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Hasan S, Al Zubaidi H, Saidawi W, Zitouni H, Hussein SA. Pharmacist insights into antimicrobial stewardship: A social marketing approach. Res Social Adm Pharm 2024; 20:190-202. [PMID: 37993380 DOI: 10.1016/j.sapharm.2023.11.003] [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: 09/08/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Antimicrobial resistance is a worldwide public health problem. Antimicrobial stewardship programs (ASPs) optimize antimicrobial use within hospitals. The social marketing framework has been used in analyzing systems and devising best practices. OBJECTIVE (s): To use the social marketing framework to explore pharmacist experiences and perceptions of structural, behavioral and interventional strategies that support ASPs. METHODS A qualitative approach utilizing semi-structured individual interviews was utilized. A purposive sample of hospital pharmacists was invited to participate. An interview guide was constructed to describe participant experience and perceptions regarding ASPs in their institutions based on elements of social marketing: Behavioral goals; Customer Insight; Segmentation and Targeting; Competition; Exchange; and Marketing and Interventional mix. Interviews were recorded digitally and transcribed verbatim. Thematic analysis was conducted using deductive methods. A combination of case-based and code-based approaches allowed individual and holistic analyses respectively. Codes were collated into themes and subthemes. RESULTS Saturation of themes occurred with 25 interviews from 17 hospitals. ASP metrics included: consumption of antibiotics using days of therapy and defined daily dose, rates of C. difficile and multidrug resistant organisms, resistance patterns, and provider adherence to the ASP. Active stewardship tools such as preauthorization, and prospective feedback/audit were preferred over passive tools such as order sets and automatic stop orders. A physician champion and a clinical pharmacist with infectious disease training were core elements in the multidisciplinary team. Despite certain areas being considered key for stewardship, participants emphasized a hospital-wide approach including outpatient departments; discharge stewardship emerged as a primary theme. Leadership supported ASPs with finances, rapid and novel diagnostics, Clinical Decision Support Systems, mobile technology, and continuous staff training. CONCLUSIONS The social marketing framework has been used to explore pharmacist perceptions that inform successful qualities including metrics, restriction methods, personnel, benefits, barriers, training needs/modes, and promotional avenues that support ASPs in hospitals.
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Affiliation(s)
- Sanah Hasan
- Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates; Center of Medical and Bio-allied Health Sciences, Ajman University, Ajman, United Arab Emirates.
| | - Hamzah Al Zubaidi
- Department of Pharmacy Practice and Pharmacotherapeutics, University of Sharjah, Sharjah, United Arab Emirates.
| | - Ward Saidawi
- Research Institute for Medical and Health Sciences, University of Sharjah, United Arab Emirates.
| | - Hibaterrahmane Zitouni
- Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates.
| | - Saeed Abdullah Hussein
- Department of Clinical Sciences, College of Pharmacy and Health Sciences, Ajman University, Ajman, United Arab Emirates.
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Ansari S, Hays JP, Kemp A, Okechukwu R, Murugaiyan J, Ekwanzala MD, Ruiz Alvarez MJ, Paul-Satyaseela M, Iwu CD, Balleste-Delpierre C, Septimus E, Mugisha L, Fadare J, Chaudhuri S, Chibabhai V, Wadanamby JMRWW, Daoud Z, Xiao Y, Parkunan T, Khalaf Y, M'Ikanatha NM, van Dongen MBM. The potential impact of the COVID-19 pandemic on global antimicrobial and biocide resistance: an AMR Insights global perspective. JAC Antimicrob Resist 2021; 3:dlab038. [PMID: 34192258 PMCID: PMC8083476 DOI: 10.1093/jacamr/dlab038] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The COVID-19 pandemic presents a serious public health challenge in all countries. However, repercussions of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections on future global health are still being investigated, including the pandemic’s potential effect on the emergence and spread of global antimicrobial resistance (AMR). Critically ill COVID-19 patients may develop severe complications, which may predispose patients to infection with nosocomial bacterial and/or fungal pathogens, requiring the extensive use of antibiotics. However, antibiotics may also be inappropriately used in milder cases of COVID-19 infection. Further, concerns such as increased biocide use, antimicrobial stewardship/infection control, AMR awareness, the need for diagnostics (including rapid and point-of-care diagnostics) and the usefulness of vaccination could all be components shaping the influence of the COVID-19 pandemic. In this publication, the authors present a brief overview of the COVID-19 pandemic and associated issues that could influence the pandemic’s effect on global AMR.
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Affiliation(s)
- Shamshul Ansari
- Department of Microbiology, Chitwan Medical College and Teaching Hospital, Bharatpur, 44200 Chitwan, Nepal
| | - John P Hays
- Department of Medical Microbiology & Infectious Diseases, Erasmus University Medical Centre Rotterdam (Erasmus MC), Rotterdam, The Netherlands
| | - Andrew Kemp
- Scientific Advisory Board of the British Institute of Cleaning Sciences, Northampton, UK
| | - Raymond Okechukwu
- Department of Clinical Pharmacy and Pharmacy Management, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Agulu Campus, Nigeria
| | | | - Mutshiene Deogratias Ekwanzala
- Department of Environmental, Water and Earth Sciences, Tshwane University of Technology, Pretoria, South Africa.,Environmental Engineering, Department of Civil Engineering, Kyung Hee University, Yongin-si, Gyeonggi-do, Republic of Korea
| | | | | | - Chidozie Declan Iwu
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | | | - Ed Septimus
- Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, MA, 02215, Texas A&M College of Medicine, Houston, TX 77030, USA
| | - Lawrence Mugisha
- College of Veterinary Medicine, Animal Resources & Biosecurity (COVAB), Makerere University, Kampala, Uganda
| | - Joseph Fadare
- Department of Pharmacology and Therapeutics, College of Medicine, Ekiti State University, Ado-Ekiti, Nigeria
| | - Susmita Chaudhuri
- Translational Health Science and Technology Institute, Faridabad 121001, India
| | - Vindana Chibabhai
- Department of Clinical Microbiology and Infectious Diseases, University of the Witwatersrand, and Clinical Microbiology Laboratory, Charlotte Maxeke Johannesburg Academic Hospital, National Health Laboratory Service, Johannesburg, South Africa
| | - J M Rohini W W Wadanamby
- Department of Microbiology, Lanka Hospital Diagnostics, Lanka Hospital 578, Elvitigala Mw, Colombo 05, Sri Lanka
| | - Ziad Daoud
- Department of Clinical Microbiology & Infection Prevention, Michigan Health Clinics-Saginaw, MI, USA and Department of Foundational Sciences, CMED-CMU, Mount Pleasant, MI, USA
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis & Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 300013, China
| | - Thulasiraman Parkunan
- Department of Veterinary Physiology and Biochemistry, Faculty of Veterinary and Animal Sciences, Institute of Agricultural Sciences, Rajiv Gandhi South Campus, Banaras Hindu University, Mirzapur, Uttar Pradesh, India
| | - Yara Khalaf
- Department of Epidemiology, High Institute of Public Health, Alexandria University, Alexandria, Egypt
| | - Nkuchia M M'Ikanatha
- Division of Infectious Disease Epidemiology, Pennsylvania Department of Health, Harrisburg, PA, USA
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Measuring Antibiotic Stewardship Programmes and Initiatives: An Umbrella Review in Primary Care Medicine and a Systematic Review of Dentistry. Antibiotics (Basel) 2020; 9:antibiotics9090607. [PMID: 32947838 PMCID: PMC7558917 DOI: 10.3390/antibiotics9090607] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/01/2020] [Accepted: 09/13/2020] [Indexed: 12/15/2022] Open
Abstract
Antibiotic stewardship aims to tackle the global problem of drug-resistant infections by promoting the responsible use of antibiotics. Most antibiotics are prescribed in primary care and widespread overprescribing has been reported, including 80% in dentistry. This review aimed to identify outcomes measured in studies evaluating antibiotic stewardship across primary healthcare. An umbrella review was undertaken across medicine and a systematic review in dentistry. Systematic searches of Ovid Medline, Ovid Embase and Web of Science were undertaken. Two authors independently selected and quality assessed the included studies (using Critical Appraisal Skills Programme for the umbrella review and Quality Assessment Tool for Studies with Diverse Designs for the systematic review). Metrics used to evaluate antibiotic stewardship programmes and interventions were extracted and categorized. Comparisons between medical and dental settings were made. Searches identified 2355 medical and 2704 dental studies. After screening and quality assessment, ten and five studies, respectively, were included. Three outcomes were identified across both medical and dental studies: All focused on antibiotic usage. Four more outcomes were found only in medical studies: these measured patient outcomes, such as adverse effects. To evaluate antibiotic stewardship programmes and interventions across primary healthcare settings, measures of antibiotic use and patient outcomes are recommended.
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Redding LE, Lavigne S, Aceto HW, Nolen-Walston RD. Antimicrobial prescribing patterns of clinicians and clinical services at a large animal veterinary teaching hospital. Am J Vet Res 2020; 81:103-115. [PMID: 31985290 DOI: 10.2460/ajvr.81.2.103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To characterize antimicrobial prescribing patterns of clinicians and clinical services at a large animal veterinary teaching hospital and identify factors associated with antimicrobial prescribing. ANIMALS All large animals (ie, equids, bovids, sheep, goats, camelids, swine, and cervids) evaluated at the New Bolton Center hospital at the University of Pennsylvania from 2013 through 2018. PROCEDURES In a cross-sectional study design, data on antimicrobial use by clinicians and clinical services were collected from administrative and billing records. Multivariable regression modeling was performed to identify factors associated with antimicrobial prescribing patterns. RESULTS Antimicrobials and critically important antimicrobials of the highest priority were dispensed in 42.1% (9,853/23,428) and 24.0% (2,360/9,853) of visits, respectively, and these proportions differed significantly among clinicians. Per visit, the median (interquartile [25th to 75th percentile] range) number of animal-defined daily doses dispensed was 3.6 (0.8 to 11.1) and the mean (SD) number of antimicrobial classes dispensed was 2.0 (1.3). Patient species, age, affected body system, and duration of hospitalization as well as submission of specimens for bacterial culture were significantly associated with prescribing patterns. CONCLUSIONS AND CLINICAL RELEVANCE The frequency and quantity of antimicrobials prescribed differed significantly among clinicians within and across services, even for animals with clinical signs affecting the same body system. Patient- and visit-level factors explained some but not all of the heterogeneity in prescribing patterns, suggesting that other clinician-specific factors drove such practices. More research is needed to better understand antimicrobial prescribing patterns of clinicians, particularly in situations for which no antimicrobial use guidelines have been established.
