Use of Feedback Data to Reduce Surgical Site Infections and Optimize Antibiotic Use in Surgery: A Systematic Scoping Review

OBJECTIVE

Surgical site infection (SSI) prevention remains significant, particularly in the era of antimicrobial resistance. Feedback on practices and outcomes is known to be key to reduce SSI rates and optimize antibiotic usage. However, the optimal method, format and frequency of feedback for surgical teams remains unclear. The objective of the study is to understand how data from surveillance and audit are fed back in routine surgical practice.

METHODS

A systematic scoping review was conducted, using well-established implementation science frameworks to code the data. Two electronic health-oriented databases (MEDLINE, EMBASE) were searched to September 2019. We included studies that assessed the use of feedback as a strategy either in the prevention and management of SSI and/or in the use of antibiotics perioperatively.

RESULTS

We identified 21 studies: 17 focused on SSI rates and outcomes and 10 studies described antimicrobial stewardship for SSI (with some overlap in focus). Several interventions were reported, mostly multimodal with feedback as a component. Feedback was often provided in written format (62%), either individualized (38%) or in group (48%). Only 25% of the studies reported that feedback cascaded down to the frontline perioperative staff. In 65% of the studies, 1 to 5 implementation strategies were used while only 5% of the studies reported to have utilized more than 15 implementation strategies. Among studies reporting antibiotic usage in surgery, most (71%) discussed compliance with surgical antibiotic prophylaxis.

CONCLUSIONS

Our findings highlight the need to provide feedback to all levels of perioperative care providers involved in patient care. Future research in this area should report implementation parameters in more detail.

Antibiotic Utilization and Efficacy Associated With Treating Pediatric Urinary Tract Infections in Texas Medicaid Patients in the First Year of Life

BACKGROUND

Historically, amoxicillin (Amoxil) has been used as a first-line agent to treat pediatric urinary tract infections (UTIs). However, emerging antibiotic resistance in urinary pathogens has led to broader treatment options, such as cefdinir (Omnicef). This shift in prescribing practices is predicted to vary among place of service and gender due to differing institutional protocols and antimicrobial stewardship practices.

OBJECTIVE

This study aimed to describe the antibiotic utilization patterns associated with treating pediatric UTIs in Texas Medicaid patients and to assess the real-world efficacy of the antibiotics that were prescribed.

METHODS

Texas Medicaid prescription and medical claims data for patients under 1 year of age were included in the analysis if they presented with a UTI to the healthcare practitioner’s office or the emergency department (ED) and were treated with an outpatient antibiotic. Treatment efficacy was assessed by whether a patient received a second (different) antibiotic within 7 days of their initial antibiotic fill.

RESULTS

A total of 12,795 visits met inclusion criteria; 12,561 visits included prescriptions for the top 4 antibiotics prescribed: cefdinir (50%), amoxicillin (25%), cephalexin (Keflex; 13%), and amoxicillin-clavulanate (Augmentin; 12%). Cefdinir utilization predominated in both places of service [office (50%) and ED (55%)], and gender [males (47%) and females (52%)]. Controlling for gender and place of service, initial treatment with amoxicillin when compared with cefdinir (OR = 2.54; 95% confidence intervals: 1.84–3.54; P < 0.001) was associated with a greater rate of treatment failure.

CONCLUSIONS

In this study of Texas Medicaid patients, the widespread utilization of cefdinir may be appropriate for the empiric treatment of uncomplicated UTIs because of its low rate of treatment failure compared to other commonly used antibiotics.

OpenSAFELY: impact of national guidance on switching anticoagulant therapy during COVID-19 pandemic

BACKGROUND

Early in the COVID-19 pandemic, the National Health Service (NHS) recommended that appropriate patients anticoagulated with warfarin should be switched to direct-acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately coprescribed two anticoagulants following a medication change and associated monitoring.

OBJECTIVE

To describe which people were switched from warfarin to DOACs; identify potentially unsafe coprescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic.

METHODS

With the approval of NHS England, we conducted a cohort study using routine clinical data from 24 million NHS patients in England.

RESULTS

20 000 of 164 000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in coprescribing of warfarin and DOACs from typically 50-100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. International normalised ratio (INR) testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420).

CONCLUSIONS

Increased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people coprescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.

Estimating the Theoretical Cost Implications of Funding New Drugs Considered Not to Be Cost-Effective

This study aims to estimate the theoretical excess expenditure that would be incurred by the Irish state-payer, should drugs be reimbursed at their original asking ("list") price rather than at a price at which the drug is considered cost-effective. In Ireland, all new drugs are evaluated by the National Centre for Pharmacoeconomics. For this study, drugs that were submitted by pharmaceutical companies from 2012 to 2017 and considered not cost-effective at list price were reviewed. A total of 43 such drugs met our inclusion criteria, and their pharmacoeconomic evaluations were further assessed. The price at which the drug could be considered cost-effective (cost-effective price) at the upper cost-effectiveness threshold used in Ireland (€ 45 000/quality adjusted life-year) was estimated for 18 drugs with an available cost-effectiveness model. Then, for each drug, the list price and cost-effective price (both per unit) were both individually applied to 1 year of national real-world drug utilization data. This allowed the estimation of the expected expenditures under the assumptions of list price paid and cost-effective price paid. The resulting theoretical excess expenditure, the expenditure at list price minus the expenditure at the cost-effective price, was estimated to be €108.2 million. This estimate is theoretical because of the confidentiality of actual drug prices. The estimation is calculated using the list price and likely overestimates the actual excess expenditure, which would reduce to zero if cost-effective prices are agreed. Nevertheless, this estimate illustrates the importance of a process to assess the value of new drugs so that potential excess drug expenditure is identified.

Establishing Benchmarks for Antimicrobial Use in Canadian Children's Hospitals: Results From 2 National Point Prevalence Surveys

BACKGROUND

Point prevalence surveys (PPS) are potentially useful to measure antimicrobial use across institutions. The objectives of the study were to describe and compare antimicrobial use between pediatric hospitals in Canada.

METHODS

Fifteen pediatric hospitals all with pediatric infectious diseases service participated in 2 single-day PPS in 2018/19. Children <18 years of age who were inpatients were included. Age, service, clinical diagnosis as well as name, route, and start date for each antimicrobial was collected. Antibiotics were grouped according to the World Health Organization AWaRe classification.

RESULTS

There were 3924 inpatient patients-days representing 2729 children and 1195 infants in neonatal intensive care units (NICU) surveyed. Among non-NICU patients, 1210 (44.3%) received 1830 antimicrobials of which 73.9% were for empiric or pathogen-directed therapy and 25.6% for prophylaxis. The mean proportion of core Access and Watch group antibiotics was 45.8% and 63.5%, respectively, with no differences in means between tertiary and quaternary care sites. Among 1195 infants in NICU, 19.7% received 410 antimicrobials of which 17.1% were for prophylaxis and a mean of 45.4% were Watch group antibiotics. Of patients admitted for community-acquired pneumonia, 32.7% received penicillin or aminopenicillins only with variability among sites.

CONCLUSIONS

PPS of antimicrobial use in Canadian pediatric hospitals revealed a high proportion of Watch group (broader spectrum) antibiotics, even among children with community-acquired pneumonia. This study demonstrates the feasibility of PPS to document antimicrobial use and potentially to use this data to establish goals for decreasing both overall and Watch group antibiotics.

Changes in Metronidazole and Vancomycin Utilization for Nonsevere Clostridioides difficile Infection Among Institutions Caring for Children

Clostridioides difficile infection guidelines were published in final format on April 1, 2018. Among 4962 and 3545 C. difficile infection cases in children the year before and after publication, oral metronidazole use decreased from 63.0% to 44.3% (P < 0.001) and oral vancomycin use increased from 27.3% to 47.7% (P < 0.001). Quarterly metronidazole utilization decreased postguidelines among 117 institutions, incidence rate ratios 0.86 (95% confidence intervals: 0.78-0.96).

