Design and analysis of a pharmacist-enhanced antimicrobial stewardship program in Thailand

From Epidemiology of Community-Onset Bloodstream Infections to the Development of Empirical Antimicrobial Treatment-Decision Algorithm in a Region with High Burden of Antimicrobial Resistance

Antimicrobial-resistant (AMR) infections have increased in community settings. Our objectives were to study the epidemiology of community-onset bloodstream infections (BSIs), identify risk factors for AMR-BSI and mortality-related factors, and develop the empirical antimicrobial treatment-decision algorithm. All adult, positive blood cultures at the emergency room and outpatient clinics were evaluated from 08/2021 to 04/2022. AMR was defined as the resistance of organisms to an antimicrobial to which they were previously sensitive. A total of 1151 positive blood cultures were identified. There were 450 initial episodes of bacterial BSI, and 114 BSIs (25%) were AMR-BSI. Non-susceptibility to ceftriaxone was detected in 40.9% of 195 E. coli isolates and 16.4% among 67 K. pneumoniae isolates. A treatment-decision algorithm was developed using the independent risk factors for AMR-BSI: presence of multidrug-resistant organisms (MDROs) within 90 days (aOR 3.63), prior antimicrobial exposure within 90 days (aOR 1.94), and urinary source (aOR 1.79). The positive and negative predictive values were 53.3% and 83.2%, respectively. The C-statistic was 0.73. Factors significantly associated with 30-day all-cause mortality were Pitt bacteremia score (aHR 1.39), solid malignancy (aHR 2.61), and urinary source (aHR 0.30). In conclusion, one-fourth of community-onset BSI were antimicrobial-resistant, and one-third of Enterobacteriaceae were non-susceptible to ceftriaxone. Treatment-decision algorithms may reduce overly broad antimicrobial treatment.

Point Prevalence Survey of Antimicrobial Use during the COVID-19 Pandemic among Different Hospitals in Pakistan: Findings and Implications

The COVID-19 pandemic has significantly influenced antimicrobial use in hospitals, raising concerns regarding increased antimicrobial resistance (AMR) through their overuse. The objective of this study was to assess patterns of antimicrobial prescribing during the current COVID-19 pandemic among hospitals in Pakistan, including the prevalence of COVID-19. A point prevalence survey (PPS) was performed among 11 different hospitals from November 2020 to January 2021. The study included all hospitalized patients receiving an antibiotic on the day of the PPS. The Global-PPS web-based application was used for data entry and analysis. Out of 1024 hospitalized patients, 662 (64.64%) received antimicrobials. The top three most common indications for antimicrobial use were pneumonia (13.3%), central nervous system infections (10.4%) and gastrointestinal indications (10.4%). Ceftriaxone (26.6%), metronidazole (9.7%) and vancomycin (7.9%) were the top three most commonly prescribed antimicrobials among surveyed patients, with the majority of antibiotics administered empirically (97.9%). Most antimicrobials for surgical prophylaxis were given for more than one day, which is a concern. Overall, a high percentage of antimicrobial use, including broad-spectrums, was seen among the different hospitals in Pakistan during the current COVID-19 pandemic. Multifaceted interventions are needed to enhance rational antimicrobial prescribing including limiting their prescribing post-operatively for surgical prophylaxis.

Core Elements for Implementing Antimicrobial Stewardship Programs in Korean General Hospitals

Currently, antimicrobial resistance (AMR) is a major threat to global public health. The antimicrobial stewardship program (ASP) has been proposed as an important approach to overcome this crisis. ASP supports the optimal use of antimicrobials, including appropriate dosing decisions, administration duration, and administration routes. In Korea, efforts are being made to overcome AMR using ASPs as a national policy. The current study aimed to develop core elements of ASP that could be introduced in domestic medical facilities. A Delphi survey was conducted twice to select the core elements through expert consensus. The core elements for implementing the ASP included (1) leadership commitment, (2) operating system, (3) action, (4) tracking, (5) reporting, and (6) education. To ensure these core elements are present at medical facilities, multiple departments must collaborate as teams for ASP operations. Establishing a reimbursement system and a workforce for ASPs are prerequisites for implementing ASPs. To ensure that ASP core elements are actively implemented in medical facilities, it is necessary to provide financial support for ASPs in medical facilities, nurture the healthcare workforce in performing ASPs, apply the core elements to healthcare accreditation, and provide incentives to medical facilities by quality evaluation criteria.

