Evaluating the appropriateness of carbapenem and piperacillin-tazobactam prescribing in a tertiary care hospital in Saudi Arabia

Preliminary insights on carbapenem resistance in Enterobacteriaceae in high-income and low-/middle-income countries

The emergence of carbapenem-resistant Enterobacteriaceae in the hospital sector as well as in the natural environment is a problem that affects both high-income countries (HICs) and low-/middle-income countries (LMICs). The observed differences in the prevalence of carbapenem-resistant strains between HICs and LMICs can be attributed mainly to antibiotic consumption in healthcare facilities and the quantity of treated wastewater. Hospital wastewater is a major hotspot for the spread of carbapenem-resistant Enterobacteriaceae (CRE) and carbapenem resistance genes (CRGs) between the hospital sector and the environment. In this review article, attempts were made to describe and compare antibiotic consumption in hospitals, antimicrobial concentrations in both hospital and municipal wastewater, and the prevalence of CRE and CRGs in patients and in hospital and municipal wastewater in HICs and LMICs. A review of the literature has shown that carbapenems are more widely used in LMICs, but Saudi Arabia, an HIC, is a country with the highest carbapenem consumption in the world. The results of research conducted in both groups of countries indicate that Klebsiella sp./K. pneumoniae is the most common CRE in samples isolated from patients. Escherichia coli was the dominant pathogen in hospital and municipal wastewater in HICs, whereas Enterobacter spp. were most prevalent in LMICs. An analysis of the prevalence of CRGs demonstrated that the same genes are present in both groups of countries (blaKPC, blaKPC-2, blaVIM, blaVIM-1,2, blaNDM, blaIMP, blaIMP-8, blaOXA-48,181, blaNDM-1,5, blaGES, blaGES-5,6, blaIMI-1). The fact that the same CRGs are most prevalent in countries with different levels of economic development could suggest that these genes have a high potential to persist in the natural environment. These findings underscore the need for enhanced monitoring, effective control techniques, and a better understanding of carbapenem resistance pathways to mitigate public health hazards, notwithstanding the constraints of data analysis.

Drug Utilization Review of Monitored Parenteral Antimicrobials in a Tertiary Care Private Hospital in Cebu City

Background

Based on the 2017-2020 annual report of the Department of Health-Antimicrobial Resistance Surveillance Program, significant resistance patterns have been observed for common disease-causing pathogens. In the hospital setting, antimicrobial stewardship programs have been implemented to optimize the use of antimicrobials. Drug utilization review studies provide essential feedback to improve prescribing and use of medications.

Objectives

This study aimed to review drug utilization of monitored parenteral antimicrobials among patients admitted from January to December 2019.

Methods

The study employed a retrospective, cross-sectional, descriptive research design. A retrospective chart review of drugs administered to patients was conducted.

Results

A total of 821 patients charts met the inclusion criteria. The patients' ages ranged from 18 to 98 years old and 52% were females. General Internal Medicine practitioners (28%) were the top prescribers of monitored parenteral antimicrobials primarily for the management of moderate-risk community-acquired pneumonia (39%). They were mostly indicated for empirical treatment of infections (94%) and were given for an average of 5.73 days.Only 58% of the total cases had orders for culture and sensitivity testing. Of which, principally 47% had colony cultures. Blood (29%) and sputum (27%) were the most common specimens taken for culture and sensitivity testing. The microorganisms often isolated were Escherichia coli (19%), Klebsiella pneumoniae (18%), and Staphylococcus aureus (9%). In addition, extended-spectrum beta lactamase-producing gram-negative pathogens (4%) and methicillin-resistant S. aureus (1%) were also isolated. All the microorganisms isolated showed most resistance to ampicillin (81%) and most susceptibility to colistin (100%). There were drug therapy-related problems encountered. There was one case of an adverse drug reaction (0.1%) and two cases of contraindications (0.2%). Therapeutic duplication was also observed in 5% of the cases. Moreover, 39% had instances of drug-drug interactions.Piperacillin-tazobactam had the highest consumption (79.50 defined daily doses/1,000-patient days) among the monitored parenteral antimicrobials.Some prescriptions were deemed inappropriate upon evaluation. 12% of cases were inappropriate based on the justification indicator. As for the critical indicators, duration of therapy (78%) was the main reason. Only four components of the DUE criteria indicators have met or exceeded the established threshold level.The cost analysis indicated that the total actual cost of therapy with the monitored parenteral antimicrobials amounted to ₱17,645,601.73. Considering Department of Health National Antibiotic Guidelines recommendations, ideal total cost of treatment was ₱14,917,214.29. Potential cumulative cost savings of ₱2,728,387.44 could have been achieved for patients admitted last 2019.

