1
|
Huo X, Liu P. An agent-based model on antimicrobial de-escalation in intensive care units: Implications on clinical trial design. PLoS One 2024; 19:e0301944. [PMID: 38626111 PMCID: PMC11020418 DOI: 10.1371/journal.pone.0301944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 03/21/2024] [Indexed: 04/18/2024] Open
Abstract
Antimicrobial de-escalation refers to reducing the spectrum of antibiotics used in treating bacterial infections. This strategy is widely recommended in many antimicrobial stewardship programs and is believed to reduce patients' exposure to broad-spectrum antibiotics and prevent resistance. However, the ecological benefits of de-escalation have not been universally observed in clinical studies. This paper conducts computer simulations to assess the ecological effects of de-escalation on the resistance prevalence of Pseudomonas aeruginosa-a frequent pathogen causing nosocomial infections. Synthetic data produced by the models are then used to estimate the sample size and study period needed to observe the predicted effects in clinical trials. Our results show that de-escalation can reduce colonization and infections caused by bacterial strains resistant to the empiric antibiotic, limit the use of broad-spectrum antibiotics, and avoid inappropriate empiric therapies. Further, we show that de-escalation could reduce the overall super-infection incidence, and this benefit becomes more evident under good compliance with hand hygiene protocols among health care workers. Finally, we find that any clinical study aiming to observe the essential effects of de-escalation should involve at least ten arms and last for four years-a size never attained in prior studies. This study explains the controversial findings of de-escalation in previous clinical studies and illustrates how mathematical models can inform outcome expectations and guide the design of clinical studies.
Collapse
Affiliation(s)
- Xi Huo
- Department of Mathematics, University of Miami, Coral Gables, FL, United States of Ameica
| | - Ping Liu
- LinkedIn Corporation, Mountain View, CA, United States of Ameica
| |
Collapse
|
2
|
Painter C, Faradiba D, Chavarina KK, Sari EN, Teerawattananon Y, Aluzaite K, Ananthakrishnan A. A systematic literature review of economic evaluation studies of interventions impacting antimicrobial resistance. Antimicrob Resist Infect Control 2023; 12:69. [PMID: 37443104 PMCID: PMC10339577 DOI: 10.1186/s13756-023-01265-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 06/08/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is accelerated by widespread and inappropriate use of antimicrobials. Many countries, including those in low- and middle- income contexts, have started implementing interventions to tackle AMR. However, for many interventions there is little or no economic evidence with respect to their cost-effectiveness. To help better understand the scale of this evidence gap, we conducted a systematic literature review to provide a comprehensive summary on the value for money of different interventions affecting AMR. METHODS A systematic literature review was conducted of economic evaluations on interventions addressing AMR. a narrative synthesis of findings was produced. Systematic searches for relevant studies were performed across relevant databases and grey literature sources such as unpublished studies, reports, and other relevant documents. All identified economic evaluation studies were included provided that they reported an economic outcome and stated that the analysed intervention aimed to affect AMR or antimicrobial use in the abstract. Studies that reported clinical endpoints alone were excluded. Selection for final inclusion and data extraction was performed by two independent reviewers. A quality assessment of the evidence used in the included studies was also conducted. RESULTS 28,597 articles were screened and 35 articles were identified that satisfied the inclusion criteria. The review attempted to answer the following questions: (1) What interventions to address AMR have been the subject of an economic evaluation? (2) In what types of setting (e.g. high-income, low-income, regions etc.) have these economic evaluations been focused? (3) Which interventions have been estimated to be cost-effective, and has this result been replicated in other settings/contexts? (4) What economic evaluation methods or techniques have been used to evaluate these interventions? (5) What kind and quality of data has been used in conducting economic evaluations for these interventions? DISCUSSION The review is one of the first of its kind, and the most recent, to systematically review the literature on the cost-effectiveness of AMR interventions. This review addresses an important evidence gap in the economics of AMR and can assist AMR researchers' understanding of the state of the economic evaluation literature, and therefore inform future research. Systematic review registration PROSPERO (CRD42020190310).
