Antimicrobial stewardship in a Gastroenterology Department: Impact on antimicrobial consumption, antimicrobial resistance and clinical outcome

The role of antimicrobial stewardship in preventing KPC-producing Klebsiella pneumoniae

Antimicrobial stewardship programmes are widely considered to be a core component of the response to the antimicrobial resistance threat. However, a positive impact of these interventions in terms of microbiological outcomes remains difficult to demonstrate, especially when focusing on specific resistant phenotypes. The first part of this review aims to explore the complex relationship between antibiotic exposure and resistance development in KPC-producing Klebsiella pneumoniae. In the second part we aim to summarize published examples of antimicrobial stewardship interventions intended to impact on the epidemiology of KPC-producing K. pneumoniae. For this purpose, a literature search was performed and seven studies were included in the review. Both restrictive and non-restrictive interventions were associated with an overall reduction in antibiotic consumption, and a decrease in carbapenem resistance rates was observed in five studies. The overall quality of the evidence was low, mainly due to the poor reporting of microbiological outcomes, lack of a control group and suboptimal study design. Although the link between antibiotic use and resistance development is supported by strong evidence, demonstrating the impact of antimicrobial stewardship interventions on microbiological outcomes remains difficult. Studies with adequate design and appropriate outcome measures are needed to further promote antimicrobial stewardship and elucidate which interventions are more successful for controlling the spread of KPC-producing K. pneumoniae.

Review of antimicrobial resistance control strategies: low impact of prospective audit with feedback on bacterial antibiotic resistance within hospital settings

BACKGROUND

Antimicrobial stewardship constitutes an essential element of any concerted effort to tackle bacterial resistance, a rising public health threat both in community as well as hospital settings. The term comprises variable strategies which aim to optimise prescribing practices through either antibiotic restrictions or prospective audits of prescriptions with subsequent feedback to clinicians. Although highly debated, the actual effects of the latter on the antimicrobial susceptibility patterns of hospital flora are uncertain. The present study aims to review and evaluate the literature concerning the impact of persuasive stewardship strategies on antimicrobial resistance within hospitals.

MATERIALS AND METHODS

A literature review covering the period to 1st April 2020 was conducted using the PubMed/Medline, Embase, Global Health and CINAHL Plus databases.

RESULTS

Fifteen studies were retrieved, including twelve simple before-and-after, and three interrupted time-series studies. Audit frequency and compliance rates varied broadly. The rationale of treatment optimisation is not clear in most cases. Overall, surveillance of sentinel microorganisms through antibiograms indicates ambiguous results, with uncertainty as to whether the few successes are due to a causal effect, random incidence fluctuations, or confounding. The most informative approach targeted solely fluoroquinolones, reporting improvements in relevant Pseudomonas susceptibilities and MRSA, but without sufficient data on other effects of the strategy to assess its overall utility in clinical practice.

CONCLUSION

Higher standard research is needed to address the actual effects of persuasive stewardship strategies on antimicrobial susceptibility patterns. At present, they seem inadequate to play a decisive role in bacterial resistance control within hospitals.

Impact of a Multifaceted Pharmacist-Led Intervention on Antimicrobial Stewardship in a Gastroenterology Ward: A Segmented Regression Analysis

BACKGROUND

Irrational use of antimicrobial agents for gastrointestinal diseases deserves attention, but corresponding antimicrobial stewardship programs (ASPs) are generally not a priority for managers. We conducted this study to evaluate the effectiveness of multifaceted pharmacist-led (MPL) interventions in the gastroenterology ward (GW) to provide evidence for the efficacy of ASPs in a non-priority department.

METHODS

This was an interventional, retrospective study implemented in China. The MPL intervention lasting 1.5 years involved daily ward rounds with physicians, regular review of medical orders, monthly indicator feedback, frequent physician training, and necessary patient education. Data on all hospitalized adults receiving antibiotics was extracted from the hospital information system over a 36-month period from January 2016 to December 2018. Segmented regression analysis of interrupted time series was performed to evaluate the effect of the MPL interventions (started in July 2017) on antibiotic use and length of hospital stay, which was calculated monthly as analytical units.