Conclusion

Consumption of piperacillin-tazobactam was relatively high as compared to the other monitored parenteral antimicrobials covered in this study. Physicians at the study site seldom prescribe monitored parenteral antimicrobials as recommended by the National Antibiotic Guidelines. This is evidenced in the incidence of inappropriate therapy regimens, with inapt duration of therapy as the leading explanation.From the patient's perspective, the main economic implication was on the direct medical costs, particularly the increased cost of the actual antimicrobial therapy prescribed to manage various infections. Adherence of physicians to the established guidelines and selection of the most cost-effective therapy could have resulted in considerable cost savings.

Evaluation of the Appropriateness of Piperacillin-Tazobactam Prescription in Community-Acquired Pneumonia: A Tertiary-Center Experience

Background Antimicrobial resistance (AMR) has been designated a public health crisis by the World Health Organization. AMR can lead to escalated healthcare costs, higher mortality rates, increased morbidity, and more frequent hospitalizations. This study aimed to retrospectively evaluate the appropriateness of Tazocin prescription for community-acquired pneumonia (CAP). Methodology We conducted a retrospective analysis of patients aged ≥18 years who were admitted with a diagnosis of CAP and administered intravenous Tazocin between November 2021 and October 2022. The primary objective was to assess the appropriateness of Tazocin prescriptions in patients with CAP. Results A total of 39 patients with CAP were included, with a mean age of 61 ± 17.36 years. Overall, 24 (61%) patients were male. The rate of inappropriate prescriptions of Tazocin was 66.6%. The incidence of inappropriate Tazocin prescription varied significantly among different medical specialties, with the highest rate observed in the oncology-palliative specialty (90%; p = 0.033). Conclusions Our study affirms the inclination of physicians to prescribe Tazocin for CAP without justifiable indications and highlights the unwarranted use of Tazocin for CAP across various medical specialties. This is evidenced by the notably high rate of inappropriate empirical prescriptions.

Drug Utilization Evaluation and Impact of Pharmacist Interventions on Optimization of Piperacillin/Tazobactam Use: A Retrospective Analysis and Prospective Audit

(1) Background: Piperacillin/tazobactam is a broad-spectrum antimicrobial encompassing most Gram-positive and Gram-negative aerobic and anaerobic bacteria. The inappropriate use of such broad-spectrum antibiotics is an important contributor to the rising rates of antimicrobial drug resistance worldwide. Drug utilization evaluation studies and pharmacists' interventions are vital to assess, develop, and promote the rational use of antibiotics. This drug utilization study aimed to evaluate the current utilization practice of piperacillin/tazobactam in a hospital setting and assess the impact of pharmacist intervention in improving its appropriate use. (2) Methodology: In this study, we used a retrospective cohort and a prospective cohort, a cross-sectional, observational method. It included a retrospective (Cycle A/pre-intervention-CycA) phase followed by an educational interventional phase conducted by the pharmacists. During the 2 months of educational intervention, pharmacists used several methods, including workshops, lectures, oral presentations, and the development and reinforcement of clinical pathways to promote the judicious use of piperacillin/tazobactam. This was followed by a prospective (Cycle B/post-intervention-CycB) phase to improve piperacillin/tazobactam usage appropriateness. The appropriateness criteria for this drug utilization evaluation were established based on antimicrobial guidelines, the published literature, the institutional antibiogram, consultation from the antimicrobial stewardship committee, and the product monograph (Tazocin). The appropriateness of CycA and CycB patients was compared using the measurable elements, including indication and dose based on renal function, timely order for cultures, de-escalation, and use of extended infusion protocol. (3) Results: The study population comprised 100 patients in both CycA and CycB. The mean age of the patients was 66.28 ± 16.15 and 67.35 ± 17.98, and the ratios of men to women were found to be 49:51 and 61:39 in CycA and CycB, respectively. It was observed that inappropriate usage was high in CycA patients, and the appropriateness was improved in CycB patients. A total of 31% of inappropriate empirical broad-spectrum use was found in CycA, and it was reduced to 12% in CycB patients. The transition of appropriateness was observed in all measurable criteria, which includes the optimized dose according to the renal function (CycA = 49% to CycB = 94%), timely bacterial culture orders (CycA = 47% to CycB = 74%), prompt de-escalation (CycA = 31% to CycB = 53%), and adherence to extended infusion institutional guidelines (CycA = 34% to CycB = 86%). (4) Conclusions: The study highlighted important aspects of inappropriate piperacillin/tazobactam use. This can be considerably improved by proper education and timely interventions based on the pharmacists' vigilant approach. The study results emphasized the need for surveillance of piperacillin/tazobactam usage by conducting similar drug utilization evaluations and practice to improve quality and safety in healthcare organizations globally.

