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Tverdek FP, Aitken SL, Mulanovich VE, Adachi J, Wu C, Cantu SS, McDaneld PM, Chemaly RF. Implementation of an Automated Antibiotic Time-out at a Comprehensive Cancer Center. Open Forum Infect Dis 2024; 11:ofae235. [PMID: 38798895 PMCID: PMC11127483 DOI: 10.1093/ofid/ofae235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
Background Antimicrobial stewardship programs can optimize antimicrobial use and have been federally mandated in all hospitals. However, best stewardship practices in immunocompromised patients with cancer are not well established. Methods An antimicrobial time out, in the form of an email, was sent to physicians caring for hospitalized patients reaching 5 days of therapy for targeted antimicrobials (daptomycin, linezolid, tigecycline, vancomycin, imipenem/cilastatin, meropenem) in a comprehensive cancer center. Physicians were to discontinue the antimicrobial if unnecessary or document a rationale for continuation. This is a quasi-experimental, interrupted time series analysis assessing antimicrobial use during the following times: period 1 (before time-out: January 2007-June 2010) and period 2 (after time-out: July 2010-March/2015). The primary antimicrobial consumption metric was mean duration of therapy. Days of therapy per 1000 patient-days were also assessed. Results Implementation of the time-out was associated with a significant decrease in mean duration of therapy for the following antimicrobials; daptomycin: -0.89 days (95% confidence interval [CI], -1.38 to -.41); linezolid: -0.89 days (95% CI, -1.27 to -.52); meropenem: -0.97 days (95% CI, -1.39 to -.56); tigecycline: -1.41 days (95% CI, -2.19 to -.63); P < .001 for each comparison. Days of therapy/1000 patient-days decreased significantly for meropenem (-43.49; 95% CI, -58.61 to -28.37; P < .001), tigecycline (-35.47; 95% CI, -44.94 to -26.00; P < .001), and daptomycin (-9.47; 95% CI, -15.25 to -3.68; P = .002). Discussion A passive day 5 time-out was associated with reduction in targeted antibiotic use in a cancer center and could potentially be successfully adopted to several settings and electronic health records.
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Affiliation(s)
- Frank P Tverdek
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Samuel L Aitken
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Center for Antimicrobial Resistance and Microbial Genomics, UTHealth McGovern Medical School, Houston, Texas, USA
| | - Victor E Mulanovich
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Adachi
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cai Wu
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sherry S Cantu
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patrick M McDaneld
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Jabeen N, Ullah W, Khalid J, Samad Z. Estimating antibiotics consumption in a tertiary care hospital in Islamabad using a WHO's defined daily dose methodology. Antimicrob Resist Infect Control 2023; 12:132. [PMID: 37996947 PMCID: PMC10666294 DOI: 10.1186/s13756-023-01311-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/20/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Antibiotics have helped to reduce the incidence of common infectious diseases in all modern healthcare systems, but improper use of antibiotics including their overuse and misuse can change the bacteria so much that antibiotics don't work against them. In case of developing imposable selective pressure with regard to the proportion of hospitalized patients who receive antibiotics, the quantity of antibiotics that are prescribed to them, and the proportion of patients who receive antibiotic treatment is one of the major contributors to the rising global health issue of antimicrobial resistance. Concerning the levels of antibiotic consumption in Pakistani hospitals, there is negligible research data available. AIM This study aimed to evaluate five-year inpatient antibiotic use in a tertiary care hospital in Islamabad using the World Health Organization (WHO) Recommended Anatomical Therapeutic Chemical (ATC) Classification / Defined Daily Dose (DDD) methodology. METHOD It was a descriptive study involving a retrospective record review of pharmacy records of antibiotics dispensed (amount in grams) to patients across different specialties of the hospital from January 2017 to December 2021 (i.e., 60 consecutive months). The antibiotic consumption was calculated by using the DDD/100-Bed Days (BDs) formula, and then relative percent change was estimated using Microsoft Excel 2021 edition. RESULT A total of 148,483 (77%) patients who received antibiotics were included in the study out of 193,436 patients admitted in the hospital. Antibiotic consumption trends showed considerable fluctuations over a five-year period. It kept on declining irregularly from 2017 to 2019, inclined vigorously in 2020, and then suddenly dropped to the lowest DDD/100 BDs value (96.02) in the last year of the study. The overall percentage of encounters in which antibiotics were prescribed at tertiary care hospital was 77% which is very high compared to the WHO standard reference value (< 30%). WATCH group antibiotics were prescribed (76%) and consumed more within inpatient settings than Access (12%) and Reserve (12%) antibiotics. CONCLUSION The hospital antibiotic consumption data is well maintained across different inpatient specialties but it is largely non-aligned with WHO AWaRe (Access-Watch-Reserve) antibiotics use and optimization during 2017-2021. Compared to the WHO standard reference figure, the overall percentage of antibiotics encountered was higher by about 47%. Antibiotic consumption trends vary with a slight increase in hospital occupancy rate, with positive relative changes being lower in number but higher in proportion than negative changes. Although the hospital antibiotics policy is in place but seems not to be followed with a high degree of adherence.
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Affiliation(s)
- Naila Jabeen
- Department of Pharmacy Practice, Shifa College of Pharmaceutical Sciences, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Waseem Ullah
- Department of Pharmacy Practice, Shifa College of Pharmaceutical Sciences, Shifa Tameer-e-Millat University, Islamabad, Pakistan.
| | | | - Zia Samad
- National Tuberculosis Control Program, Islamabad Capital Territory, Islamabad, Pakistan
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Villaverde S, Caro JM, Domínguez-Rodríguez S, Orellana MÁ, Rojo P, Epalza C, Blázquez-Gamero D. PACTA-Ped: Antimicrobial stewardship programme in a tertiary care hospital in Spain. An Pediatr (Barc) 2023; 99:312-320. [PMID: 37891136 DOI: 10.1016/j.anpede.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 09/12/2023] [Indexed: 10/29/2023] Open
Abstract
INTRODUCTION Fighting against antimicrobial resistance is a current priority, and further efforts need to be made to improve antimicrobial prescribing and reduce the spread of infections in paediatric care settings. METHODS We conducted a prospective longitudinal study on the use of antimicrobials from the time the antimicrobial stewardship programme (ASP) was introduced in January 2016 to December 2017 (period 2 [P2]) in our children's hospital. We compared the obtained results on antimicrobial prescribing with retrospective data from the period preceding the introduction of the ASP (2014-2015, period 1 [P1]). The sample consisted of paediatric inpatients who received broad-spectrum antimicrobials, antifungals or intravenous antibiotherapy lasting more than 5 days. We compared the use of antimicrobials in P1 versus P2. RESULTS A total of 160 patients were included during P2. The antibiotics for which a recommendation was made most frequently were meropenem (41.6%) and cefotaxime (23.4%). In 45% of care episodes, the consultant recommended "no change" to the prescribed antimicrobial. The final rate of acceptance of received recommendations by the prescribing physicians was 89%. We found average decreases of 27.8% in the days of treatment per 1000 inpatient days and 22.9% in the number of antimicrobial starts per 1000 admissions in P2. The use of carbapenems, cephalosporins and glycopeptides decreased in P2 compared to P1. The average annual cost of antimicrobial treatment decreased from є150 356/year during P1 to є98 478/year in P2. CONCLUSION Our ASP achieved a significant decrease in the use of broad-spectrum antibiotics and antifungals. The costs associated with antimicrobial prescribing decreased following the introduction of the ASP, which was a cost-effective action in this study period.
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Affiliation(s)
- Serena Villaverde
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.
| | - José Manuel Caro
- Department of Pharmacy, Hospital Universitario 12 de Octubre, Madrid, Spain; Antimicrobial Stewardship Programme, Hospital 12 de Octubre, Madrid, Spain
| | - Sara Domínguez-Rodríguez
- Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
| | - María Ángeles Orellana
- Antimicrobial Stewardship Programme, Hospital 12 de Octubre, Madrid, Spain; Department of Microbiology, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Pablo Rojo
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Cristina Epalza
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain; Antimicrobial Stewardship Programme, Hospital 12 de Octubre, Madrid, Spain
| | - Daniel Blázquez-Gamero
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Universitario 12 de Octubre, Madrid, Spain; Pediatric Research and Clinical Trials Unit (UPIC), Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
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Hamad MA, Williams A, Kneebusch J, Butala N. Impact of Board Certified Psychiatric Pharmacists on improving urinary tract infection antibiotic appropriateness at an acute psychiatric hospital. Ment Health Clin 2023; 13:233-238. [PMID: 38131054 PMCID: PMC10732127 DOI: 10.9740/mhc.2023.10.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/27/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction Urinary tract infections (UTIs) are one of the most common indications for antibiotic use; patients with psychiatric disorders have a greater risk for UTI compared with patients without these disorders. However, there is little guidance on how best to manage antibiotic therapy in psychiatric hospitals. This study assessed the impact of a Board Certified Psychiatric Pharmacist (BCPP)-driven guideline on managing UTI treatment in an acute psychiatric hospital. Methods The guideline was developed by the psychiatric pharmacy team and distributed to internists, psychiatrists, and pharmacists. Preintervention data were assessed for patients admitted between November 30, 2019, and February 23, 2020; postintervention data were assessed from February 25, 2020, to April 24, 2020. All patients ages 13 years and older who were admitted and had orders for an antibiotic to treat a UTI were included in this study. Appropriate UTI management was defined as an appropriate agent, dose, route, and frequency per the treatment guideline. Additionally, the following criteria were to be ordered and assessed to be deemed appropriate: urinalysis, urine culture, complete blood count, basic or complete metabolic panel, temperature, and subjective symptoms. Results Before intervention, 19.0% of antibiotic orders were appropriate; after intervention, 46.7% of antibiotic orders were appropriate (P = .048). Conclusion The implementation of a BCPP-driven treatment algorithm was associated with a significant increase in appropriate antibiotic regimens for the treatment of UTIs in patients admitted to a psychiatric hospital.
