Effectiveness and safety of mandatory antimicrobial indications and durations and a pharmacist-driven 48-hour time-out in a pediatric hospital

Approaches to Reduce Use and Duration of Anti-MRSA Agents for Antimicrobial Stewardship Programs: A Review of Recent Literature

Antimicrobial stewardship programs (ASPs) have the potential to effectively deescalate unnecessary methicillin-resistant Staphylococcus aureus (MRSA) coverage. This review summarizes literature published from 2014 through 2021 describing contemporary ASP methods and their resulting effectiveness at reducing anti-MRSA agent use (ie vancomycin, linezolid, daptomycin, ceftaroline, and clindamycin). This review of the literature examined the following strategies, which had reports of success in either decreasing the use or duration of anti-MRSA agents: prospective review and feedback, antibiotic timeouts, health system or department protocol changes, polymerase chain reaction (PCR) and rapid testing of patient samples. Most of the current literature continue to support most ASP interventions including antibiotic timeouts, pathways, and molecular testing including MRSA nasal PCRs and rapid diagnostic testing can be successful at reducing unnecessary anti-MRSA use.

Rapid Decrease in Fluoroquinolones Consumption following Implementation of a Simple Antimicrobial Stewardship Bundled Intervention in a University Hospital during the COVID-19 Pandemic

Fluoroquinolones (FQs) represent an class of antibiotics of medical importance, but their use has been restricted due to their ecologic impact and associated side effects. The reduction of FQs use is an important goal of antimicrobial stewardship programs (ASP). This work describes an ASP focused on overall antibiotics and FQs consumption reduction. From January 2021, an ASP was implemented in a 700-bed teaching hospital. The ASP was based on: (i) antibiotics consumption monitoring system (DDD/100 bed days); (ii) mandatory antibiotic prescription-motivation (using a dedicated informatic format) with the goal of >75% of motivated prescriptions; and (iii) data feedback and training on FQs use indications. We evaluated the impact of the intervention on overall systemic antibiotics and FQs consumption according to the objectives posed by Italian PNCAR (National Action Plan on Antimicrobial Resistance). A decrease of 6.6% in antibiotic use was observed (2019 vs. 2021). Notably, the FQs consumption fell by 48.3% from 7.1 DDD/100 bd in 2019 to 3.7 DDD/100 bd in 2021 (p < 0.001). After six months of mandatory antibiotic prescription-indication, all units achieved the target set. The study suggests that a simple, bundled ASP intervention can be rapidly effective obtaining the objectives of PNCAR on the reduction of overall antibiotics and FQs consumption.

Documenting the indication for antimicrobial prescribing: a scoping review

BACKGROUND

Documenting an indication when prescribing antimicrobials is considered best practice; however, a better understanding of the evidence is needed to support broader implementation of this practice.

OBJECTIVES

We performed a scoping review to evaluate antimicrobial indication documentation as it pertains to its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in all patient populations.

ELIGIBILITY CRITERIA

Published and unpublished literature evaluating the documentation of an indication for antimicrobial prescribing.

SOURCES OF EVIDENCE

A search was conducted in MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts in addition to a review of the grey literature.

CHARTING AND ANALYSIS

Screening and extraction was performed by two independent reviewers. Studies were categorised inductively and results were presented descriptively.

RESULTS

We identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (109, 89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%-100%). Studies evaluating the impact of indication documentation on prescribing and patient outcomes most commonly examined appropriateness and identified a benefit to prescribing or patient outcomes in 17 of 19 studies. Qualitative studies evaluating healthcare worker perspectives (n=10) noted the common barriers and facilitators to this practice.

CONCLUSION

There is growing interest in the importance of documenting an indication when prescribing antimicrobials. While antimicrobial indication documentation is not uniformly implemented, several studies have shown that multipronged approaches can be used to improve this practice. Emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes both in community and hospital settings. But setting-specific and larger trials are needed to provide a more robust evidence base for this practice.

Novel expansion of a well-established antimicrobial stewardship program: Enhancing program efficiency and reach

Objective:

To evaluate efficiency and impact of a novel antimicrobial stewardship program (ASP) prospective-audit-with-feedback (PAF) review process using the Cerner Multi-Patient Task List (MPTL).

Design:

Retrospective cohort study.

Setting:

A 367-bed free-standing, pediatric academic medical center.

Methods:

The ASP PAF review process expanded to monitor all systemic and inhaled antibiotics through use of the MPTL on July 23, 2020. Average number of daily ASP reviews, absolute number of monthly interventions, and time to conduct ASP reviews were compared between the preimplementation period and the postimplementation period following expansion. Antibiotic days of therapy (DOT) per 1,000 patient days for overall and select antibiotics were compared between periods. ASP intervention characteristics were assessed.

