Long‐Term Antibiotic Cost Savings from a Comprehensive Intervention Program in a Medical Department of a University‐Affiliated Teaching Hospital

Dalbavancin Use in Bone and Joint Infections

Background

Dalbavancin (DAL) off-label use for treating bone and joint infections has increased especially as long-term intravenous access is not needed. Little is known about the effectiveness and safety of its use.

Methods

This retrospective, single-center, descriptive study included adults treated with DAL for bone or joint infections over a 4-year period (2019-2023). Patient demographics, infection type and location, pre-DAL antibiotic and surgical treatments, indication for DAL, and clinical outcomes were collected. Risk factor analysis for 1-year infection recurrence was performed.

Results

There were 58 patient encounters of bone and/or joint infections treated with DAL. The majority of patients were treated for osteomyelitis (81.0%) followed by native (8.6%) and peri-prosthetic (10.4%) joint infection. Fifty (86.2%) patients underwent surgical intervention, and 17 (68%) of the 25 patients with infected hardware had full hardware removal. The most common pathogen identified was Staphylococcus aureus (41; 70.7%), with methicillin-resistant Staphylococcus aureus isolated in 23 (40.0%) cases. Ten (17.2%) patients had recurrence within 1 year. Hardware removal was found to significantly decrease the risk of infection recurrence (P = .026). None of the peri-prosthetic joint infection patients had infection recurrence within 1 year.

Conclusions

Our findings support DAL as an effective treatment for bone and joint infection when combined with surgical debridement and hardware removal. Failure to remove infected hardware significantly increased the risk of infection recurrence within 1 year. Randomized controlled trials are needed to further support DAL as a novel treatment for orthopedic infections.

The Appropriateness of Empirical Uses of Antibiotics Based on Antimicrobial Susceptibility Results for Inpatients at a Tertiary Hospital in Saudi Arabia

The optimal use of antibiotics represents a cornerstone in controlling antibiotic resistance. Strategies such as antibiotic stewardship programs (ASPs) have been developed to influence the rational use of antibiotics. This study evaluated the appropriateness of the empirical use of antibiotics based on antibiotic susceptibility results with the aim of participating effectively in improving local ASPs. In a cross-sectional study conducted at a tertiary hospital in Saudi Arabia, 500 inpatients received empirical antibiotics, and their culture and sensitivity results were included. The appropriateness of the empirical use of antibiotics was determined based on their alignment with the culture and sensitivity results. More than half of the participants (56.4%) were men, and nearly half (43%) were over 61 years old. The empirical uses of antibiotics were appropriately prescribed in 58% of the patients. Ciprofloxacin and ceftriaxone were the most prescribed antibiotics, while vancomycin, piperacillin-tazobactam, and tigecycline were the most appropriately prescribed antibiotics. E. coli was the main microorganism isolated in the susceptibility results and was appropriately prescribed in 59% of the patients. The highest microbial sensitivity was observed for linezolid, vancomycin, and tigecycline. Antibiotics were appropriately prescribed empirically in more than half of the participants. Activating interventional ASP is crucial to fill the gap in prescribing antimicrobials. Considering the expected type of organisms and the local susceptibility pattern is likely to yield a more appropriate empirical use of antibiotics.

Impact of Urine Culture Reflex Policy Implementation in a Large County Hospital Inpatient Rehabilitation Unit-A Pilot Study

OBJECTIVE

To promote antimicrobial stewardship, many institutions have implemented a policy of reflexing to a urine culture based on a positive urinalysis result. The rehabilitation patient population, including individuals with brain and spinal cord injuries, may have atypical presentations of urinary tract infections. The study objective is to determine the effects of implementing a urine culture reflex policy in this specific patient population.

DESIGN

In an inpatient rehabilitation unit, 348 urinalyses were analyzed from August 2019 to June 2021. Urinalysis with greater than or equal to 10 white blood cells per high power field was automatically reflexed to a urine culture in this prospective study. Primary outcome was return to acute care related to urinary tract infection. Secondary outcomes included adherence to reflex protocol, antibiotic utilization and appropriateness, adverse outcomes related to antibiotic use, and reduction in urine cultures processed and the associated reduction in healthcare costs.

RESULTS

There was no statistically significant difference before and after intervention related to the primary outcome. Urine cultures processed were reduced by 58% after intervention.

CONCLUSIONS

Urine culture reflex policy is likely an effective intervention to reduce the frequency of urine cultures without significantly affecting the need to transfer patients from inpatient rehabilitation back to the acute care setting.

Assessment of antimicrobial prescribing practice, knowledge, and culture in three teaching hospitals

BACKGROUND

Antimicrobial resistance (AR) is one of the most critical threats to global health. One of its root causes, misuse of antibiotics, can stem from prescribers' preconceived ideas, differing attitudes, and lack of knowledge. Canadian data on this subject are scarce. This study aimed to understand the culture and knowledge of antimicrobial prescribing to optimize strategies targeting prescribers in the local antimicrobial stewardship program (ASP).

METHODS

An anonymous online survey was developed and distributed to antimicrobials prescribers at three acute-care teaching hospitals. The questionnaire surveyed perception of AR and ASPs.

RESULTS

A total of 440 respondents completed the entire survey. All agreed that AR is a significant challenge in Canada. The vast majority (86%) of respondents believed that AR is a significant problem at their working hospital. However, only 36% of respondents believed that antibiotics are misused locally. Most (92%) agreed that ASPs can decrease AR. Several knowledge gaps were identified through clinical questions. For example, respondents failed to identify treatment indications for asymptomatic bacteriuria 15% of the time and 59% chose an unnecessarily broad antibiotic when presented a microbiology report with susceptibility results associated with a common clinical syndrome. Prescribers' self-reported confidence did not correlate with their knowledge score.

CONCLUSIONS

Respondents recognized AR as a critical issue but awareness and knowledge on antibiotic misuse were lacking. As shown in previous studies, respondents see the threat of AR in a more theoretical way. This study provided a better understanding of antimicrobial prescribing practices and ways to optimize them within three teaching hospitals in Montréal. Barriers to optimal antimicrobial prescribing were identified and strategies for improving the effectiveness of the ASP will be developed accordingly.

Practical Concerns about the Metrics and Methods of Financial Outcome Measurement in Antimicrobial Stewardship Programs: A Narrative Review

Emerging pathogens in the meantime of paucity of new antibiotics discovery, put antimicrobial stewardship in the center of attention, to preserve the existing antimicrobial effect. Implementation of antimicrobial stewardship programs, however, needs approval from healthcare system managers. The approval process can be enhanced, when the beneficial effects of stewardship programs are supported by both clinical and financial evidence. Focusing on the financial outcome evaluation, the practitioners who run the stewardship programs, may choose certain methods and metrics, depending on the clinical setting scale and type, available human resources, and budget. The wise selection of the methods and metrics warrants a comprehensive insight of the existing methods and metrics, deployed by typically published works that set good examples to follow. This review is an attempt to provide such an insight along with typical relevant examples for each metric and method.

