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Lee R, Nho D, Cho SY, Park S, Cho BS, Kim HJ, Yoon JH, Lee S, Kim YJ, Lee DG. Impact of an antimicrobial stewardship programme on antibiotic utilization and resistance burden in patients with acute leukaemia: an 11-year longitudinal cohort study using interrupted time-series analysis. J Antimicrob Chemother 2024:dkae199. [PMID: 38863389 DOI: 10.1093/jac/dkae199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 05/02/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR), driven by inappropriate and overuse of antibiotics, poses a significant threat, especially to patients with acute leukaemia. OBJECTIVES To evaluate the impact of antimicrobial stewardship programmes (ASPs) on antibiotic use and analyse temporal changes in bloodstream infections (BSI) caused by AMR organisms. METHODS We performed a retrospective, interventional, longitudinal cohort study spanning an 11-year period. ASPs included optimizing antibiotic use, enhancing tracking and reporting systems and delineating leadership and accountability. A segmented regression model of interrupted time series was used to evaluate the trend of antibiotic consumption and BSI with AMR organisms after the interventions. RESULTS A total of 3296 BSI episodes with 454 419 days of therapy (DOT) from 7754 patients were obtained. ASPs were significantly associated with an immediate reduction [-70.03 DOT/1000 patient-days (PD), P = 0.036] and a decreasing trend (-11.65 DOT/1000 PD per quarter, P < 0.001) in overall antibiotic use. The increasing incidence of BSI with AMR before ASP intervention was notably curbed and revealed a decreasing trend (slope change: -0.06 BSI/1000 PD per quarter, P = 0.002). The decreasing trend was more significant for Enterobacterales: ciprofloxacin-resistant and ESBL-producing isolates showed a slope change of -0.06 BSI/1000 PD and -0.08 BSI/1000 PD per quarter, respectively (all P < 0.05). However, Pseudomonas aeruginosa BSI increased. CONCLUSIONS Multidimensional ASPs effectively reduced both the immediate and trends in overall antibiotic usage even in patients with acute leukaemia. Additionally, there was a notable decrease in the incidence of BSI caused by AMR organisms, particularly among Enterobacterales.
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Affiliation(s)
- Raeseok Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Catholic Hematology Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Dukhee Nho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Catholic Hematology Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Sung-Yeon Cho
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Catholic Hematology Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Silvia Park
- Catholic Hematology Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
- Department of Hematology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung-Sik Cho
- Catholic Hematology Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
- Department of Hematology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hee-Je Kim
- Catholic Hematology Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
- Department of Hematology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae-Ho Yoon
- Catholic Hematology Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
- Department of Hematology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Lee
- Catholic Hematology Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
- Department of Hematology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoo-Jin Kim
- Catholic Hematology Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
- Department of Hematology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Catholic Hematology Hospital, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
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Mudenda S, Chabalenge B, Daka V, Jere E, Sefah I, Wesangula E, Yamba K, Nyamupachitu J, Mugenyi N, Mustafa ZU, Mpundu M, Chizimu J, Chilengi R. Knowledge, awareness and practices of healthcare workers regarding antimicrobial use, resistance and stewardship in Zambia: a multi-facility cross-sectional study. JAC Antimicrob Resist 2024; 6:dlae076. [PMID: 38764535 PMCID: PMC11100357 DOI: 10.1093/jacamr/dlae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 04/29/2024] [Indexed: 05/21/2024] Open
Abstract
Background Antimicrobial resistance (AMR) poses a threat to public health globally. Despite its consequences, there is little information about the knowledge, awareness, and practices towards AMR among healthcare workers (HCWs). Therefore, this study assessed the knowledge, awareness and practices regarding antimicrobial use (AMU), AMR and antimicrobial stewardship (AMS) among HCWs who are involved in the implementation of AMS activities across eight hospitals in Zambia. Methods A cross-sectional study was conducted among 64 HCWs from October to December 2023 using a semi-structured questionnaire. Data were analysed using IBM SPSS version 25.0. Results Of the 64 HCWs, 59.4% were females, 60.9% were aged between 25 and 34 years, 37.5% were nurses, 18.7% were pharmacists, 17.2% were medical doctors and only one was a microbiologist. Overall, 75% of the HCWs had good knowledge, 84% were highly aware and 84% had good practices regarding AMU, AMR and AMS. Most of the HCWs (90.6%) responded that they had a multidisciplinary AMS team at their hospitals and were implementing the use of the WHO AWaRe classification of antibiotics. Conclusion This study found good knowledge levels, high awareness and good practices regarding AMU, AMR and AMS among HCWs who were involved in the implementation of AMS activities in hospitals in Zambia. Additionally, most hospitals have been conducting AMS training and implementing the use of the WHO AWaRe classification of antibiotics. However, there is still a need to address some identified gaps in AMU and AMR through the strengthening of AMS activities in hospitals.