Abuse of Antibiotics in Perinatology: Negative Impact for Health and the Economy

To use medications appropriately, patients need to be treated based on their clinical conditions, in doses that are based on their individual requirements, for an adequate amount of time, and at the lowest expense. The perinatal period is characterized by an excessive use of antibiotics. This antibiotic abuse can lead to antibiotic resistance, microbiome alterations, and dysbiosis, which have been associated with serious complications such as infections, abnormal brain development, allergies, autoimmune disorders, obesity, and an increase in mortality as well as an increase in health care expenditures. The need to optimize antibiotic utilization in perinatal medicine has never been more urgent; there is not much more time to wait.

Benefits of Prior Authorizations

DISCLOSURES

No funding supported the writing of this article. The author has nothing to disclose.

Coverage of antimicrobial resistance in the revised indian medical curriculum: Lip service only?

BACKGROUND

The undergraduate medical curriculum has undergone a major revision. This study was designed to systematically review the revised Indian medical school curriculum to assess the extent of coverage of antimicrobial resistance (AMR) and antibiotic stewardship-related competencies.

METHODS

We undertook a document review of the recently revised Indian medical curriculum to identify the extent of coverage of competencies related to AMR and antibiotic stewardship. With the use of a previously described search strategy, we queried the online freely accessible version of the curriculum in duplicate and independently. We describe by volume, by subject and by the tenets of Miller's pyramid all references to AMR and stewardship.

RESULTS

Out of 2939 competencies that medical students are expected to complete over a 5.5-year period, 17 (0.57%) relate to AMR and antibiotic stewardship policies (ASP). There are no references to AMR or ASP in Pediatrics, Surgery, Obstetrics and Gynecology, Ear, Nose and Throat, Ophthalmology and Orthopedics. Community Medicine has few links through integrated teaching but has no direct AMR or ASP content. When categorized by Miller's domains, two of the competencies, both in Pharmacology, deal with the "Does" category, which is the practical skill gained by the student. There are five competencies which belong to the "Shows How" category and the remaining 10 belong to the knowledge categories.

DISCUSSION

There is poor coverage of AMR and stewardship in the revised Indian medical curriculum, suggesting that there is very little appreciation of the enormous threat that AMR poses to public health. This is a huge missed opportunity that needs immediate corrective action.

Evaluation of current practice of antimicrobial use and clinical outcome of patients with pneumonia at a tertiary care hospital in Ethiopia: A prospective observational study

BACKGROUND

Antimicrobial resistance, which is commonly observed in the management of pneumonia, is a major threat to public health and is driven by inappropriate antimicrobial use. The aim of this study was therefore to assess the current practice of antimicrobial utilization and clinical outcomes in the management of adult pneumonia at Tikur Anbessa Specialized Hospital.

METHOD

A prospective observational study was conducted in the internal medicine wards of Tikur Anbessa Specialized Hospital. The study was conducted from 1 September 2016 to 30 June 2017 and patients aged ≥ 14 years and diagnosed with pneumonia were included. Chart review and self-administered questionnaire were used to collect data regarding pneumonia diagnosis and management as well as clinical outcomes (stable, complications, and in-hospital mortality). Descriptive statistics and binary logistic regressions were performed for data analyses.

RESULTS

Out of 200 enrolled patients, clinical diagnosis was supported by microbiologic testing and imaging in 75 (37.5%) and 122 (61.0%) cases, respectively. The treatment approach in almost all patients (99.5%) was empirical and no de-escalation therapy was made even after acquiring culture results. The total duration of antimicrobial therapy was 12.05±5.09 days and vancomycin was the most commonly prescribed antimicrobial agent (25%), with 70% of the patients receiving this drug empirically. Nearly, 30% of the patients missed their antimicrobial doses during the course of treatment and stock-out (36.7%) was the major reason. Close to 113 (66%) of the treating physicians used reference books to prescribe antimicrobial agents. Patients' outcomes were found to be stable (66%), in-hospital mortality (18.5%), and ending up in complications (17%). Poor clinical outcome (death and complicated cases) was found to be associated with recent antimicrobial use history (p = 0.007, AOR 2.86(1.33-6.13)), cancer (p = 0.023, AOR 3.46(1.18-10.13)), recent recurrent upper respiratory tract infection (p = 0.046, AOR 3.70(1.02-13.40)), respiratory rate >24 breaths/min or <12 breaths/min (p = 0.013, AOR 2.45(1.21-4.95)) and high level of serum creatinine after initiation of antimicrobial therapy (>1.4mg/dl) (p = 0.032, AOR 2.37(1.07-5.20)).

CONCLUSION

Antimicrobials are empirically prescribed without sufficient evidence of indication and microbiological or radiological findings. The practice also is not based on local guidelines and no multidisciplinary approach is apparent. [How about: "It is likely that these factors contributed to higher rates of mortality (18.5%) when compared with similar studies in other countries" instead of this "As a result, there were higher rates of mortality (18.5%) when compared with other similar studies"]. Hence, the hospital requires a coordinated intervention to improve rational use of antimicrobials and clinical outcomes through establishing an antimicrobial stewardship program.

Antibiotic prescribing without documented indication in ambulatory care clinics: national cross sectional study

OBJECTIVES

To identify the frequency with which antibiotics are prescribed in the absence of a documented indication in the ambulatory care setting, to quantify the potential effect on assessments of appropriateness of antibiotics, and to understand patient, provider, and visit level characteristics associated with antibiotic prescribing without a documented indication.

DESIGN

Cross sectional study.

SETTING

2015 National Ambulatory Medical Care Survey.

PARTICIPANTS

28 332 sample visits representing 990.9 million ambulatory care visits nationwide.

MAIN OUTCOME MEASURES

Overall antibiotic prescribing and whether each antibiotic prescription was accompanied by appropriate, inappropriate, or no documented indication as identified through ICD-9-CM (international classification of diseases, 9th revision, clinical modification) codes. Survey weighted multivariable logistic regression was used to evaluate potential risk factors for receipt of an antibiotic prescription without a documented indication.

RESULTS

Antibiotics were prescribed during 13.2% (95% confidence interval 11.6% to 13.7%) of the estimated 990.8 million ambulatory care visits in 2015. According to the criteria, 57% (52% to 62%) of the 130.5 million prescriptions were for appropriate indications, 25% (21% to 29%) were inappropriate, and 18% (15% to 22%) had no documented indication. This corresponds to an estimated 24 million prescriptions without a documented indication. Being an adult male, spending more time with the provider, and seeing a non-primary care specialist were significantly positively associated with antibiotic prescribing without an indication. Sulfonamides and urinary anti-infective agents were the antibiotic classes most likely to be prescribed without documentation.

CONCLUSIONS

This nationally representative study of ambulatory visits identified a large number of prescriptions for antibiotics without a documented indication. Antibiotic prescribing in the absence of a documented indication may severely bias national estimates of appropriate antibiotic use in this setting. This study identified a wide range of factors associated with antibiotic prescribing without a documented indication, which may be useful in directing initiatives aimed at supporting better documentation.

A cross sectional comparison of drug use indicators using WHO methodology in primary level hospitals participating in an Auditable Pharmaceutical Transactions and Services program versus non-APTS primary hospitals in Southern Ethiopia

INTRODUCTION

Ethiopian pharmaceutical sector has been facing inaccessibility and unaffordability to key essential medicines due to medicines diversion from the public to private health care facilities, lack of transparency, poor inventory management, and poor dispensing workflow. In an effort to improve the pharmaceutical sector, the government of Ethiopia in 2011 introduced Auditable Pharmaceutical Transactions and Services program. This study intended to compare drug use indicators in auditable and non-auditable primary level hospitals.

METHODS

A cross-sectional comparative study was conducted between January 2018 and December 2018 at primary level hospitals in southern Ethiopia: one with Auditable Pharmaceutical Transactions and Services (APTS) program; another without APTS (Non-APTS).WHO drug use indicators in auditable primary hospitals (n = 10) and similar non-auditable primary hospitals (n = 10) were compared. The prescribing indicators and average cost of medicines were evaluated retrospectively using 1000 prescriptions from each group. Patient care indicators were evaluated prospectively by interviewing and observing 1000 patients from each group. Patient satisfaction was assessed by interviewing 1000 patients from each group. Health care facilities were evaluated through observation. We performed descriptive analysis, t-test, logistic regression, Mann-Whitney U test and linear regression using SPSS version 20.0.

