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Hayakawa K, Asai Y, Tajima T, Endo M, Kawabata J, Fujii N, Sakaguchi M, Ishioka H, Tsuzuki S, Matsunaga N, Ohmagari N, Fukuda H. Evaluation of antimicrobial selective pressure using the multicenter semiautomatic surveillance system Japan surveillance for infection prevention and healthcare epidemiology. J Infect Public Health 2024; 17:102474. [PMID: 38908067 DOI: 10.1016/j.jiph.2024.102474] [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: 10/25/2023] [Revised: 04/30/2024] [Accepted: 06/05/2024] [Indexed: 06/24/2024] Open
Abstract
BACKGROUND Evaluating the selective pressure of antimicrobials on bacteria is important for promoting antimicrobial stewardship programs (ASPs). The aim of this study was to assess the selective pressure of antimicrobials by evaluating their use (carbapenem [CBP] and CBP-sparing therapy) over time and the detection status of CBP-resistant organisms using multicenter data. METHODS Among the facilities whose data were registered in the Japan Surveillance for Infection Prevention and Healthcare Epidemiology from 2017 to 2020, those that had data on the use of CBP and CBP-sparing therapy (fluoroquinolones [FQs], cefmetazole [CMZ], piperacillin-tazobactam [PIP/TAZ], ampicillin-sulbactam [ABPC/SBT], ceftriaxone/cefotaxime [CTRX/CTX], CAZ (ceftazidime), cefepime [CFPM], and aminoglycosides [AGs]) as well as on CBP-resistant Enterobacterales (CRE) and CBP-resistant Pseudomonas aeruginosa (CRPA) detection were included. Alcohol-based hand rubbing (ABHR) usage was also analyzed. Regression analyses, including multivariable regression analysis, were performed to evaluate trends. The association of antimicrobial use density (AUD) with CRE and CRPA detection rates was evaluated. RESULTS In 28 facilities nationwide, CBP, FQ, CAZ, AG, and PIP/TAZ use decreased over the 3-year period, whereas the use of CMZ, ABPC/SBT, CTRX/CTX, CFPM, and ABHR as well as the rates of CRE and CRPA detection increased. The average AUD did not significantly correlate with CRE and CRPA detection rates. The multivariable regression analysis did not reveal any significant correlation between each AUD or ABHR and CRE or CRPA detection. CONCLUSION CBP and ABHR use showed a decreasing and an increasing trend, respectively, while CRPA and CRE detection rates exhibited a gradual increase. The considerably low CRE and CRPA detection rates suggest that slight differences in numbers may have been observed as excessive trend changes. Further investigation is warranted to evaluate selective pressure while considering the characteristics of ASP and the mechanisms underlying resistance.
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Affiliation(s)
- Kayoko Hayakawa
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan; Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Yusuke Asai
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan; Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Taichi Tajima
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mio Endo
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Jun Kawabata
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume, Japan
| | - Naoki Fujii
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mikiyo Sakaguchi
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Haruhiko Ishioka
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shinya Tsuzuki
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan; Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Nobuaki Matsunaga
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Ohmagari
- AMR Clinical Reference Center, National Center for Global Health and Medicine, Tokyo, Japan; Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Haruhisa Fukuda
- Department of Health Care Administration and Management, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Szymczak JE, Petty LA, Gandhi TN, Neetz RA, Hersh A, Presson AP, Lindenauer PK, Bernstein SJ, Muller BM, White AT, Horowitz JK, Flanders SA, Smith JD, Vaughn VM. Protocol for a parallel cluster randomized trial of a participatory tailored approach to reduce overuse of antibiotics at hospital discharge: the ROAD home trial. Implement Sci 2024; 19:23. [PMID: 38439076 PMCID: PMC10910678 DOI: 10.1186/s13012-024-01348-w] [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: 01/03/2024] [Accepted: 02/02/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Antibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care. There may be different pathways to improve discharge antibiotic prescribing that vary widely in feasibility. Supporting hospitals in selecting interventions tailored to their context may be an effective approach to feasibly reduce antibiotic overuse at discharge across diverse hospitals. The objective of this study is to evaluate the effectiveness of the Reducing Overuse of Antibiotics at Discharge Home multicomponent implementation strategy ("ROAD Home") on antibiotic overuse at discharge for community-acquired pneumonia and urinary tract infection. METHODS This 4-year two-arm parallel cluster-randomized trial will include three phases: baseline (23 months), intervention (12 months), and postintervention (12 months). Forty hospitals recruited from the Michigan Hospital Medicine Safety Consortium will undergo covariate-constrained randomization with half randomized to the ROAD Home implementation strategy and half to a "stewardship as usual" control. ROAD Home is informed by the integrated-Promoting Action on Research Implementation in Health Services Framework and includes (1) a baseline needs assessment to create a tailored suite of potential stewardship interventions, (2) supported decision-making in selecting interventions to implement, and (3) external facilitation following an implementation blueprint. The primary outcome is baseline-adjusted days of antibiotic overuse at discharge. Secondary outcomes include 30-day patient outcomes and antibiotic-associated adverse events. A mixed-methods concurrent process evaluation will identify contextual factors influencing the implementation of tailored interventions, and assess implementation outcomes including acceptability, feasibility, fidelity, and sustainment. DISCUSSION Reducing antibiotic overuse at discharge across hospitals with varied resources requires tailoring of interventions. This trial will assess whether a multicomponent implementation strategy that supports hospitals in selecting evidence-based stewardship interventions tailored to local context leads to reduced overuse of antibiotics at discharge. Knowledge gained during this study could inform future efforts to implement stewardship in diverse hospitals and promote equity in access to the benefits of quality improvement initiatives. TRIAL REGISTRATION Clinicaltrials.gov NCT06106204 on 10/30/23.
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Affiliation(s)
- Julia E Szymczak
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Lindsay A Petty
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Tejal N Gandhi
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Robert A Neetz
- MyMichigan Medical Center Midland, MyMichigan Health, Midland, MI, USA
| | - Adam Hersh
- Department of Pediatrics, Division of Pediatric Infectious Diseases, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Angela P Presson
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Peter K Lindenauer
- Baystate Medical Center Department of Healthcare Delivery and Population Science, Center for Quality of Care Research, Springfield, MA, USA
| | - Steven J Bernstein
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, Division of General Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Brandi M Muller
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Andrea T White
- Department of Internal Medicine, Division of General Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Jennifer K Horowitz
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Scott A Flanders
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Justin D Smith
- Department of Population Health Sciences, Division of Health System Innovation & Research, University of Utah School of Medicine, Salt Lake City, USA
| | - Valerie M Vaughn
- Department of Internal Medicine, Division of General Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Internal Medicine, Division of General Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Population Health Sciences, Division of Health System Innovation & Research, University of Utah School of Medicine, Salt Lake City, USA.
