Antibiotic combinations with redundant antimicrobial spectra: clinical epidemiology and pilot intervention of computer-assisted surveillance

Pharmacist insights into antimicrobial stewardship: A social marketing approach

BACKGROUND

Antimicrobial resistance is a worldwide public health problem. Antimicrobial stewardship programs (ASPs) optimize antimicrobial use within hospitals. The social marketing framework has been used in analyzing systems and devising best practices.

OBJECTIVE

(s): To use the social marketing framework to explore pharmacist experiences and perceptions of structural, behavioral and interventional strategies that support ASPs.

METHODS

A qualitative approach utilizing semi-structured individual interviews was utilized. A purposive sample of hospital pharmacists was invited to participate. An interview guide was constructed to describe participant experience and perceptions regarding ASPs in their institutions based on elements of social marketing: Behavioral goals; Customer Insight; Segmentation and Targeting; Competition; Exchange; and Marketing and Interventional mix. Interviews were recorded digitally and transcribed verbatim. Thematic analysis was conducted using deductive methods. A combination of case-based and code-based approaches allowed individual and holistic analyses respectively. Codes were collated into themes and subthemes.

RESULTS

Saturation of themes occurred with 25 interviews from 17 hospitals. ASP metrics included: consumption of antibiotics using days of therapy and defined daily dose, rates of C. difficile and multidrug resistant organisms, resistance patterns, and provider adherence to the ASP. Active stewardship tools such as preauthorization, and prospective feedback/audit were preferred over passive tools such as order sets and automatic stop orders. A physician champion and a clinical pharmacist with infectious disease training were core elements in the multidisciplinary team. Despite certain areas being considered key for stewardship, participants emphasized a hospital-wide approach including outpatient departments; discharge stewardship emerged as a primary theme. Leadership supported ASPs with finances, rapid and novel diagnostics, Clinical Decision Support Systems, mobile technology, and continuous staff training.

CONCLUSIONS

The social marketing framework has been used to explore pharmacist perceptions that inform successful qualities including metrics, restriction methods, personnel, benefits, barriers, training needs/modes, and promotional avenues that support ASPs in hospitals.

Gamified antimicrobial decision support app (GADSA) changes antibiotics prescription behaviour in surgeons in Nigeria: a hospital-based pilot study

AIMS

Surgical Antibiotic Prophylaxis (SAP) in Nigeria is often not evidence based. The aim of this study is to test if the GADSA application can change prescription behaviour of surgeons in Nigeria. In addition, the study aims to identify AMS strategies and policies for the future.

METHODS

The GADSA gamified decision support app uses WHO and Sanford prescribing guidelines to deliver real-time persuasive technology feedback to surgeons through an interactive mentor. The app can advise on whether clinician's decisions align with SAP recommendations and provides the opportunity for clinicians to make adjustments. Twenty surgeons actively participated in a 6-month pilot study in three hospitals in Nigeria. The surgeons determined the risk of infection of a surgical procedure, and the need, type and duration of SAP. The study used a longitudinal approach to test whether the GADSA app significantly changed prescribing behaviour of participating surgeons by analysing the reported prescription decisions within the app.

RESULTS

321 SAP prescriptions were recorded. Concerning the surgical risk decision, 12% of surgeons changed their decision to be in line with guidelines after app feedback (p < 0.001) and 10% of surgeons changed their decision about the need for SAP (p = 0.0035) to align with guidelines. The change in decision making for SAP use in terms of "type" and "duration" to align with guidelines was similar with 6% and 5% respectively (both p-values < 0.001).

CONCLUSION

This study suggests that the GADSA app, with its game based and feedback feature, could significantly change prescribing behaviour at the point of care in an African setting, which could help tackle the global challenge of antibiotic resistance.

Guidelines on Implementing Antimicrobial Stewardship Programs in Korea

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.

Computer Informatics for Infection Control

Computer informatics have the potential to improve infection control outcomes in surveillance, prevention, and public health. Surveillance activities include surveillance of infections, device use, and facility/ward outbreak detection and investigation. Prevention activities include awareness of multidrug-resistant organism carriage on admission, identification of high-risk individuals or populations, reducing device use, and antimicrobial stewardship. Enhanced communication with public health and other health care facilities across networks includes automated electronic communicable disease reporting, syndromic surveillance, and regional outbreak detection. Computerized public health networks may represent the next major evolution in infection control. This article reviews the use of informatics for infection control.

Evaluation of antibiotic use among hospitalised patients in a paediatric department of a training hospital in Turkey

BACKGROUND

Antibiotics are widely used and inaccurate or inappropriate prescription of antibiotics causes a significant increase in the prevalence of multidrug-resistant bacterial infections among children. This research aimed to study antibiotic prescriptions in hospitalised paediatric patients and to determine the prevalence of inappropriate antimicrobial use and the main types of prescribing errors.

METHODS

After obtaining the Ethics Committee approval, screening was conducted among 535 patients admitted to the Department of Pediatrics at Haydarpasa Numune Training and Research Hospital in the period from 01 January 2016 to 31 December 2016 who had been treated with an antibiotic. Patients' demographics, diagnosis and antibiotic therapy details were collected using a standardised case report form and assessed by a clinical pharmacologist and an infectious disease specialist regarding the convenience and accurateness of prescription of antibiotics.

RESULTS

Out of 535 antibiotic prescriptions, single antibiotics were used inappropriately in 216 (56.10%) of the patients and there were 39 (26%) unnecessary antibiotic combinations. Most of the errors were made in the dose frequency (55.69%), followed by indication (25.88%), administration route (16.08%) and dosage (2.67%).

