A Survey of Antimicrobial Stewardship Programs in Korea, 2015

Principles and practices of antimicrobial stewardship programs in Korea

This review addresses the escalating challenge posed by antibiotic resistance, highlighting its profound impact on global public health, including increased mortality rates and healthcare expenditures. The review focuses on the need to adopt the One Health approach to effectively manage antibiotic usage across human, animal, and environmental domains. Antimicrobial stewardship programs (ASPs) are considered as comprehensive strategies that encompass both core and supplementary initiatives aimed at enhancing prudent antibiotic use. The 2021 "Guidelines on Implementing ASP in Korea" introduced such strategies, with a strong emphasis on fostering multidisciplinary and collaborative efforts. Furthermore, the "Core Elements for Implementing ASPs in Korean General Hospitals," established in 2022, provide a structured framework for ASPs, delineating leadership responsibilities, the composition of interdisciplinary ASP teams, a range of interventions, and continuous monitoring and reporting mechanisms. In addition, this review examines patient-centric campaigns such as "Speak Up, Get Smart" and emphasizes the pivotal role of a multidisciplinary approach and international cooperation in addressing the multifaceted challenges associated with antibiotic resistance.

Implementing antimicrobial stewardship: lessons and perspectives from a university-affiliated tertiary hospital in Korea

Antimicrobial stewardship programs (ASPs) can lower antibiotic use, decrease medical expenses, prevent the emergence of resistant bacteria, and enhance treatment for infectious diseases. This study summarizes the stepwise implementation and effects of ASPs in a single university-affiliated tertiary care hospital in Korea; it also presents future directions and challenges in resource-limited settings. At the study hospital, the core elements of the ASP such as leadership commitment, accountability, and operating system were established in 2000, then strengthened by the formation of the Antimicrobial Stewardship (AMS) Team in 2018. The actions of ASPs entail key components including a computerized restrictive antibiotic prescription system, prospective audit, post-prescription review through quantitative and qualitative intervention, and pharmacy-based interventions to optimize antibiotic usage. The AMS Team regularly tracked antibiotic use, the effects of interventions, and the resistance patterns of pathogens in the hospital. The reporting system was enhanced and standardized by participation in the Korea National Antimicrobial Use Analysis System, and educational efforts are ongoing. Stepwise implementation of the ASP and the efforts of the AMS Team have led to a substantial reduction in the overall consumption of antibiotics, particularly regarding injectables, and optimization of antibiotic use. Our experience highlights the importance of leadership, accountability, institution-specific interventions, and the AMS Team.

Impact of financial incentives for infection prevention and management on antibiotic use: A Korea National Health Insurance cohort study

BACKGROUND

The Korean government implemented financial incentives to enhance infection prevention and management within general hospital settings. This study aimed to evaluate the impact of infection control compensation on antibiotic usage using a controlled interrupted time series analysis.

METHODS

The main unit of analysis was 270,901 inpatient episodes extracted from the Korean National Health Insurance Service Cohort Database from 2013 to 2019. The 96-month period was examined before and after the intervention, which was set to September 1, 2017, by applying a 1-year lag time after the incentive was introduced. Segmented regression was used to estimate the effects of interventions in a controlled interrupted time series. Hospitals that received nationwide financial incentives for infection prevention and management were included in the analysis. The study's primary outcome was the use of antibiotics based on the WHO Access, Watch, and Reserve (AWaRe) classification of antibiotics, and the secondary outcome was the number of days of antibiotic use as days of therapy (DOTs) per patient day (PD).

RESULTS

The probability of overall antibiotic use decreased between incentivized and unincentivized hospitals (odds ratio [OR], 0.922; 95% confidence interval [CI], 0.859-1.000). The difference in level change in the use of third-generation cephalosporins (OR,0.894; 95% CI, 0.817-0.977) and carbapenem (OR,0.790; 95% CI, 0.630-0.992) was significantly reduced between incentivized and unincentivized hospitals. The difference in slope change on DOTs/PD of glycopeptides was - 0.005 DOT/PDs, and that of carbapenem was - 0.003 between incentivized and unincentivized hospitals.

