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Mittal N, Verma M, Siwach S, Bansal P, Singhal SK. Drug Utilization Research and Predictors of Outcomes in the Intensive Care Unit of a Tertiary Care Hospital: A Prospective Observational Study. Cureus 2023; 15:e50653. [PMID: 38229777 PMCID: PMC10790238 DOI: 10.7759/cureus.50653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Multiple drugs are commonly prescribed to intensive care unit (ICU) patients owing to the disease profile, multiple organ dysfunction, prophylaxis, management of stress ulcers, nosocomial infections, etc. This study aimed to evaluate the drug utilization patterns and factors influencing mortality and duration of stay in ICU patients. Methodology: A prospective observational study was conducted in the ICU of our tertiary care hospital, Postgraduate Institute of Medical Sciences, Rohtak. Data was collected from treatment charts of patients using a structured pretested proforma. World Health Organization Anatomical Therapeutic Chemical/Defined Daily Dose (WHO ATC/DDD) methodology and core prescribing indicators were used to assess drug utilization data. The effect of different variables on mortality and duration of stay in the ICU was evaluated using regression analysis. RESULTS An average of 8.78 drugs were prescribed per patient. Among the 922 prescriptions, anti-infectives, anti-inflammatory drugs, and drugs acting on the gastrointestinal tract were the most frequent medication classes prescribed. Polypharmacy and trade name prescribing were common. For most of the drugs, the prescribed daily dose corresponded to the WHO-DDD except ceftriaxone and levofloxacin. Age, presence of cardiac disorders, and Glasgow Coma Scale (GCS) score at admission directly correlated with mortality while the use of diuretics had a negative correlation with the duration of ICU stay. Conclusions: There is a need to rationalize drug therapy in the ICU with regard to limiting polypharmacy and emphasizing generic drug name prescribing and adherence to the essential drug list. Antibiotic prescription patterns, in particular, deserve a special focus keeping in mind the multitude of factors demanding aggressive antibiotic use in critically ill intensive care patients.
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Affiliation(s)
- Niti Mittal
- Pharmacology and Therapeutics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Monika Verma
- Pharmacology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Shaveta Siwach
- Pharmacology and Therapeutics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Priyanka Bansal
- Critical Care, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Suresh Kumar Singhal
- Anaesthesiology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
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Abdelkarim OA, Abubakar U, Taha LO, Ashour SA, Abass WY, Osman EM, Muslih MS. Impact of Irrational Use of Antibiotics Among Patients in the Intensive Care Unit on Clinical Outcomes in Sudan. Infect Drug Resist 2023; 16:7209-7217. [PMID: 38023395 PMCID: PMC10656842 DOI: 10.2147/idr.s378645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Background Intensive Care Unit (ICU) is a specialized ward where critically ill patients are admitted to provide intensive health care Inappropriate antimicrobial therapy (AMT) and high mortality rates were documented in the ICU. The influence of irrational use of empiric antibiotics on clinical outcomes in ICU patients is not well studied in Sudan. Aim This study aims to determine the rational use of antibiotics and its impact on clinical outcomes among ICU patients. Methods Using data collection form, a retrospective longitudinal study was conducted among ICU patients at Omdurman Military Hospital, Khartoum State. Patients admitted from January 2019 to December 2019 were included in the study. Patients who stayed in ICU < 48 hr were excluded. Appropriateness of AMT is assessed using culture sensitivity test (CST) and the American Society of Infectious Diseases (IDSA) guideline. Results Among 102 patients, 54.9% male, one-third of patients developed nosocomial infections, 80.4% received empiric therapy with broad-spectrum antibiotics. The CST is done in 19%, and 43% patients are prescribed inappropriate AMT. Inappropriate AMT is associated with recurrent infections 38.4% (p=0.028) and high mortality 33.8% (p=0.014). Overall mortality rate 63.7% ICU patients. Elevated mortality in nosocomial 57.8%, decreased with inappropriate AMT in 21.6% patients. Significantly higher mortality rates 90.7% among uncontrolled infections (p<0.001), 80.6% nosocomial infections (p=0.001), and 76.7% renal compromised (p=0.002). Conclusion Empirical AMT reduces the frequency of nosocomial infections, which has an impact on mortality. Inappropriate AMT is significantly associated with uncontrolled infections and lower mortality. Implementing a restrictive infectious control system and effective stewardship programs in hospital ICU wards is recommended.
