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Gwynne PJ, Stocks KLK, Karozichian ES, Pandit A, Hu LT. Metabolic modeling predicts unique drug targets in Borrelia burgdorferi. mSystems 2023; 8:e0083523. [PMID: 37855615 PMCID: PMC10734484 DOI: 10.1128/msystems.00835-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 08/22/2023] [Indexed: 10/20/2023] Open
Abstract
IMPORTANCE Lyme disease is often treated using long courses of antibiotics, which can cause side effects for patients and risks the evolution of antimicrobial resistance. Narrow-spectrum antimicrobials would reduce these risks, but their development has been slow because the Lyme disease bacterium, Borrelia burgdorferi, is difficult to work with in the laboratory. To accelerate the drug discovery pipeline, we developed a computational model of B. burgdorferi's metabolism and used it to predict essential enzymatic reactions whose inhibition prevented growth in silico. These predictions were validated using small-molecule enzyme inhibitors, several of which were shown to have specific activity against B. burgdorferi. Although the specific compounds used are not suitable for clinical use, we aim to use them as lead compounds to develop optimized drugs targeting the pathways discovered here.
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Affiliation(s)
- Peter J. Gwynne
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts, USA
- Tufts Lyme Disease Initiative, Tufts University, Boston, Massachusetts, USA
| | - Kee-Lee K. Stocks
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts, USA
- Tufts Lyme Disease Initiative, Tufts University, Boston, Massachusetts, USA
| | - Elysse S. Karozichian
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts, USA
- Tufts Lyme Disease Initiative, Tufts University, Boston, Massachusetts, USA
| | - Aarya Pandit
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts, USA
- Tufts Lyme Disease Initiative, Tufts University, Boston, Massachusetts, USA
| | - Linden T. Hu
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts, USA
- Tufts Lyme Disease Initiative, Tufts University, Boston, Massachusetts, USA
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de Nies L, Kobras CM, Stracy M. Antibiotic-induced collateral damage to the microbiota and associated infections. Nat Rev Microbiol 2023; 21:789-804. [PMID: 37542123 DOI: 10.1038/s41579-023-00936-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 08/06/2023]
Abstract
Antibiotics have transformed medicine, saving millions of lives since they were first used to treat a bacterial infection. However, antibiotics administered to target a specific pathogen can also cause collateral damage to the patient's resident microbial population. These drugs can suppress the growth of commensal species which provide protection against colonization by foreign pathogens, leading to an increased risk of subsequent infection. At the same time, a patient's microbiota can harbour potential pathogens and, hence, be a source of infection. Antibiotic-induced selection pressure can cause overgrowth of resistant pathogens pre-existing in the patient's microbiota, leading to hard-to-treat superinfections. In this Review, we explore our current understanding of how antibiotic therapy can facilitate subsequent infections due to both loss of colonization resistance and overgrowth of resistant microorganisms, and how these processes are often interlinked. We discuss both well-known and currently overlooked examples of antibiotic-associated infections at various body sites from various pathogens. Finally, we describe ongoing and new strategies to overcome the collateral damage caused by antibiotics and to limit the risk of antibiotic-associated infections.
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Affiliation(s)
- Laura de Nies
- Sir William Dunn School of Pathology, University of Oxford, Oxford, UK
| | - Carolin M Kobras
- Sir William Dunn School of Pathology, University of Oxford, Oxford, UK
| | - Mathew Stracy
- Sir William Dunn School of Pathology, University of Oxford, Oxford, UK.
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Prayag PS, Patwardhan SA, Panchakshari SP, Prayag AP. Clostridium difficile in Oncology Patients—Review of Diagnosis and Management in the Indian Setting. Indian J Med Paediatr Oncol 2023. [DOI: 10.1055/s-0042-1760316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Abstract
Clostridoides (formerly Clostridium) difficile (C. difficile) is a toxin-producing, gram-positive anaerobic bacillus, commonly implicated in antibiotic-associated diarrhea and pseudomembranous colitis. The true burden of C. difficile infection is unclear in India, as it is likely underdiagnosed and underreported. Its incidence is much higher in oncology patients where it can contribute significantly to morbidity and mortality. There are several challenges in the Indian setting, including lack of uniform availability of testing infrastructure, as well as therapy. Oncology patients further present with a unique set of challenges. This article will review the approach to diagnosis and management of C. difficile-associated diarrhea in India, with a focus on oncology patients.
