Antimicrobial stewardship programs in adult intensive care units in Latin America: Implementation, assessments, and impact on outcomes

Progress and challenges in the implementation of antimicrobial stewardship programs in 50 hospitals in Mexico

OBJECTIVES

Antimicrobial stewardship programs (ASP) aim to improve the quality of medical prescribing and contain antimicrobial resistance (AMR). There is little information on the implementation of ASP in hospitals in Mexico. This study aimed to characterize ASP in a sample of hospitals in Mexico and to identify the facilitators and barriers perceived in their implementation, including the COVID-19 pandemic.

METHODS

A self-assessment electronic survey was adapted from the CDC and WHO ASP's core elements, considering ASP organization, structure, education, guidelines, interventions, surveillance, monitoring, and reporting processes. The survey was addressed to ASP team leaders in a sample of public and private hospitals carrying out regular antimicrobial stewardship activities in Mexico in 2021 and 2022.

RESULTS

Fifty hospitals participated: 32 (64%) public and 18 (36%) private. Fifty-two percent of hospitals had an official ASP document, 12% allocated protected time for ASP professionals, and 34% had an annual plan. Most hospitals had an ASP committee (68%); only 14% allocated funding. Most interventions were restrictive (68%); 61% of hospitals prepared cumulative antibiograms periodically, 54% monitored antimicrobial consumption (DDD/DOT), 44% monitored adherence to guidelines, and 24% monitored the implementation of interventions. The main barriers identified were work overload, insufficient human resources, and hospital reconversion due to COVID-19 (particularly in public hospitals), while the support of hospital authorities was the most important facilitator.

CONCLUSIONS

This diagnosis provides a baseline for strengthening ASP implementation in the country's hospitals. National and institutional policies should prioritize targeting ASP planning, monitoring, and human resources allocation.

Evidence based QUality Improvement for Prescribing Stewardship in ICU (EQUIPS-ICU): protocol for type III hybrid implementation-effectiveness study

BACKGROUND

Approximately half of all antimicrobial prescriptions in intensive care units (ICUs) may be inappropriate, including those prescribed when not needed, in unnecessary combinations or for longer durations than needed. Inappropriate prescribing is costly, exposes patients to unnecessary side-effects and drives population-level antimicrobial resistance, the prevalence and consequences of which are greatest in low- and middle-income countries. However, the implementation of interventions to improve the appropriateness of antimicrobial prescribing has been variable and requires further study.

METHODS

We propose a type III hybrid implementation/effectiveness interventional cohort trial in 35 ICUs in up to 11 low- and middle- income countries. The study intervention is a structured review of antimicrobial prescriptions as recommended by the World Health Organisation. Strategies to support stakeholder-led implementation include development of local protocols, registry-enabled audit and feedback, and education. Evaluation of implementation, and the determinants of its success, is informed by the RE-AIM framework and the Consolidated Framework for Implementation Research respectively. The primary outcome is a composite measure of fidelity, reach and adoption. Secondary outcomes describe the effectiveness of the intervention on improving antimicrobial prescribing. Qualitative interviews will assess relevant implementation acceptability, adaptations and maintenance. A baseline survey will investigate ICU-level antimicrobial stewardship structures and processes.

DISCUSSION

This study addresses global policy priorities by supporting implementation research of antimicrobial stewardship, and strengthening associated healthcare professional competencies. It does this in a setting where improvement is sorely needed: low- and middle- income country ICUs. The study will also describe the influence of pre-existing antimicrobial stewardship structures and processes on implementation and improve understanding about the efficacy of strategies to overcome barriers to implementation in these settings.

TRIAL REGISTRATION

This study protocol has been registered with ClinicalTrials.gov (ref NCT06666738) on 31 Oct 2004. https://clinicaltrials.gov/study/NCT06666738?term=NCT06666738&rank=1 .

Physician's perception and practices on antimicrobial resistance in a tertiary care hospital in Bangladesh: a cross-sectional study

BACKGROUND

Antimicrobial resistance (AMR) is a global health and development concern. Antimicrobial misuse and overuse are key contributors to the emergence of drug-resistant infections.

OBJECTIVE

The current study aimed to determine the level of perception and practices of physicians regarding AMR in a tertiary-level hospital.