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Affiliation(s)
- Omalhassan Amir Abdelkarim
- Department of Pharmacy Practice and Clinical Pharmacy, Faculty of Pharmacy, International University of Africa, Khartoum, Sudan
| | - Usman Abubakar
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Lubna Osman Taha
- Department of Pharmacy Practice and Clinical Pharmacy, Faculty of Pharmacy, International University of Africa, Khartoum, Sudan
| | - Sondos Ahmed Ashour
- Department of Pharmacy Practice and Clinical Pharmacy, Faculty of Pharmacy, International University of Africa, Khartoum, Sudan
| | - Wiaam Yousif Abass
- Department of Pharmacy Practice and Clinical Pharmacy, Faculty of Pharmacy, International University of Africa, Khartoum, Sudan
| | - Eslam Mohamed Osman
- Department of Pharmacy Practice and Clinical Pharmacy, Faculty of Pharmacy, International University of Africa, Khartoum, Sudan
| | - Mustafa Shith Muslih
- Department of Pharmacy Practice and Clinical Pharmacy, Faculty of Pharmacy, International University of Africa, Khartoum, Sudan
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Ali M, Shoaib MH, Nesar S, Akhtar H, Shahnaz S, Khan Q, Imran J. Assessment of potential drug-related problems (PDRP) and clinical outcomes in bacterial meningitis patients admitted to tertiary care hospitals. PLoS One 2023; 18:e0285171. [PMID: 37812604 PMCID: PMC10561832 DOI: 10.1371/journal.pone.0285171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 04/17/2023] [Indexed: 10/11/2023] Open
Abstract
Meningitis is an important cause of morbidity and mortality in children and adults. Its treatment strategy varies with age and gender. To assess potential drug-related problems (PDRP) and clinical outcomes in bacterial meningitis patients, a multicenter, clinical, descriptive, cross-sectional prospective observational study in 120 patients admitted to different tertiary care hospitals in Karachi was conducted. It includes both males 48% and females 52% belonging from all age groups i.e. peadiatrics (01 to 12 years), adults (18 to 65 years), and geriatrics (66 to 75 years). Out of these 72 patients were admitted in the public sector and 48 patients were admitted in private sector hospitals. Nosocomial infections were developed in 41% of patients during their stay at the hospital. Potentially nephrotoxic drugs were administered to all BM patients, these drugs should be administered carefully. Majorly Ceftriaxone was administered to 86% of patients, Vancomycin 71%, and meropenem 73% whereas 68% of patients were administered piperacillin-tazobactam. Organisms involved as causative agents in the majority of patients are Neisseria meningitides, Pseudomonas aeruginosa and, Streptococcus pneumoniae. DRPs impacted patient clinical outcomes in presence of many other factors like comorbidities, DDIs, Nis, administration of potentially nephrotoxic drugs, and administration of watch group and reserve group antibiotics without having culture sensitivity test, even after having CST no principles of de-escalation for antibiotics were done, which is a very important factor for hospitalized patients having IV antibiotics. The mortality rate among BM patients was 66%. The majority of patients (87%) stay at the hospital was 1-10 days. The present study helped in the identification of DRPs along with some other factors affecting the clinical outcomes in patients suffering from bacterial meningitis. Healthcare professionals should receive awareness and education on the importance of CST before initiating antibiotic therapy. Pharmacist-led medication review is necessary and should be followed to avoid negative outcomes and serious consequences related to DRPs.