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Affiliation(s)
- Mohammad Adam Hamad
- Clinical Pharmacist, Western University of Health Sciences College of Pharmacy, Pomona, California; Clinical Pharmacist, Riverside University Health Systems Medical Center, Moreno Valley, California
| | - Andrew Williams
- Clinical Pharmacist, Western University of Health Sciences College of Pharmacy, Pomona, California; Clinical Pharmacist, Riverside University Health Systems Medical Center, Moreno Valley, California
- Health Sciences Assistant Clinical Professor, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California-San Diego, La Jolla, California
- Clinical Pharmacist III, Behavioral Health, Riverside University Health Systems Medical Center, Moreno Valley, California
| | - Jamie Kneebusch
- Health Sciences Assistant Clinical Professor, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California-San Diego, La Jolla, California
| | - Niyati Butala
- Clinical Pharmacist III, Behavioral Health, Riverside University Health Systems Medical Center, Moreno Valley, California
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Osakwe N. Transitioning Antibiotics from Hospitals to Nursing Homes: Bridging the Gap. J Am Med Dir Assoc 2023; 24:1223-1224. [PMID: 37500225 DOI: 10.1016/j.jamda.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Nonso Osakwe
- Northern Westchester Hospital, Mount Kisco, NY, USA.
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Chang CY, Devi Nath N, Lam K, Zaid M. Impact of an Antimicrobial Stewardship Intervention on the Appropriateness of Carbapenem Use at a Tertiary Hospital in Malaysia. Cureus 2022; 14:e31660. [DOI: 10.7759/cureus.31660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 11/21/2022] Open
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Wang Y, Zhou C, Liu C, Liu S, Liu X, Li X. The impact of pharmacist-led antimicrobial stewardship program on antibiotic use in a county-level tertiary general hospital in China: A retrospective study using difference-in-differences design. Front Public Health 2022; 10:1012690. [PMID: 36262226 PMCID: PMC9574199 DOI: 10.3389/fpubh.2022.1012690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/05/2022] [Indexed: 01/27/2023] Open
Abstract
Background Inappropriate use of antibiotics has become a major driver for the spread of antimicrobial resistance globally, particularly common in China. Antimicrobial stewardship programs are effective in optimizing antimicrobial use and decreasing the emergence of multi-drug-resistant organisms, and the pharmacist has performed a leading role in this program. Objective To evaluate the impact of antimicrobial stewardship programs driven by pharmacists on antibiotic consumption and costs and the appropriateness of antibiotic use. Methods A single-center retrospective quasi-experimental design was conducted in two independent hepatobiliary surgery wards and two independent respiratory wards in a county-level tertiary general hospital in Jiangsu, China. Each intervention group was served with antimicrobial stewardship programs with prescriptions audit and feedback, antibiotics restriction, education, and training. The propensity score matching method was employed to balance confounding variables between the intervention group and control group, and a difference-in-differences analysis was used to evaluate the impact of antimicrobial stewardship programs. The primary outcome was measured by scores of rationality evaluation of antibiotics. Results The DID results demonstrated that the implementation of the antimicrobial stewardship programs was associated with a reduction in the average length of hospital stay (coefficient = -3.234, p = 0.006), DDDs per patient (coefficient = -2.352, p = 0.047), and hospitalization costs (coefficient = -7745.818, p = 0.005) in the hepatobiliary surgery ward, while it was associated with a decrease in DDDs per patient (coefficient = -3.948, p = 0.029), defined daily doses per patient day (coefficient = -0.215, p = 0.048), and antibiotic costs (coefficient = -935.087, p = 0.014) in the respiratory ward. The program was also associated with a decrease in rationality evaluation scores (p < 0.001) in two wards. Conclusion The result reveals that the implementation of the antimicrobial stewardship programs is effective in reducing the length of hospital stay, decreasing antibiotics consumption and costs, and improving the appropriateness of antimicrobial use such as decreasing irrational use of cephalosporins, reducing combinations, and improving timely conversion. However, great attention ought to be paid to the improper use of broad-spectrum antibiotics. The government is responsible for providing sustainable formal education for pharmacists, and more funding and staff support to promote antimicrobial stewardship programs.
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Affiliation(s)
- Ying Wang
- Department of Infection Management, The First Affiliated Hospital of Soochow University, Suzhou, China,School of Health Policy and Management, Nanjing Medical University, Nanjing, China
| | - Chongchong Zhou
- Department of Clinical Pharmacy, School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Chengying Liu
- Department of Respiratory Medicine, The Affiliated Jiangyin Hospital of Nantong University, Jiangyin, China
| | - Shuanghai Liu
- Department of Hepatobiliary Surgery, The Affiliated Jiangyin Hospital of Nantong University, Jiangyin, China
| | - Xiaoliang Liu
- Department of Infection Management, The Affiliated Jiangyin Hospital of Nantong University, Jiangyin, China,Xiaoliang Liu
| | - Xin Li
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China,Department of Clinical Pharmacy, School of Pharmacy, Nanjing Medical University, Nanjing, China,Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China,*Correspondence: Xin Li
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Chandler EL, Wallace KL, Palavecino E, Beardsley JR, Johnson JW, Luther V, Ohl C, Williamson JC. A comparison of active versus passive methods of responding to rapid diagnostic blood culture results. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e75. [PMID: 36483427 PMCID: PMC9726544 DOI: 10.1017/ash.2022.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To compare 2 methods of communicating polymerase chain reaction (PCR) blood-culture results: active approach utilizing on-call personnel versus passive approach utilizing notifications in the electronic health record (EHR). DESIGN Retrospective observational study. SETTING A tertiary-care academic medical center. PATIENTS Adult patients hospitalized with ≥1 positive blood culture containing a gram-positive organism identified by PCR between October 2014 and January 2018. METHODS The standard protocol for reporting PCR results at baseline included a laboratory technician calling the patient's nurse, who would report the critical result to the medical provider. The active intervention group consisted of an on-call pager system utilizing trained pharmacy residents, whereas the passive intervention group combined standard protocol with real-time in-basket notifications to pharmacists in the EHR. RESULTS Of 209 patients, 105, 61, and 43 patients were in the control, active, and passive groups, respectively. Median time to optimal therapy was shorter in the active group compared to the passive group and control (23.4 hours vs 42.2 hours vs 45.9 hours, respectively; P = .028). De-escalation occurred 12 hours sooner in the active group. In the contaminant group, empiric antibiotics were discontinued faster in the active group (0 hours) than in the control group and the passive group (17.7 vs 7.2 hours; P = .007). Time to active therapy and days of therapy were similar. CONCLUSIONS A passive, electronic method of reporting PCR results to pharmacists was not as effective in optimizing stewardship metrics as an active, real-time method utilizing pharmacy residents. Further studies are needed to determine the optimal method of communicating time-sensitive information.
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Affiliation(s)
| | - Katie L. Wallace
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky
| | - Elizabeth Palavecino
- Department of Pathology, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - James R. Beardsley
- Department of Pharmacy, Atrium Health–Wake Forest Baptist, Winston Salem, North Carolina
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - James W. Johnson
- Department of Pharmacy, Atrium Health–Wake Forest Baptist, Winston Salem, North Carolina
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Vera Luther
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Christopher Ohl
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - John C. Williamson
- Department of Pharmacy, Atrium Health–Wake Forest Baptist, Winston Salem, North Carolina
- Section on Infectious Diseases, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, North Carolina
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Khadem TM, Nguyen MH, Mellors JW, Bariola JR. Development of a Centralized Antimicrobial Stewardship Program Across a Diverse Health System and Early Antimicrobial Usage Trends. Open Forum Infect Dis 2022; 9:ofac168. [PMID: 35615296 PMCID: PMC9126488 DOI: 10.1093/ofid/ofac168] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background Expanding antimicrobial stewardship to community hospitals is vital and now required by regulatory agencies. UPMC instituted the Centralized Health system Antimicrobial Stewardship Efforts (CHASE) Program to expand antimicrobial stewardship to all UPMC hospitals regardless of local resources. For hospitals with few local stewardship resources, we used a model integrating local non-Infectious Diseases (ID) trained pharmacists with centralized ID experts. Methods Thirteen hospitals were included. Eleven were classified as robust (4) or nonrobust (7) depending on local stewardship resources and fulfillment of Centers for Disease Control and Prevention core elements of hospital antimicrobial stewardship. In addition to general stewardship oversight at all UPMC hospitals, the centralized team interacted regularly with nonrobust hospitals for individual patient reviews and local projects. We compared inpatient antimicrobial usage rates at nonrobust versus robust hospitals and at 2 UPMC academic medical centers. Results The CHASE Program expanded in scope between 2018 and 2020. During this period, antimicrobial usage at these 13 hospitals decreased by 16% with a monthly change of −4.7 days of therapy (DOT)/1000 patient days (PD) (95% confidence interval [CI], −5.5 to −3.9; P < .0001). Monthly decrease at nonrobust hospitals was −3.3 DOT/1000 PD per month (−4.5 to −2.0, P < .0001), similar to rates of decline at both robust hospitals (−3.3 DOT/1000 PD) and academic medical centers (−4.8 DOT/1000 PD) (P = .167). Conclusions Coordinated antimicrobial stewardship can be implemented across a large and diverse health system. Our hybrid model incorporating a central team of experts with local community hospital pharmacists led to usage decreases over 3 years at a rate comparable to that seen in larger hospitals with more established stewardship programs.
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Affiliation(s)
- Tina M Khadem
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh PA USA
- UPMC Centralized Health system Antimicrobial Stewardship Efforts, Pittsburgh PA USA
| | - M Hong Nguyen
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh PA USA
| | - John W Mellors
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh PA USA
| | - J Ryan Bariola
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh PA USA
- UPMC Centralized Health system Antimicrobial Stewardship Efforts, Pittsburgh PA USA
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Jantarathaneewat K, Montakantikul P, Weber DJ, Nanthapisal S, Rutjanawech S, Apisarnthanarak A. Impact of an infectious diseases pharmacist-led intervention on antimicrobial stewardship program guideline adherence at a Thai medical center. Am J Health Syst Pharm 2022; 79:1266-1272. [PMID: 35390112 DOI: 10.1093/ajhp/zxac107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Kittiya Jantarathaneewat
- Department of Pharmaceutical Care, Faculty of Pharmacy, Thammasat University, Pathum Thani, andResearch Group in Infectious Diseases, Epidemiology, and Prevention, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | | | - David J Weber
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Sira Nanthapisal
- Research Group in Infectious Diseases, Epidemiology, and Prevention, Faculty of Medicine, Thammasat University, Pathum Thani, and Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Sasinuch Rutjanawech
- Research Group in Infectious Diseases, Epidemiology, and Prevention, Faculty of Medicine, Thammasat University, Pathum Thani, and Division of Infectious Diseases, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Anucha Apisarnthanarak
- Research Group in Infectious Diseases, Epidemiology, and Prevention, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
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Alsayed A, Darwish El Hajji F, Al-Najjar MA, Abazid H, Al-Dulaimi A. Patterns of antibiotic use, knowledge, and perceptions among different population categories: A comprehensive study based in Arabic countries. Saudi Pharm J 2022; 30:317-328. [PMID: 35498229 PMCID: PMC9051960 DOI: 10.1016/j.jsps.2022.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/17/2022] [Indexed: 10/26/2022] Open
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Mills JP, Marchaim D. Multidrug-Resistant Gram-Negative Bacteria: Infection Prevention and Control Update. Infect Dis Clin North Am 2021; 35:969-994. [PMID: 34752228 DOI: 10.1016/j.idc.2021.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Multidrug-resistant gram-negative bacteria (MDR-GNB) pose one of the greatest challenges to health care today because of their propensity for human-to-human transmission and lack of therapeutic options. Containing the spread of MDR-GNB is challenging, and the application of multifaceted infection control bundles during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article will review the utility of various infection control measures in containing the spread of various MDR-GNB and will provide the supporting evidence for these interventions.