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Affiliation(s)
- Parikshit S Prayag
- Department of Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Sampada A Patwardhan
- Department of Microbiology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Shweta P Panchakshari
- Department of Infectious Diseases, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
| | - Amrita P Prayag
- Department of Research, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
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Zay Ya K, Win PTN, Bielicki J, Lambiris M, Fink G. Association Between Antimicrobial Stewardship Programs and Antibiotic Use Globally: A Systematic Review and Meta-Analysis. JAMA Netw Open 2023; 6:e2253806. [PMID: 36757700 PMCID: PMC9912134 DOI: 10.1001/jamanetworkopen.2022.53806] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
IMPORTANCE Antimicrobial resistance continues to spread rapidly at a global scale. Little evidence exists on the association of antimicrobial stewardship programs (ASPs) with the consumption of antibiotics across health care and income settings. OBJECTIVE To synthesize current evidence regarding the association between antimicrobial stewardship programs and the consumption of antibiotics globally. DATA SOURCES PubMed, Web of Science, and Scopus databases were searched from August 1, 2010, to Aug 1, 2020. Additional studies from the bibliography sections of previous systematic reviews were included. STUDY SELECTION Original studies of the association of ASPs with antimicrobial consumption across health care and income settings. Animal and environmental studies were excluded. DATA EXTRACTION AND SYNTHESIS Following the Preferred Reporting Items in Systematic Reviews and Meta-Analyses guideline, the pooled association of targeted ASPs with antimicrobial consumption was measured using multilevel random-effects models. The Effective Public Health Practice Project quality assessment tool was used to assess study quality. MAIN OUTCOMES AND MEASURES The main outcome measures were proportion of patients receiving an antibiotic prescription and defined daily doses per 100 patient-days. RESULTS Overall, 52 studies (with 1 794 889 participants) measured the association between ASPs and antimicrobial consumption and were included, with 40 studies conducted in high-income countries and 12 in low- and middle-income countries (LMICs). ASPs were associated with a 10% (95% CI, 4%-15%) reduction in antibiotic prescriptions and a 28% reduction in antibiotic consumption (rate ratio, 0.72; 95% CI, 0.56-0.92). ASPs were also associated with a 21% (95% CI, 5%-36%) reduction in antibiotic consumption in pediatric hospitals and a 28% reduction in World Health Organization watch groups antibiotics (rate ratio, 0.72; 95% CI, 0.56-0.92). CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, ASPs appeared to be effective in reducing antibiotic consumption in both hospital and nonhospital settings. Impact assessment of ASPs in resource-limited settings remains scarce; further research is needed on how to best achieve reductions in antibiotic use in LMICs.
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Affiliation(s)
- Kyaw Zay Ya
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Julia Bielicki
- Paediatric Infectious Diseases Research Group, Institute of Infection and Immunity, St George’s, University of London, London, United Kingdom
- Paediatric Pharmacology and Paediatric Infectious Diseases, University Children’s Hospital Basel, Basel, Switzerland
| | - Mark Lambiris
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Günther Fink
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
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Tracking antimicrobial stewardship activities beyond days of therapy (DOT): Comparison of days of antibiotic spectrum coverage (DASC) and DOT at a single center. Infect Control Hosp Epidemiol 2023:1-4. [PMID: 36625069 DOI: 10.1017/ice.2022.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Even though antimicrobial days of therapy did not significantly decrease during a period of robust stewardship activities at our center, we detected a significant downward trend in antimicrobial spectrum, as measured by days of antibiotic spectrum coverage (DASC). The DASC metric may help more broadly monitor the effect of stewardship activities.
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Singh S, Ark R, Tatlock J, Mandalia S, Chung C, Azadian B, Hughes S, Mughal N, Moore LSP, Singh S. Evaluating the long-term impact of an antimicrobial stewardship programme in a Central London mixed medical and surgical intensive care unit. JAC Antimicrob Resist 2022; 4:dlac108. [PMID: 36226228 PMCID: PMC9549738 DOI: 10.1093/jacamr/dlac108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/16/2022] [Indexed: 02/05/2023] Open
Abstract
Background Antimicrobial overuse causes increased antimicrobial resistance in ICUs; antimicrobial stewardship programmes (ASPs) aim to optimize usage. Following an MDR Acinetobacter baumannii (MRAb) outbreak in 2008, an ASP was implemented at a London ICU, and then continued as a long-term programme. This study aimed to determine long-term changes in antimicrobial prescribing 9 years on. Methods Data were collected from ICU patients in 2008 immediately before ASP implementation, and thereafter for 6 month cohort periods in 2010-2011, 2012 and 2017. Antimicrobial usage in DDD per 1000 occupied bed days (OBD) were compared. Multivariate linear regression models for antimicrobial days were fitted, adjusting for APACHE II score and patient days. Antimicrobial resistance in Pseudomonas aeruginosa (as an indicator organism) was compared across cohort periods. Findings Across 400 patients over 9 years, antimicrobial use changed significantly (P < 0.011) and remained lower in all post-ASP cohorts compared with pre-ASP [(2008; 1827 DDD/1000 OBD), (2010; 1264 DDD/1000 OBD), (2012; 1270 DDD/1000 OBD) and (2017; 1566 DDD/1000 OBD)]. There was reduction in usage of all antimicrobial classes except β-lactams (where there was no significant increase nor decrease, P = 0.178) and aminoglycosides (where there was a significant increase in usage, P < 0.0001). The latter was temporally associated with restrictions on specific carbapenems. There was an increase in carbapenem-resistant P. aeruginosa in 2012 only (P = 0.028) but not subsequently. Conclusions Following ASP implementation after an outbreak of MRAb, reduced antimicrobial prescribing was maintained 9 years on. We identify several factors influencing successful long-term maintenance of ASPs in ICUs.