CONCLUSIONS

The results of our study show that a high level of antibiotics in the paediatric clinic was misprescribed. Inappropriate usage increases the chances of microbial resistance and the cost of treatment. Precautions should be taken in this regard.

Interventions to optimize antimicrobial stewardship

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.

Impact of a Systematic Pharmacist-Initiated Antibiotic Time-Out Intervention for Hospitalized Adults

INTRODUCTION

Antibiotic time-outs (ATO) are a recommended antimicrobial stewardship action, but data assessing their impact are lacking. This study investigated the impact of a systematic, pharmacist initiated ATO intervention.

METHODS

This pre-post study included inpatients on hospitalist and intensivist services receiving empiric antibiotics for ≥48 hours. The ATO was initiated by pharmacists after 48 hours of empiric therapy and the outcome was documented including antibiotic indication, plan, and duration. An electronic medical record (EMR) alert facilitated ATO completion and pharmacists and prescribers received education prior to implementation. The primary outcome was EMR documentation of an antibiotic plan by 72 hours. Secondary outcomes included antibiotic utilization and antibiotic therapy modifications by 2 hours.

RESULTS

399 patients were included, 199 pre- and 200 post-intervention. The most common indications were pneumonia (32%), intra-abdominal infection (20%) and urinary tract infection (19%), with no between-group differences. EMR documentation of an antibiotic plan significantly improved in the post-intervention group (19% vs. 79%, p<0.0001) as did modifications to antibiotic therapy. The median duration of in-hospital antibiotic therapy was similar between groups (4.0 vs. 4.0 days, p = 0.2499). Approximately 45% of patients in each group received discharge antibiotics and median duration of discharge antibiotic therapy prescribed was reduced (7 vs. 5 days in the pre- and post-intervention groups, respectively; p = 0.0140).

DISCUSSION

Implementation of pharmacist initiated ATO was associated with improvements in supporting EMR documentation and antibiotic therapy modifications. These findings highlight an important role in which pharmacists can serve as part of a collaborative antibiotic stewardship team.

Anaerobic resistance: should we be worried?

PURPOSE OF REVIEW

Anaerobic bacteria are implicated in a broad range of infections and can cause significant morbidity and mortality. As such, development of antimicrobial resistance (AMR) increases the risk of worse clinical outcomes and death.

RECENT FINDINGS

Anaerobe AMR is highly variable according to region and species included in the survey. The overall trend is to increasing resistance, particularly in Europe and Asia, and in the Bacteroides fragilis group and Clostridium sp. Conversely, with the decline in RT027, resistance in Clostridiodes difficile is decreasing. Resistance to moxifloxacin and clindamycin has reached 30-50%, whereas prevalence of metronidazole and carbapenem resistance is generally low. Infections due to multidrug anaerobes have been increasingly reported, with clinical studies demonstrating adverse clinical outcomes, including higher mortality, with anaerobic resistance or inappropriate therapy. The role of antimicrobial stewardship in the setting of increasing anaerobe resistance is yet to be fully elucidated.

SUMMARY

These findings highlight the importance of continuous surveillance in monitoring emerging trends in anaerobe AMR. Mean inhibitory concentrations should be reported due to variable susceptibility breakpoints and for detection of isolates with reduced susceptibility. At a local level, the clinical microbiology laboratory has a key role in identifying and undertaking susceptibility testing to inform individual patient management, develop local antibiograms and liaise with antimicrobial stewardship teams. A greater understanding of the clinical impact of anaerobic resistance and the role of antimicrobial stewardship in preventing resistance is required.

Redundant Anaerobic Antimicrobial Prescriptions in German Acute Care Hospitals: Data from a National Point Prevalence Survey

Despite limited indications, redundant anaerobic antimicrobial prescriptions (RAAPs) are frequent. The objective of this study was to assess the prevalence and characteristics of RAAPs in German acute care hospitals. In a retrospective data analysis, antimicrobial prescriptions from a point prevalence survey on antimicrobial use in German acute care hospitals in 2016 were analyzed and RAAPs were identified. RAAPs were defined as a patient simultaneously receiving any of the following combinations: Penicillin/beta-lactamase inhibitor (PenBLI) plus clindamycin; PenBLI plus metronidazole; PenBLI plus moxifloxacin; PenBLI plus carbapenem; carbapenem plus clindamycin; carbapenem plus metronidazole; carbapenem plus moxifloxacin; clindamycin plus metronidazole; clindamycin plus moxifloxacin; and metronidazole plus moxifloxacin. Data from 64,412 patients in 218 hospitals were included. Overall, 4486 patients (7%) received two or more antimicrobials. In total, 441 RAAP combinations were identified. PenBLI plus metronidazole was the most common anaerobic combination (N = 166, 38%). The majority of RAAPs were for the treatment of community-acquired (N = 258, 59%) infections. Lower respiratory tract infections (N = 77; 20%) and skin/soft tissue infections (N = 76; 20%) were the most frequently recorded types of infections. RAAPs are common in German hospitals. Reducing redundant antimicrobial coverage should be a key component of future antimicrobial stewardship activities.

Antibiotic use among hospitalized patients in northern Nigeria: a multicenter point-prevalence survey

BACKGROUND

The evaluation of antibiotic use among hospitalized patients is a primary step required to design antibiotic stewardship intervention. There is paucity of data describing antibiotic use in hospitals across Northern Nigeria. This study evaluates the prevalence and indications for antibiotic use among inpatients in three acute care hospitals.

METHODS

A point-prevalence survey was conducted among patients in the wards before or at 8.00 a.m. on the day of the survey, using the point-prevalence survey of healthcare-associated infections and antimicrobial use in European acute care hospitals protocol. The survey was conducted between April and May 2019. The medical records of the patients were reviewed by a clinical pharmacist with the support of physicians and nurses.

