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Wang SH, Yang KY, Sheu CC, Lin YC, Chan MC, Feng JY, Chen CM, Chen CY, Zheng ZR, Chou YC, Peng CK. Efficacy of combination therapy with standard-dose carbapenem for treating nosocomial pneumonia caused by carbapenem-resistant Acinetobacter baumannii in intensive care units: A multicentre retrospective propensity score-matched study. Int J Antimicrob Agents 2024; 63:107044. [PMID: 38040319 DOI: 10.1016/j.ijantimicag.2023.107044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 10/22/2023] [Accepted: 11/27/2023] [Indexed: 12/03/2023]
Abstract
Carbapenem-resistant Acinetobacter baumannii (CRAB) infection is common worldwide. Despite carbapenem resistance, standard-dose carbapenems are still used in clinical practice. Hence in this study, we aimed to compare the efficacy and outcomes of a regimen containing standard-dose carbapenems with those of a regimen lacking carbapenems during the treatment of critically ill patients with CRAB nosocomial pneumonia in the intensive care unit (ICU). Initially, 735 patients were recruited for this multicentre retrospective cohort study. After exclusion, time-window bias adjustment, and propensity score matching, multiple clinical outcomes were compared between the carbapenem-containing (CC) (n = 166) and no carbapenem-containing (NCC) (n = 166) groups. The CC group showed a higher risk of clinical failure on day 7 than the NCC group (44.6% vs. 33.1%, P = 0.043). The lengths of ICU stay (21 and 16 days, P = 0.024) and hospital stay (61 and 44 days, P = 0.003) were longer in the CC group than in the NCC group. Multivariate analysis showed that the CC regimen was associated with higher clinical failure (adjusted odds ratio (aOR) = 1.64, 95% CI = 1.05-2.56, P = 0.031) and lower microbiological eradication (aOR = 0.48, 95% CI = 0.23-1.00, P = 0.049) at day 7 than the NCC group. Thus, a regimen containing a standard dose of carbapenem should be prescribed with caution for treating CRAB nosocomial pneumonia in the ICU.
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Affiliation(s)
- Sheng-Huei Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Cancer Progression Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Chao Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Ming-Cheng Chan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; National Chung Hsing University, Taichung, Taiwan
| | - Jia-Yih Feng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chia-Min Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Yu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Zhe-Rong Zheng
- Division of Pulmonary Medicine, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan; Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Ching Chou
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Chung-Kan Peng
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Xu S, Kitchen C, Liu Y, Kabba JA, Hayat K, Wang X, Wang G, Zhang F, Chang J, Fang Y, Wagner AK, Ross-Degnan D. Effect of a national antibiotic stewardship intervention in China targeting carbapenem overuse: An interrupted time-series analysis. Int J Antimicrob Agents 2023; 62:106936. [PMID: 37517625 DOI: 10.1016/j.ijantimicag.2023.106936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/12/2023] [Accepted: 07/26/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES To assess trends and patterns of carbapenem use and to evaluate the effects of a nationwide antibiotic stewardship policy to reduce carbapenem overuse. METHODS In this quasi-experimental study, using longitudinal data from the national drug procurement database and interrupted time-series analyses with carbapenems as the intervention group and possible carbapenem substitutes as the comparison group, we evaluated the effects of a national stewardship policy on carbapenem consumption and expenditures, by region and types of healthcare institutions. RESULTS The carbapenem procurement volume declined by -28.8% (95% CI -35.0 to -22.6) (-334.4 thousand defined daily doses [DDDs] per month), and carbapenem expenditures showed a relative reduction of -38.1% (-43.9 to -32.2). The gap between the use of carbapenems and each drug in the comparison group narrowed after the policy intervention, with an increase in tigecycline use (14.9 thousand DDDs [10.8-18.9]) and a slower decrease in use of certain third-generation cephalosporin combinations (-85.7 [-143.0 to -28.4]), penicillin combinations (-200.9 [-421.4-19.6]), and fourth-generation cephalosporins (-116.9 [-219.8 to -14.0]). Consumption was highest during the pre-policy period, and declines were largest following the intervention in the eastern region (-32.1%, -39.8 to -24.4) and among tertiary hospitals (-266.2 [-339.5 to -192.9] thousand DDDs per month). CONCLUSION This population-level drug utilization research represents the first comprehensive evaluation of the effectiveness of China's nationwide carbapenem stewardship. The national policy targeting carbapenem prescribing has led to a sustained reduction in carbapenem use with limited substitution. Effects varied geographically and were concentrated in tertiary and secondary hospitals.
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Affiliation(s)
- Sen Xu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University; Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Shaanxi, China; Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Chenai Kitchen
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University; Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Shaanxi, China
| | - Yang Liu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts; School of Health Policy and Management, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - John Alimamy Kabba
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University; Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Shaanxi, China
| | - Khezar Hayat
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University; Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Shaanxi, China
| | - Xinyu Wang
- Foshan Women and Children Hospital, Guangdong, China
| | - Geng Wang
- The Third People's Hospital of Datong, Shanxi, China
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Jie Chang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University; Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Shaanxi, China.
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University; Center for Drug Safety and Policy Research, Xi'an Jiaotong University, Shaanxi, China.
| | - Anita K Wagner
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Hamed SM, Elkhatib WF, Brangsch H, Gesraha AS, Moustafa S, Khater DF, Pletz MW, Sprague LD, Neubauer H, Wareth G. Acinetobacter baumannii Global Clone-Specific Resistomes Explored in Clinical Isolates Recovered from Egypt. Antibiotics (Basel) 2023; 12:1149. [PMID: 37508245 PMCID: PMC10376554 DOI: 10.3390/antibiotics12071149] [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: 06/08/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023] Open
Abstract
Acinetobacter baumannii (A. baumannii) is a highly problematic pathogen with an enormous capacity to acquire or upregulate antibiotic drug resistance determinants. The genomic epidemiology and resistome structure of 46 A. baumannii clinical isolates were studied using whole-genome sequencing. The isolates were chosen based on reduced susceptibility to at least three classes of antimicrobial compounds and were initially identified using MALDI-TOF/MS, followed by polymerase chain reaction amplification of blaOXA-51-like genes. The susceptibility profiles were determined using a broth microdilution assay. Multi-, extensive-, and pan-drug resistance was shown by 34.8%, 63.0%, and 2.2% of the isolates, respectively. These were most susceptible to colistin (95.7%), amikacin, and trimethoprim/sulfamethoxazole (32.6% each), while only 26.1% of isolates were susceptible to tigecycline. In silico multi-locus sequence typing revealed 8 Pasteur and 22 Oxford sequence types (STs) including four novel STs (STOxf 2805, 2806, 2807, and 2808). The majority of the isolates belonged to Global Clone (GC) 2 (76.4%), GC5 (19.6%), GC4 (6.5%), GC9 (4.3%), and GC7 (2.2%) lineages. An extensive resistome potentially conferring resistance to the majority of the tested antimicrobials was identified in silico. Of all known carbapenem resistance genes, blaOXA-23 was carried by most of the isolates (69.6%), followed by ISAba1-amplified blaADC (56.5%), blaNDM-1 and blaGES-11 (21.7% each), and blaGES-35 (2.2%) genes. A significant correlation was found between carbapenem resistance and carO mutations, which were evident in 35 (76.0%) isolates. A lower proportion of carbapenem resistance was noted for strains possessing both blaOXA-23- and blaGES-11. Amikacin resistance was most probably mediated by armA, aac(6')-Ib9, and aph(3')-VI, most commonly coexisting in GC2 isolates. No mutations were found in pmrABC or lpxACD operons in the colistin-resistant isolates. Tigecycline resistance was associated with adeS (N268Y) and baeS (A436T) mutations. While the lineage-specific distribution of some genes (e.g., blaADC and blaOXA-51-like alleles) was evident, some resistance genes, such as blaOXA-23 and sul1, were found in all GCs. The data generated here highlight the contribution of five GCs in A. baumannii infections in Egypt and enable the comprehensive analysis of GC-specific resistomes, thus revealing the dissemination of the carbapenem resistance gene blaOXA-23 in isolates encompassing all GCs.