RESULTS

The mean consultation time in auditable and non-auditable hospitals was found to be 6.5 minutes and 3.46 minutes, respectively. The average dispensing time in auditable and non-auditable hospitals was found to be 6.6 minutes and 1.02 minutes, respectively.The proportion of drugs actually dispensed was 97.59% in APTS facilities and 76.44% in the non-auditable facilities with the lowest value seen in a non-auditable facility (51.65%). The average number of drugs per prescription was 2.32 (±1.26) and 2.84 (±1.17) in auditable and non-auditable facilities, respectively. The level of patient satisfaction on the convenience of pharmacy location, information on contraindications, availability of drugs and amount of time for counseling was significantly higher in the auditable facilities than the non-auditable facilities (p<0.001).

CONCLUSIONS

This study revealed that patient care indicator values, the level of patient satisfaction on the pharmacy services and health facility indicator values were significantly better in APTS than Non-APTS primary level hospitals. Most of prescribing indicators and labeling practices were not met WHO stated standard in both auditable and non-auditable facilities.This indicates that the auditable programshould include additional strategies to reverse the existing irrational prescribing and inadequate labeling practices.

Health care providers' perceptions regarding antimicrobial stewardship programs (AMS) implementation-facilitators and challenges: a cross-sectional study in the Eastern province of Saudi Arabia

BACKGROUND

Infections result from invasions of an organism into body tissues leading to diseases and complications that might eventually lead to death. Inappropriate use of antimicrobials has led to development of antimicrobial resistance (AMR) which has been associated with increased mortality, morbidity and health costs. Antimicrobial stewardship (AMS) programs are designed to ensure appropriate selections of an effective antimicrobial drugs and optimizing antibiotic use to minimize antibiotic resistance by implementing certain policies, strategies and guidelines. The aim of this study was to investigate practitioners' perceptions regarding AMS implementation and to identify challenges and facilitators of these programs execution.

METHODS

Cross-sectional study among health care providers in Eastern province of Saudi Arabia Hospitals. The data was collected using a survey including questions about demographic data and information about clinicians' (physicians, pharmacists and nurses) previous experience with AMS and prescribing of antibiotics, the level of knowledge and attitudes regarding AMS programs' implementation.

RESULTS

More than 50% of clinicians (N = 184) reported lack of awareness of AMS programs and their components, whereas 71.2% do not have previous AMS experience. The majority of clinicians (72.3%) noticed increasing number of AMR infections over the past 5 years and (69.6%) were involved in care of patients with an antibiotic-resistant infection. Around 77.2% of respondents reported that formulary management can be helpful for AMS practice and majority of respondents (79.9%) reported that the availability of pathogens and antimicrobial susceptibility testing can be helpful for AMS. Major barriers to AMS implementation identified were lack of internal policy/guidelines and specialized AMS information resources. Lack of administrative awareness about AMS programs; lack of personnel, time limitation, limited training opportunities, lack of confidence, financial issue or limited funding and lack of specialized AMS information resources were also reported 65.8%, 62.5%, 60.9%, 73.9%, 50%, 54.3 and 74.5%, respectively.

CONCLUSION

Our study identified comprehensive education and training needs for health care providers about AMS programs. Furthermore, it appears that internal policy and guidelines need revision to ensure that the health care providers work consistently with AMS. Future research must focus on the benefit of implementing AMS as many hospitals are not implementing AMS as revealed by the clinicians. We recommend policy makers and concerned health authorities to consider the study findings into account to optimize AMS implementation.

Overcoming Antibiotic Resistance

We invited eleven experts in their fields to share their insights on the growing threats of antibiotic resistance, and how we, as a community, can address them.

Protocol for a double-blind placebo-controlled trial to evaluate the efficacy of probiotics in reducing antibiotics for infection in care home residents: the Probiotics to Reduce Infections iN CarE home reSidentS (PRINCESS) trial

INTRODUCTION

Care home residents are at increased risk of infections and antibiotic prescription. Reduced antibiotic use from fewer infections would improve quality of life. The Probiotics to Reduce Infections iN CarE home reSidentS (PRINCESS) trial aims to determine the efficacy and investigate mechanisms of daily probiotics on antibiotic use and incidence of infections in care home residents.

METHODS AND ANALYSIS

PRINCESS is a double-blind, individually randomised, placebo-controlled trial that will assess the effect of a daily oral probiotic combination of Lactobacillus rhamnosus, GG (LGG) and Bifidobacterium animalis subsp. lactis, BB-12 (BB-12) on cumulative antibiotic administration days (CAADs) (primary outcome) for infection in up to 330 care home residents aged ≥65 years over up to 12 months. Secondary outcomes include: Infection: Total number of days of antibiotic administration for each infection type (respiratory tract infection, urinary tract infection, gastrointestinal infection, unexplained fever and other); number, site, duration of infection; estimation of incidence and duration of diarrhoea and antibiotic-associated diarrhoea; Stool microbiology: Clostridium difficile infection; Gram-negative Enterobacteriaceae and vancomycin-resistant enterococci; LGG and BB-12. Oral microbiology: Candida spp. Health and well-being: Self and/or proxy health-related quality of life EQ5D (5 L); self-and/or proxy-reported ICEpop CAPability measure for older people. Hospitalisations: number and duration of all-cause hospital stays. Mortality: deaths. Mechanistic immunology outcomes: influenza vaccine efficacy (haemagglutination inhibition assay and antibody titres); full blood count and immune cell phenotypes, plasma cytokines and chemokines; cytokine and chemokine response in whole blood stimulated ex vivo by toll-like receptor 2 and 4 agonists; monocyte and neutrophil phagocytosis of Escherichia coli; serum vitamin D.

ETHICS AND DISSEMINATION

Ethics approval is from the Wales Research Ethics Committee 3. Findings will be disseminated through peer-reviewed journals and conferences; results will be of interest to patient and policy stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN16392920; Pre-results.

Comparison of antimicrobial stewardship programmes in acute-care hospitals in four European countries: A cross-sectional survey

Antimicrobial stewardship programmes (ASPs) are designed to improve antibiotic use. A survey was systematically developed to assess ASP prerequisites, objectives and improvement strategies in hospitals. This study assessed the current state of ASPs in acute-care hospitals throughout Europe. A survey containing 46 questions was disseminated to acute-care hospitals: all Dutch (n = 80) and Slovenian (n = 29), 215 French (25%, random stratified sampling) and 62 Italian (49% of hospitals with an infectious diseases department, convenience sampling) acute-care hospitals, for a Europe-wide assessment. Response rates for the Netherlands (Nl), Slovenia (Slo), France (Fr) and Italy (It) were 80%, 86%, 45% and 66%. There was variation between countries in the prerequisites met and the objectives and improvement strategies chosen. A formal ASP was present mainly in the Netherlands (90%) and France (84%) compared with Slovenia (60%) and Italy (60%). Presence of an antimicrobial stewardship (AMS) team ranged from 42% (Fr) to 94% (Nl). Salary support for AMS teams was provided in 68% (Fr), 51% (Nl), 33% (Slo) and 12% (It) of surveyed hospitals. Quantity of antibiotic use was monitored in the majority of hospitals, ranging from 72% (Nl) to 100% (Slo and Fr) of acute-care hospitals. Participating countries varied substantially in the use of 'prospective monitoring and advice' as a strategy to improve AMS objectives. ASP prerequisites, objectives and improvement activities vary considerably across Europe, with room for improvement. Stimulating appropriate system prerequisites throughout Europe, e.g. by introducing staffing standards and financial support for ASPs, seems a first priority.

