A whole-health-economy approach to antimicrobial stewardship: Analysis of current models and future direction

Improving Antibiotic Stewardship in a Pediatric Long-term Care Facility

OBJECTIVES

Antimicrobial stewardship is little studied in pediatric long-term care facilities. We sought to determine whether empirical ciprofloxacin for febrile respiratory illnesses could be safely reduced in our pediatric long-term care facility.

METHODS

All patients living in the 45-bed facility were included. A 1-year educational intervention for antimicrobial stewardship was implemented. Days of ciprofloxacin therapy, infections, microbiology, hospitalizations, other antibiotic use, methicillin-resistant Staphylococcus aureus and Clostridioides difficile infections, and mortality were recorded at regular intervals retrospectively from 5 years before intervention and prospectively for 8 years after intervention. Data were analyzed using statistical process control charts.

RESULTS

A majority of patients had tracheostomy tubes (96%) and ventilator dependence (58%). Ciprofloxacin use declined by 76% (17 to 4 days/1000 facility patient days). Antibiotic prescriptions for bacterial tracheitis decreased by 89% (38 to 4 courses per 6-month period). No increases in positive blood or urine cultures, hospitalizations, or need for hospital antibiotics were observed.

CONCLUSIONS

An antimicrobial stewardship intervention in a pediatric long-term care facility led to decreases in ciprofloxacin use, bacterial tracheitis diagnoses, and overall antibiotic use without increasing negative outcomes.

Healthcare as a driver, reservoir and amplifier of antimicrobial resistance: opportunities for interventions

Antimicrobial resistance (AMR) is a global health challenge that threatens humans, animals and the environment. Evidence is emerging for a role of healthcare infrastructure, environments and patient pathways in promoting and maintaining AMR via direct and indirect mechanisms. Advances in vaccination and monoclonal antibody therapies together with integrated surveillance, rapid diagnostics, targeted antimicrobial therapy and infection control measures offer opportunities to address healthcare-associated AMR risks more effectively. Additionally, innovations in artificial intelligence, data linkage and intelligent systems can be used to better predict and reduce AMR and improve healthcare resilience. In this Review, we examine the mechanisms by which healthcare functions as a driver, reservoir and amplifier of AMR, contextualized within a One Health framework. We also explore the opportunities and innovative solutions that can be used to combat AMR throughout the patient journey. We provide a perspective on the current evidence for the effectiveness of interventions designed to mitigate healthcare-associated AMR and promote healthcare resilience within high-income and resource-limited settings, as well as the challenges associated with their implementation.

Institutional governance and responsiveness to antimicrobial resistance: a qualitative study of Australian hospital executives

OBJECTIVES

Despite escalating antimicrobial resistance (AMR), implementing effective antimicrobial optimisation within healthcare settings has been hampered by institutional impediments. This study sought to examine, from a hospital management and governance perspective, why healthcare providers may find it challenging to enact changes needed to address rising AMR.

DESIGN

Semistructured qualitative interviews around their experiences of antimicrobial stewardship (AMS) and responsiveness to the requirement for optimisation. Data were analysed using the framework approach.

SETTING

Two metropolitan tertiary-referral hospitals in Australia.

PARTICIPANTS

Twenty hospital managers and executives from the organisational level of department head and above, spanning a range of professional backgrounds and in both clinical and non-clinical roles, and different professional streams were represented.

RESULTS

Thematic analysis demonstrated three key domains which managers and executives describe, and which might function to delimit institutional responsiveness to present and future AMR solutions. First, the primacy of 'political' priorities. AMR was perceived as a secondary priority, overshadowed by political priorities determined beyond the hospital by state health departments/ministries and election cycles. Second, the limits of accreditation as a mechanism for change. Hospital accreditation processes and regulatory structures were not sufficient to induce efficacious AMS. Third, a culture of acute problem 'solving' rather than future proofing. A culture of reactivity was described across government and healthcare institutions, precluding longer term objectives, like addressing the AMR crisis.