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Al-Omari A, Al Mutair A, Alhumaid S, Salih S, Alanazi A, Albarsan H, Abourayan M, Al Subaie M. The impact of antimicrobial stewardship program implementation at four tertiary private hospitals: results of a five-years pre-post analysis. Antimicrob Resist Infect Control 2020; 9:95. [PMID: 32600391 PMCID: PMC7322716 DOI: 10.1186/s13756-020-00751-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/04/2020] [Indexed: 11/23/2022] Open
Abstract
Background Antimicrobial stewardship (AMS) programs have shown to reduce the emergence of antimicrobial resistance (AMR) and health-care-associated infections (HAIs), and save health-care costs associated with an inappropriate antimicrobial use. The primary objective of this study was to compare the consumption and cost of antimicrobial agents using defined daily dose (DDD) and direct cost of antibiotics before and after the AMS program implementation. Secondary objective was to determine the rate of HAIs [Clostridium difficile (C. difficile), ventilator-associated pneumonia (VAP), and central line-associated bloodstream infection (CLABSI) before and after the AMS program implementation. Methods This is a pre-post quasi-experimental study. Adult inpatients were enrolled in a prospective fashion under the active AMS arm and compared with historical inpatients who were admitted to the same units before the AMS implementation. Study was conducted at four tertiary private hospitals located in two cities in Saudi Arabia. Adult inpatients were enrolled under the pre- AMS arm and post- AMS arm if they were on any of the ten selected restricted broad-spectrum antibiotics (imipenem/cilastatin, piperacillin/tazobactam, colistin, tigecycline, cefepime, meropenem, ciprofloxacin, moxifloxacin, teicoplanin and linezolid). Results A total of 409,403 subjects were recruited, 79,369 in the pre- AMS control and 330,034 in the post- AMS arm. Average DDDs consumption of all targeted broad-spectrum antimicrobials from January 2016 to June 2019 post- AMS launch was lower than the DDDs use of these agents pre- AMS (233 vs 320 DDDs per 1000 patient-days, p = 0.689). Antimicrobial expenditures decreased by 28.45% in the first year of the program and remained relatively stable in subsequent years, with overall cumulative cost savings estimated at S.R. 6,286,929 and negligible expenses of S.R. 505,115 (p = 0.648). Rates of healthcare associated infections involving C. difficile, VAP, and CLABSI all decreased significantly after AMS implementation (incidence of HAIs in 2015 compared to 2019: for C. difficile, 94 vs 13, p = 0.024; for VAP, 24 vs 6, p = 0.001; for CLABSI, 17 vs 1, p = 0.000; respectively). Conclusion Implementation of AMS program at HMG healthcare facilities resulted in reduced antimicrobials use and cost, and lowered incidence of healthcare associated infections.
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Affiliation(s)
- Awad Al-Omari
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia.,Alfaisal University, Riyadh, Saudi Arabia
| | - Abbas Al Mutair
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia. .,Alfaisal University, Riyadh, Saudi Arabia. .,School of Nursing, Wollongong University, Wollongong, Australia.
| | | | - Samer Salih
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Ahmed Alanazi
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Hesham Albarsan
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Maha Abourayan
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Maha Al Subaie
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
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Rout J, Essack S, Brysiewicz P. Are nursing infusion practices delivering full-dose antimicrobial treatment? J Antimicrob Chemother 2019; 74:3418-3422. [DOI: 10.1093/jac/dkz365] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Abstract
Antimicrobial stewardship (AMS) has developed over the past decade as a critical tool to promote the appropriate use of antimicrobials in order to contain antimicrobial resistance (AMR) and conserve antimicrobial medicines. Current literature supports the role of the nurse in AMR, with a strong focus on the responsibilities of the nurse in infection prevention and control (IPC), both in the formal role of the IPC nurse specialist, and the more general IPC role of the bedside nurse. There is also growing support for the collaborative role of the nurse in the multidisciplinary AMS team. There is, however, very little literature examining the clinical practice role of the nurse in AMS. In this discussion, we contend that nursing practice may unknowingly contribute to AMR owing to varying methods of administration of intermittent intravenous infusions, resulting in under-dosing of antimicrobial medicines.
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Affiliation(s)
- J Rout
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - S Essack
- Antimicrobial Research Unit, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - P Brysiewicz
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Mitchell KF, Safdar N, Abad CL. Evaluating carbapenem restriction practices at a private hospital in Manila, Philippines as a strategy for antimicrobial stewardship. ACTA ACUST UNITED AC 2019; 77:31. [PMID: 31312447 PMCID: PMC6610803 DOI: 10.1186/s13690-019-0358-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/13/2019] [Indexed: 11/10/2022]
Abstract
Background Hospital antimicrobial stewardship programs are especially critical in countries such as the Philippines, where antibiotic resistant infections are highly prevalent. At the study institution in Manila, Philippines, a Prior Approval for Restricted Antimicrobials (PARA) is required for non-infectious disease specialists to prescribe certain antimicrobials, including carbapenems. PARA request forms include specification of empiric or definitive therapy based on diagnostic tests. Recommended duration of therapy is typically 3 days for empiric use and 7 days for definitive, with possible extension upon specialist approval. Methods The study took place at an 800-bed tertiary hospital. We performed a retrospective review of patient medical records and laboratory reports dating from January 1 to December 31, 2016. Information related to patient demographics, carbapenem prescription, laboratory diagnosis, and therapy were compiled. Carbapenem prescriptions were classified as 'adherent' or 'non-adherent' according to clinical guidelines related to infection diagnosis, treatment duration, and de-escalation. Results Of the 185 patients on carbapenem therapy, Prescriptions of carbapenems were either definitive (n = 56), empiric (n = 127), or prophylactic (n = 2) as defined by the ordering provider. 69 out of 185 (37%) prescriptions were deemed non-adherent to guidelines, despite receiving approvals for their respective requests. Of these, 72% were non-adherent due to failure to de-escalate the carbapenem and 28% were non-adherent due to an incomplete course of therapy. Conclusion Despite initial PARA approval for carbapenem therapy, 37% of prescriptions were non-guideline-adherent, highlighting the ongoing challenges in implementing this type of stewardship strategy. In order to increase the effectiveness of PARA, additional approaches may be warranted, including the application of strict policies which reinforce follow-up of available culture results, justification of therapy extension, or referral to an infectious disease specialist.
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Affiliation(s)
- Kaitlin F Mitchell
- 1Division of Infectious Diseases, Department of Medicine, University of Wisconsin-Madison, Madison, WI USA.,5Present Address: Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO USA
| | - Nasia Safdar
- 1Division of Infectious Diseases, Department of Medicine, University of Wisconsin-Madison, Madison, WI USA.,2William S. Middleton Memorial Veterans Hospital, Madison, WI USA.,3Infection Control Department, University of Wisconsin-Madison, Madison, WI USA
| | - Cybele L Abad
- Department of Medicine, Section of Infectious Diseases, The Medical City Hospital, Ortigas Ave, Pasig City, Philippines
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Monnier AA, Eisenstein BI, Hulscher ME, Gyssens IC. Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure. J Antimicrob Chemother 2018; 73:vi3-vi16. [PMID: 29878216 PMCID: PMC5989615 DOI: 10.1093/jac/dky114] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project, this study aimed to identify key elements for a global definition of responsible antibiotic use based on diverse stakeholder input. Methods A three-step RAND-modified Delphi method was applied. First, a systematic review of antibiotic stewardship literature and relevant organization web sites identified definitions and synonyms of responsible use. Identified elements of definitions were presented by questionnaire to a multidisciplinary international stakeholder panel for appraisal of their relevance. Finally, questionnaire results were discussed in a consensus meeting. Results The systematic review and the web site search identified 17 synonyms (e.g. appropriate, correct) and 22 potential elements to include in a definition of responsible use. Elements were grouped into patient-level (e.g. Indication, Documentation) or societal-level elements (e.g. Education, Future Effectiveness). Forty-eight stakeholders with diverse backgrounds [medical community, public health, patients, antibiotic research and development (R&D), regulators, governments] from 18 countries across all continents participated in the questionnaire. Based on relevance scores, 21 elements were retained, 9 were rephrased and 1 was added. Together, the 22 elements and associated best-practice descriptions comprise an exhaustive list of elements to be considered when defining responsible use. Conclusions Combination of concepts from the literature and stakeholder opinion led to an international multidisciplinary consensus on a global definition of responsible antibiotic use. The widely diverging perspectives of stakeholders providing input should ensure the comprehensiveness and relevance of the definition for both individual patients and society. An aspirational goal would be to address all elements.
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Affiliation(s)
- Annelie A Monnier
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
| | | | - Marlies E Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge C Gyssens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
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Owens RC, Bulik CC, Andes DR. Pharmacokinetics-pharmacodynamics, computer decision support technologies, and antimicrobial stewardship: the compass and rudder. Diagn Microbiol Infect Dis 2018; 91:371-382. [PMID: 29776710 DOI: 10.1016/j.diagmicrobio.2018.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 03/21/2018] [Accepted: 03/26/2018] [Indexed: 12/19/2022]
Abstract
The first guidelines for conducting antimicrobial stewardship in the hospitalized setting were published in 2007. These guidelines recommend that stewardship programs employ the science of pharmacokinetics-pharmacodynamics (PK-PD) as well as adopting computerized decision support technologies when possible. The United States Food and Drug Administration have adopted PK-PD as a cornerstone in the evaluation of antimicrobial agents during clinical development. The core principles of PK-PD center around describing the relationship between drug exposure indexed to the susceptibility of the infecting bacterial pathogen and patient response. Using such relationships with population pharmacokinetic models and simulation, rational drug and dosing regimens can be selected. But because PK-PD modeling and simulation programs are generally absent in clinical practice, systematic application of this science is missing. Herein we explain advances in technology that allow clinicians to apply PK-PD to optimize the agents and dosing regimens selected for the treatment of hospitalized patients with infection.