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

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

Impact of an infectious diseases pharmacist-led intervention on antimicrobial stewardship program guideline adherence at a Thai medical center

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To evaluate and compare antimicrobial stewardship program (ASP) guideline adherence (primary outcome) as well as length of stay, 30-day all-cause mortality, clinical cure, antimicrobial consumption, and incidence of multidrug-resistant (MDR) pathogens (secondary outcomes) between an infectious diseases (ID) pharmacist-led intervention group and a standard ASP group.

METHODS

A quasi-experimental study was performed at Thammasat University Hospital between August 2019 and April 2020. Data including baseline characteristics and primary and secondary outcomes were collected from the electronic medical record by the ID pharmacist.

RESULTS

The ASP guideline adherence in the ID pharmacist-led intervention group was significantly higher than in the standard ASP group (79% vs 56.6%; P < 0.001), especially with regard to appropriate indication (P < 0.001), dosage regimen (P = 0.005), and duration (P = 0.001). The acceptance rate of ID pharmacist recommendations was 81.8% (44/54). The most common key barriers to following recommendations were physician resistance (11/20; 55%) and high severity of disease in the patient (6/20; 30%). Compared to the standard ASP group, there was a trend toward clinical cure in the ID pharmacist-led intervention group (63.6% vs 56.1%; P = 0.127), while 30-day all-cause mortality (15.9% vs 1.5%; P = 0.344) and median length of stay (20 vs 18 days; P = 0.085) were similar in the 2 groups. Carbapenem (P = 0.042) and fosfomycin (P = 0.014) consumption declined in the ID pharmacist-led intervention group. A marginally significant decrease in the overall incidence of MDR pathogens was also observed in the ID pharmacist-led intervention group (coefficient, -5.93; P = 0.049).

CONCLUSION

Our study demonstrates that an ID pharmacist-led intervention can improve ASP guideline adherence and may reduce carbapenem consumption.

Hospital-Based Antimicrobial Stewardship Programs Used in Low- and Middle-Income Countries: A Scoping Review

The burden of antimicrobial resistance (AMR) is considerable in many low- and middle-income countries (LMICs), and it is important to describe the antimicrobial stewardship program (ASP) activities found in these countries and report their impact. Importantly, as these programs target prescribing behavior, the factors influencing prescription of antimicrobials must also be taken into account. This scoping review aimed to (1) describe hospital-based ASP activities, (2) report methods used to measure the impact of ASPs, and (3) explore factors influencing antimicrobial prescribing behavior in LMICs. PubMed was searched from database inception until April 2021. Factors influencing antimicrobial prescribing behavior were canvassed using the Capability-Opportunity-Motivation and Behavior framework. Most of ASP studies in LMICs were predominantly conducted in tertiary care and university-based hospitals. Audit of antimicrobial prescriptions with feedback and restrictive-based strategies was the main reported activity. Total antimicrobial consumption was the main method used to measure the impact of ASPs. Positive outcomes were observed for both clinical and microbiological outcomes; however, these were measured from nonrandomized controlled trials. Dominant factors identified through the behavioral framework were a limited awareness of AMR as a local problem, a perception that overprescription of antimicrobials had limited consequences and was mainly driven by a motivation to help improve patient outcomes. In addition, antimicrobial prescribing practices were largely influenced by existing hierarchy among prescribers. Our scoping review suggests that LMICs need to evaluate antimicrobial appropriateness as an added measure to assess impact. Furthermore, improvements in the access of microbiology and diagnostic facilities and ensuring ASP champions are recruited from senior prescribers will positively influence antimicrobial prescribing behavior, helping improve stewardship of antimicrobials in these countries.

A Systematic Review of Pharmacist-Led Antimicrobial Stewardship Programs in Sub-Saharan Africa

BACKGROUND

The misuse of antibiotics contributes significantly to antimicrobial resistance (AMR). Higher treatment costs, longer hospital stays, and clinical failure can all result from AMR. According to projections, Africa and Asia will bear the heaviest burden of AMR-related mortalities in the coming years. Antimicrobial stewardship (AMS) programmes are therefore critical in mitigating the effects of AMR. Pharmacists may play an important role in such programmes, as seen in Europe and North America, but the impact, challenges, and opportunities of pharmacist-led antimicrobial stewardship interventions in Sub-Saharan African hospitals are unknown. The purpose of this systematic review was to assess the impact, challenges, and opportunities of pharmacist-led antimicrobial stewardship interventions in Sub-Saharan African hospitals.

METHODS

The Joanna Briggs Institute (JBI) guidelines were used to search for peer-reviewed pharmacist-led studies based in hospitals in Sub-Saharan Africa that were published in English between January 2015 and January 2021. The PubMed, Embase, and Ovid databases were used.