CONCLUSION

There are dynamics between political and health service institutions, as well as enduring governance norms, that may significantly shape capacity to enact AMS and respond to AMR. Until these issues are addressed, and the field moves beyond individual behaviour modification models, antimicrobial misuse will likely continue, and stewardship is likely to have a limited impact.

Antimicrobial Stewardship Activities in Public Healthcare Facilities in South Africa: A Baseline for Future Direction

Antimicrobial resistance (AMR) is a growing problem worldwide, including South Africa, where an AMR National Strategy Framework was implemented to instigate antimicrobial stewardship programmes (ASPs) and improve antimicrobial prescribing across sectors. To address the need to assess progress, a sequential mixed methodology with an explanatory research design was employed. In Phase 1, a self-administered questionnaire was completed by healthcare professionals (HCPs) from 26 public sector healthcare facilities across South Africa to assess compliance with the Framework. The results were explored in Phase 2 through 10 focus group discussions and two in-depth interviews, including 83 participants. Emerging themes indicated that public healthcare facilities across South Africa are facing many challenges, especially at entry level primary healthcare (PHC) facilities, where antimicrobial stewardship activities and ASPs are not yet fully implemented. Improved diagnostics and surveillance data are a major shortcoming at these facilities. Continuous education for HCPs is deficient, especially for the majority of prescribers at PHC level and health campaigns are nearly non-existent. Involvement and visibility of management at certain facilities is a serious shortfall. Consequently, it is important to call attention to the challenges faced with improving antimicrobial prescribing across countries and address these to reduce AMR, especially in PHC facilities, being the first point of access to healthcare for the vast majority of patients in developing countries.

Optimising antimicrobial use in humans - review of current evidence and an interdisciplinary consensus on key priorities for research

Addressing the silent pandemic of antimicrobial resistance (AMR) is a focus of the 2021 G7 meeting. A major driver of AMR and poor clinical outcomes is suboptimal antimicrobial use. Current research in AMR is inequitably focused on new drug development. To achieve antimicrobial security we need to balance AMR research efforts between development of new agents and strategies to preserve the efficacy and maximise effectiveness of existing agents. Combining a review of current evidence and multistage engagement with diverse international stakeholders (including those in healthcare, public health, research, patient advocacy and policy) we identified research priorities for optimising antimicrobial use in humans across four broad themes: policy and strategic planning; medicines management and prescribing systems; technology to optimise prescribing; and context, culture and behaviours. Sustainable progress depends on: developing economic and contextually appropriate interventions; facilitating better use of data and prescribing systems across healthcare settings; supporting appropriate and scalable technological innovation. Implementing this strategy for AMR research on the optimisation of antimicrobial use in humans could contribute to equitable global health security.

A computerized decision support system (CDSS) for antibiotic prescription in primary care-Antibioclic: implementation, adoption and sustainable use in the era of extended antimicrobial resistance

OBJECTIVES

To describe the implementation and use of a computerized decision support system (CDSS) for antibiotic prescription in primary care in France (Antibioclic). The CDSS targets 37 infectious diseases and has been freely available on a website since 2011.

METHODS

Description and implementation of the architecture of a CDSS for antibiotic prescription in general practice. Analysis of the queries made between 2012 and 2018 on the CDSS by GPs. Analysis of two cross-sectional studies of users in 2014 and 2019.

RESULTS

The number of queries increased from a median of 796/day [IQR, 578-989] in 2012 to 11 125/day [5592-12 505] in 2018. Unique users increased from 414/day [245-494] in 2012 to 5365/day [2891-5769] in 2018. Time taken to make a query was 2 min [1.9-2.1]. Among 3 542 347 queries in 2018, 78% were for adults. Six situations accounted for ≥50% of queries: cystitis; acute otitis media; acute sinusitis; community-acquired pneumonia; sore throat; and pyelonephritis. Queries concerned pathologies for which antibiotic prescription was necessary (64%), was conditional on additional clinical steps (34%) or was not recommended (2%). Most users (81%) were GPs, with median age of 38 years [31-52] and 58% were female. Among the 4016 GPs who responded to the surveys, the vast majority (96%) reported using the CDSS during the consultation, with 24% systematically using Antibioclic to initiate an antibiotic course and 93% having followed the CDSS recommendation for the latest prescription. Most GPs were comfortable using the CDSS in front of a patient.