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Affiliation(s)
- Steward Mudenda
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Billy Chabalenge
- Department of Medicines Control, Zambia Medicines Regulatory Authority, Lusaka, Zambia
| | - Victor Daka
- Department of Public Health, Michael Chilufya Sata School of Medicine, Copperbelt University, Ndola, Zambia
| | - Elimas Jere
- Department of Medicines Control, Zambia Medicines Regulatory Authority, Lusaka, Zambia
| | - Isaac Sefah
- Pharmacy Practice Department, School of Pharmacy, University of Health and Allied Sciences, Volta Region, PMB 31, Ho, Ghana
| | - Evelyn Wesangula
- Strengthening Pandemic Preparedness, Eastern, Central, and Southern Africa Health Community, Arusha, Tanzania
| | - Kaunda Yamba
- Antimicrobial Resistance Coordinating Committee, Zambia National Public Health Institute, Lusaka, Zambia
| | | | - Nathan Mugenyi
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Zia Ul Mustafa
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Gelugor, Penang, 11800, Malaysia
- Department of Pharmacy Services, District Headquarter (DHQ) Hospital, Pakpattan, 57400, Pakistan
| | - Mirfin Mpundu
- Action on Antibiotic Resistance (ReAct) Africa, Lusaka, Zambia
| | - Joseph Chizimu
- Antimicrobial Resistance Coordinating Committee, Zambia National Public Health Institute, Lusaka, Zambia
| | - Roma Chilengi
- Antimicrobial Resistance Coordinating Committee, Zambia National Public Health Institute, Lusaka, Zambia
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3
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Kwon KT, Kim SW. Principles and practices of antimicrobial stewardship programs in Korea. Korean J Intern Med 2024; 39:373-382. [PMID: 38649160 PMCID: PMC11076894 DOI: 10.3904/kjim.2023.482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/22/2023] [Accepted: 01/07/2024] [Indexed: 04/25/2024] Open
Abstract
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.
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Affiliation(s)
- Ki Tae Kwon
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Shin-Woo Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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Moon SM, Kim B, Kim HB. Quantitative and qualitative evaluation of antimicrobial usage: the first step for antimicrobial stewardship. Korean J Intern Med 2024; 39:383-398. [PMID: 38715229 PMCID: PMC11076899 DOI: 10.3904/kjim.2023.506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 12/19/2023] [Indexed: 05/12/2024] Open
Abstract
The identification of antimicrobial use patterns is essential for determining key targets for antimicrobial stewardship interventions and evaluating the effectiveness thereof. Accurately identifying antimicrobial use patterns requires quantitative evaluation, which focuses on measuring the quantity and frequency of antimicrobial use, and qualitative evaluation, which assesses the appropriateness, effectiveness, and potential side effects of antimicrobial prescriptions. This paper summarizes the quantitative and qualitative methods used to evaluate antimicrobials, drawing insights from overseas and domestic cases.
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Affiliation(s)
- Song Mi Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul,
Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam,
Korea
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Thakral Y, Sahay S, Mukherjee A. Microfoundations of Data-Driven Antimicrobial Stewardship Policy (ASP). Antibiotics (Basel) 2023; 13:24. [PMID: 38247583 PMCID: PMC10812814 DOI: 10.3390/antibiotics13010024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 11/23/2023] [Accepted: 11/29/2023] [Indexed: 01/23/2024] Open
Abstract
This paper introduces a comprehensive framework that elucidates the microfoundations of data-driven antimicrobial stewardship programs (ASPs), specifically focusing on resource-constrained settings. Such settings necessitate the utilization of available resources and engagement among multiple stakeholders. The microfoundations are conceptualized as interlinked components: input, process, output, and outcome. Collectively, these components provide a comprehensive framework for understanding the development and implementation of data-driven ASPs in resource-constrained settings. It underscores the importance of considering both the social and material dimensions when evaluating microbiological, clinical, and social impacts. By harmonizing technology, practices, values, and behaviors, this framework offers valuable insights for the development, implementation, and assessment of ASPs tailored to resource-constrained environments.