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Affiliation(s)
- Muhammad Ali
- Faculty of Pharmacy and Pharmaceutical Sciences, Department of Pharmaceutics, University of Karachi, Karachi, Pakistan
- Niazi College of Pharmacy, Niazi Medical and Dental College, Sargodha, Pakistan
| | - Muhammad Harris Shoaib
- Faculty of Pharmacy and Pharmaceutical Sciences, Department of Pharmaceutics, University of Karachi, Karachi, Pakistan
| | - Shagufta Nesar
- Jinnah College of Pharmacy Sohail University, Karachi, Pakistan
| | - Hira Akhtar
- Department of Pharmaceutics, Nazeer Hussain University Karachi, Karachi, Pakistan
| | - Saira Shahnaz
- Department of Pharmacy Practice, Nazeer Hussain University Karachi, Karachi, Pakistan
| | - Quratulain Khan
- Sindh Government Dispensary, Gharibabad District Central, Karachi, Pakistan
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de Castro TL, Cambiais AMVB, Sforsin ACP, Pinto VB, Falcão MAP. Characterization of consumption and costs of antimicrobials in intensive care units in a Brazilian tertiary hospital. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2023; 11:100289. [PMID: 37455809 PMCID: PMC10338357 DOI: 10.1016/j.rcsop.2023.100289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/11/2023] [Accepted: 06/10/2023] [Indexed: 07/18/2023] Open
Abstract
Background The consumption of antimicrobials and the growing resistance of infectious agents to these drugs are not related only to health issues, but also to economic parameters. Objectives The study objective was to evaluate the consumption of antimicrobials in General and Covid-19 Intensive Care Units (ICUs) and the impact on institutional costs in the largest institute of a tertiary public hospital. Methods This is a quantitative and retrospective study, which analyzed consumption, through the Defined Daily Dose (DDD), and the annual direct cost of antimicrobials in Reais (R$) and Dollars (US$), from January to December 2021. Results The total annual consumption (DDD/1000 patient-day) of antimicrobials in the ICUs was 14,368.85. β-Lactams had the highest total annual value, with a DDD/1000 patient-day of 7062.98, being meropenem the antimicrobial that reached the highest consumption (3107.20), followed by vancomycin (2322.6). Total consumption was higher in Covid-19 ICUs than in General ICUs, and the annual direct cost of antimicrobials in ICUs was US$560,680.79. Conclusions The study showed high consumption of broad-spectrum antimicrobials, highlighting the importance of structuring programs to manage the use of antimicrobials, both to reduce antimicrobial consumption and hospital costs, consolidating rational use even in pandemic scenarios.
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Affiliation(s)
- Tázia Lopes de Castro
- Pharmacy Division, Hospital das Clínicas, Faculty of Medicine, University of São Paulo (HC-FMUSP), São Paulo, SP, Brazil
- Uniprofessional Residency Program in Hospital and Clinical Pharmaceutical Assistance, Hospital das Clínicas of the Faculty of Medicine of the University of São Paulo (HC-FMUSP), São Paulo, SP, Brazil
| | | | - Andrea Cassia Pereira Sforsin
- Pharmacy Division, Hospital das Clínicas, Faculty of Medicine, University of São Paulo (HC-FMUSP), São Paulo, SP, Brazil
| | - Vanusa Barbosa Pinto
- Pharmacy Division, Hospital das Clínicas, Faculty of Medicine, University of São Paulo (HC-FMUSP), São Paulo, SP, Brazil
| | - Maria Alice Pimentel Falcão
- Pharmacy Division, Hospital das Clínicas, Faculty of Medicine, University of São Paulo (HC-FMUSP), São Paulo, SP, Brazil
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Negm EM, Elgharabawy ES, Badran SG, Soliman ALZM, El Sayed AM, Raafat AON, Soliman ST, Mahmoud HM, Tawfik AE, El Hawary AT, El Hawary A, Elhewala A, El-Sokkary RH. Analysis of cumulative antibiogram reports in intensive care units at an Egyptian University Hospital. J Infect Public Health 2023; 16:1220-1229. [PMID: 37276716 DOI: 10.1016/j.jiph.2023.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/10/2023] [Accepted: 05/25/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND Institutions must have access to antibiograms to monitor changes in antimicrobial resistance and direct empirical antibiotic therapy. The first facility-specific cumulative antibiogram was launched in the ICU in 2019. Consequently, many antibiogram-operation-related actions have been adopted in the institution based on reported data. This study aimed to analyze the cumulative antibiogram reports for multiple intensive care units (ICUs) for 2020, and compare the antimicrobial susceptibility testing (AST) patterns between the 2019 and 2020 years in an academic medical center. METHODS This cross-sectional study was performed of routine bacterial culture and AST data extracted from a laboratory information system in a 2252-bed capacity hospital. Only the first diagnostic isolate of a given species per patient per year was included in the study. Interpretation and reporting were done in accordance with the applicable Clinical and Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing guidelines. RESULTS Of the 46,791 clinical isolates, the Gram-negative bacilli isolation rate witnessed a significant increase: 35,670 isolates in 2020 versus. 33,652 isolates in 2019. Klebsiella pneumoniae showed a statistically significant increase, mainly in pediatric, emergency, and cardiothoracic ICUs (p < 0.001). Neonatal and pediatric ICUs showed statistically significant increases in Pseudomonas aeruginosa and Proteus mirabilis isolates (p < 0.001). A statistically significant decrease was noted in the prevalence of Acinetobacter, Escherichia coli, Burkholderia cepacia, and Enterobacter cloacae. The sensitivities of K. pneumoniae and E. coli to imipenem and tigecycline significantly improved (p < 0.001). The sensitivity to colistin was significantly decreased (p < 0.001). The sensitivity of P. aeruginosa isolates to colistin and carbapenems was improved (p < 0.001). We reported a statistically significant decrease in all Gram-positive cocci (11,121 in 2020 versus. 11,528 in 2019). Staphylococcus aureus showed a statistically significant increase (p < 0.001), particularly in the medical ICU. CONCLUSION The high susceptibility rates of Enterobacteriaceae toward colistin and tigecycline, should be cautiously considered in empiric therapy while looking for alternatives. The majority of isolates of Gram-positive cocci were coagulase negative staphylococci (CONS), we still need to confirm whether they are true pathogens or commensals before considering anti-staphylococcal agents in the empirical therapy. We underscored some corrective actions that might have improved the susceptibility rates, such as antibiotic cycling.