RESULTS

Overall, 80.1% (257/321) of the patients used at least one antibiotic on the day of the survey. The prevalence of antibiotic use ranged from 72.9% in obstetrics and gynecology to 94.6% in pediatric medical specialty. Community acquired infections (38.7%) and surgical antibiotic prophylaxis (22.5%) were the most common indications. Surgical antibiotic prophylaxis was used or scheduled to be used for more than a day in all the cases. Metronidazole (30.5%), ciprofloxacin (17.1%), ceftriaxone (16.8%), amoxicillin-clavulanate (12.5%) and gentamicin (11.8%) were the most commonly prescribed antibiotics. Overall, broad spectrum antibiotics represented one-third of all the prescriptions. The change of initial antibiotic prescription was reported in one-third of the patients and the reasons include a switch to oral antibiotic (28.5%), escalation (4.5%) and de-escalation (3.6%). Of the 257 patients with an antibiotic prescription, 6.2% had redundant antibiotic combinations.

CONCLUSION

The prevalence of antibiotic use was high with one in three prescriptions having a broad spectrum antibiotic. Prolonged use of surgical antibiotic prophylaxis and redundant antibiotic combination were observed. Antimicrobial stewardship interventions are recommended in order to reduce the use of antibiotics and promote appropriate antibiotics prescribing.

The quality of antimicrobial prescribing in acute care hospitals: results derived from a national point prevalence survey, Germany, 2016

BackgroundRobust data on the quality of antimicrobial prescriptions in German acute care hospitals are scarce. To establish and implement antimicrobial stewardship (AMS) measures and to increase prudent antimicrobial use (AMU), the identification of appropriate process and quality indicators is pertinent.AimOur main objective was to identify parameters associated with adequate AMU and inadequate AMU by analysing point prevalence data. Our secondary goal was to describe the current state of AMS implementation in Germany.MethodsA national point prevalence survey for healthcare-associated infections and AMU was conducted in German hospitals in 2016. Data on structure and process parameters were also collected. Recorded antimicrobial prescriptions were divided into adequate, inadequate and undefinable AMU. A multivariable linear regression analysis was performed to examine the correlation of selected structure and process parameters with the adequacy of recorded antimicrobials.ResultsData from 218 acute care hospitals, 64,412 patients and 22,086 administered antimicrobials were included. Multivariable linear regression analysis revealed that documentation of a reason for AMU in the patient notes increased the likelihood of adequate AMU and decreased the likelihood of inadequate AMU significantly (p < 0.001), while tertiary care hospital type had the opposite effect (p < 0.001).ConclusionThrough associating structural and process parameters with adequacy of AMU, we identified parameters that increased the odds of prudent AMU. Documentation was a key element for improving AMU. Revealed deficits regarding the implementation of AMS in German hospitals concerning dedicated staff for AMS activities and establishment of regular AMU training and AMU audits should be tackled.

Redundant combinations of antianaerobic antimicrobials: impact of pharmacist-based prospective audit and feedback and prescription characteristics

This study aimed to evaluate the impact of the intervention targeting the redundant combination of antianaerobic antimicrobials on its incidence and associated antimicrobial consumption. To reveal the characteristics of the combination and the change in the related workload over time was an additional aim of the study. The combinations of metronidazole or clindamycin with antianaerobic antimicrobials were classified into redundant or acceptable, according to the target indications. A pharmacist-based prospective audit and feedback targeting the redundant antianaerobic combination was conducted. Segmented regression analysis was performed to evaluate the impact of the intervention. As a quantitative index of the interventional activity, the change in the number of signed consultation notes was evaluated. After the initiation of the intervention, the median monthly cumulative incidence of the redundant combination decreased from 5.29 (Interquartile range [IQR] 4.94-5.70) to 3.33 (IQR 2.87-3.71) (p < 0.001) per 1000 admissions per month. The consumption of concurrently administered metronidazole and clindamycin decreased from 3.34 (IQR 2.97-4.10) to 1.74 (IQR 1.19-1.93) (p < 0.001) per 1000 patient-days per month. Segmented regression analysis revealed that the monthly cumulative incidence decreased by 28.5% after the initiation of the intervention (change in level - 1.640, p = 0.019) and the monthly consumption decreased by 33.9% (change in level - 1.409, p = 0.009). The number of consultation notes per 1000 admissions per month decreased over time (regression coefficient - 0.004, p < 0.001). The pharmacist-based intervention significantly reduced the incidence and associated antimicrobial consumption of the redundant antianaerobic combination. The overall related workload reduced steadily over time.

Impact of pharmacist-led antibiotic stewardship interventions on compliance with surgical antibiotic prophylaxis in obstetric and gynecologic surgeries in Nigeria

Background

Inappropriate and excessive use of surgical antibiotic prophylaxis are associated with the emergence of antibiotic resistance. Antibiotic prophylaxis malpractices are common in obstetrics and gynecology settings and antibiotic stewardship is used to correct such malpractice.

Objective

To evaluate the impact of antibiotic stewardship interventions on compliance with surgical antibiotic prophylaxis practice in obstetrics and gynecology surgeries.

Method

A prospective pre- and post-intervention study was conducted in two tertiary hospitals between May and December 2016. The duration of the each period was 3 months. Antibiotic stewardship interventions including development of a protocol, educational meeting and audit and feedback were implemented. Data were collected using the patient records and analyzed with SPSS version 23.