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Affiliation(s)
- Samira M Hamed
- Department of Microbiology and Immunology, Faculty of Pharmacy, October University for Modern Sciences and Arts (MSA), Giza 12451, Egypt
| | - Walid F Elkhatib
- Microbiology and Immunology Department, Faculty of Pharmacy, Ain Shams University, African Union Organization Street, Cairo 11566, Egypt
- Department of Microbiology and Immunology, Faculty of Pharmacy, Galala University, Suez 43727, Egypt
| | - Hanka Brangsch
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler Institut, 07743 Jena, Germany
| | - Ahmed S Gesraha
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Tanta University, Tanta 31511, Egypt
| | - Shawky Moustafa
- Faculty of Veterinary Medicine, Benha University, Toukh 13736, Egypt
| | - Dalia F Khater
- Tanta Laboratory, Animal Health Research Institute, Agricultural Research Center, Tanta 31511, Egypt
| | - Mathias W Pletz
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, 07747 Jena, Germany
| | - Lisa D Sprague
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler Institut, 07743 Jena, Germany
| | - Heinrich Neubauer
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler Institut, 07743 Jena, Germany
| | - Gamal Wareth
- Institute of Bacterial Infections and Zoonoses, Friedrich-Loeffler Institut, 07743 Jena, Germany
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, 07747 Jena, Germany
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Wi YM, Kwon KT, Jeon CH, Kim SH, Hwang S, Bae S, Kim Y, Chang HH, Kim SW, Cheong HS, Lee S, Jung DS, Sohn KM, Moon C, Heo ST, Kim B, Lee MS, Hur J, Kim J, Yoon YK. Carbapenem Use in the Last Days of Life: A Nationwide Korean Study. Antibiotics (Basel) 2023; 12:964. [PMID: 37370283 DOI: 10.3390/antibiotics12060964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/09/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023] Open
Abstract
The appropriate use of carbapenem is a critical concern for patient safety and public health, and is a national priority. We investigated the nationwide status of carbapenem prescription in patients within their last 14 days of life to guide judicious-use protocols from the previous study comprised of 1350 decedents. Carbapenem use was universally controlled through computerised authorisation system at all centres during the study period. Carbapenem prescribing patterns and their optimality were evaluated. A total of 1201 patients received antimicrobial agents within the last two weeks of their lives, of whom 533 (44.4%) received at least one carbapenem. The median carbapenem treatment duration was seven days. Of the 533 patients receiving carbapenems, 510 (95.7%) patients had microbiological samples drawn and 196 (36.8%) yielded carbapenem-resistant pathogens. A total of 200 (37.5%) patients were referred to infectious disease (ID) specialists. Of the 333 patients (62.5%) who did not have ID consultations, 194 (58.2%) were assessed as "not optimal", 79 (23.7%) required escalation, 100 (30.0%) required de-escalation, and 15 (4.5%) were discontinued. Notwithstanding the existing antibiotic restriction program system, carbapenems are commonly prescribed to patients in their last days of life.
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Affiliation(s)
- Yu Mi Wi
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu 41404, Republic of Korea
| | - Cheon-Hoo Jeon
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea
| | - Si-Ho Kim
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea
| | - Soyoon Hwang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu 41404, Republic of Korea
| | - Sohyun Bae
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Yoonjung Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Hyun-Ha Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Shin-Woo Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Hae Suk Cheong
- Division of Infectious Diseases, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul 03181, Republic of Korea
| | - Shinwon Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, Busan 50612, Republic of Korea
| | - Dong Sik Jung
- Department of Internal Medicine, Dong-A University College of Medicine, Busan 49201, Republic of Korea
| | - Kyung Mok Sohn
- Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon 35015, Republic of Korea
| | - Chisook Moon
- Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan 47392, Republic of Korea
| | - Sang Taek Heo
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Jeju National University, Jeju 63241, Republic of Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Republic of Korea
| | - Mi Suk Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul 02447, Republic of Korea
| | - Jian Hur
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu 42415, Republic of Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Republic of Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, Republic of Korea
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Wi YM, Kwon KT, Hwang S, Bae S, Kim Y, Chang HH, Kim SW, Cheong HS, Lee S, Jung DS, Sohn KM, Moon C, Heo ST, Kim B, Lee MS, Hur J, Kim J, Yoon YK. Use of Antibiotics Within the Last 14 Days of Life in Korean Patients: A Nationwide Study. J Korean Med Sci 2023; 38:e66. [PMID: 36880107 PMCID: PMC9988432 DOI: 10.3346/jkms.2023.38.e66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/06/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Antimicrobial prescriptions for serious chronic or acute illness nearing its end stages raise concerns about the potential for futile use, adverse events, increased multidrug-resistant organisms, and significant patient and social cost burdens. This study investigated the nationwide situation of how antibiotics are prescribed to patients during the last 14 days of life to guide future actions. METHODS This nationwide multicenter retrospective cohort study was conducted at 13 hospitals in South Korea from November 1 to December 31, 2018. All decedents were included in the study. Antibiotic use during the last two weeks of their lives was investigated. RESULTS A total of 1,201 (88.9%) patients received a median of two antimicrobial agents during the last two weeks of their lives. Carbapenems were prescribed to approximately half of the patients (44.4%) in the highest amount (301.2 days of therapy per 1,000 patient-days). Among the patients receiving antimicrobial agents, 63.6% were inappropriate and only 327 patients (27.2%) were referred by infectious disease specialists. The use of carbapenem (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.13-2.03; P = 0.006), underlying cancer (OR, 1.56; 95% CI, 1.20-2.01, P = 0.047), underlying cerebrovascular disease (OR, 1.88; 95% CI, 1.23-2.89, P = 0.004), and no microbiological testing (OR, 1.79; 95% CI, 1.15-2.73; P = 0.010) were independent predictors for inappropriate antibiotic prescribing. CONCLUSION A considerable number of antimicrobial agents are administered to patients with chronic or acute illnesses nearing their end-of-life, a high proportion of which are prescribed inappropriately. Consultation with an infectious disease specialist, in addition to an antimicrobial stewardship program, may be necessary to induce the optimal use of antibiotics.
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Affiliation(s)
- Yu Mi Wi
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Soyoon Hwang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sohyun Bae
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yoonjung Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyun-Ha Chang
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Shin-Woo Kim
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hae Suk Cheong
- Division of Infectious Diseases, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Shinwon Lee
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dong Sik Jung
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Kyung Mok Sohn
- Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Chisook Moon
- Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Sang Taek Heo
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, Jeju National University, Jeju, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Mi Suk Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Jian Hur
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Jieun Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Cheong HS, Park KH, Kim HB, Kim SW, Kim B, Moon C, Lee MS, Yoon YK, Jeong SJ, Kim YC, Eun BW, Lee H, Shin JY, Kim HS, Hwang IS, Park CS, Kwon KT. Core Elements for Implementing Antimicrobial Stewardship Programs in Korean General Hospitals. Infect Chemother 2022; 54:637-673. [PMID: 36596679 PMCID: PMC9840955 DOI: 10.3947/ic.2022.0171] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
Currently, antimicrobial resistance (AMR) is a major threat to global public health. The antimicrobial stewardship program (ASP) has been proposed as an important approach to overcome this crisis. ASP supports the optimal use of antimicrobials, including appropriate dosing decisions, administration duration, and administration routes. In Korea, efforts are being made to overcome AMR using ASPs as a national policy. The current study aimed to develop core elements of ASP that could be introduced in domestic medical facilities. A Delphi survey was conducted twice to select the core elements through expert consensus. The core elements for implementing the ASP included (1) leadership commitment, (2) operating system, (3) action, (4) tracking, (5) reporting, and (6) education. To ensure these core elements are present at medical facilities, multiple departments must collaborate as teams for ASP operations. Establishing a reimbursement system and a workforce for ASPs are prerequisites for implementing ASPs. To ensure that ASP core elements are actively implemented in medical facilities, it is necessary to provide financial support for ASPs in medical facilities, nurture the healthcare workforce in performing ASPs, apply the core elements to healthcare accreditation, and provide incentives to medical facilities by quality evaluation criteria.