CONCLUSIONS

Antibioclic has been adopted and is widely used in primary care in France. Its interoperability could allow its adaptation and implementation in other countries.

Strategies to Improve Antimicrobial Utilization with a Special Focus on Developing Countries

Antimicrobial resistance (AMR) is a high priority across countries as it increases morbidity, mortality and costs. Concerns with AMR have resulted in multiple initiatives internationally, nationally and regionally to enhance appropriate antibiotic utilization across sectors to reduce AMR, with the overuse of antibiotics exacerbated by the COVID-19 pandemic. Effectively tackling AMR is crucial for all countries. Principally a narrative review of ongoing activities across sectors was undertaken to improve antimicrobial use and address issues with vaccines including COVID-19. Point prevalence surveys have been successful in hospitals to identify areas for quality improvement programs, principally centering on antimicrobial stewardship programs. These include reducing prolonged antibiotic use to prevent surgical site infections. Multiple activities centering on education have been successful in reducing inappropriate prescribing and dispensing of antimicrobials in ambulatory care for essentially viral infections such as acute respiratory infections. It is imperative to develop new quality indicators for ambulatory care given current concerns, and instigate programs with clear public health messaging to reduce misinformation, essential for pandemics. Regular access to effective treatments is needed to reduce resistance to treatments for HIV, malaria and tuberculosis. Key stakeholder groups can instigate multiple initiatives to reduce AMR. These need to be followed up.

Organization of antibiotic stewardship in Europe: the way to go

It is more than two decades ago that a European Union conference on "The Microbial Threat" hosted by the Danish Government in Copenhagen in September 1998 issued recommendations to encourage good practice in the use of antimicrobial agents and reduce inappropriate prescribing. Essential components of those recommendations were antimicrobial teams in hospitals and the use of feedback to prescribers as well as educational activities. Two decades later, important surveillance systems on both antimicrobial resistance as well as on antibiotic consumption are functioning at the European level and in most European countries; European Committee on Antimicrobial Susceptibility Testing (EUCAST) has thoroughly re-evaluated, standardized and harmonized antibiotic susceptibility testing and breakpoints; there have been educational activities in many countries; and stewardship teams are now included in many guidelines and policy papers and recommendations. Yet, antimicrobial resistance problems in Europe have shifted from methicillin-resistant Staphylococus aureus (MRSA) to vancomycin-resistent Enterococcus faecium (VRE) and to multidrug-resistant gramnegative bacteria, while antibiotic consumption volumes, trends and patterns across countries do not show major and highly significant improvements. The way to go further is to recognize that better prescribing comes at a cost and requires investment in expert personnel, practice guideline drafting, and implementation aids, and, secondly, the setting of clear goals and quantitative targets for prescribing quality.

Nanotheranostics: A Possible Solution for Drug-Resistant Staphylococcus aureus and their Biofilms?

Staphylococcus aureus is a notorious pathogen that colonizes implants (orthopedic and breast implants) and wounds with a vicious resistance to antibiotic therapy. Methicillin-resistant S. aureus (MRSA) is a catastrophe mainly restricted to hospitals and emerged to community reservoirs, acquiring resistance and forming biofilms. Treating biofilms is problematic except via implant removal or wound debridement. Nanoparticles (NPs) and nanofibers could combat superbugs and biofilms and rapidly diagnose MRSA. Nanotheranostics combine diagnostics and therapeutics into a single agent. This comprehensive review is interpretative, utilizing mainly recent literature (since 2016) besides the older remarkable studies sourced via Google Scholar and PubMed. We unravel the molecular S. aureus resistance and complex biofilm. The diagnostic properties and detailed antibacterial and antibiofilm NP mechanisms are elucidated in exciting stories. We highlight the challenges of bacterial infections nanotheranostics. Finally, we discuss the literature and provide "three action appraisals". (i) The first appraisal consists of preventive actions (two wings), avoiding unnecessary hospital visits, hand hygiene, and legislations against over-the-counter antibiotics as the general preventive wing. Our second recommended preventive wing includes preventing the adverse side effects of the NPs from resistance and toxicity by establishing standard testing procedures. These standard procedures should provide breakpoints of bacteria's susceptibility to NPs and a thorough toxicological examination of every single batch of synthesized NPs. (ii) The second appraisal includes theranostic actions, using nanotheranostics to diagnose and treat MRSA, such as what we call "multifunctional theranostic nanofibers. (iii) The third action appraisal consists of collaborative actions.

Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health

Antimicrobial resistance (AMR) is a serious threat to global public health. It increases morbidity and mortality, and is associated with high economic costs due to its health care burden. Infections with multidrug-resistant (MDR) bacteria also have substantial implications on clinical and economic outcomes. Moreover, increased indiscriminate use of antibiotics during the COVID-19 pandemic will heighten bacterial resistance and ultimately lead to more deaths. This review highlights AMR's scale and consequences, the importance, and implications of an antimicrobial stewardship program (ASP) to fight resistance and protect global health. Antimicrobial stewardship (AMS), an organizational or system-wide health-care strategy, is designed to promote, improve, monitor, and evaluate the rational use of antimicrobials to preserve their future effectiveness, along with the promotion and protection of public health. ASP has been very successful in promoting antimicrobials' appropriate use by implementing evidence-based interventions. The "One Health" approach, a holistic and multisectoral approach, is also needed to address AMR's rising threat. AMS practices, principles, and interventions are critical steps towards containing and mitigating AMR. Evidence-based policies must guide the "One Health" approach, vaccination protocols, health professionals' education, and the public's awareness about AMR.

Advocacy for Increased International Efforts for Antimicrobial Stewardship Actions in Low-and Middle-Income Countries on Behalf of Alliance for the Prudent Use of Antimicrobials (APUA), Under the Auspices of the International Society of Antimicrobial Chemotherapy (ISAC)

Antimicrobial stewardship (AMS) is a set of coordinated strategies to improve the use of antimicrobials, to enhance patient outcomes, reduce antimicrobial resistance, and decrease unnecessary costs. The pioneer years of AMS were restricted to high-income countries (HIC), where overconsumption of antibiotics was associated with emergence of multidrug-resistant (MDR) bacteria. AMS in low- and middle-income countries (LMIC) is also necessary. However, programs effective in HIC may not perform as well in LMIC, because (i) While decreased consumption of antibiotics may be an appropriate target in overconsuming HIC, this may be dangerous in LMIC, where many patients die from the lack of access to antibiotics; (ii) although AMS programs in HIC can be designed and monitored through laboratory surveillance of resistance, surveillance programs are not available in many LMIC; (iii) the heterogeneity of health care systems implies that AMS programs must be carefully contextualized. Despite the need to individually tailor AMS programs in LMIC, international collaborations remain highly valuable, through the dissemination of high-quality documents and educational material, that may be shared, adapted where needed, and adopted worldwide. This process, facilitated by modern communication tools, combines many benefits, including: (i) saving time, a precious dimension for health care workers, by avoiding the duplication of similar works in different settings; (ii) taking advantage of colleagues skills, and initiatives, through open access to the work performed in other parts of the world; (iii) sharing experiences, so that we all learn from each others' successes and failures.