Results

A total of 226 and 238 surgical procedures were included in the pre- and post-intervention periods respectively. Age, length of stay and estimated blood loss were similar between the two groups. However, specialty and surgical procedures varied significantly. There was a significant increase in compliance with timing (from 14.2% to 43.3%) and duration (from 0% to 21.8%) of surgical antibiotic prophylaxis after the interventions. The interventions significantly reduced the prescription of third generation cephalosporin (-8.6%), redundant antibiotic (-19.1%), antibiotic utilization (-3.8 DDD/procedure) and cost of antibiotic prophylaxis (-$4.2/procedure). There was no significant difference in the rate of surgical site infection between the two periods. Post-intervention group (OR: 5.60; 95% CI: 3.31–9.47), elective surgery (OR: 4.62; 95% CI: 2.51–8.47) and hospital attended (OR: 9.89; 95% CI: 5.66–17.26) were significant predictors of compliance with timing while elective surgery (OR: 12.49; 95% CI: 2.85–54.71) and compliance with timing (OR: 58.55; 95% CI: 12.66–270.75) were significantly associated with compliance to duration of surgical antibiotic prophylaxis.

Conclusion

The interventions improve compliance with surgical antibiotic prophylaxis and reduce antibiotic utilization and cost. However, there is opportunity for further improvement, particularly in non-elective surgical procedures.

Exploring views of pharmacists on antibacterial prescribing: a Maltese perspective

OBJECTIVES

To investigate the perception of Maltese pharmacists to prescribe a selected number of antibiotics.

METHODS

A self-administered questionnaire entitled 'Antibiotic Prescribing by Pharmacists' was developed to study pharmacist perception to prescribing a selected number of antibacterial agents. The questionnaire was validated by a two-round Delphi technique and disseminated to all practising pharmacists (N = 930) during a 3-month period.

KEY FINDINGS

Two hundred and nine pharmacists answered the questionnaire. The majority of pharmacists (77%) were in agreement with pharmacists prescribing a selected number of antibacterials. Reasons given are that pharmacist prescribing would increase recognition of the participation of pharmacists within patient care and as members of the healthcare team. Protocol-based prescribing was the preferred model for prescribing by 60% of pharmacists. Half of the respondents (50%) feel competent to prescribe, 34% have no opinion and 16% do not feel competent at all. Co-amoxiclav for an uncomplicated upper respiratory tract infection was the antibacterial that most pharmacists (51%) feel confident prescribing. When pharmacists were asked whether they feel comfortable prescribing other medications rather than antibacterials, 93% answered positively, with 83% feeling mostly comfortable prescribing lactulose solution.

CONCLUSION

Pharmacists in Malta are in agreement with prescribing selected antibiotics for minor ailments. A collaborative approach between medical practitioners and pharmacists should be evaluated as a possible national structure towards achieving better antibiotic prescribing whilst giving patient access to the use of antibacterials as necessary.

It is time to define antimicrobial never events

Inappropriate antibiotic use is associated with increased antimicrobial resistance and adverse events that can lead to further downstream patient harm. Preventative strategies must be employed to improve antibiotic use while reducing avoidable harm. We use the term “antibiotic never events” to globally recognize and define the most inappropriate antibiotic use.

How to Make Antimicrobial Stewardship Work: Practical Considerations for Hospitals of All Sizes

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.

Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases

Introduction

In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute.

Materials and methods

A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development.

Conclusion

The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.

Antimicrobial agents - optimising the ecological balance

BACKGROUND

There is no more challenging a group of pharmaceuticals than antimicrobials. With the antibiotic era came great optimism as countless deaths were prevented from what were previously fatal conditions. Although antimicrobial resistance was quickly identified, the abundance of antibiotics entering the market helped cement attitudes of arrogance as the "battle against pestilence appeared won". Opposite emotions soon followed as many heralded the return of the pre-antibiotic era, suggesting that the "antibiotic pipeline had dried up" and that our existing armament would soon be rendered worthless.

DISCUSSION

In reality, humans overrate their ecological importance. For millions of years there has been a balance between factors promoting bacterial survival and those disturbing it. The first half century of the "antibiotic era" was characterised by a cavalier attitude disturbing the natural balance; however, recent efforts have been made through several mechanisms to respond and re-strengthen the antimicrobial armament. Such mechanisms include a variety of incentives, educational efforts and negotiations. Today, there are many more "man-made" factors that will determine a new balance or state of ecological harmony.

CONCLUSION

Antibiotics are not a panacea nor will they ever be inutile. New resistance mechanisms will be identified and new antibiotics will be discovered, but most importantly, we must optimise our application of these extraordinary "biological tools"; therein lays our greatest challenge - creating a society that understands and respects the determinants of the effectiveness of antibiotics.

Management of ventilator-associated pneumonia in intensive care units: a mixed methods study assessing barriers and facilitators to guideline adherence

Background

Guidelines from the Infectious Diseases Society of America/The American Thoracic Society (IDSA/ATS) provide recommendations for diagnosis and treatment of ventilator-associated pneumonia (VAP). However, the mere presence of guidelines is rarely sufficient to promote widespread adoption and uptake. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model framework, we undertook a study to understand barriers and facilitators to the adoption of the IDSA/ATS guidelines.

Methods

We conducted surveys and focus group discussions of different health care providers involved in the management of VAP. The setting was medical-surgical ICUs at a tertiary academic hospital and a large multispecialty rural hospital in Wisconsin, USA.

Results

Overall, we found that 55 % of participants indicated that they were aware of the IDSA/ATS guideline. The top ranked barriers to VAP management included: 1) having multiple physician groups managing VAP, 2) variation in VAP management by differing ICU services, 3) physicians and level of training, and 4) renal failure complicating doses of antibiotics.

Facilitators to VAP management included presence of multidisciplinary rounds that include nurses, pharmacist and respiratory therapists, and awareness of the IDSA/ATS guideline. This awareness was associated with receiving effective training on management of VAP, keeping up to date on nosocomial infection literature, and belief that performing a bronchoscopy to diagnose VAP would help with expeditious diagnosis of VAP.