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Affiliation(s)
- Essamedin M Negm
- Anasthesia, Intensive Care And Pain Management, Zagazig University, Egypt
| | | | | | | | - Aya M El Sayed
- Clinical Pharmacist, Zagazig University Hospitals, Egypt
| | - Aya O N Raafat
- Clinical Pharmacist, Zagazig University Hospitals, Egypt; Clinical Nutritionists, Zagazig University Hospitals, Egypt
| | - Sara T Soliman
- Clinical Pharmacist, Zagazig University Hospitals, Egypt
| | - Heba M Mahmoud
- Clinical Pharmacist, Zagazig University Hospitals, Egypt
| | - Ahmed E Tawfik
- Clinical Pharmacist, Zagazig University Hospitals, Egypt
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6
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Vlad ND, Dumea E, Cambrea CS, Puscasu CG, Ionescu C, Averian B, Mihai RV, Dumitru A, Dumitru IM. Risk factors in non‑surviving patients with infection with carbapenemase‑producing Enterobacterales strains in an intensive care unit. MEDICINE INTERNATIONAL 2023; 3:30. [PMID: 37359053 PMCID: PMC10288429 DOI: 10.3892/mi.2023.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023]
Abstract
Carbapenemase-producing Enterobacterales (CPE) are Gram-negative bacteria that belong to the Enterobacterales family and produce enzymes known as carbapenemases, which inhibit carbapenems, cephalosporins and penicillins. Carbapenem-resistant Enterobacterales (CRE) are resistant to carbapenems, cephalosporins and penicillins via mechanisms that may or may not produce carbapenemases. The identification of carbapenems is critical for the initiation of proper antibiotic therapy. The present case-control, retrospective study included 64 patients with CPE strains admitted to an intensive care unit between September, 2017 and October, 2021; of these, 34 patients with CPE succumbed and 30 control patients with CPE strains survived. CPE strains in the deceased patients were caused by Klebsiella spp. in 31 cases (91.2%) and Escherichia coli in 3 cases (8.8%). The univariate analysis revealed that the predictive factors associated with mortality in patients with CPE were admission with coronavirus disease 2019 (COVID-19) (P=0.001), invasive mechanical ventilation (P=0.001), and treatment with corticosteroids (P=0.006). The multivariate analysis revealed that admission with COVID-19 [odds ratio (OR), 16.26; 95% confidence interval (CI), 3.56-74.14; P≤0.05] and invasive mechanical ventilation (OR, 14.98; 95% CI, 1.35-166.22; P≤0.05) were associated with mortality as independent risk factors. Admission with COVID-19 increased the risk of mortality 16.26-fold and invasive mechanical ventilation increased the risk of mortality by 14.98-fold. On the whole, the present study demonstrates that the length of hospital duration in patients who acquired CPE did not influence mortality, whereas infection with COVID-19 increased and invasive mechanical ventilation were associated with an increased risk of mortality.
