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Lim SYC, Zhou YP, Yii D, Chin DZ, Hung KC, Lee LW, Lim JL, Loo LW, Koomanan N, Chua NG, Liew Y, Cherng BPZ, Thien SY, Lee WHL, Kwa ALH, Chung SJ. Stemming the Rise of Antibiotic Use for Community-Acquired Acute Respiratory Infections during COVID-19 Pandemic. Antibiotics (Basel) 2022; 11:antibiotics11070846. [PMID: 35884100 PMCID: PMC9312342 DOI: 10.3390/antibiotics11070846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/19/2022] [Accepted: 06/21/2022] [Indexed: 01/08/2023] Open
Abstract
At the start of the COVID-19 pandemic, there was an increase in the use of antibiotics for the treatment of community-acquired respiratory tract infection (CA-ARI) in patients admitted for suspected or confirmed COVID-19, raising concerns for misuse. These antibiotics are not under the usual purview of the antimicrobial stewardship unit (ASU). Serum procalcitonin, a biomarker to distinguish viral from bacterial infections, can be used to guide antibiotic recommendations in suspected lower respiratory tract infection. We modified our stewardship approach, and used a procalcitonin-guided strategy to identify “high yield” interventions for audits in patients admitted with CA-ARI. With this approach, there was an increase in the proportion of patients with antibiotics discontinued within 4 days (16.5% vs. 34.9%, p < 0.001), and the overall duration of antibiotic therapy was significantly shorter [7 (6−8) vs. 6 (3−8) days, p < 0.001]. There was a significant decrease in patients with intravenous-to-oral switch of antibiotics to “complete the course” (45.3% vs. 34.4%, p < 0.05). Of the patients who had antibiotics discontinued, none were restarted on antibiotics within 48 h, and there was no-30-day readmission or 30-day mortality attributed to respiratory infection. This study illustrates the importance of the antimicrobial stewardship during the pandemic and the need for ASU to remain attuned to prescriber’s practices, and adapt accordingly to address antibiotic misuse to curb antimicrobial resistance.
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Affiliation(s)
- Shena Y. C. Lim
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Yvonne P. Zhou
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Daphne Yii
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - De Zhi Chin
- Department of Clinical Quality and Performance Management, Singapore General Hospital, Singapore 169608, Singapore;
| | - Kai Chee Hung
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Lai Wei Lee
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Jia Le Lim
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Li Wen Loo
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Narendran Koomanan
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Nathalie Grace Chua
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Yixin Liew
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Benjamin P. Z. Cherng
- Department of Infectious Diseases, Singapore General Hospital, Singapore 169608, Singapore; (B.P.Z.C.); (S.Y.T.)
| | - Siew Yee Thien
- Department of Infectious Diseases, Singapore General Hospital, Singapore 169608, Singapore; (B.P.Z.C.); (S.Y.T.)
| | - Winnie H. L. Lee
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Andrea L. H. Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore; (S.Y.C.L.); (Y.P.Z.); (D.Y.); (K.C.H.); (L.W.L.); (J.L.L.); (L.W.L.); (N.K.); (N.G.C.); (Y.L.); (W.H.L.L.); (A.L.H.K.)
| | - Shimin J. Chung
- Department of Infectious Diseases, Singapore General Hospital, Singapore 169608, Singapore; (B.P.Z.C.); (S.Y.T.)
- Correspondence:
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Lim SYC, Zhou PY, Yii DYC, Hung KC, Lee LW, Liew YX, Lim JL, Loo LW, Koomanan N, Chua NGS, Cherng BPZ, Thien SY, Lee W, Kwa LHA, Chung SJ. 34. Stemming the Rise in Antibiotic Prescription for Community Acquired Respiratory Infections (ARI) During COVID-19 Pandemic in Singapore General Hospital (SGH). Open Forum Infect Dis 2021. [PMCID: PMC8690381 DOI: 10.1093/ofid/ofab466.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
In early months of COVID-19 pandemic, SGH recorded a year-on-year increase in antibiotic (ABx) use for community acquired acute respiratory infection (CA ARI) from Feb-Apr 2019 (48.7 defined daily doses (DDD)/100 bed-days) to 2020 (50.8 DDD/100 bed-days). To address concerns of misuse, the antibiotic stewardship unit (ASU) expanded prospective audit feedback (PAF) to CA ARI patients admitted to ARI wards, with low procalcitonin (PCT). PAF was conducted on day 2-3 of ABx, on weekdays. Doctors received feedback to stop/modify when ABx was deemed inappropriate. Here, we describe the impact of ASU’s adaptive approach to curb rising ABx use in patients admitted for ARI during COVID-19 pandemic.