CONCLUSION

We observed that incentives for infection prevention and management have had a positive impact on some aspects of antibiotic usage. A partial decrease was observed in antibiotic use, accompanied by a modest reduction in DOTs/PD, particularly for antibiotics aimed at addressing multidrug-resistant pathogens. Further investigation is necessary to establish evidence for extending these incentives.

Changes in antibiotic consumption patterns after the implementation of the National Action Plan according to the Access, Watch, Reserve (AWaRe) classification system

OBJECTIVE

The Korean government published the first National Action Plan (NAP) on antimicrobial resistance (AMR) in August 2016, followed by a second plan in November 2021. The objective of this study was to analyze changes in antibiotic use patterns after the implementation of the NAP in South Korea.

METHODS

We analyzed National Health Insurance claims data for hospitals and clinics from January 2011 to December 2020. Consumption was measured using a defined daily dose per 1000 inhabitants per day (DID). We analyzed data for each year, dimension, and category of the Access, Watch, Reserve classification system by the World Health Organization. Monthly inpatient and outpatient antibiotic use were calculated, and an interrupted time-series (ITS) analysis to assess the trend in antibiotic use was conducted.

RESULTS

The consumption of antibiotics increased from 25.78 DID in 2011 to 29.06 DID in 2016, then decreased in 2017 after the implementation of the NAP on AMR. The watch group showed a temporal decrease after the implementation of the NAP; however, these figures increased until 2019, and the reserve group showed a downward trend beginning in 2017. According to the ITS analysis, the level (β₂) and the slope of the trend (β₃) of total antibiotic use decreased by 0.17 and 0.001, respectively. After implementation of the NAP, antibiotic use was reduced from 7.18 DID in 2016 to 4.84 DID in 2017 for amoxicillin and beta-lactamase inhibitors, 0.86 DID to 0.70 DID for ciprofloxacin, and 0.66 DID to0.66 DID for levofloxacin.

CONCLUSION

After the implementation of the NAP in South Korea, antibiotic use in terms of total antibiotics and fluoroquinolone in the watch and reserve groups decreased. Further policies to improve the use of antibiotics in the watch and reserve groups are needed.

Guidelines on Implementing Antimicrobial Stewardship Programs in Korea

These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.

Effect of discontinuation of an antimicrobial stewardship programme on the antibiotic usage pattern

OBJECTIVES

This study aimed to analyse the effect of discontinuation of antimicrobial stewardship programme (ASP) activity on the usage pattern of antibiotics.

METHODS

An interrupted time-series analysis assessing the trends in antibiotic use was conducted between September 2015 and August 2019 in an 859-bed university-affiliated hospital in Korea, where all ASP activities were discontinued in March 2018. The major activity of the ASP was a restrictive antibiotic programme.

RESULTS

The use of restrictive antibiotics increased immediately after the discontinuation of the ASP by 41.06 days of therapy (DOT)/1000 patient-days in the general ward (95% confidence interval (CI) 21.04-61.08) and by 391.04 DOT/1000 patient-days in the intensive care unit (ICU) (95%CI 207.56-574.51). In addition, there were positive changes in the slope for the use of restrictive antibiotics in the general ward (7.06 DOT/1000 patient-days per month, 95%CI 4.63-9.50) and ICU (35.95 DOT/1000 patient-days per month, 95%CI 18.70-53.19). The use of broad-spectrum antibiotics in the general ward significantly decreased (-87.54 DOT/1000 patient-days, 95%CI -149.29 to -25.79). For non-broad-spectrum antibiotics, there were positive changes in the slope in the general ward (16.54 DOT/1000 patient-days per month, 95%CI 12.99-20.09) and ICU (12.85 DOT/1000 patient-days per month, 95%CI 2.32-23.38).

CONCLUSIONS

After discontinuation of the ASP, antibiotic usage patterns rapidly returned to the patterns prior to the implementation of the programme.

Status of antimicrobial stewardship programmes in Korean hospitals including small to medium-sized hospitals and the awareness and demands of physicians: a nationwide survey in 2020

OBJECTIVES

This study aimed to identify the status of antimicrobial stewardship programmes (ASPs) in small to medium-sized Korean hospitals as well as the awareness and demands about ASPs of physicians.