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Affiliation(s)
- Hae Suk Cheong
- Division of Infectious Diseases, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung-Hwa Park
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Shin-Woo Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Chisook Moon
- Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Mi Suk Lee
- Department of Internal Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Kim
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Wook Eun
- Department of Pediatrics, Nowon Eulji University Hospital, Seoul, Korea
| | - Hyukmin Lee
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji-Yeon Shin
- Department of Preventive Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyung-sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In Sun Hwang
- Korea Institute for Healthcare Accreditation, Seoul, Korea
| | - Choon-Seon Park
- Health Insurance Review and Assessment Research Institute, Health Insurance Review and Assessment Service, Wonju, Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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7
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Keshavarzi F. Practical Concerns about the Metrics and Methods of Financial Outcome Measurement in Antimicrobial Stewardship Programs: A Narrative Review. IRANIAN JOURNAL OF MEDICAL SCIENCES 2022; 47:394-405. [PMID: 36117584 PMCID: PMC9445868 DOI: 10.30476/ijms.2021.92213.2343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/23/2021] [Accepted: 09/28/2021] [Indexed: 11/13/2022]
Abstract
Emerging pathogens in the meantime of paucity of new antibiotics discovery, put antimicrobial stewardship in the center of attention, to preserve the existing antimicrobial effect. Implementation of antimicrobial stewardship programs, however, needs approval from healthcare system managers. The approval process can be enhanced, when the beneficial effects of stewardship programs are supported by both clinical and financial evidence. Focusing on the financial outcome evaluation, the practitioners who run the stewardship programs, may choose certain methods and metrics, depending on the clinical setting scale and type, available human resources, and budget. The wise selection of the methods and metrics warrants a comprehensive insight of the existing methods and metrics, deployed by typically published works that set good examples to follow. This review is an attempt to provide such an insight along with typical relevant examples for each metric and method.
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Affiliation(s)
- Fazlollah Keshavarzi
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, Malaysia
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8
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Thirty-Day Mortality Rates in Patients with Extended-Spectrum β-Lactamase-Producing Enterobacterales Bacteremia Receiving Ertapenem versus Other Carbapenems. Antimicrob Agents Chemother 2022; 66:e0028722. [PMID: 35708330 DOI: 10.1128/aac.00287-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Ertapenem is one of the carbapenems recommended for treating extended-spectrum β-lactamase (ESBL)-producing Enterobacterales. However, efficacy data are limited. We compared 30-day mortality rates for patients receiving ertapenem and other carbapenems for treatment of ESBL-producing Enterobacterales bacteremia. A multicenter, retrospective study was performed from January 2013 to December 2020 at three hospitals. Patients who received only members of one group of carbapenems (group 1 or group 2) throughout their treatment for ESBL-producing Escherichia coli or Klebsiella pneumoniae bacteremia were enrolled. To compare 30-day all-cause mortality rates in the two groups, propensity score matching was used to control for selection bias. Subgroup analyses were performed for several subgroups. Secondary outcomes included Clostridioides difficile infection (CDI) and the emergence of multidrug-resistant Gram-negative bacteria within 90 days after initiation of carbapenem treatment. One-to-one propensity score matching yielded 162 pairs of patients from the total of 603 patients included. There was no difference in 30-day mortality rates between ertapenem and the other carbapenems in adjusted analyses (hazard ratio, 0.60 [95% confidence interval [CI], 0.29 to 1.22]) of the propensity score-matched cohorts. A similar result was obtained in a subgroup analysis of patients who suffered severe sepsis or septic shock and those who did not (P = 0.54 for interaction). Emergence of CDI (odds ratio [OR], 0.99 [95% CI, 0.44 to 2.20]) and carbapenem-resistant Enterobacterales (OR, 1.31 [95% CI, 0.51 to 3.53]) did not differ between the two groups. Our study suggests that the efficacy of ertapenem may be comparable to that of the other carbapenems in treatment of ESBL-producing E. coli and K. pneumoniae bacteremia.
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9
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Jean SS, Harnod D, Hsueh PR. Global Threat of Carbapenem-Resistant Gram-Negative Bacteria. Front Cell Infect Microbiol 2022; 12:823684. [PMID: 35372099 PMCID: PMC8965008 DOI: 10.3389/fcimb.2022.823684] [Citation(s) in RCA: 108] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 02/15/2022] [Indexed: 01/08/2023] Open
Abstract
Infections caused by multidrug-resistant (MDR) and extensively drug-resistant (XDR) Gram-negative bacteria (GNB), including carbapenem-resistant (CR) Enterobacterales (CRE; harboring mainly blaKPC, blaNDM, and blaOXA-48-like genes), CR- or MDR/XDR-Pseudomonas aeruginosa (production of VIM, IMP, or NDM carbapenemases combined with porin alteration), and Acinetobacter baumannii complex (producing mainly OXA-23, OXA-58-like carbapenemases), have gradually worsened and become a major challenge to public health because of limited antibiotic choice and high case-fatality rates. Diverse MDR/XDR-GNB isolates have been predominantly cultured from inpatients and hospital equipment/settings, but CRE has also been identified in community settings and long-term care facilities. Several CRE outbreaks cost hospitals and healthcare institutions huge economic burdens for disinfection and containment of their disseminations. Parenteral polymyxin B/E has been observed to have a poor pharmacokinetic profile for the treatment of CR- and XDR-GNB. It has been determined that tigecycline is suitable for the treatment of bloodstream infections owing to GNB, with a minimum inhibitory concentration of ≤ 0.5 mg/L. Ceftazidime-avibactam is a last-resort antibiotic against GNB of Ambler class A/C/D enzyme-producers and a majority of CR-P. aeruginosa isolates. Furthermore, ceftolozane-tazobactam is shown to exhibit excellent in vitro activity against CR- and XDR-P. aeruginosa isolates. Several pharmaceuticals have devoted to exploring novel antibiotics to combat these troublesome XDR-GNBs. Nevertheless, only few antibiotics are shown to be effective in vitro against CR/XDR-A. baumannii complex isolates. In this era of antibiotic pipelines, strict implementation of antibiotic stewardship is as important as in-time isolation cohorts in limiting the spread of CR/XDR-GNB and alleviating the worsening trends of resistance.