Do Inpatient Antimicrobial Stewardship Programs Help Us in the Battle Against Antimicrobial Resistance?

BACKGROUND

Antibiotic stewardship programs (ASPs) have demonstrated success at reducing costs, yet there is limited quality evidence of their effectiveness in reducing infections of high-profile drug-resistant organisms.

METHODS

This retrospective, cohort study included all Kaiser Permanente Southern California (KPSC) members aged ≥18 years hospitalized in 9 KPSC hospitals from 1 January 2008 to 31 December 2016. We measured the impact of staggered ASP implementation on consumption of 18 ASP-targeted antibiotics using generalized linear mixed-effects models. We used multivariable generalized linear mixed-effects models to estimate the adjusted effect of an ASP on rates of infection with drug-resistant organisms. Analyses were adjusted for confounding by time, cluster effects, and patient- and hospital-level characteristics.

RESULTS

We included 765 111 hospitalizations (288 257 pre-ASP, 476 854 post-ASP). By defined daily dose, we found a 6.1% (-7.5% to -4.7%) overall decrease antibiotic use post-ASP; by days of therapy, we detected a 4.3% (-5.4% to -3.1%) decrease in overall use of antibiotics. The number of prescriptions increased post-ASP (1.04 [1.03-1.05]). In adjusted analyses, we detected an overall increase in vancomycin-resistant enterococci infections post-ASP (1.37 [1.10-1.69]). We did not detect a change in the rates of extended-spectrum beta-lactamase, carbapenem-resistant Enterobacteriaceae, and multidrug-resistant Pseudomonas aeruginosa infections post-ASP.

CONCLUSIONS

ASPs with successful reductions in consumption of targeted antibiotics may not see changes in infection rates with antibiotic-resistant organisms in the 2 to 6 years post-implementation. There are likely differing timescales for reversion to susceptibility across organisms and antibiotics, and unintended consequences from compensatory prescribing may occur.

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.

Antimicrobial Stewardship and the Infection Control Practitioner: A Natural Alliance

Antibiotic overuse and misuse has contributed to rising rates of multidrug-resistant organisms and Clostridioides difficile. Decreasing antibiotic misuse has become a national public health priority. This review outlines the goals of antimicrobial stewardship, essential members of the program, implementation strategies, approaches to measuring the program's impact, and steps needed to build a program. Highlighted is the alliance between antimicrobial stewardship programs and infection prevention programs in their efforts to improve antibiotic use, improve diagnostic stewardship for C difficile and asymptomatic bacteriuria, and decrease health care-associated infections and the spread of multidrug-resistant organisms.

Estrategias de protección antimicrobiana en el cuidado de heridas: evidencia para el uso de apósitos recubiertos con DACC

BACKGROUND

Antimicrobial resistance (AMR) is one of the most serious health threats globally. The development of new antimicrobials is not keeping pace with the evolution of resistant microorganisms, and novel ways of tackling this problem are required. One of such initiatives has been the development of antimicrobial stewardship programmes (AMS). The use of wound dressings that employ a physical sequestration and retention approach to reduce bacterial burden offers a novel approach to support AMS. Bacterial-binding by dressings and their physical removal can minimise their damage and prevent the release of harmful endotoxins.

OBJECTIVE

To highlight AMS to promote the correct use of antimicrobials and to investigate how dialkylcarbamyl chloride (DACC)-coated dressings can support AMS.

METHOD

MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar were searched to identify articles relating to AMS, and the use of wound dressings in the prevention and treatment of wound infections. The evidence supporting alternative wound dressings that can reduce bioburden and prevent wound infection in a way that does not kill or damage the microorganisms were reviewed.

RESULTS

The evidence demonstrated that using bacterial-binding wound dressings that act in a physical manner (eg, DACC-coated dressings) to preventing infection in both acute and hard-to-heal wounds does not exacerbate AMR and supports AMS.

CONCLUSION

Some wound dressings work via a mechanism that promotes the binding and physical sequestration and removal of intact microorganisms from the wound bed (eg, a wound dressing that uses DACC technology to prevent/reduce infection). They provide a valuable tool that aligns with the requirements of AMS by effectively reducing wound bioburden without inducing/selecting for resistant bacteria.

Antibiotic stewardship implementation at hospitals without on-site infectious disease specialists: A qualitative study

BACKGROUND

Hospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist.

OBJECTIVE

In this study, we sought to understand ASP implementation at hospitals that lack on-site ID support within the Veterans' Health Administration (VHA).

METHODS

Using a mandatory VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. We conducted semistructured interviews with personnel involved in ASP activities.

SETTING

The study was conducted across 7 VHA hospitals.

PARTICIPANTS

In total, 42 hospital personnel were enrolled in the study.

RESULTS

The primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. The pharmacist champions were more successful at gaining buy-in when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers and improving the acceptance of their stewardship recommendations. In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals.

CONCLUSION

In this study of 7 hospitals without on-site ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.

Antimicrobial stewardship strategies in wound care: evidence to support the use of dialkylcarbamoyl chloride (DACC)- coated wound dressings

BACKGROUND

Traditionally, infections are treated with antimicrobials (for example, antibiotics, antiseptics, etc), but antimicrobial resistance (AMR) has become one of the most serious health threats of the 21st century (before the emergence of COVID-19). Wounds can be a source of infection by allowing unconstrained entry of microorganisms into the body, including antimicrobial-resistant bacteria. The development of new antimicrobials (particularly antibiotics) is not keeping pace with the evolution of resistant microorganisms and novel ways of addressing this problem are urgently required. One such initiative has been the development of antimicrobial stewardship (AMS) programmes, which educate healthcare workers, and control the prescribing and targeting of antimicrobials to reduce the likelihood of AMR. Of great importance has been the European Wound Management Association (EWMA) in supporting AMS by providing practical recommendations for optimising antimicrobial therapy for the treatment of wound infection. The use of wound dressings that use a physical sequestration and retention approach rather than antimicrobial agents to reduce bacterial burden offers a novel approach that supports AMS. Bacterial-binding by dressings and their physical removal, rather than active killing, minimises their damage and hence prevents the release of damaging endotoxins.

AIM

Our objective is to highlight AMS for the promotion of the judicious use of antimicrobials and to investigate how dialkylcarbamoyl chloride (DACC)-coated dressings can support AMS goals.

METHOD

MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar were searched to identify published articles describing data relating to AMS, and the use of a variety of wound dressings in the prevention and/or treatment of wound infections. The evidence supporting alternative wound dressings that can reduce bioburden and prevent and/or treat wound infection in a manner that does not kill or damage the microorganisms (for example, by actively binding and removing intact microorganisms from wounds) were then narratively reviewed.

RESULTS

The evidence reviewed here demonstrates that using bacterial-binding wound dressings that act in a physical manner (for example, DACC-coated dressings) as an alternative approach to preventing and/or treating infection in both acute and hard-to-heal wounds does not exacerbate AMR and supports AMS.