Potential for More Rational Use of Antibiotics in Hospitalized Children in a Country With Low Resistance: Data From eight Point Prevalence Surveys

BACKGROUND

Antimicrobial resistance is low in Norway, but to prevent an increase, the Norwegian Government has launched a National Strategy including a 30% reduction of broad-spectrum antibiotics (BSA) in hospitals within 2020. BSA are defined as second- and third-generation cephalosporins, carbapenems, piperacillin/tazobactam and quinolones. There are no recent studies of antibiotic use in Norwegian hospitalized children. The aim of this study was to describe the use of antibiotics with emphasis on BSA in Norwegian hospitalized children and neonates to detect possibilities for optimization.

METHODS

Data were extracted from 8 national point prevalence surveys of systemic antibiotic prescriptions in Norwegian hospitals between 2015 and 2017. The choices of antibiotics were compared with the empirical recommendations given in available Norwegian guidelines. In total, 1323 prescriptions were issued for 937 patients.

RESULTS

Twenty-four percent of pediatric inpatients were given antibiotics. Adherence to guidelines was 48%, and 30% (95% confidence interval: 27%-33%) of all patients on antibiotics received BSA. We identified only small variations in use of BSA between hospitals. One-third of the patients on antibiotic therapy received prophylaxis whereof 13% were given BSA. In 30% of prescriptions with BSA, no microbiologic sample was obtained before treatment.

CONCLUSIONS

This study reveals an excess of prescriptions with BSA in relation to the low resistance rate in Norway. Our findings reveal areas for improvement that can be useful in the forthcoming antibiotic stewardship programs in Norwegian pediatric departments.

Drug samples in family medicine teaching units: a cross-sectional descriptive study: Part 2: portrait of drug sample management in Quebec

OBJECTIVE

To draw a portrait of drug sample management in academic primary health care settings and assess conformity to existing Canadian guidelines.

DESIGN

Descriptive cross-sectional survey.

SETTING

All 33 family medicine teaching units (FMTUs) in Quebec that kept drug samples.

PARTICIPANTS

Health care professionals or FMTU staff who managed drug samples (ie, managers).

MAIN OUTCOME MEASURES

Drug sample managers completed a self-administered questionnaire between February and December 2013. Questionnaires inquired about sample selection, procurement, reception, storage, inventory, and disposal. Results were compared with the Canada's Research-Based Pharmaceutical Companies Code of Ethical Practices (2012) and the Canadian Medical Association Guidelines for Physicians in Interactions with Industry (2007).

RESULTS

All 33 FMTUs responded to the questionnaire. According to managers, no FMTUs had written selection criteria to guide sample choice. Almost one-third (30%) of FMTUs had uncontrolled access to drug sample cabinets. Even though pharmaceutical companies must distribute drug samples to authorized professionals only, these professionals were involved in the procurement and the reception of samples in 79% and 56% of FMTUs, respectively. Only 15% of FMTUs kept track of samples distributed, 82% checked expiration dates, and 85% ensured proper disposal as recommended.

CONCLUSION

The management of drug samples in the FMTUs in Quebec is heterogeneous, with many FMTUs and pharmaceutical companies not following Canadian guidelines.

Drug samples in family medicine teaching units: a cross-sectional descriptive study: Part 1: drug sample management policies and the relationship between the pharmaceutical industry and residents in Quebec

OBJECTIVE

To determine the existence and the level of health care professional (HCP) knowledge of local policies regarding drug sample use and the relationship between residents and the pharmaceutical industry in academic primary health care settings.

DESIGN

Descriptive cross-sectional survey. Health care providers were invited to complete a self-administered questionnaire on drug sample use between February and December 2013. Managers of drug samples were also asked to complete a specific questionnaire on drug sample management and policies and an inventory log sheet. Data about the existence of written policies were validated with health and social services centre (HSCC) directors or pharmacy departments and family medicine teaching unit (FMTU) directors between February and June 2014.

SETTING

All 42 FMTUs in Quebec.

PARTICIPANTS

All HCPs in the FMTUs authorized to hand out drug samples (practising physicians, residents, pharmacists, and nurses). Dispensers were defined as those who reported using drug samples. Managers were defined as HCPs or staff members who managed drug samples.

MAIN OUTCOME MEASURES

Existence of written policies on drug sample use in HSCCs and FMTUs; whether FMTUs applied the HSCC policies if they existed; whether dispensers were aware of the existence of the policies; and whether policies on the relationships between residents and pharmaceutical companies existed.

RESULTS

Among the 42 FMTUs, 33 (79%) kept drug samples. Of these, 30% (10 of 33) did not have policies about drug samples in the FMTU or in the HSCC. A total of 67% (579 of 859) of HCPs from these FMTUs reported using drug samples. Most dispensers did not know if a policy existed in their FMTU (n = 297; 51%) or their HSCC (n = 420; 73%). Eleven (26%) of the 42 FMTU directors reported having a policy regarding relationships between residents and the pharmaceutical industry. Most drug sample dispensers were not aware whether such a policy existed (n = 310; 54%).

CONCLUSION

Many FMTUs did not have policies regarding drug samples or relationships between residents and the pharmaceutical industry. Variation in use and management of drug samples and the lack of knowledge of HCPs about the existence of policies point to the need to implement uniform policies in all FMTUs in Quebec.

Comparing outpatient oral antibiotic use in Germany and the Netherlands from 2012 to 2016

PURPOSE

Overuse of antibiotics is of concern, but may differ between European countries. This study compares outpatient use of oral antibiotics between Germany (DE) and the Netherlands (NL).

METHODS

For DE, we used the DAPI database with information on dispensings at the expense of the Statutory Health Insurance Funds from > 80% of community pharmacies. For NL, data were obtained from the Dutch Foundation for Pharmaceutical Statistics. Use of oral antibiotics was estimated as defined daily doses per 1000 inhabitants per day (DID), except for age comparisons as packages per 1000 inhabitants annually. National time trends were assessed with linear regression, stratified for the major antibiotic classes, and individual substances.

RESULTS

From 2012 to 2016, outpatient antibiotic use was lower in NL than in DE (9.64 vs 14.14 DID in 2016) and non-significantly decreased slightly over time in both countries. In DE, dispensings of oral antibiotics to children were higher compared with NL for the age groups 2 to 5 (2.0-fold in 2016) and 6 to 14 years (2.7-fold in 2016). Use of cephalosporins was very low in NL (0.02 DID in 2016), but the second most frequently dispensed class in DE (2.95 DID in 2016).

CONCLUSION

From 2012 to 2016, outpatient use of oral antibiotics was lower in NL than in DE. Differences were primarily observed in the age groups 2 to 5 and 6 to 14 years, although the recommendations of evidence-based guidelines in both countries were in agreement.

Drug samples in family medicine teaching units: a cross-sectional descriptive study: Part 3: availability and use of drug samples in Quebec

OBJECTIVE

To draw a portrait of drug sample distribution and to assess the concordance between drug samples distributed and the medical problems encountered in the ambulatory primary health care setting.

DESIGN

Descriptive cross-sectional survey. A self-administered questionnaire was distributed to all health care professionals (HCPs) in family medicine teaching units (FMTUs) that kept drug samples between February and December 2013. Dispensers were defined as HCPs reporting the use of drug samples. Concurrently, an inventory log sheet was completed by managers of drug samples to document the contents of sample cabinets. Data from the Canadian Disease and Therapeutic Index were used as the criterion standard to assess the consistency between the drug samples found in the cabinets and the profile of the most frequent health problems encountered in primary care.

SETTING

All 33 FMTUs that kept drug samples in Quebec.

PARTICIPANTS

Health care professionals authorized to hand out drug samples (practising physicians, residents, pharmacists, and nurses), and managers of drug sample cabinets.

MAIN OUTCOME MEASURES

Dispensing practices of HCPs; number of doses of each drug contained in the sample cabinets; total market value of the samples; concordance between the drug sample categories made available and the most common medical problems encountered in primary care; and data on safe handling, ethical issues, effect of the pharmaceutical industry on prescribing behaviour, and inventory of samples.