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Affiliation(s)
| | | | - Jason Tatlock
- Adult Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, UK
| | - Sundhiya Mandalia
- Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Christine Chung
- Adult Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, UK
| | - Berge Azadian
- Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
- Adult Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, UK
| | - Stephen Hughes
- Adult Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, UK
| | - Nabeela Mughal
- Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
- Adult Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, UK
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK
| | - Luke S P Moore
- Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
- Adult Intensive Care Unit, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, UK
- North West London Pathology, Imperial College Healthcare NHS Trust, Fulham Palace Road, London W6 8RF, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Du Cane Road, London W12 0NN, UK
| | - Suveer Singh
- Corresponding author. E-mail: @respitudoc, @dr_luke_moore
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Sadeq AA, Hasan SS, AbouKhater N, Conway BR, Abdelsalam AE, Shamseddine JM, Babiker ZOE, Nsutebu EF, Bond SE, Aldeyab MA. Exploring Antimicrobial Stewardship Influential Interventions on Improving Antibiotic Utilization in Outpatient and Inpatient Settings: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2022; 11:antibiotics11101306. [PMID: 36289964 PMCID: PMC9598859 DOI: 10.3390/antibiotics11101306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/18/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022] Open
Abstract
Antimicrobial stewardship interventions are targeted efforts by healthcare organizations to optimize antimicrobial use in clinical practice. The study aimed to explore effective interventions in improving antimicrobial use in hospitals. Literature was systemically searched for interventional studies through PubMed, CINAHL, and Scopus databases that were published in the period between January 2010 to April 2022. A random-effects model was used to pool and evaluate data from eligible studies that reported antimicrobial stewardship (AMS) interventions in outpatient and inpatient settings. Pooled estimates presented as proportions and standardized mean differences. Forty-eight articles were included in this review: 32 in inpatient and 16 in outpatient settings. Seventeen interventions have been identified, and eight outcomes have been targeted. AMS interventions improved clinical, microbiological, and cost outcomes in most studies. When comparing non-intervention with intervention groups using meta-analysis, there was an insignificant reduction in length of stay (MD: -0.99; 95% CI: -2.38, 0.39) and a significant reduction in antibiotics' days of therapy (MD: -2.73; 95% CI: -3.92, -1.54). There were noticeable reductions in readmissions, mortality rates, and antibiotic prescriptions post antimicrobial stewardship multi-disciplinary team (AMS-MDT) interventions. Studies that involved a pharmacist as part of the AMS-MDT showed more significant improvement in measured outcomes than the studies that did not involve a pharmacist.
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Affiliation(s)
- Ahmed A. Sadeq
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Syed Shahzad Hasan
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Noha AbouKhater
- Department of Medicine, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Barbara R. Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Institute of Skin Integrity and Infection Prevention, University of Huddersfield, Huddersfield HD1 3DH, UK
| | - Abeer E. Abdelsalam
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Jinan M. Shamseddine
- Department of Pharmacy, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Zahir Osman Eltahir Babiker
- Division of Infecious Diseases, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Emmanuel Fru Nsutebu
- Division of Infecious Diseases, Shaikh Shakhbout Medical City in Partnership with Mayo Clinic, Abu Dhabi P.O. Box 11001, United Arab Emirates
| | - Stuart E. Bond
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Pharmacy Department, Mid Yorkshire Hospitals NHS Trust, Wakefield WF1 4DG, UK
| | - Mamoon A. Aldeyab
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Huddersfield HD1 3DH, UK
- Correspondence: ; Tel.: +44-01484-472825
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Antimicrobial Stewardship Improvement in Pediatric Intensive Care Units in Spain-What Have We Learned? CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9060902. [PMID: 35740839 PMCID: PMC9222022 DOI: 10.3390/children9060902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/03/2022] [Accepted: 06/10/2022] [Indexed: 12/03/2022]
Abstract
Antibiotic misuse in pediatric intensive care units (PICUs) can lead to increased antimicrobial resistance, antibiotic-triggered side effects, hospital costs, and mortality. We performed a multicenter, prospective study, analyzing critically ill pediatric patients (≥1 month to ≤18 years) admitted to 26 Spanish PICUs over a 3-month period each year (1 April−30 June) from 2014−2019. To make comparisons and evaluate the influence of AMS programs on antibiotic use in PICUs, the analysis was divided into two periods: 2014−2016 and 2017−2019 (once 84% of the units had incorporated an AMS program). A total of 11,260 pediatric patients were included. Total antibiotic prescriptions numbered 15,448 and, overall, 8354 patients (74.2%) received at least one antibiotic. Comparing the two periods, an increase was detected in the number of days without antibiotics in patients who received them divided by the number of days in PICUs, for community-acquired infections (p < 0.001) and healthcare-associated infections (HAIs) acquired in PICUs (p < 0.001). Antibiotics were empirical in 7720 infections (85.6%), with an increase in appropriate antibiotic indications during the second period (p < 0.001). The main indication for antibiotic adjustment was de-escalation, increasing in the second period (p = 0.045). Despite the high rate of antibiotic use in PICUs, our results showed a significant increase in appropriate antibiotic use and adjustment following the implementation of AMS programs.