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Dighriri IM, Alnomci BA, Aljahdali MM, Althagafi HS, Almatrafi RM, Altwairqi WG, Almagati AA, Shunaymir AM, Haidarah GA, Alanzi MH, Hadadi AA, Suwaydi HM, Aqdi MJ, Alharthi HN, Alshahrani AF. The Role of Clinical Pharmacists in Antimicrobial Stewardship Programs (ASPs): A Systematic Review. Cureus 2023; 15:e50151. [PMID: 38186441 PMCID: PMC10771624 DOI: 10.7759/cureus.50151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 01/09/2024] Open
Abstract
Antimicrobial resistance (AMR) is a major global health threat, increasing deaths and healthcare costs. Antimicrobial stewardship programs (ASPs) have been implemented to optimize antibiotic use and curb resistance. This systematic review aimed to summarize evidence on the role and impact of pharmacists in hospital ASPs. A comprehensive literature search was conducted across databases to identify relevant studies published from 2016 to 2023. Twenty-four studies met the inclusion criteria, comprising global observational and randomized clinical trials. Pharmacists performed various stewardship activities, including prospective audits, formulary management, de-escalation, guideline development, and education. Pharmacist-led interventions significantly improved antibiotic prescribing, reduced unnecessary antibiotic use, optimized therapy, and enhanced outcomes. Multiple studies found that pharmacist reviews decreased the time to optimal antibiotics and improved guideline compliance without affecting readmissions or revisits. De-escalation programs safely reduced antibiotic duration and length of stay. Acceptance rates for recommendations were high. Pharmacist stewardship curbed overall antibiotic use, costs, and duration across hospital departments, leading to savings. While most studies showed positive impacts, fewer detected significant changes in resistance or mortality over short periods. More research is needed, but current evidence demonstrates that pharmacists play critical roles in ASPs, leading to improved antibiotic use and patient outcomes. These findings support integrating pharmacists into stewardship activities, significantly extending programs to ambulatory settings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Mohmmad H Alanzi
- Department of Emergency Pharmacy, Dr. Sulaiman Al Habib Hospital, Riyadh, SAU
| | | | | | - Maha J Aqdi
- Faculty of Pharmacy, Jazan University, Jazan, SAU
| | - Hamed N Alharthi
- Department of Forensic Center, Forensic Medical Services Center, Al Baha, SAU
| | - Amaal F Alshahrani
- Department of Pharmacy, Armed Forces Hospital Southern Region, Abha, SAU
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Lack of correlation between standardized antimicrobial administration ratios (SAARs) and healthcare-facility–onset Clostridioides difficile infection rates in Veterans Affairs medical facilities. Infect Control Hosp Epidemiol 2022:1-3. [DOI: 10.1017/ice.2022.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Abstract
We detected no correlation between standardized antimicrobial administration ratios (SAARs) and healthcare facility-onset Clostridioides difficile infection (HO-CDI) rates in 102 acute-care Veterans Affairs medical centers over 16 months. SAARs may be useful for investigating trends in local antimicrobial use, but no ratio threshold demarcated HO-CDI risk.
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Umemura T, Mutoh Y, Ota A, Ito Y, Mizuno T, Oguchi H, Yamada T, Ikeda Y, Ichihara T. Influence of Change of Full-Time Equivalents on Post-prescription Review with Feedback Interventions in an Antimicrobial Stewardship. Biol Pharm Bull 2022; 45:235-239. [PMID: 35110510 DOI: 10.1248/bpb.b21-00856] [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: 01/02/2023]
Abstract
Few studies have investigated the influence of more full-time equivalents (FTEs) of infectious disease (ID) pharmacists on the likelihood of a post-prescription review with feedback (PPRF) intervention. This study focused on this in community hospitals before and after the Japanese medical reimbursement system was revised to introduce antimicrobial stewardship (AS) fees. We collected data for two periods: before (April 2017 to March 2018) and after (April 2018 to March 2019) AS fee implementation. The efficacy of the PPRF by the ID pharmacist was assessed based on the usage of broad-spectrum antimicrobials in days of therapy (DOT) per 100 patient-days. Further, we generated the susceptibility rate for antimicrobial-resistant organisms. The number of PPRF drugs was 2336 (2596 cases) before AS fee implementation and 2136 (1912 cases) after implementation. The overall monthly FTE for AS for an ID pharmacist increased from [median (interquartile range; IQR)] 0.34 (0.33-0.36) to 0.63 (0.61-0.63) after AS fee implementation. The DOT of the broad-spectrum antibiotics decreased from 10.46 (9.61-12.48) to 8.68 (8.14-9.18). The DOT of carbapenems and quinolones decreased significantly from 4.11 (3.69-4.41) to 3.07 (2.79-3.22) and 0.96 (0.61-1.14) to 0.37 (0.19-0.46), respectively (p < 0.05). Furthermore, the rate of levofloxacin (LVFX)-susceptible Pseudomonas (P.) aeruginosa improved from 71.5 to 84.8% (p < 0.01). We observed that increasing the FTE of ID pharmacists influences the DOTs of broad-spectrum antibiotics; a higher FTE contributes to fewer DOTs. Further, the susceptibility of P. aeruginosa to meropenem and LVFX increased as the FTE increased.