RESULTS

Among 859 HCPs, 579 (67%) reported dispensing drug samples. A large proportion of dispensers (88%) were unable to find the specific drug they sought and half of them (51%) provided the patients with a drug sample even if it was not their first choice for treatment. The drug sample cabinet inventory revealed products from 292 different companies and identified a total of 382 363 medication doses for a total value of $201 872. We found gaps among types of drugs provided to patients, those the HCPs would consider useful, and those available in the cabinets.

CONCLUSION

Drug samples available in FMTUs do not meet the needs of many patients and HCPs, suggesting that the main driving force for drug sample distribution is not patient care. Policies on drug samples in FMTUs should be uniform across the province, and management should be as strict as in community pharmacies. Otherwise, prohibiting their use should be considered.

Assessing use of patient-focused pharmacotherapy in glycemic management through the Diabetes Collaborative Registry (DCR)

BACKGROUND

Although practice guidelines stress individualization of glucose management in patients with type 2 diabetes (T2D), the extent to which providers take patient factors into account when selecting medications is not well known.

METHODS

Diabetes Collaborative Registry (DCR) is an outpatient diabetes registry including primary care, cardiology, and endocrinology practices. T2D medications were grouped as those which may be suboptimal for key patient subgroups, and we examined patient factors associated with use of these agents using hierarchical, multivariable Poisson models.

RESULTS

In DCR, 157,551 patients from 374 US practices were prescribed a glucose-lowering medication. Patients with morbid obesity were more likely treated with medications prone to cause weight gain (relative rate [RR] 1.09, 95% CI 1.07-1.11). Older patients were more likely to be treated with medications with increased risk of hypoglycemia (RR 1.04 per 5 years, 95% CI 1.04-1.05). Patients with CKD 4/5 were less likely to be treated with agents with known risk in patients with advanced CKD (RR 0.74, 95% CI 0.71-0.77). Patients with coronary artery disease were no more or less likely to be treated with medications with potential cardiovascular safety issues (RR 0.99, 95% CI 0.96-1.01).

CONCLUSIONS

We observed some targeted use of glucose-lowering therapies in certain subgroups but also identified potential opportunities for better personalization of treatment. Data sources such as the DCR can highlight potential areas for improving targeted approaches to pharmacologic therapy in order to optimize selection of patients most likely to benefit (and least likely to be harmed) from treatments.

Effect of an Educational Intervention on Knowledge and Perception Regarding Rational Medicine Use and Self-medication

BACKGROUND

Rational use of medicines is important for safe and cost-effective pharmacotherapy. However, nearly half of the medicines available in the market may be used irrationally. The present study assessed the perceptions and knowledge about rational medicine use and responsible self-medication among participants before and after an educational intervention at KIST Medical College, Lalitpur.

METHODS

An educational module was conducted among healthcare professionals, media personnel and female community health volunteers. The questionnaire was administered before and immediately after the module. The areas addressed were rational medicine use, ethical prescribing, rational drug use situation in Nepal, pharmaceutical promotion, rational self-medication, safe use of antibiotics, and drug use problems in Nepal.

RESULTS

Among healthcare professionals, the rational drug use situation in Nepal and the total score significantly increased post-intervention (p<0.05). Among media personnel the mean scores increased significantly in pharmaceutical promotion and drug use problems in Nepal areas but there was a significant decrease in safe use of antibiotics. The pre-intervention pharmaceutical promotion score was significantly higher among healthcare professionals compared to media personnel while the rational self-medication scores were highest among female community health volunteers, safe use of antibiotics scores were highest among the media personnel. Post-intervention the mean pharmaceutical promotion scores was highest among healthcare professionals, rational self-medication scores among female community health volunteers, safe use of antibiotics, drug use problems in Nepal and total scores were highest among the media personnel.

CONCLUSIONS

There were differences in the mean pre-intervention scores among different subgroups. A single session may not be enough to bring about significant changes in knowledge and perception. The retention of knowledge could be measured in future studies.

The Assessment of Drug Use Pattern Using WHO Prescribing Indicators

BACKGROUND

In order to promote rational drug use in developing countries, assessment of drug use pattern using the World Health Organization drug use indicators is important. The aim of this study was to assess the drug prescription patterns at Kathmandu Medical College Teaching Hospital, using some of the World Health Organization core drug use indicators.

METHODS

A prospective cross-sectional study was carried out in order to determine current prescribing trends at Kathmandu Medical College Teaching Hospital. A total of 605 prescriptions were collected and analyzed in the study.

RESULTS

The average number of drugs per prescription was 5.85 considering the total amount of prescriptions. Furthermore, assuming each prescription as an individual patient, 64.1% of patients received antibiotics, and 71% of patients received injectable form of drugs. Among antibiotics the most common antibiotics prescribed were Ceftriaxone, Amoxicillin/Cloxacillin, Azithromycin, Cefixime, and Cloxacillin. Only 16.94% of the medicines were prescribed in generic names with the rest 83.06% of the medicines being prescribed in brand names and 47.55% of medicines prescribed were from the National List of Essential Medicines-Nepal.

CONCLUSIONS

The current study revealed that polypharmacy and prescription writing using brand names were common. Prescriptions writing in generic name needs to be promoted and encouraged. There appears to be a crucial need for the development of prescribing guidelines when it comes to antibiotics.

Health care worker perceptions toward computerized clinical decision support tools for Clostridium difficile infection reduction: A qualitative study at 2 hospitals

BACKGROUND

Clostridium difficile infection (CDI) is associated with significant morbidity and mortality. Computerized clinical decision support (CCDS) tools can aid process improvement in infection prevention and antibiotic stewardship, but implementation and health care workers (HCWs) uptake of these tools is often variable. The objective of this study was to describe HCWs' perceptions of barriers and facilitators related to uptake of CCDS tools as part of a CDI reduction bundle.

METHODS

We conducted a qualitative study among HCWs at 2 acute care hospitals in Maryland. Semi-structured interviews and structured surveys were completed by HCWs to evaluate their perception to CCDS tools at 2 different stages: predevelopment and preimplementation. Emergent themes and patterns in the data were identified and condensed.

RESULTS

Gaps in CDI-related knowledge and in communication between HCWs were identified throughout the evaluation. HCWs agreed on the potential of the tools to improve CDI diagnosis, prevention, and control. An important barrier for uptake was the perceived loss of autonomy and clinical judgment, whereas standardization and error reduction were perceived advantages.

CONCLUSIONS

These observations shaped the development and implementation of the CDI reduction bundle. Qualitative findings can provide valuable contextual information during the development stages of CCDS tools in infection prevention and antibiotic stewardship.

A Health System-Wide Initiative to Decrease Opioid-Related Morbidity and Mortality

BACKGROUND

The opioid overdose crisis now claims more than 40,000 lives in the United States every year, and many hospitals and health systems are responding with opioid-related initiatives, but how best to coordinate hospital or health system-wide strategy and approach remains a challenge.

METHODS

An organizational opioid stewardship program (OSP) was created to reduce opioid-related morbidity and mortality in order to provide an efficient, comprehensive, multidisciplinary approach to address the epidemic in one health system. An executive committee of hospital leaders was convened to empower and launch the program. To measure progress, metrics related to care of patients on opioids and those with opioid use disorder (OUD) were evaluated.

RESULTS

The OSP created a holistic, health system-wide program that addressed opioid prescribing, treatment of OUD, education, and information technology tools. After implementation, the number of opioid prescriptions decreased (-73.5/month; p < 0.001), mean morphine milligram equivalents (MME) per prescription decreased (-0.4/month; p < 0.001), the number of unique patients receiving an opioid decreased (-52.6/month; p < 0.001), and the number of prescriptions ≥ 90 MME decreased (-48.1/month; p < 0.001). Prescriptions and providers for buprenorphine increased (+6.0 prescriptions/month and +0.4 providers/month; both p < 0.001). Visits for opioid overdose did not change (-0.2 overdoses/month; p = 0.29).

CONCLUSION

This paper describes a framework for a new health system-wide OSP. Successful implementation required strong executive sponsorship, ensuring that the program is not housed in any one clinical department in the health system, creating an environment that empowers cross-disciplinary collaboration and inclusion, as well as the development of measures to guide efforts.