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Affiliation(s)
- Yogita Thakral
- Department of Informatics, University of Oslo, 0373 Oslo, Norway;
- HISP India, New Delhi 110025, India
| | - Sundeep Sahay
- Department of Informatics, University of Oslo, 0373 Oslo, Norway;
- HISP India, New Delhi 110025, India
| | - Arunima Mukherjee
- HISP India, New Delhi 110025, India
- SUSTAINIT—Unit for sustainable health, Faculty of Medicine, University of Oslo, 0316 Oslo, Norway
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Gu H, Sun L, Sheng B, Gu X, Wang S, Liu L, Dai B, Chen W. Benefits of pharmacist intervention in the critical care patients with infectious diseases: A propensity score matching retrospective cohort study. Aust Crit Care 2023; 36:933-939. [PMID: 36809868 DOI: 10.1016/j.aucc.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND The importance of optimising antimicrobial therapy is highlighted in the hospital intensive care unit (ICU) patients. But roles of ICU pharmacists are still in its infancy in China. OBJECTIVES This study's objective was to evaluate the values of clinical pharmacist interventions in the antimicrobial stewardship (AMS) on ICU patients with infections. AIM The aim of this study was to evaluate the value of clinical pharmacist interventions in the antimicrobial stewardship (AMS) in critically ill patients with infections. METHODS From 2017 to 2019, a propensity score matching retrospective cohort research was conducted on critically ill patients with infectious illnesses. The trial was split into groups that received pharmacist assistance and those who did not. Baseline demographics, pharmacist actions, and clinical results were compared between the two groups. Factors influencing mortality were demonstrated using univariate analysis and bivariate logistic regression. The State Administration of Foreign Exchange in China monitored the exchange rate between the RMB and the US dollar and also gathered the charges of the agents as an economic indicator. RESULTS Out of the 1523 patients who were evaluated, 102 critically ill patients with infectious diseases were included in each group after matching. The top five prescription regimens adjusted were settled by sickness progression, microbiological results, de-escalation, drug withdrawal, and therapeutic drug monitoring suggestions. The pharmacist exposure group's antibiotic use density (AUD) decreased significantly (p = 0.018) compared to the control group, going from 241.91 to 176.64 defined daily doses/100 bed days. Following pharmacist interventions, the AUD proportion for carbapenems dropped from 23.7 to 14.43%, while for tetracyclines, it dropped from 11.5 to 6.26%. In the group exposed to the pharmacist, the median cost of antibiotics decreased significantly from $836.3 to $362.15 per patient stay (p < 0.001), and the median cost of all medications dropped from $2868.18 to $1941.5 per patient stay (p = 0.06). RMB was converted into US dollars according to the current exchange rate. According to univariate analyses, pharmacist interventions did not differ between the groups that survived and died (p = 0.288). CONCLUSIONS This study showed that antimicrobial stewardship had a significant financial return on investment without raising the mortality rate.
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Affiliation(s)
- Hongyan Gu
- Pharmacy Department, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China; Beijing Key Laboratory of Bio-Characteristic Profiling for Evaluation of Rational Drug Use, Beijing 100038, China; International Cooperation & Joint Laboratory of Bio-Characteristic Profiling for Evaluation of Rational Drug Use, Beijing 100038, China
| | - Lulu Sun
- Pharmacy Department, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Bo Sheng
- Department of Critical Care Medicine, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Xuyun Gu
- Department of Critical Care Medicine, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Suozhu Wang
- Department of Critical Care Medicine, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Lei Liu
- Office of Academic Research, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Bin Dai
- Neurosurgery, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China
| | - Wei Chen
- Department of Critical Care Medicine, Beijing Shijitan Hospital Affiliated to Capital Medical University, Beijing 100038, China.