Methods
A Pre- & Post-intervention study was conducted. All patients started on ABx (ceftriaxone/co-amoxiclav/piptazo/carbapenems/levofloxacin) for CA ARI & PCT < 0.5µg/L were analysed. Those who died ≤48h of admission; admitted to intensive care; required ABx escalation; >1 infective sites; complex lung infection were excluded. Primary objective was to compare the proportion of ABx stopped ≤4 days (time to final infection diagnosis) Pre (22/3-18/4/20) & Post (21/4-13/7/20).
Results
184 (Pre) & 528 (Post) ABx courses were analysed. ASU audited 51 (Pre) & 380 (Post) courses with the rest discontinued/discharged before review. Patients were largely similar in both periods; a third had low likelihood of bacterial infection (C reactive protein < 30mg/L). In Post, 73 feedback was given to stop ABx (often because symptoms suggested viral/fluid overload) & 18 to switch to oral ABx. 82 (90%) feedback was accepted. No ABx was restarted ≤48h or deaths ≤30 days due to ARI. 1 patient had C. difficile diarrhoea a day after ABx cessation as per ASU feedback.
Proportion of all ABx stopped ≤4 days was higher in Post than Pre [27/184 (15%) vs 152/528 (29%), p< 0.01]. Median duration of therapy of IV ABx was reduced (6.5 vs 3 days, p< 0.01), with corresponding shorter median length of stay (10.5 vs 6 days, p< 0.01).
Conclusion
PAF directly and indirectly reduced ABx duration in patients treated for CA ARI as prescribers become more conscious about stopping ABx when investigations show low likelihood of bacterial infection. ASU must remain agile during pandemics to detect emerging problems and adapt processes to counter early.
Disclosures
All Authors: No reported disclosures
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Affiliation(s)
| | | | | | - Kai Chee Hung
- Singapore General Hospital, Singapore, Not Applicable, Singapore
| | - Lai Wei Lee
- Singapore General Hospital, Singapore, Not Applicable, Singapore
| | - Yi Xin Liew
- Singapore General Hospital, Singapore, Not Applicable, Singapore
| | - Jia Le Lim
- Singapore General Hospital, Singapore, Not Applicable, Singapore
| | - Li Wen Loo
- Singapore General Hospital, Singapore, Not Applicable, Singapore
| | | | | | | | - Siew Yee Thien
- Singapore General Hospital, Singapore, Not Applicable, Singapore
| | - Winnie Lee
- Singapore General Hospital, Singapore, Not Applicable, Singapore
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Tan SH, Koomanan N, Chung SJ, Kwa ALH. Will ceftazidime-avibactam replace polymyxins in Asia? Clin Infect Dis 2021; 73:1743-1744. [PMID: 34009275 DOI: 10.1093/cid/ciab390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sock Hoon Tan
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore.,Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Narendran Koomanan
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore
| | - Shimin Jasmine Chung
- Department of Infectious Diseases, Singapore General Hospital, Singapore, Singapore
| | - Andrea Lay-Hoon Kwa
- Department of Pharmacy, Singapore General Hospital, Singapore, Singapore.,Emerging Infectious Diseases, Duke-NUS Medical School, Singapore, Singapore.,Singhealth Duke-NUS Medicine Academic Clinical Programme, Singapore, Singapore
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Tan CJ, Kumar R, Koomanan N, Loo WS, Farid M, Tao M, Somasundaram N, Poon E, Chan JY, Yang VS, Chang E, Lim ST, Chow WC, Chan A, Tang T. Clinical and economic evaluation of a surveillance protocol to manage hepatitis B virus (HBV) reactivation among lymphoma patients with resolved HBV infection receiving rituximab. Pharmacotherapy 2021; 41:332-341. [PMID: 33547823 DOI: 10.1002/phar.2508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/09/2021] [Accepted: 01/15/2021] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVE To evaluate a surveillance protocol in managing the risk of hepatitis B virus (HBV) reactivation among lymphoma patients with resolved HBV infection receiving rituximab. DESIGN Prospective, single-arm study. SETTING National Cancer Centre, Singapore. PATIENTS Lymphoma patients with resolved HBV infection and scheduled to receive rituximab-based treatment. INTERVENTION Close monitoring of HBV DNA levels, ie. every 4-6 weeks during rituximab treatment, every 6-8 weeks in the first year post-treatment, and every 3-4 months in the second year post-treatment. MEASUREMENTS The efficacy of the surveillance protocol was examined by evaluating the rates of reactivation-related events. Feasibility was evaluated based on patient adherence. An economic analysis using a cost-minimization approach was conducted to