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Affiliation(s)
- Nicoleta-Dorina Vlad
- Clinical Infectious Diseases Hospital of Constanta, 900709 Constan£a, Romania
- Military Emergency Hospital Constanta, 900228 Constan£a, Romania
- Doctoral School of Medicine, Ovidius University of Constan£a, 900470 Constanta, Romania
| | - Elena Dumea
- Clinical Infectious Diseases Hospital of Constanta, 900709 Constan£a, Romania
- Faculty of Medicine, Ovidius University of Constan£a, 900470 Constanta, Romania
| | - Claudia-Simona Cambrea
- Clinical Infectious Diseases Hospital of Constanta, 900709 Constan£a, Romania
- Doctoral School of Medicine, Ovidius University of Constan£a, 900470 Constanta, Romania
- Faculty of Medicine, Ovidius University of Constan£a, 900470 Constanta, Romania
| | | | - Constantin Ionescu
- Faculty of Medicine, Ovidius University of Constan£a, 900470 Constanta, Romania
| | - Bianca Averian
- Doctoral School of Medicine, Ovidius University of Constan£a, 900470 Constanta, Romania
| | - Raluca-Vasilica Mihai
- Clinical Infectious Diseases Hospital of Constanta, 900709 Constan£a, Romania
- Doctoral School of Medicine, Ovidius University of Constan£a, 900470 Constanta, Romania
| | - Andrei Dumitru
- Doctoral School of Medicine, Ovidius University of Constan£a, 900470 Constanta, Romania
| | - Irina-Magdalena Dumitru
- Clinical Infectious Diseases Hospital of Constanta, 900709 Constan£a, Romania
- Doctoral School of Medicine, Ovidius University of Constan£a, 900470 Constanta, Romania
- Faculty of Medicine, Ovidius University of Constan£a, 900470 Constanta, Romania
- Romania Academy of Sciences, 50085 Bucharest, Romania
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Liu Y, Wang L, Shao H, Han P, Jiang J, Duan X. Nursing students' experience during their practicum in an intensive care unit: A qualitative meta-synthesis. Front Public Health 2022; 10:974244. [PMID: 36249222 PMCID: PMC9556851 DOI: 10.3389/fpubh.2022.974244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/14/2022] [Indexed: 01/21/2023] Open
Abstract
Background Clinical practicum provides nursing students with more opportunities to learn their professional knowledge and develop basic nursing skills. Intensive care unit (ICU) is often used as one of the clinical practicum departments for nursing students. Due to the characteristic fast-paced working environments, high acuity of patient care, and technical complexities of an ICU, nursing students are more susceptible to experiencing stress and lack of confidence in these settings, which hinders their professionalization and affects patient care. Objective The study aimed to summarize and evaluate the nursing students' experience in an ICU during their practicum and to provide a supportive ICU clinical practicum environment for them. One of the main objectives was to increase the ICU specialty nurse reserve and improve nursing care in the ICU. Methods The following databases were searched for related qualitative publications in Chinese and English by systematic searches across January 2022, including the nursing students' experience in ICU during their practicum: PubMed, Cochrane Library, Web of Science, and so on. The qualitative meta-synthesis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Two reviewers independently selected these studies and carefully evaluated the quality of each study. Meta-synthesis was then used to summarize the results. Results Eleven sub-themes and 3 themes were revealed in 9 studies: challenges of clinical practicum in the ICU, the expectation of support from multiple sources, and the importance and necessity of practicum in the ICU. Conclusion Performing one's practicum in ICU was considered by the nursing students in this review as a beneficial practicum despite the challenges involved. The appropriate guidance and monitoring should be given by hospital managers and college educators.
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Affiliation(s)
- Yue Liu
- Emergency Department, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lingmin Wang
- Emergency Department, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Haiyan Shao
- Emergency Department, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Peng Han
- Emergency Department, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jinxia Jiang
- Emergency Department, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xia Duan
- Nursing Department, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, China
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Sami R, Salehi K, Sadegh R, Solgi H, Atashi V. Barriers to rational antibiotic prescription in Iran: a descriptive qualitative study. Antimicrob Resist Infect Control 2022; 11:109. [PMID: 36038933 PMCID: PMC9422156 DOI: 10.1186/s13756-022-01151-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 08/22/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Rational antibiotic prescription (RAP) refers to the purposeful and appropriate antibiotic prescription with correct dose and course to produce the most possible benefits and less possible side effects. Identification and management of the barriers to RAP can help promote RAP. The aim of the study was to explore the barriers to RAP in Iran.
Methods
This descriptive qualitative study was conducted in 2021 on 46 physicians (including general physicians, specialists, and subspecialists), pharmacologists, microbiologists, and nurses. Participants were purposefully selected from five specialty and subspecialty hospitals in Isfahan, Iran, and the Treatment Administration of Isfahan University of Medical Sciences, Isfahan, Iran. Data were collected via semi-structured interviews and were analyzed via conventional content analysis.
Results
The barriers to RAP in Iran came into sixteen subcategories and four main categories, namely physicians’ limited professional competence (with six subcategories), poor informational and functional resources (with four subcategories), ineffective supervision of RAP (with three subcategories), and inappropriate context for RAP (with three subcategories). The subcategories of these categories were physicians’ limited professional knowledge, physicians’ poor attitude towards RAP, physicians’ routine-based practice instead of evidence-based practice, physicians’ limited accountability, physicians’ fear over the legal consequences of not prescribing antibiotics, physicians’ financial motives, limited access to quality educational materials, poor in-service training for physicians, lack of culturally appropriate guidelines, inefficiency of the stewardship committee, limited supervision of physicians’ performance, ineffective managerial supervision, limited supervision of sampling for antimicrobial susceptibility testing, sociocultural factors contributing to irrational antibiotic prescription, poor adherence of insurance companies to their financial commitments, and financial incentives of pharmaceutical companies for physicians.