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Affiliation(s)
- John P Mills
- Division of Infectious Diseases, University of Michigan Medical School, F4177 University Hospital South, 1500 E. Medical Center Dr, Ann Arbor, MI 48109-5226, USA.
| | - Dror Marchaim
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
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Sadeq AA, Shamseddine JM, Babiker ZOE, Nsutebu EF, Moukarzel MB, Conway BR, Hasan SS, Conlon-Bingham GM, Aldeyab MA. Impact of Multidisciplinary Team Escalating Approach on Antibiotic Stewardship in the United Arab Emirates. Antibiotics (Basel) 2021; 10:antibiotics10111289. [PMID: 34827227 PMCID: PMC8614643 DOI: 10.3390/antibiotics10111289] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/02/2021] [Accepted: 10/18/2021] [Indexed: 01/21/2023] Open
Abstract
Antimicrobial stewardship programs (ASP) are an essential strategy to combat antimicrobial resistance. This study aimed to measure the impact of an ASP multidisciplinary team (MDT) escalating intervention on improvement of clinical, microbiological, and other measured outcomes in hospitalised adult patients from medical, intensive care, and burns units. The escalating intervention reviewed the patients’ cases in the intervention group through the clinical pharmacists in the wards and escalated complex cases to ID clinical pharmacist and ID physicians when needed, while only special cases required direct infectious disease (ID) physicians review. Both non-intervention and intervention groups were each followed up for six months. The study involved a total of 3000 patients, with 1340 (45%) representing the intervention group who received a total of 5669 interventions. In the intervention group, a significant reduction in length of hospital stay (p < 0.01), readmission (p < 0.01), and mortality rates (p < 0.01) was observed. Antibiotic use of the WHO AWaRe Reserve group decreased in the intervention group (relative rate change = 0.88). Intravenous to oral antibiotic ratio in the medical ward decreased from 4.8 to 4.1. The presented ASP MDT intervention, utilizing an escalating approach, successfully improved several clinical and other measured outcomes, demonstrating the significant contribution of clinical pharmacists atimproving antibiotic use and informing antimicrobial stewardship.
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Affiliation(s)
- Ahmed A. Sadeq
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. BOX 11001, United Arab Emirates; (A.A.S.); (J.M.S.); (M.B.M.)
| | - Jinan M. Shamseddine
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. BOX 11001, United Arab Emirates; (A.A.S.); (J.M.S.); (M.B.M.)
| | - Zahir Osman Eltahir Babiker
- Division of Infecious Diseases, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. BOX 11001, United Arab Emirates; (Z.O.E.B.); (E.F.N.)
| | - Emmanuel Fru Nsutebu
- Division of Infecious Diseases, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. BOX 11001, United Arab Emirates; (Z.O.E.B.); (E.F.N.)
| | - Marleine B. Moukarzel
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. BOX 11001, United Arab Emirates; (A.A.S.); (J.M.S.); (M.B.M.)
| | - Barbara R. Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK; (B.R.C.); (S.S.H.)
- Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Syed Shahzad Hasan
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK; (B.R.C.); (S.S.H.)
| | | | - Mamoon A. Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK; (B.R.C.); (S.S.H.)
- Correspondence: ; Tel.: +44-01484-472825
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14
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Yoon YK, Kwon KT, Jeong SJ, Moon C, Kim B, Kiem S, Kim HS, Heo E, Kim SW. Guidelines on Implementing Antimicrobial Stewardship Programs in Korea. Infect Chemother 2021; 53:617-659. [PMID: 34623784 PMCID: PMC8511380 DOI: 10.3947/ic.2021.0098] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022] Open
Abstract
These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Korean Society for Antimicrobial Therapy, Seoul, Korea
| | - Ki Tae Kwon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Korean Society of Infectious Diseases, Seoul, Korea
| | - Chisook Moon
- Korean Society of Infectious Diseases, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Bongyoung Kim
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungmin Kiem
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyung-Sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Eunjeong Heo
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Shin-Woo Kim
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
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15
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Xie L, Du Y, Wang X, Zhang X, Liu C, Liu J, Peng X, Guo X. Effects of Regulation on Carbapenem Prescription in a Large Teaching Hospital in China: An Interrupted Time Series Analysis, 2016-2018. Infect Drug Resist 2021; 14:3099-3108. [PMID: 34408453 PMCID: PMC8364849 DOI: 10.2147/idr.s322938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/14/2021] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Lewei Xie
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Yaling Du
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Xuemei Wang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Chenxi Liu
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Junjie Liu
- School of Statistics and Mathematics, Central University of Finance and Economics, Beijing, People's Republic of China
| | - Xi Peng
- First Affiliated Hospital, School of Medicine, Shihezi University, Xinjiang, Shihezi, People's Republic of China
| | - Xinhong Guo
- First Affiliated Hospital, School of Medicine, Shihezi University, Xinjiang, Shihezi, People's Republic of China
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16
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Villanueva P, Freyne B, Hickey L, Carr J, Bryant PA. Impact of an antimicrobial stewardship intervention in neonatal intensive care: Recommendations and implementation. J Paediatr Child Health 2021; 57:1208-1214. [PMID: 33729615 DOI: 10.1111/jpc.15427] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/10/2021] [Accepted: 02/17/2021] [Indexed: 12/18/2022]
Abstract
AIM To (i) determine the appropriateness of antimicrobial prescribing in the neonatal intensive care unit (NICU) and (ii) assess the impact of a collaborative antimicrobial stewardship (AMS) intervention on prescribing practices. METHODS The intervention was a weekly AMS audit-feedback joint ward round (6-month period) of Neonatology and Infectious Diseases clinicians in a tertiary neonatal intensive care unit in Melbourne, Australia. Antibiotic prescriptions were audited and recommendations delivered in real time. The proportion of recommendations implemented was used to assess acceptability of the intervention. RESULTS During the study period, there were 23 AMS rounds, during which 249 patients were reviewed at 627 separate episodes. Of these, 233 (37%) episodes were for patients receiving antimicrobials. Of these, 147 (63%) received empirical antimicrobial treatment, 43 (18%) targeted antimicrobial treatment and 43 (18%) antimicrobial prophylaxis. There were 58 (25%) of 233 episodes of inappropriate antibiotic use, and 62 recommendations for improvement. Most common recommendations were to narrow (33/62, 53%) or stop (12/62, 19%) antimicrobials. The majority (45, 73%) of recommendations were accepted, resulting in significant improvement in the proportion of the 233 episodes that had completely appropriate antibiotic prescribing: 175 (75%) to 217 (93%) (relative risk 1.2, 95% confidence intervals 1.1-1.3, P < 0.001). CONCLUSIONS A collaborative audit-feedback AMS intervention was effective in identifying inappropriate antimicrobial prescriptions and impacted positively on treatment plans. Ancillary benefits were improved communication between departments and the revision of antimicrobial prescribing guidelines.
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Affiliation(s)
- Paola Villanueva
- Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Bridget Freyne
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Leah Hickey
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Neonatal Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Jeremy Carr
- Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Penelope A Bryant
- Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Hospital-in-the-Home, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
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17
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Xu S, Wang X, Song Z, Han F, Zhang C. Impact and barriers of a pharmacist-led practice with computerized reminders on intravenous to oral antibiotic conversion for community-acquired pneumonia inpatients. J Clin Pharm Ther 2021; 46:1055-1061. [PMID: 34101230 DOI: 10.1111/jcpt.13397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Intravenous to oral (IV-PO) antibiotic conversion, one of the critical elements in antimicrobial stewardship (AMS), is not well implemented in China. Studies on the strategy to apply the IV-PO conversion are needed. Our objective was to evaluate the impact and its barriers of a pharmacist-led practice with computerized reminders on IV-PO antibiotic conversion for community-acquired pneumonia (CAP) inpatients. METHOD This was a retrospective, observational pre- and post-intervention study. Interventions were introduced in 2 sequential 12-month phases: Phase 1: pharmacists implemented the conventional practice of reviewing patient charts and medication records every 24 h and verbally informed the prescribers on eligible IV-PO conversions; Phase 2: pharmacists implemented a new intervention practice to inform the prescribers with a computerized reminder in electronic medical record system on eligible IV-PO conversions. MAIN OUTCOME MEASURES The primary outcome was the proportion of patients who converted to oral therapy on the day patients were eligible for the conversion. The secondary outcomes were length of IV antibiotic therapy days, total length of antibiotic therapy days and length of hospital stay. RESULTS A total of 524 patients were studied (256 in phase 1 and 268 in phase 2). The proportion of patients who converted to oral therapy on the day patients were eligible for the conversion was significantly increased from 34.77% (89/256) in phase 1 to 62.69% (168/268) in phase 2 (p < 0.05). Length of IV antibiotic therapy days in phase 2 was shortened by 1.23 days, which was 5.52 days compared to 6.75 days in phase 1 (p < 0.05). Total length of antibiotic therapy days was 12.05 days in Phase 1, compared to 10.75 days in phase 2 (p > 0.05). Length of hospital stay for patients in phase 2 was significantly shorter, with a difference of 1.38 days (6.02 days vs. 7.40 days, p < 0.05). The most common barrier of not converting IV-PO was the presence of co-morbidity. CONCLUSION The pharmacist-led IV-PO antibiotic conversion practice with computerized reminders was successful and feasible in Chinese hospitals. More IV-PO intervention studies in patients with other infections are needed in the future.