Using risk adjustment to improve the interpretation of global inpatient pediatric antibiotic prescribing

Objectives

Assessment of regional pediatric last-resort antibiotic utilization patterns is hampered by potential confounding from population differences. We developed a risk-adjustment model from readily available, internationally used survey data and a simple patient classification to aid such comparisons.

Design

We investigated the association between pediatric conserve antibiotic (pCA) exposure and patient / treatment characteristics derived from global point prevalence surveys of antibiotic prescribing, and developed a risk-adjustment model using multivariable logistic regression. The performance of a simple patient classification of groups with different expected pCA exposure levels was compared to the risk model.

Setting

226 centers in 41 countries across 5 continents.

Participants

Neonatal and pediatric inpatient antibiotic prescriptions for sepsis/bloodstream infection for 1281 patients.

Results

Overall pCA exposure was high (35%), strongly associated with each variable (patient age, ward, underlying disease, community acquisition or nosocomial infection and empiric or targeted treatment), and all were included in the final risk-adjustment model. The model demonstrated good discrimination (c-statistic = 0.83) and calibration (p = 0.38). The simple classification model demonstrated similar discrimination and calibration to the risk model. The crude regional pCA exposure rates ranged from 10.3% (Africa) to 67.4% (Latin America). Risk adjustment substantially reduced the regional variation, the adjusted rates ranging from 17.1% (Africa) to 42.8% (Latin America).

Conclusions

Greater comparability of pCA exposure rates can be achieved by using a few easily collected variables to produce risk-adjusted rates.

Impact of antibiotic stewardship programmes in Asia: a systematic review and meta-analysis

Background

The use of antibiotic stewardship programmes (ASPs) is increasing in Asia, but their effectiveness in reducing antibiotic consumption and their impact on clinical outcomes is not known.

Objectives

To determine the impact of ASPs conducted in Asia on the consumption of antibiotics and on patients' clinical outcomes.

Methods

We systematically searched the Embase and Medline (PubMed) databases for studies that compared antibiotic consumption or clinical outcomes of patients in an Asian hospital or clinic with an ASP (intervention) with those in a similar setting without an ASP (control). Meta-analyses of all-cause mortality and hospital-acquired infection (HAI) were performed using random-effects models.

Results

The search identified 77 studies of which 22 and 19 reported antibiotic usage and cost, respectively. Among these, 20 (91%) studies reported reduced antibiotic usage and 19 (100%) reported cost savings in the intervention group. Duration of antibiotic therapy was reduced in six of seven studies in association with an ASP. Rates of all-cause mortality and HAI were not significantly different between the intervention and control groups. However, mortality rates were significantly improved by ASPs using drug monitoring, while HAI rates were also improved by ASPs that included infection control or hand hygiene programmes.

Conclusions

In Asia, ASPs reduce antibiotic consumption in hospital and clinic settings and do not worsen clinical outcomes. The findings strongly support the broad implementation of antimicrobial stewardship interventions in hospital and clinic settings in Asia.

Delivering precision antimicrobial therapy through closed-loop control systems

Sub-optimal exposure to antimicrobial therapy is associated with poor patient outcomes and the development of antimicrobial resistance. Mechanisms for optimizing the concentration of a drug within the individual patient are under development. However, several barriers remain in realizing true individualization of therapy. These include problems with plasma drug sampling, availability of appropriate assays, and current mechanisms for dose adjustment. Biosensor technology offers a means of providing real-time monitoring of antimicrobials in a minimally invasive fashion. We report the potential for using microneedle biosensor technology as part of closed-loop control systems for the optimization of antimicrobial therapy in individual patients.

Surveillance of antimicrobial consumption in animal production sectors of low- and middle-income countries: Optimizing use and addressing antimicrobial resistance

In a policy forum, Daniel Schar and colleagues discuss the need for surveillance of antimicrobial consumption in animals in low- and middle-income countries and propose the establishment of antimicrobial consumption monitoring systems.

Antibiotic Expenditures by Medication, Class, and Healthcare Setting in the United States, 2010-2015

BACKGROUND

Improving antibiotic use has the potential to decrease healthcare costs by reducing the incidence of antibiotic-resistant infections, antibiotic-associated adverse events, and expenditures due to unnecessary prescriptions. Antibiotic expenditures in 2009 totaled $10.7 billion in the United States. Since then, national and local antibiotic stewardship initiatives have grown. The purpose of this study was to assess trends in antibiotic expenditures by healthcare setting in the United States between 2010 and 2015.

METHODS

Systemic (nontopical) antibiotic expenditures from January 2010 to December 2015 were extracted from the QuintilesIMS National Sales Perspectives database. These data represent a statistically valid projection of US medication purchases. Regression analyses evaluated trends in expenditures over the study period.

RESULTS

Antibiotic expenditures totaled $56.0 billion over the 6-year period; the majority (59.1%) of expenditures were associated with the outpatient setting. Overall antibiotic expenditures in 2015 ($8.8 billion) were 16.6% lower than in 2010 ($10.6 billion). Antibiotic expenditures similarly decreased in the community by 25.5% (P = .05), but outpatient clinics and mail service pharmacy expenditures experienced significant growth (148% and 67% increase, respectively; P < .01 for both). In 2015, 16.5% of antibiotic expenditures in the community were for parenteral formulations, an increase of 25%.

CONCLUSIONS

From 2010 to 2015, antibiotic expenditures decreased. The majority of antibiotic expenditures were in the outpatient setting, specifically community pharmacies. Expenditures for intravenous agents in the community are increasing and may represent increased use. These results reinforce the importance of antibiotic stewardship efforts across the spectrum of healthcare.

Nurses as Antibiotic Brokers: Institutionalized Praxis in the Hospital

We are likely moving rapidly toward a post-antibiotic era, as a result of escalating antimicrobial resistance, rapidly declining antibiotic production and profligate overuse. Hitherto research has almost exclusively focused on doctors' prescribing, with nurses' roles in antibiotic use remaining virtually invisible. Drawing on interviews with 30 nurses, we focus on nurses as brokers of doctors' antibiotic decisions, nursing capacity to challenge doctors' decisions, and, "back stage" strategies for circumnavigating organizational constraints. We argue that nurses occupy an essential and conscious position as brokers within the hospital; a subject position that is not neutral, facilitates (short-term) cohesion, and involves the pursuit of particular (preferred) nursing outcomes. Illustrating how authority can be diffuse, mediated by institutionalized praxis, and how professionals evade attempts to govern their practice, we challenge the reification of physician prescribing power, arguing that it may work against the utilization of nurses as important stakeholders in the future of antibiotics.

Does electronic stewardship work?

Faced with national requirements to promote antimicrobial stewardship and reduce drug-resistant infections, community hospitals are challenged to make the best use of existing resources. Eighteen months after building antibiotic decision support into our electronic order platform, high-risk antibiotic use decreased by 83% (P < .001) at our community hospital. Hospital-acquired Clostridium difficile infections declined 24% (P = .07).

Evaluation of effects of an operational multidisciplinary team on antibiotic use in the medium to long term at a French university hospital

Background Antibiotic-resistant bacteria are a major public health problem throughout the world. In 2006, in accordance with the national guidelines for antibiotic use, the CHRU of Nancy created an operational multidisciplinary antibiotic team at one of its sites. In 2011, a cluster-controlled trial showed that the operational multidisciplinary antibiotic team (the intervention) had a favourable short-term effect on antibiotic use and costs. Objective Our objective was to determine whether these effects continued over the medium to long term (that is, 2-7 years after creation of the operational multidisciplinary antibiotic team, 2009-2014). Setting The 1800-bed University Hospital of Nancy (France). Method The effect in the medium to long term is measured according to the same criteria and assessed by the same methods as the first study. A cluster controlled trial was performed on the period 2009-2014. The intervention group comprised 11 medical and surgical wards in settings where the operational multidisciplinary antibiotic team was implemented and the control group comprised 6 wards without this operational team. Main outcome measure Consumption of antibiotics overall and by therapeutic class (in defined daily doses per 1000 patient-days) and costs savings (in €). Results The reduction in antibiotic use and costs continued, but at a lower rate than in the short term (11% between 2009 and 2014 compared with 33% between 2007 and 2009) at the site of the intervention. The principal decreases concerned fluoroquinolones and glycopeptides. At the site without an operational multidisciplinary antibiotic team (the control group), total antibiotic use remained stable. Between 2009 and 2014, costs fell 10.5% in the intervention group and 5.7% in the control group. Conclusion This study shows that it is possible to maintain the effectiveness over time of such an intervention and demonstrates its role in defining a hospital's antibiotic policy.