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Affiliation(s)
- Shio-Shin Jean
- Department of Emergency and Critical Care Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan
- Department of Pharmacy, College of Pharmacy and Health care, Tajen University, Pingtung, Taiwan
| | - Dorji Harnod
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Po-Ren Hsueh
- Departments of Laboratory Medicine and Internal Medicine, China Medical University Hospital, School of Medicine, China Medical University, Taichung, Taiwan
- School of Medicine, China Medical University, Taichung, Taiwan
- Ph.D Program for Aging, School of Medicine, China Medical University, Taichung, Taiwan
- Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
- *Correspondence: Po-Ren Hsueh,
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10
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Correlation between Carbapenem Consumption and Carbapenems Susceptibility Profiles of Acinetobacter baumannii and Pseudomonas aeruginosa in an Academic Medical Center in Thailand. Antibiotics (Basel) 2022; 11:antibiotics11020143. [PMID: 35203746 PMCID: PMC8868269 DOI: 10.3390/antibiotics11020143] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 11/17/2022] Open
Abstract
The emergent issue of carbapenem-resistant Acinetobacter baumannii (A. baumannii) and Pseudomonas aeruginosa (P. aeruginosa) is a major problem in Thailand. The wide use of carbapenems can increase selective pressure of bacterial resistance. The objective of this study was to determine the relationship between carbapenem consumption and the susceptibility rates of A. baumannii and P. aeruginosa, including multi-drug resistance (MDR) strains. This was a retrospective study. Carbapenem consumption and susceptibility profiles were collected from 2007 to 2013 at the Her Royal Highness Princess Maha Chakri Sirindhorn Medical Center, Thailand. We found that the susceptibility rate of A. baumannii to imipenem and meropenem from the sputum and the bronchoalveolar lavage (BAL) specimens was significantly decreased during the study period, but no significant change was found in the P. aeruginosa data. The relationship between carbapenem consumption and the susceptibility rate of A. baumannii had a clear association with the use of ertapenem. We found a statistically significant negative correlation between ertapenem consumption and the susceptibility rate of A. baumannii to imipenem (r = −0.91; p = 0.004) and meropenem (r = −0.97; p = 0.000) in the data from the non-ICU wards. In addition, imipenem use had a moderate negative correlation with the MDR P. aeruginosa data but no statistical significance (r = −0.714; p > 0.05). In conclusion, our study suggested there is an association between carbapenem use and the susceptibility of A. baumannii and P. aeruginosa. Notwithstanding this, information on ecological factors should be considered for further study. These findings showed the need to optimize the carbapenem prescription policy. Avoiding carbapenem overuse and rethinking the appropriate initial therapy might decrease the rate of resistant organisms.
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11
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Yoon YK, Kwon KT, Jeong SJ, Moon C, Kim B, Kiem S, Kim HS, Heo E, Kim SW. Guidelines on Implementing Antimicrobial Stewardship Programs in Korea. Infect Chemother 2021; 53:617-659. [PMID: 34623784 PMCID: PMC8511380 DOI: 10.3947/ic.2021.0098] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022] Open
Abstract
These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Korean Society for Antimicrobial Therapy, Seoul, Korea
| | - Ki Tae Kwon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Korean Society of Infectious Diseases, Seoul, Korea
| | - Chisook Moon
- Korean Society of Infectious Diseases, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Bongyoung Kim
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungmin Kiem
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyung-Sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Eunjeong Heo
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Shin-Woo Kim
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
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12
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Nguyen M, Joshi SG. Carbapenem resistance in Acinetobacter baumannii, and their importance in hospital-acquired infections: a scientific review. J Appl Microbiol 2021; 131:2715-2738. [PMID: 33971055 DOI: 10.1111/jam.15130] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/30/2021] [Accepted: 05/04/2021] [Indexed: 02/05/2023]
Abstract
Carbapenem is an important therapy for serious hospital-acquired infections and for the care of patients affected by multidrug-resistant organisms, specifically Acinetobacter baumannii; however, with the global increase of carbapenem-resistant A. baumannii, this pathogen has significantly threatened public health. Thus, there is a pressing need to better understand this pathogen in order to develop novel treatments and control strategies for dealing with A. baumannii. In this review, we discuss an overview of carbapenem, including its discovery, development, classification and biological characteristics, and its importance in hospital medicine especially in critical care units. We also describe the peculiarity of bacterial pathogen, A. baumannii, including its commonly reported virulence factors, environmental persistence and carbapenem resistance mechanisms. In closing, we discuss various control strategies for overcoming carbapenem resistance in hospitals and for limiting outbreaks. With the appearance of strains that resist carbapenem, the aim of this review is to highlight the importance of understanding this increasingly problematic healthcare-associated pathogen that creates significant concern in the field of nosocomial infections and overall public health.
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Affiliation(s)
- M Nguyen
- Center for Surgical Infections, Drexel University School of Biomedical Engineering, Science & Health Systems, Philadelphia, PA, USA
| | - S G Joshi
- Center for Surgical Infections, Drexel University School of Biomedical Engineering, Science & Health Systems, Philadelphia, PA, USA.,Institute of Molecular Medicine and Infectious Diseases, Center for Surgical Infections, Drexel University, Philadelphia, PA, USA
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13
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Kousovista R, Athanasiou C, Liaskonis K, Ivopoulou O, Ismailos G, Karalis V. Correlation between Acinetobacter baumannii Resistance and Hospital Use of Meropenem, Cefepime, and Ciprofloxacin: Time Series Analysis and Dynamic Regression Models. Pathogens 2021; 10:pathogens10040480. [PMID: 33920945 PMCID: PMC8071258 DOI: 10.3390/pathogens10040480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/06/2021] [Accepted: 04/09/2021] [Indexed: 12/02/2022] Open
Abstract
Acinetobacter baumannii is one of the most difficult-to-treat pathogens worldwide, due to developed resistance. The aim of this study was to evaluate the use of widely prescribed antimicrobials and the respective resistance rates of A. baumannii, and to explore the relationship between antimicrobial use and the emergence of A. baumannii resistance in a tertiary care hospital. Monthly data on A. baumannii susceptibility rates and antimicrobial use, between January 2014 and December 2017, were analyzed using time series analysis (Autoregressive Integrated Moving Average (ARIMA) models) and dynamic regression models. Temporal correlations between meropenem, cefepime, and ciprofloxacin use and the corresponding rates of A. baumannii resistance were documented. The results of ARIMA models showed statistically significant correlation between meropenem use and the detection rate of meropenem-resistant A. baumannii with a lag of two months (p = 0.024). A positive association, with one month lag, was identified between cefepime use and cefepime-resistant A. baumannii (p = 0.028), as well as between ciprofloxacin use and its resistance (p < 0.001). The dynamic regression models offered explanation of variance for the resistance rates (R2 > 0.60). The magnitude of the effect on resistance for each antimicrobial agent differed significantly.
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Affiliation(s)
- Rania Kousovista
- Department of Mathematics, University of Crete, Heraklion, 70013 Crete, Greece;
| | - Christos Athanasiou
- Pharmacy Department, General Military Hospital of Athens, 11525 Athens, Greece;
| | - Konstantinos Liaskonis
- Department of Medical Biopathology, General Military Hospital of Athens, 11525 Athens, Greece; (K.L.); (O.I.)
| | - Olga Ivopoulou
- Department of Medical Biopathology, General Military Hospital of Athens, 11525 Athens, Greece; (K.L.); (O.I.)