Collapse
Affiliation(s)
- Chris Painter
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Dian Faradiba
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand.
| | - Kinanti Khansa Chavarina
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand
| | - Ella Nanda Sari
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand
| | - Yot Teerawattananon
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand
- National University of Singapore, Singapore, Singapore
| | | | - Aparna Ananthakrishnan
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, Nonthaburi, Thailand
| |
Collapse
|
3
|
Elfanagely YM, Tanzer JR, Shobayo A, Mohamed MF, Ho JJ, Shemin D, Pavlech L, D’Agata EM. Prevalence and trends of Clostridioides difficile infection among persons requiring maintenance hemodialysis: A systematic review and meta-analysis. Infect Control Hosp Epidemiol 2023; 44:1068-1075. [PMID: 36148878 PMCID: PMC10369223 DOI: 10.1017/ice.2022.217] [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: 04/21/2022] [Revised: 08/01/2022] [Accepted: 08/11/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Clostridioides difficile infection (CDI) is among the most common cause of healthcare-associated infections. Persons requiring maintenance hemodialysis (MHD) are at increased risk of CDI and associated mortality compared to persons not requiring MHD. Given the clinical impact of CDI among persons requiring MHD, we aimed to quantify the burden of CDI and trends over time in this patient population. STUDY DESIGN A systematic review and meta-analysis of studies reporting rates of CDI among persons requiring MHD in MEDLINE, Embase, Web of Science Core Collection, CINAHL, and Cochrane Central Register of Controlled Trials were performed. Searches were conducted on May 17, 2021, and March 4, 2022. RESULTS In total, 2,408 titles and abstracts were identified; 240 underwent full text review. Among them, 15 studies provided data on rates of CDI among persons requiring MHD, and 8 of these also provided rates among persons not requiring MHD. The pooled prevalence of CDI among persons requiring MHD was 19.14%, compared to 5.16% among persons not requiring MHD (odds ratio [OR], 4.35; 95% confidence interval [CI], 2.07-9.16; P = .47). The linear increase in CDI over time was significant, increasing an average of 31.97% annually between 1993 and 2017 (OR, 1.32; 95% CI, 1.1-1.58; P < .01). The linear annual increase was similar among persons requiring and not requiring MHD (OR, 1.28; 95% CI, 1.13-1.45; P = .11). CONCLUSIONS Persons requiring MHD have a 4-fold higher risk of CDI compared to persons not requiring MHD, and rates of CDI are increasing over time in both groups.
Collapse
Affiliation(s)
- Yousef M. Elfanagely
- Department of Internal Medicine, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Joshua Ray Tanzer
- Department of Biostatistics, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Anuoluwapo Shobayo
- Division of Infectious Diseases, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Mouhand F.H. Mohamed
- Department of Internal Medicine, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Jonathan J.C. Ho
- Department of Internal Medicine, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Douglas Shemin
- Division of Nephrology, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | | | - Erika M.C. D’Agata
- Department of Biostatistics, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| |
Collapse
|
4
|
Wilson WW, Gouin KA, Fike L, Apata IW, Bell JM, Edwards JR, Novosad S, Kabbani S. Intravenous Antimicrobial Starts among Hemodialysis Patients in the National Healthcare Safety Network Dialysis Component, 2016-2020. KIDNEY360 2023; 4:971-975. [PMID: 37257087 PMCID: PMC10371262 DOI: 10.34067/kid.0000000000000167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/04/2023] [Indexed: 06/02/2023]
Abstract
NHSN total IV antimicrobial start rates for patients on hemodialysis decreased from 2016 to 2020, but rates unsupported by NHSN surveillance documentation did not. There were 80% of reporting hemodialysis facilities that had ≥1 unsupported IV antimicrobial start, and the fraction of facilities with unsupported starts increased yearly. Accurate reporting and timely review of antimicrobial data is critical to understanding prescribing trends and practices in hemodialysis facilities.