Conclusion
The barriers to RAP are different and complex and include physician-related, resource-related, supervision-related, and contextual factors. Physicians with limited professional competence, limited access to resources, and limited supervision will have problems in RAP. Effective management of the barriers to RAP can promote RAP and minimize irrational antibiotic prescription and its consequences, chiefly antimicrobial resistance.
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9
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Murila BL, Nyamu DG, Kinuthia RN, Njogu PM. Rational use of antibiotics and covariates of clinical outcomes in patients admitted to intensive care units of a tertiary hospital in Kenya. Hosp Pract (1995) 2022; 50:151-158. [PMID: 35297278 DOI: 10.1080/21548331.2022.2054632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES : Rational use of antibiotics implies appropriate choice of an antibiotic administered at correct dose, frequency and duration using the most suitable route of administration. Irrational antibiotics use is associated with antimicrobial resistance, drug failure and high mortality in the critical care units (CCUs). This study sought to establish rational use of antibiotics and determinants of clinical outcomes of patients admitted in the CCUs at the Kenyatta National Hospital (KNH). The findings would guide policy formulation of antibiotics use in hospital CCUs in Kenya and the region. METHODS : Retrospective review of 220 admissions to the KNH CCUs over the period February 2018-February 2020 was conducted. Participants' sociodemographics, clinical characteristics, antibiotics therapy, and outcome of admission were extracted from patient files and analyzed using STATA version 23. Determinants of irrational antibiotic use and covariates of clinical outcomes were computed at 95% confidence. RESULTS The prevalence of rational use of antibiotics was only 18.5%. Inappropriate choice of antibiotics (51.0%) and incorrect duration (32.3%) were the most common irrational practices. Flucloxacillin (100%), cefuroxime (93.3%), cefazolin (85.7%) and ceftriaxone (83.0%) were the most irrationally used antibiotics. Irrational use of ceftriaxone was significantly associated with clinical diagnosis (p=0.012) while that of amoxiclav was associated with patient risk category (p=0.039). Mortality in the CCUs was 10%, and the odds of dying were almost six times among intubated patients compared to those who were not (AOR 5.5, 95% CI=1.1-28.1, p=0.042). CONCLUSION Irrational antibiotics prescribing is high in the KNH CCUs, attributable largely to incorrect choice and wrong duration of antibiotic use. Mortality was significantly associated with intubation. Intensification of management in critical care settings should be directed towards intubated patients while ensuring appropriate choice of antibiotics administered for the correct duration. Future studies should explore factors that could promote rational antibiotics use in critical care settings.
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Affiliation(s)
- Babra Ligogo Murila
- Pharmaceutics and Pharmacy Practice Unit, Department of Pharmacy, University of Nairobi, Nairobi, Kenya
| | - David Gitonga Nyamu
- Pharmaceutics and Pharmacy Practice Unit, Department of Pharmacy, University of Nairobi, Nairobi, Kenya
| | | | - Peter Mbugua Njogu
- Pharmaceutics and Pharmacy Practice Unit, Department of Pharmacy, University of Nairobi, Nairobi, Kenya
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Saleem Z, Godman B, Azhar F, Kalungia AC, Fadare J, Opanga S, Markovic-Pekovic V, Hoxha I, Saeed A, Al-Gethamy M, Haseeb A, Salman M, Khan AA, Nadeem MU, Rehman IU, Qamar MU, Amir A, Ikram A, Hassali MA. Progress on the national action plan of Pakistan on antimicrobial resistance (AMR): a narrative review and the implications. Expert Rev Anti Infect Ther 2021; 20:71-93. [PMID: 34038294 DOI: 10.1080/14787210.2021.1935238] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: The emergence of antimicrobial resistance (AMR) is a threat to public health. In 2015, the World Health Organization (WHO) introduced a global action plan to tackle AMR in the World Health Assembly. Pakistan's national action plan (NAP) for AMR was released in May 2017 by the Ministry of National Health Services. Based on the NAP, strategies have been initiated on a national and provincial scale in Pakistan.Areas covered: This narrative review of the five components of the Pakistan NAP has been undertaken to discuss some of the challenges in implementation of the NAP for AMR in Pakistan including different opinions and views of key stakeholders, combined with suggestions on potential ways to reduce the burden of the AMR.Expert opinion: Going forward, healthcare authorities should focus on screening and monitoring of all the objectives of the NAP by establishing proper policies as well as promoting antimicrobial stewardship interventions and Infection prevention and control (IPC) practices. Overall, the comprehensive strengthening of the healthcare system is required to adequately implement the NAP, tackle continued inappropriate antimicrobial use and high AMR rates in Pakistan.