CONCLUSION

Some wound dressings work via a mechanism that promotes the binding and physical uptake, sequestration and removal of intact microorganisms from the wound bed (for example, a wound dressing that uses DACC technology to successfully prevent/reduce infection). They provide a valuable tool that aligns with the requirements of AMS (for example, reducing the use of antimicrobials in wound treatment regimens) by effectively reducing wound bioburden without inducing/selecting for resistant bacteria.

Impact of an Antibiotic Stewardship Program on the Incidence of Resistant Escherichia coli: A Quasi-Experimental Study

Infections caused by multidrug-resistant Gram-negative bacteria increase hospitalizations and mortality rates; antibiotic pressure increases resistance rates. We evaluated the impact of the antibiotics stewardship program (ASP) on Escherichia coli resistance rates, evaluating all antibiotic use and patients with positive cultures hospitalized between 2011 and 2018. Data on antibiotics were collected quarterly as the defined daily dose (DDD)/100 days hospitalization. In 2014, an intervention was introduced, targeting the reduction of overall antibiotic use as well as specifically targeting quinolones and other broad-spectrum antibiotics. Using interrupted time series analysis (ITS), we compared the rates and trends of antibiotic use and resistant E. coli. We included 6001 patients, 3182 pre-ASP and 2819 post-ASP. We observed significant changes in absolute numbers as well as in trends for use of DDD/100 days of all antibiotics by 31% from 76 to 52, and by 52% from 10.4 to 4.9 for quinolones. ITS demonstrated that before the ASP intervention, there was a slope pattern for increased E. coli resistance to antibiotics. This slope was reversed following the intervention for quinolones −1.52, aminoglycosides −2.04, and amoxicillin clavulanate (amox/clav) −1.76; the effect of the intervention was observed as early as three months after the intervention and continued to decrease over time until the end of the study, at 48 months. We conclude that the ASP can positively impact the resistance rate of Gram-negative infections over time, regardless of the targeted combination of antibiotics, if the overall use is reduced.

Antibiotic stewardship from a decision-making, behavioral economics, and incentive design perspective

Antibiotic-resistant infections cause over 20 thousand deaths and $20 billion annually in the United States. Antibiotic prescribing decision making can be described as a "tragedy of the commons" behavioral economics problem, for which individual best interests affecting human decision-making lead to suboptimal societal antibiotic overuse. In 2015, the U.S. federal government announced a $1.2 billion National Action Plan to combat resistance and reduce antibiotic use by 20% in inpatient settings and 50% in outpatient settings by 2020. We develop and apply a behavioral economics model based on game theory and "tragedy of the commons" concepts to help illustrate why rational individuals may not practice ideal stewardship and how to potentially structure three specific alternate approaches to accomplish these objectives (collective cooperative management, usage taxes, resistance penalties), based on Ostrom's economic governance principles. Importantly, while each approach can effectively incentivize ideal stewardship, the latter two do so with 10-30% lower utility to all providers. Encouraging local or state-level self-managed cooperative stewardship programs thus is preferred to national taxes and penalties, in contrast with current trends and with similar implications in other countries.

Collaborative Antimicrobial Stewardship for Surgeons

Antimicrobial stewardship efforts that include surgeons rely on healthy and open communications between surgeons, infectious diseases specialists, and pharmacists. These efforts most frequently are related to surgical prophylaxis, the management of surgical infections, and surgical critical care. Policy should be based on best evidence and timely interactions to develop consensus on how to develop appropriate guidelines and protocols. Flexibility on all sides leads to increasingly strong relationships over time.

Knowledge, Attitudes and Practices of Veterinarians Towards Antimicrobial Resistance and Stewardship in Nigeria

Antimicrobial resistance (AMR) is a global health concern and the inappropriate use of antibiotics in animals and humans is considered a contributing factor. A cross-sectional survey to assess the knowledge, attitudes and practices of veterinarians regarding AMR and antimicrobial stewardship was conducted in Nigeria. A total of 241 respondents completed an online survey. Only 21% of respondents correctly defined the term antimicrobial stewardship and 59.8% were unaware of the guidelines provided by the Nigeria AMR National Action Plan. Over half (51%) of the respondents indicated that prophylactic antibiotic use was appropriate when farm biosecurity was poor. Only 20% of the respondents conducted antimicrobial susceptibility testing (AST) frequently, and the unavailability of veterinary laboratory services (82%) and the owner’s inability to pay (72%) were reported as key barriers to conducting AST. The study findings suggest strategies focusing on the following areas may be useful in improving appropriate antibiotic use and antimicrobial stewardship among veterinarians in Nigeria: increased awareness of responsible antimicrobial use among practicing and newly graduated veterinarians, increased dissemination of regularly updated antibiotic use guidelines, increased understanding of the role of good biosecurity and vaccination practices in disease prevention, and increased provision of laboratory services and AST at affordable costs.

Value of hospital antimicrobial stewardship programs [ASPs]: a systematic review

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.

Principles and Practice of Antibiotic Stewardship in the ICU

In the face of emerging drug-resistant pathogens and a decrease in the development of new antimicrobial agents, antibiotic stewardship should be practiced in all critical care units. Antibiotic stewardship should be a core competency of all critical care practitioners in conjunction with a formal antibiotic stewardship program (ASP). Prospective audit and feedback, and antibiotic time-outs, are effective components of an ASP in the ICU. As rapid diagnostics are introduced in the ICU, assessment of performance and effect on outcomes will clearly be needed. Disease-specific stewardship for community-acquired pneumonia that relies on clinical pathways may be particularly high-yield. Computerized decision support has the potential to individualize stewardship for specific patients. Finally, infection control and prevention is the cornerstone of every ASP.

Antimicrobial Stewardship Programs: Principles and Practice

Antimicrobial stewardship involves optimizing antibiotic use while using cost-effective interventions to minimize antibiotic resistance and control Clostridium difficile. An effective hospital-wide antimicrobial stewardship program (ASP) should be led by an infectious disease (ID) physician. The ASP team needs full and ongoing financial support for the ASP from the hospital administration. The ID clinician leader should have special expertise in various aspects of antimicrobial therapy, that is, pharmacokinetics, resistance, pharmacoeconomics, and C difficile. The ASP ID team leader and ID-trained clinical pharmacist staff are responsible for customizing ASP interventions to the hospital's unique set of antibiotic use-related concerns.

Role of the microbiome, probiotics, and 'dysbiosis therapy' in critical illness

PURPOSE OF REVIEW

Loss of 'health-promoting' microbes and overgrowth of pathogenic bacteria (dysbiosis) in ICU is believed to contribute to nosocomial infections, sepsis, and organ failure (multiple organ dysfunction syndrome). This review discusses new understanding of ICU dysbiosis, new data for probiotics and fecal transplantation in ICU, and new data characterizing the ICU microbiome.

