systematic review did not identify a change in mortality associated with antimicrobial stewardship using audit and feedback in the ICU setting. These results increase our confidence that audit and feedback can be safely implemented in this setting. Future studies should report standardized estimates of mortality and use more robust study designs to assess mortality, when feasible.
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Affiliation(s)
| | - Sagar Rohailla
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Linda R Taggart
- Department of Medicine, University of Toronto, Ontario, Canada.,St Michael's Hospital, University of Toronto, Ontario, Canada
| | - David Lightfoot
- St Michael's Hospital, University of Toronto, Ontario, Canada
| | - Thomas Havey
- Division of Infectious Diseases, William Osler Health System, Ontario, Canada
| | - Nick Daneman
- Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Christopher Lowe
- Division of Medical Microbiology, Providence Health Care, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Matthew P Muller
- Department of Medicine, University of Toronto, Ontario, Canada.,St Michael's Hospital, University of Toronto, Ontario, Canada
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Szymczak JE. Are Surgeons Different? The Case for Bespoke Antimicrobial Stewardship. Clin Infect Dis 2020; 69:21-23. [PMID: 30445615 DOI: 10.1093/cid/ciy847] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/28/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania.,Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia
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Neo JRJ, Niederdeppe J, Vielemeyer O, Lau B, Demetres M, Sadatsafavi H. Evidence-Based Strategies in Using Persuasive Interventions to Optimize Antimicrobial Use in Healthcare: a Narrative Review. J Med Syst 2020; 44:64. [PMID: 32040649 DOI: 10.1007/s10916-020-1531-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 01/24/2020] [Indexed: 01/22/2023]
Abstract
A rise in antimicrobial resistance, seen especially since 2000, is in part caused by indiscriminate antimicrobial use. Varied types of persuasive interventions aimed to optimize antimicrobial use have been tried with varying success. Our review seeks to identify and assess factors associated with the successful implementation of persuasive interventions. We searched five databases (MEDLINE, EMBASE, The Cochrane Library, PsycINFO, and ERIC) to identify critical studies published between 2000 and December 2018 of interventions employing audit and feedback, education through meetings, academic detailing, reminders, and patient, family, or public education. Outcome measures of interest were any means to measure antimicrobial use. We included 26 articles in our analysis. Seventeen examined multimodal interventions and the most common was audit and feedback and meeting (four studies). Nine examined single interventions and the most common was audit and feedback (five studies). Our findings inform four evidence-based strategies to enable healthcare administrators, clinicians, and researchers to make informed choices when planning and designing an antimicrobial stewardship program: (1) implement a combination of persuasive interventions from both groups: audit and feedback, academic detailing, or patient, family, or provider education; and meeting or reminders, (2) design interventions that last one year or longer; post-intervention, assess the intervention's long-term effects for at least another one year, (3) conduct quality improvement projects examining persuasive interventions if the prescribing database provides adequate diagnosis information, and most importantly, (4) make patient, family, or provider education an integral component of multimodal intervention.
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Affiliation(s)
- Jun Rong Jeffrey Neo
- Department of Design and Environmental Analysis, Cornell University, Martha Van Rensselaer Hall, Ithaca, NY, 14853, USA.