METHODS

A questionnaire was designed based on a questionnaire from a previous nationwide survey in 2018 targeting large hospitals in Korea and modified to reflect the results of in-depth interviews with non-infectious diseases (IDs) physicians at secondary care hospitals. The survey targeted all hospitals with ≥150 beds in South Korea and was performed in May-June 2020. Only one ASP-associated physician per hospital participated in the survey.

RESULTS

The survey response rate was 31.9% (217/680). ID specialists comprised the majority of medical personnel participating in ASPs in tertiary care hospitals. Conversely, in secondary and primary care hospitals there was no predominant medical personnel for ASPs and the median full-time equivalent was 0 for all types of medical personnel. Tertiary care hospitals, more than secondary and primary care hospitals, tended to perform ASP activities more actively. 'Workforce for ASPs', 'Establishment of healthcare fees for ASPs' and 'Development of tools for ASPs' were the most important required support for ASP improvement.

CONCLUSION

The level of ASP establishment was more limited in primary care hospitals than in secondary and tertiary care hospitals in Korea. To improve ASPs in Korean hospitals, a supporting workforce and the establishment of a healthcare fee for ASPs appear to be necessary.

Antimicrobial stewardship capacity and manpower needs in the Asia Pacific

OBJECTIVES

Antimicrobial stewardship is a strategy to combat antimicrobial resistance in hospitals. Given the burden and impact of antimicrobial resistance in the Asia Pacific, it is important to document capacity and gaps in antimicrobial stewardship programmes (ASP). We aimed to understand existing capacities and practices, and define the resources needed to establish antimicrobial stewardship where it is lacking.

METHODS

An anonymous online survey, consisting of questions on antimicrobial control at country, hospital and programme levels, was circulated to healthcare providers in the field of infectious diseases and microbiology through Asian Network for Surveillance of Resistant Pathogens, ReAct Group and the Australasian Society for infectious Diseases.

RESULTS

139 participants from 16 countries or regions completed the survey. The majority of participants were adult infectious diseases physicians (61/139, 43.9%) and microbiologists (31/139, 22.3%). Participants from 7 countries reported that antimicrobials can be obtained without prescriptions. Despite the high percentage (75.5%) of respondents working in large hospitals, only 22/139 participants (15.8%) from Australia, China, Singapore, Taiwan, Thailand and Vietnam reported having more than 10 infectious diseases physicians. Hospital empiric antimicrobial guidelines for common infections were available according to 110/139 (79.1%) participants. Pre-authorisation of antimicrobials was reported by 88/113 (77.9%) respondents while prospective audit and feedback was reported by 93/114 (81.6%). Automatic stop orders and culture-guided de-escalation were reported by only 52/113 (46.0%) and 27/112 (24.1%) respectively.

CONCLUSION

The survey reveals a wide range of ASP development in Asia Pacific. Establishing national workgroups and guidelines will help advance antimicrobial stewardship in this diverse region.

Human resources required for antimicrobial stewardship activities for hospitalized patients in Korea

OBJECTIVES

We calculated the human resources required for an antimicrobial stewardship program (ASP) in Korean hospitals.

DESIGN

Multicenter retrospective study.

SETTING

Eight Korean hospitals ranging in size from 295 to 1,337 beds.

METHODS

The time required for performing ASP activities for all hospitalized patients under antibiotic therapy was estimated and converted into hours per week. The actual time spent on patient reviews of each ASP activity was measured with a small number of cases, then the total time was estimated by applying the determined times to a larger number of cases. Full-time equivalents (FTEs) were measured according to labor laws in Korea (52 hours per week).

RESULTS

In total, 225 cases were reviewed to measure time spent on patient reviews. The median time spent per patient review for ASP activities ranged from 10 to 16 minutes. The total time spent on the review for all hospitalized patients was estimated using the observed number of ASP activities for 1,534 patients who underwent antibiotic therapy on surveillance days. The most commonly observed ASP activity was 'review of surgical prophylactic antibiotics' (32.7%), followed by 'appropriate antibiotics recommendations for patients with suspected infection without a proven site of infection but without causative pathogens' (28.6%). The personnel requirement was calculated as 1.20 FTEs (interquartile range [IQR], 1.02-1.38) per 100 beds and 2.28 FTEs (IQR, 1.93-2.62) per 100 patients who underwent antibiotic therapy, respectively.