Extended Spectrum- and Carbapenemase-Based β-Lactam Resistance in the Arabian Peninsula-A Descriptive Review of Recent Years

Antimicrobial resistance (AMR) is a global problem that also includes countries of the Arabian Peninsula. Of particular concern, is the continuing development of extended-spectrum β-lactamases (ESBLs) in the countries of this region. Additionally, antibiotic treatment options for ESBL-producing bacteria are becoming limited, primarily due to the continuing development of carbapenem resistance (CR), carbapenems being frequently used to treat such infections. An overview of recent publications (2018-2021) indicates the presence of ESBL and/or CR in patients and hospitals in most countries of the Arabian Peninsula, although the delay between microbial isolation and publication inevitably makes an accurate analysis of the current situation rather difficult. However, there appears to be greater emphasis on CR (including combined ESBL and CR) in recent publications. Furthermore, although publications from Saudi Arabia are the most prevalent, this may simply reflect the increased interest in ESBL and CR within the country. Enhanced ESBL/CR surveillance is recommended for all countries in the Arabian Peninsula.

Antimicrobial therapy, resistance, and appropriateness in healthcare-associated and community-associated infections; a point prevalence survey

BACKGROUND

Data examining differences in antimicrobial therapy and its appropriateness between healthcare-associated infections (HAIs) and community-associated infections (CAIs) are limited. The objective was to compare antimicrobial therapy, resistance, and appropriateness between CAIs and HAIs.

METHODS

One-day point prevalence survey targeting admitted patients with active infections was conducted in six tertiary care hospitals. Antimicrobial appropriateness was decided based on hospital antimicrobial guidelines, clinical assessment, culture results, and other relevant investigations.

RESULTS

Out of 1666 patient records reviewed, 240 (14.4%) infection events were identified. Prevalence of infections treated with antimicrobials were 6.5% for HAIs and 7.1% for CAIs. The most commonly prescribed antimicrobials were carbapenems (19.6%), cephalosporins (14.8%), and vancomycin (13.2%), with some differences between HAIs and CAIs. The overall contribution of MDR pathogens to both HAIs and CAIs was similar (34.0% versus 34.3%, p = 0.969). ESBL was significantly associated with CAIs while other gram-negative MDR pathogens significantly associated with HAIs. Overall appropriateness of antimicrobial therapy was similar in HAI and CAI events (64.2% versus 64.7%, p = 0.934). However, it was highest in aminoglycosides (78.6%) and lowest in vancomycin (40.8%). It was lowest in bloodstream infections than other infections (48.5% versus 61% to 78%, p = 0.044).

CONCLUSION

Although the overall burden of MDR pathogens and appropriateness of antimicrobial therapy were similar in HAI and CAI events, there were some differences related to the type of MDR, type of antimicrobials, and type of infection. The current finding can guide training and educational activities of local antimicrobial stewardship initiatives aiming to improve antimicrobial therapy in hospital setting.