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Affiliation(s)
- Robert C Owens
- Institute for Clinical Pharmacodynamics, Schenectady, New York.
| | | | - David R Andes
- University of Wisconsin, School of Medicine, Madison, Wisconsin
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Patel D, Macdougall C. How to Make Antimicrobial Stewardship Work: Practical Considerations for Hospitals of All Sizes. Hosp Pharm 2017. [DOI: 10.1310/hpj4511-s10] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Implementation of an antimicrobial stewardship program in a hospital is complicated by a variety of challenges. Key issues facing stewardship personnel include recruiting personnel and building relationships, establishing program metrics, selecting stewardship strategies, working with clinicians, reporting results, and adapting the program. These issues can present different challenges at community hospitals and academic medical centers. Strategies for overcoming these challenges require accounting for the unique characteristics of each institution.
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Affiliation(s)
- Dimple Patel
- Infectious Diseases, Comprehensive Pharmacy Services, John F. Kennedy Medical Center, Edison, New Jersey
| | - Conan Macdougall
- University of California San Francisco School of Pharmacy, San Francisco, California
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Zaragoza R, Ferrer R, Llinares P, Maseda E, Rodríguez A, Grau S, Quindós G. EPICO 4.0. 'Total quality' in the management of invasive candidiasis in critically ill patients by analysing the integrated process. Rev Iberoam Micol 2017; 34:143-157. [PMID: 28734773 DOI: 10.1016/j.riam.2017.03.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/12/2017] [Accepted: 03/30/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND A high quality integrated process in the clinical setting of non-neutropenic critically ill patients at risk for invasive candidiasis is a necessary tool to improve the management of these patients. AIMS To identify the key points on invasive candidiasis in order to develop a set of recommendations with a high level of consensus required for the creation of a total quality integrated process for the management of non-neutropenic critically ill patients at risk of invasive candidiasis. METHODS After a thorough review of the literature of the previous five years, a Spanish prospective questionnaire, which measured consensus by the Delphi technique, was anonymously conducted by e-mail, including 31 national multidisciplinary experts with extensive experience in invasive fungal infections, from six national scientific societies. The experts included a specialist in intensive care medicine, anesthetists, microbiologists, pharmacologists, and specialists in infectious diseases that responded 27 questions prepared by the coordination group. The educational objectives considered six processes that included knowledge of the local epidemiology, the creation and development of multidisciplinary teams, the definitions of the process, protocols, and indicators (KPI), an educational phase, hospital implementation, and the measurement of outcomes. The level of agreement among experts in each category to be selected should exceed 70%. In a second phase, after drawing up the recommendations of the selected processes, a face to face meeting with more than 60 specialists was held. The specialists were asked to validate the pre-selected recommendations. MEASURES AND MAIN OUTCOMES Firstly, 20 recommendations from all the sections were pre-selected: Knowledge of local epidemiology (3 recommendations), creation and development of multidisciplinary teams (3), definition of the process, protocols and indicators (1), educational phase (3), hospital implementation (3), and measurement of outcomes (7). After the second phase, 18 recommendations were validated, and it was concluded that the minimum team or core necessary for the development of an efficient program in the use of antifungal drugs in non-neutropenic critically ill patients must consist of a specialist in infectious diseases, a clinical pharmacist, a microbiologist, a specialist in intensive care medicine, a specialist in anesthesia and recovery, and an administrator or member of the medical management team, and, in order to be cost-effective, it should be implemented in hospitals with over 200 beds. In addition, it is recommended to apply a consensual check list for the evaluation of the diagnostic process and treatment of invasive candidiasis in patients that have started an antifungal treatment. The management of external knowledge and individual learning stand out as active educational strategies. The main strategies for measuring patient safety outcomes are the analysis of the results achieved, and learning activities; assess, review and refine the deployment of the processes; quality control; epidemiological surveillance and applied research; benchmarking; and basic research. The results of the integrated process should be annually disseminated outside the hospital. CONCLUSIONS Optimizing the management of invasive candidiasis requires the application of the knowledge and skills detailed in our recommendations. These recommendations, based on the Delphi methodology, facilitate the creation of a total quality integrated process in critically-ill patients at risk for invasive candidiasis.
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Affiliation(s)
- Rafael Zaragoza
- Unidad de Sepsis, Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain.
| | - Ricard Ferrer
- Servicio de Medicina Intensiva, Hospital Universitario Valle de Hebrón, Barcelona, Spain
| | - Pedro Llinares
- Unidad de Enfermedades Infecciosas, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| | - Emilio Maseda
- Servicio de Anestesiología y Reanimación, Hospital Universitario La Paz, Madrid, Spain
| | - Alejandro Rodríguez
- Unidad de Cuidados Intensivos, Hospital Universitario Juan XXIII, Tarragona, Spain
| | - Santiago Grau
- Servicio de Farmacia, Hospital del Mar, Barcelona, Spain
| | - Guillermo Quindós
- Departamento de Inmunología, Microbiología y Parasitología, Facultad de Medicina y Odontología, Universidad del País Vasco (UPV/EHU), Bilbao, Vizcaya, Spain
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de With K, Allerberger F, Amann S, Apfalter P, Brodt HR, Eckmanns T, Fellhauer M, Geiss HK, Janata O, Krause R, Lemmen S, Meyer E, Mittermayer H, Porsche U, Presterl E, Reuter S, Sinha B, Strauß R, Wechsler-Fördös A, Wenisch C, Kern WV. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2017; 44:395-439. [PMID: 27066980 PMCID: PMC4889644 DOI: 10.1007/s15010-016-0885-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. Materials and methods A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. Conclusion The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.
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Affiliation(s)
- K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - F Allerberger
- Division Public Health, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - S Amann
- Hospital Pharmacy, Munich Municipal Hospital, Munich, Germany
| | - P Apfalter
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - H-R Brodt
- Department of Infectious Disease Medical Clinic II, Goethe-University Frankfurt, Frankfurt, Germany
| | - T Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - M Fellhauer
- Hospital Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - H K Geiss
- Department of Hospital Epidemiology and Infectiology, Sana Kliniken AG, Ismaning, Germany
| | - O Janata
- Department for Hygiene and Infection Control, Danube Hospital, Vienna, Austria
| | - R Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
| | - S Lemmen
- Division of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany
| | - E Meyer
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Berlin, Germany
| | - H Mittermayer
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - U Porsche
- Department for Clinical Pharmacy and Drug Information, Landesapotheke, Landeskliniken Salzburg (SALK), Salzburg, Austria
| | - E Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - S Reuter
- Clinic for General Internal Medicine, Infectious Diseases, Pneumology and Osteology, Klinikum Leverkusen, Leverkusen, Germany
| | - B Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Strauß
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Erlangen, Germany
| | - A Wechsler-Fördös
- Department of Antibiotics and Infection Control, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Wenisch
- Medical Department of Infection and Tropical Medicine, Kaiser Franz Josef Hospital, Vienna, Austria
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, Freiburg University Medical Center, Freiburg, Germany
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Smith RG, Joseph WS. Antibiotic stewardship: the lower-extremity physician's prescription for effectively treating infection. J Am Podiatr Med Assoc 2016; 104:77-84. [PMID: 24504581 DOI: 10.7547/0003-0538-104.1.77] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The discovery of antibiotic drugs was one of the most significant medical achievements of the 20th century. The improper use of antibiotic drugs to prevent and treat infections has resulted in the emergence of resistance. Antimicrobic stewardship programs are becoming a mainstay in the fight against multidrug-resistant organisms. Individual clinicians should be encouraged to adopt the principles of antibiotic stewardship when treating lower-extremity infections in their scope of practice. First, a review of the available literature outlining the concept and practice of antibiotic stewardship is offered. Second, a discussion describing how to adopt and apply these principles to the individual clinician's practice as it applies to lower-extremity infections is offered. Finally, specific antimicrobial pharmacologic spectra and antibiogram information are offered.
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Avent ML, Hall L, Davis L, Allen M, Roberts JA, Unwin S, McIntosh KA, Thursky K, Buising K, Paterson DL. Antimicrobial stewardship activities: a survey of Queensland hospitals. AUST HEALTH REV 2016; 38:557-63. [PMID: 25376911 DOI: 10.1071/ah13137] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 08/20/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE In 2011, the Australian Commission on Safety and Quality in Health Care (ACSQHC) recommended that all hospitals in Australia must have an Antimicrobial Stewardship (AMS) program by 2013. Nevertheless, little is known about current AMS activities. This study aimed to determine the AMS activities currently undertaken, and to identify gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. METHODS The AMS activities of 26 facilities from 15 hospital and health services in Queensland were surveyed during June 2012 to address strategies for effective AMS: implementing clinical guidelines, formulary restriction, reviewing antimicrobial prescribing, auditing antimicrobial use and selective reporting of susceptibility results. RESULTS The response rate was 62%. Nineteen percent had an AMS team (a dedicated multidisciplinary team consisting of a medically trained staff member and a pharmacist). All facilities had access to an electronic version of Therapeutic Guidelines: Antibiotic, with a further 50% developing local guidelines for antimicrobials. One-third of facilities had additional restrictions. Eighty-eight percent had advice for restricted antimicrobials from in-house infectious disease physicians or clinical microbiologists. Antimicrobials were monitored with feedback given to prescribers at point of care by 76% of facilities. Deficiencies reported as barriers to establishing AMS programs included: pharmacy resources, financial support by hospital management, and training and education in antimicrobial use. CONCLUSIONS Several areas for improvement were identified: reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use. There also appears to be a lack of resources to support AMS programs in some facilities. WHAT IS KNOWN ABOUT THE TOPIC?: The ACSQHC has recommended that all hospitals implement an AMS program by 2013 as a requirement of Standard 3 (Preventing and Controlling Healthcare-Associated Infections) of the National Safety and Quality Health Service Standards. The intent of AMS is to ensure appropriate prescribing of antimicrobials as part of the broader systems within a health service organisation to prevent and manage healthcare-associated infections, and improve patient safety and quality of care. This criterion also aligns closely with Standard 4: Medication Safety. Despite this recommendation, little is known about what AMS activities are undertaken in these facilities and what additional resources would be required in order to meet these national standards. WHAT DOES THE PAPER ADD?: This is the first survey that has been conducted of public hospital and health services in Queensland, a large decentralised state in Australia. This paper describes what AMS activities are currently being undertaken, identifies practice gaps, barriers to implementation and opportunities for improvement in Queensland hospitals. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS?: Several areas for improvement such as reviewing antimicrobial prescribing with feedback to the prescriber, auditing, and training and education in antimicrobial use have been identified. In addition, there appears to be a lack of resources to support AMS programs in some facilities.
