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

Clinical Outcomes Associated with the Implementation of a Dedicated Clinical Pharmacy Service in a Resource-Limited Neurocritical Intensive Care Unit

Background: Patients in neurocritical care units are particularly vulnerable to medication errors and adverse drug events, necessitating specialized care and comprehensive pharmacological management. Despite this need, the scarcity of clinical pharmacist specialists in South Korean hospitals results in limited direct patient care within multidisciplinary teams. Objective: This study aimed to evaluate the impact of a dedicated pharmacy service program in the neurocritical care intensive care unit (neuro-ICU) on patient outcomes and to propose a clinical pharmacy service model tailored for resource-limited settings. Methods: We conducted a retrospective cohort study comparing neuro-ICU mortality rates and length of stay between periods with and without the presence of a dedicated neurocritical care pharmacist (d-NCP) from May 1, 2016, to December 31, 2017. The study also assessed the frequency and nature of pharmacy interventions alongside factors associated with patient outcomes. Results: The analysis included 769 patients in the group with d-NCP and 676 patients in the group without d-NCP. The presence of a d-NCP was associated with significantly shorter neuro-ICU stays (3.4 ± 8 days vs 3.5 ± 6.4 days, P = .012). Multivariate analysis indicated that the involvement of a d-NCP correlated with reduced length of neuro-ICU stay (β coefficient -0.077, 95% CI: -0.148 to -0.006, P = .033), whereas the number of prescribed medications was linked to longer stays (β coefficient 0.004, 95% CI: 0.014 to 0.005, P < .001). Conclusion: The implementation of a dedicated pharmacy service program in the neuro-ICU leads to improved patient outcomes and mitigates drug-related complications. This model offers a feasible and effective approach for enhancing care in hospitals with limited resources.

The current state of antimicrobial and urine culture stewardship in Thailand: Results from a national survey

BACKGROUND

Antimicrobial stewardship in Thailand has made major progress backed by a national strategic plan. The current study aimed to assess the antimicrobial stewardship program (ASP) composition, reach, and breadth, as well as urine culture stewardship in Thai hospitals.

METHODS

We sent an electronic survey to 100 Thai hospitals between February 1, 2021 and August 31, 2021. This hospital sample represented 20 hospitals in each of Thailand's 5 geographical regions.

RESULTS

The response rate was 100%. A total of 86 of 100 hospitals had an ASP. These were often multi-disciplinary in nature, with half including infectious disease-trained physicians and pharmacists, infection preventionists, and nursing staff. Urine culture stewardship protocols existed in 51% of hospitals.

CONCLUSIONS

The national strategic plan in Thailand has allowed the country to stand up robust ASPs. Further research should examine the effectiveness of such programs and ways to expand them into other medical settings, like nursing homes, urgent care, and outpatient while continuing to grow telehealth and urine culture stewardship.

Antimicrobial Resistance in the Global Health Network: Known Unknowns and Challenges for Efficient Responses in the 21st Century

Antimicrobial resistance (AMR) is one of the Global Health challenges of the 21st century. The inclusion of AMR on the global map parallels the scientific, technological, and organizational progress of the healthcare system and the socioeconomic changes of the last 100 years. Available knowledge about AMR has mostly come from large healthcare institutions in high-income countries and is scattered in studies across various fields, focused on patient safety (infectious diseases), transmission pathways and pathogen reservoirs (molecular epidemiology), the extent of the problem at a population level (public health), their management and cost (health economics), cultural issues (community psychology), and events associated with historical periods (history of science). However, there is little dialogue between the aspects that facilitate the development, spread, and evolution of AMR and various stakeholders (patients, clinicians, public health professionals, scientists, economic sectors, and funding agencies). This study consists of four complementary sections. The first reviews the socioeconomic factors that have contributed to building the current Global Healthcare system, the scientific framework in which AMR has traditionally been approached in such a system, and the novel scientific and organizational challenges of approaching AMR in the fourth globalization scenario. The second discusses the need to reframe AMR in the current public health and global health contexts. Given that the implementation of policies and guidelines are greatly influenced by AMR information from surveillance systems, in the third section, we review the unit of analysis ("the what" and "the who") and the indicators (the "operational units of surveillance") used in AMR and discuss the factors that affect the validity, reliability, and comparability of the information to be applied in various healthcare (primary, secondary, and tertiary), demographic, and economic contexts (local, regional, global, and inter-sectorial levels). Finally, we discuss the disparities and similarities between distinct stakeholders' objectives and the gaps and challenges of combatting AMR at various levels. In summary, this is a comprehensive but not exhaustive revision of the known unknowns about how to analyze the heterogeneities of hosts, microbes, and hospital patches, the role of surrounding ecosystems, and the challenges they represent for surveillance, antimicrobial stewardship, and infection control programs, which are the traditional cornerstones for controlling AMR in human health.