RESULTS

Education and training, audits and feedback, protocol development, and ward rounds were identified as primary components of pharmacist-led antimicrobial stewardship interventions in Sub-Saharan Africa. The pharmacist-led antimicrobial interventions improved adherence to guidelines and reduced inappropriate prescribing, but were hampered by a lack of laboratory and technological support, limited stewardship time, poor documentation, and a lack of guidelines and policies. Funding, mentorship, guidelines, accountability, continuous monitoring, feedback, multidisciplinary engagements, and collaborations were identified as critical in the implementation of pharmacist-led antimicrobial stewardship programmes.

CONCLUSIONS

These findings suggest that pharmacists in Sub-Saharan African hospitals can successfully lead antimicrobial stewardship programmes but their implementation is limited by lack of mentorship, accountability, continuous monitoring, feedback, collaborations, and poor funding.

Evaluation of inappropriate antibiotic prescribing and management through pharmacist-led antimicrobial stewardship programmes: a meta-analysis of evidence

Purpose

This meta-analysis aims to evaluate inappropriate antibiotic prescribing in the Gulf region and determine the effect of pharmacist-led antimicrobial stewardship (AMS) programmes on reducing inappropriateness.

Method

Articles were searched, analysed, and quality assessed through the risk of bias (ROB) quality assessment tool to select articles with a low level of bias. In step 1, 515 articles were searched, in step 2, 2360 articles were searched, and ultimately 32 articles were included by critical analysis. Statistical analysis used to determine risk ratio and standard mean differences were calculated using Review manager 5.4; 95% confidence intervals were calculated using the fixed-effect model. The I² statistic assessed heterogeneity. In statistical heterogeneity, subgroup and sensitivity analyses, a random effect model was performed. The α threshold was 0.05. The primary outcome was inappropriateness in antibiotic prescribing in the Gulf region and reduction of inappropriateness through AMS.

Result

Detailed review and analysis of 18 studies of inappropriate antibiotic prescribing in the Gulf region showed the risk of inappropriateness was 43 669/100 846=43.3% (pooled RR 1.31, 95% CI 1.30 to 1.32). Test with overall effect was 58.87; in the second step 28 AMS programmes led by pharmacists showed reduced inappropriateness in AMS with pharmacist versus pre-AMS without pharmacist (RR 0.36, 95% CI 0.32 to 0.39).

Conclusion

Inappropriate antibiotic prescribing in the Gulf region is alarming and needs to be addressed through pharmacist-led AMS programmes.

Effects of Regulation on Carbapenem Prescription in a Large Teaching Hospital in China: An Interrupted Time Series Analysis, 2016-2018

Purpose

Carbapenem resistance due to the overuse of carbapenems has become a public health problem worldwide, particularly in low- and middle-income countries (LMICs). However, there are few policies guiding carbapenem prescription, and their effectiveness is still unclear. A regulation targeting carbapenem prescription was implemented in March 2017 in China. This study aimed to assess the effects of the regulation for providing evidence on the prudent use of carbapenems.

Patients and Methods

This was an interventional, retrospective study started in January 2017. The intervention covered establishing performance appraisal indicators, special authorisation, strict prescribing restrictions, and dedicated supervision, particularly in the intensive care unit (ICU). Data on adult inpatients who received at least one carbapenems were extracted from January 2016 to December 2018. Segmented regression analysis was performed to evaluate the effect of the regulation.

Results

A total of 2005 inpatients received carbapenems. Segmented regression models showed an immediate decline in the intensity of antibiotic consumption (IAC) of carbapenems (coefficient = −9.65, p < 0.001), particularly imipenem (coefficient = −6.82, p = 0.002), and the antibiotic consumption of carbapenems (coefficient = −133.60, p = 0.003) in the ICU. And there is a decreasing trend in the IAC of meropenem (coefficient = −0.03, p = 0.008) in all departments. Furthermore, the IAC of carbapenems and imipenem (coefficient = −0.36, p = 0.035; coefficient = −0.49, p = 0.025, respectively), and the average length of stay (ALoS) (coefficient = −0.73, p < 0.001) showed downward trends in the ICU.

Conclusion

The intervention effectively reduced the IAC of carbapenems and imipenem, carbapenem consumption and the ALoS in the ICU, and the IAC of meropenem in all departments. The effects of the intervention were significant in the ICU, which indicated an urgent need for stronger regulations focusing on critical departments in the future.