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Affiliation(s)
- Takumi Umemura
- Department of Pharmacy, Tosei General Hospital.,Department of Infection and Prevention, Tosei General Hospital.,College of Pharmacy, Kinjo Gakuin University
| | - Yoshikazu Mutoh
- Department of Infection and Prevention, Tosei General Hospital
| | - Aiko Ota
- Department of Pharmacy, Tosei General Hospital
| | - Yuki Ito
- Department of Pharmacy, Tosei General Hospital
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Prasopchoknapaporn P, Boonsathorn S, Techasaensiri C, Chaisavaneeyakorn S, Apiwattanakul N. Pediatric drug utilization evaluation of cefepime and piperacillin/tazobactam. Pediatr Int 2022; 64:e15276. [PMID: 36257611 DOI: 10.1111/ped.15276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/02/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Drug utilization evaluation (DUE) is a systematic, criteria-based assessment of medicine that aims to optimize the appropriateness of antibiotic prescription. This study aimed to evaluate the performance of the DUE on prescriptions of two commonly used antibiotics in a pediatric population, cefepime and piperacillin/tazobactam, in a tertiary care hospital. METHODS This quasi-experimental study was conducted at the Department of Pediatrics, Ramathibodi Hospital, between March 2020 and August 2021. All hospitalized children aged 1 month to 20 years who received at least one dose of cefepime or piperacillin/tazobactam were enrolled. Before implementing the DUE, cefepime and piperacillin/tazobactam prescriptions were retrospectively evaluated using the DUE criteria. During the 6 month DUE implementation period, physicians voluntarily chose to use DUE to assess the prescriptions' appropriateness. Demographic data, antibiotic use, and clinical data were recorded. RESULTS There were 304 prescriptions of cefepime and piperacillin/tazobactam, with 108 empirical prescriptions (72 patients) in the DUE group and 158 prescriptions (138 patients) in the non-DUE group. The appropriateness of empirical prescriptions of cefepime and piperacillin/tazobactam was significantly higher in the DUE group (93.5% vs. 83.5%; P = 0.003). Drug utilization evaluation was significantly associated with appropriate empirical prescriptions (adjusted OR 5.32: 95% CI 1.80-15.73; P = 0.003). Prescriptions in critical care wards and urinary tract infections (UTIs) were associated with not fulfilling the DUE criteria for appropriateness. CONCLUSIONS Drug utilization evaluation could improve the appropriateness of empirical use of cefepime and piperacillin/tazobactam in pediatric patients. Patients in critical care units and with UTIs appeared to be associated with inappropriate empirical treatment.
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Affiliation(s)
| | - Sophida Boonsathorn
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chonnamet Techasaensiri
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sujittra Chaisavaneeyakorn
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nopporn Apiwattanakul
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Nanayakkara AK, Boucher HW, Fowler VG, Jezek A, Outterson K, Greenberg DE. Antibiotic resistance in the patient with cancer: Escalating challenges and paths forward. CA Cancer J Clin 2021; 71:488-504. [PMID: 34546590 DOI: 10.3322/caac.21697] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/23/2021] [Accepted: 08/12/2021] [Indexed: 12/13/2022] Open
Abstract
Infection is the second leading cause of death in patients with cancer. Loss of efficacy in antibiotics due to antibiotic resistance in bacteria is an urgent threat against the continuing success of cancer therapy. In this review, the authors focus on recent updates on the impact of antibiotic resistance in the cancer setting, particularly on the ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.). This review highlights the health and financial impact of antibiotic resistance in patients with cancer. Furthermore, the authors recommend measures to control the emergence of antibiotic resistance, highlighting the risk factors associated with cancer care. A lack of data in the etiology of infections, specifically in oncology patients in United States, is identified as a concern, and the authors advocate for a centralized and specialized surveillance system for patients with cancer to predict and prevent the emergence of antibiotic resistance. Finding better ways to predict, prevent, and treat antibiotic-resistant infections will have a major positive impact on the care of those with cancer.
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Affiliation(s)
- Amila K Nanayakkara
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, University of Texas Southwestern, Dallas, Texas
| | - Helen W Boucher
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts
| | - Vance G Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Amanda Jezek
- Infectious Diseases Society of America, Arlington, Virginia
| | - Kevin Outterson
- CARB-X, Boston, Massachusetts
- Boston University School of Law, Boston, Massachusetts
| | - David E Greenberg
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, University of Texas Southwestern, Dallas, Texas
- Department of Microbiology, University of Texas Southwestern, Dallas, Texas
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Abstract
OBJECTIVES To formulate new "Choosing Wisely" for Critical Care recommendations that identify best practices to avoid waste and promote value while providing critical care. DATA SOURCES Semistructured narrative literature review and quantitative survey assessments. STUDY SELECTION English language publications that examined critical care practices in relation to reducing cost or waste. DATA EXTRACTION Practices assessed to add no value to critical care were grouped by category. Taskforce assessment, modified Delphi consensus building, and quantitative survey analysis identified eight novel recommendations to avoid wasteful critical care practices. These were submitted to the Society of Critical Care Medicine membership for evaluation and ranking. DATA SYNTHESIS Results from the quantitative Society of Critical Care Medicine membership survey identified the top scoring five of eight recommendations. These five highest ranked recommendations established Society of Critical Care Medicine's Next Five "Choosing" Wisely for Critical Care practices. CONCLUSIONS Five new recommendations to reduce waste and enhance value in the practice of critical care address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care. These recommendations supplement the initial critical care recommendations from the "Choosing Wisely" campaign.
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Moore R, Wattengel BA, Carter MT, Lesse AJ, Sellick JA, Mergenhagen KA. Sputum susceptibilities in a nationwide veteran cohort. Am J Infect Control 2021; 49:995-999. [PMID: 33662473 DOI: 10.1016/j.ajic.2021.02.016] [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: 11/03/2020] [Revised: 02/08/2021] [Accepted: 02/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Respiratory infections are one of the most common causes of morbidity and mortality. This study examined antimicrobial susceptibility of common respiratory isolates from veterans. METHODS Sputum culture data from the Veteran Health Administration were obtained retrospectively between January 2009 and 2019. Cumulative antibiograms were constructed for bacterial isolate susceptibility. RESULTS Sputum and bronchial cultures from approximately 10,345 veterans were included each year. Haemophilus influenzae has maintained high levels of susceptibility to third generation cephalosporins from 2009 (99.7%) to 2018 (97.2%). Third generation cephalosporin susceptibilities amongst Klebsiella pneumoniae have trended upward from 2009 to 2018 as well (79.1% vs 86.4%). In Pseudomonas aeruginosa isolates, there has been an increase in susceptibility rates to cefepime from 2009 to 2018 (79.6%, to 86.6%), gentamicin (81.5% to 89.1%), and piperacillin/tazobactam (86.5% to 90%). Fluoroquinolone susceptibilities amongst Escherichia coli have remained low but stable between 2009 and 2018. Third generation cephalosporin susceptibilities for S. pneumoniae improved slightly from 92.2% to 95% between 2009 and 2018 while susceptibility to azithromycin trended down slightly from 56.8% in 2009 to 51.7% in 2018 for S. pneumoniae. DISCUSSION The antibiogram of sputum isolates from the VA Healthcare System were examined to determine changes in patterns of resistance over a decade of use. CONCLUSIONS This large-scale study investigated nationwide sputum culture susceptibility trends. Avoidance of macrolides for empiric treatment of community acquired pneumonia and avoidance of fluoroquinolones for empiric treatment of hospital acquired or ventilator associated pneumonia may be warranted based on susceptibility trends.