compare the costs between the surveillance protocol and universal prophylaxis with entecavir 0.5 mg daily up to 1 year after cessation of rituximab. MAIN RESULTS A total of 66 patients provided analyzable data with a follow-up period of 966.6 months. No hepatitis flare or reactivation-related events were detected. The median adherence rate to the surveillance protocol was 90.5%. Cost savings of US$946.40 per patient over the entire surveillance period were achieved if the surveillance protocol was adopted and was most affected by changes in prophylaxis duration and the cost of antiviral prophylaxis. CONCLUSIONS The surveillance protocol is an effective, feasible and cost-saving strategy to manage HBV reactivation among lymphoma patients with resolved HBV infection receiving rituximab.
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Affiliation(s)
- Chia Jie Tan
- Department of Pharmacy, National University of Singapore, Singapore City, Singapore.,Department of Pharmacy, National Cancer Centre Singapore, Singapore City, Singapore
| | - Rajneesh Kumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore City, Singapore
| | - Narendran Koomanan
- Department of Pharmacy, National University of Singapore, Singapore City, Singapore
| | - Wei Sheng Loo
- Department of Pharmacy, National Cancer Centre Singapore, Singapore City, Singapore
| | - Mohamad Farid
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Miriam Tao
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Nagavalli Somasundaram
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Eileen Poon
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Jason Yongsheng Chan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Valerie Shiwen Yang
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore.,Institute of Molecular and Cell Biology, A*STAR, Singapore City, Singapore
| | - Esther Chang
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Soon Thye Lim
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
| | - Wan Cheng Chow
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore City, Singapore
| | - Alexandre Chan
- Department of Pharmacy, National Cancer Centre Singapore, Singapore City, Singapore.,Department of Clinical Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University of California, Irvine, California, USA
| | - Tiffany Tang
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore
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Dorajoo SR, See V, Chan CT, Tan JZ, Tan DSY, Abdul Razak SMB, Ong TT, Koomanan N, Yap CW, Chan A. Identifying Potentially Avoidable Readmissions: A Medication-Based 15-Day Readmission Risk Stratification Algorithm. Pharmacotherapy 2017; 37:268-277. [PMID: 28052412 DOI: 10.1002/phar.1896] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Stratifying patients according to 15-day readmission risk would be useful in identifying those who may benefit from targeted interventions during and/or following hospital discharge that are designed to reduce the likelihood of readmission. METHODS A prediction model was derived via a case-control analysis of patients discharged from a tertiary hospital in Singapore using multivariate logistic regression. The model was validated in two independent external cohorts separated temporally and geographically. Model discrimination was assessed using the C-statistic, while calibration was assessed using the Hosmer-Lemeshow χ2 and the Brier score statistics. RESULTS A total of 1291 patients were included with 670, 101, and 520 patients in the derivation, temporal, and geographical validation cohorts, respectively. Age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.03, p=0.008), anemia (OR 2.08, 95% CI 1.15-8.05, p=0.015), malignancy (OR 3.37, 95% CI 1.16-9.80, p=0.026), peptic ulcer disease (OR 3.05, 95% CI 1.12-8.26, p=0.029), chronic obstructive pulmonary disease (OR 3.16, 95% CI 1.24-8.05, p=0.016), number of discharge medications (OR 1.06, 95% CI 1.01-1.12, p=0.026), discharge to nursing homes (OR 3.57, 95% CI 1.57-8.34, p=0.003), and premature discharge against medical advice (OR 5.05, 95% CI 1.20-21.23, p=0.027) were independent predictors of 15-day readmission risk. The model demonstrated reasonable discrimination on the temporal and geographical validation cohorts with a C-statistic of 0.65 and 0.64, respectively. Model miscalibration was observed in both validation cohorts. CONCLUSION A 15-day readmission risk prediction model is proposed and externally validated. The model facilitates the targeting of interventions for patients who are at high risk of an early readmission.