CONCLUSION

The estimated time required for human resources performing extensive ASP activities on all hospitalized patients undergoing antibiotic therapy in Korean hospitals was ~1.20 FTEs (IQR, 1.02-1.38) per 100 beds.

Antimicrobial stewardship: an evaluation of structure and process and their association with antimicrobial prescribing in NHS hospitals in England

BACKGROUND

Rigorous antimicrobial stewardship programmes (ASPs) are an essential strategy against antimicrobial resistance.

OBJECTIVES

To evaluate and score ASPs in acute English NHS hospitals and determine association of ASP scores with antimicrobial prescribing.

METHODS

ASP structure and process were evaluated through an online survey in 148/152 acute hospitals in 2017. Scores were assigned to quality indicators based on resource- and labour-intensiveness, and their association with total and modified WHO-categorized 'Access', 'Watch' and 'Reserve' (AwaRe) prescribing was analysed.

RESULTS

The survey response rate was 97% with 78% of trusts submitting antimicrobial prescribing data. Over 80% of ASPs contained stewardship teams, policies and access to outpatient parenteral antimicrobial therapy, whilst less than 50% scored well for leadership or funding. High process performance was observed for antimicrobial pre-authorization, prescribing review and feedback, restricted susceptibility reporting, antimicrobial consumption monitoring, adherence to guidelines and junior doctor training. Low process attainment included education of senior prescribers and lack of resistance surveillance data distribution. Between 2016 and 2017, there was no difference in total trust prescribing (P = 0.117) although carbapenem prescribing fell (incidence rate ratio = 0.93, 95% CI 0.88-0.98) in non-teaching hospitals; 'Watch' prescribing also increased for specialist hospitals (OR = 1.10, 95% CI 1.01-1.20), as did 'Reserve' category prescribing in teaching (OR = 1.58, 95% CI 1.23-3.02) and specialist hospitals (OR = 3.09, 95% CI 2.02-4.74). A high process score was associated with lower 'Reserve' prescribing (OR = 0.82, 95% CI 0.67-1.01).

CONCLUSIONS

All responding trusts had established ASPs. The association of a scoring system with total and 'AWaRe' prescribing to assess effectiveness of ASPs merits further study.

Ten-year trends in antibiotic usage at a tertiary care hospital in Korea, 2004 to 2013

BACKGROUND/AIMS

This study was performed to evaluate trends in antibiotic usage at a tertiary care hospital in Korea.

METHODS

This study collated antibiotic prescription data and total patient days for inpatients at a tertiary care hospital in Korea between 2004 and 2013. The consumption of each class of antibiotic was converted to defined daily dose (DDD)/1,000 patient-days. We defined 3rd generation cephalosporins, 4th generation cephalosporins, β-lactam/β-lactamase inhibitors, and fluoroquinolones as broad-spectrum antibiotics; carbapenems, tigecycline, glycopeptides, oxazolidinone, and polymyxin were defined as antibiotics against multidrug-resistant (MDR) pathogens. Other antibiotic classes were defined as nonbroad-spectrum antibiotics.

RESULTS

Mean antibiotic consumption was 920.69 DDD/1,000 patient-days. The proportions of broad-spectrum antibiotics, antibiotics against MDR pathogens, and nonbroad-spectrum antibiotics were 41.8% (384.48/920.69), 3.5% (32.24/920.69), and 54.7% (503.97/920.69), respectively. Consumption of broad-spectrum antibiotics (coefficient for time 0.141; p = 0.049) and antibiotics against MDR pathogens (coefficient for time 0.185; p < 0.001) showed a significant increasing trend over the study period. Nonbroad-spectrum antibiotic consumption showed a significant decreasing trend over the study period (coefficient for time -2.601; p < 0.001).