Results:

Average daily ASP reviews significantly increased following program expansion (9 vs 14 reviews; P < .0001), and the absolute number of ASP interventions each month also increased (34 vs 52 interventions; P ≤ .0001). Time to conduct daily ASP reviews increased in the postimplementation period (1.03 vs 1.32 hours). Overall antibiotic DOT per 1,000 patient days significantly decreased in the postimplementation period (457.9 vs 427.9; P < .0001) as well as utilization of select, narrow-spectrum antibiotics such as ampicillin and clindamycin. Intervention type and antibiotics were similar between periods. The ASP documented 128 “nonantibiotic interventions” in the postimplementation period, including culture and/or susceptibility testing (32.8%), immunizations (25.8%), and additional diagnostic testing (22.7%).

Conclusions:

Implementation of an ASP PAF review process using the MPTL allowed for efficient expansion of a pre-existing ASP and a decrease in overall antibiotic utilization. ASP documentation was enhanced to fully track the impact of the program.

Implementation of an Automatic 48-Hour Vancomycin Hard-Stop in a Pediatric Community Hospital

OBJECTIVE

Previous studies evaluating antimicrobial time-outs and required stop dates on antimicrobial orders indicate that these strategies are effective in decreasing antimicrobial duration and cost without a negative impact on patient outcomes. Few have evaluated use of a hard-stop strategy. The purpose of this study was to determine the feasibility and impact of a vancomycin hard-stop at 48 hours of therapy on vancomycin use.

METHODS

This retrospective review compared 2 groups, a hard-stop pre-implementation group from April 2018 through March 2019 and a hard-stop post-implementation group from May 2019 through April 2020. The primary outcome was change in days of therapy (DOT) per ordered course of vancomycin therapy. Secondary outcomes included DOT per 1000 patient days (PD), number of courses continued beyond 48 hours, number of vancomycin concentrations drawn and drug acquisition cost.

RESULTS

A total of 554 courses of vancomycin were prescribed (228 in the pre-implementation group and 326 in the post-implementation group). The median DOT per ordered course of vancomycin was 1.58 days (IQR, 1.00–2.59) in the pre-implementation group compared with 1.55 days (IQR, 1.00–1.99) in the post-implementation group (p = 0.51). Fewer vancomycin courses continued beyond 48 hours after hard-stop implementation (23% versus 33%) and fewer vancomycin concentrations were obtained in the post-implementation period than in the pre-implementation period despite more ordered courses of vancomycin therapy, 114 concentrations versus 153 concentrations, respectively. Overall, the total yearly drug acquisition cost savings to the pharmacy equated to $3000.

CONCLUSIONS

Implementation of a vancomycin hard-stop at 48 hours of therapy is a feasible antimicrobial stewardship tool that may have significant clinical and operational impacts.

Antibiotics in critically ill children-a narrative review on different aspects of a rational approach

Especially critically ill children are exposed to antibiotic overtreatment, mainly caused by the fear of missing out a severe bacterial infection. Potential adverse effects and selection of multi-drug resistant bacteria play minor roles in decision making. This narrative review first describes harm from antibiotics and second focuses on different aspects that could help to reduce antibiotic overtreatment without harming the patient: harm from antibiotic treatment, diagnostic approaches, role of biomarkers, timing of antibiotic therapy, empiric therapy, targeted therapy, and therapeutic drug monitoring. Wherever possible, we linked the described evidence to the current Surviving Sepsis Campaign guidelines. Antibiotic stewardship programs should help guiding antibiotic therapy for critically ill children. IMPACT: Critically ill children can be harmed by inadequate or overuse of antibiotics. Hemodynamically unstable children with a suspicion of infection should be immediately treated with broad-spectrum antibiotics. In contrast, in hemodynamically stable children with sepsis and organ dysfunction, a time frame of 3 h for proper diagnostics may be adequate before starting antibiotics if necessary. Less and more targeted antibiotic treatment can be achieved via antibiotic stewardship programs.

Impact of pharmacist intervention in antibiotic stewardship programmes for critically ill neonates: A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Antibiotic stewardship programmes (ASPs) are introduced to ensure effective antibiotic use. Pharmacists can be involved in ASPs to facilitate the appropriate antibiotic use. Prolonged use of antibiotics causes adverse events in critically ill neonates. Hence, this systematic review and meta-analysis was aimed at investigating pharmacists' functions in ASPs in critically ill neonates and the effect of ASP implementation on antibiotic use.

METHODS

A comprehensive search of PubMed/Medline, Embase, and Cochrane Library databases until January 2021 was conducted and studies that reported the functions of pharmacists in ASPs for critically ill neonates and the results of ASP implementation were included in this review. All processes were performed by two reviewers independently, and any discordance between the two was resolved by discussion.

RESULTS AND DISCUSSION

In all, 19 studies were included in this review. Pharmacists were found to have various functions in ASPs, such as participating in the development of antibiotic use guidelines, auditing antibiotic prescriptions, participating in multidisciplinary ward rounds, educating other ASP team members, checking blood culture or laboratory data, and monitoring antibiotic use. A meta-analysis revealed that ASP implementation in critically ill neonates was significantly associated with a 23% reduction in the overall antibiotic use rate (ratio of means: 0.77, 95% confidence interval: 0.69-0.87, p < 0.001). Moreover, the overall duration of antibiotic therapy significantly reduced by 15% with ASP implementation (ratio of means: 0.85, 95% confidence interval: 0.78-0.91, p < 0.001).