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Ghert M, Schneider P, Guyatt G, Thabane L, Vélez R, O'Shea T, Randall RL, Turcotte R, Wilson D, Wunder JS, Baptista AM, Cheng EY, Doung YC, Ferguson PC, Giglio V, Hayden J, Heels-Ansdell D, Khan SA, Sampath Kumar V, McKay P, Miller B, van de Sande M, Zumárraga JP, Bhandari M. Comparison of Prophylactic Intravenous Antibiotic Regimens After Endoprosthetic Reconstruction for Lower Extremity Bone Tumors: A Randomized Clinical Trial. JAMA Oncol 2022; 8:345-353. [PMID: 34989778 PMCID: PMC8739829 DOI: 10.1001/jamaoncol.2021.6628] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Question Can a 5-day regimen of postoperative, prophylactic, intravenous antibiotics reduce the rate of surgical site infections in patients with a lower extremity bone tumor undergoing complex endoprosthetic reconstruction compared with a 1-day regimen? Findings In this randomized clinical trial including 604 patients in the primary analysis, the 5-day regimen did not reduce the rate of surgical site infection compared with the 1-day regimen, although it resulted in a higher rate of antibiotic-related complications, notably Clostridioides difficile–associated colitis. Meaning The results of this study suggest that prolonging use of postoperative antibiotics beyond 1 day does not reduce the rate of surgical site infection but increases the risk of clinically significant antibiotic-related complications. Importance The use of perioperative, prophylactic, intravenous antibiotics is standard practice to reduce the risk of surgical site infection after oncologic resection and complex endoprosthetic reconstruction for lower extremity bone tumors. However, evidence guiding the duration of prophylactic treatment remains limited. Objective To assess the effect of a 5-day regimen of postoperative, prophylactic, intravenous antibiotics compared with a 1-day regimen on the rate of surgical site infections within 1 year after surgery. Design, Setting, and Participants This randomized clinical superiority trial was performed at 48 clinical sites in 12 countries from January 1, 2013, to October 29, 2019. The trial included patients with a primary bone tumor or a soft tissue sarcoma that had invaded the femur or tibia or oligometastatic bone disease of the femur or tibia with expected survival of at least 1 year who required surgical management by excision and endoprosthetic reconstruction. A total of 611 patients were enrolled, and 7 were excluded for ineligibility. Interventions A 1- or 5-day regimen of postoperative prophylactic intravenous cephalosporin (cefazolin or cefuroxime) that began within 8 hours after skin closure and was administered every 8 hours thereafter. Those randomized to the 1-day regimen received identical saline doses every 8 hours for the remaining 4 days; patients, care providers, and outcomes assessors were blinded to treatment regimen. Main Outcomes and Measures The primary outcome in this superiority trial was a surgical site infection (superficial incisional, deep incisional, or organ space) classified according to the criteria established by the Centers for Disease Control and Prevention within 1 year after surgery. Secondary outcomes included antibiotic-related complications, unplanned additional operations, oncologic and functional outcomes, and mortality. Results Of the 604 patients included in the final analysis (mean [SD] age, 41.2 [21.9] years; 361 [59.8%] male; 114 [18.9%] Asian, 43 [7.1%] Black, 34 [5.6%] Hispanic, 15 [2.5%] Indigenous, 384 [63.8%] White, and 12 [2.0%] other), 293 were randomized to a 5-day regimen and 311 to a 1-day regimen. A surgical site infection occurred in 44 patients (15.0%) allocated to the 5-day regimen and in 52 patients (16.7%) allocated to the 1-day regimen (hazard ratio, 0.93; 95% CI, 0.62-1.40; P = .73). Antibiotic-related complications occurred in 15 patients (5.1%) in the 5-day regimen and in 5 patients (1.6%) allocated to the 1-day regimen (hazard ratio, 3.24; 95% CI, 1.17-8.98; P = .02). Other secondary outcomes did not differ significantly between treatment groups. Conclusions and Relevance This randomized clinical trial did not confirm the superiority of a 5-day regimen of postoperative intravenous antibiotics over a 1-day regimen in preventing surgical site infections after surgery for lower extremity bone tumors that required an endoprosthesis. The 5-day regimen group had significantly more antibiotic-related complications. Trial Registration ClinicalTrials.gov Identifier: NCT01479283
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Affiliation(s)
| | - Michelle Ghert
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Patricia Schneider
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Roberto Vélez
- Hospital Vall d'Hebron, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Timothy O'Shea
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - R Lor Randall
- Department of Orthopaedic Surgery, University of California Davis Health, Sacramento
| | - Robert Turcotte
- Division of Orthopaedic Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - David Wilson
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jay S Wunder
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - André Mathias Baptista
- Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | - Edward Y Cheng
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis
| | - Yee-Cheen Doung
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland
| | - Peter C Ferguson
- University of Toronto Musculoskeletal Oncology Unit, Mount Sinai Hospital, Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Victoria Giglio
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - James Hayden
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shah Alam Khan
- Department of Orthopaedics, All India Institute of Medical Sciences, Delhi, India
| | | | - Paula McKay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Benjamin Miller
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City
| | - Michiel van de Sande
- Department of Orthopaedic Surgery, Leids Universitair Medisch Centrum, Leiden, the Netherlands
| | - Juan P Zumárraga
- Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Gursoy G, Uzun O, Metan G, Yildirim M, Bahap M, Demirkan SK, Topeli A, Akinci SB, Topcuoglu MA, Berker M, Hazirolan G, Akova M, Unal S. Does Antimicrobial Stewardship Program Improve the Quality of Care in ICU Patients Consulted to Infectious Diseases? Experience in a Tertiary Care Hospital. Int J Infect Dis 2021; 115:201-207. [PMID: 34883234 DOI: 10.1016/j.ijid.2021.12.315] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/26/2021] [Accepted: 12/02/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND One of the most important public health problems is the ever growing problem of antibiotic resistance. On one hand, the rate of introduction of new molecules into clinical practice has considerably slowed down, on the other hand, rapid emergence of resistance shortens the effective "life-span" of these molecules. OBJECTIVE In this study, the quality of care before and after active intervention and feedback was evaluated in patients diagnosed with sepsis/septic shock or ventilator-associated pneumonia (VAP) in Hacettepe University Adult and Oncology Hospitals ICUs. RESULTS There was a significant increase in total scores. Significant improvements were achieved in the management of these patients in terms of requesting necessary diagnostic tests, and prolonged infusion of beta-lactam agents. CONCLUSION Implementation of an ASP in centers where antimicrobial management of ICU patients is largely controlled by infectious diseases specialists is still a feasible strategy that leads to better patient care.