| | - George Ismailos
- Experimental-Research Center ELPEN, ELPEN Pharmaceuticals, Pikermi, 19009 Attika, Greece;
| | - Vangelis Karalis
- Department of Pharmacy, School of Health Sciences, National and Kapodistrian University of Athens, 15784 Athens, Greece
- Correspondence: ; Tel.: +30-210-727-4267
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14
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Schuts EC, Boyd A, Muller AE, Mouton JW, Prins JM. The Effect of Antibiotic Restriction Programs on Prevalence of Antimicrobial Resistance: A Systematic Review and Meta-Analysis. Open Forum Infect Dis 2021; 8:ofab070. [PMID: 33880388 PMCID: PMC8043261 DOI: 10.1093/ofid/ofab070] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/09/2021] [Indexed: 11/17/2022] Open
Abstract
Background In hospital settings, restriction of selected classes of antibiotics is usually believed to contribute to containment of resistance development. We performed a systematic review and meta-analysis to assess the effect of restricting the use of specific antibiotic classes on the prevalence of resistant bacterial pathogens. Methods We conducted a systematic literature search in Embase and PubMed/OVID MEDLINE. We included studies until June 4, 2020 in which a restrictive antibiotic policy was applied and prevalence of resistance and use of antibiotics were reported. We calculated the overall effect of antimicrobial resistance between postintervention versus preintervention periods using pooled odds ratios (ORs) from a mixed-effects model. We stratified meta-analysis by antibiotic-pathogen combinations. We assessed heterogeneity between studies using the I2 statistic and sources of heterogeneity using meta-regression. Results We included 15 individual studies with an overall low quality of evidence. In meta-analysis, significant reductions in resistance were only observed with nonfermenters after restricting fluoroquinolones (OR = 0.77, 95% confidence interval [CI] = 0.62–0.97) and piperacillin-tazobactam (OR = 0.81, 95% CI = 0.72–0.92). High degrees of heterogeneity were observed with studies restricting carbapenem (Enterobacterales, I2 = 70.8%; nonfermenters, I2 = 81.9%), third-generation cephalosporins (nonfermenters, I2 = 63.3%), and fluoroquiolones (nonfermenters, I2 = 64.0%). Results were comparable when excluding studies with fewer than 50 bacteria. There was no evidence of publication bias for any of the antibiotic-pathogen combinations. Conclusions We could not confirm that restricting carbapenems or third-generation cephalosporins leads to decrease in prevalence of antibiotic resistance among Enterobacterales, nonfermenters, or Gram-positive bacteria in hospitalized patients. Nevertheless, reducing fluoroquinolone and piperacilline-tazobactam use may decrease resistance in nonfermenters.
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Affiliation(s)
- Emelie C Schuts
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anders Boyd
- Department of Infectious Diseases, Public Health Service Amsterdam, Amsterdam, the Netherlands.,Stichting HIV Monitoring, Amsterdam, Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands.,Department of Medical Microbiology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | - Jan M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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15
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Zequinão T, Telles JP, Gasparetto J, Tuon FF. Carbapenem stewardship with ertapenem and antimicrobial resistance-a scoping review. Rev Soc Bras Med Trop 2020; 53:e20200413. [PMID: 33174959 PMCID: PMC7670755 DOI: 10.1590/0037-8682-0413-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 08/24/2020] [Indexed: 11/25/2022] Open
Abstract
Consumption of carbapenem has increased due to extended-spectrum
beta-lactamase-producing bacteria spreading. Ertapenem has been suggested as a
not carbapenem-resistance inducer. We performed a scoping review of
carbapenem-sparing stewardship with ertapenem and its impact on the antibiotic
resistance of Gram-negative bacilli. We searched PubMed for studies that used
ertapenem as a strategy to reduce resistance to carbapenems and included
epidemiologic studies with this strategy to evaluate susceptibility patterns to
cephalosporins, quinolones, and carbapenems in Gram-negative-bacilli. The search
period included only studies in English, up to February 2018. From 1294
articles, 12 studies were included, mostly from the Americas.
Enterobacteriaceae resistance to quinolones and
cephalosporins was evaluated in 6 studies and carbapenem resistance in 4
studies. Group 2 carbapenem (imipenem/meropenem/doripenem) resistance on
A. baumannii was evaluated in 6
studies. All studies evaluated P.
aeruginosa resistance to Group 2 carbapenem. Resistance profiles of
Enterobacteriaceae and P. aeruginosa to
Group 2 carbapenems were not associated with ertapenem consumption. The
resistance rate of A. baumannii to Group 2 carbapenems after
ertapenem introduction was not clear due to a lack of studies without bias. In
summary, ertapenem as a strategy to spare use of Group 2 carbapenems may be an
option to stewardship programs without increasing resistance of
Enterobacteriaceae and P. aeruginosa. More
studies are needed to evaluate the influence of ertapenem on A.
baumannii.
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Affiliation(s)
- Tiago Zequinão
- Pontifícia Universidade Católica do Paraná, Faculdade de Medicina, Laboratório de Doenças Infecciosas Emergentes, Curitiba, PR, Brasil
| | - João Paulo Telles
- Pontifícia Universidade Católica do Paraná, Faculdade de Medicina, Laboratório de Doenças Infecciosas Emergentes, Curitiba, PR, Brasil.,A.C.Camargo Cancer Center, São Paulo, SP, Brasil
| | - Juliano Gasparetto
- Pontifícia Universidade Católica do Paraná, Faculdade de Medicina, Laboratório de Doenças Infecciosas Emergentes, Curitiba, PR, Brasil
| | - Felipe Francisco Tuon
- Pontifícia Universidade Católica do Paraná, Faculdade de Medicina, Laboratório de Doenças Infecciosas Emergentes, Curitiba, PR, Brasil
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16
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Yoshida J, Kikuchi T, Ueno T, Mataga A, Asano I, Otani K, Tamura T, Tanaka M. Interprofessional Antimicrobial Stewardship Influencing Clostridioides difficile Infection: An 8-Year Study Using Antimicrobial Use Density. Infect Drug Resist 2019; 12:3409-3414. [PMID: 31807031 PMCID: PMC6839804 DOI: 10.2147/idr.s184050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/18/2019] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To reduce Clostridioides difficile infection (CDI), we implemented interprofessional antimicrobial, infection control, and diagnostic stewardship (ipAS) conducted by physicians/pharmacists, infection control nurses, and medical technologists, respectively. As a numerical indicator for ipAS, we used antimicrobial use density (AUD) in an 8-year study to validate its efficacy in CDI reduction. PATIENTS AND METHODS This was an observational study. CDI was defined as stool samples or C. difficile isolates containing toxin A and/or B from a patient with diarrhea occurring three or more times per day. From 2011-2018 at a 10-ward single site the subjects were in-patients with CDI, and the following data were collected: AUDs for 23 antibiotics, and antimicrobial test results. By 2015, we had established ipAS, consisting of culture submission before the administration of broad-spectrum antimicrobials, the promotion of point-of-care testing for diagnosis-based antimicrobials, perioperative prophylactic antibiotics, intervention at positive diagnosis of blood culture, team round for diarrhea, and inspection on contact precautions and disinfection in CDI cases. The study outcomes included annual numbers of CDI patients and blood culture sets. We compared annual AUDs between former (2011-14) and latter (2015-18) periods using Kruskal-Wallis tests and examined the correlation between AUDs and CDI numbers. RESULTS Of a total 50,970 patients, 1,750 patients underwent C. difficile toxin tests, of whom 171 patients (9.8%) were positive for CDI. Between the former and latter periods, AUDs for flomoxef (11.96 to 2.71 by medians), panipenem/betamipron (0.30 to 0.00), and clindamycin (3.87 to 2.19) significantly decreased (P<0.05) as did numbers of CDIs (26.5 to 10) (P=0.043). The correlation analysis revealed a significant correlation between AUD for flomoxef and CDIs (P=0.004) and the AUD for piperacillin/tazobactam and CDIs (P=0.010) with a positive Pearson r. CONCLUSION The integrated antimicrobial, diagnostic, and infection control approach used in ipAS may reduce CDIs.