Conclusions

Findings from our study complement existing studies by identifying perceptions of the many different types of healthcare workers in ICU settings. These findings have implications for antibiotic stewardship teams, clinicians, and organizational leaders.

Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review

The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.

Prescribing Patterns in Outpatient Clinics of Township Hospitals in China: A Comparative Study before and after the 2009 Health System Reform

OBJECTIVE

China introduced a series of health reforms in 2009, including a national essential medicines policy and a medical insurance system for primary care institutions. This study aimed to determine the changing prescribing patterns associated with those reforms in township hospitals.

METHODS

A multi-stage stratified random cluster sampling method was adopted to identify 29 township hospitals from six counties in three provinces. A total of 2899 prescriptions were collected from the participating township hospitals using a systematic random sampling strategy. Seven prescribing indicators were calculated and compared between 2008 and 2013, assessing use of medicines (antibiotics and adrenal corticosteroids) and polypharmacy, administration route of medicines (injections), and affordability of medicines.

RESULTS

Significant changes in prescribing patterns were found. The average number of medicines and costs per-prescription dropped by about 50%. The percentage of prescriptions requiring antibiotics declined from 54% to 38%. The percentage of prescriptions requiring adrenal corticosteroid declined from 14% to 4%. The percentage of prescriptions requiring injections declined from 54% to 25%. Despite similar changing patterns, significant regional differences were observed.

CONCLUSIONS

Significant changes in prescribing patterns are evident in township hospitals in China. Overprescription of antibiotics, injections and adrenal corticosteroids has been reduced. However, salient regional disparities still exist. Further studies are needed to determine potential shifts in the risk of the inappropriate use of medicines from primary care settings to metropolitan hospitals.

A systematic review of approaches for calculating the cost of medication errors

Introduction

Although medication errors may cause significant morbidity and mortality, the true cost of avoidable harm from such errors is unclear. While studies describe different methods for calculating a financial cost from an error, there remains variability in the way calculations are conducted depending on the clinical context. This review aimed to investigate the range of approaches for calculating medication error costs across healthcare settings.

Methods

A systematic review was carried out with a duplicate data extraction approach and mixed methods data synthesis. Medline, Embase and Web of Science were searched for studies published between 1993 and 2015. Studies that explicitly described a method for calculating medication error cost were included. The variables used for the calculations and a description of the approach for calculating errors were reported.

Results

21 studies were included in the final review. There was wide variation in the way calculations were undertaken, with some calculations using a single variable only and others using several variables in a multistep approach. Few calculations included indirect costs, such as loss of earnings for the patient, and only one calculation considered opportunity cost. The majority of studies presented direct medication error costs whereas others approximated error costs from the savings made following an intervention.

Conclusions

There are a wide range of methods used for calculating the cost of medication errors. The diversity arises from the number of variables used in calculations, the perspective from which the calculation is conducted from, and the degree of economic rigour applied by researchers.

Indications and Types of Antibiotic Agents Used in 6 Acute Care Hospitals, 2009-2010: A Pragmatic Retrospective Observational Study

BACKGROUND To design better antimicrobial stewardship programs, detailed data on the primary drivers and patterns of antibiotic use are needed. OBJECTIVE To characterize the indications for antibiotic therapy, agents used, duration, combinations, and microbiological justification in 6 acute-care US facilities with varied location, size, and type of antimicrobial stewardship programs. DESIGN, PARTICIPANTS, AND SETTING Retrospective medical chart review was performed on a random cross-sectional sample of 1,200 adult inpatients, hospitalized (>24 hrs) in 6 hospitals, and receiving at least 1 antibiotic dose on 4 index dates chosen at equal intervals through a 1-year study period (October 1, 2009-September 30, 2010). METHODS Infectious disease specialists recorded patient demographic characteristics, comorbidities, microbiological and radiological testing, and agents used, dose, duration, and indication for antibiotic prescriptions. RESULTS On the index dates 4,119 (60.5%) of 6,812 inpatients were receiving antibiotics. The random sample of 1,200 case patients was receiving 2,527 antibiotics (average: 2.1 per patient); 540 (21.4%) were prophylactic and 1,987 (78.6%) were therapeutic, of which 372 (18.7%) were pathogen-directed at start. Of the 1,615 empirical starts, 382 (23.7%) were subsequently pathogen-directed and 1,231 (76.2%) remained empirical. Use was primarily for respiratory (27.6% of prescriptions) followed by gastrointestinal (13.1%) infections. Fluoroquinolones, vancomycin, and antipseudomonal penicillins together accounted for 47.1% of therapy-days. CONCLUSIONS Use of broad-spectrum empirical therapy was prevalent in 6 US acute care facilities and in most instances was not subsequently pathogen directed. Fluoroquinolones, vancomycin, and antipseudomonal penicillins were the most frequently used antibiotics, particularly for respiratory indications. Infect. Control Hosp. Epidemiol. 2015;37(1):70-79.

Use of computerized decision support systems to improve antibiotic prescribing

This decade will see the emergence of the electronic medical record, electronic prescribing and computerized decision support in the hospital setting. Current opinion from key infectious diseases bodies supports the use of computerized decision support systems as potentially useful tools in antibiotic stewardship programs. However, although antibiotic decision support systems appear beneficial for improving the quality of prescribing and reducing the costs of antibiotic prescribing, their overall cost-effectiveness, impact on patient outcome and antimicrobial resistance is much less certain. This review describes computerized decision support systems used to assist with antibiotic prescribing, the evidence for their effectiveness and the current and future roles.