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Affiliation(s)
- Gamze Gursoy
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Hacettepe, A. Adnan Saygun Street, 06230 Altındag/Ankara.
| | - Omrum Uzun
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Hacettepe, A. Adnan Saygun Street, 06230 Altındag/Ankara
| | - Gokhan Metan
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Hacettepe, A. Adnan Saygun Street, 06230 Altındag/Ankara
| | - Mehmet Yildirim
- Hacettepe University Faculty of Medicine, Department of Internal Medicine, Section of Intensive Care Medicine
| | - Melda Bahap
- Hacettepe University Faculty of Pharmacy, Department of Clinical Pharmacy
| | | | - Arzu Topeli
- Hacettepe University Faculty of Medicine, Department of Internal Medicine, Section of Intensive Care Medicine
| | - Seda Banu Akinci
- Hacettepe University Faculty of Medicine, Department of Anesthesiology and Reanimation, Section of Intensive Care Medicine
| | - Mehmet Akif Topcuoglu
- Hacettepe University Faculty of Medicine, Department of Neurology, Section of Intensive Care Medicine
| | - Mustafa Berker
- Hacettepe University Faculty of Medicine, Department of Neurosurgery, Section of Intensive Care Medicine
| | | | - Murat Akova
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Hacettepe, A. Adnan Saygun Street, 06230 Altındag/Ankara
| | - Serhat Unal
- Hacettepe University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Hacettepe, A. Adnan Saygun Street, 06230 Altındag/Ankara
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Feihl S, Querbach C, Hapfelmeier A, Busch DH, von Eisenhart-Rothe R, Gebhardt F, Pohlig F, Mühlhofer HML. Effect of an Intensified Antibiotic Stewardship Program at an Orthopedic Surgery Department. Surg Infect (Larchmt) 2021; 23:105-112. [PMID: 34762545 DOI: 10.1089/sur.2021.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Institutional programs such as antibiotic stewardship (ABS) programs offer possibilities to monitor and modify antibiotic usage with the aim of reducing antibiotic resistance. In orthopedic units that treat peri-prosthetic joint infections (PJIs), ABS programs are still rare, however, there is extensive use of high-risk antibiotic agents and an increased risk for the occurrence of Clostridium difficile infections (CDIs). Patients and Methods: An ABS program was implemented at the Department of Orthopedic Surgery at a university hospital. Quarterly antibiotic consumption was measured in defined daily doses (DDDs) per 100 patient-days (PDs) at 10 quarters before the intervention and seven quarters after the intervention. The effect of the new antibiotic policy on drug use rates was evaluated using an interrupted time-series analysis. Estimated changes over time in the incidence of CDIs (cases per 1,000 PDs) were analyzed. Results: A remarkable percentual reduction in second-generation cephalosporin use of 83% (p < 0.001; pre-intervention level, 81.486 DDDs/100 patient-days; post-intervention level, 13.751 DDDs/100 PDs) and clindamycin administration of 78% (p < 0.001; pre-intervention level, 18.982 DDDs/100 PDs; post-intervention level, 4.216 DDDs/100 PDs) was observed after implementation of ABS interventions. Total antibiotic use declined by 25% (p < 0.001; pre-intervention level, 129.078 DDDs/100 PDs; post-intervention level, 96.826 DDDs/100 PDs). Conclusions: This research assessed the positive impact of an intensified ABS program at an orthopedic department specializing in PJIs. Antibiotic stewardship program interventions encourage the reduction of total antibiotic usage and especially high-risk antibiotic agents, associated with the development of antimicrobial resistance.
