Pharmacist-led multi-faceted intervention in an antimicrobial stewardship programme at a dental university hospital in Japan

Longitudinal impact of a pharmacist-led stepwise antimicrobial stewardship program on intravenous antimicrobial use at a small resource-limited Japanese hospital

BACKGROUND

Clinical pharmacists play a central role in the implementation of antimicrobial stewardship programs (ASP). However, personnel shortages, the lack of a system for career development, and other challenges impede the active contribution of clinical pharmacists to ASPs in Japan.

AIM

To conduct a long-term evaluation of a pharmacist-led antimicrobial stewardship program.

METHODS

The present, retrospective study used segmented time-series analysis to examine antimicrobial consumption, blood culture practices, and the rate of resistance in pathogens to the antimicrobials prescribed.

FINDINGS

After the ASP was introduced, days of therapy (DOT) with anti-pseudomonal agents demonstrated a downward trend (-0.31; 95 % confidence interval [CI]: -0.43 to -0.19; p < 0.01). Moreover, the trend in the number of blood cultures after the intervention significantly increased (0.20; 95 % CI: 0.05 to 0.35; p = 0.01), and the rate of resistance of Pseudomonas aeruginosa to cefepime and piperacillin decreased. No significant change was observed in the DOT trend for total intravenous antimicrobial use before or after the intervention (-1.07; 95 % CI: -2.44 to 0.29; p = 0.12).

CONCLUSION

Although the role of pharmacists in an ASP should continue to be examined, the present, longitudinal study found that stepwise introduction of an ASP reduced broad-spectrum antimicrobial use and was associated with a decrease in the antimicrobial resistance rate of Pseudomonas aeruginosa but not of third-generation cephalosporin-resistant Escherichia coli or MRSA.

Interventions to improve antibiotic use among dentists: a systematic review and meta-analysis

OBJECTIVES

To analyse the effectiveness of various strategies, such as audits, education and digital tools, in reducing inappropriate antibiotic prescription by dentists. This study provides a comprehensive overview of how such interventions can contribute to improving clinical practice and combatting antimicrobial resistance in the dental setting.

METHODS

An electronic search of articles published until 2023 in the following databases was performed: MEDLINE, SCOPUS, EMBASE, COCHRANE CENTRAL, LILACS and BBO. Systematic data synthesis and meta-analysis was carried out. A total of 23 studies regarding interventions to reduce antibiotic prescription among dentists were included. The studies were mostly published in the UK between 1997 and 2023. Of the 23 studies, three were trials and 20 were pre-post studies.

RESULTS

In general, interventions among dentists resulted in a 70% reduction in the inappropriate prescription of antibiotics (95% CI: 33.3% to 86.4%), which is an extremely high percentage. In the pre-post studies, the reduction was 71% (95% CI 28.8%-88.1%) I2 99.2%. In randomized controlled trial studies, a 63.9% (95% CI 41%-78.1%) I2 0% reduction was achieved. The greatest magnitude of effect was found in audit-based interventions with audit and education intervention at 73.3% (95% CI 44%-87.4%) and audit and feedback 75% (95% CI 33%-91.4%), respectively. However, the quality of the evidence is low, mostly due to the study design.

CONCLUSION

Given the magnitude of the effect found, it has been shown that dentists are receptive to improving their prescription of antibiotics. However, it is clear that there is ample room for improvement.

Impact of automated pop-up alerts on simultaneous prescriptions of antimicrobial agents and metal cations

BACKGROUND

Antimicrobial agents (AMAs) are essential for treating infections. A part of AMAs chelate with metal cations (MCs), reducing their blood concentrations. That drug-drug interaction could lead to a reduction of therapeutic efficacy and the emergence of drug-resistant bacteria. However, prescriptions ordering concomitant intake (co-intake) of AMAs and MCs are frequently seen in clinical settings. A method for preventing such prescriptions is urgently needed.

METHODS

We implemented pop-up alerts in the hospital's ordering and pharmacy dispensation support system to notify the prescriptions ordering co-intake of AMAs and MCs for physicians and pharmacists, respectively. To assess the effectiveness of the pop-up alerts, we investigated the number of prescriptions ordering co-intake of AMAs and MCs and the number of pharmacist inquiries to prevent co-intake of AMAs and MCs before and after the implementation of pop-up alerts.

RESULTS

Before the implementation of pop-up alerts, 84.5% of prescriptions containing AMA and MCs ordered co-intake of AMAs and MCs. Implementing pop-up alerts time-dependently reduced the proportion of prescriptions ordering co-intake of AMAs and MCs to 43.8% and 29.5% one year and two years later, respectively. The reduction of tetracycline-containing prescriptions was mainly significant. Before the implementation of pop-up alerts, the proportion of prescriptions in which pharmacists prevented co-intake of AMAs and MCs was 3.4%. Implementing pop-up alerts time-dependently increased proportions of such prescriptions to 20.9% and 28.2% one year and two years later.

CONCLUSION

Implementing pop-up alerts reduced prescriptions ordering co-intake of AMAs and MCs and accelerated pharmacists to prevent co-intake of AMAs and MCs. The implementation of dual pop-up alerts in the hospital's ordering and pharmacy dispensation support system could help prevent co-intake of AMAs and MCs.

Effect of Antimicrobial Stewardship 2018 on severe pneumonia with bacterial infection in paediatric intensive care units

OBJECTIVES

Antimicrobial Stewardship 2018 (ASP 18) in China emphasizes the hierarchical control of antimicrobial drugs and the management of physicians' prescribing authority, especially in children. The purpose of this study was to assess the effect of implementation of ASP 2018 on antibiotic consumption, resistance, and treatment outcomes in children with severe pneumonia from bacterial infections.

METHODS

A single center, retrospective study was conducted on 287 children with severe bacterial pneumonia, including 165 patients before intervention (May 2016-April 2018) and 122 patients after intervention (May 2018-April 2020). The antimicrobial resistance rates, antibiotic consumption, and clinical outcomes of the two periods were compared.

RESULTS

After the implementation of ASP 2018, Staphylococcus aureus (17.9%) became the predominant Gram-positive bacterium. The resistance of Streptococcus pneumoniae to clindamycin, erythromycin, and tetracycline was significantly reduced (P < 0.001), and Staphylococcus aureus to tetracycline also decreased (P = 0.034). In addition, Klebsiella pneumoniae (18.4%) replaced Pseudomonas aeruginosa (9.5%) as the most common Gram-negative bacterium. The resistance rates of Klebsiella pneumoniae to amoxicillin/clavulanic acid (AMC) and trimethoprim/sulfamethoxazole (SXT), and Acinetobacter baumannii to cefotaxime and SXT decreased significantly (P < 0.02). Total consumption (DDD/100 patient-days) of five antibiotics (cephalosporins, carbapenems, macrolides, antifungal agents, and linezolid) showed a decreasing trend, and the decrease in antifungal agents and linezolid was the most significant (27.4% and 25.6%, P < 0.001). The isolation rate of multidrug-resistant (MDR) strains decreased significantly from the highest, 16.8%, before intervention to 6.7% after intervention (P < 0.001).

CONCLUSION

Our data indicate that the implementation of antimicrobial management strategies has significantly reduced the consumption of antibiotics and the occurrence of antimicrobial resistance in children with severe bacterial pneumonia in PICU.