Collapse
Affiliation(s)
- W. Wyatt Wilson
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Katryna A. Gouin
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lucy Fike
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ibironke W. Apata
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
- Division of Renal Medicine, Department of Medicine, Emory School of Medicine, Atlanta, Georgia
| | - Jeneita M. Bell
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jonathan R. Edwards
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shannon Novosad
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
5
|
Mustafa ZU, Manzoor MN, Shahid A, Salman M, Hayat K, Yasmin K, Baraka MA, Mathew S, Kanwal M, Parveen S, Jamal I, Khan AH, Godman B, Saleem F, Bashaar M. Nurses’ Perceptions, Involvement, Confidence and Perceived Barriers Towards Antimicrobial Stewardship Program in Pakistan: Findings from a Multi-Center, Cross-Sectional Study. J Multidiscip Healthc 2022; 15:2553-2562. [PMID: 36388630 PMCID: PMC9642086 DOI: 10.2147/jmdh.s376664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose Antimicrobial resistance (AMR) is leading to greater therapeutic cost, length of hospital stays, adverse events, morbidity and mortality. Hospital-based antimicrobial stewardship programs (ASPs) engaging physicians, pharmacists, microbiologists and nurses are considered as effective way to ensure appropriate use of antimicrobial agents. The aims of our study were to assess nurses’ perception, involvement, confidence and barriers towards hospital-based ASPs, and use the findings to provide future guidance. Methods A web-based, cross-sectional study was conducted among the nurses serving at eleven hospitals of Punjab province of Pakistan during a period of two months (December 2021-January 2022). Data were collected using a validated self-administered questionnaire. All data were analyzed using SPSS version 22. Results A total of 583 nurses participated in the study (response rate = 77.7%). All the participants were female staff nurses and 86% had a minimum of 3 years of working experience. The overall median score on the perception towards ASPs among the nurses was 18 (IQR: 16, 19) on a 0 to 20 scale whereas median score on the involvement in ASPs was 18 (IQR: 15, 37) on a 0 to 64 scale. Median perception and involvement score were statistically significantly differed by age (p < 0.001) and years of experience (p < 0.001). The overall median score on the confidence to perform ASP activities was 22 (IQR: 14, 24) on a 0 to 28 scale. Lack of knowledge, insufficient support from administration, and heavy workload were found to be the common barriers to perform ASP. Conclusion Our study concluded that Pakistani nurses have positive perception but limited involvement in ASPs. Moreover, they are confident to perform ASP besides many barriers.
Collapse
Affiliation(s)
- Zia Ul Mustafa
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- Department of Pharmacy Services, District Headquarter (DHQ) Hospital, Pakpattan54700, Pakistan
| | | | - Arfah Shahid
- Department of Medicine, Rawalpindi Medical University, Rawalpindi46000, Pakistan
| | - Muhammad Salman
- Institute of Pharmacy, Faculty of Pharmaceutical and Allied Health Sciences, Lahore College for Women University, Lahore, Pakistan
| | - Khezar Hayat
- Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Khalida Yasmin
- Lahore School of Nursing, The University of Lahore, Lahore, Pakistan
| | - Mohamed A Baraka
- Clinical Pharmacy Program, College of Pharmacy, Al Ain Campus, Al Ain University, Al Ain, Abu Dhabi, United Arab Emirates
- Clinical Pharmacy Department, College of Pharmacy, Al-Azhar University, Nasr city, Cairo, Egypt
| | - Smitha Mathew
- Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Mahpara Kanwal
- Department of Pharmacy Services, District Headquarter Hospital, Okara South City, Pakistan
| | - Samina Parveen
- Department of Pharmacy Services, District Headquarter Hospital, Chakwal, Pakistan
| | - Irsa Jamal
- Department of Pharmacy Services, District Headquarter Hospital, Kasur, Pakistan
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Brian Godman
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
- Centre of Medical and Bio-allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Fahad Saleem
- Faculty of Pharmacy & Health Sciences, University of Balochistan, Quetta, Pakistan
| | - Mohammad Bashaar
- SMART Afghan International Trainings and Consultancy, Kabul, Afghanistan
- Correspondence: Mohammad Bashaar, SMART Afghan International Trainings and Consultancy, Shahri Naw, Hospital Street No. 1, Kabul, Afghanistan, Tel +93788233865, Email
| |
Collapse
|
6
|
Davey K, Aveyard H. Nurses' perceptions of their role in antimicrobial stewardship within the hospital environment. An integrative literature review. J Clin Nurs 2022; 31:3011-3020. [PMID: 35092116 PMCID: PMC9787640 DOI: 10.1111/jocn.16204] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/12/2021] [Accepted: 12/08/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Antimicrobial stewardship (AMS) has traditionally been the domain of doctors and pharmacists but there is a growing recognition that successful stewardship incorporates a multidisciplinary approach that includes nursing staff. This literature review explores nurses' perceptions of their role in antimicrobial stewardship within the hospital environment and provides new insights to inform future practice. METHODOLOGY An integrative literature review was undertaken. Five academic databases were searched, which identified six relevant studies. Whittemore and Knafl's method for conducting an integrative review was followed. ENTREQ guidelines have been adhered to. FINDINGS Two themes were identified: nurses' working in partnership with other professionals and engagement in education. DISCUSSION Antimicrobial stewardship illustrates the role of the nurse within the wider multidisciplinary team regarding wider patient safety issues and the need for education to enhance this role. RELEVANCE TO CLINICAL PRACTICE Nurses have a clear role to play in antimicrobial stewardship but need to be fully cognisant of the issues involved. Further clarity on how nurses should enact this role in their complex working environments is required. It is essential that both student and qualified nurses are able to speak up in order to maximise patient safety, fulfil their professional duty and promote the overall effectiveness of AMS if they witness poor antibiotic management practices.