The role of the clinical pharmacist in antimicrobial stewardship in Asia: A review

Clinical pharmacist-driven antimicrobial stewardship programs (ASPs) have been successfully implemented. Although relevant guidance and several studies suggest that clinical pharmacists be integrated into the current ASP team model, barriers still exist in Asia, primarily due to lack of dedicated personnel and lack of career advancement. We review the effectiveness and the ideal role of clinical pharmacist among ASPs in Asia. Several studies conducted in Asia have shown the effectiveness of pharmacist-led ASP interventions in hospitals and other healthcare settings. However, opportunities to expand the role of clinical pharmacists in ASPs in Asia exist in the implementation of rapid diagnostic test and drug allergies.

Community engagement: The key to tackling Antimicrobial Resistance (AMR) across a One Health context?

Antimicrobial resistance (AMR) is a One Health problem underpinned by complex drivers and behaviours. This is particularly so in low - and middle-income countries (LMICs), where social and systemic factors fuel (mis)use and drive AMR. Behavioural change around antimicrobial use could safeguard both existing and future treatments. However, changing behaviour necessitates engaging with people to understand their experiences. This publication describes a knowledge-exchange cluster of six LMIC-based projects who co-designed and answered a series of research questions around the usage of Community Engagement (CE) within AMR. Findings suggest that CE can facilitate AMR behaviour change, specifically in LMICs, because it is a contextualised approach which supports communities to develop locally meaningful solutions. However, current CE interventions focus on human aspects, and demand-side drivers, of AMR. Our cluster suggests that broader attention should be paid to AMR as a One Health issue. The popularity of mixed methods approaches within existing CE for AMR interventions suggests there is interdisciplinary interest in the uptake of CE. Unfortunately, the specificity and context-dependency of CE can make it difficult to evaluate and scale. Nevertheless, we suggest that in synthesising learnings from CE, we can develop a collective understanding of its scope to tackle AMR across contexts.   .

Development and testing of data infrastructure in the American College of Emergency Physicians' Clinical Emergency Data Registry for opioid-related research

Objective

Prior research has identified gaps in the capacity of electronic health records (EHRs) to capture the intricacies of opioid-related conditions. We sought to enhance the opioid data infrastructure within the American College of Emergency Physicians' Clinical Emergency Data Registry (CEDR), the largest national emergency medicine registry, through data mapping, validity testing, and feasibility assessment.

Methods

We compared the CEDR data dictionary to opioid common data elements identified through prior environmental scans of publicly available data systems and dictionaries used in national informatics and quality measurement of policy initiatives. Validity and feasibility assessments of CEDR opioid-related data were conducted through the following steps: (1) electronic extraction of CEDR data meeting criteria for an opioid-related emergency care visit, (2) manual chart review assessing the quality of the extracted data, (3) completion of feasibility scorecards, and (4) qualitative interviews with physician reviewers and informatics personnel.

Results

We identified several data gaps in the CEDR data dictionary when compared with prior environmental scans including urine drug testing, opioid medication, and social history data elements. Validity testing demonstrated correct or partially correct data for >90% of most extracted CEDR data elements. Factors affecting validity included lack of standardization, data incorrectness, and poor delimitation between emergency department (ED) versus hospital care. Feasibility testing highlighted low-to-moderate feasibility of date and social history data elements, significant EHR platform variation, and inconsistency in the extraction of common national data standards (eg, Logical Observation Identifiers Names and Codes, International Classification of Diseases, Tenth Revision codes).

Conclusions

We found that high-priority data elements needed for opioid-related research and clinical quality measurement, such as demographics, medications, and diagnoses, are both valid and can be feasibly captured in a national clinical quality registry. Future work should focus on implementing structured data collection tools, such as standardized documentation templates and adhering to data standards within the EHR that would better characterize ED-specific care for opioid use disorder and related research.

Indonesian healthcare providers' perceptions and attitude on antimicrobial resistance, prescription and stewardship programs

Background: A successful antimicrobial stewardship program (ASP) is sustained through improving antimicrobial prescribing by changing prescribing behavior. This requires a better understanding of hospital stakeholders' views regarding antimicrobial resistance (AMR), antimicrobial use and participation in ASP activities. Objectives: Identify perceptions and attitudes among physicians and pharmacists in a public hospital toward AMR, prescription and ASP. Methods: A questionnaire consisting of 45 items was distributed to physicians and pharmacists in a 320-bed public hospital. All responses were formatted into the Likert scale. Results: A total of 78 respondents (73% response rate) completed the questionnaire. The majority of the respondents perceived AMR within hospital as less of a severe problem, and factors outside hospital were considered to be greater contributors to AMR. In addition, interprofessional conflict was identified as a serious concern in relation to implementing ASP. Conclusion: This finding indicates the need to address existing perceptions and attitudes toward ASP activities that may hamper its successful implementation in Indonesia.