DESIGN

Cross-sectional study.

SETTING

A tertiary care hospital in Dhaka, Bangladesh.

PARTICIPANTS

The study included 360 physicians who worked for more than 6 months in different departments of the hospital.

PRIMARY AND SECONDARY OUTCOME MEASURES

Perceptions of AMR among physicians and secondary outcome measures were to find out the practices of physicians regarding AMR. The current study used 8 defined responses and 6 multiple-choice questions for scoring physicians' perception of AMR and 12 items to score physicians' self-reported practice regarding AMR. After converting these scores into percentages, the median split method was used to categorise them into poor and good categories.

RESULTS

Among 360 physicians, 51% were male, the median (IQR) age was 30 (27.0-34.0) years and 46% had private practices. More than half (52%) had a poor perception of AMR but had good practice (57%) with no significant association between perception and practice. The perception of AMR was significantly associated with age (p=0.048), years in practice (p=0.011) and AMR training (p=0.030). Physicians with private practice had 1.71 times higher odds of having a good perception of AMR (95% CI 2.07 to 2.75, p=0.026) and 2.44 times higher odds of having good practice (95% CI 1.51 to 3.94, p<0.001). The odds of having a good perception of AMR increase 1.20 times with a 1-year increase in years of practice (95% CI 1.01 to 1.44, p=0.042).

CONCLUSION

The study revealed that most physicians had poor perception but good practice regarding AMR. Both poor perception and good practice were associated with private practice. To increase good practice and perception regarding AMR, efforts need to be made to establish an AMR education programme for practicing physicians as soon as possible. Moreover, medical audits and continuous quality improvement (such as programmes for antimicrobial stewardship) should be legislated, and monitoring prescribing behaviour and formulating policies accordingly are the way forward in combating AMR.

Efficacy of quality improvement interventions on antibiotic prescription practices for ventilator-associated pneumonia at a tertiary care centre: a prospective pre-post interventional study

BACKGROUND

Ventilator-associated pneumonia (VAP) is a prevalent nosocomial infection in the intensive care unit (ICU), significantly increasing patient morbidity, mortality, and healthcare costs. Effective management is essential, particularly in the context of antimicrobial resistance and the frequent use of antibiotics in ICUs.

METHODS

This prospective pre-post interventional study was conducted in the medical ICU of a tertiary care centre, over 6 months. Adult patients diagnosed with VAP and receiving antibiotics for more than 48 hours were included. The study involved three phases: preintervention (baseline antibiotic prescription audit), intervention (educational sessions, multidisciplinary meetings and tailored feedback) and postintervention (follow-up audit). Data analysis included Kaplan-Meier survival curves and statistical comparisons of ICU stay durations.

RESULTS

In the preintervention phase, the median treatment duration was 24 days, while the postintervention phase reduced this to 17 days. Kaplan-Meier curves showed improved survival probabilities and shorter ICU stays in the postintervention phase. The mean ICU stay decreased significantly from 24 days preintervention to 11.3 days postintervention (p=0.027). Mortality rates also improved, with 38.5% discharged and 61.5% deaths postintervention, compared with 23.5% discharged and 76.5% deaths preintervention. Antibiotic prescription patterns shifted towards more targeted therapy, adhering better to culture and sensitivity results and reducing the use of broad-spectrum antibiotics and polypharmacy.

CONCLUSION

Quality improvement interventions significantly improved VAP management by reducing treatment duration, ICU stay and mortality rates. Educational sessions, multidisciplinary collaboration and tailored feedback enhanced antibiotic prescription practices, highlighting the importance of continuous quality improvement in ICU settings. Further research and sustained efforts in antimicrobial stewardship are essential to combat VAP and improve patient outcomes.

Antibiotic Use in Medical-Surgical Intensive Care Units and General Wards in Latin American Hospitals

Background

The objective of this study was to identify antibiotic stewardship (AS) opportunities in Latin American medical-surgical intensive care units (MS-ICUs) and general wards (Gral-wards).