Collapse
|
7
|
Polisetty RS, Borkowski J, Georges D, Mowers S, Bolch C, Quiñones-Boex A, Murray M. Antibiotic Stewardship Attitudes and Beliefs Among Frontline Staff Nurses: Impact of Virtual Education. EMJ MICROBIOLOGY & INFECTIOUS DISEASES 2022. [DOI: 10.33590/emjmicrobiolinfectdis/10151610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background: Nurses are vital healthcare team members and are often underutilised in antimicrobial stewardship (AS) activities. Several nursing responsibilities, such as taking allergy history and obtaining cultures, already overlap with AS activities. Nurses can play a crucial role in promoting AS in resource-limited settings. This study was conducted to assess frontline staff nurses’ baseline attitudes and beliefs towards AS, and see if a virtual education campaign consisting of newsletters and tip sheets would affect those attitudes and beliefs.
Methods: An online survey (pre-survey) was conducted of all in-patient nurses employed in the authors’ hospital on their attitudes and beliefs regarding AS. The survey consisted of 24 questions divided into three domains: demographic and practice information, nursing roles, and beliefs and attitudes towards AS programmes (ASP). After obtaining the results of the pre-survey, the authors started distributing monthly newsletters on various AS topics via email and posting them on a resource page. Topics included how to obtain an accurate allergy history, how to use microbiology results to help guide decisions, and stop therapy in cases of colonisation. The authors also distributed the same survey as a follow-up 6-month survey (post-survey) in March 2021 to gauge the impact of their virtual education efforts.
Results: In total, 109 nurses working in the adult in-patient setting of the authors’ institution completed the pre-survey in September 2020, and 64 nurses completed the post-survey in March 2021. Overall, most nurses had a positive attitude towards AS tasks, and over 90% of those who responded in the pre-survey and post-survey agreed with the statement that nurses are antibiotic stewards, thought it was important or very important to obtain appropriate cultures, and understood the relationship between Clostridioides difficile and antibiotics. Most pre-survey respondents listed knowledge gaps in microbiology (47 out of 64 [86%]) and antibiotics (53 out of 64 [84%]) as well as scope of practice concerns (48 out of 64 [75%]) as barriers to nurse participation. The virtual education helped raise the familiarity with the ASP and more nurses in the post-survey said they were familiar with the stewardship programme compared with the pre-survey (48.4% versus 23.2%; p=0.001).
Conclusions: This study showed that most nurses consider themselves antibiotic stewards and want to participate in AS activities; however, barriers to nursing involvement, such as lack of knowledge, scope of practice concerns, and time constraints, persist. Virtual education may be an option to increase nursing awareness and participation on ASPs in resource-limited settings.