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Rachina S, Belkova Y, Kozlov R, Mladov V, Mishchenko V, Andreeva A, Domanskaya O, Portnjagina U, Dushina A, Zainalabidova K. Assessment of Antimicrobial Consumption in Multi-Field Hospitals with Pediatric Inpatients: Conventional vs. Novel Pediatric-Adjusted Methodologies. Antibiotics (Basel) 2023; 12:1162. [PMID: 37508258 PMCID: PMC10376229 DOI: 10.3390/antibiotics12071162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/30/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND the objective of this study was to propose a methodology for the assessment of antimicrobial consumption (AMC) in pediatric inpatients and to estimate variances in consumption levels in multi-field hospitals with pediatric inpatients, calculated by means of the pediatric-adjusted methodology vs. the conventional methodology. METHODS the pediatric-adjusted methodology based on the conventional ATC/DDD method and children's DDDs (cDDD) for antimicrobials were proposed and validated in a series of probabilistic sensitivity analyses of real clinical data extracted from the receipt notes of three multi-field hospitals. Differences in AMC in multi-field hospitals with pediatric inpatients, calculated by means of the proposed methodology vs. the conventional methodology, were assessed for a virtual cohort of inpatients, with the pediatric share increasing by 1%. RESULTS in children ≤12 years old, assessment by the standard methodology resulted in a 59% underestimation of AMC from the levels based on prescribed doses, vs. a 25% underestimation for the proposed methodology. In a mixed-age virtual population of inpatients, the underestimation of consumption levels rose to 321% for the ATC/DDD methodology compared to the proposed one. CONCLUSIONS the proposed methodology demonstrated a higher accuracy of AMC estimates compared to the conventional one and can be considered for the quantification of antimicrobial utilization in pediatric institutions and multi-field hospitals with a substantial share of pediatric inpatients.
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Affiliation(s)
- Svetlana Rachina
- Hospital Therapy Department No. 2, I.M. Sechenov First Moscow State Medical University, 119435 Moscow, Russia
| | - Yuliya Belkova
- Department of Clinical Pharmacology, Smolensk State Medical University, 214019 Smolensk, Russia
| | - Roman Kozlov
- Institute of Antimicrobial Chemotherapy, Smolensk State Medical University, 214019 Smolensk, Russia
| | - Vladimir Mladov
- Faculty of Applied Mathematics and Control Processes, St. Petersburg State University, 199034 St. Petersburg, Russia
| | - Vladimir Mishchenko
- Federal Centre of Traumatology, Orthopedics and Endoprosthesis Replacement, 214019 Smolensk, Russia
| | - Alla Andreeva
- Smolensk Regional Clinical Hospital, 214018 Smolensk, Russia
| | - Olga Domanskaya
- Kuzbas Children's Clinical Hospital n.a. Professor Y.E. Malachovskiy, 654063 Novokuznetsk, Russia
| | - Ulyana Portnjagina
- Department of Internal Medicine and General Medical Practice (Family Medicine), North-Eastern Federal University, 677007 Yakutsk, Russia
| | - Anastasiia Dushina
- Institute of Engineering Physics for Biomedicine, National Research Nuclear University MEPhI (Moscow Engineering Physics Institute), 115409 Moscow, Russia
| | - Khadizhat Zainalabidova
- Hospital Therapy Department No. 2, I.M. Sechenov First Moscow State Medical University, 119435 Moscow, Russia
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Hassan SK, Dahmash EZ, Madi T, Tarawneh O, Jomhawi T, Alkhob W, Ghanem R, Halasa Z. Four years after the implementation of antimicrobial stewardship program in Jordan: evaluation of program's core elements. Front Public Health 2023; 11:1078596. [PMID: 37325334 PMCID: PMC10262748 DOI: 10.3389/fpubh.2023.1078596] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 05/09/2023] [Indexed: 06/17/2023] Open
Abstract
Objectives To combat antimicrobial resistance, the World Health Organization (WHO) urged healthcare organizations in Low- and Middle-Income Countries (LMICs) to implement the core elements of the antimicrobial stewardship (AMS) programs. In response, Jordan took action and developed a national antimicrobial resistance action plan (NAP) in 2017 and commenced the AMS program in all healthcare facilities. It is paramount to evaluate the efforts to implement the AMS programs and understand the challenges of implementing a sustainable and effective program, in Low-Middle Income Country (LMIC) contexts. Therefore, the aim of this study was to appraise the compliance of public hospitals in Jordan to the WHO core elements of effective AMS programs after 4 years of commencement. Methods A cross-sectional study in public hospitals in Jordan, using the WHO AMS program core elements for LMICs was carried out. The questionnaire comprised 30 questions that covered the program's six core elements: leadership commitment, accountability and responsibility, AMS actions, education and training, monitoring, and evaluation, and reporting and feedback. A five-point Likert scale was employed for each question. Results A total of 27 public hospitals participated, with a response rate of 84.4%. Adherence to core elements ranged from (53%) in the leadership commitment domain to (72%) for AMS procedure application (actions). Based on the mean score, there was no significant difference between hospitals according to location, size, and specialty. The most neglected core elements that emerged as top priority areas were the provision of financial support, collaboration, access, as well as monitoring and evaluation. Conclusion The current results revealed significant shortcomings in the AMS program in public hospitals despite 4 years of implementation and policy support. Most of the core elements of the AMS program were below average, which requires hospital leadership commitment, and multifaceted collaborative actions from the concerned stakeholders in Jordan.