CONCLUSION

Over the 10-year period, a stepwise increase in the consumption of broad-spectrum antibiotics and antibiotics against MDR pathogens was observed at a tertiary care hospital in Korea. Conversely, during the same period, nonbroad-spectrum antibiotic consumption showed a significant decreasing trend.

Antimicrobial Stewardship Programs in Community Health Systems Perceived by Physicians and Pharmacists: A Qualitative Study with Gap Analysis

Antimicrobial stewardship program (ASP) is one of the most important strategies for managing infectious disease treatment and preventing antimicrobial resistance. The successful implementation of ASP in the community health system (CHS) has been challenging. We evaluated perceptions of current ASP, potential setbacks of ASP implementation, and future demands on ASP services among physicians and pharmacists in the CHS. The qualitative research was conducted through in-depth individual interviews and focus group discussions with 11 physicians and 11 pharmacists. In addition, a quantitative gap analysis was conducted to assess the different awareness and demands on services of ASP and preferred antimicrobial-related problems (ARP). In overall, perceptions of ASP varied by profession. The identified setbacks were unorganized institutional leadership, the undefined roles of healthcare professionals, a lack of reimbursement, the hierarchical structure of the health system, and the labor-intensive working environment of pharmacy services. Although demands for ASP improvement were similar among professionals, they had different preferences in prioritizing each service item of ASP/ARP development and the profession responsible for each service. Continuous administrative and financial investments, understanding ASP contents, ASP-specific information technology, and interdisciplinary collaboration with good communication among healthcare professions are needed to continue the progression of ASP.

Redundant combinations of antianaerobic antimicrobials: impact of pharmacist-based prospective audit and feedback and prescription characteristics

This study aimed to evaluate the impact of the intervention targeting the redundant combination of antianaerobic antimicrobials on its incidence and associated antimicrobial consumption. To reveal the characteristics of the combination and the change in the related workload over time was an additional aim of the study. The combinations of metronidazole or clindamycin with antianaerobic antimicrobials were classified into redundant or acceptable, according to the target indications. A pharmacist-based prospective audit and feedback targeting the redundant antianaerobic combination was conducted. Segmented regression analysis was performed to evaluate the impact of the intervention. As a quantitative index of the interventional activity, the change in the number of signed consultation notes was evaluated. After the initiation of the intervention, the median monthly cumulative incidence of the redundant combination decreased from 5.29 (Interquartile range [IQR] 4.94-5.70) to 3.33 (IQR 2.87-3.71) (p < 0.001) per 1000 admissions per month. The consumption of concurrently administered metronidazole and clindamycin decreased from 3.34 (IQR 2.97-4.10) to 1.74 (IQR 1.19-1.93) (p < 0.001) per 1000 patient-days per month. Segmented regression analysis revealed that the monthly cumulative incidence decreased by 28.5% after the initiation of the intervention (change in level - 1.640, p = 0.019) and the monthly consumption decreased by 33.9% (change in level - 1.409, p = 0.009). The number of consultation notes per 1000 admissions per month decreased over time (regression coefficient - 0.004, p < 0.001). The pharmacist-based intervention significantly reduced the incidence and associated antimicrobial consumption of the redundant antianaerobic combination. The overall related workload reduced steadily over time.

Status of antimicrobial stewardship programmes in Nigerian tertiary healthcare facilities: Findings and implications

OBJECTIVES

The problem of antimicrobial resistance (AMR) is increasing worldwide, with health-related and economic consequences. This is a concern in Africa, including Nigeria, the most populous country in Africa, with its high rates of infectious diseases. Approaches to reducing AMR include instigating antimicrobial stewardship programmes (ASPs) in hospitals. Currently, no information is available regarding the extent of ASPs in Nigerian hospitals. Consequently, the objective was to address this starting in tertiary hospitals.

METHODS

This was a cross-sectional, questionnaire-based study among tertiary healthcare facilities. Tertiary hospitals were chosen initially since if there are concerns in these training hospitals, such concerns will likely to be exacerbated in other hospitals.