Association Between Opioid and Benzodiazepine Use and Clinical Deterioration in Ward Patients

BACKGROUND

Opioids and benzodiazepines are frequently used in hospitals, but little is known about outcomes among ward patients receiving these medications.

OBJECTIVE

To determine the association between opioid and benzodiazepine administration and clinical deterioration.

DESIGN

Observational cohort study.

SETTING

500-bed academic urban tertiary-care hospital.

PATIENTS

All adults hospitalized on the wards from November 2008 to January 2016 were included. Patients who were "comfort care" status, had tracheostomies, sickle-cell disease, and patients at risk for alcohol withdrawal or seizures were excluded.

MEASUREMENTS

The primary outcome was the composite of intensive care unit transfer or ward cardiac arrest. Discrete-time survival analysis was used to calculate the odds of this outcome during exposed time periods compared to unexposed time periods with respect to the medications of interest, with adjustment for patient demographics, comorbidities, severity of illness, and pain score.

RESULTS

In total, 120,518 admissions from 67,097 patients were included, with 67% of admissions involving opioids, and 21% involving benzodiazepines. After adjustment, each equivalent of 15 mg oral morphine was associated with a 1.9% increase in the odds of the primary outcome within 6 hours (odds ratio [OR], 1.019; 95% confidence interval [CI], 1.013-1.026; P < 0.001), and each 1 mg oral lorazepam equivalent was associated with a 29% increase in the odds of the composite outcome within 6 hours (OR, 1.29; CI, 1.16- 1.45; P < 0.001).

CONCLUSION

Among ward patients, opioids were associated with increased risk for clinical deterioration in the 6 hours after administration. Benzodiazepines were associated with even higher risk. These results have implications for ward-monitoring strategies. Journal of Hospital Medicine 2017;12:428-434.

An online course improves nurses' awareness of their role as antimicrobial stewards in nursing homes

BACKGROUND

To support the role of nurses as active proponents of antimicrobial stewardship in long-term care facilities, we developed an educational intervention consisting of a free online course comprised of 6 interactive modules. Here, we report the effect of the course on the knowledge, beliefs, and attitudes toward antimicrobial stewardship of nurses working in long-term care facilities.

METHODS

We used a paired pre- and postcourse survey instrument to assess nurses' knowledge regarding the care of long-term care facility residents with infections and attitudes and beliefs regarding antimicrobial stewardship.

RESULTS

There were 103 respondents, registered nurses or licensed practical nurses, who completed the pre- and postsurveys. Their mean knowledge scores improved from 75% (precourse) to 86% (postcourse, P <.001). After the course, nurses' agreement that their role influences whether residents receive antimicrobials increased significantly (P <.001).

CONCLUSIONS

The online course improves nurses' knowledge regarding the care of long-term care facility residents with infections and improves their confidence to engage in antimicrobial stewardship activities. Empowering nurses to be antimicrobial stewards may help reduce unnecessary antibiotic use among institutionalized older adults.

Systematic review of public-targeted communication interventions to improve antibiotic use

Background

Excessive use of antibiotics accelerates the acquisition/spread of antimicrobial resistance. A systematic review was conducted to identify the components of successful communication interventions targeted at the general public to improve antibiotic use.

Methods

The databases MEDLINE, EMBASE, CINAHL, Web of Science and Cochrane Library were searched. Search terms were related to the population (public, community), intervention (campaign, mass media) and outcomes (antibiotic, antimicrobial resistance). References were screened for inclusion by one author with a random subset of 10% screened by a second author. No date restrictions were applied and only articles in the English language were considered. Studies had to have a control group or be an interrupted time-series. Outcomes had to measure change in antibiotic-related prescribing/consumption and/or the public's knowledge, attitudes or behaviour. Two reviewers assessed the quality of studies. Narrative synthesis was performed.

Results

Fourteen studies were included with an estimated 74-75 million participants. Most studies were conducted in the United States or Europe and targeted both the general public and clinicians. Twelve of the studies measured changes in antibiotic prescribing. There was quite strong ( P  < 0·05 to ≥ 0·01) to very strong ( P  < 0·001) evidence that interventions that targeted prescribing for RTIs were associated with decreases in antibiotic prescribing; the majority of these studies reported reductions of greater than -14% with the largest effect size reaching -30%.

Conclusion

Multi-faceted communication interventions that target both the general public and clinicians can reduce antibiotic prescribing in high-income countries but the sustainability of reductions in antibiotic prescribing is unclear.

A parainfluenza virus type 3 outbreak at a residential aged care facility: The role of microbiologic testing in early identification and antimicrobial stewardship

We report an outbreak of parainfluenza 3, which had an attack rate of 30%, in a residential care facility in Melbourne, Australia. One-fifth of affected residents required hospitalization, but there were no deaths. The outbreak demonstrated the value of active surveillance and early microbiologic testing and the urgent need for antimicrobial stewardship programs in the aged care setting.

Antimicrobial stewardship in Kansas: Results from a statewide survey

BACKGROUND

The availability of effective antibiotics is considered one of the most important developments in medicine. However, many organisms that were once susceptible to common antibiotics are becoming resistant. Antimicrobial stewardship programs (ASPs) are considered to be vital for combating the emergence of resistance. To understand current antimicrobial stewardship practices in Kansas, the authors designed a 36-question survey. Results of this survey will be used to develop a coordinated, public health strategy for improving current practices.

METHODS

To assess the number of ASPs and general antimicrobial stewardship practices in Kansas, a 36-question survey was developed and sent out to infection preventionists at all 154 acute care facilities in Kansas via e-mail.

RESULTS

Of the 154 eligible facilities, 129 (83.7%) responded to this survey, and 61 of 127 (48%) had a formal committee devoted to antimicrobial stewardship. Acute care facilities were more likely than critical access facilities to have formal committees and were also more likely to engage in core stewardship strategies.

CONCLUSIONS

In a world with increasing microbial resistance, the role of public health in antimicrobial stewardship is becoming more important. After surveying all hospitals in Kansas about antimicrobial stewardship practices, we realize that critical access hospitals have the greatest need for support and may see the greatest opportunities for development and improvements.

Rapid MRSA PCR on respiratory specimens from ventilated patients with suspected pneumonia: a tool to facilitate antimicrobial stewardship

Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of pneumonia in ventilated patients. Our objective was to evaluate the GeneXpert MRSA/SA SSTI Assay (Xpert MRSA/SA) (Cepheid, Sunnyvale, CA) for use in lower respiratory tract (LRT) specimens for rapid MRSA detection and to determine the potentially saved antibiotic-days if a culture-based identification method was replaced by this assay. Remnant LRT samples from ventilated patients submitted to the microbiology laboratory for routine culture were tested using conventional culture and Xpert MRSA/SA. One hundred of 310 LRT specimens met the inclusion criteria. Ten samples were positive for MRSA by Xpert MRSA/SA, while six were positive by routine culture methods. Xpert MRSA/SA correctly identified 5/6 positive and 89/94 negative MRSA specimens, for a sensitivity of 83.3%, specificity of 94.7%, positive predictive value of 45.6%, and negative predictive value of 98.9%. The assay also correctly detected 3/3 positive and 90/97 negative methicillin-susceptible S. aureus (MSSA) specimens, for a sensitivity of 100%, specificity of 92.8%, positive predictive value of 30%, and negative predictive value of 100%. A total of 748 vancomycin and 305 linezolid antibiotic-days were associated with the enrolled specimens. Vancomycin and linezolid utilization could decrease by 68.4% and 83%, respectively, if discontinued 1 day after negative polymerase chain reaction (PCR) results. The Xpert MRSA/SA SSTI rapid MRSA PCR assay performed well in respiratory samples from ventilated patients with suspected pneumonia and has the potential to facilitate stewardship efforts such as reducing empiric vancomycin and linezolid therapy.