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Affiliation(s)
- Minyon L Avent
- Infection and Immunity Theme, UQ Centre for Clinical Research (UQCCR), Level 8, Building 71/918 Royal Brisbane and Women's Hospital, Herston, Qld 4006, Australia.
| | - Lisa Hall
- Centre for Healthcare Related Infection Surveillance and Prevention, Communicable Diseases Unit, Queensland Health, Herston, Qld 4006, Australia.
| | - Louise Davis
- Centre for Healthcare Related Infection Surveillance and Prevention, Communicable Diseases Unit, Queensland Health, Herston, Qld 4006, Australia.
| | - Michelle Allen
- Centre for Healthcare Related Infection Surveillance and Prevention, Communicable Diseases Unit, Queensland Health, Herston, Qld 4006, Australia.
| | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Level 3 Ned Hanlon Building, Royal Brisbane and Women's Hospital, Butterfield St, Herston, Qld 4029, Australia.
| | - Sean Unwin
- Princess Alexandra Hospital, Woolloongabba, Qld 4102, Australia.
| | - Kylie A McIntosh
- Department of Health, 50 Lonsdale Street, Melbourne, Victoria 3000.
| | - Karin Thursky
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Melbourne, Vic. 3000, Australia.
| | - Kirsty Buising
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Melbourne, Vic. 3000, Australia.
| | - David L Paterson
- Infection and Immunity Theme, UQ Centre for Clinical Research (UQCCR), Level 8, Building 71/918 Royal Brisbane and Women's Hospital, Herston, Qld 4006, Australia.
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Beaudoin M, Kabanza F, Nault V, Valiquette L. Evaluation of a machine learning capability for a clinical decision support system to enhance antimicrobial stewardship programs. Artif Intell Med 2016; 68:29-36. [PMID: 26947174 DOI: 10.1016/j.artmed.2016.02.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 01/29/2016] [Accepted: 02/15/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Antimicrobial stewardship programs have been shown to limit the inappropriate use of antimicrobials. Hospitals are increasingly relying on clinical decision support systems to assist in the demanding prescription reviewing process. In previous work, we have reported on an emerging clinical decision support system for antimicrobial stewardship that can learn new rules supervised by user feedback. In this paper, we report on the evaluation of this system. METHODS The evaluated system uses a knowledge base coupled with a supervised learning module that extracts classification rules for inappropriate antimicrobial prescriptions using past recommendations for dose and dosing frequency adjustments, discontinuation of therapy, early switch from intravenous to oral therapy, and redundant antimicrobial spectrum. Over five weeks, the learning module was deployed alongside the baseline system to prospectively evaluate its ability to discover rules that complement the existing knowledge base for identifying inappropriate prescriptions of piperacillin-tazobactam, a frequently used antimicrobial. RESULTS The antimicrobial stewardship pharmacists reviewed 374 prescriptions, of which 209 (56% of 374) were identified as inappropriate leading to 43 recommendations to optimize prescriptions. The baseline system combined with the learning module triggered alerts in 270 prescriptions with a positive predictive value of identifying inappropriate prescriptions of 74%. Of these, 240 reviewed prescriptions were identified by the alerts of the baseline system with a positive predictive value of 82% and 105 reviewed prescriptions were identified by the alerts of the learning module with a positive predictive value of 62%. The combined system triggered alerts for all 43 recommendations, resulting in a rate of actionable alerts of 16% (43 recommendations of 270 reviewed alerts); the baseline system triggered alerts for 38 interventions, resulting in a rate of actionable alerts of 16% (38 of 240 reviewed alerts); and the learning module triggered alerts for 17 interventions, resulting in a rate of actionable alerts of 16% (17 of 105 reviewed alerts). The learning module triggered alerts for every inappropriate prescription missed by the knowledge base of the baseline system (n=5). CONCLUSIONS The learning module was able to extract clinically relevant rules for multiple types of antimicrobial alerts. The learned rules were shown to extend the knowledge base of the baseline system by identifying pharmacist interventions that were missed by the baseline system. The learned rules identified inappropriate prescribing practices that were not supported by local experts and were missing from its knowledge base. However, combining the baseline system and the learning module increased the number of false positives.
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Affiliation(s)
- Mathieu Beaudoin
- Department of Computer Science, Université de Sherbrooke, 2500 boul. de l'Université, Sherbrooke, Québec, Canada J1K 2R1.
| | - Froduald Kabanza
- Department of Computer Science, Université de Sherbrooke, 2500 boul. de l'Université, Sherbrooke, Québec, Canada J1K 2R1.
| | - Vincent Nault
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, Québec, Canada J1H 5N4.
| | - Louis Valiquette
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, Québec, Canada J1H 5N4.
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Dodds Ashley ES, Kaye KS, DePestel DD, Hermsen ED. Antimicrobial stewardship: philosophy versus practice. Clin Infect Dis 2015; 59 Suppl 3:S112-21. [PMID: 25261538 DOI: 10.1093/cid/ciu546] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
To promote the judicious use of antimicrobials and preserve their usefulness in the setting of growing resistance, a number of policy-making bodies and professional societies have advocated the development of antimicrobial stewardship programs. Although these programs have been implemented at many institutions in the United States, their impact has been difficult to measure. Current recommendations advocate the use of both outcome and process measures as metrics for antimicrobial stewardship. Although patient outcome metrics have the greatest impact on the quality of care, the literature shows that antimicrobial use and costs are the indicators measured most frequently by institutions to justify the effectiveness of antimicrobial stewardship programs. The measurement of more meaningful outcomes has been constrained by difficulties inherent to these measures, lack of funding and resources, and inadequate study designs. Antimicrobial stewardship can be made more credible by refocusing the antimicrobial review process to target specific disease states, reassessing the usefulness of current metrics, and integrating antimicrobial stewardship program initiatives into institutional quality and safety efforts.
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Affiliation(s)
| | - Keith S Kaye
- Division of Infectious Diseases, Wayne State University School of Medicine and Detroit Medical Center, Michigan
| | - Daryl D DePestel
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts
| | - Elizabeth D Hermsen
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha
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Recognition of Advanced Pharmacy Practice Experience Student Participation Within Antimicrobial Stewardship Activities. J Pharm Technol 2015; 31:3-7. [DOI: 10.1177/8755122514545885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Antimicrobial stewardship is important in managing patients with infectious diseases. Limited data exist documenting the extent of pharmacy student involvement within antimicrobial stewardship activities. Objectives: The purpose of this study was to document the types of hospital-based antimicrobial stewardship activities in which Advanced Pharmacy Practice Experience (APPE) students are involved. Methods: A questionnaire was developed using the most current guideline for developing an institutional antimicrobial stewardship program. It was designed to collect preceptor-reported perceptions and APPE student involvement in antimicrobial stewardship activities. Pharmacist preceptors of APPE students from 2 Florida Colleges of Pharmacy were surveyed in October 2011. Questionnaires fully completed by hospital pharmacists currently serving as an APPE preceptor were included. Results: Forty-eight questionnaires met all inclusion criteria, collectively reporting APPE student participation within every element of antimicrobial stewardship. The most common areas of student participation were dose optimization based on patient characteristics (n = 40, 83%), acquiring patient information for prospective audit with feedback (n = 39, 81%), intravenous to oral conversion (n = 37, 77%), and pharmacokinetic services (n = 36, 75%). Anti-infective subcommittee participation (n = 3, 6%) was uncommon. Respondent perceptions were overall favorable regarding student participation in antimicrobial stewardship activities. Conclusion: With supervision from pharmacist preceptors, APPE students from 2 Florida colleges of pharmacy were reported to participate in each element and activity of antimicrobial stewardship as set forth by current guidelines. The role and value of such involvement is not fully understood. Future research investigating activity-specific outcomes and policy creation are needed to guide appropriate use of APPE students as a resource for optimizing antimicrobial use in hospitals.
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18
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Antimicrobial use metrics and benchmarking to improve stewardship outcomes: methodology, opportunities, and challenges. Infect Dis Clin North Am 2015; 28:195-214. [PMID: 24857388 DOI: 10.1016/j.idc.2014.01.006] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Measurement of antimicrobial use before and after an intervention and the associated outcomes are key activities of antimicrobial stewardship programs. In the United States, the recommended metric for aggregate antibiotic use is days of therapy/1000 patient-days. Clinical outcomes, including response to therapy and bacterial resistance, are critical measures but are more difficult to document than economic outcomes. Interhospital benchmarking of risk adjusted antimicrobial use is possible, although several obstacles remain before it can have an impact on patient care. Many challenges for stewardship programs remain, but the methods and science to support their efforts are rapidly evolving.
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Hermsen ED, VanSchooneveld TC, Sayles H, Rupp ME. Implementation of a Clinical Decision Support System for Antimicrobial Stewardship. Infect Control Hosp Epidemiol 2015; 33:412-5. [DOI: 10.1086/664762] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Clinical decision support systems (CDSSs) for antimicrobial stewardship require considerable human resources and financial investments. This pre-/postimplementation study evaluated the effect of a CDSS on performance of prospective audit with intervention and feedback and demonstrated an increase in interventions and recommendation acceptance countered by a substantial number of non-actionable alerts.