ESBL Activity, MDR, and Carbapenem Resistance among Predominant Enterobacterales Isolated in 2019

Antimicrobial-resistance in Enterobacterales is a serious concern in Saudi Arabia. The present study retrospectively analyzed the antibiograms of Enterobacterales identified from 1 January 2019 to 31 December 2019 from a referral hospital in the Aljouf region of Saudi Arabia. The revised document of the Centers for Disease Control (CDC) CR-2015 and Magiorakos et al.'s document were used to define carbapenem resistance and classify resistant bacteria, respectively. The association of carbapenem resistance, MDR, and ESBL with various sociodemographic characteristics was assessed by the chi-square test and odds ratios. In total, 617 Enterobacterales were identified. The predominant (n = 533 (86.4%)) isolates consisted of 232 (37.6%), 200 (32.4%), and 101 (16.4%) Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis, respectively. In general, 432 (81.0%) and 128 (24.0%) isolates were of MDR and ESBL, respectively. The MDR strains were recovered in higher frequency from intensive care units (OR = 3.24 (1.78-5.91); p < 0.01). E. coli and K. pneumoniae resistance rates to imipenem (2.55 (1.21-5.37); p < 0.01) and meropenem (2.18 (1.01-4.67); p < 0.04), respectively, were significantly higher in winter. The data emphasize that MDR isolates among Enterobacterales are highly prevalent. The studied Enterobacterales exhibited seasonal variation in antimicrobial resistance rates towards carbapenems and ESBL activity.

Antimicrobial susceptibility of gram-positive and gram-negative bacteria: a 5-year retrospective analysis at a multi-hospital healthcare system in Saudi Arabia

BACKGROUND

Studying time-related changes in susceptible pathogens causing healthcare-associated infections (HAIs) is vital in improving local antimicrobial and infection control practices.

OBJECTIVES

Describe susceptibility patterns to several antimicrobials in gram-positive and gram-negative pathogens isolated from patients causing HAIs at three private tertiary care hospitals in Saudi Arabia over a 5-year period.

METHODS

Data on trends of antimicrobial susceptibility among bacteria causing HAIs events in children and adults at three tertiary private hospitals located in Riyadh and Qassim, Saudi Arabia, were collected retrospectively between 2015 and 2019 using the surveillance data datasets.

RESULTS

Over a 5-year period, 38,624 pathogens caused 17,539 HAI events in 17,566 patients. About 9450 (53.8%) of patients who suffered HAIs were females and the average age was 41.7 ± 14.3 years (78.1% were adults and 21.9% were children). Gram-negative pathogens were 2.3-times more likely to cause HAIs compared to gram-positive bacteria (71.9% vs. 28.1%). The ranking of causative pathogens in decreasing order was: Escherichia coli (38%), Klebsiella species (15.1%), and Staphylococcus aureus (12.6%). Gram-positive isolates were mostly susceptible to linezolid (91.8%) whereas they were resistant to ampicillin (52.6%), cefoxitin (54.2%), and doxycycline (55.9%). Gram-negative isolates were mostly sensitive to tigecycline (95%) whereas they were resistant to cefotaxime (49.5%) and cefixime (59.6%). During the 5 years, there were relatively stable susceptibility patterns to all tested antimicrobials, except for cefotaxime which shown a susceptibility reduction by 41.4%, among Escherichia coli and Klebsiella species. An increase in the susceptibility of Acinetobacter and Enterobacter and Citrobacter species to all studied antimicrobials was observed except for colistin that had a slight sensitivity reduction in 2019 by 4.3% against Acinetobacter species. However, we noted reduced sensitivity of MRSA, CoNS and Enterococcus species to gentamicin; and increased resistance of MRSA to linezolid and vancomycin.

CONCLUSION

The observed increase in susceptibility of gram-positive and gram-negative bacteria to studied antimicrobials is important; however, reduced sensitivity of MRSA, CoNS and Enterococcus species to gentamicin; and increased resistance of MRSA to linezolid and vancomycin is a serious threat and calls for effective antimicrobial stewardship programs.