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Affiliation(s)
- Samar Khaled Hassan
- Department of Accreditation, Healthcare Accreditation Council, Amman, Jordan
| | - Eman Zmaily Dahmash
- Department of Chemical and Pharmaceutical Sciences, School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Kingston upon Thames, United Kingdom
| | - Thaira Madi
- Department of Accreditation, Healthcare Accreditation Council, Amman, Jordan
| | - Omar Tarawneh
- Department of Consultation, Healthcare Accreditation Council, Amman, Jordan
| | - Tuqa Jomhawi
- Department of Accreditation, Healthcare Accreditation Council, Amman, Jordan
| | - Worood Alkhob
- Department of Accreditation, Healthcare Accreditation Council, Amman, Jordan
| | - Rola Ghanem
- Laboratory Directorate, Ministry of Health, Amman, Jordan
| | - Zina Halasa
- Clinical Pharmacy Directorate, Ministry of Health, Amman, Jordan
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Haseeb A, Saleem Z, Maqadmi AF, Allehyani RA, Mahrous AJ, Elrggal ME, Kamran SH, AlGethamy M, Naji AS, AlQarni A, Alhariqi KW, Khan MA, Ibrahim K, Raees F, Azmat A, Cook A, Campbell SM, Lorenzetti G, Meyer JC, Godman B, Moore CE. Ongoing Strategies to Improve Antimicrobial Utilization in Hospitals across the Middle East and North Africa (MENA): Findings and Implications. Antibiotics (Basel) 2023; 12:827. [PMID: 37237730 PMCID: PMC10215537 DOI: 10.3390/antibiotics12050827] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/22/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023] Open
Abstract
Antimicrobial resistance (AMR) is an increasing global concern, increasing costs, morbidity, and mortality. National action plans (NAPs) to minimize AMR are one of several global and national initiatives to slow down rising AMR rates. NAPs are also helping key stakeholders understand current antimicrobial utilization patterns and resistance rates. The Middle East is no exception, with high AMR rates. Antibiotic point prevalence surveys (PPS) provide a better understanding of existing antimicrobial consumption trends in hospitals and assist with the subsequent implementation of antimicrobial stewardship programs (ASPs). These are important NAP activities. We examined current hospital consumption trends across the Middle East along with documented ASPs. A narrative assessment of 24 PPS studies in the region found that, on average, more than 50% of in-patients received antibiotics, with Jordan having the highest rate of 98.1%. Published studies ranged in size from a single to 18 hospitals. The most prescribed antibiotics were ceftriaxone, metronidazole, and penicillin. In addition, significant postoperative antibiotic prescribing lasting up to five days or longer was common to avoid surgical site infections. These findings have resulted in a variety of suggested short-, medium-, and long-term actions among key stakeholders, including governments and healthcare workers, to improve and sustain future antibiotic prescribing in order to decrease AMR throughout the Middle East.
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Affiliation(s)
- Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 24382, Saudi Arabia; (A.H.); (A.F.M.); (R.A.A.); (A.J.M.); (M.E.E.)
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan 60800, Pakistan
| | - Aseel Fayk Maqadmi
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 24382, Saudi Arabia; (A.H.); (A.F.M.); (R.A.A.); (A.J.M.); (M.E.E.)
| | - Roaa Abdulrahman Allehyani
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 24382, Saudi Arabia; (A.H.); (A.F.M.); (R.A.A.); (A.J.M.); (M.E.E.)
- Batterjee Medical College, Jeddah 21442, Saudi Arabia
| | - Ahmad J. Mahrous
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 24382, Saudi Arabia; (A.H.); (A.F.M.); (R.A.A.); (A.J.M.); (M.E.E.)
| | - Mahmoud E. Elrggal
- Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah 24382, Saudi Arabia; (A.H.); (A.F.M.); (R.A.A.); (A.J.M.); (M.E.E.)
| | - Sairah Hafeez Kamran
- Institute of Pharmacy, Lahore College for Women University, Lahore 54000, Pakistan;
| | - Manal AlGethamy
- Department of Infection Prevention and Control Program, Alnoor Specialist Hospital, Makkah 24241, Saudi Arabia;
| | - Asem Saleh Naji
- Infectious Diseases Department, Alnoor Specialist Hospital, Makkah 24241, Saudi Arabia; (A.S.N.); (A.A.); (K.W.A.)