RESULTS

Completed questionnaires were received from 17 of 25 tertiary healthcare facilities across five of the six geopolitical regions of Nigeria. Ten (59%), four (24%), two (12%) and one (6%) respondents were in internal medicine, infectious diseases, medical microbiology and clinical pharmacology, respectively. Only six healthcare facilities (35%) had a formal organisational structure and a team responsible for ASP. Facility-specific treatment recommendations, based on local AMR patterns, were available in only four facilities (24%). Policies on approval for prescribing specified antimicrobials and formal procedures for reviewing their appropriateness after 48h were present in only two facilities (12%). A cumulative antimicrobial susceptibility report for the previous year was available in only two facilities (12%), and only one facility routinely monitored antimicrobial use.

CONCLUSION

Significant inadequacies in the availability of ASPs were observed. This needs to be urgently addressed to reduce AMR rates in Nigeria.

Trends and correlation between antibiotic usage and resistance pattern among hospitalized patients at university hospitals in Korea, 2004 to 2012: A nationwide multicenter study

The aim of this study was to evaluate the changing pattern of antibiotic usage and antimicrobial resistance of bacterial pathogens among hospitalized patients in Korea. We simultaneously investigated the correlation between antimicrobial resistance and antibiotic consumption.Data on total antibiotic prescriptions, patient days, and antimicrobial sensitivity tests among inpatients from 6 university hospitals in Korea in 2004, 2008, and 2012 were collected. The consumption of each antibiotic class was converted to defined daily dose/1000 patient-days by using the anatomical therapeutic chemical classification system by the World Health Organization. We defined third-generation cephalosporins (3rd CEPs), fourth-generation cephalosporins, beta-lactam/beta-lactamase inhibitors, and fluoroquinolones (FQs) as broad-spectrum antibiotics and carbapenems, tigecycline, glycopeptides, oxazolidinone, and polymyxin as antibiotics against multidrug-resistant (MDR) pathogens.A 15.1% decrease in total antibiotic consumption was observed in 2012 compared to that observed in 2004. In contrast, a 10.2% and 70.7% increase in broad-spectrum antibiotics and antibiotics against MDR pathogens were observed, respectively, in the same period. The resistance rate of Escherichia coli to 3rd CEPs (17.6% in 2004, 21.7% in 2008, and 33.8% in 2012, P <.001) and ciprofloxacin (37.5% in 2004, 38.7% in 2008, and 46.6% in 2012, P = .001) demonstrated a significantly increasing trend. Similarly, the resistance rate of Klebsiella pneumoniae to 3rd CEPs (34.3% in 2004, 33.7% in 2008, and 44.5% in 2012, P <.001) gradually increased. Resistance of Acinetobacter baumanii and Pseudomonas aeruginosa to imipenem significantly increased throughout the study period (A baumanii: 8.9% in 2004, 40.8% in 2008, and 65.3% in 2012, P <.001; P aeruginosa: 25.1% in 2004, 31.5% in 2008, and 29.7% in 2008, P = .050).The consumption of carbapenems and FQs demonstrated significant positive correlation for resistance of E coli or K pneumoniae to 3rd CEPs as well as E coli or K pneumoniae to ciprofloxacin. Increasing resistance of A baumanii to ciprofloxacin was significantly correlated with increasing consumption of FQs; increasing resistance of A baumanii to imipenem was significantly correlated with increasing consumption of carbapenems.In conclusion, overall antimicrobial resistance increased and consumption of broad-spectrum antibiotics and antibiotics against MDR pathogens subsequently increased in Korean hospitals.

Impact of an infectious diseases specialist-led antimicrobial stewardship programmes on antibiotic use and antimicrobial resistance in a large Korean hospital