| | - Jeff Niederdeppe
- Department of Communication, Cornell University, 476 Mann Library Building, Ithaca, NY, 14853, USA
| | - Ole Vielemeyer
- Weill Cornell Medicine, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
| | - Brandyn Lau
- Johns Hopkins Medicine, Department of Radiology and Radiological Science, 600 North Wolfe Street - Radiology 127, Baltimore, MD, 21205, USA
| | | | - Hessam Sadatsafavi
- Department of Emergency Medicine, University of Virginia School of Medicine, University of Virginia Health Sciences Center, P.O. Box 800699, Charlottesville, VA, 22908, USA
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Schweitzer VA, van Werkhoven CH, Rodríguez Baño J, Bielicki J, Harbarth S, Hulscher M, Huttner B, Islam J, Little P, Pulcini C, Savoldi A, Tacconelli E, Timsit JF, van Smeden M, Wolkewitz M, Bonten MJM, Walker AS, Llewelyn MJ. Optimizing design of research to evaluate antibiotic stewardship interventions: consensus recommendations of a multinational working group. Clin Microbiol Infect 2019; 26:41-50. [PMID: 31493472 DOI: 10.1016/j.cmi.2019.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/20/2019] [Accepted: 08/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antimicrobial stewardship interventions and programmes aim to ensure effective treatment while minimizing antimicrobial-associated harms including resistance. Practice in this vital area is undermined by the poor quality of research addressing both what specific antimicrobial use interventions are effective and how antimicrobial use improvement strategies can be implemented into practice. In 2016 we established a working party to identify the key design features that limit translation of existing research into practice and then to make recommendations for how future studies in this field should be optimally designed. The first part of this work has been published as a systematic review. Here we present the working group's final recommendations. METHODS An international working group for design of antimicrobial stewardship intervention evaluations was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). The group comprised clinical and academic specialists in antimicrobial stewardship and clinical trial design from six European countries. Group members completed a structured questionnaire to establish the scope of work and key issues to develop ahead of a first face-to-face meeting that (a) identified the need for a comprehensive systematic review of study designs in the literature and (b) prioritized key areas where research design considerations restrict translation of findings into practice. The working group's initial outputs were reviewed by independent advisors and additional expertise was sought in specific clinical areas. At a second face-to-face meeting the working group developed a theoretical framework and specific recommendations to support optimal study design. These were finalized by the working group co-ordinators and agreed by all working group members. RESULTS We propose a theoretical framework in which consideration of the intervention rationale the intervention setting, intervention features and the intervention aims inform selection and prioritization of outcome measures, whether the research sets out to determine superiority or non-inferiority of the intervention measured by its primary outcome(s), the most appropriate study design (e.g. experimental or quasi- experimental) and the detailed design features. We make 18 specific recommendation in three domains: outcomes, objectives and study design. CONCLUSIONS Researchers, funders and practitioners will be able to draw on our recommendations to most efficiently evaluate antimicrobial stewardship interventions.
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Affiliation(s)
- V A Schweitzer
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - C H van Werkhoven
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - J Rodríguez Baño
- Unit of Infectious Diseases, Clinical Microbiology and Preventive Medicine, Department of Medicine, Hospital Universitario Virgen Macarena, Universidad de Sevilla and Biomedicine Institute of Sevilla (IBiS), Seville, Spain
| | - J Bielicki
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
| | - S Harbarth
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - M Hulscher
- Scientific Centre for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - B Huttner
- Department of Infectious Diseases and Infection Control, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - J Islam
- Department of Global Health and Infection, Brighton and Sussex Medical School, Falmer, UK
| | - P Little
- Department of Primary Care Research, University of Southampton, Southampton, UK
| | - C Pulcini
- Infectious Diseases Department, Université de Lorraine, CHRU-Nancy, APEMAC, Université de Lorraine, Nancy, France
| | - A Savoldi
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - E Tacconelli
- Infectious Diseases, Department of Diagnostic and Public Health, Verona, Italy; University Hospital, Internal Medicine, Tuebingen University, Germany
| | - J-F Timsit
- Medical and Infectious Diseases ICU, Bichat University Hospital, AP-HP, Paris, France; UMR 1137, Infection Antimicrobials Modelling Evolution, Paris Diderot University, Paris, France
| | - M van Smeden
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Wolkewitz
- Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - M J M Bonten
- Department of Medical Microbiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - A S Walker
- MRC Clinical Trials Unit, University College London, London, UK; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M J Llewelyn
- Department of Primary Care Research, University of Southampton, Southampton, UK.