Pharmacist-supported antimicrobial stewardship in a retirement home

In an 80-bed fee-based retirement home with nursing care, the dispatched-pharmacist has provided prescription recommendations to visiting physicians based on pathogen identification using Gram staining as part of an antimicrobial stewardship program. Thus, we evaluated the effects of pharmacist-supported antimicrobial stewardship. We calculated the total number of all antimicrobials and macrolides, fluoroquinolones, and cephalosporins prescriptions per 100 residents per month at the retirement home from January 2013 to December 2017. Using log-transformed monthly resident numbers with an offset before and after the intervention, we performed Poisson regression analyses that adjusted for monthly mean age. Interrupted time series analyses (ITSA) were conducted to examine the changes in the incidence rate ratios for the baseline and slope before and after the intervention. The total number of all antimicrobial prescriptions per 100 residents per month from 2013 to 2017 was 14.10, 18.51, 10.59, 5.41, and 3.90, respectively. Although there was a significant pre-intervention increase in the total number of all antimicrobial prescriptions, the intervention was followed by a significant decrease. There was also a significant reduction in the slope. ITSA of the changes in the prescription of macrolides and fluoroquinolones showed that there were significant pre-intervention increase and followed by a significant post-intervention decrease in the slope. There was no significant change in cephalosporin prescriptions by the intervention. Our study shows that pharmacist-supported AS can reduce antimicrobial prescriptions in a retirement home. Nevertheless, further studies are needed to collect and analyse more data on similar interventions.

Moral and Contextual Dimensions of "Inappropriate" Antibiotic Prescribing in Secondary Care: A Three-Country Interview Study

Overuse of broad-spectrum antibiotics in secondary care is a key contributor to the emergence and spread of antimicrobial resistance (AMR); efforts are focused on minimizing antibiotic overuse as a crucial step toward containing the global threat of AMR. The concept of overtreatment has, however, been difficult to define. Efforts to address the overuse of medicine need to be informed by an understanding of how prescribers themselves understand the problem. We report findings from a qualitative interview study of 46 acute care hospital prescribers differing in seniority from three countries: United Kingdom, Sri Lanka and South Africa. Prescribers were asked about their understanding of inappropriate use of antibiotics. Prescriber definitions of inappropriate use included relatively clear-cut and unambiguous cases of antibiotics being used "incorrectly" (e.g., in the case of viral infections). In many cases, however, antibiotic prescribing decisions were seen as involving uncertainty, with prescribers having to make decisions about the threshold for appropriate use. Decisions about thresholds were commonly framed in moral terms. Some prescribers drew on arguments about their duty to protect public health through having a high threshold for prescribing, while others made strong arguments for prioritizing risk avoidance for the patients in front of them, even at a cost of increased resistance. Notions of whether prescribing was inappropriate were also contextually dependent: high levels of antibiotic prescribing could be seen as a rational response when prescribers were working in challenging contexts, and could be justified in relation to financial and social considerations. Inappropriate antibiotic use is framed by prescribers not just in clinical, but also in moral and contextual terms; this has implications for the design and implementation of antibiotic stewardship interventions aiming to reduce inappropriate use of antibiotics globally.

Strengthening strategic management approaches to address antimicrobial resistance in global human health: a scoping review

Introduction

The development and implementation of national strategic plans is a critical component towards successfully addressing antimicrobial resistance (AMR). This study aimed to review the scope and analytical depth of situation analyses conducted to address AMR in human health to inform the development and implementation of national strategic plans.

Methods

A systematic search of the literature was conducted to identify all studies since 2000, that have employed a situation analysis to address AMR. The included studies are analysed against frameworks for strategic analysis, primarily the PESTELI (Political, Economic, Sociological, Technological, Ecological, Legislative, Industry) framework, to understand the depth, scope and utility of current published approaches.

Results

10 studies were included in the final review ranging from single country (6) to regional-level multicountry studies (4). 8 studies carried out documentary review, and 3 of these also included stakeholder interviews. 2 studies were based on expert opinion with no data collection. No study employed the PESTELI framework. Most studies (9) included analysis of the political domain and 1 study included 6 domains of the framework. Technological and industry analyses is a notable gap. Facilitators and inhibitors within the political and legislative domains were the most frequently reported. No facilitators were reported in the economic or industry domains but featured inhibiting factors including: lack of ring-fenced funding for surveillance, perverse financial incentives, cost-shifting to patients; joint-stock drug company ownership complicating regulations.

Conclusion

The PESTELI framework provides further opportunities to combat AMR using a systematic, strategic management approach, rather than a retrospective view. Future analysis of existing quantitative data with interviews of key strategic and operational stakeholders is needed to provide critical insights about where implementation efforts should be focussed, and also how to build contingency at the strategic level for agile responses to macro-level environmental influences.