The aim of this study was to evaluate the impact of an infectious diseases specialist (IDS)-led antimicrobial stewardship programmes (ASPs) in a large Korean hospital. An interrupted time series analysis assessing the trends in antibiotic use and antimicrobial resistance rate of major pathogens between September 2015 and August 2017 was performed in an 859-bed university-affiliated hospital in Korea. The restrictive measure for designated antibiotics led by an IDS reduced carbapenems usage by -4.57 days of therapy (DOT)/1,000 patient-days per month in general wards (GWs) (95% confidence interval [CI], -6.69 to -2.46; P < 0.001), and by -41.50 DOT/1,000 patient-days per month in intensive care units (ICUs) (95% CI, -57.91 to -25.10; P < 0.001). Similarly, glycopeptides usage decreased by -2.61 DOT/1,000 patient-days per month in GWs (95% CI, -4.43 to -0.79; P = 0.007), and -27.41 DOT/1,000 patient-days per month in ICUs (95% CI, -47.03 to -7.79; P = 0.009). Use of 3^rd generation cephalosporins, beta-lactam/beta-lactamase inhibitors, and fluoroquinolones in GWs showed change comparable with that of carbapenems or glycopeptides use. Furthermore, trends of antimicrobial resistance rate of Staphylococcus aureus to gentamicin in GWs, Staphylococcus aureus to ciprofloxacin and oxacillin in ICUs, and Pseudomonas aeruginosa to imipenem in ICUs decreased in slope in the intervention period. The in-hospital mortality rate per 1,000 patient-days among ICU patients remained stable between the pre-intervention and intervention periods. In conclusion, an IDS-led ASPs could enact a meaningful reduction in antibiotic use, and a decrease in antibiotic resistance rate, without changing mortality rates in a large Korean hospital.

A survey on antimicrobial stewardship in 116 tertiary hospitals in China

OBJECTIVES

We aimed to assess the status and possible problems of antimicrobial stewardship (AMS) in Grade-A tertiary hospitals in China.

METHODS

A questionnaire was designed according to the United States Centers for Disease Control and Prevention 'Core Elements of Hospital Antibiotic Stewardship Programs'. We extracted 10-15% from Grade A tertiary hospitals in every province of mainland China; 165 hospitals in total were selected. Electronic questionnaires were forwarded to these hospitals.

RESULTS

Of the hospitals surveyed, 116 (70.3%) responded. Participating hospitals accounted for 8.9% (116/1308) of all the Grade A tertiary hospitals in mainland China, covering all provinces and municipalities. Our study revealed that an AMS team was set up for an antimicrobial stewardship programme (ASP) in 110 hospitals (94.8%). Thirty hospitals lacked a formal department of infectious diseases (DID). A formal DID can positively promote an ASP. More hospitals with a formal DID developed their internal guidelines (54.7% versus 33.3%, p 0.044) and technical documents (83.7% versus 63.3%, p 0.019) on antimicrobial use than hospitals without a formal DID. All the 116 hospitals strengthened appropriate use of antimicrobials by some administration-dominated measures, among which the most frequent measures were classification management of antimicrobial agents (114 hospitals, 98.3%) and post-prescription review with feedback (106 hospitals, 91.4%). Prescription preauthorization and pre-prescription review with feedback were implemented in nearly 50% of the hospitals. More hospitals with a DID conducted pre-prescription review with feedback (53.5% versus 26.7%, p 0.027). The most frequent indicator to assess the impact of AMS was the defined daily dose (DDD) (103 hospitals, 96.3%).

CONCLUSIONS

The survey showed significant achievements in China in AMS, mainly including the antibiotic consumption index; there is still a lot of work to be done, such as how to evaluate patient safety and infection outcome after strict restriction of antibiotic use.

Increased use of third-generation cephalosporin antibiotics in the outpatient setting in Korean children and adolescents

BACKGROUND

Antimicrobial resistance is a concern to public health, and controlling antibiotic use is therefore important. This study analyzed the trend in outpatient antibiotic prescriptions in children and adolescents in Korea.

METHODS

Using National Prescribing Sample data from the Korea Health Insurance Review and Assessment Service between 1 January 2010 and 31 December 2014, we analyzed outpatient systemic antibiotic (anatomical therapeutic chemical [ATC] J01) prescriptions in patients aged 2-17 years. The antibiotic rate was defined as the proportion of all outpatient prescriptions for antibiotics. We calculated absolute and relative differences with 95%CI between 2010 and 2014 in the antibiotic rate by age group (2-6, 7-11, and 12-17 years) and the percentage of antibiotic prescriptions by antibiotic class. Seven of the most commonly used antibiotic drugs were identified based on defined daily dose.