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20
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Lew KY, Ng TM, Tan M, Tan SH, Lew EL, Ling LM, Ang B, Lye D, Teng CB. Safety and clinical outcomes of carbapenem de-escalation as part of an antimicrobial stewardship programme in an ESBL-endemic setting. J Antimicrob Chemother 2014; 70:1219-25. [PMID: 25473028 DOI: 10.1093/jac/dku479] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To evaluate the safety and clinical outcomes of patients who received carbapenem de-escalation as guided by an antimicrobial stewardship programme (ASP) in a setting where ESBL-producing Enterobacteriaceae are endemic. METHODS Patients receiving meropenem or imipenem underwent a prospective ASP review for eligibility for de-escalation according to defined institutional guidelines. Patients in whom carbapenem was de-escalated or not de-escalated, representing the acceptance and rejection of the ASP recommendation, respectively, were compared. The primary outcome was the clinical success rate; secondary outcomes included the 30 day readmission and mortality rates, the duration of carbapenem therapy, the incidence of adverse drug reactions due to antimicrobials, the acquisition of carbapenem-resistant Gram-negative bacteria and the occurrence of Clostridium difficile-associated diarrhoea (CDAD). RESULTS The de-escalation recommendations for 300 patients were evaluated; 204 (68.0%) were accepted. The patient demographics and disease severity were similar. The clinical success rates were similar [de-escalated versus not de-escalated, 183/204 (89.7%) versus 85/96 (88.5%), P=0.84], as was the survival at hospital discharge [173/204 (84.8%) versus 79/96 (82.3%), P=0.58]. In the de-escalated group, the duration of carbapenem therapy was shorter (6 versus 8 days, P<0.001), the rate of adverse drug reactions was lower [11/204 (5.4%) versus 12/96 (12.5%), P=0.037], there was less diarrhoea [9/204 (4.4%) versus 12/96 (12.5%), P=0.015], there was a lower incidence of carbapenem-resistant Acinetobacter baumannii acquisition [4/204 (2.0%) versus 7/96 (7.3%), P=0.042] and there was a lower incidence of CDAD [2/204 (1.0%) versus 4/96 (4.2%), P=0.081]. CONCLUSIONS This study suggests that the ASP-guided de-escalation of carbapenems led to comparable clinical success, fewer adverse effects and a lower incidence of the development of resistance. This approach is safe and practicable, and should be a key component of an ASP.
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Affiliation(s)
- Kaung Yuan Lew
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, 117543 Singapore
| | - Tat Ming Ng
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Michelle Tan
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Sock Hoon Tan
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Ee Ling Lew
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Li Min Ling
- Communicable Disease Center, Institute of Infectious Diseases and Epidemiology, Department of Infectious Disease, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - Brenda Ang
- Communicable Disease Center, Institute of Infectious Diseases and Epidemiology, Department of Infectious Disease, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
| | - David Lye
- Communicable Disease Center, Institute of Infectious Diseases and Epidemiology, Department of Infectious Disease, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road 119228, Singapore
| | - Christine B Teng
- Department of Pharmacy, Faculty of Science, National University of Singapore, 18 Science Drive 4, 117543 Singapore Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng 308433, Singapore
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Abstract
A thorough knowledge of the principles of antibiotic stewardship is a crucial part of high-quality orthopaedic surgical care. These principles include (1) determining appropriate indications for antibiotic administration, (2) choosing the correct antibiotic based on known or expected pathogens, (3) determining the correct dosage, and (4) determining the appropriate duration of treatment. Antibiotic stewardship programs have a multidisciplinary staff that can help guide antibiotic selection and dosage. These programs also perform active surveillance of antimicrobial use and may reduce Clostridium difficile and other drug-resistant bacterial infections by providing expert guidance on judicious antibiotic usage. The emergence of antibiotic-resistant pathogens, the geographical diversity of these infecting pathogens, and the changing patient population require customization of prophylactic regimens to reduce infectious complications. A multidisciplinary approach to antibiotic stewardship can lead to improved patient outcomes and cost-effective medical care.
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Ruhnke M, Arnold R, Gastmeier P. Infection control issues in patients with haematological malignancies in the era of multidrug-resistant bacteria. Lancet Oncol 2014; 15:e606-e619. [PMID: 25456379 DOI: 10.1016/s1470-2045(14)70344-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Drug-resistant Gram-negative and Gram-positive bacteria are now increasingly identified as a cause of infections in immunocompromised hosts. Bacteria identified include the multidrug-resistant (MDR) and even pandrug-resistant Acinetobacter baumannii and Pseudomonas aeruginosa, as well as carbapenem-resistant Enterobacteriaceae spp. The threat from MDR pathogens has been well-documented in the past decade with warnings about the consequences of inappropriate use of antimicrobial drugs. Resistant bacteria can substantially complicate the treatment of infections in critically ill patients and can have a substantial effect on mortality. Inappropriate antimicrobial treatment can affect morbidity, mortality, and overall health-care costs. Evidence-based data for prevention and control of MDR pathogen infections in haematology are scarce. Although not yet established a bundle of infection control and prevention measures with an anti-infective stewardship programme is an important strategy in infection control, diagnosis, and antibiotic selection with optimum regimens to ensure a successful outcome for patients.
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Affiliation(s)
- Markus Ruhnke
- Department of Hematology and Oncology, Paracelsus-Hospital Osnabrück, Germany.
| | - Renate Arnold
- Medical Department, Division of Haematology, Oncology and Tumour Immunology, Charité Campus Virchow Klinikum, Institute of Hygiene and Environmental Medicine, University Medicine, Berlin, Germany
| | - Petra Gastmeier
- Medical Department, Division of Haematology, Oncology and Tumour Immunology, Charité Campus Benjamin Franklin, Institute of Hygiene and Environmental Medicine, University Medicine, Berlin, Germany
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Hermsen ED, McDaneld PM, Eiland EH, Destache CJ, Lusardi K, Estrada SJ, Mercier RC, DePestel DD, Lamp KC, Anderson E, Chung TJ, McKinnon PS. Breaking down the barriers: challenges with development and implementation of an industry-sponsored antimicrobial stewardship data collection and analysis tool. Clin Infect Dis 2014; 59 Suppl 3:S179-84. [PMID: 25261545 DOI: 10.1093/cid/ciu539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Partnership between clinicians and the pharmaceutical industry with a focus on antimicrobial stewardship research initiatives is a necessary step toward meeting the shared goals of combating inappropriate antimicrobial use, improving patient outcomes, and minimizing resistance development. Achieving these goals requires outcomes-focused data collection and monitoring tools for antimicrobial stewardship programs (ASP) that consider real-world data about how antimicrobials are used to treat patients. Here we highlight the experiences and challenges associated with the development and implementation of an industry-sponsored electronic antimicrobial stewardship data collection and analysis tool (AS-DCAT). The benefits and risks of the industry-sponsored AS-DCAT from the perspectives of the sponsoring company and participating sites are discussed. Barriers encountered as well as general considerations and recommendations for preventing or overcoming those barriers for future studies and tool development are provided.
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Affiliation(s)
- Elizabeth D Hermsen
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha
| | - Patrick M McDaneld
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Worcester/Manchester
| | | | | | - Katherine Lusardi
- Department of Pharmacy, University of Arkansas for Medical Sciences Medical Center, Little Rock
| | - Sandy J Estrada
- Department of Pharmacy, Lee Memorial Health System, Fort Myers, Florida
| | | | - Daryl D DePestel
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts
| | - Kenneth C Lamp
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts
| | - Evette Anderson
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts
| | - Thomas J Chung
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts
| | - Peggy S McKinnon
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts
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Pujol M, Delgado O, Puigventós F, Corzo JE, Cercenado E, Martínez JA. Evaluation of new antimicrobials for the hospital formulary. Policies restricting antibiotic use in hospitals. Enferm Infecc Microbiol Clin 2014; 31 Suppl 4:45-50. [PMID: 24129289 DOI: 10.1016/s0213-005x(13)70132-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In Spain, the inclusion of new antibiotics in hospital formularies is performed by the Infection Policy Committee or the Pharmacy and Therapeutic Committee, although now the decision is moving to a regional level. Criteria for the evaluation of new drugs include efficacy, safety and cost. For antimicrobial drugs evaluation it is necessary to consider local sensibility and impact in bacterial resistance to determinate the therapeutic positioning. There is compelling evidence that the use of antibiotics is associated with increasing bacterial resistance, and a great number of antibiotics are used incorrectly. In order to decrease the inappropriate use of antibiotics, several approaches have been proposed. Limiting the use of antimicrobials through formulary restrictions, often aimed at drugs with a specific resistance profile, shows benefits in improving antimicrobial susceptibilities and decreasing colonization by drug-resistant organisms. However, the restriction of one agent may result in the increased utilization of other agents. By using antibiotic cycling, the amount of antibiotics is maintained below the threshold where bacterial resistance develops, thus preserving highly efficient antibiotics. Unfortunately, cumulative evidence to date suggests that antibiotic cycling has limited efficacy in preventing antibiotic resistance. Finally, although there is still little clinical evidence available on antibiotic heterogeneity, the use of most of the existing antimicrobial classes could limit the emergence of resistance. This review summarizes information regarding antibiotic evaluation and available restrictive strategies to limit the use of antibiotics at hospitals with the aim of curtailing increasing antibiotic resistance.
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Affiliation(s)
- Miquel Pujol
- Servicio de Enfermedades Infecciosas, Hospital Universitario de Bellvitge, IDIBELL, Universitat de Barcelona, Barcelona, Spain.