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Pagels CM, McCreary EK, Rose WE, Dodds Ashley ES, Bookstaver PB, Dilworth TJ. Designing antimicrobial stewardship initiatives to enhance scientific dissemination. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2019. [DOI: 10.1002/jac5.1164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
| | - Erin K. McCreary
- University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
| | - Warren E. Rose
- School of Pharmacy, University of Wisconsin-Madison; Madison Wisconsin
| | | | - P. Brandon Bookstaver
- Department of Clinical Pharmacy & Outcomes Sciences; University of South Carolina College of Pharmacy; Columbia South Carolina
| | - Thomas J. Dilworth
- Department of Pharmacy Services; Aurora St. Luke's Medical Center; Milwaukee Wisconsin
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Cortes D, Leung J, Ryl A, Lieu J. Pharmacy Informatics: Where Medication Use and Technology Meet. Can J Hosp Pharm 2019; 72:320-326. [PMID: 31452544 PMCID: PMC6699873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Daniel Cortes
- BScPhm, RPh, is with the Pharmacy Department and Clinical Informatics, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario BScPhm, RPh, is with the Pharmacy Department and Clinical Informatics, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario BScPhm, RPh, is with the Pharmacy Department, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario BScPhm, ACPR, RPh, is with Clinical Informatics, St Joseph's Health Centre, Unity Health Toronto, Toronto, Ontario
| | - Jodie Leung
- BScPhm, RPh, is with the Pharmacy Department and Clinical Informatics, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario BScPhm, RPh, is with the Pharmacy Department and Clinical Informatics, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario BScPhm, RPh, is with the Pharmacy Department, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario BScPhm, ACPR, RPh, is with Clinical Informatics, St Joseph's Health Centre, Unity Health Toronto, Toronto, Ontario
| | - Andrea Ryl
- BScPhm, RPh, is with the Pharmacy Department and Clinical Informatics, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario BScPhm, RPh, is with the Pharmacy Department and Clinical Informatics, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario BScPhm, RPh, is with the Pharmacy Department, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario BScPhm, ACPR, RPh, is with Clinical Informatics, St Joseph's Health Centre, Unity Health Toronto, Toronto, Ontario
| | - Jenny Lieu
- BScPhm, RPh, is with the Pharmacy Department and Clinical Informatics, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario BScPhm, RPh, is with the Pharmacy Department and Clinical Informatics, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario BScPhm, RPh, is with the Pharmacy Department, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario BScPhm, ACPR, RPh, is with Clinical Informatics, St Joseph's Health Centre, Unity Health Toronto, Toronto, Ontario
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Analysis of multisite intervention studies using generalized linear mixed models. Infect Control Hosp Epidemiol 2019; 40:910-917. [DOI: 10.1017/ice.2019.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AbstractMultisite intervention studies have become increasingly common in infection control, for example, looking for a change in hospital infection rates after a regional policy change. The design of these studies can take various forms, from pre–post observational studies to randomized trials, in which sites are randomly assigned to the intervention or in which the intervention is sequentially introduced to different sites over time. Data collected under these settings are clustered by hospital and/or ward, consist of repeated measurements and, in some cases, exhibit temporal and/or seasonal patterns. Failure to account for these features in data analysis could well result in biased estimates of intervention effectiveness and impact on the generalizability of model results.
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Antibiotic stewardship in the intensive care unit: Challenges and opportunities. Infect Control Hosp Epidemiol 2019; 40:693-698. [PMID: 31046851 DOI: 10.1017/ice.2019.74] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Infections due to antibiotic-resistant organisms are increasing in prevalence and represent a major public health threat. Antibiotic overuse is a major driver of this epidemic, and antibiotic stewardship an important means of limiting antibiotic resistance. The intensive care unit (ICU) setting presents an intersection of opportunities and challenges for effective antibiotic stewardship, but limited data inform optimal stewardship interventions in this setting. In this review, we present unique considerations for stewardship interventions the ICU setting and summarize available data evaluating the impact of prospective audit and feedback, diagnostic test stewardship, rapid molecular diagnostic tests, and procalcitonin-guided algorithms for antibiotic discontinuation. The existing knowledge gaps ripe for future research are emphasized.
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40
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Thampi N, Shah PS, Nelson S, Agarwal A, Steinberg M, Diambomba Y, Morris AM. Prospective audit and feedback on antibiotic use in neonatal intensive care: a retrospective cohort study. BMC Pediatr 2019; 19:105. [PMID: 30975119 PMCID: PMC6458619 DOI: 10.1186/s12887-019-1481-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/31/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Antimicrobial stewardship programs potentially lead to appropriate antibiotic use, yet the optimal approach for neonates is uncertain. Such a program was implemented in a tertiary care neonatal intensive care unit in October 2012. We evaluated the impact of this program on antimicrobial use and its association with clinical outcomes. METHODS In a retrospective cohort study, we examined 1580 neonates who received antimicrobials in the 13-months before and 13-months during program implementation. Prospective audit and feedback was given 5 days a week on each patient who was receiving antibiotic. Pharmacy and microbiology data were linked to clinical data from the local Canadian Neonatal Network database. The primary outcome was days of antibiotic therapy per 1000 patient-days; secondary outcomes included mortality, necrotizing enterocolitis, and antibiotic duration for culture-positive and culture-negative late-onset sepsis. The breadth of antibiotic exposure was compared using the Antibiotic Spectrum Index. RESULTS Overall antibiotic use decreased to 339 days of therapy per 1000 patient-days from 395 (14%, P < 0.001), without an increase in mortality. There was no difference in duration of therapy in culture-negative or culture-positive sepsis, rates of necrotizing enterocolitis, or breadth of antibiotic exposure. Fewer antibiotic starts occurred during program implementation (63% versus 59%, P < 0.001). The use of narrow-spectrum agents decreased (P < 0.001) whereas the use of cefotaxime increased (P = 0.016) during program implementation. CONCLUSIONS Daily prospective audit and feedback was not associated with a change in antibiotic duration or clinical outcomes, however there were fewer babies started on antibiotics, suggesting that additional interventions are required to inform and sustain changes in antibiotic prescribing practices.