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Ababneh MA, Nasser SA, Rababa'h AM. A systematic review of Antimicrobial Stewardship Program implementation in Middle Eastern countries. Int J Infect Dis 2021; 105:746-752. [PMID: 33737132 DOI: 10.1016/j.ijid.2021.03.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Antimicrobial resistance is a serious threat to global health. Antimicrobial Stewardship Programs (ASPs) are adopted by healthcare systems worldwide. This review aimed to evaluate the published practices of ASPs in Middle Eastern countries. METHODS Searches were carried out in PubMed/MEDLINE, Embase, EBSCO, Cochrane Library, Google, and Google Scholar electronic databases for studies published from January 2005 to December 2020 that assessed ASP practices in Middle Eastern countries, following PRISMA guidelines. RESULTS Of the 422 titles identified, 20 studies met the inclusion criteria. Eight studies were conducted in the Kingdom of Saudi Arabia, five in Qatar, two each in Lebanon and Jordan, and one each in Palestine and UAE; there was also one multinational study. Different ASP practices, including prospective auditing and feedback, pre-authorization, tracking, antibiotic restriction, education, de-escalation, and intravenous-to-oral switch, were reported. ASP practices correlated with improved susceptibility rates and decreases in antimicrobial use. CONCLUSION The outcomes of this review reveal the scarcity of data on ASP practices. The introduction of ASPs in hospitals in Middle Eastern countries has led to favorable clinical effects. Policymakers and stakeholders should promote and invest in implementing these programs as an essential component of their healthcare systems.
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Affiliation(s)
- Mera A Ababneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan.
| | - Sara A Nasser
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Abeer M Rababa'h
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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Agarwal J, Singh V, Das A, Nath SS, Kumar R, Sen M. Reversing the Trend of Antimicrobial Resistance in ICU: Role of Antimicrobial and Diagnostic Stewardship. Indian J Crit Care Med 2021; 25:635-641. [PMID: 34316142 PMCID: PMC8286411 DOI: 10.5005/jp-journals-10071-23861] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Increasing antimicrobial resistance (AMR) among common bacteria combined with the slow development of new antibiotics has posed a challenge to clinicians. Aim and objective To demonstrate whether antimicrobial and diagnostic stewardship program (ASP and DSP)-related interventions improve antibiotic susceptibilities among common bacteria causing bloodstream infections (BSI) in patients admitted to the intensive care unit (ICU) and whether these resulted in changes in the volume of antimicrobial consumption. Materials and methods We compared the susceptibility patterns of gram-negative bacteria (GNB) and gram-positive cocci (GPC) causing BSI and changes in the volume of antibiotics prescribed for the same before and after 2017 by a retrospective analysis. Results Postintervention, there was increased susceptibility of all GNBs to aminoglycosides; Escherichia coli and Klebsiella spp. to beta-lactambeta-lactamase inhibitors (BLBLI) combinations; and Klebsiella spp. and Pseudomonas spp. to carbapenems. Acinetobacter spp., Klebsiella spp., and Pseudomonas spp. showed improved susceptibility to doxycycline, whereas E. coli and Klebsiella spp. showed significantly improved susceptibility to fluoroquinolones. Among GPCs, there was increased susceptibility of Staphylococcus aureus (levofloxacin, clindamycin, and aminoglycoside), coagulase-negative S. aureus (CoNS) (chloramphenicol, levofloxacin, clindamycin, and aminoglycoside), and enterococci (chloramphenicol, levofloxacin, and clindamycin). There was a significant reduction in usage of antimicrobials for the treatment of GPCs (linezolid, doxycycline, chloramphenicol, levofloxacin, BLBLI, macrolide, and cephalosporin) and GNBs (levofloxacin, cephalosporin, carbapenem, and colistin), which caused BSI. Conclusion The present study illustrated that combined ASP and DSP interventions successfully reversed the resistance pattern of organisms causing BSI and resulted in a reduction in antibiotic utilization. How to cite this article Agarwal J, Singh V, Das A, Nath SS, Kumar R, Sen M. Reversing the Trend of Antimicrobial Resistance in ICU: Role of Antimicrobial and Diagnostic Stewardship. Indian J Crit Care Med 2021;25(6):635-641.
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Affiliation(s)
- Jyotsna Agarwal
- Department of Microbiology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vikramjeet Singh
- Department of Microbiology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anupam Das
- Department of Microbiology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Soumya S Nath
- Department of Anaesthesiology and Critical Care, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajeev Kumar
- Department of Critical Care Medicine, Vivekananda Polyclinic Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Manodeep Sen
- Department of Microbiology, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Interrupted time-series analysis to evaluate the impact of a behavioral change outpatient antibiotic stewardship intervention. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e37. [PMID: 36168485 PMCID: PMC9495536 DOI: 10.1017/ash.2021.203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 11/30/2022]
Abstract
Objective: We evaluated the effect of a behaviorally enhanced quality improvement intervention in reducing the number of antibiotic prescriptions written for antibiotic nonresponsive acute respiratory infections (ARIs). A secondary objective was identifying whether a reduction in inappropriate antibiotic prescriptions, if present, persisted after the immediate implementation of the intervention. Design: Nonrandomized, quasi-experimental study conducted from January 2017 through February 2020. Setting: University of California, Davis Health outpatient clinics. In total, 21 pediatric, family, and internal medicine practices in 10 cities and towns were included. Patients: Patients evaluated by a participating physician at an enrolled practice site during the study period with diagnoses (primary and secondary) from the International Classification of Diseases, Tenth Revision codes consistent with antibiotic nonresponsive ARI diagnoses. Intervention: A behaviorally enhanced quality improvement intervention to reduce inappropriate prescribing for antibiotic nonresponsive ARI. Results: In total, 63,028 eligible patient visits across 21 locations were included in the analysis. The most frequently prescribed antibiotic for antibiotic nonresponsive ARI was azithromycin (n = 3,551), followed by amoxicillin (n = 924). Overall, the intervention was associated with an immediate 46% reduction in antibiotic prescriptions for antibiotic nonresponsive ARI (P = .001) following the intervention. We detected no significant change in the month-to-month trend after the intervention was implemented (P = .87), indicating that the reduction was sustained throughout the postintervention period. Conclusion: Our findings demonstrate that a behaviorally enhanced quality improvement intervention to reduce inappropriate prescribing for antibiotic nonresponsive ARI in ambulatory care encounters was successful in reducing potentially inappropriate prescriptions for presumed antibiotic nonresponsive ARI.