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Affiliation(s)
- Junichi Yoshida
- Division of Infection Control, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Tetsuya Kikuchi
- Division of Infection Control, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Takako Ueno
- Division of Infection Control, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Akiko Mataga
- Division of Infection Control, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Ikuyo Asano
- Division of Infection Control, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Kazuhiro Otani
- Division of Infection Control, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Tetsuro Tamura
- Division of Infection Control, Shimonoseki City Hospital, Shimonoseki, Japan
| | - Masao Tanaka
- Division of Infection Control, Shimonoseki City Hospital, Shimonoseki, Japan
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17
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Role of antimicrobial restrictions in bacterial resistance control: a systematic literature review. J Hosp Infect 2019; 104:125-136. [PMID: 31542456 DOI: 10.1016/j.jhin.2019.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 09/13/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Antimicrobial stewardship is considered as one of the most fundamental aspects of bacterial resistance control. Among the multitude of initiatives, restrictive strategies have been widely practiced in hospital settings. However, data concerning their potential effectiveness have not been methodically collected and evaluated to date. AIM To identify, collect and evaluate the available evidence regarding the impact of restrictive policies on bacterial resistance in hospital settings. METHODS A systematic literature review was conducted using the PubMed/Medline, Embase, Global Health and CINAHL Plus databases. FINDINGS In total, 5555 papers were retrieved in the search process, and 29 studies were included in the final analysis. There were no randomized studies, and the inherent limitations of the observational designs employed impede the deduction of safe conclusions. Seemingly beneficial interventions encompass the restriction of broad-spectrum cephalosporins in favour of beta-lactam/lactamase inhibitor combinations as well as the restriction of fluoroquinolones. Antimicrobial restrictions might also play a role in the control of vancomycin-resistant enterococci, while carbapenem stewardship in the form of the preferred use of ertapenem did not produce the anticipated results. Complex restrictions are not offered for informative comparative analyses. Hospital-wide policies could perhaps be superior to those confined to high-risk departments. Carbapenem-resistant Acinetobacter baumannii might be difficult to control through solely formulary interventions. CONCLUSION The presumably effective restrictive strategies rely mainly on inadequately tested hypotheses and low-quality evidence. Therefore, systematic, high-quality research is needed to confirm and expand comprehension of the subject so that the most successful policies are employed in the field.
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18
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Smoke SM, Abdul W, Grigoriu A, Vasant D. Effect of Carbapenem Selection on Drug Acquisition Costs and Carbapenem Resistance. J Pharm Pract 2019; 32:7-8. [DOI: 10.1177/0897190018766155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Steven M. Smoke
- Department of Pharmacy, Jersey City Medical Center, Jersey City, NJ, USA
| | - Waheed Abdul
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ, USA
| | - Adriana Grigoriu
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ, USA
| | - Dhruv Vasant
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ, USA
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19
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Fujibayashi A, Niwa T, Takeichi S, Suzuki K, Ohta H, Niwa A, Tsuchiya M, Yamamoto M, Hatakeyama D, Suzuki A, Baba H, Murakami N, Itoh Y. Clinical impact of a prospective audit with intervention and feedback without carbapenem restriction in patients receiving carbapenem injection. Int J Clin Pract 2019; 73:e13262. [PMID: 30259617 DOI: 10.1111/ijcp.13262] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/27/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Antimicrobial stewardship is required to ensure the appropriate use of antimicrobials. However, few reports have shown the impact of antimicrobial stewardship on clinical outcomes. METHODS To evaluate the clinical outcomes of implementing a prospective audit with intervention and feedback without carbapenem pre-authorisation, we conducted a single-centre, prospective cohort study in patients who received carbapenem injection. Subjects were allocated to groups receiving antimicrobial agents before (non-intervention group) or after (intervention group) the implementation of an antimicrobial stewardship programme in the clinical setting. RESULTS The intervention facilitated the rate of choice of effective antimicrobials on day 2 from the onset of infection (from 63.2% to 90.2%; P < 0.001). Moreover, the rates of clinical failure-free survival (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.47-0.89; P = 0.008) and re-infection-free survival (HR, 0.35; 95% CI, 0.18-0.68; P = 0.002) were significantly higher in the intervention group than in the non-intervention group. A multivariate Cox proportional hazard analysis indicated that non-implementation of antimicrobial stewardship was a significant risk factor for clinical failure in patients receiving carbapenem injection (HR, 1.56; 95% CI, 1.11-2.19; P = 0.010). CONCLUSIONS Our prospective audit with intervention and feedback strategy without carbapenem restriction facilitated the choice of optimal antimicrobials at an early stage of infection and improved clinical outcomes in patients who received carbapenem.
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Affiliation(s)
- Ayasa Fujibayashi
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Takashi Niwa
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Syuri Takeichi
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Keiko Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Hirotoshi Ohta
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Ayumi Niwa
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Mayumi Tsuchiya
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Masayo Yamamoto
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Daijiro Hatakeyama
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Hisashi Baba
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Nobuo Murakami
- Center for Nutrition Support & Infection Control, Gifu University Hospital, Gifu, Japan
| | - Yoshinori Itoh
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
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Bertollo LG, Lutkemeyer DS, Levin AS. Are antimicrobial stewardship programs effective strategies for preventing antibiotic resistance? A systematic review. Am J Infect Control 2018; 46:824-836. [PMID: 29472107 DOI: 10.1016/j.ajic.2018.01.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/05/2018] [Accepted: 01/05/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) have been proposed as a solution for the global burden of antibiotic resistance, despite the lack of evidence on the subject. OBJECTIVE To analyze the role of ASPs in reducing bacterial resistance to antibiotics in hospital settings. DATA SOURCES A review in PubMed, Scopus, LILACS, and SciELO databases was performed. The period analyzed was January 1, 2012-January 4, 2017. ELIGIBILITY CRITERIA Studies that related ASPs to bacterial resistance. DATA EXTRACTION All studies that did not focus on ASPs were removed. Antifungal and antiviral programs were excluded. RESULTS Only 8 studies had quasi-experimental designs, and none were controlled trials. ASP strategies and microorganism-antibiotic pairs evaluated varied widely. Seven studies were classified as presenting clearly positive results, 3 had limited positive results, 7 had doubtful results, 4 had negative results, and 5 had noninterpretable results. The implementation of new infection control practices occurred in 7 studies. LIMITATIONS There are yet few studies on this matter, and most of them have inadequate study designs. Great heterogeneity between study features was detrimental to drawing evidence-based conclusions. CONCLUSIONS There is no solid evidence that ASPs are effective in reducing antibiotic resistance in hospital settings. We uphold the need for more studies with appropriate study designs, standardized ASP interventions targeting common microorganism-antibiotic pairs, and avoiding simultaneous implementation of infection control practices.
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Affiliation(s)
- Leandro G Bertollo
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Diego S Lutkemeyer
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Anna S Levin
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Honda H, Ohmagari N, Tokuda Y, Mattar C, Warren DK. Antimicrobial Stewardship in Inpatient Settings in the Asia Pacific Region: A Systematic Review and Meta-analysis. Clin Infect Dis 2017; 64:S119-S126. [DOI: 10.1093/cid/cix017] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Role of piperacillin/tazobactam as a carbapenem-sparing antibiotic for treatment of acute pyelonephritis due to extended-spectrum β-lactamase-producing Escherichia coli. Int J Antimicrob Agents 2017; 49:410-415. [PMID: 28263710 DOI: 10.1016/j.ijantimicag.2016.12.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 12/01/2016] [Accepted: 12/17/2016] [Indexed: 01/12/2023]
Abstract
Extended-spectrum β-lactamase-producing Escherichia coli (ESBL-Ec) is a frequent cause of acute pyelonephritis (APN), requiring carbapenem therapy. However, alternatives to carbapenems are needed due to the emergence of carbapenemase-producing micro-organisms. The purpose of this study was to compare the clinical efficacy of piperacillin/tazobactam (TZP) versus ertapenem in the treatment of adult patients with APN caused by ESBL-Ec. A retrospective observational study of APN caused by ESBL-Ec susceptible to TZP was performed at a university-affiliated hospital in the Republic of Korea between February 2011 and June 2013. All adult patients initially treated with in vitro-active TZP were compared with those treated with ertapenem to evaluate antibiotic clinical efficacy. The primary endpoint was treatment failure, defined as a composite of in-hospital mortality, change of initial antibiotic regimen and microbiological eradication failure. During the study period, 68 patients prescribed TZP and 82 patients prescribed ertapenem were eligible for inclusion in the study. There was no significant difference between the two treatment groups in the occurrence of in-hospital mortality, change of initial antibiotic regimen or microbiological eradication failure. In the multivariate analyses, predictors associated with treatment failure included septic shock [odds ratio (OR) = 4.27, 95% confidence interval (CI) 1.66-10.99] and recent administration of immunosuppressive agents (OR = 2.84, 95% CI 1.02-7.91). However, the type of antibiotic was not associated with treatment failure. TZP could be an effective alternative to ertapenem for the treatment of APN caused by ESBL-Ec, sparing carbapenem consumption in the multidrug-resistant era.