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Affiliation(s)
- Nisha Thampi
- Department of Pediatrics, CHEO, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Prakesh S. Shah
- Department of Pediatrics, Sinai Health System, 600 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Sandra Nelson
- Antimicrobial Stewardship Program, Sinai Health System-University Health Network, 600 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Amisha Agarwal
- Research Institute, CHEO, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Marilyn Steinberg
- Antimicrobial Stewardship Program, Sinai Health System-University Health Network, 600 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Yenge Diambomba
- Department of Pediatrics, Sinai Health System, 600 University Avenue, Toronto, ON M5G 1X5 Canada
| | - Andrew M. Morris
- Antimicrobial Stewardship Program, Sinai Health System-University Health Network, 600 University Avenue, Toronto, ON M5G 1X5 Canada
- Department of Medicine, Sinai Health System, University Health Network, 600 University Avenue, Toronto, ON M5G 1X5 Canada
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Horton CD, Rawlins MDM, Manning L, Ingram PR. Non-adherence to antimicrobial stewardship prospective audit and feedback advice: Risk factors and clinical consequences. J Infect Chemother 2019; 25:485-488. [PMID: 30904463 DOI: 10.1016/j.jiac.2019.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/24/2018] [Accepted: 02/20/2019] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Christopher D Horton
- Medical School, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, 6009, Australia
| | - Matthew D M Rawlins
- Department of Pharmacy, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Laurens Manning
- Medical School, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia, 6150, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Paul R Ingram
- Medical School, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, 6009, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia, 6150, Australia; Department of Microbiology, PathWest Laboratory Medicine, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia, 6150, Australia.
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42
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Nathwani D, Varghese D, Stephens J, Ansari W, Martin S, Charbonneau C. Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review. Antimicrob Resist Infect Control 2019; 8:35. [PMID: 30805182 PMCID: PMC6373132 DOI: 10.1186/s13756-019-0471-0] [Citation(s) in RCA: 213] [Impact Index Per Article: 42.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/11/2019] [Indexed: 12/21/2022] Open
Abstract
Background Hospital antimicrobial stewardship programs (ASPs) aim to promote judicious use of antimicrobials to combat antimicrobial resistance. For ASPs to be developed, adopted, and implemented, an economic value assessment is essential. Few studies demonstrate the cost-effectiveness of ASPs. This systematic review aimed to evaluate the economic and clinical impact of ASPs. Methods An update to the Dik et al. systematic review (2000–2014) was conducted on EMBASE and Medline using PRISMA guidelines. The updated search was limited to primary research studies in English (30 September 2014–31 December 2017) that evaluated patient and/or economic outcomes after implementation of hospital ASPs including length of stay (LOS), antimicrobial use, and total (including operational and implementation) costs. Results One hundred forty-six studies meeting inclusion criteria were included. The majority of these studies were conducted within the last 5 years in North America (49%), Europe (25%), and Asia (14%), with few studies conducted in Africa (3%), South America (3%), and Australia (3%). Most studies were conducted in hospitals with 500–1000 beds and evaluated LOS and change in antibiotic expenditure, the majority of which showed a decrease in LOS (85%) and antibiotic expenditure (92%). The mean cost-savings varied by hospital size and region after implementation of ASPs. Average cost savings in US studies were $732 per patient (range: $2.50 to $2640), with similar trends exhibited in European studies. The key driver of cost savings was from reduction in LOS. Savings were higher among hospitals with comprehensive ASPs which included therapy review and antibiotic restrictions. Conclusions Our data indicates that hospital ASPs have significant value with beneficial clinical and economic impacts. More robust published data is required in terms of implementation, LOS, and overall costs so that decision-makers can make a stronger case for investing in ASPs, considering competing priorities. Such data on ASPs in lower- and middle-income countries is limited and requires urgent attention.