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Mehta JM, Haynes K, Wileyto EP, Gerber JS, Timko DR, Morgan SC, Binkley S, Fishman NO, Lautenbach E, Zaoutis T. Comparison of prior authorization and prospective audit with feedback for antimicrobial stewardship. Infect Control Hosp Epidemiol 2014; 35:1092-9. [PMID: 25111916 PMCID: PMC4198070 DOI: 10.1086/677624] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Although prior authorization and prospective audit with feedback are both effective antimicrobial stewardship program (ASP) strategies, the relative impact of these approaches remains unclear. We compared these core ASP strategies at an academic medical center. DESIGN Quasi-experimental study. METHODS We compared antimicrobial use during the 24 months before and after implementation of an ASP strategy change. The ASP used prior authorization alone during the preintervention period, June 2007 through May 2009. In June 2009, many antimicrobials were unrestricted and prospective audit was implemented for cefepime, piperacillin/tazobactam, and vancomycin, marking the start of the postintervention period, July 2009 through June 2011. All adult inpatients who received more than or equal to 1 dose of an antimicrobial were included. The primary end point was antimicrobial consumption in days of therapy per 1,000 patient-days (DOT/1,000-PD). Secondary end points included length of stay (LOS). RESULTS In total, 55,336 patients were included (29,660 preintervention and 25,676 postintervention). During the preintervention period, both total systemic antimicrobial use (-9.75 DOT/1,000-PD per month) and broad-spectrum anti-gram-negative antimicrobial use (-4.00 DOT/1,000-PD) declined. After the introduction of prospective audit with feedback, however, both total antimicrobial use (+9.65 DOT/1,000-PD per month; P < .001) and broad-spectrum anti-gram-negative antimicrobial use (+4.80 DOT/1,000-PD per month; P < .001) increased significantly. Use of cefepime and piperacillin/tazobactam both significantly increased after the intervention (P = .03). Hospital LOS and LOS after first antimicrobial dose also significantly increased after the intervention (P = .016 and .004, respectively). CONCLUSIONS Significant increases in antimicrobial consumption and LOS were observed after the change in ASP strategy.
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Affiliation(s)
- Jimish M. Mehta
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin Haynes
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - E. Paul Wileyto
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S. Gerber
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel R. Timko
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven C. Morgan
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shawn Binkley
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil O. Fishman
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theoklis Zaoutis
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Ruhnke M. Antifungal stewardship in invasive Candida infections. Clin Microbiol Infect 2014; 20 Suppl 6:11-8. [DOI: 10.1111/1469-0691.12622] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 03/06/2014] [Accepted: 03/08/2014] [Indexed: 11/28/2022]
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Spivey JR, Townsend ML, Drew RH. Workforce Supply and Training in Antimicrobial Stewardship. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2014. [DOI: 10.1007/s40506-014-0012-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Cruickshank M, Duguid M, Gotterson F, Carter D. Taking action to preserve the miracle of antibiotics. Aust Vet J 2014; 92:3-7. [DOI: 10.1111/avj.12144] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2013] [Indexed: 11/28/2022]
Affiliation(s)
- M Cruickshank
- Australian Commission on Safety and Quality in Health Care (ACSQHC); Sydney New South Wales Australia
- Chair: Antimicrobial Resistance Standing Committee (AMRSC); Sydney New South Wales Australia
| | - M Duguid
- Australian Commission on Safety and Quality in Health Care (ACSQHC); Sydney New South Wales Australia
| | - F Gotterson
- Australian Commission on Safety and Quality in Health Care (ACSQHC); Sydney New South Wales Australia
| | - D Carter
- Australian Commission on Safety and Quality in Health Care (ACSQHC); Sydney New South Wales Australia
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Crader MF. Development of antimicrobial competencies and training for staff hospital pharmacists. Hosp Pharm 2014; 49:32-40. [PMID: 24421561 DOI: 10.1310/hpj4901-32] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Antimicrobial stewardship is an important component in health care outcomes of all patients. Many institutions are seeking the best methods to incorporate antimicrobial stewardship strategies into their hospitals including pharmacy services. Multiple factors should be considered when beginning or expanding an antimicrobial stewardship program. The purpose of this article is to discuss the development of basic antibiotic competencies and training for staff pharmacists in a community hospital. The article includes an assessment of pharmacists' knowledge pre education and post education, perception of benefits from an antibiotic education program, and learning needs and preferences.
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Affiliation(s)
- Marsha F Crader
- Associate Professor of Pharmacy Practice, University of Arkansas for Medical Sciences College of Pharmacy, 4301 W. Markham Street, Slot #522, Little Rock, AR 72205; phone: 870-207-4463; e-mail:
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30
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Griffith M, Postelnick M, Scheetz M. Antimicrobial stewardship programs: methods of operation and suggested outcomes. Expert Rev Anti Infect Ther 2014; 10:63-73. [DOI: 10.1586/eri.11.153] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Sallach-Ruma R, Nieman J, Sankaranarayanan J, Reardon T. Correlates and Economic and Clinical Outcomes of an Adult IV to PO Antimicrobial Conversion Program at an Academic Medical Center in Midwest United States. J Pharm Pract 2014; 28:238-48. [DOI: 10.1177/0897190013516367] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The study objectives were to evaluate the correlates and outcomes of a parenteral (IV) to oral (PO) antimicrobial conversion program at a Midwest US Academic Medical Center with the hypothesis that it will be associated with reduced drug costs. Patient-level data (n = 237; sex, race, admission source, admission status, admission severity, risk of mortality [relative expected, admission], and early death) were extracted from the Clinical Data Base/Resource Manager. Medication-level, drug-encounter data (n = 317; antibiotic/dose/route/frequency/duration, conversion status, 10-day IV/PO switch-eligibility criteria) were extracted from patient’s hospital medical records. Univariate analyses using chi-square or Fisher’s exact test for categorical variables and Wilcoxon rank-sum test for continuous variables showed patients not converted (n = 149) versus converted (n = 88) at some point from IV to PO were more likely to be of white race and had higher risk of relative expected mortality. By applying the unit drug cost (derived from 2010 Thomson Reuters RED BOOKTM) and labor costs for IV/PO administration, both per dose, the overall 1-month drug cost-saving estimates in 2010 in US dollars were US$5242 from converting and US$8805 savings missed from not converting 518 and 1387 switch-eligible antibiotic doses, respectively. Despite sample-size limitations, this study demonstrated correlates and missed opportunities to convert antimicrobials from IV to PO, which warrants providers’ attention.
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Affiliation(s)
- Rory Sallach-Ruma
- Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jennifer Nieman
- Pharmacy Relations & Clinical Decision Support, The Nebraska Medical Center, Omaha, NE, USA
| | - Jayashri Sankaranarayanan
- Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut/Hartford Hospital, Storrs, CT, USA
| | - Tom Reardon
- Information Technology Services, University of Nebraska Medical Center, Omaha, NE, USA
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Chahine EB, El-Lababidi RM, Sourial M. Engaging Pharmacy Students, Residents, and Fellows in Antimicrobial Stewardship. J Pharm Pract 2014; 28:585-91. [PMID: 24399574 DOI: 10.1177/0897190013516506] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antimicrobial stewardship programs are mainly established by infectious diseases physicians and infectious diseases-trained clinical pharmacists with the goal of optimizing patients' outcomes while halting antimicrobial resistance, decreasing adverse events, and controlling health care cost. The role of the infectious diseases-trained clinical pharmacist in antimicrobial stewardship is well established; however, there are not enough formally trained pharmacists to assume the challenging responsibilities of the steward coordinator. The purpose of this article was to review the available literature and resources and propose a model to engage introductory pharmacy practice experience students, advanced pharmacy practice experience students, postgraduate year (PGY) 1 pharmacy residents, PGY2 infectious diseases pharmacy residents, and PGY2 or PGY3 infectious diseases pharmacy fellows in antimicrobial stewardship. Further studies are needed to assess and document the impact of pharmacy students and postgraduate trainees on antimicrobial stewardship programs.
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Trivedi KK, Rosenberg J. The state of antimicrobial stewardship programs in California. Infect Control Hosp Epidemiol 2013; 34:379-84. [PMID: 23466911 DOI: 10.1086/669876] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess antimicrobial stewardship programs (ASPs) and strategies in California general acute care hospitals and to describe the effect of state legislation (Senate Bill 739) requiring hospitals to develop processes for evaluating the judicious use of antimicrobials. DESIGN Web-based survey of general acute care hospitals. PARTICIPANTS All 422 general acute care hospital campuses in California were invited to participate. RESULTS Responses from 223 (53%) of California's general acute care hospital campuses were included and were statistically representative of all acute care hospital campuses by region but not bed size or rurality. Community hospitals represented 73% of respondents. Fifty percent of hospitals described a current ASP and 30% reported planning an ASP; of these, 51% reported measuring outcomes. Twenty percent of hospitals reported no planned ASP or uncertainty whether an ASP existed and described barriers including staffing constraints (47%), lack of funding (42%), and lack of initiation of a formal proposal to start an ASP (42%). Of 135 responding hospitals, 22% reported that Senate Bill 739 influenced initiation of their ASP. CONCLUSIONS Although many studies have been published that describe hospital-specific ASPs, most have been described within academic centers, and there are limited assessments of ASP strategies across hospital systems. Our study verifies that many ASPs exist in California, particularly in community settings where a scarcity of antimicrobial restriction was thought to exist. Additionally, Senate Bill 739 appears to have played a role in initiating many hospital ASPs, which supports the adoption of similar legislation in other states and nationally.
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Affiliation(s)
- Kavita K Trivedi
- Healthcare-Associated Infections Program, California Department of Public Health, Richmond, CA 94804, USA.
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Reed EE, Stevenson KB, West JE, Bauer KA, Goff DA. Impact of formulary restriction with prior authorization by an antimicrobial stewardship program. Virulence 2012; 4:158-62. [PMID: 23154323 PMCID: PMC3654616 DOI: 10.4161/viru.21657] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
In an era of increasing antimicrobial resistance and few antimicrobials in the developmental pipeline, many institutions have developed antimicrobial stewardship programs (ASPs) to help implement evidence-based (EB) strategies for ensuring appropriate utilization of these agents. EB strategies for accomplishing this include formulary restriction with prior authorization. Potential limitations to this particular strategy include delays in therapy, prescriber pushback, and unintended increases in use of un-restricted antimicrobials; however, our ASP found that implementing prior authorization for select antimicrobials along with making a significant effort to educate clinicians on criteria for use ensured more appropriate prescribing of these agents, hopefully helping to preserve their utility for years to come.