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Affiliation(s)
- Shanshan Xu
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Xin Wang
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Zhihui Song
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Furong Han
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Chao Zhang
- Department of Pharmacy, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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18
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St Louis J, Okere AN. Clinical impact of pharmacist-led antibiotic stewardship programs in outpatient settings in the United States: A scoping review. Am J Health Syst Pharm 2021; 78:1426-1437. [PMID: 33889930 PMCID: PMC8083201 DOI: 10.1093/ajhp/zxab178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
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 provide an overview of the impact of pharmacist interventions on antibiotic prescribing and the resultant clinical outcomes in an outpatient antibiotic stewardship program (ASP) in the United States. Methods Reports on studies of pharmacist-led ASP interventions implemented in US outpatient settings published from January 2000 to November 2020 and indexed in PubMed or Google Scholar were included. Additionally, studies documented at the ClinicalTrials.gov website were evaluated. Study selection was based on predetermined inclusion criteria; only randomized controlled trials, observational studies, nonrandomized controlled trials, and case-control studies conducted in outpatient settings in the United States were included. The primary outcome was the observed differences in antibiotic prescribing or clinical benefits between pharmacist-led ASP interventions and usual care. Results Of the 196 studies retrieved for full-text review, a cumulative total of 15 studies were included for final evaluation. Upon analysis, we observed that there was no consistent methodology in the implementation of ASPs and, in most cases, the outcome of interest varied. Nonetheless, there was a trend toward improvement in antibiotic prescribing with pharmacist interventions in ASPs compared with that under usual care (P < 0.05). However, the results of these studies are not easily generalizable. Conclusion Our findings suggest a need for a consistent approach for the practical application of outpatient pharmacist-led ASPs. Managed care organizations could play a significant role in ensuring the successful implementation of pharmacist-led ASPs in outpatient settings.
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Affiliation(s)
- James St Louis
- Florida A&M University College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Tallahassee, FL,USA
| | - Arinze Nkemdirim Okere
- Florida A&M University College of Pharmacy and Pharmaceutical Sciences, Institute of Public Health, Tallahassee, FL,USA
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19
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Mixon MA, Dietrich S, Bushong B, Peksa GD, Rogoszewski R, Theiler A, Spears L, Werth J, Meister E, Martin MS. Urinary tract infection pocket card effect on preferred antimicrobial prescribing for cystitis among patients discharged from the emergency department. Am J Health Syst Pharm 2021; 78:1417-1425. [PMID: 33889933 PMCID: PMC8083212 DOI: 10.1093/ajhp/zxab175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To evaluate the impact of a urinary tract infection (UTI) pocket card on preferred antibiotic prescribing for patients discharged from the emergency department (ED) with a diagnosis of cystitis. METHODS A multicenter, retrospective, pre-post study was conducted to compare outcomes following the introduction of a UTI pocket card. The primary outcome was prescribing rates for institutional first-line preferred antibiotics (cephalexin and nitrofurantoin) versus other antimicrobials for cystitis. Secondary outcomes included prescriber adherence to recommended therapy in regards to discharge dose, frequency, duration, and healthcare utilization rates. RESULTS The study included 915 patients in total, 407 in the preintervention group and 508 in the postintervention group. The frequency of preferred antibiotic prescribing was significantly increased after the introduction of a UTI pocket card compared to prior to its introduction (81.7% vs 72.0%, P = 0.001). Significant increases in prescribing of an appropriate antibiotic dose (78.0% vs 66.8%, P < 0.0001) and frequency (64.2% vs 47.4%, P < 0.0001) were also found post intervention. No significant differences were seen between the pre- and postintervention groups with regards to healthcare utilization rates. CONCLUSION A UTI pocket card increased preferred antibiotic prescribing for cystitis in the ED. This study provides data on a successful antimicrobial stewardship intervention in the ED setting.
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Affiliation(s)
| | - Scott Dietrich
- Department of Pharmacy, Medical Center of the Rockies, Loveland, CO,USA
| | | | - Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL,USA
| | - Ryan Rogoszewski
- Department of Pharmacy, Poudre Valley Hospital, Fort Collins, CO,USA
| | - Alexander Theiler
- Department of Emergency Medicine, Emergency Physicians of the Rockies, Fort Collins CO,USA
| | - Lindsey Spears
- Department of Pharmacy, Poudre Valley Hospital, Fort Collins, CO,USA
| | - Joshua Werth
- Department of Pharmacy, Poudre Valley Hospital, Fort Collins, CO,USA
| | - Erin Meister
- Department of Pharmacy, Poudre Valley Hospital, Fort Collins, CO,USA
| | - Matthew Steven Martin
- Department of Emergency Medicine, Emergency Physicians of the Rockies, Fort Collins CO,USA
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20
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Marino KK, Crowley KE, Tran LK, Sylvia D, Dell'Orfano H, DeGrado JR, Szumita PM. Intravenous levothyroxine stewardship program at a tertiary academic medical center. Am J Health Syst Pharm 2021; 78:1200-1206. [PMID: 33821921 DOI: 10.1093/ajhp/zxab155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Based on the pharmacokinetic profile of levothyroxine, a 3-day hold guideline for adult patients ordered for intravenous (IV) levothyroxine was implemented at a tertiary academic medical center. The purpose of this study was to evaluate the impact of the implementation of an IV levothyroxine hold guideline. METHODS This single-center, retrospective analysis identified patients ordered for IV levothyroxine during a 13-week period before and after implementation of the guideline. The primary outcome was guideline adherence, defined as full implementation of the 3-day hold. Secondary outcomes included the number of IV levothyroxine administrations avoided in the post-guideline group, extrapolated yearly cost avoidance (EYCA) after guideline implementation, reasons for guideline non-adherence, and number of safety reports involving IV levothyroxine. RESULTS A total of 166 and 134 patients met inclusion criteria for the pre- and post-guideline groups, respectively. Guideline adherence was observed in 94 (70.1%) patients, resulting in 276 vials saved in the 13-week post-guideline period, which translated to an EYCA of $139,877. Forty orders (29.9%) were non-adherent to the guideline, with the most common reason stated as nil per os (NPO). No difference in safety outcomes was seen between the pre- and post-guideline groups, as evidenced by 1 safety report in each group. CONCLUSION We observed a high rate of adherence to an IV levothyroxine hold guideline. This was associated with a substantial cost savings over the study period with no increase in reported safety events. To our knowledge, this is the first published report of an inpatient IV levothyroxine 3-day hold guideline.
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Affiliation(s)
- Kaylee K Marino
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Kaitlin E Crowley
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Lena K Tran
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Daniel Sylvia
- Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
| | - Heather Dell'Orfano
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Jeremy R DeGrado
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Paul M Szumita
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
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21
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Hasegawa S, Tagashira Y, Murakami S, Urayama Y, Takamatsu A, Nakajima Y, Honda H. Antimicrobial Time-Out for Vancomycin by Infectious Disease Physicians Versus Clinical Pharmacists: A Before-After Crossover Trial. Open Forum Infect Dis 2021; 8:ofab125. [PMID: 34189155 PMCID: PMC8232390 DOI: 10.1093/ofid/ofab125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 03/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background The present study assessed the impact of time-out on vancomycin use and compared the strategy's efficacy when led by pharmacists versus infectious disease (ID) physicians at a tertiary care center. Methods Time-out, consisting of a telephone call to inpatient providers and documentation of vancomycin use >72 hours, was performed by ID physicians and clinical pharmacists in the Departments of Medicine and Surgery/Critical Care. Patients in the Department of Medicine were assigned to the clinical pharmacist-led arm, and patients in the Department of Surgery/Critical Care were assigned to the ID physician-led arm in the initial, 6-month phase and were switched in the second, 6-month phase. The primary outcome was the change in weekly days of therapy (DOT) per 1000 patient-days (PD), and vancomycin use was compared using interrupted time-series analysis. Results Of 587 patients receiving vancomycin, 132 participated, with 79 and 53 enrolled in the first and second phases, respectively. Overall, vancomycin use decreased, although the difference was statistically nonsignificant (change in slope, -0.25 weekly DOT per 1000 PD; 95% confidence interval [CI], -0.68 to 0.18; P = .24). The weekly vancomycin DOT per 1000 PD remained unchanged during phase 1 but decreased significantly in phase 2 (change in slope, -0.49; 95% CI, -0.84 to -0.14; P = .007). Antimicrobial use decreased significantly in the surgery/critical care patients in the pharmacist-led arm (change in slope, -0.77; 95% CI, -1.33 to -0.22; P = .007). Conclusions Vancomycin time-out was moderately effective, and clinical pharmacist-led time-out with surgery/critical care patients substantially reduced vancomycin use.
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Affiliation(s)
- Shinya Hasegawa
- Division of Infectious Diseases, Fuchu, Tokyo, Japan.,Department of Infection Control Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
| | - Yasuaki Tagashira
- Division of Infectious Diseases, Fuchu, Tokyo, Japan.,Department of Infection Control Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan.,Department of Microbiology, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Shutaro Murakami
- Department of Infection Control Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan.,Department of Pharmacy, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
| | - Yasunori Urayama
- Department of Pharmacy, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
| | - Akane Takamatsu
- Division of Infectious Diseases, Fuchu, Tokyo, Japan.,Department of Infection Control Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
| | - Yuki Nakajima
- Division of Infectious Diseases, Fuchu, Tokyo, Japan
| | - Hitoshi Honda
- Division of Infectious Diseases, Fuchu, Tokyo, Japan.,Department of Infection Control Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
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22
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Short and long term impact of combining restrictive and enabling interventions to reduce aztreonam consumption in a community hospital. Int J Clin Pharm 2021; 43:1345-1351. [PMID: 33677793 PMCID: PMC7937360 DOI: 10.1007/s11096-021-01257-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/22/2021] [Indexed: 10/28/2022]
Abstract
Background Antimicrobial stewardship initiatives combining restrictive and enabling components may be an effective strategy to achieve short- and long-term objectives. Aztreonam, a relatively high-cost antipseudomonal antibiotic, is an appropriate target for stewardship initiatives based on propensity for overuse in penicillin allergy, an activity profile often warranting additional empiric gram-negative and gram-positive coverage, and a unique durability to Ambler class B metallo-beta-lactamases. Objective Analyze the immediate and long-term impact on aztreonam prescribing of combining restrictive and enabling interventions. Setting Single 233-bed community hospital with 45 adult intensive care unit beds in Nashville, Tennessee. Method Retrospective, interrupted time series analysis comparing all patients receiving aztreonam prior to intervention between January 1, 2010 and September 30, 2011 and following intervention between October 1, 2011 and September 30, 2019. Quarterly defined daily doses/1000 adjusted patient days and microbiology laboratory annual surveillance data were utilized for analysis. Main outcome measure Post-intervention change in trend of aztreonam consumption. Results Following intervention, a significant decline in aztreonam consumption was observed (- 1.97 defined daily doses/1000 adjusted patient days; p = 0.003) resulting in a sustained decrease in aztreonam consumption from 2011 (3rd quarter) to 2019 (3rd quarter) from 15.2 to 0.26 defined daily doses/1000 adjusted patient days. Short-term group 2 carbapenem consumption increased (p = 0.044). Pseudomonas aeruginosa susceptibility to aztreonam improved from 2011 to 2018 (72% vs. 84%; p = 0.0004) without deleterious effects to alternative antipseudomonal beta-lactams. Conclusion Combining restrictive and enabling interventions had immediate and sustained impact on aztreonam consumption with P. aeruginosa susceptibility improvement.