RESULTS

A total of 7 261 176 prescriptions were written for 1 039 756 pediatric patients between 2010 and 2014. The antibiotic rate in all patients increased from 34.8% in 2010 to 70.4% in 2014, resulting in the relative difference of 102.1% (95%CI: 101.7-102.5). Extended spectrum penicillins were the most commonly prescribed antibiotic class, accounting for 40.0-41.0% of all antibiotic prescriptions. The use of third-generation cephalosporins increased steeply with the relative difference of 55.7% (95%CI: 55.2-56.2). Amoxicillin/clavulanate, an extended spectrum antibiotic drug, was the predominately used antibiotic drug but the use of cefpodoxime, a third-generation cephalosporin, increased by 96%.

CONCLUSIONS

The use of outpatient antibiotics, especially third-generation cephalosporins, has increased in children and adolescents in Korea.

A few antibiotics can represent the total hospital antibiotic consumption

Background

Appropriate antibiotic use has become an important issue. However, collecting data on the use of all antibiotics in a hospital is difficult without an advanced computerized system and dedicated staff. This paper examines if 1–3 antibiotics can satisfactorily represent the total antibiotic consumption at the hospital level.

Methods

We collected antibiotic data from six large university hospitals in Korea for some years between 2004 and 2012. Since the total antibiotics consist of a few chosen representative antibiotics and the rest, we used those chosen antibiotics along with additional variables constructed only with t (time) such as t, t², and t³ to capture the time trend and whether t belongs to each month or not to capture the monthly variations. The ordinary least squares method was used to explain the total antibiotic amount with these variables, and then the estimated model was employed to predict the use for 2013. To determine which antibiotics were the most representative in tracking general trends in antibiotic use over time, we tried various combinations of antibiotics to find the combination that best minimized the 2013 prediction error.

Results

We found that fluoroquinolones and aminoglycosides were the most representative, followed by beta-lactam/beta-lactamase inhibitors and 4th-generation and 3rd-generation cephalosporins. The mean prediction error over 12 months in 2013 with these few antibiotics was only 1–3% of the monthly antibiotic consumption amount.

Conclusions

The total antibiotic consumption amount at the hospital level can be represented sufficiently by a few antibiotics, such as fluoroquinolones and aminoglycosides, which means that hospitals can save resources by tracing only the usage of those few antibiotics instead of the entire inventory. Since the choice of fluoroquinolones and aminoglycosides is based solely on our Korean data, other hospitals may follow the same modelling methodology to find their own representative antibiotics.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3132-7) contains supplementary material, which is available to authorized users.

From Visiting a Physician to Expecting Antibiotics: Korean Perspectives and Practices toward Respiratory Tract Infections

Antibiotic resistance is steadily rising worldwide. Respiratory tract infections (RTIs) are common indications, mostly imprudent, for antibiotic prescriptions in outpatient setting. In Korea, antibiotic prescription rate for RTIs is still high. As physician visit and antibiotic prescribing are influenced by patient's perceptions and beliefs, we aimed to explore the general public's perspectives and practices toward RTIs and to develop the 'RTI clinical iceberg.' A cross-sectional survey was conducted in Wonju Severance Christian Hospital (WSCH) among 550 adults attending outpatient departments during January 2016. Differences in distributions between groups were examined using two-tailed Pearson χ² test. Using the Andersen's behavioral model as a conceptual framework, we constructed logistic regression models to assess factors associated with physician visit. Of 547 participants with complete questionnaires, 62.9% reported having experienced an RTI in the previous six months; 59.3% visited a physician for the illness, most commonly because the symptoms were severe or prolonged, and approximately 16% of them expected an antibiotic prescription from the visit. Perceptions of symptoms severity, the need factor, most strongly influenced physician visit. Predisposing and enabling factors such as inappropriate expectations for antibiotic for a sore throat or having national health insurance also influenced physician visit. Almost all participants who reported asking for an antibiotic were prescribed one, with a 37.1% non-adherence rate. Conclusively, public education on self-care for RTI symptoms that addresses their main concerns may reduce physician visits. Improving physician-patient relationship and informing patients about the lack of antibiotic benefit for most RTIs may also reduce antibiotic prescriptions.