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Affiliation(s)
- Erica E Reed
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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35
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Khadem TM, Dodds Ashley E, Wrobel MJ, Brown J. Antimicrobial Stewardship: A Matter of Process or Outcome? Pharmacotherapy 2012; 32:688-706. [DOI: 10.1002/j.1875-9114.2012.01154.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Tina M. Khadem
- Department of Pharmacy; University of Rochester Medical Center; Rochester; New York
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36
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Goff DA, Jankowski C, Tenover FC. Using Rapid Diagnostic Tests to Optimize Antimicrobial Selection in Antimicrobial Stewardship Programs. Pharmacotherapy 2012; 32:677-87. [DOI: 10.1002/j.1875-9114.2012.01137.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Debra A. Goff
- Department of Pharmacy; The Ohio State University Medical Center; Columbus; Ohio
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37
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Michaels K, Mahdavi M, Krug A, Kuper K. Implementation of an Antimicrobial Stewardship Program in a Community Hospital: Results of a Three-Year Analysis. Hosp Pharm 2012. [DOI: 10.1310/hpj4708-608] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background In July 2007, the Pharmacy Department at Suburban Hospital implemented an antimicrobial stewardship program (ASP) using existing clinical pharmacy resources that did not include an on-site infectious diseases (ID) pharmacist. Medical staff personnel were supportive of the ASP, but there were no ID physician resources actively dedicated to the program. Remote access to an ID pharmacist was available. Objectives This program evaluated the impact of a pharmacy-driven ASP on cost, antimicrobial utilization, and quality indicators in a community hospital with limited ID professional resources. Methods The tenets of the program were adopted from recommendations in the most current Infectious Diseases Society of America/Society for Healthcare Epidemiology of America antimicrobial stewardship guidelines. Antimicrobial utilization, cost, prospective medication use data, and interventions were tracked using customized spreadsheets. Three years of utilization and cost data were captured to provide a baseline and post implementation comparison. Results Antimicrobial utilization decreased 5.2% compared to baseline ( P < .001) as measured by the defined daily dose (DDD) per 1,000 patient days. The associated cost reduction during the period was 24% compared to baseline ( P < .001), resulting in estimated savings of approximately $290,000. Quality of care indicators improved, and physicians were responsive to daily clinical pharmacist review and pharmacy interventions. Conclusions An ASP can be implemented in a community hospital setting with existing clinical pharmacy resources that do not include an ID specialist dedicated full time to the program. Prospective monitoring of antimicrobial usage resulted in decreased antimicrobial cost and utilization and improvements on key quality of care indicators. Based on this evidence of success, the program continues.
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Affiliation(s)
| | | | - Allison Krug
- Statistical Analysis, Artemis Biomedical Communications LLC, Bainbridge Island, Washington
| | - Kristi Kuper
- Infectious Diseases, Cardinal Health Pharmacy Solutions, Houston, Texas
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38
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Jahansouz F, Lee J, James CL. Enforcement of antimicrobial policy through restrictions built into system for computerized prescriber order entry. Am J Health Syst Pharm 2012; 69:1191. [DOI: 10.2146/ajhp120244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Farivar Jahansouz
- Skaggs School of Pharmacy and Pharmaceutical Sciences University of California San Diego 9500 Gilman Drive #0719 La Jolla, CA 92093-0719
| | | | - Charles L. James
- Department of Pharmacy University of California San Diego Health System San Diego, CA
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40
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Teng CB, Lee W, Yeo CL, Lee SY, Ng TM, Yeoh SF, Lim WH, Kwa AL, Thoon KC, Ooi ST, Tan TY, Hsu LY, Lye DC, Chlebicki MP. Guidelines for Antimicrobial Stewardship Training and Practice. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2012. [DOI: 10.47102/annals-acadmedsg.v41n1p29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Li Yang Hsu
- National University Health System, Singapore
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41
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Kaye KS. Antimicrobial de-escalation strategies in hospitalized patients with pneumonia, intra-abdominal infections, and bacteremia. J Hosp Med 2012; 7 Suppl 1:S13-21. [PMID: 23677630 DOI: 10.1002/jhm.983] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 09/08/2011] [Accepted: 09/13/2011] [Indexed: 01/15/2023]
Abstract
Increasing numbers of serious hospital/healthcare- or community-acquired infections are caused by resistant (often multi-drug resistant) bacterial pathogens. Because delayed or ineffective initial therapy can have severe negative consequences, patients at risk for these types of infections typically receive initial empiric antibiotic therapy with a broad-spectrum regimen covering the most likely pathogens, based on local surveillance data and risk factors for infection with a resistant microorganism. While improving the likelihood of a successful outcome, use of broad-spectrum, often high-dose, empiric antimicrobial therapy also creates pressure for the selection or development of resistant microorganisms, as well as increasing costs and possibly exposing patients to adverse events or collateral damage such as Clostridium difficile-associated disease. De-escalation is a strategy that attempts to balance the competing aims of providing initial empiric therapy that is appropriate and covers the likely pathogens, and limiting antimicrobial exposure and increased risk for emergence of resistant pathogens. More specifically, the de-escalation strategy involves collection of cultures for later microbiological assessment before initiating broad-spectrum empiric therapy covering the most likely pathogens, with the intention of streamlining or de-escalating to a more narrow-spectrum antimicrobial regimen 2-3 days later if warranted by clinical status and culture results. In some cases, negative culture results and subsequent clinical review may allow for termination of initial empiric therapy. In this manner, de-escalation enables more effective targeting of the causative pathogen(s), elimination of redundant therapy, a decrease in antimicrobial pressure for emergence of resistance, and cost savings. This article examines application of the de-escalation strategy to 3 case patients, one with healthcare-associated pneumonia, another with complicated intra-abdominal infection, and a third with central line-associated bacteremia.
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Affiliation(s)
- Keith S Kaye
- Infection Prevention, Epidemiology and Antimicrobial Stewardship, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA.
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Johannsson B, Beekmann SE, Srinivasan A, Hersh AL, Laxminarayan R, Polgreen PM. Improving antimicrobial stewardship: the evolution of programmatic strategies and barriers. Infect Control Hosp Epidemiol 2011; 32:367-74. [PMID: 21460488 DOI: 10.1086/658946] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe the prevalence and characteristics of antimicrobial stewardship programs (ASPs) in hospitals across the United States and to describe financial support provided for these programs. DESIGN Electronic and paper 14-question survey of infectious diseases physician members of the Infectious Diseases Society of America Emerging Infections Network (IDSA EIN). PARTICIPANTS All 1,044 IDSA EIN members who care for adult patients were invited to participate. RESULTS Five hundred twenty-two (50%) members responded. Seventy-three percent of respondents reported that their institutions had or were planning an ASP, compared with 50% reporting the same thing in an EIN survey 10 years before. A shift was noted from formulary restriction alone to use of a set of tailored strategies designed to provide information and feedback to prescribers, particularly in community hospitals. Lack of funding and lack of personnel were reported as major barriers to implementing a program. Fifty-two percent of respondents with an ASP reported that infectious diseases physicians do not receive direct compensation for their participation in the ASP, compared with 18% 10 years ago. CONCLUSIONS The percentage of institutions reporting ASPs has increased over the last decade, although small community hospitals were least likely to have these programs. In addition, ASP strategies have shifted dramatically. Lack of funding remains a key barrier for ASPs, and administrators need additional cost savings data in order to support ASPs. Interestingly, while guidelines and editorials regard compensated participation by an infectious diseases physician in these programs as critical, we found that more than half of the respondents reported no direct compensation for ASP activities.
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Affiliation(s)
- Birgir Johannsson
- Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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Bosso JA, Drew RH. Application of antimicrobial stewardship to optimise management of community acquired pneumonia. Int J Clin Pract 2011; 65:775-83. [PMID: 21676120 DOI: 10.1111/j.1742-1241.2011.02704.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to review the application of antimicrobial stewardship principles to the management of community-acquired pneumonia (CAP). Data from 14 published clinical studies, meta-analyses and practice guidelines regarding the application of antimicrobial stewardship strategies to the management of CAP were identified and analysed. In the context of CAP, application of stewardship strategies (alone or in combination) has been shown to increase physician awareness of guidelines, improve appropriate antimicrobial use and reduce unnecessary antimicrobial prescribing. In addition, application has had a profound favourable impact on patient outcomes, including decreased 30-day mortality and in-hospital mortality rates, reduced length of hospital stay, reduced treatment failure rates and reduced healthcare costs. Antimicrobial stewardship programmes have been demonstrated to successfully increase the level of appropriate antibiotic prescribing, reduce pathogen resistance and improve clinical outcomes in the management of CAP within hospitals. Studies have also shown that adherence to evidence-based guidelines, even at the level of the individual clinician, can have a profound and positive impact on patient outcomes and healthcare costs. Adherence to evidence-based guidelines can have a profound and positive impact on patient outcomes and healthcare costs.
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Affiliation(s)
- J A Bosso
- Department of Clinical Pharmacy & Outcome Sciences, South Carolina College of Pharmacy, Medical University of South Carolina Campus, Charleston, SC 29425, USA.
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McKinnon PS, Boening AJ, Amin AN. Optimizing delivery of care for patients with MRSA infection: focus on transitions of care. Hosp Pract (1995) 2011; 39:18-31. [PMID: 21576894 DOI: 10.3810/hp.2011.04.391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Staphylococcus aureus is among the most prevalent pathogens isolated from hospitalized patients; those infected with methicillin-resistant strains have longer hospital stays and higher total costs compared with those infected by methicillin-susceptible strains. A multidisciplinary team of health care providers, including hospitalists and other hospital-based physicians, clinical pharmacists, infectious disease specialists, infection control professionals, and case managers, is key to improving treatment and outcomes in these patients. Optimizing transitions of care for hospitalized patients with S aureus infections can improve quality and reduce total costs of care. Hospital length of stay can be shortened by initiating timely, appropriate empiric therapy and by transitioning suitable patients to outpatient antimicrobial therapy. The number of hospitalizations can be reduced by identifying patients who are suitable candidates for initial outpatient antimicrobial therapy. Consistent with good antimicrobial stewardship, the risk of resistance can be minimized by de-escalating empiric therapy to a more narrow-spectrum agent once culture and susceptibility testing results are known. There are several antimicrobial agents available for the management of S aureus infections, including methicillin-resistant S aureus. Consideration of these agents' characteristics may facilitate optimal transition of patients through health care settings.