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Interventions to optimize antimicrobial stewardship. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e46. [PMID: 36168471 PMCID: PMC9495515 DOI: 10.1017/ash.2021.210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/27/2021] [Indexed: 12/14/2022]
Abstract
Abstract
Developing and improving an antimicrobial stewardship program successfully requires evaluation of numerous factors. As technology progresses and our understanding of antimicrobial resistance grows, careful consideration should be taken to ensure that a program meets the needs of the institution and is achievable given the available resources. In this review, we explore fundamental initiatives and strategies for both new and established antimicrobial stewardship programs, including the specific areas to target and key elements required for sustainable implementation.
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Olans RD, Hausman NB, Olans RN. Nurses and Antimicrobial Stewardship: Past, Present, and Future. Infect Dis Clin North Am 2020; 34:67-82. [PMID: 32008696 DOI: 10.1016/j.idc.2019.10.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Successful antimicrobial stewardship programs must be a truly collaborative multidisciplinary team effort. Nurses have critical contributions and are recognized more in publications about antimicrobial stewardship. Examination of patient care workflow patterns indicates the central role of nurses in the application of stewardship concepts in patient care. Education about antimicrobial resistance and antimicrobial stewardship is important not only for nurses and other health care providers but also for the general public. Analysis of the health care workforce population shows the importance of integrating this largest segment of health care providers in the routine daily care of patients into all stewardship efforts.
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Affiliation(s)
- Rita Drummond Olans
- MGH Institute of Health Professions - School of Nursing, 36 First Avenue, Boston, MA 02129, USA.
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Who listens and who doesn't? Factors associated with adherence to antibiotic stewardship intervention in a Singaporean tertiary hospital. J Glob Antimicrob Resist 2020; 22:391-397. [PMID: 32311504 DOI: 10.1016/j.jgar.2020.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/12/2020] [Accepted: 04/09/2020] [Indexed: 11/20/2022] Open
Abstract
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.
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Amélioration de l’adéquation des antibiothérapies aux recommandations et de leur réévaluation par une action pluridisciplinaire : étude prospective dans un service de médecine interne. Rev Med Interne 2020; 41:8-13. [DOI: 10.1016/j.revmed.2019.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 08/30/2019] [Accepted: 09/23/2019] [Indexed: 11/24/2022]
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Hamdy RF, Neal W, Nicholson L, Ansusinha E, King S. Pediatric Nurses' Perceptions of Their Role in Antimicrobial Stewardship: A Focus Group Study. J Pediatr Nurs 2019; 48:10-17. [PMID: 31200142 DOI: 10.1016/j.pedn.2019.05.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/30/2019] [Accepted: 05/30/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE To explore pediatric nurses' perceptions of their role in antimicrobial stewardship. DESIGN AND METHODS Twelve focus group sessions were conducted at a freestanding children's hospital including 90 nurses across a range of settings, units, and years of experience. Transcripts of the focus group sessions were jointly coded, from which themes were developed. RESULTS Specific nursing roles in antibiotic stewardship identified include: (1) advocating for the patient, (2) communicating with the team, (3) administering medications safely, (4) educating caregivers, and (5) educating themselves. Identified barriers hindering effective execution of these roles include inconsistent inclusion on rounds and lack of institutional protocols for antibiotic use. CONCLUSION Nurses easily identified numerous daily nursing tasks that fit within the framework of antimicrobial stewardship and desired additional education and engagement in antibiotic stewardship. IMPLICATIONS Engaging nurses could improve the structure of antibiotic stewardship programs and break down the barriers that keep nurses from fulfilling their role.
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Affiliation(s)
- Rana F Hamdy
- Division of Infectious Diseases, Children's National Health System, Washington, DC, United States of America; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, United States of America.
| | - Wayne Neal
- Division of Nursing, Children's National Health System, Washington, DC, United States of America.
| | - Laura Nicholson
- Division of Nursing, Children's National Health System, Washington, DC, United States of America.
| | - Emily Ansusinha
- Division of Infectious Diseases, Children's National Health System, Washington, DC, United States of America.
| | - Simmy King
- Division of Nursing, Children's National Health System, Washington, DC, United States of America.
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Siegfried J, Merchan C, Scipione MR, Papadopoulos J, Dabestani A, Dubrovskaya Y. Role of postgraduate year 2 pharmacy residents in providing weekend antimicrobial stewardship coverage in an academic medical center. Am J Health Syst Pharm 2019; 74:417-423. [PMID: 28274985 DOI: 10.2146/ajhp160133] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The integration of pharmacy residents into an antimicrobial stewardship program (ASP) is described, and data on the residents' ASP interventions and outcomes are reported. SUMMARY ASP coverage of nighttime, holiday, and weekend shifts is often provided by infectious diseases (ID) medical fellows and staff pharmacists, potentially leading to inconsistent stewardship practices. As part of an initiative by a large urban hospital to provide around-the-clock, comprehensive ASP services 7 days a week, postgraduate year 2 (PGY2) pharmacy residents in ID or critical care were assigned to provide ASP coverage on weekends. Over a 12-month period, residents providing ASP weekend coverage documented a total of 1,443 interventions, of which 1,000 (69%) were pursuant to 72-hour prospective audit and feedback review and 443 (31%) occurred during ASP phone coverage. A comparison of overall antimicrobial utilization (mean ± S.D. days of therapy [DOT] per 1,000 patient-days [PD]) before and after implementation of resident ASP coverage on weekends showed a decrease in aggregate antimicrobial use from 799.3 ± 46.8 to 740.7 ± 17.3 DOT/1,000 PD (a difference of 58.6 DOT/1,000 PD, p = 0.08), with a corresponding decline in the incidence of hospital-onset Clostridium difficile infection (from 1.18 cases to 0.9 case per 1,000 PD). CONCLUSION By expanding the hospital's ASP services by assigning PGY2 pharmacy residents to weekend coverage, the institution was able to provide high-level clinical care 7 days per week, which benefited both patients and PGY2 pharmacy residents while meeting national ASP regulatory requirements.
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Affiliation(s)
- Justin Siegfried
- Department of Pharmacy, NYU Langone Medical Center, New York, NY
| | - Cristian Merchan
- Department of Pharmacy, NYU Langone Medical Center, New York, NY
| | - Marco R Scipione
- Department of Pharmacy, NYU Langone Medical Center, New York, NY
| | | | - Arash Dabestani
- Department of Pharmacy, NYU Langone Medical Center, New York, NY
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Nathwani D, Varghese D, Stephens J, Ansari W, Martin S, Charbonneau C. Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review. Antimicrob Resist Infect Control 2019; 8:35. [PMID: 30805182 PMCID: PMC6373132 DOI: 10.1186/s13756-019-0471-0] [Citation(s) in RCA: 209] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/11/2019] [Indexed: 12/21/2022] Open
Abstract
Background Hospital antimicrobial stewardship programs (ASPs) aim to promote judicious use of antimicrobials to combat antimicrobial resistance. For ASPs to be developed, adopted, and implemented, an economic value assessment is essential. Few studies demonstrate the cost-effectiveness of ASPs. This systematic review aimed to evaluate the economic and clinical impact of ASPs. Methods An update to the Dik et al. systematic review (2000–2014) was conducted on EMBASE and Medline using PRISMA guidelines. The updated search was limited to primary research studies in English (30 September 2014–31 December 2017) that evaluated patient and/or economic outcomes after implementation of hospital ASPs including length of stay (LOS), antimicrobial use, and total (including operational and implementation) costs. Results One hundred forty-six studies meeting inclusion criteria were included. The majority of these studies were conducted within the last 5 years in North America (49%), Europe (25%), and Asia (14%), with few studies conducted in Africa (3%), South America (3%), and Australia (3%). Most studies were conducted in hospitals with 500–1000 beds and evaluated LOS and change in antibiotic expenditure, the majority of which showed a decrease in LOS (85%) and antibiotic expenditure (92%). The mean cost-savings varied by hospital size and region after implementation of ASPs. Average cost savings in US studies were $732 per patient (range: $2.50 to $2640), with similar trends exhibited in European studies. The key driver of cost savings was from reduction in LOS. Savings were higher among hospitals with comprehensive ASPs which included therapy review and antibiotic restrictions. Conclusions Our data indicates that hospital ASPs have significant value with beneficial clinical and economic impacts. More robust published data is required in terms of implementation, LOS, and overall costs so that decision-makers can make a stronger case for investing in ASPs, considering competing priorities. Such data on ASPs in lower- and middle-income countries is limited and requires urgent attention.