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Affiliation(s)
| | - Vincent See
- Department of Pharmacy, National University of Singapore, Singapore
| | - Chen Teng Chan
- Department of Pharmacy, National University of Singapore, Singapore
| | - Joyce Zhenyin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital Singapore, Singapore
| | - Doreen Su Yin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital Singapore, Singapore
| | | | - Ting Ting Ong
- Department of Pharmacy, Singapore General Hospital, Singapore
| | | | - Chun Wei Yap
- Department of Pharmacy, National University of Singapore, Singapore
| | - Alexandre Chan
- Department of Pharmacy, National University of Singapore, Singapore
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Ong PYS, Koomanan N, Cheen MHH, Lai YF, Lim SH, Kong MC, Ng HJ. Real-World Impact of Setting a Narrow International Normalized Ratio Target Range in the Management of Older Adult Patients on Warfarin. Clin Appl Thromb Hemost 2015; 22:528-34. [PMID: 26239317 DOI: 10.1177/1076029615598220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Elderly patients intrinsically have higher bleeding risks, deterring clinicians from prescribing them oral anticoagulants. Setting a narrow international normalized ratio (INR) target range might potentially mitigate some of these risks. This study sought to compare the outcomes of elderly patients who were assigned to either a narrow INR target range or the conventional INR target range in a real-world environment. METHODS This was a retrospective cohort study with the primary and secondary outcomes being the mean percentage time above INR 3.0 and the mean percentage time below INR 2.0 and the incidents of bleeding and thromboembolism associated with oral anticoagulant therapy, respectively. Patients and health care workers managing them had no prior knowledge of this study. RESULTS Data of 150 patients with a narrow INR target range (2.0-2.5) and 164 patients with a conventional INR target range (2.0-3.0) were collected and analyzed. The narrow INR group had significantly higher underlying risks of bleeding than the conventional INR group. Patients in the narrow INR group had a significantly lower percentage time above INR 3.0 but no significant difference in the percentage time below INR 2.0. Adjusted incidence rate ratio (IRR) for bleeding events was significantly lower for the narrow INR group, while the adjusted IRR for thromboembolic events between both groups was similar. CONCLUSION Patients assigned to a narrow INR target range in real-world practice spent a significantly lower amount of time below an INR of 3.0 compared to conventional INR target range with lower incidents of bleeding complications and no increase in subtherapeutic INRs.
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Affiliation(s)
- Peter Y S Ong
- Department of Pharmacy, Singapore General Hospital, Singapore
| | | | - McVin H H Cheen
- Department of Pharmacy, Singapore General Hospital, Singapore Department of Pharmacy, National University of Singapore, Singapore
| | - Yi Feng Lai
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Seng Han Lim
- Department of Pharmacy, Singapore General Hospital, Singapore Department of Pharmacy, National University of Singapore, Singapore
| | - Ming Chai Kong
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Heng Joo Ng
- Department of Hematology, Singapore General Hospital, Singapore
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Koomanan N, Ko Y, Yong WP, Ng R, Wong YP, Lim SW, Salim A, Chan A. Clinical Impact of Drug–Drug Interaction Between Aspirin and Prednisolone at a Cancer Center. Clin Ther 2012. [DOI: 10.1016/j.clinthera.2012.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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