WHAT IS NEW AND CONCLUSION

The implementation of ASPs involving pharmacists, especially in critically ill neonates, was associated with the reduced use and duration of antibiotic treatment. Thus, pharmacists played a key role in ASPs in critically ill neonates.

Impact of a Pharmacist-Led Antimicrobial Stewardship Program on the Number of Days of Antimicrobial Therapy for Uncomplicated Gram-Negative Bacteremia in a Community Hospital

Introduction The need for pharmacist-led antimicrobial stewardship programs (ASP) is increasing. Objective We performed a retrospective study to assess whether pharmacist-led ASPs can decrease the duration of treatment for uncomplicated gram-negative bacteremia among patients admitted in a community hospital. Methods This research was conducted at a 325-bed regional general hospital in Japan, from January 2013 to June 2015. There are no infectious diseases specialists affiliated with the hospital. The outcomes of the pharmacist-led ASP group, who received pharmacist intervention, and the control group, who did not receive pharmacist intervention, were compared. The study included patients aged 18 years or older who were diagnosed with gram-negative bacteremia. The pharmacist performed an antimicrobial time-out at 72 hours after blood culture collection and optimized treatment based on the patient's clinical response and test results. The primary outcome was the duration of antibiotic treatment.  Results In total, 34 patients in the pharmacist-led ASP group and 32 in the control group were included in the final analysis. The median number of days of antimicrobial treatment was 8 (interquartile range [IQR]: 7-14) days in the pharmacist-led ASP group and 14 (IQR: 10-15) days in the control group. The number of days of antimicrobial treatment significantly reduced in the pharmacist-led ASP group (p < 0.001). The de-escalation rates were 11 (32.4%) cases in the pharmacist-led ASP group and 4 (12.5%) cases in the control group. Hence, the trend was higher in the pharmacist-led ASP group than in the control group (p = 0.08). Conclusion The pharmacist-led ASP reduced the number of days of antimicrobial therapy for uncomplicated gram-negative bacteremia among patients admitted in a community hospital without an infectious diseases specialist.

The Effectiveness of Clinical Pharmacist-Led Consultation in the Treatment of Infectious Diseases: A Prospective, Multicenter, Cohort Study

Background

Antimicrobial resistance (AMR) is a serious global health threat and leads to a huge challenge to infectious diseases (ID) treatment. To tackle AMR, regional ‘Antimicrobial Stewardship Programs’ (ASP) have been implemented in many countries. Due to insufficient clinical pharmacy resources, a major intervention mode of ASP in China is through clinical pharmacist-led consultation (CPC). The current study aims to prospectively evaluate this intervention and compare the effectiveness of CPC served by ID and non-ID clinical pharmacists.

Methods

We conducted a prospective and multicenter cohort study based on a regional registry database in 17 hospitals in Western China, including consecutive patients with ID between April 2017 and December 2019. Baseline characteristics including sex, age, liver and kidney function, comorbidity, infection severity were prospectively collected and recorded. The main exposure of interest was whether the attending physician adopted recommendations of the clinical pharmacist in the therapeutic scheme. The outcome was the infection effective response, assessed during day 3–7 after completing CPC. Multivariate analyses were performed by generalized linear mixed models.

Results

A total of 2,663 ID patients were included in the final analysis according to the predesigned inclusion and exclusion criteria. The number of patients whose treatment followed and did not follow the pharmacists’ suggestion was 2,529 and 134, respectively. CPC intervention could improve the ID patient prognosis in the context of other confounders controlled (Adjusted Odds ratio(AOR)=1.838, 95%Confidence Interval(CI)=[1.212, 2.786]), and the effectiveness of CPC served by ID and non-ID clinical pharmacists might be equivalent (AOR=0.958, 95%CI[0.740, 1.240]). Special consultation (AOR=1.832, 95%CI[1.106, 3.035]) and surgical treatment of infectious sites (AOR=1.380, 95%CI[1.039, 1.834]) had positive influences on the patient prognosis, while hypoalbuminemia (AOR=0.694, 95%CI[0.523, 0.921]), liver dysfunction (AOR=0.705, 95%CI[0.559, 0.889]), presence of high-risk factors (AOR=0.775, 95%CI[0.613, 0.980]), and increased infection severity (AOR=0.631, 95%CI[0.529, 0.753])were associated with a decrease in effective response rate, independently.

Conclusion

This study suggests that CPC is a promising pharmacist-led intervention to improve ID treatment, and it can achieve standardization among clinical pharmacists with different backgrounds by some measures. Policy/decision-makers should promote this intervention mode in developing countries or regions where there is an insufficient number of clinical pharmacists.