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Affiliation(s)
- Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK.,School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa.,School of Pharmaceutical Sciences, Universiti Sains Malaysia, George Town Malaysia
| | - Faiza Azhar
- Department of Pharmaceutical Chemistry, University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | | | - Joseph Fadare
- Department of Pharmacology and Therapeutics, Ekiti State University, Ado-Ekiti, Nigeria
| | - Sylvia Opanga
- Department of Pharmaceutics and Pharmacy Practice, School of Pharmacy, University of Nairobi, Nairobi, Kenya
| | - Vanda Markovic-Pekovic
- Department of Social Pharmacy, Faculty of Medicine, University of Banja Luka, Republic of Srpska, Bosnia and Herzegovina
| | - Iris Hoxha
- Department of Pharmacy, Faculty of Medicine, University of Medicine Tirana, Albania
| | - Amna Saeed
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Manal Al-Gethamy
- Alnoor Specialist Hospital Makkah, Department of Infection Prevention & Control Program, Makkah, Kingdom of Saudi Arabia
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al Qura University, Makkah, Kingdom of Saudi Arabia
| | - Muhammad Salman
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Ayaz Ali Khan
- Department of Pharmacy Practice, Faculty of Pharmacy, The University of Lahore, Lahore, Pakistan
| | - Muhammad Umer Nadeem
- Department of Pharmaceutical Chemistry, University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | - Inaam Ur Rehman
- Department of Pharmaceutical Chemistry, University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | - Muhammad Usman Qamar
- Department of Microbiology, Faculty of Life Sciences, Government College University Faisalabad, Faisalabad, Pakistan
| | - Afreenish Amir
- Department of Microbiology, National Institute of Health Islamabad, Pakistan
| | - Aamer Ikram
- Department of Microbiology, National Institute of Health Islamabad, Pakistan
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11
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Rafique Z, Tariq MH, Khan AU, Farrukh MJ, Khan N, Burki AM, Mehmood K. Bicarbonate Therapy in Renally Compromised Critically Ill Patients with Metabolic Acidosis: Study of Clinical Outcomes and Mortality Rate. Int J Gen Med 2021; 14:2817-2826. [PMID: 34194241 PMCID: PMC8238540 DOI: 10.2147/ijgm.s296095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background Metabolic acidosis is the most frequent medical condition occurring in critically ill renally compromised patients. This study was aimed to determine clinical outcomes of bicarbonate therapy in renally compromised critically ill patients having metabolic acidosis. Methods A prospective longitudinal cohort study was undertaken in three military hospitals in Rawalpindi, Pakistan. All patients fulfilling the inclusion criteria who were admitted to the ICU of any of the three study hospitals from July 2019 to March 2020 were studied for clinical outcomes of bicarbonate therapy using an evidence-based clinical checklist. Outcome measures include changes in blood pH, serum potassium, and sodium levels, blood pressure and weight, along with other clinically significant laboratory parameters. Results Eighty-one patients fulfilling the inclusion criteria were evaluated. The mean age of the patients was 55.61±19.5 years, while the mean weight was 63.43±14.19 Kg. A mortality rate of 45.7% was observed. Disease-related complications including hypoxia, cardiac failure, multiple organ failure, elevated blood pressure, and ischemic heart disease (IHD) were found to be associated with a higher mortality rate (P<0.005). Whereas using Fisher’s exact test, concomitant administration of sodium chloride, along with bicarbonate therapy was associated with a low mortality rate and had no significant impact on sodium loading or weight gain. Moreover, various drug–drug interactions were found to be associated with a higher mortality rate (P<0.05). Conclusion Bicarbonate therapy was not found to affect the mortality rate in critically ill renally compromised patients with metabolic acidosis.