RECENT FINDINGS

ICU dysbiosis results from many factors, including ubiquitous antibiotic use and overuse. Despite advances in antibiotic therapy, infections and mortality from often multidrug-resistant organisms (i.e., Clostridium difficile) are increasing. This raises the question of whether restoration of a healthy microbiome via probiotics or other 'dysbiosis therapies' would be an optimal alternative, or parallel treatment option, to antibiotics. Recent clinical data demonstrate probiotics can reduce ICU infections and probiotics or fecal microbial transplant (FMT) can treat Clostridium difficile. This contributes to recommendations that probiotics should be considered to prevent infection in ICU. Unfortunately, significant clinical variability limits the strength of current recommendations and further large clinical trials of probiotics and FMT are needed. Before larger trials of 'dysbiosis therapy' can be thoughtfully undertaken, further characterization of ICU dysbiosis is needed. To addressing this, we conducted an initial analysis demonstrating a rapid and marked change from a 'healthy' microbiome to an often pathogen-dominant microbiota (dysbiosis) in a broad ICU population.

SUMMARY

A growing body of evidence suggests critical illness and ubiquitous antibiotic use leads to ICU dysbiosis that is associated with increased ICU infection, sepsis, and multiple organ dysfunction syndrome. Probiotics and FMT show promise as ICU therapies for infection. We hope future-targeted therapies using microbiome signatures can be developed to correct 'illness-promoting' dysbiosis to restore a healthy microbiome post-ICU to improve patient outcomes.

Perioperative Antibiotics for Clean Hand Surgery: A National Study

PURPOSE

Given that surgical site infections remain a common performance metric in assessing the quality of health care, we hypothesized that prophylactic antibiotics are overutilized in soft tissue hand surgery when antimicrobials are not indicated.

METHODS

We studied insurance claims from the Truven MarketScan Databases to identify patients who underwent 1 of 5 outpatient hand surgery procedures: open or endoscopic carpal tunnel release, trigger finger release, de Quervain release, and wrist ganglion excision between 2009 and 2015 (n = 305,946). Hospital payment claims for preoperative intravenous antibiotics and prescriptions filled for postoperative oral antibiotics were analyzed. We examined the rate and temporal trend of prophylactic antibiotics use and identified risk factors using multivariable logistic regression. We also calculated health care expenditures related to prophylaxis.

RESULTS

Prior to surgery, 13.6% (2009-2015) of patients received prophylactic intravenous antibiotics and trend analysis showed a statistically significant increase from 2009 (10.6%) to 2015 (18.3%), an increase of 72.5%. Preoperative prophylaxis was used most often prior to trigger finger release (17.5%) and least often prior to endoscopic carpal tunnel release (11.2%). Younger age, male sex, lower income, and obese patients had higher odds of receiving antibiotics. The total charge of prophylactic antibiotics medication used in this study equaled $1.6 million.

CONCLUSIONS

In 2015, prophylactic intravenous antibiotics were administered to nearly 1 in 5 patients prior to clean soft tissue hand surgery. Although consensus guidelines indicate prophylaxis is not indicated, their use has increased steadily in the United States from 2009 to 2015.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Knowledge, Attitudes, and Practices Regarding Antimicrobial Use and Stewardship Among Prescribers at Acute-Care Hospitals

OBJECTIVE To assess antimicrobial prescriber knowledge, attitudes, and practices (KAP) regarding antimicrobial stewardship (AS) and associated barriers to optimal prescribing. DESIGN Cross-sectional survey. SETTING Online survey. PARTICIPANTS A convenience sample of 2,900 US antimicrobial prescribers at 5 acute-care hospitals within a hospital network. INTERVENTION The following characteristics were assessed with an anonymous, online survey in February 2015: attitudes and practices related to antimicrobial resistance, AS programs, and institutional AS resources; antimicrobial prescribing and AS knowledge; and practices and confidence related to antimicrobial prescribing. RESULTS In total, 402 respondents completed the survey. Knowledge gaps were identified through case-based questions. Some respondents sometimes selected overly broad therapy for the susceptibilities given (29%) and some "usually" or "always" preferred using the most broad-spectrum empiric antimicrobials possible (32%). Nearly all (99%) reported reviewing antimicrobial appropriateness at 48-72 hours, but only 55% reported "always" doing so. Furthermore, 45% of respondents felt that they had not received adequate training regarding antimicrobial prescribing. Some respondents lacked confidence selecting empiric therapy using antibiograms (30%), interpreting susceptibility results (24%), de-escalating therapy (18%), and determining duration of therapy (31%). Postprescription review and feedback (PPRF) was the most commonly cited AS intervention (79%) with potential to improve patient care. CONCLUSIONS Barriers to appropriate antimicrobial selection and de-escalation of antimicrobial therapy were identified among front-line prescribers in acute-care hospitals. Prescribers desired more AS-related education and identified PPRF as the most helpful AS intervention to improve patient care. Educational interventions should be preceded by and tailored to local assessment of educational needs. Infect Control Hosp Epidemiol 2018;39:316-322.

Reducing Antimicrobial Use in an Academic Pediatric Institution: Evaluation of the Effectiveness of a Prospective Audit With Real-Time Feedback

INTRODUCTION

Antimicrobial use is decreasing across freestanding children's hospitals, predominantly in institutions with antimicrobial stewardship programs (ASPs) in place. A highly effective ASP should effect a greater decrease in use than predicted by existing trends. Antimicrobial stewardship programs depend on clinician adherence to program recommendations, but little is known about factors associated with adherence.

METHODS

Parenteral antimicrobial-use data for our institution and 43 additional freestanding children's hospitals were obtained and normalized for patient census. Segmental linear regression was used to compare rates of change of parenteral antimicrobial use before and after ASP implementation. Time-series models were developed to predict use in the absence of intervention. The odds of adherence to ASP recommendations were determined based on provider characteristics and recommendation type.

RESULTS

In the 38 months before ASP implementation, parenteral antimicrobial use was decreasing at our hospital by 3.7%/year, similar to the 3.4%/year found across children's hospitals. The rate of change after implementation of the ASP at our hospital was 11.1%/year, compared to 5.6%/year for other hospitals over the same period. Of 643 interventions, teams adhered with recommendations in 495 cases (77.0%). According to adjusted analysis, primary service was not associated with adherence (P = .356). There was an association between adherence and the role of the clinician receiving a recommendation (P = .009) and the recommendation type (P = .009).

CONCLUSIONS

Understanding factors associated with adherence to ASP recommendations can help those who administer such programs to strategize interventions for maximizing efficacy. Our findings reveal the value of a formal ASP in reducing use when controlling for secular trends.

Preventing microbial biofilms on catheter tubes using ultrasonic guided waves

Biofilms on indwelling tubes and medical prosthetic devices are among the leading causes of antibiotic-resistant bacterial infections. In this work, a new anti-biofilm catheter prototype was proposed. By combining an endotracheal tube (ET) with a group of ultrasonic guided wave (UGW) transducers, the general idea was to prevent bacteria aggregation with UGW vibrations. Based on quantitative analysis of UGW propagation, detailed approach was achieved through (a) selection of ultrasonic frequency, wave modes and vibration amplitude; and (b) adoption of wave coupling and 45° wave incidence technique. Performance of the proposed UGW-ET prototype was demonstrated via in vitro experiments, during which it deterred deposition of Pseudomonas aeruginosa (P. aeruginosa) biofilms successfully. With current configuration, UGW amplitudes ranged from 0.05-5 nm could be optimal to achieve biofilm prevention. This work sheds a light in the underlying mechanism of ultrasound-mediated biofilm prevention, and will inspire the development of new catheters of better antibacterial capability.