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Affiliation(s)
- Susanne Feihl
- Institute for Medical Microbiology, Immunology and Hygiene, Statistics, Epidemiology, Technical University Munich, School of Medicine, Munich, Germany
| | - Christiane Querbach
- Pharmacy Department, University Hospital Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics, Epidemiology, Technical University Munich, School of Medicine, Munich, Germany
| | - Dirk H Busch
- Institute for Medical Microbiology, Immunology and Hygiene, Statistics, Epidemiology, Technical University Munich, School of Medicine, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopedic Surgery, University Hospital Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | - Friedemann Gebhardt
- Institute for Medical Microbiology, Immunology and Hygiene, Statistics, Epidemiology, Technical University Munich, School of Medicine, Munich, Germany
| | - Florian Pohlig
- Department of Orthopedic Surgery, University Hospital Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
| | - Heinrich M L Mühlhofer
- Department of Orthopedic Surgery, University Hospital Klinikum rechts der Isar, Technical University Munich, School of Medicine, Munich, Germany
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12
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Yoon YK, Kwon KT, Jeong SJ, Moon C, Kim B, Kiem S, Kim HS, Heo E, Kim SW. Guidelines on Implementing Antimicrobial Stewardship Programs in Korea. Infect Chemother 2021; 53:617-659. [PMID: 34623784 PMCID: PMC8511380 DOI: 10.3947/ic.2021.0098] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022] Open
Abstract
These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Korean Society for Antimicrobial Therapy, Seoul, Korea
| | - Ki Tae Kwon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Korean Society of Infectious Diseases, Seoul, Korea
| | - Chisook Moon
- Korean Society of Infectious Diseases, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Bongyoung Kim
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungmin Kiem
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyung-Sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Eunjeong Heo
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Shin-Woo Kim
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
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13
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Chrysou K, Zarkotou O, Kalofolia S, Papagiannakopoulou P, Mamali V, Chrysos G, Themeli-Digalaki K, Sypsas N, Tsakris A, Pournaras S. Impact of a 4-year antimicrobial stewardship program implemented in a Greek tertiary hospital. Eur J Clin Microbiol Infect Dis 2021; 41:127-132. [PMID: 34264401 DOI: 10.1007/s10096-021-04290-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 06/09/2021] [Indexed: 01/22/2023]
Abstract
This study aimed to investigate the effects of a 4-year antibiotic stewardship program (ASP) in a tertiary hospital. We monitored data for 2015 (pre-intervention) and 2016-2019 (post-intervention) about antibiotic consumption (DDD/100 bed days), Clostridioides difficile infections (CDIs), resistance rates, length of stay (LOS), and annual antibiotic costs. Significant reductions were observed for total antibiotics/colistin/carbapenems/quinolones/tigecycline consumption and resistance rates of Pseudomonas aeruginosa, Klebsiella pneumoniae, and vancomycin-resistant enterococci. Considerable reductions occurred for LOS (4.18 [2015]/3.0 [2019] days), CDIs (1.47 [2015]/0.86 [2019] per 1000 patients), antibiotic cost/patient (39.45€ [2015]/23.69€ [2019]). The ASP was successful in reducing antibiotic consumption, antibiotic costs, length of hospital stay, and CDIs.
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Affiliation(s)
- Konstantina Chrysou
- Department of Microbiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Olympia Zarkotou
- Department of Clinical Microbiology, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Sofia Kalofolia
- Hospital Pharmacy, Tzaneio General Hospital of Piraeus, Athens, Greece
| | | | - Vasiliki Mamali
- Department of Clinical Microbiology, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Georgios Chrysos
- 2nd Department of Medicine and Infectious Disease Unit, Tzaneio General Hospital of Piraeus, Athens, Greece
| | | | - Nikolaos Sypsas
- General Hospital of Athens "Laiko", National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios Tsakris
- Department of Microbiology, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyros Pournaras
- Department of Microbiology, National and Kapodistrian University of Athens, Athens, Greece. .,Laboratory of Clinical Microbiology, ATTIKON University Hospital, National and Kapodistrian University of Athens, 1 Rimini Street, 12462, Chaidari, Athens, Greece.
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14
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Gerber JS, Jackson MA, Tamma PD, Zaoutis TE. Policy Statement: Antibiotic Stewardship in Pediatrics. J Pediatric Infect Dis Soc 2021; 10:641-649. [PMID: 33595086 DOI: 10.1093/jpids/piab002] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/04/2021] [Indexed: 11/15/2022]
Abstract
Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting the use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy and duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs (ASPs); essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient ASPs are provided.
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Affiliation(s)
- Jeffrey S Gerber
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mary Anne Jackson
- Department of Pediatrics, Section of Infectious Disease, Children's Mercy Hospital, UMKC School of Medicine, Kansas City, Missouri, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Pediatric Infectious Diseases, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Theoklis E Zaoutis
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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15
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Felsen CB, Dodds Ashley ES, Barney GR, Nelson DL, Nicholas JA, Yang H, Aydelotte ME, Karlic A, Nicholas NC, Petrone KK, Pine RD, Schabel SL, Medina-Walpole A, Dumyati GK. Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration. J Am Med Dir Assoc 2021; 21:55-61.e2. [PMID: 31888865 DOI: 10.1016/j.jamda.2019.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones. DESIGN Quasi-experimental, pre- and post-intervention study. SETTING AND PARTICIPANTS Six NHs in Monroe County, NY. METHODS A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time. RESULTS Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042). CONCLUSIONS AND IMPLICATIONS A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.
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Affiliation(s)
- Christina B Felsen
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY
| | - Elizabeth S Dodds Ashley
- Division of Infectious Diseases and International Health, Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC
| | - Grant R Barney
- Emerging Infections Program, New York State Department of Health, Albany, NY
| | - Dallas L Nelson
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | - Joseph A Nicholas
- Department of Medicine and Physical Medicine and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - Hongmei Yang
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY
| | | | - Alexander Karlic
- Unity Living Center and Unity Hospital, Rochester Regional Health, Rochester, NY
| | - Nirmala C Nicholas
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | | | | | - Scott L Schabel
- Division of Long Term Care, Rochester Regional Health, Rochester, NY
| | - Annette Medina-Walpole
- Department of Medicine, Geriatrics/Aging University of Rochester Medical Center, Rochester, NY
| | - Ghinwa K Dumyati
- Center for Community Health and Prevention, University of Rochester Medical Center, Rochester, NY; Department of Medicine, Division of Infectious Disease, University of Rochester Medical Center, Rochester, NY.