Methods

We conducted serial cross-sectional point prevalence surveys in MS-ICUs and Gral-wards in 41 Latin American hospitals between March 2022 and February 2023. Patients >18 years of age in the units of interest were evaluated for antimicrobial use (AU) monthly (MS-ICUs) or quarterly (Gral-wards). Antimicrobial data were collected using a standardized form by the local AS teams and submitted to the coordinating team for analysis.

Results

We evaluated AU in 5780 MS-ICU and 7726 Gral-ward patients. The hospitals' median bed size (interquartile range) was 179 (125-330), and 52% were nonprofit. The aggregate AU prevalence was 53.5% in MS-ICUs and 25.5% in Gral-wards. Most (88%) antimicrobials were prescribed to treat infections, 7% for surgical prophylaxis and 5% for medical prophylaxis. Health care-associated infections led to 63% of MS-ICU and 38% of Gral-ward AU. Carbapenems, piperacillin-tazobactam, intravenous (IV) vancomycin, and ampicillin-sulbactam represented 50% of all AU to treat infections. A minority of IV vancomycin targeted therapy was associated with documented methicillin-resistant Staphylococcus aureus infection or therapeutic drug monitoring. In both units, 17% of antibiotics prescribed as targeted therapy represented de-escalation, while 24% and 15% in MS-ICUs and Gral-wards, respectively, represented an escalation of therapy. In Gral-wards, 32% of antibiotics were used without a microbiologic culture ordered. Half of surgical prophylaxis antibiotics were prescribed after the first 24 hours.

Conclusions

Based on this cohort, areas to improve AU in Latin American hospitals include antibiotic selection, de-escalation, duration of therapy, and dosing strategies.

Antibiotic stewardship and nosocomial infection prevention in critically ill patients: a quality improvement program

OBJECTIVE

The objective of this study was to evaluate the impact of the implementation of a bundle of interventions through a "Program for Antibiotic Management and Nosocomial Infection Prevention" in the intensive care unit on antibiotic and devices use and healthcare-associated infections.

METHODS

This was a quasi-experimental study of consecutive series of cases in periods before and after the establishment of protocols and checklists for the use of antibiotics as well as other measures to prevent healthcare-associated infection as part of a quality improvement program. Antimicrobial consumption was assessed by the defined daily dose.

RESULTS

A total of 1,056 and 1,323 admissions in the pre-intervention and post-intervention phases, respectively, were evaluated. The defined daily dose per 100 patient-day decreased from 89±8 to 77±11 (p=0.100), with a decrease in carbapenems, glycopeptides, polymyxins, penicillins, and cephalosporins. The rates of ventilator and central venous catheter use decreased from 52.8 to 44.1% and from 76 to 70%, respectively. The rates of healthcare-associated infection decreased from 19.2 to 15.5%.

CONCLUSION

Quality improvement actions focused primarily on antimicrobial management and prevention of healthcare-associated infection are feasible and have the potential to decrease antibiotic use and healthcare-associated infection rates.

Challenges and success stories of the implementation of infection control and antimicrobial stewardship strategies: proceedings of the 5th Global Ministerial Summit on Patient Safety, 2023

The 5th edition of the Global Ministerial Summit on Patient Safety was held in Montreux, Switzerland, in February 2023, delayed by three years due to the COVID-19 pandemic. The overarching theme of the summit was "Less Harm, Better Care - from Resolution to Implementation", focusing on the challenges of implementation of infection prevention and control (IPC) strategies as well as antimicrobial stewardship programs (ASP) around the world. IPC strategies and ASP are of increasing importance due to the substantial burden of healthcare-associated infections and antimicrobial resistance threatening patient safety. Here, we summarize countries' and regional experiences and activities related to the implementation of IPC strategies and ASP shared at the meeting. Full implementation of effective programs remains a major challenge in all settings due to limited support by political and healthcare leaders, and human and financial constraints. In addition, the COVID-19 pandemic challenged already well-established programs. By enforcing sustained implementation by dedicated, cross-disciplinary healthcare personnel with a broad skill set, a reduction in healthcare-associated infections and multidrug-resistant pathogens can be achieved, leading ultimately to improved patient safety.