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Grill E, Weber A, Lohmann S, Vetter-Kerkhoff C, Strobl R, Jauch KW. Effects of pharmaceutical counselling on antimicrobial use in surgical wards: intervention study with historical control group. Pharmacoepidemiol Drug Saf 2011; 20:739-46. [PMID: 21452339 DOI: 10.1002/pds.2126] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 01/24/2011] [Accepted: 01/25/2011] [Indexed: 01/12/2023]
Abstract
PURPOSE The objective of this study was to assess the impact of pharmaceutical consulting on the quality of antimicrobial use in a surgical hospital department in a prospective controlled intervention study. METHODS Patients receiving pharmaceutical intervention (intervention group, IG, n = 317) were compared with a historical control group (control group, CG, n = 321). During the control period, antimicrobial use was monitored without intervention. During the subsequent intervention period, a clinical pharmacist reviewed the prescriptions and gave advice on medication. RESULTS Intervention reduced the length of antimicrobial courses (IG = 10 days, CG = 11 days, incidence rate ratio for i.v. versus o.p. = 0.88, 95% confidence interval 0.84 to 0.93) and shortened i.v. administration (IG = 8 days, CG = 10 days, hazard rate = 1.76 in favour of switch from i.v. to p.o., 95% confidence interval 1.23 to 2.52). Intervention also helped to avoid useless combination therapy and reduced total costs for antimicrobials. CONCLUSIONS A clinical pharmacist who reviews prescriptions can promote an increase in efficiency, for example, by shortening the course of treatment. Counselling by ward-based clinical pharmacists was shown to be effective to streamline antimicrobial therapy in surgical units and to increase drug safety.
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Affiliation(s)
- Eva Grill
- Institute for Health and Rehabilitation Sciences, Ludwig Maximilians University, Munich, Germany
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46
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Abstract
PURPOSE OF REVIEW Management of hospital-associated infections (HAIs) has been made more challenging by the increasing proportion of immunocompromised or otherwise severely ill patients and increasing prevalence of antibiotic-resistant pathogens in this environment. This review examines strategies to optimize clinical outcomes and lower healthcare costs for patients with HAIs by focusing on patient-related, pathogen-related, and drug-related factors. RECENT FINDINGS Factors have converged to increase the risk of infection with antibiotic-resistant pathogens in the current hospital environment, including the increasing prevalence of resistant species and number of hospitalized patients with conditions increasingly susceptible to infection with drug-resistant bacteria. Although the list of bacterial pathogens associated with HAIs has been fairly constant over time, the prevalence and resistance profile of these individual species continues to evolve. Periodic antibiograms should be utilized to access local patterns of resistance within the different hospital wards. Outcomes for patients with HAIs are optimized with early empiric treatment with an appropriate regimen, selected on the basis of patient characteristics and local resistance patterns. Dosing strategies should be utilized to ensure that the efficacy of an appropriate antibiotic is optimized, by achieving the pharmacodynamic target predictive of its efficacy. Using these strategies improves quality of care and is associated with lower overall healthcare costs. SUMMARY Bacterial resistance is an increasing problem in the hospital environment, and has been associated with poorer clinical outcomes and elevated healthcare costs. By using patient characteristics, local antibiograms, and dosing strategies to achieve an optimal pharmacodynamic profile, early appropriate empiric therapy can be utilized to improve clinical outcomes, minimize the development of resistance, and reduce healthcare costs.
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Abstract
PURPOSE OF REVIEW Antibiotic resistance continues to rise, whereas development of new agents to counter it has slowed. A heightened need exists to maintain the effectiveness of currently available agents. This review focuses on the need for better antimicrobial stewardship, expected benefits of well designed antimicrobial stewardship programs (ASPs), and provides suggestions for development of an effective ASP. RECENT FINDINGS Healthcare-associated infections (HAIs) are a significant cause of poor treatment outcomes and elevated healthcare and societal costs worldwide. HAIs are often caused by antibiotic-resistant pathogens; overuse of antibiotics has been linked with antibiotic resistance. Benefits of improved antimicrobial stewardship include reduced emergence of antibiotic resistance, limitation of drug-related adverse events, minimization of other consequences of antibiotic use (e.g., superinfection), and reduction of societal and healthcare-related costs. In 2007, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) provided guidelines for the development of institutional programs to enhance antimicrobial stewardship. Experiences at The Ohio State University Medical Center (OSUMC) reinforce this message, while providing specific examples of ways to optimize ASP development and implementation. The focus of an ASP should be on improving quality of care, reducing drug resistance, and cost savings. When implementing an ASP, it is important to identify those most likely to resist the ASP, understand their concerns, and develop easy-to-understand messages that address these concerns and highlight the benefits of the proposed changes. Antibiograms play a key role in identifying local and interdepartmental trends in antibiotic susceptibility or resistance. These data are important not only in devising best-treatment practices for the institution, but also in evaluating the impact of a recently implemented ASP. Other measures of the impact of an ASP should include patient outcomes and overall costs or savings. SUMMARY Better antimicrobial stewardship is needed to limit the emergence of antibiotic resistance, prolong the effectiveness of currently available agents, improve patient outcomes, and reduce healthcare and societal costs associated with HAIs. Guidelines from the IDSA/SHEA and experiences at OSUMC provide examples of how best to develop an institutional ASP to accomplish these goals.
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Abstract
Antibiotic stewardship aims to improve patient care and reduce unwanted consequences of antimicrobial overuse or misuse, including lowered efficacy, emergence of antimicrobial resistance, development of secondary infections, adverse drug reactions, increased length of hospital stay, and additional healthcare costs. Recent guidelines make specific recommendations for the development of institutional programs to enhance antimicrobial stewardship. Optimally, such programs should be comprehensive, multidisciplinary, supported by hospital and medical staff leadership, and should employ evidence-based strategies that best fit local needs and resources. An infectious diseases physician and clinical pharmacist with infectious diseases training are recommended as core members of the multidisciplinary team, although a hospitalist with interest (and perhaps additional training) in antimicrobial therapy may be able to fill the void. Program directors and core members should be compensated for their time. Principal proactive strategies--with evidence supporting their consideration--include prospective audits, with intervention and feedback, formulary restriction, and preauthorization. Other strategies include persistent one-on-one education, guidelines adapted to local needs, and informatics to support clinical decision making. Intervention goals are to prevent unnecessary antimicrobial starts, to streamline or de-escalate therapy early in its course, and to convert from parenteral to oral therapy, optimize dosing, and ensure the appropriate length of therapy. Most community hospitals, if sufficiently resourced, should be able to implement a successful antimicrobial stewardship program. Evidence suggests that good antimicrobial stewardship can lead to less overall and inappropriate antimicrobial use, lower drug-related costs, reductions in Clostridium difficile-associated disease, and, in some studies, less emergence of antimicrobial resistance.
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Affiliation(s)
- Christopher A Ohl
- Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
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McNeil V, Cruickshank M, Duguid M. Safer use of antimicrobials in hospitals: the value of antimicrobial usage data. Med J Aust 2010; 193:S114-7. [PMID: 20955139 DOI: 10.5694/j.1326-5377.2010.tb04026.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Accepted: 08/11/2010] [Indexed: 11/17/2022]
Abstract
The National Antimicrobial Utilisation Surveillance Program (NAUSP) collects aggregate data from hospitals in all Australian states and provides reports of monthly hospital inpatient antimicrobial usage to contributing hospitals. These data provide an Australian peer-group benchmark; hospitals can compare their usage with similar hospitals and identify areas of antimicrobial use that require more in-depth analysis. Overall high usage has been used by hospitals and area health services as a stimulus for initiation or expansion of antimicrobial stewardship programs. High use of particular classes of antimicrobials has triggered individual drug audits and been used to tailor interventions. Longitudinal antimicrobial usage data have been used by hospitals to measure the effects of antimicrobial stewardship strategies and provide feedback to prescribers.
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Affiliation(s)
- Vicki McNeil
- Antimicrobial Utilisation Surveillance Programs, Infection Control Service, Communicable Disease Control Branch, SA Health, Adelaide, SA, Australia.
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[Questionnaire surveying nephrologists on drug dose adjustment in patients with impaired kidney function]. Wien Klin Wochenschr 2010; 122:479-85. [PMID: 20683672 DOI: 10.1007/s00508-010-1421-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Accepted: 07/05/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Our intention was to assess knowledge and requirements related to drug dose adjustment in patients with impaired kidney function. METHOD In 2005, we sent a questionnaire containing 22 questions to nephrologists in Germany and Austria. With 77 responses, the study was not representative. However, it was probably of importance for the target group of practising physicians and potential users of a future drug information system. RESULTS Only 28% of the responding colleagues use the package inserts; these are obviously not considered to be an obligatory guideline for dose adjustment. The most common dosing problems (p < 0.05) were associated with anti-infective (48%) and anti-cancer drugs (25%). The greatest problems with dosing were encountered within intensive care units (29%). The risk of excessive dosing is estimated significantly more serious than the risk of underdosing (51% vs. 23%, p = 0.02). There was support for the statement that for cephalosporin antibiotics the trough levels are more important than peak levels (58% vs. 27%, p < 0.01). However, only 8% knew that in patients with impaired kidney function, trough concentrations of aminoglycosides and vancomycin need to be higher than in patients with normal kidney function for adequate peak levels to be obtained. Forty-five percent of respondents erroneously presumed that ceftriaxone must be adjusted to the kidney function. Half of the respondents were incorrect in assuming that ceftriaxone or moxifloxacin would be removed by dialysis. CONCLUSIONS We see the need for more knowledge-based information on drug dosing in patients with kidney impairment and those in the intensive care unit. The risk to life posed by underdosage might be underestimated, especially for anti-infective drugs.
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