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Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, Gould IM, Ramsay CR, Michie S. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017; 2:CD003543. [PMID: 28178770 PMCID: PMC6464541 DOI: 10.1002/14651858.cd003543.pub4] [Citation(s) in RCA: 397] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Antibiotic resistance is a major public health problem. Infections caused by multidrug-resistant bacteria are associated with prolonged hospital stay and death compared with infections caused by susceptible bacteria. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. We updated this systematic review to evaluate the impact of interventions to improve antibiotic prescribing to hospital inpatients. OBJECTIVES To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and to investigate the effect of two intervention functions: restriction and enablement. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, and Embase. We searched for additional studies using the bibliographies of included articles and personal files. The last search from which records were evaluated and any studies identified incorporated into the review was January 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies (NRS). We included three non-randomised study designs to measure behavioural and clinical outcomes and analyse variation in the effects: non- randomised trials (NRT), controlled before-after (CBA) studies and interrupted time series (ITS) studies. For this update we also included three additional NRS designs (case control, cohort, and qualitative studies) to identify unintended consequences. Interventions included any professional or structural interventions as defined by the Cochrane Effective Practice and Organisation of Care Group. We defined restriction as 'using rules to reduce the opportunity to engage in the target behaviour (or increase the target behaviour by reducing the opportunity to engage in competing behaviours)'. We defined enablement as 'increasing means/reducing barriers to increase capability or opportunity'. The main comparison was between intervention and no intervention. DATA COLLECTION AND ANALYSIS Two review authors extracted data and assessed study risk of bias. We performed meta-analysis and meta-regression of RCTs and meta-regression of ITS studies. We classified behaviour change functions for all interventions in the review, including those studies in the previously published versions. We analysed dichotomous data with a risk difference (RD). We assessed certainty of evidence with GRADE criteria. MAIN RESULTS This review includes 221 studies (58 RCTs, and 163 NRS). Most studies were from North America (96) or Europe (87). The remaining studies were from Asia (19), South America (8), Australia (8), and the East Asia (3). Although 62% of RCTs were at a high risk of bias, the results for the main review outcomes were similar when we restricted the analysis to studies at low risk of bias.More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% confidence interval (CI) 14% to 16%; 23,394 participants; high-certainty evidence). This represents an increase from 43% to 58% .There were high levels of heterogeneity of effect size but the direction consistently favoured intervention.The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67; 14 RCTs; 3318 participants; high-certainty evidence) from 11.0 days. Information from non-randomised studies showed interventions to be associated with improvement in prescribing according to antibiotic policy in routine clinical practice, with 70% of interventions being hospital-wide compared with 31% for RCTs. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs; 15,827 participants; moderate-certainty evidence). Antibiotic stewardship interventions probably reduce length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs; 3834 participants; moderate-certainty evidence). One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence).Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions (high-certainty evidence). Enabling interventions that included feedback were probably more effective than those that did not (moderate-certainty evidence).There was very low-certainty evidence about the effect of the interventions on reducing Clostridium difficile infections (median -48.6%, interquartile range -80.7% to -19.2%; 7 studies). This was also the case for resistant gram-negative bacteria (median -12.9%, interquartile range -35.3% to 25.2%; 11 studies) and resistant gram-positive bacteria (median -19.3%, interquartile range -50.1% to +23.1%; 9 studies). There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use. Heterogeneity of intervention effect on prescribing outcomesWe analysed effect modifiers in 29 RCTs and 91 ITS studies. Enablement and restriction were independently associated with a larger effect size (high-certainty evidence). Feedback was included in 4 (17%) of 23 RCTs and 20 (47%) of 43 ITS studies of enabling interventions and was associated with greater intervention effect. Enablement was included in 13 (45%) of 29 ITS studies with restrictive interventions and enhanced intervention effect. AUTHORS' CONCLUSIONS We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment. Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Additional trials comparing antibiotic stewardship with no intervention are unlikely to change our conclusions. Enablement consistently increased the effect of interventions, including those with a restrictive component. Although feedback further increased intervention effect, it was used in only a minority of enabling interventions. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Consequently, effective dissemination of our findings could have considerable health service and policy impact. Future research should instead focus on targeting treatment and assessing other measures of patient safety, assess different stewardship interventions, and explore the barriers and facilitators to implementation. More research is required on unintended consequences of restrictive interventions.
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Affiliation(s)
- Peter Davey
- University of DundeePopulation Health SciencesMackenzie BuildingKirsty Semple WayDundeeScotlandUKDD2 4BF
| | - Charis A Marwick
- University of DundeePopulation Health Sciences Division, Medical Research InstituteDundeeUK
| | - Claire L Scott
- NHS Education for ScotlandScottish Dental Clinical Effectiveness ProgrammeDundee Dental Education CentreSmall's WyndDundeeUKDD1 4HN
| | - Esmita Charani
- Imperial College LondonNIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial ResistanceDu Cane RoadLondonUKW12 OHS
| | - Kirsty McNeil
- University of DundeeSchool of Medicine147 Forth CrescentDundeeScotlandUKDD2 4JA
| | - Erwin Brown
- No affiliation31 Park CrescentFrenchayBristolUKBS16 1NZ
| | - Ian M Gould
- Aberdeen Royal InfirmaryDepartment of Medical MicrobiologyForesterhillAberdeenUKAB25 2ZN
| | - Craig R Ramsay
- University of AberdeenHealth Services Research Unit, Division of Applied Health SciencesPolwarth BuildingForesterhillAberdeenUKAB25 2ZD
| | - Susan Michie
- University College LondonResearch Department of Primary Care and Population HealthUpper Floor 3, Royal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Hwang AY, Gums JG. The emergence and evolution of antimicrobial resistance: Impact on a global scale. Bioorg Med Chem 2016; 24:6440-6445. [PMID: 27117692 DOI: 10.1016/j.bmc.2016.04.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/06/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
Abstract
The evolution of antimicrobial resistance is a multifaceted issue that is influenced by numerous factors. This growing healthcare problem has significantly impacted the public welfare and has substantially burdened the economic system on a global scale. In an effort to combat this rising problem, several strategies have been implemented in the recent years to stall the progression and decrease the emergence of antimicrobial resistance. The aim of this review article is to describe the various factors that have contributed to the current state of antimicrobial resistance and to evaluate potential strategies developed to reduce the burden of antimicrobial resistance.