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Thabit AK, Shea KM, Guzman OE, Garey KW. Antibiotic utilization within 18 community hospitals in the United States: A 5-year analysis. Pharmacoepidemiol Drug Saf 2020; 30:403-408. [PMID: 33094502 DOI: 10.1002/pds.5156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/12/2020] [Accepted: 10/18/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Antibiotic overuse is associated with antibiotic resistance. We evaluated antibiotic utilization defined by days of therapy/1000 patient days (DOT/1000 PD) in various community hospitals across the United States. METHODS Community hospitals within the Cardinal Health Drug Cost Opportunity Analytics database were evaluated for the availability of DOT/1000 PD data between 2012 to 2016 for overall and specific antibiotic use and the following classes: narrow-spectrum β-lactams (ampicillin, nafcillin, oxacillin, cefazolin, and cephalexin), non-carbapenem antipseudomonal β-lactams (piperacillin/tazobactam, ceftazidime, and cefepime), carbapenems, anti-methicillin-resistant Staphylococcus aureus agents (vancomycin, linezolid, daptomycin, and tigecycline), and fluoroquinolones. Antibiotic utilization and change in utilization during the study period was calculated using linear regression (β coefficient). RESULTS Eighteen hospitals had antibiotic utilization data available. Hospitals were primarily urban (72%) with an average of 209 total beds and 22 intensive care unit beds. Mean number of pharmacists in these hospitals was nine with a mean pharmacist: bed ratio of 0.05. While all hospitals had antimicrobial stewardship programs established during the study period, only 78% and 22% had infectious diseases (ID) physician and ID pharmacist on staff, respectively. A decrease in antipseudomonal β-lactams (excluding carbapenems) and fluoroquinolones was observed (β coefficients = -1.2 and -2.6, respectively), all other antibiotic classes had increased utilization. CONCLUSION Overall antibiotic utilization increased over 5 years. The increase in narrow-spectrum β-lactams utilization along with the reduction in the use of antipseudomonal β-lactams and fluoroquinolones indicate appropriate antimicrobial stewardship. Institutional antibiotic utilization should be evaluated for appropriateness to limit the overuse of broad-spectrum antibiotics in an effort to reduce resistance development.
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Affiliation(s)
- Abrar K Thabit
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.,Cardinal Health, Houston, Texas, USA.,University of Houston College of Pharmacy, Houston, Texas, USA
| | | | | | - Kevin W Garey
- University of Houston College of Pharmacy, Houston, Texas, USA
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Haque M, McKimm J, Sartelli M, Dhingra S, Labricciosa FM, Islam S, Jahan D, Nusrat T, Chowdhury TS, Coccolini F, Iskandar K, Catena F, Charan J. Strategies to Prevent Healthcare-Associated Infections: A Narrative Overview. Risk Manag Healthc Policy 2020; 13:1765-1780. [PMID: 33061710 PMCID: PMC7532064 DOI: 10.2147/rmhp.s269315] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/09/2020] [Indexed: 12/13/2022] Open
Abstract
Healthcare-associated infections (HCAIs) are a major source of morbidity and mortality and are the second most prevalent cause of death. Furthermore, it has been reported that for every one-hundred patients admitted to hospital, seven patients in high-income economies and ten in emerging and low-income economies acquire at least one type of HCAI. Currently, almost all pathogenic microorganisms have developed antimicrobial resistance, and few new antimicrobials are being developed and brought to market. The literature search for this narrative review was performed by searching bibliographic databases (including Google Scholar and PubMed) using the search terms: "Strategies," "Prevention," and "Healthcare-Associated Infections," followed by snowballing references cited by critical articles. We found that although hand hygiene is a centuries-old concept, it is still the primary strategy used around the world to prevent HCAIs. It forms one of a bundle of approaches used to clean and maintain a safe hospital environment and to stop the transmission of contagious and infectious microorganisms, including multidrug-resistant microbes. Finally, antibiotic stewardship also has a crucial role in reducing the impact of HCAIs through conserving currently available antimicrobials.