Collapse
Affiliation(s)
- Radhika S. Polisetty
- Department of Pharmacy, Northwestern Medicine Central DuPage Hospital, Winfield, Illinois, USA; Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove Campus, Illinois, USA
| | - Jaime Borkowski
- Department of Infectious Diseases, Northwestern Medicine Delnor Hospital, Geneva, Illinois, USA
| | - Dorothy Georges
- Medical Care Center, Northwestern Medicine Central DuPage Hospital, Winfield, Illinois, USA; Department of Professional Practice, Northwestern Medicine Central DuPage Hospital, Winfield, Illinois, USA
| | - Stacy Mowers
- Department of Professional Practice, Northwestern Medicine Central DuPage Hospital, Winfield, Illinois, USA
| | - Charlotte Bolch
- Office of Research and Sponsored Programs, College of Graduate Studies, Midwestern University, Glendale, Arizona, USA
| | - Ana Quiñones-Boex
- Midwestern University College of Pharmacy, Downers Grove Campus, Illinois, USA
| | - Milena Murray
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove Campus, Illinois, USA; Northwestern Medicine, Chicago, Illinois, USA
| |
Collapse
|
8
|
Sivarajahkumar S, So M, Morris AM, Lok C, Bell CM, Battistella M. Patterns of Antimicrobial Use in an Outpatient Hemodialysis Unit. Can J Hosp Pharm 2022; 75:15-20. [PMID: 34987258 PMCID: PMC8677003 DOI: 10.4212/cjhp.v75i1.3250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Patients receiving hemodialysis (HD) are at high risk of infections, including those caused by multidrug-resistant organisms. Given that antimicrobial exposure is a major risk factor for the emergence of these resistant organisms, minimizing inappropriate use is imperative. To optimize use, it is important to understand patterns of antimicrobial prescribing in this setting. OBJECTIVES To measure antimicrobial use and to describe prescribing patterns among patients receiving outpatient HD. METHODS A retrospective observational case series study was performed in an outpatient HD unit from February to April 2017. Adults for whom at least 1 antimicrobial was prescribed were included. The primary outcome was total antimicrobial days of therapy (DOT) per 1000 patient-days. Secondary outcomes were the characteristics of the antimicrobial prescriptions, in terms of antimicrobial class, indication, purpose, route, and prescriber group. RESULTS Antimicrobials were prescribed for 53 (16%) of the 330 patients treated in the HD unit during the study period; the total number of prescriptions was 75. Antimicrobial use was 27.5 DOTs/1000 patient-days. Fluoroquinolones were the most frequently prescribed type of antimicrobial (n = 17, 23%), whereas the second most frequently prescribed were first-generation cephalosporins (n = 16, 21%). The most common indication was skin or soft-tissue infection (n = 14, 19%), followed by bloodstream infection (n = 13, 17%). Of the 75 antimicrobials, 48 (64%) were prescribed for empiric therapy, 19 (25%) for targeted therapy, and 8 (11%) for prophylaxis. Two-thirds of the antimicrobials prescribed (n = 50, 67%) were oral medications, and most (n = 72, 96%) were ordered by hospital prescribers. CONCLUSIONS Antimicrobial use was common in this study setting, with 1 in 6 HD patients receiving this type of medication. The findings of this study create opportunities to standardize antimicrobial prescribing at the local level for common infections that occur in patients receiving outpatient HD.