RESULTS

A total of 1763 patients receiving antibiotics were enrolled. Segmented regression models showed descending trends from the baseline in the intensity of antibiotic consumption (coefficient = -0.88, p = 0.01), including a significant decline in the level of change of the proportion of patients receiving combined antibiotics (coefficient = -9.91, p = 0.03) and average length of hospital stay (coefficient = -1.79, p = 0.00), after MPL interventions. The MPL interventions led to a temporary increase in the proportion of patients receiving antibiotics (coefficient = 4.95, p = 0.038), but this was part of a declining secular trend (coefficient = -0.45, p = 0.05).

CONCLUSION

The MPL interventions led a statistically significant decline in the number of patients receiving antibiotics, the antibiotic consumption, and the average hospital stay post-intervention compared to the pre-intervention phase of the study. Health policymakers should actively practice MPL interventions by clinical pharmacists in ASPs in those departments that are not included in priority management.

Hospital Antibiotic Stewardship Programs - Qualitative analysis of numerous hospitals in a developing country

Antimicrobial stewardship programs (ASP) are an essential practice to prevent increasing resistance against antibiotics. A successful ASP monitors not only prescribing patterns and practices but also contributes in minimizing the toxic effects of antibiotics. Moreover, ASP also facilitates the selection of disease specific antibiotics and enforces rules and regulations to rationalize the use of antibiotics. The aim of the study is to highlight the core elements of Hospital Antibiotic Stewardship Programs in Karachi. The key elements proposed by center of disease control (CDC) such as; leadership, accountability, drug expertise, actions to support optimal antibiotic use, tracking (monitoring antibiotic prescribing, use and resistance), reporting information to staff on improving antibiotic use and resistance and education were evaluated on Yes/No scale. The data was collected from 44 hospitals of different categories in Karachi and all the major elements were studied. It was observed that all the hospitals in one setting failed to comply with all the guidelines. It has been concluded that efforts should be made to design ASP at each hospital and implemented through suitable policies and procedures.

Spontaneous bacterial peritonitis caused by Gram-negative bacteria: an update of epidemiology and antimicrobial treatments

Introduction: Spontaneous bacterial peritonitis (SBP) is a main infectious complication in end-stage liver disease (ESLD) patients. The increasing trend of bacterial resistance in ESLD patients with SBP has been associated with low treatment efficacy of traditional therapy. Cephalosporin use has been restricted to community-acquired infections and in areas/health care settings with low rates of multidrug-resistant (MDR) bacteria. To date, several changes are necessary with regard to empiric therapy recommendations in areas/health care settings with high rates of MDR bacteria. Areas covered: An overview of the epidemiology and antimicrobial treatments of SBP caused by Gram-negative bacteria. Expert opinion: Broad-spectrum antibiotics have been recommended as empiric therapy for suspected SBP in areas/health care settings with high rates of MDR bacteria and secondary treatment, with newer antibiotics, for SBP caused by MDR-Gram-negative bacteria (i.e. new beta-lactam/beta-lactamase inhibitor combinations, cefiderocol, plazomicin, and eravacycline) either alone or in combination.

Are antimicrobial stewardship programs effective strategies for preventing antibiotic resistance? A systematic review

BACKGROUND

Antimicrobial stewardship programs (ASPs) have been proposed as a solution for the global burden of antibiotic resistance, despite the lack of evidence on the subject.

OBJECTIVE

To analyze the role of ASPs in reducing bacterial resistance to antibiotics in hospital settings.

DATA SOURCES

A review in PubMed, Scopus, LILACS, and SciELO databases was performed. The period analyzed was January 1, 2012-January 4, 2017.

ELIGIBILITY CRITERIA

Studies that related ASPs to bacterial resistance.

DATA EXTRACTION

All studies that did not focus on ASPs were removed. Antifungal and antiviral programs were excluded.

RESULTS

Only 8 studies had quasi-experimental designs, and none were controlled trials. ASP strategies and microorganism-antibiotic pairs evaluated varied widely. Seven studies were classified as presenting clearly positive results, 3 had limited positive results, 7 had doubtful results, 4 had negative results, and 5 had noninterpretable results. The implementation of new infection control practices occurred in 7 studies.

LIMITATIONS

There are yet few studies on this matter, and most of them have inadequate study designs. Great heterogeneity between study features was detrimental to drawing evidence-based conclusions.

CONCLUSIONS

There is no solid evidence that ASPs are effective in reducing antibiotic resistance in hospital settings. We uphold the need for more studies with appropriate study designs, standardized ASP interventions targeting common microorganism-antibiotic pairs, and avoiding simultaneous implementation of infection control practices.