Exploring Physicians' Views, Perceptions and Experiences about Broad-Spectrum Antimicrobial Prescribing in a Tertiary Care Hospital Riyadh, Saudi Arabia: A Qualitative Approach

Antimicrobial resistance (AMR) is a global public health threat associated with increased mortality, morbidity and costs. Inappropriate antimicrobial prescribing, particularly of broad-spectrums antimicrobials (BSAs), is considered a major factor behind growing AMR. The aim of this study was to explore physician perception and views about BSAs and factors that impact upon their BSAs prescribing decisions. Qualitative semistructured telephone interviews over an eleven-week period were conducted with physicians in a single tertiary care hospital in Riyadh, Saudi Arabia. Purposeful and snowball sampling techniques were adopted as sampling strategy. All interviews were audio recorded, transcribed verbatim, uploaded to NVivo^® software and analysed following thematic analysis approach. Four major themes emerged: views on BSAs, factors influencing BSA prescribing and antimicrobial stewardship: practices and barriers and recommendations to improve appropriate BSA prescribing. Recommendations for the future include improving clinical knowledge, feedback on prescribing, multidisciplinary team decision-making and local guideline implementation. Identification of views and determinants of BSA prescribing can guide the design of a multifaceted intervention to support physicians and policymakers to improve antimicrobial prescribing practices.

Antibiotic dosing adjustments in hospitalized patients with chronic kidney disease: a retrospective chart review

BACKGROUND

Infections in patients with chronic kidney disease (CKD) are a major cause of hospitalization. The pharmacokinetics of renally eliminated antibiotics may lead to drug accumulation, resulting in potential toxicity. The renal dosing adjustment of antibiotics is crucial to avoid toxicity and decrease mortality. In Lebanon, limited data are available on antibiotic dose adequacy in CKD.

OBJECTIVES

To estimate the prevalence of inappropriately dosed antibiotics in non-dialysis CKD patients and to identify possible risk factors that may be associated with unadjusted renal dosing.

METHODS

A retrospective chart review was conducted at two tertiary-care hospitals in Lebanon. International Statistical Classification of Diseases (ICD-10) code for CKD was used to search the databases. Demographic and clinical data were collected for patients who received antibiotics that requires renal dosing adjustment. Lexi-Comp online Drug Information database was the guideline used to evaluate the appropriateness of dosing.

RESULTS

A total of 495 antibiotic orders were dispensed to 190 patients. 51.6% of patients received antibiotics without renal dose adjustments. The most inappropriately dosed class was penicillins (39.8%), while fluoroquinolones were the most adequately adjusted. Piperacillin/tazobactam was the most frequently prescribed drug (30.6%) without renal dose adjustment. Respiratory infections (OR 1.301, CI 95% 1.327-1.915) and multimorbidity (OR 1.183, CI 95% 1.358-2.081) were statistically highly significant associations for unadjusted antibiotic dosing from the fitted multivariable-adjusted logistic models.

CONCLUSION

Our study revealed a high frequency of guideline-discordant antibiotic dosing in patients with CKD. This dosing error is preventable by increasing awareness of prescribing physicians and collaborating with clinical pharmacists.

Antimicrobial Stewardship Program Implementation in a Saudi Medical City: An Exploratory Case Study

Antimicrobial stewardship programs (ASPs) in hospitals have long been shown to improve antimicrobials' use and reduce the rates of antimicrobial resistance. However, their implementation in hospitals, especially in developing countries such as Saudi Arabia, remains low. One of the main barriers to implementation is the lack of knowledge of how to implement them. This study aims to explore how an antimicrobial stewardship programme was implemented in a Saudi hospital, the challenges faced and how they were overcome, and the program outcomes. A key stakeholder case study design was used, involving in-depth semi-structured interviews with the core members of the ASP team and analysis of 35 ASP hospital documents. ASP implementation followed a top-down approach and involved an initial preparatory phase and an implementation phase, requiring substantial infectious diseases and clinical pharmacy input throughout. Top management support was key to the successful implementation. ASP implementation reduced rates of multi-drug resistance and prescription of broad-spectrum antimicrobials. The implementation of ASPs in hospital is administrator rather than clinician driven. Outsourcing expertise and resources may help hospitals address the initial implementation challenges.