Collapse
Affiliation(s)
- Sylvia Sivarajahkumar
- , HBSc, BScPhm, is with the University Health Network and the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario
| | - Miranda So
- , BScPhm, PharmD, is with the University Health Network and the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario
| | - Andrew M Morris
- , MD, FRCPC, SM(Epi), is with the University Health Network, the Sinai Health System, and the Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Charmaine Lok
- , MD, FRCPC, MSc, is with the University Health Network and the Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Chaim M Bell
- , MD, FRCPC, PhD, is with the University Health Network, the Sinai Health System, and the Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Marisa Battistella
- , BScPhm, PharmD, is with the University Health Network and the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario
| |
Collapse
|
9
|
Coritsidis GN, Yaphe S, Rahkman I, Lubowski T, Munro C, Lee TK, Stern A, Bhat P. Outpatient Antibiotic Prescribing Patterns for Adult End-Stage Renal Disease Patients in New York State. Clin Infect Dis 2021; 73:e4493-e4498. [PMID: 33277995 DOI: 10.1093/cid/ciaa1801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/03/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Infections are important complications of end-stage renal disease (ESRD) with few studies having investigated oral antibiotic use. Inappropriate antibiotic prescribing can contribute to multidrug-resistant organisms and Clostridioides difficile infections seen in ESRD. This study investigates antibiotic prescribing practices in ESRD across New York State (NYS). METHODS Retrospective case-control study from 2016 to 2017 of NYS ESRD and non-ESRD patients analyzing Medicare part B billing codes, 7 days before and 3 days after part D claims. Frequencies of each infection, each antibiotic, dosages, and the antibiotics associated with infections were assessed using χ 2 analysis. A NYS small dialysis organization comprising approximately 2200 patients was also analyzed. Outcomes measured were the frequencies of infections and of each antibiotic prescribed. Incidence measures included antibiotics per 1000 and individuals receiving antibiotics per 1000. RESULTS A total of 48 100 infections were treated in 35 369 ESRD patients and 2 544 443 infections treated in 3 777 314 non-ESRD patients. ESRD patients were younger, male, and African American. ESRD and non-ESRD patients receiving antibiotics was 520.29/1000 and 296.48/1000, respectively (P < .05). The prescription incidence was 1359.95/1000 ESRD vs 673.61/1000 non-ESRD patients. In 36%, trimethoprim-sulfamethoxazole dosage was elevated by current ESRD guidelines. Top infectious categories included nonspecific symptoms, skin, and respiratory for ESRD; and respiratory, nonspecific symptoms, and genitourinary in non-ESRD. CONCLUSIONS This study identifies issues with appropriate antibiotic usage stressing the importance of antibiotic education to nephrologist and nonnephrologist providers. It provides support for outpatient antibiotic stewardship programs.
Collapse
Affiliation(s)
- George N Coritsidis
- Department of Nephrology, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, Elmhurst, New York, USA.,IPRO New York Network 2, Lake Success, NY, New York, USA.,Atlantis Dialysis, College Point, NY, New York, USA
| | - Sean Yaphe
- Department of Family Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ilay Rahkman
- Department of Nephrology, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, Elmhurst, New York, USA
| | | | - Carly Munro
- Department of Nephrology, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, Elmhurst, New York, USA
| | - Ti-Kuang Lee
- IPRO New York Network 2, Lake Success, NY, New York, USA
| | - Aaron Stern
- Department of Nephrology, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, Elmhurst, New York, USA
| | - Premila Bhat
- Atlantis Dialysis, College Point, NY, New York, USA
| |
Collapse
|
10
|
D'Agata EMC, Apata IW, Booth S, Boyce JM, Deaver K, Gualandi N, Neu A, Nguyen D, Novosad S, Palevsky PM, Rodgers D. Suggestions for the prevention of Clostridioides difficile spread within outpatient hemodialysis facilities. Kidney Int 2021; 99:1045-1053. [PMID: 33667504 PMCID: PMC10506371 DOI: 10.1016/j.kint.2021.02.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/23/2021] [Accepted: 02/04/2021] [Indexed: 11/26/2022]
Abstract
Clostridioides difficile infections (CDIs) cause substantial morbidity and mortality. Patients on maintenance hemodialysis are 2 to 2.5 times more likely to develop CDI, with mortality rates 2-fold higher than the general population. Hospitalizations due to CDI among the maintenance hemodialysis population are high, and the frequency of antibiotic exposures and hospitalizations may contribute to CDI risk. In this report, a panel of experts in clinical nephrology, infectious diseases, and infection prevention provide guidance, based on expert opinion and published literature, aimed at preventing the spread of CDI in outpatient hemodialysis facilities.