De-escalation of antimicrobial treatment for adults with sepsis, severe sepsis or septic shock

BACKGROUND

Mortality rates among patients with sepsis, severe sepsis or septic shock are highly variable throughout different regions or services and can be upwards of 50%. Empirical broad-spectrum antimicrobial treatment is aimed at achieving adequate antimicrobial therapy, thus reducing mortality; however, there is a risk that empirical broad-spectrum antimicrobial treatment can expose patients to overuse of antimicrobials. De-escalation has been proposed as a strategy to replace empirical broad-spectrum antimicrobial treatment by using a narrower antimicrobial therapy. This is done by reviewing the patient's microbial culture results and then making changes to the pharmacological agent or discontinuing a pharmacological combination.

OBJECTIVES

To evaluate the effectiveness and safety of de-escalation antimicrobial treatment for adult patients diagnosed with sepsis, severe sepsis or septic shock caused by any micro-organism.

SEARCH METHODS

In this updated version, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); MEDLINE via PubMed (from inception to October 2012); EMBASE (from inception to October 2012); LILACS (from inception to October 2012); Current Controlled Trials; bibliographic references of relevant studies; and specialists in the area. We applied no language restriction. We had previously searched the databases to August 2010.

SELECTION CRITERIA

We planned to include randomized controlled trials (RCTs) comparing de-escalation (based on culture results) versus standard therapy for adults with sepsis, severe sepsis or septic shock. The primary outcome was mortality (at 28 days, hospital discharge or at the end of the follow-up period). Studies including patients initially treated with an empirical but not adequate antimicrobial therapy were not considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors planned to independently select and extract data and to evaluate methodological quality of all studies. We planned to use relative risk (risk ratio) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals. We planned to use the random-effects statistical model when the estimate effects of two or more studies could be combined in a meta-analysis.

MAIN RESULTS

Our search strategy retrieved 493 studies. No published RCTs testing de-escalation of antimicrobial treatment for adult patients diagnosed with sepsis, severe sepsis or septic were included in this review. We found one ongoing RCT.

AUTHORS' CONCLUSIONS

There is no adequate, direct evidence as to whether de-escalation of antimicrobial agents is effective and safe for adults with sepsis, severe sepsis or septic shock. This uncertainty warrants further research via RCTs and the authors are awaiting the results of an ongoing RCT testing the de-escalation of empirical antimicrobial therapy for severe sepsis.

Combating antimicrobial resistance: antimicrobial stewardship program in Taiwan

Multi-drug-resistant organisms are increasingly recognized as a global public health issue. Healthcare-associated infection and antimicrobial resistance are also current challenges to the treatment of infectious diseases in Taiwan. Government health policies and the health care systems play a crucial role in determining the efficacy of interventions to contain antimicrobial resistance. National commitment to understand and address the problem is prerequisite. We analyzed and reviewed the antibiotic resistance related policies in Taiwan, USA, WHO and draft antimicrobial stewardship program to control effectively antibiotic resistance and spreading in Taiwan. Antimicrobial stewardship program in Taiwan includes establishment of national inter-sectoral antimicrobial stewardship task force, implementing antimicrobial-resistance management strategies, surveillance of HAI and antimicrobial resistance, conducting hospital infection control, enforcement of appropriate regulations and audit of antimicrobial use through hospital accreditation, inspection and national health insurance payment system. No action today, no cure tomorrow. Taiwan CDC would take a multifaceted, evidence-based approach and make every effort to combat antimicrobial resistance with stakeholders to limit the spread of multi-drug resistant strains and to reduce the generation of antibiotic resistant bacteria in Taiwan.

Double trouble: how big a problem is redundant anaerobic antibiotic coverage in Veterans Affairs medical centres?

OBJECTIVES

To assess the prevalence of, and the variation in, avoidable use of metronidazole in the Veterans Affairs (VA) healthcare system

METHODS

Barcode Medication Administration (BCMA) data were retrospectively assessed for all patients hospitalized between January 2006 and December 2010 in acute-care wards of all VA medical centres (VAMCs) with complete BCMA data and at least 10 acute-care non-intensive care unit (ICU) beds. Potentially avoidable metronidazole days of therapy (DOT) were defined as the administration of metronidazole with another anti-anaerobic antibiotic on the same day for at least two consecutive days during the same hospitalization. Metronidazole was not considered redundant in combination with another anti-anaerobic agent within 28 days after a positive test for Clostridium difficile and during hospitalizations associated with discharge diagnosis codes for cholecystitis or cholangitis.

RESULTS

A total of 128 VAMCs satisfied the inclusion criteria. Over the study period there were a total of 782,821 DOT of metronidazole (57.4 DOT per 1000 patient-days), of which 183,267 (23.4%) fulfilled the criteria for avoidable metronidazole DOT. The percentage of avoidable metronidazole DOT remained stable over the study period (22.8% in 2006 and 22.9% in 2010) despite a decrease in overall metronidazole use. There was wide variation in the percentage of avoidable metronidazole DOT among facilities (2010: median 20.3%, IQR 15.3%-29.4%). Piperacillin/tazobactam was the most commonly administered drug on avoidable metronidazole DOT (56.8%).

CONCLUSIONS

Potentially avoidable use of metronidazole affected about a quarter of all days when metronidazole was given. The combination of metronidazole with piperacillin/tazobactam was particularly common and represents a possible target for antibiotic stewardship interventions.

Effects of pharmaceutical counselling on antimicrobial use in surgical wards: intervention study with historical control group

PURPOSE

The objective of this study was to assess the impact of pharmaceutical consulting on the quality of antimicrobial use in a surgical hospital department in a prospective controlled intervention study.