A Systematic Review of Quality Indicators for Appropriate Antibiotic Use in Hospitalized Adult Patients

Many quality indicators for appropriate antibiotic use have been developed. We aimed to make a systematic inventory, including the development methodology and validation procedures, of currently available quality indicators (QIs) for appropriate antibiotic use in hospitalized adult patients. We performed a literature search in the Pubmed interface. From the included articles we abstracted i) the indicators developed ii) the type of infection the QIs applied to iii) study design used for the development of the QIs iv) relation of the QIs to outcome measures v) whether the QIs were validated and vi) the characteristics of the validation cohort. Fourteen studies were included, in which 200 QIs were developed. The most frequently mentioned indicators concerned empirical antibiotic therapy according to the guideline (71% of studies), followed by switch from IV to oral therapy (64% of studies), followed by drawing at least two sets of blood cultures and change to pathogen-directed therapy based on culture results (57% of studies). Most QIs were specifically developed for lower respiratory tract infection, urinary tract infection or sepsis. A RAND-modified Delphi procedure was used in the majority of studies (57%). Six studies took outcome measures into consideration during the procedure. Five out of fourteen studies (36%) tested the clinimetric properties of the QIs and 65% of the tested QIs were considered valid. Many studies report the development of quality indicators for appropriate antibiotic use in hospitalized adult patients. However, only a small number of studies validated the developed QIs. Future validation of QIs is needed if we want to implement them in daily practice.

The efficacy of the direct clinical intervention for infectious diseases by a pediatric infectious disease specialist in the pediatric ward of a tertiary medical facility without a pediatric antimicrobial stewardship program

Antimicrobial stewardship programs (ASPs) have been introduced in most hospital complexes; however, they are not always useful for pediatric patients. The aim of this study is to investigate the efficacy of direct clinical intervention for infectious diseases by a pediatric infectious disease specialist in a tertiary medical facility without pediatric ASP. This retrospective study included 1,821 patients who were hospitalized in the pediatric ward of a large metropolitan hospital from 2010 to 2015. The clinical course, the use of intravenous antimicrobial agents and the results of a microbiological analysis were compared between the period after the beginning of direct intervention by the specialist (post-intervention period) and the previous period (pre-intervention period). In the post-intervention period, the proportion of the patients who received intravenous antimicrobial agents, the number of antimicrobial agents used for each episode, and the proportion of episodes in which an antimicrobial agent was re-administrated were significantly lower (P = 0.006, P = 0.004, P = 0.036, respectively), and the duration of antimicrobial treatment was significantly shorter (P < 0.001). In addition, narrower spectrum antimicrobial agents were used, and the incidence of meropenem-sensitive Pseudomonas aeruginosa significantly increased (P = 0.037) in the post-intervention period. There was no change of mortality between the two periods. Direct clinical intervention by a pediatric infectious diseases specialist is useful for the treatment of infectious diseases in the pediatric ward of a tertiary medical facility without a pediatric ASP. The creation of a pediatric ASP is recommended in hospital complexes.

Systematic Review and Meta-analysis of Clinical and Economic Outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs

The implementation of antimicrobial stewardship programs (ASPs) is a promising strategy to help address the problem of antimicrobial resistance. We sought to determine the efficacy of ASPs and their effect on clinical and economic parameters. We searched PubMed, EMBASE, and Google Scholar looking for studies on the efficacy of ASPs in hospitals. Based on 26 studies (extracted from 24,917 citations) with pre- and postimplementation periods from 6 months to 3 years, the pooled percentage change of total antimicrobial consumption after the implementation of ASPs was -19.1% (95% confidence interval [CI] = -30.1 to -7.5), and the use of restricted antimicrobial agents decreased by -26.6% (95% CI = -52.3 to -0.8). Interestingly, in intensive care units, the decrease in antimicrobial consumption was -39.5% (95% CI = -72.5 to -6.4). The use of broad-spectrum antibiotics (-18.5% [95% CI = -32 to -5.0] for carbapenems and -14.7% [95% CI = -27.7 to -1.7] for glycopeptides), the overall antimicrobial cost (-33.9% [95% CI = -42.0 to -25.9]), and the hospital length of stay (-8.9% [95% CI = -12.8 to -5]) decreased. Among hospital pathogens, the implementation of ASPs was associated with a decrease in infections due to methicillin-resistant Staphylococcus aureus (risk difference [RD] = -0.017 [95% CI = -0.029 to -0.005]), imipenem-resistant Pseudomonas aeruginosa (RD = -0.079 [95% CI = -0.114 to -0.040]), and extended-spectrum beta-lactamase Klebsiella spp. (RD = -0.104 [95% CI = -0.153 to -0.055]). Notably, these improvements were not associated with adverse outcomes, since the all-cause, infection-related 30-day mortality and infection rates were not significantly different after implementation of an ASP (RD = -0.001 [95% CI = -0.009 to 0.006], RD = -0.005 [95% CI = -0.016 to 0.007], and RD = -0.045% [95% CI = -0.241 to 0.150], respectively). Hospital ASPs result in significant decreases in antimicrobial consumption and cost, and the benefit is higher in the critical care setting. Infections due to specific antimicrobial-resistant pathogens and the overall hospital length of stay are improved as well. Future studies should focus on the sustainability of these outcomes and evaluate potential beneficial long-term effects of ASPs in mortality and infection rates.

Systematic review of antibiotic treatment for acute calculous cholecystitis

BACKGROUND

Intravenous antibiotics are frequently used in the initial management of acute calculous cholecystitis (ACC), although supportive care alone preceding delayed elective cholecystectomy may be sufficient. This systematic review assessed the success rate of antibiotics in the treatment of ACC.

METHODS

A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Primary outcomes were the need for emergency intervention and recurrence of ACC after initial non-operative management of ACC. Risk of bias was assessed. Pooled event rates were calculated using a random-effects model.

RESULTS

Twelve randomized trials, four prospective and ten retrospective studies were included. Only one trial including 84 patients compared treatment with antibiotics to that with no antibiotics; there was no significant difference between the two groups in terms of length of hospital stay and morbidity. Some 5830 patients with ACC were included, of whom 2997 had early cholecystectomy, 2791 received initial antibiotic treatment, and 42 were treated conservatively. Risk of bias was high in most studies, and all but three studies had a low level of evidence. For randomized studies, pooled event rates were 15 (95 per cent c.i. 10 to 22) per cent for the need for emergency intervention and 10 (5 to 20) per cent for recurrence of ACC. The pooled event rate for both outcomes combined was 20 (13 to 30) per cent.

CONCLUSION

Antibiotics are not indicated for the conservative management of ACC or in patients scheduled for cholecystectomy.