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Affiliation(s)
- Zakia Rafique
- Riphah Institute of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan
| | - Muhammad Haseeb Tariq
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Gelugor Penang, Malaysia.,Division of Pharmaceutical Evaluation & Registration, Drug Regulatory Authority of Pakistan (DRAP), Islamabad, Pakistan
| | - Arif-Ullah Khan
- Riphah Institute of Pharmaceutical Sciences, Riphah International University, Islamabad, Pakistan
| | | | - Nida Khan
- Advanced Educational Institute & Research Center (AEIRC), Karachi, Pakistan
| | | | - Khalid Mehmood
- Pak Emirates Military Hospital (PEMH), Rawalpindi, Pakistan
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12
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Abstract
Drugs are the third leading cause of acute kidney injury (AKI) in critically ill patients. Nephrotoxin stewardship ensures a structured and consistent approach to safe medication use and prevention of patient harm. Comprehensive nephrotoxin stewardship requires coordinated patient care management strategies for safe medication use, ensuring kidney health, and avoiding unnecessary costs to improve the use of nephrotoxins, renally eliminated drugs, and kidney disease treatments. Implementing nephrotoxin stewardship reduces medication errors and adverse drug events, prevents or reduces severity of drug-associated AKI, prevents progression to or worsening of chronic kidney disease, and alleviates financial burden on the health care system.
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Affiliation(s)
- Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, Center for Critical Care Nephrology, School of Medicine, University of Pittsburgh, PRESBY/SHY Pharmacy Administration Building, 3507 Victoria Street, Mailcode PFG-01-01-01, Pittsburgh, PA 15213, USA.
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13
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Gönel A, Kirhan I. Effects of Broad Spectrum Antibiotics on Measurement of Immunosuppressant Drugs. Antiinflamm Antiallergy Agents Med Chem 2021; 20:101-105. [PMID: 32208127 DOI: 10.2174/1871523019666200324111436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/07/2020] [Accepted: 02/19/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Antibiotics used parenterally can affect blood drug level measurements, as measured in diagnostic tests. OBJECTIVE To investigate the effect of six different antibiotics commonly used in intensive care units on tacrolimus, sirolimus, everolimus and cyclosporin A levels measured by mass spectrometry. METHODS Ampicillin + sulbactam (AB1, IV, 1 g), imipenem + cilastatin sodium (AB2, IV, 500 mg), piperacillin + tazobactam (AB3, 4.5 g, IV), ertapenem (AB4, IV, 1 g), meropenem trihydrate (AB5, 500 mg, IV) and ceftriaxone (AB6, 1 g, IV) antibiotics were used for the interference assay. Measurements were performed on the Shimadzu 8045 (Japan) LC-MS/MS instrument. Bias values were calculated. RESULTS The least affected immunosuppressant was cyclosporine A (between -6.88% and 3.40%). The most affected were everolimus and sirolimus. Ertapenem caused negative interference on the level of everolimus at the rate of -27.34% and sirolimus at the rate of -26.79%. Piperacillin + tazobactam and imipenem + cilastatin sodium caused positive interferences on sirolimus at the rate of 24.24% and 22.73%, respectively. Ampicillin + sulbactam, meropenem trihydrate and ceftriaxone affected the sirolimus levels at lower rates (-4.49%, 5.93% and 9.86%). Everolimus levels deviated at the rate of -11.21% to -16.99% due to imipenem + cilastatin sodium, meropenem trihydrate and ceftriaxone. CONCLUSION This study demonstrated the potential of antibiotic use affecting immunosuppressant levels. Antibiotic interference, especially in transplant patients, may cause erroneous immunosuppression, increasing the likelihood of rejection.
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Affiliation(s)
- Ataman Gönel
- Department of Medicinal Biochemistry, Medicine Faculty, Harran University, Sanliurfa, Turkey
| | - Idris Kirhan
- Department of Internal Medicine, Medicine Faculty, Harran University, Sanliurfa, Turkey
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14
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Choy A, Freedberg DE. Impact of microbiome-based interventions on gastrointestinal pathogen colonization in the intensive care unit. Therap Adv Gastroenterol 2020; 13:1756284820939447. [PMID: 32733601 PMCID: PMC7370550 DOI: 10.1177/1756284820939447] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/15/2020] [Indexed: 02/04/2023] Open
Abstract
In the intensive care unit (ICU), colonization of the gastrointestinal tract by potentially pathogenic bacteria is common and often precedes clinical infection. Though effective in the short term, traditional antibiotic-based decolonization methods may contribute to rising resistance in the long term. Novel therapies instead focus on restoring gut microbiome equilibrium to achieve pathogen colonization resistance. This review summarizes the existing data regarding microbiome-based approaches to gastrointestinal pathogen colonization in ICU patients with a focus on prebiotics, probiotics, and synbiotics.
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Affiliation(s)
| | - Daniel E. Freedberg
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
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