METHODS

Patients receiving pharmaceutical intervention (intervention group, IG, n = 317) were compared with a historical control group (control group, CG, n = 321). During the control period, antimicrobial use was monitored without intervention. During the subsequent intervention period, a clinical pharmacist reviewed the prescriptions and gave advice on medication.

RESULTS

Intervention reduced the length of antimicrobial courses (IG = 10 days, CG = 11 days, incidence rate ratio for i.v. versus o.p. = 0.88, 95% confidence interval 0.84 to 0.93) and shortened i.v. administration (IG = 8 days, CG = 10 days, hazard rate = 1.76 in favour of switch from i.v. to p.o., 95% confidence interval 1.23 to 2.52). Intervention also helped to avoid useless combination therapy and reduced total costs for antimicrobials.

CONCLUSIONS

A clinical pharmacist who reviews prescriptions can promote an increase in efficiency, for example, by shortening the course of treatment. Counselling by ward-based clinical pharmacists was shown to be effective to streamline antimicrobial therapy in surgical units and to increase drug safety.

De-escalation of antimicrobial treatment for adults with sepsis, severe sepsis or septic shock

BACKGROUND

Mortality rates among patients with sepsis, severe sepsis or septic shock ranges from 27% to 54%. Empirical broad-spectrum antimicrobial treatment is aimed at achieving adequate antimicrobial therapy and thus reducing mortality. However, there is a risk that empirical broad-spectrum antimicrobial treatment can expose patients to overuse of antimicrobials. De-escalation has been proposed as a strategy to replace empirical broad-spectrum antimicrobial treatment with a narrower antimicrobial therapy. This is done by either changing the pharmacological agent or discontinuing a pharmacological combination according to the patient's microbial culture results.

OBJECTIVES

To evaluate the effectiveness and safety of de-escalation antimicrobial treatment for adult patients diagnosed with sepsis, severe sepsis or septic shock caused by any micro-organism.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 8); MEDLINE via PubMed (from inception to August 2010); EMBASE (from inception to August 2010); LILACS (from inception to August 2010); Current Controlled Trials and bibliographic references of relevant studies. We also contacted the main authors in the area. We applied no language restriction.

SELECTION CRITERIA

We planned to include randomized controlled trials comparing de-escalation (based on culture results) versus standard therapy for adults with sepsis, severe sepsis or septic shock. The primary outcome was mortality (at 28 days, hospital discharge or the end of the follow-up period). Studies including patients initially treated with an empirical but not adequate antimicrobial therapy were not considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors planned to independently select and extract data and evaluate methodological quality of all studies. We planned to use relative risk (risk ratio) for dichotomous data and mean difference (MD) for continuous data, with 95% confidence intervals. We planned to use the random-effects statistical model when the estimate effects of two or more studies could be combined in a meta-analysis.

MAIN RESULTS

We retrieved 436 references via the search strategy. No randomized controlled trials testing de-escalation antimicrobial treatment for adult patients diagnosed with sepsis, severe sepsis or septic shock could be included in this review.

AUTHORS' CONCLUSIONS

There is no adequate, direct evidence as to whether de-escalation of antimicrobial agents is effective and safe for adults with sepsis, severe sepsis or septic shock. Therefore, it is not possible to either recommend or not recommend the de-escalation of antimicrobial agents in clinical practice for septic patients. This uncertainty warrants further research via randomized controlled trials or cohort studies.

Importance and Impact of Antimicrobial Stewardship

The landscape of health care is rapidly changing. With health care reform on the horizon, institutions are examining many practices to determine the best way to provide optimal care while minimizing economic burden. Antimicrobial stewardship is one method many institutions are implementing to achieve this balance. Antimicrobial stewardship encompasses a wide range of services aimed at improving patient outcomes and minimizing the untoward effects of antimicrobial agents including side effects as well as induction of resistance. These programs have been shown to decrease both the development of resistance as well as expenditures on antimicrobial agents. Recently, computerized decision support software has been implemented at many institutions. This technology has greatly improved the productivity of antimicrobial stewardship programs. Combining available technology with expert knowledge in infectious diseases is necessary to ensure the continued efficacy of current antimicrobial agents.

Nationwide implementation of antibiotic management teams in Belgian hospitals: a self-reporting survey

OBJECTIVES

Antibiotic management teams (AMTs) have been advocated to optimize the use of antimicrobials in hospitals. Since 2002, the Belgian Antibiotic Policy Coordination Committee (BAPCOC) has supported the development of AMTs in Belgian hospitals with policy guidance and federal funding for antibiotic managers. We performed a national, self-reporting survey to assess the level of AMT activities in 2007.

METHODS

A structured questionnaire survey was performed on the composition, organization and service activities of the AMT in all acute care and larger chronic care hospitals in the country in 2007. Descriptive statistics were stratified by duration of AMT funding.

RESULTS

Completed questionnaires were provided by 112 of 116 hospitals (response rate, 96.6%). Mutidisciplinary AMTs varied in size (mean 10, range 2-28 members). Antibiotic stewardship tools used by AMTs included: hospital antibiotic formulary (96.3% of hospitals); practice guidelines for antibiotic therapy and surgical prophylaxis (91.6% and 96.3%, respectively); list of 'restricted' antimicrobial agents (75.9%); concurrent review of antibiotic therapies (64.2%); de-escalation of therapy after a few days (63.9%); sequential intravenous/oral therapy for antibiotics with equivalent bioavailability (78.7%); dedicated antimicrobial order forms (36.1%); automatic stop of delivery (43.5%); analysis of antibiotic consumption data (96.2%); and analysis of microbial resistance data (89.8%).