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Affiliation(s)
- Mainul Haque
- Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur 57000, Malaysia
| | - Judy McKimm
- Medical Education, Swansea University School of Medicine, Grove Building, Swansea University, Swansea, Wales SA2 8PP, UK
| | - Massimo Sartelli
- Department of General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Sameer Dhingra
- School of Pharmacy, The University of the West Indies, St. Augustine Campus, Faculty of Medical Sciences, Eric Williams Medical Sciences Complex, Uriah Butler Highway, Trinidad & Tobago, West Indies
| | | | - Salequl Islam
- Department of Microbiology, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh
| | - Dilshad Jahan
- Department of Hematology, Asgar Ali Hospital, Dhaka 1204, Bangladesh
| | - Tanzina Nusrat
- Department of Microbiology, Chittagong Medical College, Chattogram 4203, Bangladesh
| | | | - Federico Coccolini
- Department of General Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Katia Iskandar
- School of Pharmacy, Lebanese University, Beirut, Lebanon
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Jaykaran Charan
- Department of Pharmacology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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15
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Mathew P, Ranjalkar J, Chandy SJ. Challenges in Implementing Antimicrobial Stewardship Programmes at Secondary Level Hospitals in India: An Exploratory Study. Front Public Health 2020; 8:493904. [PMID: 33072690 PMCID: PMC7531198 DOI: 10.3389/fpubh.2020.493904] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 08/17/2020] [Indexed: 01/23/2023] Open
Abstract
Introduction: Implementing a sustainable and effective Antimicrobial Stewardship (AMS) programme in secondary level hospitals, in Low-Middle Income Country (LMIC) contexts, has numerous challenges. It is important to understand these challenges so that the stewardship initiatives can be tailored according to the unique requirements thrown up by these healthcare facilities. This study explores the experiences of implementing AMS in secondary level hospitals in the state of Kerala, India. Methods: A qualitative study was planned to map the challenges in implementing AMS in the secondary level hospitals. Toward the end of the 1 year followup period, the nodal officers at each hospital were interviewed using a semi-structured interview guide. The in-depth interviews were transcribed and later subjected to content analysis using N-Vivo 11.0, a popular software tool used for qualitative analysis. Results: Many physicians cite perceived patient satisfaction as one of the reasons for increased antibiotic use, as many patients consider antibiotics as standard of care. Also, the distance traveled by the patient and advancing age are factors which increase antibiotic use. The physician factors which determine use include empiric treatment needs, outbreak of diseases, absence of education programmes in antibiotic usage to fill in the knowledge gap and fear of litigation. The promotional activities by companies and antibiotics being a major source of income for small hospitals, affects use patterns. The factors which determine antibiotic selection includes conformism, experience of the physician, perceived resistance to certain antibiotics, emergence of specific diseases, and promotional activities related to antimicrobial agents. The challenges in implementing a sustainable stewardship programme is multifactorial. It includes competition between doctors, time constraints faced by physicians, absence of a champion, sub-optimal interdepartmental cooperation, absence of supporting facilities, dysfunctional regulatory systems, and unreliability of antibiograms. Discussion: AMS in resource-limited setting is going to be a challenge, especially in terms of financing, access to technologies and capacity building. Political and regulatory willpower of international partnerships should be effectively harnessed for designing solutions for LMIC contexts. Also, models for stewardship from elsewhere should undergo an adaptation process before implementation in low resource settings.
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Affiliation(s)
- Philip Mathew
- ReAct Asia Pacific, Department of Community Medicine, Pushpagiri Institute of Medical Sciences, Thiruvalla, India
| | - Jaya Ranjalkar
- ReAct Asia Pacific, Pharmacology and Clinical Pharmacology, Christian Medical College, Vellore, India
| | - Sujith John Chandy
- ReAct Asia Pacific, Pharmacology and Clinical Pharmacology, Christian Medical College, Vellore, India
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16
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Mutua F, Sharma G, Grace D, Bandyopadhyay S, Shome B, Lindahl J. A review of animal health and drug use practices in India, and their possible link to antimicrobial resistance. Antimicrob Resist Infect Control 2020; 9:103. [PMID: 32641109 PMCID: PMC7346624 DOI: 10.1186/s13756-020-00760-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 06/14/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Livestock production, particularly the dairy sector, is important for food and nutritional wellbeing of communities in India, it supports livelihoods of many farmers, and contributes to the economy of the country. India is a high consumer of antibiotics and antimicrobial resistant (AMR) bacteria are a major public health concern. OBJECTIVES Our objectives were to identify animal health and drug use practices that may contribute to emergence and spread of AMR in the country, review previous AMR- mitigation strategies, and discuss "theory of change" as an approach to informing the choice of interventions. METHODS We undertook a desk review of literature to identify practices with potential to contribute to emergence and spread of antimicrobial resistance in India. Searches were done in PubMed, Google scholar, and Google. Data were synthesized and discussed by themes. RESULTS Animal disease surveillance is less developed and infrastructure to support delivery of services is inadequate. Several groups are known to offer animal health services. The untrained "animal health workers" and para-veterinarians are more popular with farmers as they charge less for consultations (compared to veterinarians who are few and charge more). Over-the-counter access of antibiotics, without prescription, and direct marketing of drugs to farmers are common. Because of this, farmers are able to treat their animals and only consult when cases become non- responsive to treatment. Antibiotics are mostly used in management of mastitis cases. Drug withdrawal periods are rarely observed and occurrence of antibiotic- contaminated milk has been reported. Awareness on AMR is low and antimicrobial stewardship in livestock is yet to be developed. Initiatives such as the National programme for containment of AMR, National Action Plan on AMR, and the National Health policy point to government's commitment in addressing the problem of AMR in the country. CONCLUSION Several animal health and drug use practices, with potential to cause AMR, have been described, and their contribution can be discussed further by engaging stakeholders in a "theory of change" exercise. Interventions that address AMR from the animal health perspective should be promoted, and incentives to increase their adoption explored.
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Affiliation(s)
- Florence Mutua
- International Livestock Research Institute, P. O. Box 30709, Nairobi, 00100, Kenya.
| | - Garima Sharma
- International Livestock Research Institute, P. O. Box 30709, Nairobi, 00100, Kenya
- Zoonoses Science Centre, Uppsala University, P. O. Box 70790, SE 750 07, Uppsala, Sweden
| | - Delia Grace
- International Livestock Research Institute, P. O. Box 30709, Nairobi, 00100, Kenya
| | - Samiran Bandyopadhyay
- Indian Veterinary Research Institute, Eastern Regional Station, 37 Belgachia Road, Kolkata, 700 037, India
| | - Bibek Shome
- National Institute of Veterinary Epidemiology and Disease Informatics, Bangalore, India
| | - Johanna Lindahl
- International Livestock Research Institute, P. O. Box 30709, Nairobi, 00100, Kenya
- Zoonoses Science Centre, Uppsala University, P. O. Box 70790, SE 750 07, Uppsala, Sweden
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, P. O. Box 70790, SE 750 07, Uppsala, Sweden
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Masich AM, Vega AD, Callahan P, Herbert A, Fwoloshi S, Zulu PM, Chanda D, Chola U, Mulenga L, Hachaambwa L, Pandit NS, Heil EL, Claassen CW. Antimicrobial usage at a large teaching hospital in Lusaka, Zambia. PLoS One 2020; 15:e0228555. [PMID: 32040513 PMCID: PMC7010251 DOI: 10.1371/journal.pone.0228555] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 01/17/2020] [Indexed: 12/19/2022] Open
Abstract
Antimicrobial resistance is a growing global health concern. Antimicrobial stewardship (AMS) curbs resistance rates by encouraging rational antimicrobial use. However, data on antimicrobial stewardship in developing countries is scarce. The objective of this study was to characterize antimicrobial use at the University Teaching Hospital (UTH) in Lusaka, Zambia as a guiding step in the development of an AMS program. This was a cross-sectional, observational study evaluating antimicrobial appropriateness and consumption in non-critically ill adult medicine patients admitted to UTH. Appropriateness was defined as a composite measure based upon daily chart review. Sixty percent (88/146) of all adult patients admitted to the general wards had at least one antimicrobial ordered and were included in this study. The most commonly treated infectious diseases were tuberculosis, pneumonia, and septicemia. Treatment of drug sensitive tuberculosis is standardized in a four-drug combination pill of rifampicin, isoniazid, pyrazinamide and ethambutol, therefore appropriateness of therapy was not further evaluated. The most common antimicrobials ordered were cefotaxime (n = 45), ceftriaxone (n = 28), and metronidazole (n = 14). Overall, 67% of antimicrobial orders were inappropriately prescribed to some extent, largely driven by incorrect dose or frequency in patients with renal dysfunction. Antimicrobial prescribing among hospitalized patients at UTH is common and there is room for optimization of a majority of antimicrobial orders. Availability of certain antimicrobials must be taken into consideration during AMS program development.