Antifungal stewardship: the Latin American experience

Antifungal stewardship is a critical component of healthcare management that focuses on optimizing the use of antifungal medications to improve patient outcomes, minimize resistance, and reduce healthcare costs.  In resource-limited settings, the prevalence of fungal infections remains a significant health concern, often exacerbated by factors such as compromised immune systems, inadequate diagnostic capabilities, and limited access to antifungal agents. This paper reviews the current state of antifungal stewardship practices in developing countries, addressing the unique socioeconomic and healthcare landscape.

Dominance of ST131, B2, blaCTX-M-15, and papA-papC-kpsMII-uitA among ESBL Escherichia coli isolated from bloodstream infections in Quito, Ecuador: a 10-year surveillance study (2009-2019)

AIMS

This study aimed to examine antibiotic resistance and the epidemiology of extended-spectrum β-lactamases (ESBL)-producing Escherichia coli associated with bloodstream infections over a period of 10 years.

METHODS AND RESULTS

Isolates were collected from January 2009 to December 2019 and those testing for E. coli were included. Antibiotic susceptibility was tested using the VITEK® system. Selected isolates were further characterized by amplification of marker genes (virulence traits, phylogroups, and sequence types). A total of 166 ESBL-producing E. coli were recovered. The blaCTX-M-15 allele was the most abundant. Most of the isolates were resistant to ceftriaxone, cefepime, ceftazidime, ampicillin/sulbactam, piperacillin/tazobactam, and ciprofloxacin. No resistance to carbapenems was registered. More than 80% of bacteria were classified as extraintestinal pathogenic E. coli (ExPEC), and the combination of virulence traits:papA-papC-kpsMII-uitA was the most common. Phylogroup B2 was the most prevalent, and bacteria predominantly belonged to ST131.

CONCLUSIONS

There was an increase in the ExPEC ESBL-E coli in bloodstream infections and the relationship between the isolates found in these infections during these 10 years.

Impact of the Five-Year Intervention of an Antimicrobial Stewardship Program on the Optimal Selection of Surgical Prophylaxis in a Hospital without Antibiotic Prescription Restrictions in Costa Rica: A Retrospective Study

This study aims to characterize the impact of the implementation of an antimicrobial stewardship program (AMS) on the optimal selection of surgical antibiotic prophylaxis in adult patients. This is a retrospective quasi-experimental study that compared the selection and duration of antibiotics for all surgical prophylaxis prescriptions over six months, both before (pre-AMS) and after a five-year intervention of AMS (post-AMS). In addition, data related to the consumption of antibiotics, adverse drug reactions, and surgical site infections throughout the years of the intervention were analyzed. The rate of appropriate selection of antibiotic prophylaxis in surgical procedures improved to 80% during the post-AMS period. The percentage of optimal duration increased from 69.1% (N = 1598) in the pre-AMS period to 78.0% (N = 841) in the post-AMS period (p < 0.001). The consumption of ceftriaxone significantly decreased, while the use of cefazolin increased more than nine times. No severe adverse reactions or increases in surgical site infections were detected after the intervention. The implementation of an AMS in the surgical ward demonstrated a trend towards a positive overall impact on the selection and duration of prophylactic antibiotics for surgery, with positive results also observed in other variables associated with the prescription of these antibiotics.

Antimicrobial stewardship in the intensive care unit

High resistance rates to antimicrobials continue to be a global health threat. The incidence of multidrug-resistant (MDR) microorganisms in intensive care units (ICUs) is quite high compared to in the community and other units in the hospital because ICU patients are generally older, have higher numbers of co-morbidities and immune-suppressed; moreover, the typically high rates of invasive procedures performed in the ICU increase the risk of infection by MDR microorganisms. Antimicrobial stewardship (AMS) refers to the implementation of coordinated interventions to improve and track the appropriate use of antibiotics while offering the best possible antibiotic prescription (according to dose, duration, and route of administration). Broad-spectrum antibiotics are frequently preferred in ICUs because of greater infection severity and colonization and infection by MDR microorganisms. For this reason, a number of studies on AMS in ICUs have increased in recent years. Reducing the use of broad-spectrum antibiotics forms the basis of AMS. For this purpose, parameters such as establishing an AMS team, limiting the use of broad-spectrum antimicrobials, terminating treatments early, using early warning systems, pursuing infection control, and providing education and feedback are used. In this review, current AMS practices in ICUs are discussed.