CONCLUSIONS

These data demonstrate a well-developed structure of AMTs in Belgian hospitals and the broad range of services provided. Technical and financial support by healthcare authorities was key to the extensive implementation of antimicrobial stewardship programmes across the national hospital care system.

Antimicrobial stewardship: application in the intensive care unit

Critical-care units can be barometers for appropriate antimicrobial use. There, life and death hang on empirical antimicrobial therapy for treatment of infectious diseases. With increasing therapeutic empiricism, triple-drug, broad-spectrum regimens are often necessary, but cannot be continued without fear of the double-edged sword: a life-saving intervention or loss of life following Clostridium difficile infection, infection from a resistant organism, nephrotoxicity, cardiac toxicity, and so on. While broadened initial empirical therapy is considered a standard, it must be necessary, dosed according to pharmacokinetic-pharmacodynamic principles, and stopped when no longer needed. Antimicrobial stewardship interventions shepherd these considerations in antimicrobial therapy. With pharmacists and physicians trained in infectious disease and critical care, clear-cut interventions can be focused on beginning or growing a stewardship program, or proposing future studies.

Assessment of transparency of cost estimates in economic evaluations of patient safety programmes

OBJECTIVES

Transparency of costing is essential for decision-makers who require information on the efficiency of a health care programme, because effective decisions depend largely on applicability to their settings. The main objectives of this study were to assess published studies for transparency of cost estimates.

METHODS

We first developed criteria with two axes by reviewing publications dealing with economic evaluations and cost accounting studies: clarification of the scope of costing and accuracy of method evaluating costs. We then performed systematic searches of the literature for studies which estimated prevention costs and assessed the transparency and accuracy of costing based on our criteria.

RESULTS

Forty studies met the inclusion criteria. Half of the studies reported data for both the quantity and unit price of programmes in regard to prevention costs. Although 30 studies estimated costs of adverse events, 19 of these described the scope of costing only, and just five studies used a micro-costing method. Among 30 studies that estimated 'gross cost savings' and 'net cost savings', there was a huge discrepancy in labels.

CONCLUSIONS

Even if a cost study was conducted in accordance with existing techniques of economic evaluation which mostly paid attention to internal validity of cost estimates, without adequate explanation of the process of costing, reproducibility cannot be assured and the study may lose its value as scientific information. This study found that there is tremendous room for improvement.

Antibiotic prescribing patterns in village health clinics across 10 provinces of Western China

OBJECTIVES

To explore antibiotic prescribing patterns in rural areas across 10 provinces of Western China and to compare the patterns among these provinces.

METHODS

About 20 125 prescriptions were collected from 680 primary health clinics in villages from 40 counties in 10 provinces of Western China. Percentage of prescriptions with antibiotics and number of antibiotics per 100 prescriptions were used as measurements of antibiotic utilization.

RESULTS

The percentage of prescriptions with antibiotics was 48.43 (range: 41.12-57.47) in the study areas. There were 49 kinds of antibiotics prescribed in total, and 17 of them accounted for 90% of all usage. The number of antibiotics per 100 prescriptions was 54.62 (range: 43.78-69.56).

CONCLUSIONS

The frequency and proportion of prescribed antibiotics in the rural areas of Western China are higher compared with the developed countries, and the patterns of antibiotic prescription differ greatly among provinces. The findings have important policy implications for recommendations on the utilization of antibiotics in China.

Evaluation of an antimicrobial stewardship program at a pediatric teaching hospital

BACKGROUND

Thirty to 50% of hospitalized patients receive antimicrobial therapy. Previous data suggest that inappropriate use results in higher mortality rates, longer lengths of stay, and increased medical costs. Antimicrobial Stewardship Programs (ASPs) reduce the improper use of antimicrobials and improve patient safety. Despite increased awareness about the benefits of these programs, few pediatric ASPs exist and fewer comprehensive studies evaluate their effects.

METHODS

A prospective observational study was conducted to describe the use and impact of a pediatric ASP. Data were collected on the clinician's request for targeted antibiotics and the interventions made by the ASP. Retrospective chart review was performed to assess outcomes and compliance on empiric antimicrobial therapy decisions and recommendations to discontinue antimicrobial therapy.

RESULTS

During the 4-month study period, calls were placed to the ASP for 652 patients. Forty-five percent of those calls required an intervention by the ASP. These interventions included: (1) Targeting the known or suspected pathogens (20%); (2) Consultation (43%); (3) Optimize antimicrobial treatment (33%); and (4) Stop antimicrobial treatment (4%). Three of the 84 (3.5%) patients recommended to receive alternative therapy developed an infection not covered by the ASP recommendations or the antimicrobial initially requested by the clinician.

CONCLUSIONS

Our data demonstrate that an ASP improves the appropriate use of antimicrobial medications in hospitalized children. In addition, the ASP plays an integral role in providing guidance to clinicians and ensures that the appropriate antimicrobial agents are used.

Antimicrobial stewardship and the role of pharmacokinetics-pharmacodynamics in the modern antibiotic era

Antimicrobial stewardship, a term coined by Dale Gerding, is defined as the optimal selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance development. Methods to promote and ensure good antimicrobial stewardship have been implemented and studied, and have typically provided tangible benefits in terms of a reduction in overall or targeted antimicrobial usage and resistance emergence. Although most of the programmatic antimicrobial stewardship efforts have been conducted in acute care inpatient settings, some strategies usually involving education have been evaluated in the outpatient venue. In this review, we shall discuss issues related to why antimicrobial stewardship is of particular importance in the modern antibiotic era. In addition, general pharmacokinetic-pharmacodynamic (PK-PD) concepts will be reviewed and specific PK-PD analyses that support the optimal selection, dosing, and duration of therapy for beta-lactam antimicrobials will be provided.