| | - Abdullmoin AlQarni
- Infectious Diseases Department, Alnoor Specialist Hospital, Makkah 24241, Saudi Arabia; (A.S.N.); (A.A.); (K.W.A.)
| | - Khalid W. Alhariqi
- Infectious Diseases Department, Alnoor Specialist Hospital, Makkah 24241, Saudi Arabia; (A.S.N.); (A.A.); (K.W.A.)
| | | | - Kiran Ibrahim
- Primary and Secondary Healthcare Department, DHQ Hospital Khushab, Khushab 41200, Pakistan;
| | - Fahad Raees
- Department of Medical Microbiology, Faculty of Medicine, Umm Al-Qura University, Makkah 24382, Saudi Arabia;
| | - Aisha Azmat
- Department of Physiology, Faculty of Medicine, Umm Al-Qura University, Makkah 24382, Saudi Arabia;
| | - Aislinn Cook
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK; (A.C.); (G.L.); (C.E.M.)
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX1 2JD, UK
| | - Stephen M. Campbell
- Centre for Epidemiology and Public Health, School of Health Sciences, University of Manchester, Manchester M13 9PL, UK;
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria 0208, South Africa;
| | - Giulia Lorenzetti
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK; (A.C.); (G.L.); (C.E.M.)
| | - Johanna C. Meyer
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria 0208, South Africa;
- South African Vaccination and Immunisation Centre, Sefako Makgatho Health Sciences University, Molotlegi Street, Garankuwa, Pretoria 0208, South Africa
| | - Brian Godman
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria 0208, South Africa;
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow G4 0RE, UK
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman 346, United Arab Emirates
| | - Catrin E. Moore
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK; (A.C.); (G.L.); (C.E.M.)
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10
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Park SY, Kim YC, Lee R, Kim B, Moon SM, Kim HB. Current Status and Prospect of Qualitative Assessment of Antibiotics Prescriptions. Infect Chemother 2022; 54:599-609. [PMID: 36596676 PMCID: PMC9840950 DOI: 10.3947/ic.2022.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/08/2022] [Indexed: 12/29/2022] Open
Abstract
Identifying inappropriately prescribed antibiotics for infectious diseases by monitoring the quality of antibiotics use is essential for effective implementation of antibiotic stewardship. Qualitative assessment of the use of antibiotics has been conducted in some countries, including Korea, since the 2000s. The qualitative assessment generally involves an assessment of each component of the antibiotics prescription process, based on specific criteria. However, there is no standardized assessment method or cycle, and infectious diseases or antibiotics included in the assessments vary from country-to-country. According to the results reported in the United States, Europe, Australia, and Korea so far, approximately 20 - 55% of all antibiotics prescriptions are inappropriate. In this review, we describe the current progress in the quality assessment of the use of antibiotics on a global scale. Further, we highlight the future directions to improve antibiotic stewardship activities and the quality assessment of the use of antibiotics in Korea.
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Affiliation(s)
- Se Yoon Park
- Department of Hospital Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea.,Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea.,Centers for Digital Health, Yongin Severance Hospital, Yonsei University Health System, Yongin, Korea
| | - Yong Chan Kim
- Department of Internal Medicine, Division of Infectious diseases, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Korea
| | - Raeseok Lee
- Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Song Mi Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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11
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Cheong HS, Park KH, Kim HB, Kim SW, Kim B, Moon C, Lee MS, Yoon YK, Jeong SJ, Kim YC, Eun BW, Lee H, Shin JY, Kim HS, Hwang IS, Park CS, Kwon KT. Core Elements for Implementing Antimicrobial Stewardship Programs in Korean General Hospitals. Infect Chemother 2022; 54:637-673. [PMID: 36596679 PMCID: PMC9840955 DOI: 10.3947/ic.2022.0171] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
Currently, antimicrobial resistance (AMR) is a major threat to global public health. The antimicrobial stewardship program (ASP) has been proposed as an important approach to overcome this crisis. ASP supports the optimal use of antimicrobials, including appropriate dosing decisions, administration duration, and administration routes. In Korea, efforts are being made to overcome AMR using ASPs as a national policy. The current study aimed to develop core elements of ASP that could be introduced in domestic medical facilities. A Delphi survey was conducted twice to select the core elements through expert consensus. The core elements for implementing the ASP included (1) leadership commitment, (2) operating system, (3) action, (4) tracking, (5) reporting, and (6) education. To ensure these core elements are present at medical facilities, multiple departments must collaborate as teams for ASP operations. Establishing a reimbursement system and a workforce for ASPs are prerequisites for implementing ASPs. To ensure that ASP core elements are actively implemented in medical facilities, it is necessary to provide financial support for ASPs in medical facilities, nurture the healthcare workforce in performing ASPs, apply the core elements to healthcare accreditation, and provide incentives to medical facilities by quality evaluation criteria.