Systematic review of antibiotic consumption in acute care hospitals

Antibiotic consumption is an easily quantifiable performance measure in hospitals and might be used for monitoring. We conducted a review of published studies and online surveillance reports reporting on antibiotic consumption in acute care hospitals between the years 1997 and 2013. A pooled estimate of antibiotic consumption was calculated using a random effects meta-analysis of rates with 95% confidence intervals. Heterogeneity was assessed through subgroup analysis and metaregression. Eighty studies, comprising data from 3130 hospitals, met the inclusion criteria. The pooled rate of hospital-wide consumption was 586 (95% confidence interval 540 to 632) defined daily doses (DDD)/1000 hospital days (HD) for all antibacterials. However, consumption rates were highly heterogeneous. Antibacterial consumption was highest in intensive care units, at 1563 DDD/1000 HD (95% confidence interval 1472 to 1653). Hospital-wide antibacterial consumption was higher in Western Europe and in medium-sized, private and university-affiliated hospitals. The methods of data collection were significantly associated with consumption rates, including data sources, dispensing vs. purchase vs. usage data, counting admission and discharge days and inclusion of low-consumption departments. Heterogeneity remained in all subgroup analyses. Major heterogeneity currently precludes defining acceptable antibiotic consumption ranges in acute care hospitals. Guidelines on antibiotic consumption reporting that will account for case mix and a minimal set of hospital characteristics recommending standardized methods for monitoring and reporting are needed.

Antimicrobial Stewardship Knowledge, Attitudes, and Practices among Health Care Professionals at Small Community Hospitals

BACKGROUND

Very little is known about antimicrobial stewardship knowledge, attitudes, and practices (KAP) among health care practitioners in small, community hospitals (SCHs) compared to large community hospitals (LCHs).

OBJECTIVE

To compare infectious diseases (ID) clinical resources and describe KAP pertaining to antimicrobial stewardship among prescribers, pharmacists, and administrators from a large hospital network including a comparison between SCHs and LCHs.

METHODS

An anonymous 48-item antimicrobial stewardship KAP survey was administered to pharmacists, prescribers, and administrators at 15 SCH (<200 beds) and 5 LCHs (>200 beds) within an integrated health care network.

RESULTS

In total, 588 (14%) completed the survey: 198 from SCHs and 390 from LCHs. Most respondents were familiar or very familiar with the term antimicrobial stewardship and felt that antimicrobial stewardship was necessary. Most pharmacists and prescribers agreed that antimicrobials were overused at their hospital. However, SCH pharmacists and prescribers were more likely to disagree that antibiotic resistance is a significant problem locally. Pharmacists saw restrictions as a reasonable method of controlling antibiotic use more than prescribers. SCH practitioners were less familiar with IDSA guidelines and less likely to rely on ID specialists to a greater extent than LCH practitioners. Most respondents strongly agreed they would like more antimicrobial education.

CONCLUSION

SCH and LCH pharmacists, prescribers, and administrators are aware of antimicrobial resistance and overuse and agree that antimicrobial stewardship programs are necessary. SCHs are less likely to contact ID for information. These results support the development of antimicrobial stewardship programs at SCHs, while recognizing the significant differences in availability and utilization of resources.

Implementing antimicrobial stewardship in the Australian private hospital system: a qualitative study

OBJECTIVE

To explore organisational factors and barriers contributing to limited uptake of antimicrobial stewardship (AMS) in Australian private hospitals and to determine solutions for AMS implementation.

METHODS

A qualitative study using a series of focus group discussions was conducted in a large private hospital making use of a semistructured interview guide to facilitate discussion among clinical and non-clinical stakeholders. A thematic analysis using five sequential components that mapped and interpreted emergent themes surrounding AMS implementation was undertaken by a multidisciplinary team of researchers.

RESULTS

Analysis revealed that autonomy of consultant specialists was perceived as being of greater significance in private hospitals compared with public hospitals. Use of an expert team providing antimicrobial prescribing advice and education without intruding on existing patient-specialist relationships was proposed by participants as an acceptable method of introducing AMS in private hospitals. There was more opportunity for nursing and pharmacist involvement, as well as empowering patients. Opportunities were identified for the hospital executive to market an AMS service as a feature that promoted excellence in patient care.

CONCLUSIONS

Provision of advice from experts, championing by clinical leaders, marketing by hospital executives and involving nurses, pharmacists and patients should be considered during implementation of AMS in private hospitals.

Asymptomatic Bacteriuria in Clinical Urological Practice: Preoperative Control of Bacteriuria and Management of Recurrent UTI

Asymptomatic bacteriuria (ABU) is a common clinical condition that often leads to unnecessary antimicrobial use. The reduction of antibiotic overuse for ABU is consequently an important issue for antimicrobial stewardship and to reduce the emergence of multidrug resistant strains. There are two issues in everyday urological practice that require special attention: the role of ABU in pre-operative prophylaxis and in women affected by recurrent urinary tract infections (rUTIs). Nowadays, this is the time to think over our practice and change our way of thinking. Here, we aimed to summarize the current literature knowledge in terms of ABU management in patients undergoing urological surgery and in patients with rUTIs. In the last years, the approach to patient with ABU has changed totally. Prior to all surgical procedures that do not enter the urinary tract, ABU is generally not considered as a risk factor, and screening and treatment are not considered necessary. On the other hand, in the case of all procedures entering the urinary tract, ABU should be treated in line with the results of a urine culture obtained before the procedure. In patients affected by rUTIs, ABU can even have a protective role in preventing symptomatic recurrence, particularly when Enterococcus faecalis (E. faecalis) has been isolated.

Early optimization of antimicrobial therapy improves clinical outcomes of patients administered agents targeting methicillin-resistant Staphylococcus aureus

WHAT IS KNOWN AND OBJECTIVE

Antimicrobial stewardship is required to ensure the appropriate use of antimicrobials. However, no reports have been published on clinical outcomes of implementation of antimicrobial stewardship in patients receiving pathogen-specific antibiotics.

METHOD

To evaluate the clinical outcomes of patients who received drugs, we conducted a single-centre, retrospective study of the effects of an antimicrobial stewardship programme targeting methicillin-resistant Staphylococcus aureus (MRSA).

RESULTS

The time to administer effective antimicrobials was significantly (median number of days, 3 before vs. 0 after, P < 0·001) shortened, and the rate of de-escalation was significantly elevated (47·1% vs. 96·2%, P < 0·001) after implementation of daily review. The 60-day clinical failure associated with Gram-positive bacterial infection was significantly reduced (33·3% vs. 17·6%, P = 0·007) after intervention.

WHAT IS NEW AND CONCLUSIONS

Daily review of administration of antimicrobials targeting MRSA was highly effective in improving clinical outcomes by optimizing early antimicrobial therapy.