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16
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Abstract
Antibiotic overuse contributes to antibiotic resistance, which is a threat to public health. Antibiotic stewardship is a practice dedicated to prescribing antibiotics only when necessary and, when antibiotics are considered necessary, promoting use of the appropriate agent(s), dose, duration, and route of therapy to optimize clinical outcomes while minimizing the unintended consequences of antibiotic use. Because there are differences in common infectious conditions, drug-specific considerations, and the evidence surrounding treatment recommendations (eg, first-line therapy, duration of therapy) between children and adults, this statement provides specific guidance for the pediatric population. This policy statement discusses the rationale for inpatient and outpatient antibiotic stewardship programs; essential personnel, infrastructure, and activities required; approaches to evaluating their effectiveness; and gaps in knowledge that require further investigation. Key guidance for both inpatient and outpatient antibiotic stewardship programs are provided.
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Affiliation(s)
- Jeffrey S Gerber
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
| | - Mary Anne Jackson
- Section of Infectious Disease, Department of Pediatrics, Children's Mercy Hospital and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; and
| | - Pranita D Tamma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Theoklis E Zaoutis
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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17
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Heinzinger LR, Johnson A, Wurster JI, Nilson R, Penumutchu S, Belenky P. Oxygen and Metabolism: Digesting Determinants of Antibiotic Susceptibility in the Gut. iScience 2020; 23:101875. [PMID: 33354661 PMCID: PMC7744946 DOI: 10.1016/j.isci.2020.101875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Microbial metabolism is a major determinant of antibiotic susceptibility. Environmental conditions that modify metabolism, notably oxygen availability and redox potential, can directly fine-tune susceptibility to antibiotics. Despite this, relatively few studies have discussed these modifications within the gastrointestinal tract and their implication on in vivo drug activity and the off-target effects of antibiotics in the gut. In this review, we discuss the environmental and biogeographical complexity of the gastrointestinal tract in regard to oxygen availability and redox potential, addressing how the heterogeneity of gut microhabitats may modify antibiotic activity in vivo. We contextualize the current literature surrounding oxygen availability and antibiotic efficacy and discuss empirical treatments. We end by discussing predicted patterns of antibiotic activity in prominent microbiome taxa, given gut heterogeneity, oxygen availability, and polymicrobial interactions. We also propose additional work required to fully elucidate the role of oxygen metabolism on antibiotic susceptibility in the context of the gut.
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Affiliation(s)
- Lauren R. Heinzinger
- Department of Microbiology and Immunology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, NY 14214, USA
| | - Angus Johnson
- Department of Biological Science, Binghamton University, Binghamton, NY 13902, USA
| | - Jenna I. Wurster
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI 02912, USA
| | - Rachael Nilson
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI 02912, USA
| | - Swathi Penumutchu
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI 02912, USA
| | - Peter Belenky
- Department of Molecular Microbiology and Immunology, Brown University, Providence, RI 02912, USA
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18
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Kazakova SV, Baggs J, McDonald LC, Yi SH, Hatfield KM, Guh A, Reddy SC, Jernigan JA. Association Between Antibiotic Use and Hospital-onset Clostridioides difficile Infection in US Acute Care Hospitals, 2006-2012: An Ecologic Analysis. Clin Infect Dis 2020; 70:11-18. [PMID: 30820545 DOI: 10.1093/cid/ciz169] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/25/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Unnecessary antibiotic use (AU) contributes to increased rates of Clostridioides difficile infection (CDI). The impact of antibiotic restriction on hospital-onset CDI (HO-CDI) has not been assessed in a large group of US acute care hospitals (ACHs). METHODS We examined cross-sectional and temporal associations between rates of hospital-level AU and HO-CDI using data from 549 ACHs. HO-CDI was defined as a discharge with a secondary International Classification of Diseases, Ninth Revision, Clinical Modification code for CDI (008.45), and treatment with metronidazole or oral vancomycin > 3 days after admission. Analyses were performed using multivariable generalized estimating equation models adjusting for patient and hospital characteristics. RESULTS During 2006-2012, the unadjusted annual rates of HO-CDI and total AU were 7.3 per 10 000 patient-days (PD) (95% confidence interval [CI], 7.1-7.5) and 811 days of therapy (DOT)/1000 PD (95% CI, 803-820), respectively. In the cross-sectional analysis, for every 50 DOT/1000 PD increase in total AU, there was a 4.4% increase in HO-CDI. For every 10 DOT/1000 PD increase in use of third- and fourth-generation cephalosporins or carbapenems, there was a 2.1% and 2.9% increase in HO-CDI, respectively. In the time-series analysis, the 6 ACHs with a ≥30% decrease in total AU had a 33% decrease in HO-CDI (rate ratio, 0.67 [95% CI, .47-.96]); ACHs with a ≥20% decrease in fluoroquinolone or third- and fourth-generation cephalosporin use had a corresponding decrease in HO-CDI of 8% and 13%, respectively. CONCLUSIONS At an ecologic level, reductions in total AU, use of fluoroquinolones, and use of third- and fourth-generation cephalosporins were each associated with decreased HO-CDI rates.