Deep Dive Into Gaps and Barriers to Implementation of Antimicrobial Stewardship Programs in Hospitals in Latin America

BACKGROUND

Antimicrobial resistance has worsened in Latin America. There is an urgent need to understand the development of antimicrobial stewardship programs (ASPs) and the barriers to implementing effective ASPs in light of limited national action plans or policies to promote ASPs in the region.

METHODS

We performed a descriptive mixed-methods study of ASPs in 5 Latin American countries in March-July 2022. An electronic questionnaire with an associated scoring system (hospital ASP self-assessment) was used, and ASP development was classified based on the scores (inadequate, 0-25; basic, 26-50; intermediate, 51-75; or advanced, 76-100). Interviews among healthcare workers (HCWs) involved in antimicrobial stewardship (AS) inquired about behavioral and organizational factors that influence AS activities. Interview data were coded into themes. Results from the ASP self-assessment and interviews were integrated to create an explanatory framework.

RESULTS

Twenty hospitals completed the self-assessment, and 46 AS stakeholders from these hospitals were interviewed. ASP development was inadequate/basic in 35% of hospitals, intermediate in 50%, and advanced in 15%. For-profit hospitals had higher scores than not-for-profit hospitals. Interview data validated the self-assessment findings and provided further insight into ASP implementation challenges, which included limited formal hospital leadership support, inadequate staffing and tools to perform AS work more efficiently, limited awareness of AS principles by HCWs, and limited training opportunities.

CONCLUSIONS

We identified several barriers to ASP development in Latin America, suggesting the need to create accurate business cases for ASPs to obtain the necessary funding for their effective implementation and sustainability.

Four years after the implementation of antimicrobial stewardship program in Jordan: evaluation of program's core elements

Objectives

To combat antimicrobial resistance, the World Health Organization (WHO) urged healthcare organizations in Low- and Middle-Income Countries (LMICs) to implement the core elements of the antimicrobial stewardship (AMS) programs. In response, Jordan took action and developed a national antimicrobial resistance action plan (NAP) in 2017 and commenced the AMS program in all healthcare facilities. It is paramount to evaluate the efforts to implement the AMS programs and understand the challenges of implementing a sustainable and effective program, in Low-Middle Income Country (LMIC) contexts. Therefore, the aim of this study was to appraise the compliance of public hospitals in Jordan to the WHO core elements of effective AMS programs after 4 years of commencement.

Methods

A cross-sectional study in public hospitals in Jordan, using the WHO AMS program core elements for LMICs was carried out. The questionnaire comprised 30 questions that covered the program's six core elements: leadership commitment, accountability and responsibility, AMS actions, education and training, monitoring, and evaluation, and reporting and feedback. A five-point Likert scale was employed for each question.

Results

A total of 27 public hospitals participated, with a response rate of 84.4%. Adherence to core elements ranged from (53%) in the leadership commitment domain to (72%) for AMS procedure application (actions). Based on the mean score, there was no significant difference between hospitals according to location, size, and specialty. The most neglected core elements that emerged as top priority areas were the provision of financial support, collaboration, access, as well as monitoring and evaluation.

Conclusion

The current results revealed significant shortcomings in the AMS program in public hospitals despite 4 years of implementation and policy support. Most of the core elements of the AMS program were below average, which requires hospital leadership commitment, and multifaceted collaborative actions from the concerned stakeholders in Jordan.

Regional Perspective of Antimicrobial Stewardship Programs in Latin American Pediatric Emergency Departments

Antibiotic stewardship (AS) programs have become a priority for health authorities to reduce the number of infections by super-resistant microorganisms. The need for these initiatives to minimize the inadequate use of antimicrobials is essential, and the election of the antibiotic in the emergency department usually impacts the choice of treatment if the patients need hospital admission, becoming an opportunity for antibiotic stewardship. In the pediatric population, broad-spectrum antibiotics are more likely to be overprescribed without any evidence-based management, and most of the publications have focused on the prescription of antibiotics in ambulatory settings. Antibiotic stewardship efforts in pediatric emergency departments in Latin American settings are limited. The lack of literature on AS programs in the pediatric emergency departments in Latin America (LA) limits the information available. The aim of this review was to give a regional perspective on how pediatric emergency departments in LA are working towards antimicrobial stewardship.