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Affiliation(s)
- Anne M. Masich
- Virginia Commonwealth University Health System, Richmond, Virginia, United States of America
| | - Ana D. Vega
- Jackson Health System, Miami, Florida, United States of America
| | - Patricia Callahan
- University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
| | - Amber Herbert
- University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Sombo Fwoloshi
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, Zambia
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, Zambia
| | - Paul M. Zulu
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, Zambia
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, Zambia
| | - Duncan Chanda
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, Zambia
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, Zambia
| | - Uchizi Chola
- Department of Pharmacy, University Teaching Hospital, Lusaka, Zambia
| | - Lloyd Mulenga
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, Zambia
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, Zambia
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health, Nashville, Tennessee, United States of America
- Ministry of Health, Ndeke House, Lusaka, Zambia
| | - Lottie Hachaambwa
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, Zambia
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, Zambia
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Neha S. Pandit
- University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
| | - Emily L. Heil
- University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
| | - Cassidy W. Claassen
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, Zambia
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, Zambia
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Division of Infectious Diseases, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
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18
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Knight GM, Davies NG, Colijn C, Coll F, Donker T, Gifford DR, Glover RE, Jit M, Klemm E, Lehtinen S, Lindsay JA, Lipsitch M, Llewelyn MJ, Mateus ALP, Robotham JV, Sharland M, Stekel D, Yakob L, Atkins KE. Mathematical modelling for antibiotic resistance control policy: do we know enough? BMC Infect Dis 2019; 19:1011. [PMID: 31783803 PMCID: PMC6884858 DOI: 10.1186/s12879-019-4630-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 11/11/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Antibiotics remain the cornerstone of modern medicine. Yet there exists an inherent dilemma in their use: we are able to prevent harm by administering antibiotic treatment as necessary to both humans and animals, but we must be mindful of limiting the spread of resistance and safeguarding the efficacy of antibiotics for current and future generations. Policies that strike the right balance must be informed by a transparent rationale that relies on a robust evidence base. MAIN TEXT One way to generate the evidence base needed to inform policies for managing antibiotic resistance is by using mathematical models. These models can distil the key drivers of the dynamics of resistance transmission from complex infection and evolutionary processes, as well as predict likely responses to policy change in silico. Here, we ask whether we know enough about antibiotic resistance for mathematical modelling to robustly and effectively inform policy. We consider in turn the challenges associated with capturing antibiotic resistance evolution using mathematical models, and with translating mathematical modelling evidence into policy. CONCLUSIONS We suggest that in spite of promising advances, we lack a complete understanding of key principles. From this we advocate for priority areas of future empirical and theoretical research.
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Affiliation(s)
- Gwenan M Knight
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, UK.
| | - Nicholas G Davies
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Caroline Colijn
- Department of Mathematics, Simon Fraser University, Burnaby, Canada
| | - Francesc Coll
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Tjibbe Donker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Danna R Gifford
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Rebecca E Glover
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, LSHTM, London, UK
| | - Mark Jit
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | | | - Sonja Lehtinen
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jodi A Lindsay
- Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, UK
| | - Marc Lipsitch
- Center for Communicable Disease Dynamics, Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Martin J Llewelyn
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Ana L P Mateus
- Population Sciences and Pathobiology Department, Royal Veterinary College, London, UK
| | - Julie V Robotham
- Modelling and Economics Unit, National Infection Service, Public Health England, London, UK
| | - Mike Sharland
- Paediatric Infectious Disease Research Group, St George's University of London, London, UK
| | - Dov Stekel
- School of Biosciences, University of Nottingham, Loughborough, UK
| | - Laith Yakob
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, LSHTM, London, UK
| | - Katherine E Atkins
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, UK
- Centre for Global Health Research, Usher Institute for Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
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Al-Qahtani SM, Baffoe-Bonnie H, El-Saed A, Alshamrani M, Algwizani A, Alaklabi A, AlJoudi K, Albaalharith N, Mohammed A, Hussain S, Balkhy HH. Appropriateness of antimicrobial use among septic patients managed by the critical care response team: an opportunity for improvement through de-escalation. Antimicrob Resist Infect Control 2019; 8:186. [PMID: 31832186 PMCID: PMC6869254 DOI: 10.1186/s13756-019-0609-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 09/21/2019] [Indexed: 01/09/2023] Open
Abstract
Background Most septic patients managed by critical care response teams (CCRT) are prescribed antimicrobials. Nevertheless, data evaluating their appropriateness are lacking both locally and internationally. The objective was to assess antimicrobial use among septic and non-septic patients managed by CCRT. Setting Case-control design was used to compare septic (cases) and non-septic (controls) CCRT patients at tertiary care setting. The frequency of antimicrobial use was assessed before and after CCRT activation. The appropriateness of antimicrobial use was assessed at day four post-CCRT, based on standard recommendations, clinical assessment, and culture results. Main results A total of 157 cases and 158 controls were included. The average age was 61.1 ± 20.4 years, and 54.6% were males, with minor differences between groups. The use of any antimicrobial was 100.0% in cases and 87.3% in controls (p < 0.001). The use of meropenem (68.2% versus 34.8%, p < 0.001) and vancomycin (56.7% versus 25.9%, p < 0.001) were markedly higher in cases than controls. The overall appropriateness was significantly lower in cases than controls (50.7% versus 59.6%, p = 0.047). Individual appropriateness was lowest with meropenem (16.7%) and imipenem (25.0%), and highest with piperacillin/tazobactam (87.1%) and colistin (78.3%). Only 48.5% of antimicrobials prescribed by CCRT were de-escalated by a primary team within four days. Individual appropriateness and de-escalations were not different between groups. Conclusions Empiric use and inadequate de-escalation of broad-spectrum antimicrobials were major causes for inappropriate antimicrobial use in CCRT patients. Our findings highlight the necessity of urgent implementation of an antimicrobial stewardship program, including training and auditing of antimicrobial prescriptions.