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Affiliation(s)
- Dilip Nathwani
- 1Ninewells Hospital and Medical School, Dundee, DD19SY UK
| | - Della Varghese
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
| | - Jennifer Stephens
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
| | | | - Stephan Martin
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
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Systematic review of the use of time series data in the study of antimicrobial consumption and Pseudomonas aeruginosa resistance. J Glob Antimicrob Resist 2018; 15:69-73. [DOI: 10.1016/j.jgar.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/30/2018] [Accepted: 06/05/2018] [Indexed: 11/22/2022] Open
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44
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Garau J, Bassetti M. Role of pharmacists in antimicrobial stewardship programmes. Int J Clin Pharm 2018; 40:948-952. [PMID: 30242589 DOI: 10.1007/s11096-018-0675-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/14/2018] [Indexed: 11/26/2022]
Abstract
Antimicrobial resistance is a growing public health problem of global concern and, unless action is taken, the burden of death could reach 10 million per year by 2050. Resistance has been associated with increasing mortality, treatment failure and healthcare costs. In order to help combat this, antimicrobial stewardship programmes, have been implemented in many countries. These stewardship programmes can help, reduce inappropriate prescription and broad-spectrum use of antimicrobials, improve, clinical outcomes for the population as a whole, slow down the emergence of antimicrobial resistance and conserve healthcare resources. Pharmacists are an integral part of the stewardship team and have an important role in tackling antimicrobial resistance. This article aims to review the role of pharmacists within antimicrobial stewardship programmes and the opportunities for pharmacist-driven antimicrobial stewardship strategies in hospital and community settings.
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Affiliation(s)
- Javier Garau
- Department of Medicine, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain.
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria della Misericordia University Hospital, University of Udine, Udine, Italy
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45
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Bertollo LG, Lutkemeyer DS, Levin AS. Are antimicrobial stewardship programs effective strategies for preventing antibiotic resistance? A systematic review. Am J Infect Control 2018; 46:824-836. [PMID: 29472107 DOI: 10.1016/j.ajic.2018.01.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/05/2018] [Accepted: 01/05/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) have been proposed as a solution for the global burden of antibiotic resistance, despite the lack of evidence on the subject. OBJECTIVE To analyze the role of ASPs in reducing bacterial resistance to antibiotics in hospital settings. DATA SOURCES A review in PubMed, Scopus, LILACS, and SciELO databases was performed. The period analyzed was January 1, 2012-January 4, 2017. ELIGIBILITY CRITERIA Studies that related ASPs to bacterial resistance. DATA EXTRACTION All studies that did not focus on ASPs were removed. Antifungal and antiviral programs were excluded. RESULTS Only 8 studies had quasi-experimental designs, and none were controlled trials. ASP strategies and microorganism-antibiotic pairs evaluated varied widely. Seven studies were classified as presenting clearly positive results, 3 had limited positive results, 7 had doubtful results, 4 had negative results, and 5 had noninterpretable results. The implementation of new infection control practices occurred in 7 studies. LIMITATIONS There are yet few studies on this matter, and most of them have inadequate study designs. Great heterogeneity between study features was detrimental to drawing evidence-based conclusions. CONCLUSIONS There is no solid evidence that ASPs are effective in reducing antibiotic resistance in hospital settings. We uphold the need for more studies with appropriate study designs, standardized ASP interventions targeting common microorganism-antibiotic pairs, and avoiding simultaneous implementation of infection control practices.
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Affiliation(s)
- Leandro G Bertollo
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Diego S Lutkemeyer
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Anna S Levin
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Lesprit P. Place des référents en antibiothérapie en réanimation. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Dans les hôpitaux français, les référents antibiotiques ont comme principale mission d’assurer une activité de conseil sur le bon usage des antibiotiques sur avis sollicités ou à partir d’alertes générées par la microbiologie ou la pharmacie. À première vue, leurs contributions semblent donc importantes en réanimation, où près d’un patient sur deux reçoit une antibiothérapie pendant son séjour. Plusieurs études ont montré que les avis des infectiologues permettaient d’améliorer la qualité de l’antibiothérapie prescrite et de réduire l’exposition des patients aux antibiotiques. Cependant, les bénéfices de ces interventions sur l’évolution clinique des patients ou sur l’écologie bactérienne sont plus difficiles à démontrer. L’activité des référents antibiotiques doit s’intégrer dans un programme multidisciplinaire de bon usage des antibiotiques, intégrant d’autres intervenants et en premier lieu les réanimateurs, avec lesquels une collaboration étroite est fondamentale pour la réussite de ce programme.