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Affiliation(s)
- Dilip Nathwani
- 1Ninewells Hospital and Medical School, Dundee, DD19SY UK
| | - Della Varghese
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
| | - Jennifer Stephens
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
| | | | - Stephan Martin
- 2Pharmerit International, 4350 East West Highway, Suite 1100, Bethesda, MD 20184 USA
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Mostaghim M, Snelling T, Bajorek B. Factors associated with adherence to antimicrobial stewardship after-hours. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2018; 27:180-190. [PMID: 30281178 DOI: 10.1111/ijpp.12486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 08/08/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Assess restricted antimicrobials acquired after standard working hours for adherence to antimicrobial stewardship (AMS) and identify factors associated with increased likelihood of adherence at the time of acquisition, and the next standard working day. METHODS All documented antimicrobials acquired from a paediatric hospital after-hours drug room from 1 July 2014 to 30 June 2015 were reconciled with records of AMS approval, and documented AMS review in the medical record. KEY FINDINGS Of the 758 antimicrobial acquisitions from the after-hours drug room, 62.3% were restricted. Only 29% were AMS adherent at the time of acquisition, 15% took place despite documented request for approval by a pharmacist. Antimicrobials for respiratory patients (OR 3.10, 95% CI 1.68-5.5) and antifungals (2.48, 95% CI 1.43-4.30) were more likely to be AMS adherent. Half of the acquisitions that required review the next standard working day were adherent to AMS (51.8%, 129/249). Weekday acquisitions (2.10, 95% CI 1.20-3.69) and those for patients in paediatric intensive care (2.26, 95% CI 1.07-4.79) were associated with AMS adherence. Interactions with pharmacists prior to acquisition did not change the likelihood of AMS adherence the next standard working day. Access to restricted antimicrobial held as routine ward stock did not change the likelihood of AMS adherence at the time of acquisition, or the next standard working day. CONCLUSION Restricted antimicrobials acquired after-hours are not routinely AMS adherent at the time of acquisition or the next standard working day, limiting opportunities for AMS involvement.
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Affiliation(s)
- Mona Mostaghim
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia.,Department of Pharmacy, Sydney Children's Hospital, Randwick, Sydney, NSW, Australia
| | - Thomas Snelling
- Department of Infectious Diseases, Princess Margaret Hospital for Children, Perth, WA, Australia.,Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia.,Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - Beata Bajorek
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
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A noninferiority cluster-randomized controlled trial on antibiotic postprescription review and authorization by trained general pharmacists and infectious disease clinical fellows. Infect Control Hosp Epidemiol 2018; 39:1154-1162. [PMID: 30156171 DOI: 10.1017/ice.2018.198] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE We compared the effectiveness of antibiotic postprescription review and authorization (PPRA) determined by infectious disease (ID) clinical fellows with that of trained general pharmacists. METHODS We conducted a noninferiority cluster-randomized controlled trial in 6 general medical wards at Siriraj Hospital in Bangkok, Thailand. Three wards were randomly assigned to the intervention (ie, the pharmacist PPRA group), and another 3 wards were assigned to the control (ie, the fellow PPRA group). We enrolled all patients in the study wards who received 1 or more doses of the targeted antibiotics: piperacillin/tazobactam, imipenem/cilastatin, and meropenem. The noninferiority margin was 10% for the favorable clinical response and 1.5 defined daily doses (DDDs) for the targeted antibiotics. RESULTS We enrolled 303 patients in the pharmacist PPRA group and 307 patients in the ID fellow PPRA group. The baseline and clinical characteristics were similar in the 2 groups. The difference in the favorable response of patients who received the targeted antibiotics (ie, the pharmacist PPRA group minus the fellow PPRA group) was 5.15% (95% confidence interval [CI], -2.69% to 12.98%); the difference in the DDD of targeted antibiotic use (ie, the pharmacist PPRA group minus the fellow PPRA group) was 0.62 (95% CI, -1.57 to 2.82). We observed no significant difference in the DDD of overall antibiotics, 28-day mortality, 28-day ID-related mortality, favorable microbiological outcome, or antibiotic-associated complications. CONCLUSIONS We confirmed the noninferiority of pharmacist PPRA in terms of favorable clinical response; however, noninferiority in targeted antibiotic consumption could not be established. Therefore, using trained general pharmacists rather than ID clinical fellows could be an alternative in a resource-limited setting. CLINICAL TRIALS REGISTRATION clinicaltrials.gov identifier: NCT 01797133.
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Parker SK, Hurst AL, Thurm C, Millard M, Jenkins TC, Child J, Dugan C. Anti-infective Acquisition Costs for a Stewardship Program: Getting to the Bottom Line. Clin Infect Dis 2018; 65:1632-1637. [PMID: 29020143 DOI: 10.1093/cid/cix631] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/18/2017] [Indexed: 01/12/2023] Open
Abstract
Background Though antimicrobial stewardship programs (ASPs) are in place for patient safety, financial justification is often required. In 2016, the Infectious Diseases Society of America (IDSA) recommended that anti-infective costs be measured by patient-level administration data normalized for patient census. Few publications use this methodology. Here, we aim to compare 3 methods of drug cost analysis during 3 phases of an ASP as an example of this recommendation's implementation. Methods At a freestanding pediatric hospital, we retrospectively assessed anti-infective cost using pharmacy purchasing data, patient-level administration data from the electronic medical record (EMR), and patient-level administration data from the Pediatric Hospital Information Systems (PHIS) database, all normalized to patient census. Costs pre-ASP, while planning the ASP, and post-ASP were then compared for each method. Results Significant differences in costs between the methods were observed. Pharmacy purchasing endorsed minimal financial benefit (decrease planning to post-ASP of $590 dollars per 1000 patient-days), while the EMR and PHIS data endorsed a decrease of $12785 and $21380 per 1000 patient-days, respectively, for a total yearly cost savings of $54656 for pharmacy purchasing data, $1184336 for EMR data, and $2117522 for PHIS data. Conclusions Pharmacy purchasing data underestimated cost savings compared with EMR and PHIS data, while EMR and PHIS data were comparable in magnitude of savings. At Children's Hospital Colorado, savings justified the full cost of the ASP. EMR patient-level administration data, normalized to patient census, offers a readily available and standardized measure of anti-infective costs over time.
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Affiliation(s)
- Sarah K Parker
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Epidemiology, University of Colorado School of Medicine
| | - Amanda L Hurst
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kansas
| | - Matthew Millard
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Timothy C Jenkins
- Department of Medicine, Division of Infectious Diseases, University of Colorado Hospital, University of Colorado School of Medicine, Aurora.,Denver Health, Colorado
| | - Jason Child
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Casey Dugan
- Department of Pharmacy, Children's Hospital Colorado, Aurora
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McElligott M, Welham G, Pop-Vicas A, Taylor L, Crnich CJ. Antibiotic Stewardship in Nursing Facilities. Infect Dis Clin North Am 2018; 31:619-638. [PMID: 29079152 DOI: 10.1016/j.idc.2017.07.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Misuse and overuse of antibiotic therapy is a frequent cause of resident harm in nursing facilities. As a result, newly released policy and regulatory initiatives will require antibiotic stewardship programs (ASPs) in nursing facilities. Although implementing ASPs can be challenging, improving the quality of antibiotic prescribing is achievable in this setting. The authors review the determinants of antibiotic prescribing in nursing facilities, strategies to improve antibiotic prescribing in this setting, current status of ASPs in nursing facilities, and steps that facilities can take to enhance existing ASP structure and process.
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Affiliation(s)
- Miranda McElligott
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA
| | - Grace Welham
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA
| | - Aurora Pop-Vicas
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA; University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Lyndsay Taylor
- University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Christopher J Crnich
- University of Wisconsin, School of Medicine and Public Health, Madison, WI, USA; University of Wisconsin Hospital and Clinics, Madison, WI, USA; William S. Middleton Veterans Affairs Hospital, Madison, WI, USA.
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Improving Patient Safety Through Antibiotic Stewardship: The Veterans Health Administration Leads the Way, Again. Infect Control Hosp Epidemiol 2017; 38:521-523. [PMID: 28421978 DOI: 10.1017/ice.2017.38] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Jump RLP, Gaur S, Katz MJ, Crnich CJ, Dumyati G, Ashraf MS, Frentzel E, Schweon SJ, Sloane P, Nace D. Template for an Antibiotic Stewardship Policy for Post-Acute and Long-Term Care Settings. J Am Med Dir Assoc 2017; 18:913-920. [PMID: 28935515 DOI: 10.1016/j.jamda.2017.07.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 01/22/2023]
Abstract
In response to a rising concern for multidrug resistance and Clostridium difficile infections, the Centers for Medicare and Medicaid services (CMS) will require all long-term care (LTC) facilities to establish an antibiotic stewardship program by November 2017. Thus far, limited evidence describes implementation of antibiotic stewardship in LTC facilities, mostly in academic- or hospital-affiliated settings. To support compliance with CMS requirements and aid facilities in establishing a stewardship program, the Infection Advisory Committee at AMDA-The Society for Post-Acute and Long-Term Care Medicine, has developed an antibiotic stewardship policy template tailored to the LTC setting. The intent of this policy, which can be adapted by individual facilities, is to help LTC facilities implement an antibiotic stewardship policy that will meet or exceed CMS requirements. We also briefly discuss implementation of an antibiotic stewardship program in LTC settings, including a list of free resources to support those efforts.
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Affiliation(s)
- Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC), Specialty Care Center of Innovation and Infectious Disease Section, Louis Stokes Cleveland Veterans Affairs Medical Center (VAMC), Cleveland, OH; Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH.
| | - Swati Gaur
- New Horizons Nursing Facilities, Gainesville, GA
| | - Morgan J Katz
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher J Crnich
- University of Wisconsin School of Medicine and Public Health, Department of Medicine, Madison, WI; William S. Middleton VA Hospital, Department of Medicine, Madison, WI
| | - Ghinwa Dumyati
- Infectious Diseases Division and Center for Community Health, University of Rochester Medical Center, Rochester, NY
| | - Muhammad S Ashraf
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | | | | | - Philip Sloane
- Department of Family Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - David Nace
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
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Toma M, Davey PG, Marwick CA, Guthrie B. A framework for ensuring a balanced accounting of the impact of antimicrobial stewardship interventions. J Antimicrob Chemother 2017; 72:3223-3231. [DOI: 10.1093/jac/dkx312] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Patel D, Macdougall C. How to Make Antimicrobial Stewardship Work: Practical Considerations for Hospitals of All Sizes. Hosp Pharm 2017. [DOI: 10.1310/hpj4511-s10] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Implementation of an antimicrobial stewardship program in a hospital is complicated by a variety of challenges. Key issues facing stewardship personnel include recruiting personnel and building relationships, establishing program metrics, selecting stewardship strategies, working with clinicians, reporting results, and adapting the program. These issues can present different challenges at community hospitals and academic medical centers. Strategies for overcoming these challenges require accounting for the unique characteristics of each institution.