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Affiliation(s)
- Hae Suk Cheong
- Division of Infectious Diseases, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung-Hwa Park
- Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Shin-Woo Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Chisook Moon
- Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Mi Suk Lee
- Department of Internal Medicine, Kyung Hee University College of Medicine, Kyung Hee University Hospital, Seoul, Korea
| | - Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Kim
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Wook Eun
- Department of Pediatrics, Nowon Eulji University Hospital, Seoul, Korea
| | - Hyukmin Lee
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Ji-Yeon Shin
- Department of Preventive Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyung-sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In Sun Hwang
- Korea Institute for Healthcare Accreditation, Seoul, Korea
| | - Choon-Seon Park
- Health Insurance Review and Assessment Research Institute, Health Insurance Review and Assessment Service, Wonju, Korea
| | - Ki Tae Kwon
- Division of Infectious Diseases, Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
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12
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Park DW, Choi JY, Kim CJ, Kim JH, Kim HB, Lee DG. Implementation of Procalcitonin in Antibiotic Stewardship: Derivation of a Consensus Algorithm for Procalcitonin Use in Clinical Practice. Infect Chemother 2022; 54:621-636. [PMID: 36596678 PMCID: PMC9840958 DOI: 10.3947/ic.2022.0170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/19/2022] [Indexed: 12/27/2022] Open
Abstract
Reducing antibiotics overuse is essential to minimize antibiotics related side effects and to prevent the emergence of multidrug-resistant bacteria. Procalcitonin (PCT) guided antibiotics therapy has been reported to be safe in patients with acute respiratory infections and sepsis, improving clinical outcomes as well as reducing the duration of antibiotics use. However, there is still no universal agreement on clinical guidelines in Korea for optimal PCT applications. Through this expert consensus meeting, clinical research findings in the PCT-guided antibiotics treatment interventions and real-world clinical applications were discussed. From the perspective of antibiotic stewardship, PCT application target groups, cut-offs, and testing cycles were discussed to reach a consensus on the PCT-guided antibiotics treatment algorithm for application in Korea. Combining clinical assessment for patients with an appropriate PCT-guided antibiotics treatment algorithm could improve the diagnosis and treatment of acute respiratory infections and sepsis. In addition, continuous education and regular feedback would improve the effectiveness of antibiotic stewardship.
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Affiliation(s)
- Dae Won Park
- Division of Infectious Diseases, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea.,Vaccine Innovation Center, Korea University College of Medicine, Seoul, Korea
| | - Jun Yong Choi
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,AIDS Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Chung-Jong Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Jong Hun Kim
- Division of Infectious Diseases, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
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13
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Kim CJ. Current Status of Antibiotic Stewardship and the Role of Biomarkers in Antibiotic Stewardship Programs. Infect Chemother 2022; 54:674-698. [PMID: 36596680 PMCID: PMC9840952 DOI: 10.3947/ic.2022.0172] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/19/2022] [Indexed: 12/27/2022] Open
Abstract
The importance of antibiotic stewardship is increasingly emphasized in accordance with the increasing incidences of multidrug-resistant organisms and accompanying increases in disease burden. This review describes the obstacles in operating an antibiotic stewardship program (ASP), and whether the use of biomarkers within currently available resources can help. Surveys conducted around the world have shown that major obstacles to ASPs are shortages of time and personnel, lack of appropriate compensation for ASP operation, and lack of guidelines or appropriate manuals. Sufficient investment, such as the provision of full-time equivalent ASP practitioners, and adoption of computerized clinical decision systems are useful measures to improve ASP within an institution. However, these methods are not easy in terms of both time commitments and cost. Some biomarkers, such as C-reactive protein, procalcitonin, and presepsin are promising tools in ASP due to their utility in diagnosis and forecasting the prognosis of sepsis. Recent studies have demonstrated the usefulness of algorithmic approaches based on procalcitonin level to determine the initiation or discontinuation of antibiotics, which would be helpful in decreasing antibiotics use, resulting in more appropriate antibiotics use.