Effect of an antimicrobial stewardship intervention on outcomes for patients with Clostridium difficile infection

BACKGROUND

Although antimicrobial stewardship programs (ASPs) are uniquely positioned to improve treatment of Clostridium difficile infection (CDI) through targeted interventions, studies to date have not rigorously evaluated the influence of ASP involvement on clinical outcomes attributed to CDI.

METHODS

We performed a quasiexperimental study of adult patients with CDI before (n = 307) and after (n = 285) a real-time ASP review was initiated. In the intervention group, an ASP pharmacist was notified of positive CDI results and consulted with the care team to initiate optimal therapy, minimize concomitant antibiotic and acid-suppressive therapy, and recommend surgical/infectious diseases consultation in complicated cases. The primary outcome was a composite of attributable 30-day mortality, intensive care unit admission, colectomy/ileostomy, and recurrence.

RESULTS

A higher percentage of patients in the ASP intervention group had acid-suppressive therapy discontinued (30% vs 13%; P < .01). Among patients with severe CDI, more patients in the intervention group received an infectious diseases consultation (17% vs 10%; P = .04), received appropriate therapy with oral vancomycin (87% vs 59%; P <.01), and vancomycin was initiated earlier (mean, 1.1 vs 1.7 days; P <.01). Incidence of the composite outcome was not significantly different between the 2 groups (12.3% vs 14.7%; P = .40).

CONCLUSIONS

ASP review and intervention improved CDI process measures. A decrease in composite outcomes was not found, which may be due to low baseline rates of attributable complications in our institution.

Antimicrobial stewardship programs that target only high-cost, broad-spectrum antimicrobials miss opportunities to reduce Clostridium difficile infections

Antimicrobial stewardship programs are promoted as a strategy to reduce Clostridium difficile infections. We implemented an antimicrobial stewardship program comprised of formulary restriction plus prospective audit with feedback for high-cost and broad-spectrum antimicrobials. Subsequently, we reviewed all heath care facility-onset, health care facility-associated C difficile infections. We found that most of these infections were associated with the antecedent receipt of nonaudited, and often unnecessary, antimicrobials.

Exploring the coverage of antimicrobial stewardship across UK clinical postgraduate training curricula

OBJECTIVES

Antimicrobial resistance (AMR) is a global political and patient safety issue. With ongoing strategic interventions to improve the shape of UK postgraduate clinical training, ensuring that all clinicians have appropriate knowledge and practical skills in the area of AMR is essential. To assess this, a cross-sectional analysis was undertaken of the coverage and quality of antimicrobial stewardship (AMS)/AMR within UK postgraduate clinical training curricula.

METHODS

UK clinical specialty training curricula were identified. Topics and individual learning points relating to AMS or AMR were extracted for each specialty. Learning points were quality assessed against the expected level of clinical competence. Inter-specialty analysis was performed.

RESULTS

Overall 37 specialties were assessed, equating to 2318 topics and 42 527 learning points. Of these, 8/2318 (0.3%) topics and 184/42 527 (0.4%) learning points were related to AMS/AMR. Infectious diseases represented all eight topics and 43/184 (23%) of the learning points. In contrast, primary care, which is responsible for the highest proportion of antimicrobial usage, had no topics and only 2/1368 (0.15%) of the AMS/AMR learning points. This paucity of representation was reflected across most of the remaining specialties. On quality assessment, the majority of learning points (111/184; 60%) required knowledge only, with no demonstration of behaviour in clinical practice required.

CONCLUSIONS

Coverage of AMS/AMR is poor across the majority of UK postgraduate clinical training curricula, with little depth of learning required. Given the threat of AMR, and evolving changes in clinical training pathways, we call for cross-specialty action to address this current lack of engagement.

Social media as a tool for antimicrobial stewardship

BACKGROUND

To increase the reach of our antimicrobial stewardship program (ASP), social media platforms, Facebook and Twitter, were used to increase internal medicine residents' (IMRs') antibiotic (Abx) knowledge and awareness of ASP resources.

METHODS

Fifty-five of 110 (50%) IMRs consented to participate; 39 (71%) completed both pre- and postintervention surveys and followed our ASP on social media. Along with 20 basic Abx and infectious diseases (IDs) questions, this survey assessed IMR awareness of ASP initiatives, social media usage, and attitudes and beliefs surrounding Abx resistance. Over 6 months, IMRs received posts and Tweets of basic Abx/IDs trivia while promoting use of educational tools and clinical pathways on our ASP Web site. To compare pre- and postsurvey responses, McNemar test or Stuart-Maxwell test was used for categorical variables, and paired t test or Wilcoxon signed-rank test was used for continuous variables, as appropriate.

RESULTS

Of the IMRs, 98% and 58% use Facebook and Twitter, respectively. To compare pre- and postintervention, median scores for Abx knowledge increased from 12 (interquartile range, 8-13) to 13 (interquartile range, 11-15; P = .048); IMRs knowing how to access the ASP Web site increased from 70% to 94%. More IMRs indicated that they used the clinical pathways "sometimes, frequently, or always" after the intervention (33% vs 61%, P = .004).

CONCLUSIONS

Social media is a valuable tool to reinforce ASP initiatives while encouraging the use of ASP resources to promote antimicrobial mindfulness.

Introducing an antibiotic stewardship program in a humanitarian surgical hospital

Antibiotic stewardship program (ASP) implementation in humanitarian settings is a new endeavor. Doctors Without Borders/Médecins Sans Frontières introduced an ASP within a hospital in Amman, Jordan, where patients from Iraq, Syria, and Yemen with chronic, often multidrug-resistant, infections related to war are managed. Antibiotics were reviewed, and real-time recommendations were made to optimize choice, dose, duration, and route by a small team. Over the first year of implementation, acceptance of the ASP's recommendations improved. When compared with the year prior to implementation, antibiotic cost in 2014 declined considerably from approximately $252,077 (average, $21,006/month) to <$159,948 ($13,329/month), and a reduction in use of broad-spectrum agents was observed. An ASP in a humanitarian surgical hospital proved acceptable and effective, reducing antibiotic expenditures and use of broad-spectrum agents.

Impact of monitoring surgical prophylactic antibiotics and a computerized decision support system on antimicrobial use and antimicrobial resistance

BACKGROUND

Monitoring of performance indicators and implementation of a computerized decision support system (CDSS) have been suggested as effective measures to improve quality of care. We conducted this study to evaluate the effect of monitoring of surgical prophylactic antibiotics (SPAs) and the CDSS on the antimicrobial use and resistance rate of major nosocomial pathogens.

METHODS

An interrupted time series with segmented regression analysis in 3 periods (preintervention, SPAs monitoring, and CDSS) was conducted in a tertiary care hospital. Immediate change and change in trends of antimicrobial use density, resistance rate of nosocomial pathogens, and cost of antibiotics in each intervention period were compared with those of the preintervention period.

RESULTS

Compared with the preintervention period, the change in the slope of the total use of antibiotics was -8.71 defined daily dose (DDD) per 1,000 patient days per month (95% confidence interval [CI], -11.43 to -5.98; P < .01) in the SPAs monitoring period and -1.95 DDD per 1,000 patient days per month (95% CI, -2.93 to -0.96; P < .01) in the CDSS period. Use of third-generation cephalosporins and aminoglycosides showed change comparable with that of total antibiotics use, but use of vancomycin and carbapenem was unchanged in the CDSS period. Trends of the proportions of extended-spectrum β-lactamase-producing Escherichia coli, meropenem-resistant Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus have been reversed or decreased in slope in the CDSS period. Length of hospital stay also showed a negative change in slope in the CDSS period.

CONCLUSIONS

Monitoring of SPAs and implementation of the CDSS can be effective measures for antimicrobial stewardship.