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Affiliation(s)
- Dimple Patel
- Infectious Diseases, Comprehensive Pharmacy Services, John F. Kennedy Medical Center, Edison, New Jersey
| | - Conan Macdougall
- University of California San Francisco School of Pharmacy, San Francisco, California
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Durham SH, Wingler MJ, Eiland LS. Appropriate Use of Ceftriaxone in the Emergency Department of a Veteran’s Health Care System. J Pharm Technol 2017. [DOI: 10.1177/8755122517720293] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Ceftriaxone is a third-generation cephalosporin commonly utilized as an empiric antibiotic treatment option in the emergency department (ED). Overuse can lead to decreased susceptibility and emergence of multidrug-resistant pathogens, increased costs, and unnecessary adverse effects. Objective: The purpose of this project was to determine the appropriateness of ceftriaxone usage in the ED of a veteran’s health care system. Methods: This retrospective chart review included all veterans who received at least one dose of ceftriaxone in the ED between June 1, 2014, and June 1, 2015. The primary outcome was the percentage of appropriate ceftriaxone use. Usage appropriateness was determined on a case-by-case basis by examining current published guidelines and local recommendations based on the institutional antibiogram. Results: Ceftriaxone was prescribed for a wide variety of indications and was determined to be inappropriately prescribed in 164 patients (53%). The most common reason for inappropriate prescribing was lack of a first-line indication for ceftriaxone (64%). Only 120 patients (38.5%) exhibited systemic signs of infection based on vital signs and laboratory parameters, and 25 patients (8%) likely did not require antibiotic therapy at all. Conclusions: Ceftriaxone was used inappropriately in more than half of the patients who received the drug in the ED. The literature on the prescribing habits for ceftriaxone is limited in the United States, but these results are similar to studies conducted in other countries. Attempts should be made to educate prescribers on appropriate indications for the use of ceftriaxone.
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Molloy L, McGrath E, Thomas R, Kaye KS, Rybak MJ. Acceptance of Pharmacist-Driven Antimicrobial Stewardship Recommendations With Differing Levels of Physician Involvement in a Children's Hospital. Clin Pediatr (Phila) 2017; 56:744-751. [PMID: 27872355 DOI: 10.1177/0009922816678598] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This prospective interventional study assessed whether a pharmacist-physician team in a setting where physician support is not provided for daily antimicrobial stewardship (AS) activities would improve later acceptance of pharmacist recommendations once multidisciplinary efforts stopped and the pharmacist again worked alone. This was measured by AS recommendation acceptance rate during 3 study phases wherein AS recommendations were provided by a pharmacist alone (Phase 1), a pharmacist and a physician together (Phase 2), and then a pharmacist alone again (Phase 3). Recommendations were well accepted across all study phases with no differences in recommendation appropriateness or patient clinical outcomes. Prescribers were significantly ( P = .045) more likely to accept recommendations to de-escalate treatment during Phase 3 than during Phase 1. Independently pharmacist-driven AS efforts were generally successful, and recommendations for antimicrobial de-escalation were better accepted after the involvement of an infectious diseases physician.
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Affiliation(s)
- Leah Molloy
- 1 Children's Hospital of Michigan, Detroit, MI, USA.,3 Detroit Medical Center, Detroit, MI, USA
| | - Eric McGrath
- 1 Children's Hospital of Michigan, Detroit, MI, USA.,2 Wayne State University, Detroit, MI, USA.,3 Detroit Medical Center, Detroit, MI, USA
| | | | - Keith S Kaye
- 2 Wayne State University, Detroit, MI, USA.,3 Detroit Medical Center, Detroit, MI, USA
| | - Michael J Rybak
- 2 Wayne State University, Detroit, MI, USA.,3 Detroit Medical Center, Detroit, MI, USA
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Impact of a multifaceted antimicrobial stewardship program: A front-line ownership driven quality improvement project in a large urban emergency department. CAN J EMERG MED 2017; 19:441-449. [PMID: 28399946 DOI: 10.1017/cem.2017.11] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Antibiotic overuse has promoted growing rates of antimicrobial resistance and secondary antibiotic-associated infections such as Clostridium difficile (C. difficile). Antimicrobial stewardship programs (ASPs) are effective in reducing antimicrobial use in the inpatient setting; however, the unique environment of the emergency department (ED) lends itself to challenges for successful implementation. Front-line ownership (FLO) methodology has been shown to be a potentially effective strategy for the implementation of inpatient ASPs through an iterative multi-pronged approach driven by front-line providers. OBJECTIVE To determine whether a FLO approach to antimicrobial stewardship in the ED can alter antimicrobial usage. METHODS Interventions were driven by ED physicians and facilitated by Infectious Diseases Division physicians from the hospital's ASP using FLO principles. Measured end points included antibiotic usage in the ED as measured by defined daily doses, and rates of urine culture sent from the ED. RESULTS There was a step-wise significant reduction in the use of azithromycin (p=0.006), ceftriaxone (p=0.045), ciprofloxacin (p=0.034), and moxifloxacin (p=0.008). There was also a significant reduction in rates of urine cultures (p<0.001) by 2.26 urine cultures per 100 ED patient visits. CONCLUSIONS FLO offers a promising approach to successful implementation of an ASP in the ED. Future studies would be important to evaluate the generalizability of the FLO approach to ASP development in other EDs and to determine strategies to improve the sustainability of reductions in antimicrobial use.
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Barlam TF, DiVall M. Antibiotic-Stewardship Practices at Top Academic Centers Throughout the United States and at Hospitals Throughout Massachusetts. Infect Control Hosp Epidemiol 2017; 27:695-703. [PMID: 16807844 DOI: 10.1086/503346] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2004] [Accepted: 03/28/2005] [Indexed: 11/04/2022]
Abstract
Objective.Improvements in antibiotic prescribing to reduce bacterial resistance and control hospital costs is a growing priority, but the way to accomplish this is poorly defined. Our goal was to determine whether certain antibiotic stewardship interventions were universally instituted and accepted at top US academic centers and to document what interventions, if any, are used at both teaching and community hospitals within a geographic area.Design.Two surveys were conducted. In survey 1, detailed phone interviews were performed with the directors of antibiotic stewardship programs at 22 academic medical centers that are considered among the best for overall medical care in the United States or as leaders in antibiotic stewardship programs. In survey 2, teaching and community hospitals throughout Massachusetts were surveyed to ascertain what antibiotic oversight program components were present.Results.In survey 1, each of the 22 participating hospitals had instituted interventions to improve antibiotic prescribing, but none of the interventions were universally accepted as essential or effective. In survey 2, of 97 surveys that were mailed to prospective participants, a total of 54 surveys from 19 teaching hospitals and 35 community hospitals were returned. Ninety-five percent of the teaching hospitals had a restricted formulary, compared with 49% of the community hospitals, and 89% of teaching hospitals had an antibiotic approval process, compared with 29% of community hospitals.Conclusion.There was great variability among the approaches to the oversight of antibiotic prescribing at major academic hospitals. Antibiotic management interventions were lacking in more than half of the Massachusetts community hospitals surveyed. More research is needed to define the best antibiotic stewardship interventions for different hospital settings.
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Affiliation(s)
- Tamar F Barlam
- School of Medicine, Boston University Medical Center, Boston, MA 02118, USA.
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Wattal C, Javeri Y, Goel N, Dhar D, Saxena S, Singh S, Oberoi JK, Rao BK, Mathur P, Manchanda V, Nangia V, Kapil A, Rattan A, Ghosh S, Singh O, Singh V, Kaur I, Datta S, Gupta SS. Convergence of Minds: For Better Patient Outcome in Intensive Care Unit Infections. Indian J Crit Care Med 2017; 21:154-159. [PMID: 28400686 PMCID: PMC5363104 DOI: 10.4103/ijccm.ijccm_365_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There is emergence of resistance to the last-line antibiotics such as carbapenems in Intensive Care Units (ICUs), leaving little effective therapeutic options. Since there are no more newer antibiotics in the armamentarium in the near future, it has become imperative that we harness the interdisciplinary knowledge for the best clinical outcome of the patient. AIMS The aim of the conference was to utilize the synergies between the clinical microbiologists and critical care specialists for better patient care and clinical outcome. MATERIALS AND METHODS A combined continuing medical education program (CME) under the aegis of the Indian Association of Medical Microbiologists - Delhi Chapter and the Indian Society of Critical Care Medicine, Delhi and national capital region was organized to share their expertise on the various topics covering epidemiology, diagnosis, management, and prevention of hospital-acquired infections in ICUs. RESULTS It was agreed that synergy between the clinical microbiologists and critical care medicine is required in understanding the scope of laboratory tests, investigative pathway testing, hospital epidemiology, and optimum use of antibiotics. A consensus on the use of rapid diagnostics such as point-of-care tests, matrix-assisted laser desorption ionization-time of flight mass spectrometry, and molecular tests for the early diagnosis of infectious disease was made. It was agreed that stewardship activities along with hospital infection control practices should be further strengthened for better utilization of the antibiotics. Through this CME, we identified the barriers and actionables for appropriate antimicrobial usage in Indian ICUs. CONCLUSIONS A close coordination between clinical microbiology and critical care medicine opens up avenues to improve antimicrobial prescription practices.
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Affiliation(s)
- Chand Wattal
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
- Address for correspondence: Dr. Chand Wattal, Department of Clinical Microbiology and Immunology, Sir Ganga Ram Hospital, New Delhi - 110 060, India. E-mail:
| | - Yash Javeri
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Neeraj Goel
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Debashish Dhar
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Sonal Saxena
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Sarman Singh
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | | | - B. K. Rao
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Purva Mathur
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Vikas Manchanda
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Vivek Nangia
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Arti Kapil
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Ashok Rattan
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Supradip Ghosh
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Omender Singh
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Vinod Singh
- Indian Society of Critical Care Medicine, New Delhi, India
| | - Iqbal Kaur
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Sanghamitra Datta
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
| | - Sharmila Sen Gupta
- Indian Association of Medical Microbiologists – Delhi Chapter, New Delhi, India
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Abstract
Antimicrobial stewardship is a bundle of integrated interventions employed to optimize the use of antimicrobials in health care settings. While infectious-disease-trained physicians, with clinical pharmacists, are considered the main leaders of antimicrobial stewardship programs, clinical microbiologists can play a key role in these programs. This review is intended to provide a comprehensive discussion of the different components of antimicrobial stewardship in which microbiology laboratories and clinical microbiologists can make significant contributions, including cumulative antimicrobial susceptibility reports, enhanced culture and susceptibility reports, guidance in the preanalytic phase, rapid diagnostic test availability, provider education, and alert and surveillance systems. In reviewing this material, we emphasize how the rapid, and especially the recent, evolution of clinical microbiology has reinforced the importance of clinical microbiologists' collaboration with antimicrobial stewardship programs.