Collapse
Affiliation(s)
- Erika M C D'Agata
- Division of Infectious Diseases, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Ibironke W Apata
- Division of Renal Medicine, Emory University School of Medicine, Atlanta, Georgia, USA; Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Stephanie Booth
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - John M Boyce
- J.M. Boyce Consulting, LLC, Middletown, Connecticut, USA
| | - Karen Deaver
- University of Virginia Dialysis Program, Charlottesville, Virginia, USA
| | - Nicole Gualandi
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alicia Neu
- Division of Pediatric Nephrology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Duc Nguyen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sharon Novosad
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Paul M Palevsky
- Renal Section, Veterans Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA; Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Darlene Rodgers
- American Society of Nephrology Alliance for Kidney Health, Washington, DC, USA
| |
Collapse
|
11
|
Antimicrobial Stewardship and Its Impact on the Changing Epidemiology of Polymyxin Use in a South Indian Healthcare Setting. Antibiotics (Basel) 2021; 10:antibiotics10050470. [PMID: 33918994 PMCID: PMC8142974 DOI: 10.3390/antibiotics10050470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/22/2021] [Indexed: 11/17/2022] Open
Abstract
Polymyxins being last resort drugs to treat infections triggered by multidrug-resistant pathogens necessitates the implementation of antimicrobial stewardship program (ASP) initiatives to support its rational prescription across healthcare settings. Our study aims to describe the change in the epidemiology of polymyxins and patient outcomes following the implementation of ASP at our institution. The antimicrobial stewardship program initiated in February 2016 at our 1300 bed tertiary care center involved post-prescriptive audits tracking polymyxin consumption and evaluating prescription appropriateness in terms of the right indication, right frequency, right drug, right duration of therapy and administration of the right loading dose (LD) and maintenance dose (MD). Among the 2442 polymyxin prescriptions tracked over the entire study period ranging from February 2016 to January 2020, the number of prescriptions dropped from 772 prescriptions in the pre-implementation period to an average of 417 per year during the post-implementation period, recording a 45% reduction. The quarterly patient survival rates had a significant positive correlation with the quarterly prescription appropriateness rates (r = 0.4774, p = 0.02), right loading dose (r = 0.5228, p = 0.015) and right duration (r = 0.4361, p = 0.04). Our study on the epidemiology of polymyxin use demonstrated favorable effects on the appropriateness of prescriptions and mortality benefits after successful implementation of antimicrobial stewardship in a real-world setting.
Collapse
|
12
|
Apata IW, Kabbani S, Neu AM, Kear TM, D'Agata EMC, Levenson DJ, Kliger AS, Hicks LA, Patel PR. Opportunities to Improve Antibiotic Prescribing in Outpatient Hemodialysis Facilities: A Report From the American Society of Nephrology and Centers for Disease Control and Prevention Antibiotic Stewardship White Paper Writing Group. Am J Kidney Dis 2020; 77:757-768. [PMID: 33045256 PMCID: PMC7546947 DOI: 10.1053/j.ajkd.2020.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 08/02/2020] [Indexed: 11/11/2022]
Abstract
Antibiotic use is necessary in the outpatient hemodialysis setting because patients receiving hemodialysis are at increased risk for infections and sepsis. However, inappropriate antibiotic use can lead to adverse drug events, including adverse drug reactions and infections with Clostridioides difficile and antibiotic-resistant bacteria. Optimizing antibiotic use can decrease adverse events and improve infection cure rates and patient outcomes. The American Society of Nephrology and the US Centers for Disease Control and Prevention created the Antibiotic Stewardship in Hemodialysis White Paper Writing Group, comprising experts in antibiotic stewardship, infectious diseases, nephrology, and public health, to highlight strategies that can improve antibiotic prescribing for patients receiving maintenance hemodialysis. Based on existing evidence and the unique patient and clinical setting characteristics, the following strategies for improving antibiotic use are reviewed: expanding infection and sepsis prevention activities, standardizing blood culture collection processes, treating methicillin-susceptible Staphylococcus aureus infections with β-lactams, optimizing communication between nurses and prescribing providers, and improving data sharing across transitions of care. Collaboration among the Centers for Disease Control and Prevention; American Society of Nephrology; other professional societies such as infectious diseases, hospital medicine, and vascular surgery societies; and dialysis provider organizations can improve antibiotic use and the quality of care for patients receiving maintenance hemodialysis.