Pharmacist-led education-based antimicrobial stewardship interventions and their effect on antimicrobial use in hospital inpatients: a systematic review and narrative synthesis

BACKGROUND

Antimicrobial stewardship (AMS) programmes optimize antimicrobial use and address antimicrobial resistance. Pharmacists are often key agents of these programmes. The effectiveness of hospital-based AMS interventions when they are led by pharmacists, however, has not previously been reported.

AIM

To evaluate the effectiveness of pharmacist-led AMS interventions in improving antimicrobial use for hospital inpatients.

METHODS

Standard systematic review methods were used. The search strategies and databases used in a previous Cochrane review were applied. Studies that reported pharmacist-led AMS interventions were included. Narrative synthesis was used to report the findings. PRISMA guidelines were followed.

FINDINGS

From 6971 records retrieved and screened, 52 full-text articles were included. Most studies were undertaken in teaching hospitals (N = 45) and many were conducted in North America (N = 27). Most interventions targeted junior or ward physicians and lasted between one and six months. All studies evaluated educational interventions often in combination with other interventions and reported improvements 'in compliance with target AMS practice'. Greater compliance was achieved with multiple interventions. Pharmacist-led interventions reduced the duration of antimicrobial therapy without increasing mortality. No consistency of evidence was achieved in relation to interventions and reduced duration of hospital stay, nor infections due to antimicrobial resistance or occurrence of Clostridium difficile.

CONCLUSION

This is the first systematic review to evaluate the effectiveness of pharmacist-led AMS interventions in hospital inpatients. Education-based interventions were effective in increasing guideline compliance and reducing duration of antimicrobial therapy. Future hospital-based AMS programmes should consider the involvement of pharmacists to deliver and promote AMS interventions and programmes.

Strategies to Improve Antimicrobial Utilization with a Special Focus on Developing Countries

Antimicrobial resistance (AMR) is a high priority across countries as it increases morbidity, mortality and costs. Concerns with AMR have resulted in multiple initiatives internationally, nationally and regionally to enhance appropriate antibiotic utilization across sectors to reduce AMR, with the overuse of antibiotics exacerbated by the COVID-19 pandemic. Effectively tackling AMR is crucial for all countries. Principally a narrative review of ongoing activities across sectors was undertaken to improve antimicrobial use and address issues with vaccines including COVID-19. Point prevalence surveys have been successful in hospitals to identify areas for quality improvement programs, principally centering on antimicrobial stewardship programs. These include reducing prolonged antibiotic use to prevent surgical site infections. Multiple activities centering on education have been successful in reducing inappropriate prescribing and dispensing of antimicrobials in ambulatory care for essentially viral infections such as acute respiratory infections. It is imperative to develop new quality indicators for ambulatory care given current concerns, and instigate programs with clear public health messaging to reduce misinformation, essential for pandemics. Regular access to effective treatments is needed to reduce resistance to treatments for HIV, malaria and tuberculosis. Key stakeholder groups can instigate multiple initiatives to reduce AMR. These need to be followed up.

Pharmacist-Driven Antibiotic Stewardship Program in Febrile Neutropenic Patients: A Single Site Prospective Study in Thailand

The antibiotic stewardship program (ASP) is a necessary part of febrile neutropenia (FN) treatment. Pharmacist-driven ASP is one of the meaningful approaches to improve the appropriateness of antibiotic usage. Our study aimed to determine role of the pharmacist in ASPs for FN patients. We prospectively studied at Thammasat University Hospital between August 2019 and April 2020. Our primary outcome was to compare the appropriate use of target antibiotics between the pharmacist-driven ASP group and the control group. The results showed 90 FN events in 66 patients. The choice of an appropriate antibiotic was significantly higher in the pharmacist-driven ASP group than the control group (88.9% vs. 51.1%, p < 0.001). Furthermore, there was greater appropriateness of the dosage regimen chosen as empirical therapy in the pharmacist-driven ASP group than in the control group (97.8% vs. 88.7%, p = 0.049) and proper duration of target antibiotics in documentation therapy (91.1% vs. 75.6%, p = 0.039). The multivariate analysis showed a pharmacist-driven ASP and infectious diseases consultation had a favorable impact on 30-day infectious diseases-related mortality in chemotherapy-induced FN patients (OR 0.058, 95%CI:0.005–0.655, p = 0.021). Our study demonstrated that pharmacist-driven ASPs could be a great opportunity to improve antibiotic appropriateness in FN patients.