Epidemiology and Risk Factors for Echinocandin Nonsusceptible Candida glabrata Bloodstream Infections: Data From a Large Multisite Population-Based Candidemia Surveillance Program, 2008-2014

Background. Echinocandins are first-line treatment for Candida glabrata candidemia. Echinocandin resistance is concerning due to limited remaining treatment options. We used data from a multisite, population-based surveillance program to describe the epidemiology and risk factors for echinocandin nonsusceptible (NS) C glabrata candidemia.

Methods. The Centers for Disease Control and Prevention's Emerging Infections Program conducts population-based laboratory surveillance for candidemia in 4 metropolitan areas (7.9 million persons; 80 hospitals). We identified C glabrata cases occurring during 2008–2014; medical records of cases were reviewed, and C glabrata isolates underwent broth microdilution antifungal susceptibility testing. We defined echinocandin-NS C glabrata (intermediate or resistant) based on 2012 Clinical and Laboratory Standards Institute minimum inhibitory concentration breakpoints. Independent risk factors for NS C glabrata were determined by stepwise logistic regression.

Results. Of 1385 C glabrata cases, 83 (6.0%) had NS isolates (19 intermediate and 64 resistant); the proportion of NS isolates rose from 4.2% in 2008 to 7.8% in 2014 (P < .001). The proportion of NS isolates at each hospital ranged from 0% to 25.8%; 3 large, academic hospitals accounted for almost half of all NS isolates. In multivariate analysis, prior echinocandin exposure (adjusted odds ratio [aOR], 5.3; 95% CI, 2.6–1.2), previous candidemia episode (aOR, 2.5; 95% CI, 1.2–5.1), hospitalization in the last 90 days (aOR, 1.9; 95% CI, 1.0–3.5, and fluconazole resistance [aOR, 3.6; 95% CI, 2.0–6.4]) were significantly associated with NS C glabrata. Fifty-nine percent of NS C glabrata cases had no known prior echinocandin exposure.

Conclusion. The proportion of NS C glabrata isolates rose significantly during 2008–2014, and NS C glabrata frequency differed across hospitals. In addition to acquired resistance resulting from prior drug exposure, occurrence of NS C glabrata without prior echinocandin exposure suggests possible transmission of resistant organisms.

Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections

BACKGROUND

Women suffering from recurrent urinary tract infections (rUTIs) are routinely treated for asymptomatic bacteriuria (AB), but the consequences of this procedure on antibiotic resistance are not fully known. The aim of this study was to evaluate the impact of AB treatment on antibiotic resistance among women with rUTIs.

METHODS

The study population consisted of 2 groups of women who had previously been enrolled in a randomized clinical trial: group A was not treated, and group B was treated. All women were scheduled for follow-up visits every 6 months, or more frequently if symptoms arose. Microbiological evaluation was performed only in symptomatic women. All women were followed up for a mean of 38.8 months to analyze data from urine cultures and antibiograms.

RESULTS

The previous study population consisted of 673 women, but 123 did not attend the entire follow-up period. For the final analysis, 257 of the remaining 550 patients were assigned to group A, and 293 to group B. At the end of follow-up, the difference in recurrence rates was statistically significant (P < .001): 97 (37.7%) in group A versus 204 (69.6%) in group B. Isolated Escherichia coli from group B showed higher resistance to amoxicillin-clavulanic acid (P = .03), trimethoprim-sulfamethoxazole (P = .01), and ciprofloxacin (P = .03) than that from group A.

CONCLUSIONS

This study shows that AB treatment is associated with a higher occurrence of antibiotic-resistant bacteria, indicating that AB treatment in women with rUTIs is potentially dangerous.

Cost-minimization model of a multidisciplinary antibiotic stewardship team based on a successful implementation on a urology ward of an academic hospital

BACKGROUND

In order to stimulate appropriate antimicrobial use and thereby lower the chances of resistance development, an Antibiotic Stewardship Team (A-Team) has been implemented at the University Medical Center Groningen, the Netherlands. Focus of the A-Team was a pro-active day 2 case-audit, which was financially evaluated here to calculate the return on investment from a hospital perspective.

METHODS

Effects were evaluated by comparing audited patients with a historic cohort with the same diagnosis-related groups. Based upon this evaluation a cost-minimization model was created that can be used to predict the financial effects of a day 2 case-audit. Sensitivity analyses were performed to deal with uncertainties. Finally, the model was used to financially evaluate the A-Team.

RESULTS

One whole year including 114 patients was evaluated. Implementation costs were calculated to be €17,732, which represent total costs spent to implement this A-Team. For this specific patient group admitted to a urology ward and consulted on day 2 by the A-Team, the model estimated total savings of €60,306 after one year for this single department, leading to a return on investment of 5.9.

CONCLUSIONS

The implemented multi-disciplinary A-Team performing a day 2 case-audit in the hospital had a positive return on investment caused by a reduced length of stay due to a more appropriate antibiotic therapy. Based on the extensive data analysis, a model of this intervention could be constructed. This model could be used by other institutions, using their own data to estimate the effects of a day 2 case-audit in their hospital.

Financial evaluations of antibiotic stewardship programs-a systematic review

Introduction: There is an increasing awareness to counteract problems due to incorrect antimicrobial use. Interventions that are implemented are often part of an Antimicrobial Stewardship Program (ASPs). Studies publishing results from these interventions are increasing, including reports on the economical effects of ASPs. This review will look at the economical sections of these studies and the methods that were used.

Methods: A systematic review was performed of articles found in the PubMed and EMBASE databases published from 2000 until November 2014. Included studies found were scored for various aspects and the quality of the papers was assessed following an appropriate check list (CHEC criteria list).

Results: 1233 studies were found, of which 149 were read completely. Ninety-nine were included in the final review. Of these studies, 57 only mentioned the costs associated with the antimicrobial medication. Others also included operational costs (n = 23), costs for hospital stay (n = 18), and/or other costs (n = 19). Nine studies were further assessed for their quality. These studies scored between 2 and 14 out of a potential total score of 19.

Conclusions: This review gives an extensive overview of the current financial evaluation of ASPs and the quality of these economical studies. We show that there is still major potential to improve financial evaluations of ASPs. Studies do not use similar nor consistent methods or outcome measures, making it impossible draw sound conclusions and compare different studies. Finally, we make some recommendations for the future.

Antimicrobial stewardship: philosophy versus practice

To promote the judicious use of antimicrobials and preserve their usefulness in the setting of growing resistance, a number of policy-making bodies and professional societies have advocated the development of antimicrobial stewardship programs. Although these programs have been implemented at many institutions in the United States, their impact has been difficult to measure. Current recommendations advocate the use of both outcome and process measures as metrics for antimicrobial stewardship. Although patient outcome metrics have the greatest impact on the quality of care, the literature shows that antimicrobial use and costs are the indicators measured most frequently by institutions to justify the effectiveness of antimicrobial stewardship programs. The measurement of more meaningful outcomes has been constrained by difficulties inherent to these measures, lack of funding and resources, and inadequate study designs. Antimicrobial stewardship can be made more credible by refocusing the antimicrobial review process to target specific disease states, reassessing the usefulness of current metrics, and integrating antimicrobial stewardship program initiatives into institutional quality and safety efforts.

