Impact of an antimicrobial stewardship and monitoring of infection control bundle in a surgical intensive care unit of a tertiary-care hospital in India

OBJECTIVES

Antimicrobial stewardship (AMS) in resource-limited settings lacks models that can be readily adapted to their settings. Here we discuss the impact of a combined strategy of AMS and monitoring of infection control practices in a tertiary-care centre of a developing country.

METHODS

This study was undertaken in the surgical unit of a tertiary-care hospital over an 8-month period. In the first 2 months (baseline phase), prospective audit and feedback alone was undertaken, while in the next 6 months (intervention phase) this was supplemented with strategies such as antimicrobial timeout, correction of doses and bundle approach for prevention of hospital-acquired infections.

RESULTS

A total of 337 patients were included (94 in the baseline phase and 243 in the intervention phase). There was a decrease in days of therapy per 1000 patient-days (1000PD) (1112.3 days vs. 1048.6 days), length of therapy per 1000PD (956 days vs. 936.3 days) and defined daily doses (DDD) per 1000PD for most antimicrobials. A decrease in double cover for Gram-negative infections (9.6% vs. 2.9%) but an increase in double anaerobic cover (4.2% vs. 7.4%) was observed. There was a decrease in the incidence of ventilator-associated pneumonia per 1000 ventilator-days in the intervention phase (46.4 vs. 35.4), whereas central line-associated bloodstream infections per 1000 central line-days remained the same (14.7 vs. 14.8).

CONCLUSION

This study shows that implementation of routine AMS activities with monitoring of infection control practices can help decrease overall antimicrobial use. With furtherance of measures to control infection, antimicrobial use may be further curtailed.

Antimicrobial Stewardship Programs in Resource Constrained Environments: Understanding and Addressing the Need of the Systems

World Health Organization (WHO) has identified antimicrobial resistance as one of the top 10 threats to public health. The agency has formulated a global action plan to tackle antimicrobial resistance by reducing incidence of infectious diseases, increasing knowledge and awareness and promoting rational use of antimicrobials amongst other measures. While the core elements of successful antimicrobial stewardship (AMS) programs are much publicized, there application in resource limited settings is fraught with several challenges. The key limiting factors include lack of clear political commitment, inadequate funding, overcrowded healthcare systems, lax legal and regulatory frameworks, non-uniform access to diagnostics, absence of electronic health record systems, limited knowledge and awareness especially with existence of multiple systems of medicines, issues with access to quality assured medicines, in-house pharmacies, and shortage of trained manpower. Since these implementation-impeding issues may differ considerably from those experienced in developed economies, intervention efforts in low- and middle-income countries (LMICs) need to address the context and focus on the root causes prevailing locally. In this article, we review the evidence highlighting the magnitude of these challenges and suggest feasible models with effective application. We also share the evidence from our center where we have contextualized the core elements to resource constrained settings. These domains include delivering prospective audit and feedback, prescriber education, development of evidence-based and implementable guidelines, and optimization of surgical antibiotic prophylaxis. However, there is a tremendous need for scaling up, extending outreach and honing these models while at the same time, addressing the existing strategic challenges that curtail the full potential of global antimicrobial stewardship.

A study of antibiotic prescription pattern in patients referred to tertiary care center in Northern India

Background

Tremendous infectious disease burden and rapid emergence of multidrug resistant pathogens continues to burden our healthcare system. Antibiotic stewardship program often implements antibiotic policies that help in preventing unnecessary use of antibiotics and in optimizing management. To develop such a policy for management of infections in the emergency unit, it is important to analyze the information regarding antibiotic prescription patterns in patients presenting to the emergency room referred from various healthcare settings. This study was conducted with the aforementioned background.

Methods

We conducted a prospective observational study in triage area of emergency unit of a tertiary care hospital. All the referred patients were screened for antibiotic prescription. Data extraction form was used to capture information on patient demographics, diagnosis and antibiotics prescribed. Antibiotic prescription details with regard to dosage, duration and frequency of antimicrobial administration were also recorded. Data were summarized using descriptive statistics as appropriate.

Results

Out of 517 screened patients, 300 were prescribed antimicrobials. Out of 29 antibiotics prescribed, 12 were prescribed in more than 90% of patients. Broad spectrum antibiotics accounted for 67.3% of prescriptions. In 129 out of 300 patients, no evidence of infectious etiology was found.

Conclusion

Our study highlights some common but serious lapses in antibiotic prescription patterns in patients referred from various healthcare settings. This emphasizes the need to provide training for rational use of antibiotics across healthcare settings.