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Affiliation(s)
- Andrew Y Hwang
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, P.O. Box 100486, Gainesville, FL 32610, USA; Department of Community Health and Family Medicine, College of Medicine, University of Florida, 1707 North Main Street, Gainesville, FL 32609, USA.
| | - John G Gums
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, P.O. Box 100486, Gainesville, FL 32610, USA; Department of Community Health and Family Medicine, College of Medicine, University of Florida, 1707 North Main Street, Gainesville, FL 32609, USA
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Yoon YK, Park GC, An H, Chun BC, Sohn JW, Kim MJ. Trends of Antibiotic Consumption in Korea According to National Reimbursement Data (2008-2012): A Population-Based Epidemiologic Study. Medicine (Baltimore) 2015; 94:e2100. [PMID: 26579825 PMCID: PMC4652834 DOI: 10.1097/md.0000000000002100] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study determined the trends in the quantities and patterns of nationwide antibiotic consumption in the Republic of Korea (ROK).This nationwide descriptive epidemiological study was conducted in the ROK between 2008 and 2012. The quantities and patterns of total systemic antibiotic prescriptions were analyzed using National Health Insurance claims data collected through the Health Insurance Review and Assessment service. Data concerning systemic antibiotics were collected using measurement units of the defined daily dose (DDD) per 1000 people per day according to the Anatomical Therapeutic Chemical classification.Over the 5-year study period, the annual consumption of systemic antibiotics ranged from 21.68 to 23.12 DDD per 1000 people per day. Outpatient antibiotic use accounted for 80.9% of total consumption. A regression model with autoregressive errors showed significant increased consumption of major antibiotic subgroups, including 3rd-generation cephalosporins, carbapenems, and glycopeptides (P < 0.001). However, the antibiotic use of 1st- (P = 0.003), 2nd- (P = 0.004), and 3rd-generation (P = 0.018) cephalosporins among patients who underwent surgery under monitoring by the antimicrobial stewardship programs for perioperative prescription was significantly lower than in those who underwent surgery without monitoring programs. In time-series analysis, total antibiotic consumption demonstrated significant seasonality (P < 0.001).The consumption of broad-spectrum antibiotics was noted to have increased in the ROK from 2008 to 2012, providing a possible explanation for the changing epidemiology of multidrug resistance. Larger prospective studies are needed to investigate the impact on public health of monitoring programs of perioperative antibiotic usage.
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Affiliation(s)
- Young Kyung Yoon
- From the Division of Infectious Diseases, Department of Internal Medicine (YKY, JWS, MJK), Institute of Emerging Infectious Diseases (YKY, JWS, MJK), Department of Biostatistics (GCP, HA), and Department of Preventive Medicine (BCC), Korea University College of Medicine, Seoul, Republic of Korea
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Hayajneh WA, Hajj A, Hulliel F, Sarkis DK, Irani-Hakimeh N, Kazan L, Badal RE. Susceptibility trends and molecular characterization of Gram-negative bacilli associated with urinary tract and intra-abdominal infections in Jordan and Lebanon: SMART 2011–2013. Int J Infect Dis 2015; 35:56-61. [DOI: 10.1016/j.ijid.2015.04.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 03/27/2015] [Accepted: 04/18/2015] [Indexed: 02/01/2023] Open
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Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ, Wilcox M. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013:CD003543. [PMID: 23633313 DOI: 10.1002/14651858.cd003543.pub3] [Citation(s) in RCA: 358] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The first publication of this review in Issue 3, 2005 included studies up to November 2003. This update adds studies to December 2006 and focuses on application of a new method for meta-analysis of interrupted time series studies and application of new Cochrane Effective Practice and Organisation of Care (EPOC) Risk of Bias criteria to all studies in the review, including those studies in the previously published version. The aim of the review is to evaluate the impact of interventions from the perspective of antibiotic stewardship. The two objectives of antibiotic stewardship are first to ensure effective treatment for patients with bacterial infection and second support professionals and patients to reduce unnecessary use and minimize collateral damage. OBJECTIVES To estimate the effectiveness of professional interventions that, alone or in combination, are effective in antibiotic stewardship for hospital inpatients, to evaluate the impact of these interventions on reducing the incidence of antimicrobial-resistant pathogens or Clostridium difficile infection and their impact on clinical outcome. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE from 1980 to December 2006 and the EPOC specialized register in July 2007 and February 2009 and bibliographies of retrieved articles. The main comparison is between interventions that had a restrictive element and those that were purely persuasive. Restrictive interventions were implemented through restriction of the freedom of prescribers to select some antibiotics. Persuasive interventions used one or more of the following methods for changing professional behaviour: dissemination of educational resources, reminders, audit and feedback, or educational outreach. Restrictive interventions could contain persuasive elements. SELECTION CRITERIA We included randomized clinical trials (RCTs), controlled clinical trials (CCT), controlled before-after (CBA) and interrupted time series studies (ITS). Interventions included any professional or structural interventions as defined by EPOC. The intervention had to include a component that aimed to improve antibiotic prescribing to hospital inpatients, either by increasing effective treatment or by reducing unnecessary treatment. The results had to include interpretable data about the effect of the intervention on antibiotic prescribing or microbial outcomes or relevant clinical outcomes. DATA COLLECTION AND ANALYSIS Two authors extracted data and assessed quality. We performed meta-regression of ITS studies to compare the results of persuasive and restrictive interventions. Persuasive interventions advised physicians about how to prescribe or gave them feedback about how they prescribed. Restrictive interventions put a limit on how they prescribed; for example, physicians had to have approval from an infection specialist in order to prescribe an antibiotic. We standardized the results of some ITS studies so that they are on the same scale (percent change in outcome), thereby facilitating comparisons of different interventions. To do this, we used the change in level and change in slope to estimate the effect size with increasing time after the intervention (one month, six months, one year, etc) as the percent change in level at each time point. We did not extrapolate beyond the end of data collection after the intervention. The meta-regression was performed using standard weighted linear regression with the standard errors of the coefficients adjusted where necessary. MAIN RESULTS For this update we included 89 studies that reported 95 interventions. Of the 89 studies, 56 were ITSs (of which 4 were controlled ITSs), 25 were RCT (of which 5 were cluster-RCTs), 5 were CBAs and 3 were CCTs (of which 1 was a cluster-CCT).Most (80/95, 84%) of the interventions targeted the antibiotic prescribed (choice of antibiotic, timing of first dose and route of administration). The remaining 15 interventions aimed to change exposure of patients to antibiotics by targeting the decision to treat or the duration of treatment. Reliable data about impact on antibiotic prescribing data were available for 76 interventions (44 persuasive, 24 restrictive and 8 structural). For the persuasive interventions, the median change in antibiotic prescribing was 42.3% for the ITSs, 31.6% for the controlled ITSs, 17.7% for the CBAs, 3.5% for the cluster-RCTs and 24.7% for the RCTs. The restrictive interventions had a median effect size of 34.7% for the ITSs, 17.1% for the CBAs and 40.5% for the RCTs. The structural interventions had a median effect of 13.3% for the RCTs and 23.6% for the cluster-RCTs. Data about impact on microbial outcomes were available for 21 interventions but only 6 of these also had reliable data about impact on antibiotic prescribing.Meta-analysis of 52 ITS studies was used to compare restrictive versus purely persuasive interventions. Restrictive interventions had significantly greater impact on prescribing outcomes at one month (32%, 95% confidence interval (CI) 2% to 61%, P = 0.03) and on microbial outcomes at 6 months (53%, 95% CI 31% to 75%, P = 0.001) but there were no significant differences at 12 or 24 months. Interventions intended to decrease excessive prescribing were associated with reduction in Clostridium difficile infections and colonization or infection with aminoglycoside- or cephalosporin-resistant gram-negative bacteria, methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis. Meta-analysis of clinical outcomes showed that four interventions intended to increase effective prescribing for pneumonia were associated with significant reduction in mortality (risk ratio 0.89, 95% CI 0.82 to 0.97), whereas nine interventions intended to decrease excessive prescribing were not associated with significant increase in mortality (risk ratio 0.92, 95% CI 0.81 to 1.06). AUTHORS' CONCLUSIONS The results show that interventions to reduce excessive antibiotic prescribing to hospital inpatients can reduce antimicrobial resistance or hospital-acquired infections, and interventions to increase effective prescribing can improve clinical outcome. This update provides more evidence about unintended clinical consequences of interventions and about the effect of interventions to reduce exposure of patients to antibiotics. The meta-analysis supports the use of restrictive interventions when the need is urgent, but suggests that persuasive and restrictive interventions are equally effective after six months.
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Affiliation(s)
- Peter Davey
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, UK.
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