The situation of infection in the elderly in Spain: a multidisciplinary opinion document

Infection in the elderly is a huge issue whose treatment usually has partial and specific approaches. It is, moreover, one of the areas where intervention can have the most success in improving the quality of life of older patients. In an attempt to give the widest possible focus to this issue, the Health Sciences Foundation has convened experts from different areas to produce this position paper on Infection in the Elderly, so as to compare the opinions of expert doctors and nurses, pharmacists, journalists, representatives of elderly associations and concluding with the ethical aspects raised by the issue. The format is that of discussion of a series of pre-formulated questions that were discussed by all those present. We begin by discussing the concept of the elderly, the reasons for their predisposition to infection, the most frequent infections and their causes, and the workload and economic burden they place on society. We also considered whether we had the data to estimate the proportion of these infections that could be reduced by specific programmes, including vaccination programmes. In this context, the limited presence of this issue in the media, the position of scientific societies and patient associations on the issue and the ethical aspects raised by all this were discussed.

Self-perceived competence and training needs analysis on antimicrobial stewardship among government ward pharmacists in Malaysia

Background

There is a paucity of data on pharmacists' competency and learning needs in antimicrobial stewardship (AMS).

Objectives

To identify and prioritize learning needs based on self-perceived competence of ward pharmacists in AMS, to identify predictors of self-perceived competence, learning methods in AMS and perceived barriers to learning.

Methods

A cross-sectional survey involving ward pharmacists from Hospital Canselor Tuanku Muhriz (HCTM) and hospitals under the Ministry of Health was conducted from May to July 2018.

Results

A total of 553 ward pharmacists from 67 hospitals responded to this survey (71.3% response rate). Knowledge of infections, antimicrobials and AMS systems, confidence to advise on various issues relating to antimicrobial therapy and participation in clinical audit and evaluation were among the learning needs identified (median score 3.00). Meanwhile, knowledge on the epidemiology of infections, off-label use of antimicrobials and pharmacoeconomics relating to antimicrobials had lower median scores (2.00) and were thus prioritized as high learning needs. Significant predictors of self-perceived competence in AMS were: gender (P < 0.001); prior specific training in infections and AMS (P < 0.001); postgraduate degree (P < 0.001); practising in the area of infectious disease (P < 0.05); and years of working experience as a ward pharmacist (P < 0.005). Continuing medical education, seminars, courses and workshops were the most common (78.1%) and preferred (84.6%) learning methods in AMS. Lack of appropriate training (67.8%), time (44.5%) and funding (42.5%) topped the list of barriers to learning in AMS.

Conclusions

Findings in this study suggest the need to establish and intensify standardized training in AMS among government ward pharmacists.

Who listens and who doesn't? Factors associated with adherence to antibiotic stewardship intervention in a Singaporean tertiary hospital

INTRODUCTION

Antibiotic stewardship programmes (ASPs) can improve patient outcomes by prospective audit and feedback with interventions. However, adherence to ASP interventions is not mandatory. Identifying factors associated with improved adherence may help to enhance ASP recommendations and activities.

METHODS

A retrospective cohort study was conducted, comprising all ASP interventions performed as part of the prospective audit and feedback strategy in our institution (an acute tertiary-care hospital in Singapore) from January 2016 to July 2018. Adherence to ASP intervention was ascertained based on documented compliance with the recommended interventions within 48h. Factors associated with adherence to ASP interventions, such as patient demographics, clinical condition, type of infection, and characteristics of ASP interventions were identified using the χ² test for categorical variables. On multivariate analysis, factors independently associated with adherence to ASP intervention were identified using logistic regression.

RESULTS

Adherence to ASP intervention was 81.9% (5758/7028). On univariate and multivariate analysis, interventions coupled with direct communication via phone call (adjusted odds ratio [aOR] 1.61, 95% CI 1.23-2.08) were associated with higher odds of adherence, whereas admission to a surgical unit, intervention involving carbapenem use, and recommendation to de-escalate or discontinue antibiotics were associated with lower odds of adherence to ASP interventions.

CONCLUSION

Although adherence rates to ASP interventions were relatively high, interventions made to the surgical unit and recommendations related to carbapenem use were not so well received. Interventions communicated verbally via phone call were well received, highlighting the need for a close working relationship between ASP teams and hospital physicians.