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Impact of Two Different Antimicrobial Stewardship Methods on Frequency of Streamlining Antimicrobial Agents in Patients with Bacteremia. Infect Control Hosp Epidemiol 2016; 38:89-95. [PMID: 27825392 DOI: 10.1017/ice.2016.243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess the likelihood of antimicrobial streamlining between 2 antimicrobial stewardship methods. DESIGN Retrospective cohort study. SETTING Large academic medical center. METHODS Frequency and time to antimicrobial streamlining were compared during a prior authorization and a prospective audit period. Streamlining was defined as an antimicrobial change to a narrower agent if available or to a broader agent if the isolate was resistant to empiric therapy. Patients included were ≥18 years old with monomicrobial bacteremia with S. aureus, Enterococcus spp., or any aerobic Gram-negative organism. RESULTS A total of 665 cases of bacteremia met inclusion criteria. Frequency of streamlining was similar between periods for all cases of bacteremia (audit vs restriction: 60.7% vs 53.2%; P=.12), S. aureus bacteremia (73.2% vs 76.9%; P=.671), and Enterococcus bacteremia (81.6% vs 71.9%; P=.335). Compared to restriction, the audit period was associated with an increased frequency of streamlining for cases of Gram-negative bacteremia (51.4% vs 35.6%; odds ratio [OR], 1.85; 95% confidence interval [CI], 1.06-3.25), those on the medical service (67.9% vs 53.1%; OR, 1.86; 95% CI, 1.09-3.16), and those admitted through the emergency department (71.6% vs 51.4%; OR, 2.32; 95% CI, 1.24-4.34). Characteristics associated with increased streamlining included: absence of β-lactam allergy (P<.001), Gram-negative bacteremia (P<.001), admission through the emergency department (P=.001), and admission to a medical service (P=.011). CONCLUSIONS Compared with prior authorization, prospective audit increased antimicrobial streamlining for cases of Gram-negative bacteremia, those admitted through the emergency department, and those admitted to a medical but not surgical service. Infect Control Hosp Epidemiol 2016:1-7.
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Otto C, Hirl B, Schweitzer S, Gleich S. Antibiotika-Verbrauchs-Surveillance und Antibiotic Stewardship – Stand der Umsetzung in Münchner Kliniken. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016; 59:1549-1555. [DOI: 10.1007/s00103-016-2461-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Rocchio MA, Schurr JW, Hussey AP, Szumita PM. Intravenous Immune Globulin Stewardship Program at a Tertiary Academic Medical Center. Ann Pharmacother 2016; 51:135-139. [DOI: 10.1177/1060028016673071] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: In October 2010, a pharmacist-driven stewardship program was implemented at the Brigham and Women’s Hospital to ensure continued adherence to the prescribing guideline, focusing on indications for intravenous immune globulin (IVIG) use and dosing per ideal body weight. Objective: The primary objective was to describe an IVIG stewardship program at a tertiary academic medical center. Methods: This was a prospective, observational study from January 2013 through December 2014. All patients ordered to receive IVIG during the defined study period were included. The intervention assessed describes a pharmacist-driven IVIG stewardship program for medication approval. The primary end point was guideline compliance based on indication, dose, dosing weight, and frequency. Secondary end points included the number of patients receiving IVIG, indications, orders discontinued as a result of guideline nonadherence, and total amount dispensed. Results: A total of 418 patients were identified during the study time frame. The top indications were: hypogammaglobulinemia in bone marrow transplantation and hematological malignancy (50.7%), acute solid organ rejection (11.8%), and immune thrombocytopenia with bleeding (10.1%). In all, 12 patients (2.9%) received IVIG for an indication nonadherent with the IVIG prescribing guideline; 9 patients (2.2%) and 2 patients (0.5%), respectively, received a different dose or frequency per the prescribed indication; and 12 orders (2.9%) for indications nonadherent to the guideline were discontinued. A total of 26 033 g of IVIG were dispensed during the study period. Conclusions: An IVIG stewardship program, including an institution-specific prescribing guideline and a pharmacist-driven stewardship program, may ensure guideline compliance for appropriateness of indication and dose at an academic medical center.
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Adler A, Friedman ND, Marchaim D. Multidrug-Resistant Gram-Negative Bacilli: Infection Control Implications. Infect Dis Clin North Am 2016; 30:967-997. [PMID: 27660090 DOI: 10.1016/j.idc.2016.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Antimicrobial resistance is a common iatrogenic complication of both modern life and medical care. Certain multidrug resistant and extensively drug resistant Gram-negative organisms pose the biggest challenges to health care today, predominantly owing to a lack of therapeutic options. Containing the spread of these organisms is challenging, and in reality, the application of multiple control measures during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article reviews the usefulness of various infection control measures in containing the spread of multidrug-resistant Gram-negative bacilli.
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Affiliation(s)
- Amos Adler
- Clinical Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; Department of Medicine, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Dror Marchaim
- Department of Medicine, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Infectious Diseases, Assaf Harofeh Medical Center, Zerifin 70300, Israel.
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Mohammad RS, El-Sorougi WM, Eissa HH, Mohamed AS, Hassan KE. Effect of procalcitonin-guided therapy on antibiotic usage in the management of patients with chronic obstructive pulmonary disease with acute exacerbation. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2016. [DOI: 10.4103/1687-8426.184376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Lautenbach E, Weiner MG, Nachamkin I, Bilker WB, Sheridan A, Fishman NO. Imipenem Resistance Among Pseudomonas aeruginosa Isolates Risk Factors for Infection and Impact of Resistance on Clinical and Economic Outcomes. Infect Control Hosp Epidemiol 2016; 27:893-900. [PMID: 16941312 DOI: 10.1086/507274] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Accepted: 12/07/2005] [Indexed: 11/03/2022]
Abstract
Objectives.To identify risk factors for infection with imipenem-resistant Pseudomonas aeruginosa and determine the impact of imipenem resistance on clinical and economic outcomes among patients infected with P. aeruginosa.Designs.An ecologic study, a case-control study, and a retrospective cohort study.Setting.A 625-bed tertiary care medical center.Patients.All patients who had an inpatient clinical culture positive for P. aeruginosa between January 1, 1999, and December 31, 2000.Results.From 1991 through 2000, the annual prevalence of imipenem resistance among P. aeruginosa isolates increased significantly (P<.001 by the χ2 test for trend). Among 879 patients infected with P. aeruginosa during 1999-2000, a total of 142 had imipenem-resistant P. aeruginosa infection (the case group), whereas 737 had imipenem-susceptible P. aeruginosa infection (the control group). The only independent risk factor for imipenem-resistant P. aeruginosa infection was prior fluoroquinolone use (adjusted odds ratio, 2.52 [95% confidence interval {CI}, 1.61-3.92]; P<.001). Compared with patients infected with imipenem-susceptible P. aeruginosa, patients infected with imipenem-resistant P. aeruginosa had longer subsequent hospitalization durations (15.5 days vs 9 days; P = .02) and greater hospital costs ($81,330 vs $48,381; P<.001). The mortality rate among patients infected with imipenem-resistant P. aeruginosa was 31.1%, compared with 16.7% for patients infected with imipenem-susceptible P. aeruginosa (relative risk, 1.86 [95% CI, 1.38-2.51]; P<.001). In multivariable analyses, there remained an independent association between infection with imipenem-resistant P. aeruginosa and mortality.Conclusions.The prevalence of imipenem resistance among P. aeruginosa strains has increased markedly in recent years and has had a significant impact on both clinical and economic outcomes. Our results suggest that curtailing use of other antibiotics (particularly fluoroquinolones) may be important in attempts to curb further emergence of imipenem resistance.
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Affiliation(s)
- Ebbing Lautenbach
- Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia, PA, 19104-6021, USA.
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Barton TD, Fishman NO, Weiner MG, LaRosa LA, Lautenbach E. High Rate of Coadministration of Di- or Tri-valent Cation-Containing Compounds With Oral Fluoroquinolones: Risk Factors and Potential Implications. Infect Control Hosp Epidemiol 2016; 26:93-9. [PMID: 15693415 DOI: 10.1086/502493] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AbstractBackground:The characteristics of fluoroquinolone use that increase the risk of selecting for fluoroquinolone resistance remain unclear. Exposure to subtherapeutic levels of fluoroquinolone promotes bacterial development of fluoroquinolone resistance. Oral fluoroquinolone absorption is significantly impaired by coadministration with many common di- or tri-valent cation-containing compounds (DTCCs), and this interaction has been associated with therapeutic failure. However, the prevalence of, and risk factors for, in-hospital coadministration of oral fluoroquinolones with DTCCs is unknown.Design:Case-control study.Setting:A 625-bed, tertiary-care medical center.Patients:All inpatients who were dispensed oral levofloxacin from July 1, 1999, to June 30, 2001, were included. Coadministration was defined by documented administration of any DTCC within 2 hours of levofloxacin. Complete coadministration was defined as coadministration complicating every dose of a course of levofloxacin.Results:A subset of 3,227 (41.0%) of 7,871 doses of levofloxacin that occurred during the same calendar day as any DTCC was selected for further review. Overall, 1,904 (77.1%) of 2,470 doses of oral levofloxacin reviewed were complicated by coadministration with at least one DTCC. On multivariable analysis, an increased number of prescribed medications was significantly associated with complete coadministration (per increase of one medication: OR, 1.05; CI95, 1.01–1.10; P = .036), whereas patient location in an ICU was protective (OR, 0.51; CI95, 0.30–0.87; P = .013). If our prevalence results are extrapolated to all patients receiving oral levofloxacin at our hospital, approximately one in three doses was complicated by coadministration.Conclusion:Coadministration of fluoroquinolones with DTCCs is extremely common and significantly associated with polypharmacy.
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Affiliation(s)
- Todd D Barton
- Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-6021, USA
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