Collapse
Affiliation(s)
- Ibironke W Apata
- Centers for Disease Control and Prevention, Atlanta, MD; Division of Renal Medicine, Emory University School of Medicine, Atlanta, MD.
| | - Sarah Kabbani
- Centers for Disease Control and Prevention, Atlanta, MD
| | | | - Tamara M Kear
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA
| | | | | | | | - Lauri A Hicks
- Centers for Disease Control and Prevention, Atlanta, MD
| | - Priti R Patel
- Centers for Disease Control and Prevention, Atlanta, MD
| |
Collapse
|
13
|
Improving Antimicrobial Use in Adult Outpatient Clinics: the New Frontier for Antimicrobial Stewardship Programs. Curr Infect Dis Rep 2020. [DOI: 10.1007/s11908-020-00722-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
14
|
Grant JM, Porter C, Charles MK, Bryce E, Wong T, Stefanovic A, Shajari S, Roscoe DL. Potential influence of rapid diagnostics on timeliness of management decisions for patients with positive blood cultures. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2020; 5:21-28. [PMID: 36339013 PMCID: PMC9603315 DOI: 10.3138/jammi.2019-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/22/2019] [Indexed: 06/16/2023]
Abstract
BACKGROUND The Accelerate Pheno system (AXDX) provides rapid identification (ID; 90 minutes) and antimicrobial susceptibility testing (AST; approximately 7 hours) from positive blood culture (BC) bottles. We assessed the potential of AXDX results to influence more timely antibiotic interventions with a convenience sample of 158 positive BCs. METHODS BCs with a mono-microbial Gram stain likely to be on the AXDX panel were run in parallel with the standard of care (SOC). Using results from the SOC, the medical microbiologist on call (MMOC) noted interventions made at the time of BC Gram stain and when ID and AST results were available. The timing of MMOC intervention was noted and compared with fastest potential SOC time and AXDX time. RESULTS Of 158 specimens selected for analysis, 144 were evaluable. ID was available 11.9 hours and AST 27.7 hours faster than SOC. Correct ID was provided for 85.2% of specimens and AST for 59.0% of specimens, with 97.5% essential agreement compared with the SOC. One hundred and thirteen clinical interventions were made on 100 specimens: 54.9% were narrowing; 33.6%, escalation; 6.2%, consultation with ID; and 3.5%, further investigation. If AXDX data had been used immediately once available, interventions would have been possible 24 hours earlier for ID interventions and 39 hours earlier for AST results. CONCLUSIONS Results from rapid diagnostic panels such as AXDX have the potential to support timely antimicrobial de-escalation and other decisions to benefit patients, especially if paired with stewardship interventions.
Collapse
Affiliation(s)
- Jennifer M Grant
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Charlene Porter
- Department of Pathology and Laboratory Medicine, Vancouver Costal Health Authority, Vancouver, British Columbia, Canada
| | - Marthe K Charles
- Department of Pathology and Laboratory Medicine, Vancouver Costal Health Authority, Vancouver, British Columbia, Canada
| | - Elizabeth A Bryce
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Titus Wong
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Aleksandra Stefanovic
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Salomeh Shajari
- Department of Quality and Patient Safety, Vancouver Costal Health Authority, Vancouver, British Columbia, Canada
| | - Diane L Roscoe
- Department of Pathology and Laboratory Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| |
Collapse
|
15
|
Abstract
The prevalence of antimicrobial resistance among many common bacterial pathogens is increasing. The emergence and global dissemination of these antibiotic-resistant bacteria (ARB) is fuelled by antibiotic selection pressure, inter-organism transmission of resistance determinants, suboptimal infection prevention practices and increasing ease and frequency of international travel, among other factors. Patients with chronic kidney disease, particularly those with end-stage renal disease who require dialysis and/or kidney transplantation, have some of the highest rates of colonization and infection with ARB worldwide. These ARB include methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus spp. and several multidrug-resistant Gram-negative organisms. Antimicrobial resistance limits treatment options and increases the risk of infection-related morbidity and mortality. Several new antibiotic agents with activity against some of the most common ARB have been developed, but resistance to these agents is already emerging and highlights the dire need for new treatment options as well as consistent implementation and improvement of basic infection prevention practices. Clinicians involved in the care of patients with renal disease must be familiar with the local epidemiology of ARB, remain vigilant for the emergence of novel resistance patterns and adhere strictly to practices proven to prevent transmission of ARB and other pathogens.
Collapse
Affiliation(s)
- Tina Z Wang
- NewYork Presbyterian-Weill Cornell Medical Center, New York, NY, USA
| | | | - David P Calfee
- NewYork Presbyterian-Weill Cornell Medical Center, New York, NY, USA.
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medicine, New York, NY, USA.
| |
Collapse
|