Antibiotic de-escalation on internal medicine services with rounding pharmacists compared to services without

Background Antimicrobial stewardship programs ensure antibiotic therapy is used appropriately and includes de-escalation when clinical status or culture data indicates broad-spectrum agents are no longer needed. Although the impact of infectious diseases clinical pharmacists has been well documented, there is limited research evaluating the impact of adult internal medicine clinical pharmacists on broad-spectrum antibiotic de-escalation while rounding on internal medicine teams. Objective To determine if broad-spectrum antibiotics were de-escalated more regularly and more rapidly in patients on internal medicine services with a rounding pharmacist at the bedside compared to internal medicine services without rounding pharmacists. Setting A single 700 bed academic medical center in the United States of America. Method This was a prospective observational cohort chart review. Main outcome measure The primary endpoint was appropriate broad-spectrum antibiotic de-escalation within 72 h or upon return of culture results. Result A total of 64 patients were included in this study with 39 in the pharmacist group and 25 in the no pharmacist group. De-escalation occurred in 35/39 patients on services with pharmacists and in 13/25 patients on services without pharmacists (p = 0.001). In terms of mean days of broad-spectrum antibiotic therapy, services with rounding pharmacists saw patients on Methicillin-resistant Staphylococcus aureus coverage for an average of 2.12 days of their duration of therapy compared to 2.8 days in those without pharmacists (p = 0.821). Services with rounding pharmacists saw patients on Pseudomonas aeruginosa coverage for 2 days of their length of stay compared to 3 days in those without pharmacists (0.398). Conclusion This data shows that broad-spectrum antibiotics were de-escalated more frequently on medicine services with rounding pharmacists compared to services without pharmacists.

The Clinical Pharmacist-Led Consultation for Infectious Diseases in Guizhou Province, China: A Survey Among Hospital Pharmacies

BACKGROUND

As antimicrobial resistance became an increasing threat to global public health, Clinical Pharmacist-led Consultation (CPC) for Infectious Diseases (ID) was developed in China. We conducted a survey among hospital pharmacies to investigate the present situation and potential determinants of CPC for ID in China's Guizhou Province.

METHODS

The study was conducted by sending the questionnaire to the directors of hospital pharmacy who were members of Guizhou Province Pharmaceutical Administration Collaboration Network (GPPACN) from April to May 2019. We implemented the Firth's logistic regression model to analyze the factors that influence the implementation of CPC. The acceptance rate of consultation suggestions (ARCS) and effective response rate after acceptance of pharmacists' suggestions (ERRAPS) were pooled by meta-analysis using a random effect model, respectively. A pairwise meta-analysis was performed to compare the effective response rate between patients whose treatment followed the pharmacists' suggestions and those whose treatment did not.

RESULTS

A total of 83 hospitals covering 9 regions in Guizhou Province were included in this survey. The results showed that 50 hospitals (60.24%) developed the CPC for ID. Staffing ID, respiratory, or general clinical pharmacist had a significantly positive effect on the implementation of CPC [adjusted odds ratios = 7.298, 95% CI (confidence interval): 2.232 to 23.858]. The pooled ARCS and ERRAPS for secondary hospitals were 97.59% (95% CI: 94.27 to 100.00%) and 88.36% (95% CI: 84.71 to 92.17%), respectively. Importantly, CPC improved the prognosis of ID patients [risk ratio (RR) = 6.49, 95% CI: 2.84 to 14.82] in these hospitals.

CONCLUSION

CPC adoption is gradually increasing among hospitals and will be a promising intervention for ID treatment at grassroots medical institutions in Guizhou Province. Training more clinical pharmacists to specialize in ID, respiratory, or general diseases might be the most practical measure to promote the development of CPC for ID.

Redundant combinations of antianaerobic antimicrobials: impact of pharmacist-based prospective audit and feedback and prescription characteristics

This study aimed to evaluate the impact of the intervention targeting the redundant combination of antianaerobic antimicrobials on its incidence and associated antimicrobial consumption. To reveal the characteristics of the combination and the change in the related workload over time was an additional aim of the study. The combinations of metronidazole or clindamycin with antianaerobic antimicrobials were classified into redundant or acceptable, according to the target indications. A pharmacist-based prospective audit and feedback targeting the redundant antianaerobic combination was conducted. Segmented regression analysis was performed to evaluate the impact of the intervention. As a quantitative index of the interventional activity, the change in the number of signed consultation notes was evaluated. After the initiation of the intervention, the median monthly cumulative incidence of the redundant combination decreased from 5.29 (Interquartile range [IQR] 4.94-5.70) to 3.33 (IQR 2.87-3.71) (p < 0.001) per 1000 admissions per month. The consumption of concurrently administered metronidazole and clindamycin decreased from 3.34 (IQR 2.97-4.10) to 1.74 (IQR 1.19-1.93) (p < 0.001) per 1000 patient-days per month. Segmented regression analysis revealed that the monthly cumulative incidence decreased by 28.5% after the initiation of the intervention (change in level - 1.640, p = 0.019) and the monthly consumption decreased by 33.9% (change in level - 1.409, p = 0.009). The number of consultation notes per 1000 admissions per month decreased over time (regression coefficient - 0.004, p < 0.001). The pharmacist-based intervention significantly reduced the incidence and associated antimicrobial consumption of the redundant antianaerobic combination. The overall related workload reduced steadily over time.