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Antimicrobial Stewardship in the Treatment of Infections Among Patients With Cystic Fibrosis. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0157-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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48
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Adhikari S, Piza M, Taylor P, Deshpande K, Lam D, Konecny P. Sustained multimodal antimicrobial stewardship in an Australian tertiary intensive care unit from 2008–2015: an interrupted time-series analysis. Int J Antimicrob Agents 2018; 51:620-628. [DOI: 10.1016/j.ijantimicag.2018.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 01/14/2018] [Accepted: 01/20/2018] [Indexed: 01/03/2023]
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49
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A Before-and-After Study of the Effectiveness of an Antimicrobial Stewardship Program in Critical Care. Antimicrob Agents Chemother 2018; 62:AAC.01825-17. [PMID: 29339385 DOI: 10.1128/aac.01825-17] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/14/2017] [Indexed: 11/20/2022] Open
Abstract
We evaluated the use of antimicrobials expressed as defined daily doses (DDDs) per 1,000 patient days and days of therapy (DOT) per 100 occupied bed-days in a intensive care unit (ICU) of a general hospital in Barcelona, Spain, before and after implementation of an antimicrobial stewardship (AMS) program (2007 to 2010 versus 2011 to 2015). The quarterly costs of antimicrobials used in the ICU and its weight in the overall hospital costs of antimicrobials were calculated. The effect of the applied AMS program on DDDs and DOT time series data was analyzed by means of intervention time series analysis. A total of 5,002 patients were included (1,971 for the first [before] period and 3,031 for the second [after] period). The percentage of patients treated with one or more antimicrobials decreased from 88.6 to 77.2% (P < 0.001). DDDs decreased from 246.8 to 192.3 (mean difference, -54.5; P = 0.001) and DOT from 66.7 to 54.6 (mean difference, -12.1; P = 0.066). The mean cost per trimester decreased from €115,543 to €73,477 (mean difference, -42,065.4 euros; P < 0.001), and the percentage of ICU antimicrobials cost with respect to the total cost of hospital antimicrobials decreased from 28.5 to 22.8% (mean difference, -5.59; P = 0.023). Implementation of an AMS program in the ICU was associated with a marked reduction in the use of antimicrobials, with cost savings close to one million euros since its implementation. An AMS program can have a significant impact on optimizing antimicrobial use in critical care practice.
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50
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Ohnuma T, Hayashi Y, Yamashita K, Marquess J, Lefor AK, Sanui M. A nationwide survey of intravenous antimicrobial use in intensive care units in Japan. Int J Antimicrob Agents 2018; 51:636-641. [PMID: 29408737 DOI: 10.1016/j.ijantimicag.2018.01.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 01/13/2018] [Accepted: 01/24/2018] [Indexed: 12/31/2022]
Abstract
Although most patients in the intensive care unit (ICU) receive antibiotics, little is known about patterns of antibiotic use in ICUs in Japan. The objective of this study was to evaluate the pattern of antibiotic use in ICUs. A nationwide one-day cross-sectional surveillance of antibiotic use in the ICU was conducted three times between January 2011 and December 2011. All patients aged at least16 years were included. Data from 52 ICUs and 1148 patients were reviewed. There were 1028 prescriptions for intravenous antibiotics. Of 1148 patients, 834 (73%) received at least one intravenous antibiotic, and 575 had at least one known site of infection. Respiratory and intra-abdominal infections were the two most common types. Of 1028 prescriptions, 331 (34%) were for surgical or medical prophylaxis. Excluding prophylaxis, carbapenems were the most commonly prescribed agent. Infectious disease consultations, pre- and post-prescription antimicrobial stewardship, and ICU-dedicated antibiograms were available in 44%, 52%, 77%, and 21% of the ICUs, respectively. In logistic regression analysis adjusting for patient characteristics, treatment in a university hospital (adjusted odds ratio, 1.72; 95% CI, 1.05-2.84; P = 0.033) and an open ICU (adjusted odds ratio, 2.30; 95% CI, 1.02-5.17; P = 0.044) were significantly associated with greater likelihood of carbapenem use. An increase in the number of closed ICUs and more intensive care specialists may reduce carbapenem use in Japanese ICUs. Large-scale epidemiological studies of antimicrobial resistance in the ICU are needed.
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Affiliation(s)
- Tetsu Ohnuma
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan; Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan.
| | - Kazuto Yamashita
- Department of Healthcare Economics and Quality Management, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - John Marquess
- Communicable Disease Unit, Queensland Health, Herston, QLD, Australia
| | | | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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