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Affiliation(s)
- Saad M Al-Qahtani
- 1Intensive Care Medicine Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Henry Baffoe-Bonnie
- 3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Aiman El-Saed
- 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Majid Alshamrani
- 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | - Ali Alaklabi
- 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,5Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Khuloud AlJoudi
- 6Pharmacy Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Nahlah Albaalharith
- 1Intensive Care Medicine Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Azzam Mohammed
- 3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Sajid Hussain
- 1Intensive Care Medicine Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hanan H Balkhy
- 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,3Infection Prevention and Control Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,7King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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20
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Impact of an Antimicrobial Stewardship Intervention on Within- and Between-Patient Daptomycin Resistance Evolution in Vancomycin-Resistant Enterococcus faecium. Antimicrob Agents Chemother 2019; 63:AAC.01800-18. [PMID: 30718245 DOI: 10.1128/aac.01800-18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 01/17/2019] [Indexed: 12/14/2022] Open
Abstract
Vancomycin-resistant Enterococcus (VRE) is a leading cause of hospital-acquired infection, with limited treatment options. Resistance to one of the few remaining drugs, daptomycin, is a growing clinical problem and has previously been described in this hospital. In response to increasing resistance, an antimicrobial stewardship intervention was implemented to reduce hospital-wide use of daptomycin. To assess the impact of the intervention, daptomycin prescribing patterns and clinically reported culture results from vancomycin-resistant Enterococcus faecium (VREfm) bloodstream infections (BSIs) from 2011 through 2017 were retrospectively extracted and the impact of the intervention was estimated using interrupted time series analysis (ITS). We corrected for a change in MIC determination methodology by retesting 262 isolates using Etest and broth microdilution. Hospital-wide and within-patient resistance patterns of corrected daptomycin MICs are reported. Our data show that daptomycin prescriptions decreased from an average of 287 days of therapy/month preintervention to 151 days of therapy/month postintervention. Concurrently, the proportion of patients experiencing an increase in daptomycin MIC during an infection declined from 14.6% (7/48 patients) in 2014 to 1.9% (1/54 patients) in 2017. Hospital-wide resistance to daptomycin also decreased in the postintervention period, but this was not maintained. This study shows that an antimicrobial stewardship-guided intervention reduced daptomycin use and improved individual level outcomes but had only transient impact on the hospital-level trend.
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21
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Harder T, Eckmanns T, Schmidt N, Kern W, Sin MA. Human resources estimates for antibiotic stewardship teams: evidence-based approaches for recommendations are needed. Clin Microbiol Infect 2018; 24:554-556. [DOI: 10.1016/j.cmi.2017.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 10/18/2022]
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Pitiriga V, Dimitroulia E, Saroglou G, Tsakris A. The challenge of curbing aminoglycoside resistance: can antimicrobial stewardship programs play a critical role? Expert Rev Anti Infect Ther 2017; 15:947-954. [DOI: 10.1080/14787210.2017.1382355] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Vassiliki Pitiriga
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelia Dimitroulia
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Saroglou
- Department of Internal Medicine, Metropolitan General Hospital, Piraeus, Greece
| | - Athanassios Tsakris
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Deak E, Marlowe EM. Right-Sizing Technology in the Era of Consumer-Driven Health Care. CLINICAL MICROBIOLOGY NEWSLETTER 2017; 39:115-123. [PMID: 32287687 PMCID: PMC7132510 DOI: 10.1016/j.clinmicnews.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Technology for modern clinical and public health microbiology laboratories has evolved at an impressive rate over the last two decades. Contemporary diagnostics can rapidly provide powerful data that can impact patient lives and support infectious disease outbreak investigations. At the same time, dramatic changes to health care delivery are putting new pressures on a system that is now focusing on patient-centric, value-driven, convenient care. For laboratories, balancing all these demands in a cost-contained environment remains a challenge. This article explores the current and future directions of diagnostics in our dynamic health care environment.
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Affiliation(s)
- Eszter Deak
- The Permanente Medical Group, Regional Laboratories, Berkeley, California
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Bondarenka CM, Bosso JA. Successful Implementation of an Antimicrobial Stewardship Program at an Academic Medical Center. Hosp Pharm 2017; 52:508-513. [PMID: 29276281 DOI: 10.1177/0018578717721535] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Focus on antimicrobial use and infection prevention from accrediting or regulatory bodies such as the Joint Commission, as well as regulatory agencies such as the Centers for Medicare and Medicaid Services and the Centers for Disease Control, has highlighted the need for continuing development of antimicrobial stewardship programs at healthcare facilities across the country. Methods: Our institution utilized the 2007 Infectious Diseases Society of America and the Society for Healthcare Epidemiology guidelines to direct the evaluation of its antimicrobial use and develop a successful antimicrobial stewardship program. Three baseline evaluations were conducted. Retrospective chart reviews evaluating formulary restrictions for fluroquinolones and carbepenems, a dosing optimization program for meropenem, and the intravenous to oral conversion program for fluconazole and voriconazole were completed. Results: Approximately 40% of orders for levofloxacin were not supported with a clinical justification for nonformulary use in the patient chart. Forty-nine percent of orders written for meropenem did not follow the dose optimization program. Opportunity for fluconazole and voriconazole to be converted to oral therapy when appropriate was suggested. Conclusion: The baseline evaluations revealed the need for an antimicrobial stewardship program. This article outlines the process used to assess need, plan, implement, and evaluate the impact of an antimicrobial stewardship program.
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Affiliation(s)
| | - John A Bosso
- Medical University of South Carolina, Charleston, USA
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