Evaluation of the Effectiveness of Clinical Pharmacists' Consultation in the Treatment of Infectious Diseases: A Single-Arm, Prospective Cohort Study

Background: With the implementation of Antimicrobial Stewardship Program, clinical pharmacists’ consultation (CPC) for infectious diseases (ID) is gradually adopted by many hospitals in China. We conducted a cohort study to evaluate the effectiveness of CPC in ID treatment on patient outcomes and potential determinants.

Methods: Based on a registry database, a prospective cohort study was conducted in Guizhou Provincial People’s Hospital. The main exposure factor was whether clinician adopted the suggestion from clinical pharmacist. The outcome was effective response rate (ERR) of ID patients. The variables associated with the outcome (e.g., age, gender, severity of infection, liver function, and kidney function) were also prospectively recorded. A multilevel model was performed to analyze the factors related to ERR.

Results: A total of 733 ID inpatients were included in the final analysis according to the predesigned inclusion and exclusion criteria. The proportion of clinical pharmacists’ suggestions adopted by clinicians and ERR were 88.13 and 69.03%, respectively. Significant data aggregation (P < 0.05) for individuals at the level of department was observed. According to the two-level variance component model, liver dysfunction (Adjusted Odds Ratio (AOR) = 0.649, 95%Credible Interval (CI): 0.432–0.976), severity of infection (AOR = 0.602, 95%CI: 0.464–0.781), and adopting the suggestion from pharmacist (AOR = 1.738, 95%CI: 1.028–2.940) had significant association with ERR.

Conclusion: Our study suggests that the effect of CPC on ID treatment is significant. The policy/decision makers or hospital managers should be cognizant of the critical value of clinical pharmacists in ID treatment.

Efficacy of a Postprescription Review of Broad-Spectrum Antimicrobial Agents With Feedback: A 4-Year Experience of Antimicrobial Stewardship at a Tertiary Care Center

Background

An inpatient antimicrobial stewardship program is vital for judicious antimicrobial use. We began a hospital-wide, postprescription review with feedback (PPRF) in 2014; the present study evaluated its impact on antimicrobial consumption and clinical outcomes over 4 years.

Methods

Once-weekly PPRF for carbapenems and piperacillin/tazobactam was implemented. We tracked the data on each antimicrobial use as days of therapy (DOT) per 1000 patient-days (PD). Changes in the incidence of drug-resistant organisms, in-hospital mortality, and length of hospital stay per month were analyzed by an interrupted time series.

Results

Carbapenem use continued to decline in the preintervention and intervention periods (−0.73 and −0.003 DOT/1000 PD, respectively), and although monthly average use remained low in the intervention period (8.3 DOT/1000 PD), more importantly, the postintervention change in the slope diminished significantly. Piperacillin/tazobactam use showed a steeper decline in the intervention period, but the change in the slope was not statistically significant (change in slope: −0.20 DOT/1000 PD per month [P = .16]). Postintervention use of narrower-spectrum antimicrobials including ampicillin/sulbactam (change in slope: +0.58 DOT/1000 PD per month [P < .001]) increased. 

The antimicrobial cost and the monthly average length of hospital stay also declined (−37.4 USD/1000 PD per month [P < .001] and −0.04 days per month [P < .001], respectively), whereas few postintervention changes in the incidence of drug-resistant organisms were observed.

Conclusions

In our study, the 4-year PPRF for broad-spectrum antimicrobials coincided with a reduction in the use of targeted antimicrobials and resulted in an improvement in 1 patient-centered outcome, thus conferring the additional benefit of reducing expenditures for antimicrobials.

A survey on antimicrobial stewardship in 116 tertiary hospitals in China

OBJECTIVES

We aimed to assess the status and possible problems of antimicrobial stewardship (AMS) in Grade-A tertiary hospitals in China.

METHODS

A questionnaire was designed according to the United States Centers for Disease Control and Prevention 'Core Elements of Hospital Antibiotic Stewardship Programs'. We extracted 10-15% from Grade A tertiary hospitals in every province of mainland China; 165 hospitals in total were selected. Electronic questionnaires were forwarded to these hospitals.