Exploring the intersection of racism, antimicrobial resistance, and vaccine equity

Structural racism and systemic health inequities have an overwhelming and deadly impact on racially and ethnically minoritized groups. Antimicrobial resistance (AMR) is widely considered a global public health threat, and concerns that minoritized groups are disproportionately affected are increasing. With the emergence and spread of AMR, novel therapies and prevention strategies are imperative. Coronavirus disease-19 (COVID-19) has highlighted stark imbalances in the hospitalization and death rates of minoritized individuals compared to their White counterparts, irrespective of the availability of targeted preventive therapies (ie, vaccinations). Thus, dialogue regarding the utility of vaccines used prophylactically to decrease the number of infectious diseases cases and the historical lack of vaccine equity and uptake across minoritized groups is needed. All of these factors work in concert to increase the burden of AMR and ultimately health disparities within minoritized communities. Herein, we provide historical context pertaining to the impact of structural racism on healthcare inequities in the United States, we explore racial and ethnic disparities in AMR, and we discuss the intersection of racism, AMR, and vaccine equity. Lastly, we offer recommendations to mitigate the described inequities.

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.

Quantification of Teicoplanin Using the HPLC-UV Method for Clinical Applications in Critically Ill Patients in Korea

A high-performance liquid chromatography-ultraviolet detector (HPLC-UV) method has been used to quantify teicoplanin concentrations in human plasma. However, the limited analytical accuracy of previously bioanalytical methods for teicoplanin has given rise to uncertainty due to the use of an external standard. In this study, an internal standard (IS), polymyxin B, was applied to devise a precise, accurate, and feasible HPLC-UV method. The deproteinized plasma sample containing teicoplanin and an IS of acetonitrile was chromatographed on a C18 column with an acidic mobile phase consisting of NaH₂PO₄ buffer and acetonitrile (78:22, v/v) by isocratic elution and detection at 220 nm. The linearity was in the range 7.8–500 mg/L calculated by the ratio of the teicoplanin signal to the IS signal. This analytical method, validated by FDA guidelines with ICH Q2 (R1), was successfully applied to analyze the plasma samples of patients in the intensive care unit for treating serious resistant bacterial infectious diseases, such as those by methicillin-resistant Staphylococcus aureus and Enterococcus faecalis. The methods suggested the potential for use in routine clinical practice for therapeutic drug monitoring of teicoplanin, providing both improved accuracy and a wide range of linearity from lower than steady-state trough concentrations (10 mg/L) to much higher concentrations.

Validation of a Questionnaire for Patient Awareness and the Need for a Community-Based Outpatient Antimicrobial Stewardship Program (O-ASP): A Pilot Study

An outpatient antimicrobial stewardship program (O-ASP) was developed and implemented to promote appropriate antibiotic therapy in outpatient settings. As active patient involvement is a critical component of an effective O-ASP, this study aimed to develop and validate a questionnaire addressing patient awareness for appropriate antibiotic therapy and the need for pharmaceutical care services (PCS) in the O-ASP in Korea. The questionnaire was drafted based on ASPs and PCS guidelines and validated for content and construct validity using the item-content validity index (I-CVI) and Cronbach’s alpha, respectively. The estimated I-CVI and Cronbach’s alpha were considered excellent or adequate (≥0.8 and 0.70–0.90, respectively) for most of the survey items (17 out of 23 items). The validated questionnaire was utilized in a pilot survey study, including 112 individuals (37% male) with the mean ± SD age of 37 ± 13 years. Among the survey participants, 68% responded that antibiotics had been prescribed appropriately; however, ≥50% showed a lack of knowledge regarding their antibiotic therapy. The participants expressed the need for PCS as part of an O-ASP in the questionnaire (average Likert score ≥3.4/5). In conclusion, our newly validated questionnaire successfully measured patient awareness and knowledge of antimicrobial use and the need for PCS in the O-ASP.

Are We Making the Most of Community Pharmacies? Implementation of Antimicrobial Stewardship Measures in Community Pharmacies: A Narrative Review

Community pharmacists recognize the need to implement antimicrobial stewardship activities in community pharmacies. They are in a unique position to provide triage for common primary care indications and to lower the burden of patients at general practitioners’ offices. However, research shows that, in some areas, dispensing of antimicrobials without valid prescription is still highly prevalent. Regardless of training, every community pharmacist can give his contribution to antimicrobial stewardship. One of the basic elements should be antimicrobial dispensing according to regulations, either prescription only, or according to guidelines where pharmacists have prescribing authority. Patient consultation supported with educational materials, such as leaflets, may reduce patients’ expectations to receive antibiotics for self-limiting infections and reduce pressure on general practitioners to prescribe antibiotics on patients’ demand. Treatment optimization may be achieved in collaboration with the prescribing general practitioners or by providing feedback. At last, pharmacists provided with additional training may be encouraged to provide consultation services to long-term care facilities, to introduce point-of-care testing for infectious diseases in their pharmacies or prescribe antimicrobials for uncomplicated infections. These services are welcomed by patients and communities. Expanding pharmacy services and pharmacists’ prescribing autonomy have shown a positive impact by reducing antibiotics consumption, thus ensuring better compliance with treatment guidelines.