Benefits of WSES guidelines application for the management of intra-abdominal infections

INTRODUCTION

The use of antibiotics is very high in the departments of Emergency and Trauma Surgery above all in the treatment of the intra-abdominal infections, to decrease morbidity and mortality rates; often the antimicrobial drugs are prescribed without a rationale and they are second-line antibiotics; this clinical practice increases costs without decreasing mortality. Aim of our study is to report the results in the application to the clinical practice of the World Society Emergency Surgeons (WSES) guidelines for the management of intra-abdominal infections, at the department of Emergency and Trauma Surgery of the University Hospital of Parma (Italy) in 2012.

METHODS

A retrospective observational analysis was carried out about patients admitted in the department of Emergency and Trauma Surgery of Parma (Italy), between January 2011 and December 2012. The data are expressed as percentages (%) and means (± SD). The results of the compared groups were analyzed using the Pearson's Chi-Square and Fisher's tests. For means involving continuous numerical data, the independent sample T test and the Mann-Whitney U-test were used for normally and abnormally distributed data, respectively (the data had been previously tested for normality using the Kolmogorov-Smirnov test). A p-value < 0.05 was considered statistically significant.

RESULTS

Between January 2011 and December 2012, 2121 (968 in 2011 and 1153 in 2012) patients were admitted in the department of Emergency and Trauma Surgery (Italy) of Parma University Hospital with a diagnosis of acute IAI. Morbidity in 2012 was 10,2% compared to 22.7% in 2011 and mortality in 2012 was 1,1% compared to 3,2% in 2011 (p < 0,05). Costs for antibiotics in 2012 was 51392 euro, with a reduction of 31% compared to 2011.

CONCLUSIONS

This study demonstrates that an inexpensive and easily application of guidelines based on medicine evidence in the use of antibiotics can lead to a significative reduction of hospital costs with outcomes improvement.

Clinical diagnoses and antimicrobials predictive of pediatric antimicrobial stewardship recommendations: a program evaluation

BACKGROUND

The number of pediatric antimicrobial stewardship programs (ASPs) is increasing and program evaluation is a key component to improve efficiency and enhance stewardship strategies.

OBJECTIVE

To determine the antimicrobials and diagnoses most strongly associated with a recommendation provided by a well-established pediatric ASP.

DESIGN AND SETTING

Retrospective cohort study from March 3, 2008, to March 2, 2013, of all ASP reviews performed at a free-standing pediatric hospital.

METHODS

ASP recommendations were classified as follows: stop therapy, modify therapy, optimize therapy, or consult infectious diseases. A multinomial distribution model to determine the probability of each ASP recommendation category was performed on the basis of the specific antimicrobial agent or disease category. A logistic model was used to determine the odds of recommendation disagreement by the prescribing clinician.

RESULTS

The ASP made 2,317 recommendations: stop therapy (45%), modify therapy (26%), optimize therapy (19%), or consult infectious diseases (10%). Third-generation cephalosporins (0.20) were the antimicrobials with the highest predictive probability of an ASP recommendation whereas linezolid (0.05) had the lowest probability. Community-acquired pneumonia (0.26) was the diagnosis with the highest predictive probability of an ASP recommendation whereas fever/neutropenia (0.04) had the lowest probability. Disagreement with ASP recommendations by the prescribing clinician occurred 22% of the time, most commonly involving community-acquired pneumonia and ear/nose/throat infections.

CONCLUSIONS

Evaluation of our pediatric ASP identified specific clinical diagnoses and antimicrobials associated with an increased likelihood of an ASP recommendation. Focused interventions targeting these high-yield areas may result in increased program efficiency and efficacy.

Long-term outcomes of an antimicrobial stewardship program implemented in a hospital with low baseline antibiotic use

OBJECTIVE

To evaluate the long-term outcomes of an antimicrobial stewardship program (ASP) implemented in a hospital with low baseline antibiotic use.

DESIGN

Quasi-experimental, interrupted time-series study.

SETTING

Public safety net hospital with 525 beds.

INTERVENTION

Implementation of a formal ASP in July 2008.

METHODS

We conducted a time-series analysis to evaluate the impact of the ASP over a 6.25-year period (July 1, 2008-September 30, 2014) while controlling for trends during a 3-year preintervention period (July 1, 2005-June 30, 2008). The primary outcome measures were total antibacterial and antipseudomonal use in days of therapy (DOT) per 1,000 patient-days (PD). Secondary outcomes included antimicrobial costs and resistance, hospital-onset Clostridium difficile infection, and other patient-centered measures.

RESULTS

During the preintervention period, total antibacterial and antipseudomonal use were declining (-9.2 and -5.5 DOT/1,000 PD per quarter, respectively). During the stewardship period, both continued to decline, although at lower rates (-3.7 and -2.2 DOT/1,000 PD, respectively), resulting in a slope change of 5.5 DOT/1,000 PD per quarter for total antibacterial use (P=.10) and 3.3 DOT/1,000 PD per quarter for antipseudomonal use (P=.01). Antibiotic expenditures declined markedly during the stewardship period (-$295.42/1,000 PD per quarter, P=.002). There were variable changes in antimicrobial resistance and few apparent changes in C. difficile infection and other patient-centered outcomes.

CONCLUSION

In a hospital with low baseline antibiotic use, implementation of an ASP was associated with sustained reductions in total antibacterial and antipseudomonal use and declining antibiotic expenditures. Common ASP outcome measures have limitations.

Evaluation of dedicated infectious diseases pharmacists on antimicrobial stewardship teams

PURPOSE

Patient care improvements and cost savings achieved by a large integrated health system through the implementation of antimicrobial stewardship programs (ASPs) at two hospitals are reported.

METHODS

A pre-post analysis was conducted to evaluate cost and quality outcomes at the two ASP sites and three similar sites within the same health system not included in the ASP initiative. The utilization of 15 targeted antimicrobials and associated costs at the five sites during designated preimplementation and postimplementation periods were compared; changes in Hospital Standardized Mortality Ratio (HSMR) values for specific infections among Medicare patients were also assessed.

RESULTS

In the year after ASP implementation, aggregate direct antimicrobial acquisition costs at the two study sites decreased 17.3% from prior-year levels and increased by 9.1% at the three comparator sites. Significant decreases in the consumption of targeted antimicrobial classes (antipseudomonals, quinolones, and agents active against methicillin-resistant Staphylococcus aureus) were observed at the ASP sites. Among the 2446 ASP interventions recorded, 72% involved discontinuing or narrowing the use of broad-spectrum antimicrobials. Although rates of health care-associated Clostridium difficile infection were little changed at both study sites after ASP implementation, HSMR data indicated substantial gains in combating sepsis and C. difficile and respiratory infections.

CONCLUSION

After implementation of ASPs at two study sites, the utilization of all classes of antibiotics decreased and antimicrobial costs per 1000 patient-days decreased. While HSMR values for sepsis (including C. difficile-associated cases) and respiratory infections improved, the rate of C. difficile infections stayed the same.