RESULTS

Of the hospitals surveyed, 116 (70.3%) responded. Participating hospitals accounted for 8.9% (116/1308) of all the Grade A tertiary hospitals in mainland China, covering all provinces and municipalities. Our study revealed that an AMS team was set up for an antimicrobial stewardship programme (ASP) in 110 hospitals (94.8%). Thirty hospitals lacked a formal department of infectious diseases (DID). A formal DID can positively promote an ASP. More hospitals with a formal DID developed their internal guidelines (54.7% versus 33.3%, p 0.044) and technical documents (83.7% versus 63.3%, p 0.019) on antimicrobial use than hospitals without a formal DID. All the 116 hospitals strengthened appropriate use of antimicrobials by some administration-dominated measures, among which the most frequent measures were classification management of antimicrobial agents (114 hospitals, 98.3%) and post-prescription review with feedback (106 hospitals, 91.4%). Prescription preauthorization and pre-prescription review with feedback were implemented in nearly 50% of the hospitals. More hospitals with a DID conducted pre-prescription review with feedback (53.5% versus 26.7%, p 0.027). The most frequent indicator to assess the impact of AMS was the defined daily dose (DDD) (103 hospitals, 96.3%).

CONCLUSIONS

The survey showed significant achievements in China in AMS, mainly including the antibiotic consumption index; there is still a lot of work to be done, such as how to evaluate patient safety and infection outcome after strict restriction of antibiotic use.

Antimicrobial stewardship for acute-care hospitals: An Asian perspective

Inappropriate use of antibiotics is contributing to a serious antimicrobial resistance problem in Asian hospitals. Despite resource constraints in the region, all Asian hospitals should implement antimicrobial stewardship (AMS) programs to optimize antibiotic treatment, improve patient outcomes, and minimize antimicrobial resistance. This document describes a consensus statement from a panel of regional experts to help multidisciplinary AMS teams design programs that suit the needs and resources of their hospitals. In general, AMS teams must decide on appropriate interventions (eg, prospective audit and/or formulary restriction) for their hospital, focusing on the most misused antibiotics and problematic multidrug-resistant organisms. This focus is likely to include carbapenem use with the goal to reduce carbapenem-resistant gram-negative bacteria. Rather than initially trying to introduce a comprehensive, hospital-wide AMS program, it would be practical to begin by pilot testing a simple program based on 1 achievable core intervention for the hospital. AMS team members must work together to determine the most suitable AMS interventions to implement in their hospitals and how best to put them into practice. Continuous monitoring and feedback of outcomes to the AMS teams, hospital administration, and prescribers will enhance sustainability of the AMS programs.

Modeling a Production Function to Evaluate the Effect of Medical Staffing on Antimicrobial Stewardship Performance in China, 2009-2016: Static and Dynamic Panel Data Analyses

Background: Antimicrobial resistance (AMR) is an international problem. Emergence and spread of AMR are strongly associated with overuse or inappropriate use of antimicrobials. Antimicrobial stewardship ensures the appropriate use of antimicrobials, and is an effective approach to control AMR. This study aims to understand the relationship between medical staffing and antimicrobial stewardship performance in China. Methods: A provincial-level panel dataset from 2009 to 2016 is used. A macro production function is used to quantify the relationship. The output, antimicrobial stewardship performance, is measured by changes in methicillin resistance rates of Staphylococcus. aureus (S. aureus) and coagulase-negative staphylococci (CoNS). The labor input is measured by the numbers of infectious diseases physicians, pharmacists, clinical microbiologists, and nurses in hospitals per 100,000 populations, whereas the capital input is represented by the number of hospital beds per 100,000 populations. The technology is captured by the time index. Both static and dynamic panel data approaches are employed. Results: The increasing number of clinical microbiologists is a significant predictor of lower resistance of CoNS according to dynamic models (Coef. = -0.191, -0.351; p = 0.070, 0.004, respectively). However, a larger number of nurses is significantly associated with higher resistance of S. aureus (Coef. = 0.648; p = 0.044). In addition, the numbers of the other two groups of medical professionals exhibit no significant associations with stewardship performance. Conclusions: The study demonstrates the crucial role of clinical microbiologists in antimicrobial stewardship. The predicted increased risk of resistance with the higher number of nurses may be attributable to their lack of related knowledge and their unrecognized functions in antimicrobial stewardship.

A current perspective on antimicrobial resistance in Southeast Asia

Southeast Asia, a vibrant region that has recently undergone unprecedented economic development, is regarded as a global hotspot for the emergence and spread of antimicrobial resistance (AMR). Understanding AMR in Southeast Asia is crucial for assessing how to control AMR on an international scale. Here we (i) describe the current AMR situation in Southeast Asia, (ii) explore the mechanisms that make Southeast Asia a focal region for the emergence of AMR, and (iii) propose ways in which Southeast Asia could contribute to a global solution.