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Affiliation(s)
- Chung-Jong Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
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14
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Hakami AY, Felemban LH, Aljifri NA, Alyamani GM, Abosallamh KA, Aljohani RA, Aldosary T, Basheikh A. Antibacterial Resistance Patterns Among Common Infections in a Tertiary Care Hospital in Saudi Arabia. Cureus 2022; 14:e31695. [PMID: 36415476 PMCID: PMC9676098 DOI: 10.7759/cureus.31695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2022] [Indexed: 11/21/2022] Open
Abstract
Background The rapid emergence of antibiotic-resistant bacteria threatens the control of infectious diseases by reducing treatment effectiveness, prolonging illness duration, and increasing healthcare costs. This study aimed to identify the common rate of bacterial resistance against antibacterial agents in tertiary healthcare providers in Saudi Arabia. Methodology This retrospective cross-sectional observational study was conducted from May 2016 to December 2019 on 1,151 urinary tract infection (UTI) and respiratory tract infection (RTI) positive cultures collected from participants aged 15 years or older who received antibiotic treatment. The obtained variables included age, gender, diagnosis, antibiotic type, specimen source, culture results, and sensitivity test results. Results The most common bacteria in UTI were Escherichiacoli (46.7%), followed by Klebsiellapneumoniae (30.5%). Moreover, E.coli was most resistant to ampicillin (56.4%), followed by ceftriaxone (33.8%). Among the respiratory cultures, the most frequently isolated pathogen was Pseudomonas aeruginosa (28.5%), followed by K. pneumoniae (17.6%). The 162 respiratory P. aeruginosa isolates were most resistant to piperacillin/tazobactam (51.9%), followed by ciprofloxacin (25%) and ampicillin (10.6%). Conclusion High levels of antibiotic resistance were observed in both Gram-negative and Gram-positive bacteria. This indicates a need for better implementation of antibacterial stewardship and increased awareness of appropriate antibiotic use to limit the rapid spread of antibacterial resistance.
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15
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Kwon KT. Implementation of antimicrobial stewardship programs. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2022. [DOI: 10.5124/jkma.2022.65.8.498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: The antimicrobial stewardship program (ASP) is a coordinated intervention designed to improve and measure the appropriate antibiotics use by selecting an optimal antibiotic drug regimen, including dosing, therapy duration, and administration route. The implementation of ASPs decreases the consumption, cost, and adverse effects of antibiotic use. Additionally, it improves the clinical outcomes, and decreases Clostridium difficile infection and antimicrobial resistance.Current Concepts: To overcome the antimicrobial resistance and implement ASPs worldwide, various efforts are underway, such as enacting ASP guidelines, developing core elements for ASP implementation, introducing ASPs to the healthcare accreditation system, and providing healthcare facilities with adequate incentives to implement ASPs. In Korea, ASP guidelines were published in September 2021, and core elements for ASP implementation are being developed at the time of writing. However, there is a shortage of personnel required for the ASP team, including healthcare workforce and infectious disease specialists for leading the team Moreover, financial support for ASP implementation in the National Health Insurance Service is not provided yet. The awareness of hospital leadership and clinicians prescribing antibiotics for ASP implementation is still low. The reimbursement system establishment and workforce for ASPs are prerequisite for the implementation of ASPs.Discussion and Conclusion: At the national level, it is necessary to provide financial support for ASPs in healthcare facilities, nurture the healthcare workforce in performing ASPs, and advocate ASP education and publicity.
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16
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Lee HJ, Lee DG. Urgent need for novel antibiotics in Republic of Korea to combat multidrug-resistant bacteria. Korean J Intern Med 2022; 37:271-280. [PMID: 35272440 PMCID: PMC8925957 DOI: 10.3904/kjim.2021.527] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/21/2022] [Indexed: 11/27/2022] Open
Abstract
Multidrug resistance in bacteria is an important issue and is increasing in frequency worldwide because of the limitations of therapeutic agents. From 2010 to 2019, 14 new systemic antibiotics received regulatory approval in the United States. However, few new antibiotics have been introduced in Republic of Korea to combat multidrug-resistant pathogens. Here, we introduce six novel antibiotics for Gram-positive bacteria and five for Gram-negative bacteria approved by the United States Food and Drug Administration and the European Medicines Agency from 2009 to October 2021, and recommend that they be approved for use in Republic of Korea at the earliest possible date.
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Affiliation(s)
- Hyo-Jin Lee
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic University of Korea, Seoul,
Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, The Catholic University of Korea, Seoul,
Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul,
Korea
- Catholic Hematology Hospital, The Catholic University of Korea, Seoul,
Korea
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