Antimicrobial stewardship in Latin America: Past, present, and future

Implementation of antimicrobial stewardship programs (ASPs) in well-resourced countries has been associated with reductions in antibiotic-resistant infections and improved patient outcomes. Several guidance documents providing recommendations on how to structure antimicrobial stewardship activities at the national and hospital level in resource-limited settings have been published. However, few hospitals in Latin America report having a structure or resources needed for a successful ASP. Given the alarming increases in antimicrobial resistance in Latin America, better understanding of barriers to promote implementation of effective ASPs is urgently needed. We have summarized past and present antimicrobial stewardship activities in Latin American hospitals, and we describe key elements needed in future efforts to strengthen antimicrobial stewardship in the region.

Antibiotic Consumption and Its Relationship with Bacterial Resistance Profiles in ESKAPE Pathogens in a Peruvian Hospital

A descriptive design was carried out studying the correlation between antimicrobial consumption and resistance profiles of ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) in a Peruvian hospital, including the surgical, clinical areas and the intensive care unit (ICU) during the time period between 2015 and 2018. There was a significant correlation between using ceftazidime and the increase of carbapenem-resistant Pseudomonas aeruginosa isolations (R = 0.97; p < 0.05) and the resistance to piperacillin/tazobactam in Enterobacter spp. and ciprofloxacin usage (R = 0.97; p < 0.05) in the medical wards. The Pseudomonas aeruginosa resistance to piperacillin/tazobactam and amikacin in the intensive care unit (ICU) had a significant reduction from 2015 to 2018 (67% vs. 28.6%, 65% vs. 34.9%, p < 0.001). These findings give valuable information about the rates and dynamics in the relationship between antibiotic usage and antimicrobial resistance patterns in a Peruvian hospital and reinforce the need for continuous support and assessment of antimicrobial stewardship strategies, including microbiological indicators and antimicrobial consumption patterns.

Perspectives of Healthcare Professionals Regarding Factors Associated with Antimicrobial Resistance (AMR) and Their Consequences: A Cross Sectional Study in Eastern Province of Saudi Arabia

Factors reported in the literature associated with inappropriate prescribing of antimicrobials include physicians with less experience, uncertain diagnosis, and patient caregiver influences on physicians’ decisions. Monitoring antimicrobial resistance is critical for identifying emerging resistance patterns, developing, and assessing the effectiveness of mitigation strategies. Improvement in prescribing antimicrobials would minimize the risk of resistance and, consequently, improve patients’ clinical and health outcomes. The purpose of the study is to delineate factors associated with antimicrobial resistance, describe the factors influencing prescriber’s choice during prescribing of antimicrobial, and examine factors related to consequences of inappropriate prescribing of antimicrobial. A cross-sectional study was conducted among healthcare providers (190) in six tertiary hospitals in the Eastern province of Saudi Arabia. The research panel has developed, validated, and piloted survey specific with closed-ended questions. A value of p < 0.05 was considered to be statistically significant. All data analysis was performed using the Statistical Package for Social Sciences (IBM SPSS version 23.0). 72.7% of the respondents have agreed that poor skills and knowledge are key factors that contribute to the inappropriate prescribing of antimicrobials. All of the respondents acknowledged effectiveness, previous experience with the antimicrobial, and reading scientific materials (such as books, articles, and the internet) as being key factors influencing physicians’ choice during antimicrobial prescribing. The current study has identified comprehensive education and training needs for healthcare providers about antimicrobial resistance. Using antimicrobials unnecessarily, insufficient duration of antimicrobial use, and using broad spectrum antimicrobials were reported to be common practices. Furthermore, poor skills and knowledge were a key factor that contributed to the inappropriate use and overuse of antimicrobials, and the use of antimicrobials without a physician’s prescription (i.e., self-medication) represent key factors which contribute to AMR from participants’ perspectives. Furthermore, internal policy and guidelines are needed to ensure that the antimicrobials are prescribed in accordance with standard protocols and clinical guidelines.