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Affiliation(s)
- Sophia V Kazakova
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - James Baggs
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sarah H Yi
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kelly M Hatfield
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alice Guh
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sujan C Reddy
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John A Jernigan
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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19
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Li XY, Qi X, Tian SH, He R, Jiang S, Li HJ. Impact of dedicated infectious disease teamwork on the treatment and prognosis of patients with diabetic foot infection. Int J Infect Dis 2020; 100:133-138. [PMID: 32916250 DOI: 10.1016/j.ijid.2020.08.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/10/2020] [Accepted: 08/23/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE The aim was to develop and evaluate the impact of a new model in which the infectious disease (ID) physician and pharmacist work together to treat diabetic foot infections (DFIs). METHODS A quasi-experimental before-after study was conducted. The medical charts of inpatients with DFI admitted between April 1, 2017 and March 31, 2018 were reviewed retrospectively (control group, n = 30). Inpatients diagnosed with DFI between April 1, 2018 and March 31, 2019 were enrolled prospectively as the intervention group and received treatment through dedicated ID teamwork (intervention group, n = 35). RESULTS The distribution of infection severity and levels of metabolic criteria were similar in the two groups. Compared with the control group, the intervention group received adequate initial empirical treatment more frequently (96.8% vs 43.5%, p < 0.001) and had a shorter median duration of fever (1 day vs 7.5 days, p < 0.001). Rates of healing and relapse within 6 months were similar in the two groups, although the intervention group showed more sites of osteomyelitis (p = 0.036) and a higher percentage of polymicrobial infections (48.6% vs 10.0%, p = 0.001). CONCLUSION The early and full participation of ID physicians and pharmacists in the treatment of DFI facilitated targeted antimicrobial treatment and improved patient outcomes.
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Affiliation(s)
- Xiang-Yan Li
- Department of Anti-infection, Institute of Clinical Pharmacology, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing 100034, China.
| | - Xin Qi
- Department of Plastic Surgery and Burns, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing 100034, China.
| | - Shuo-Han Tian
- Department of Pharmacy, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing 100034, China.
| | - Rui He
- Department of Plastic Surgery and Burns, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing 100034, China.
| | - Shan Jiang
- Department of Plastic Surgery and Burns, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing 100034, China.
| | - Hui-Juan Li
- Department of Plastic Surgery and Burns, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing 100034, China.
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20
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Tischendorf J, Brunner M, Knobloch MJ, Schulz L, Barker A, Wright MO, Lepak A, Safdar N. Evaluation of a successful fluoroquinolone restriction intervention among high-risk patients: A mixed-methods study. PLoS One 2020; 15:e0237987. [PMID: 32841259 PMCID: PMC7446965 DOI: 10.1371/journal.pone.0237987] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/06/2020] [Indexed: 11/19/2022] Open
Abstract
Objective We conducted a quality improvement initiative to restrict fluoroquinolone prescribing on two inpatient units housing high-risk patients and applied a human factors approach to understanding the barriers and facilitators to success of this intervention by front-line providers. Methods This was a mixed-methods, quasi-experimental study. This study was conducted on two inpatient units at a tertiary care academic medical center: the medical-surgical intensive care and abdominal solid organ transplant units. Unit-level data were collected retrospectively for 24 months pre- and post- fluoroquinolone restriction intervention, implemented in July 2016, for all admissions to the study units. Our restriction intervention required antimicrobial stewardship pre-approval for fluoroquinolone prescribing. We explored barriers and facilitators to optimal fluoroquinolone prescribing using semi-structured interviews attending, fellow and resident physicians, advanced practice providers and pharmacists on these units. Results Hospital-onset C. difficile infection did not decrease significantly, but fluoroquinolone use declined significantly from 111.6 to 19.8 days of therapy per 1000 patient-days without negatively impacting length of stay, readmissions or mortality. Third generation cephalosporin and aminoglycoside use increased post-restriction. Providers identified our institution’s strong antimicrobial stewardship program and pharmacy involvement in antimicrobial decision making as key facilitators of fluoroquinolone optimization and patient complexity, lack of provider education and organizational culture as barriers to optimal prescribing. Conclusions Fluoroquinolones can be safely restricted even among high-risk patients without negatively impacting length of stay, readmissions or mortality. Our study provides a framework for successful antimicrobial stewardship interventions informed by perceptions of front line providers.
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Affiliation(s)
- Jessica Tischendorf
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
- * E-mail:
| | - Matthew Brunner
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Mary Jo Knobloch
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States of America
| | - Lucas Schulz
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, United States of America
| | - Anna Barker
- Department of Population Health Sciences, University of Wisconsin Madison, Madison, Wisconsin, United States of America
- Department of Internal Medicine, University of Michigan Ann Arbor, Ann Arbor, Michigan, United States of America
| | - Marc-Oliver Wright
- Infection Prevention Program, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, United States of America
| | - Alexander Lepak
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, United States of America
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21
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Morfín-Otero R, Petersen-Morfín S, Aguirre-Díaz S, Pérez-Gómez H, Garza-González E, González-Díaz E, Esparza-Ahumada S, Velarde-Ruiz Velasco J, León-Garnica G, Escobedo-Sánchez R, Rodríguez-Noriega E. Clostridioides difficile-associated diarrhea in surgical service patients in Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [DOI: 10.1016/j.rgmxen.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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22
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Al-Omari A, Al Mutair A, Alhumaid S, Salih S, Alanazi A, Albarsan H, Abourayan M, Al Subaie M. The impact of antimicrobial stewardship program implementation at four tertiary private hospitals: results of a five-years pre-post analysis. Antimicrob Resist Infect Control 2020; 9:95. [PMID: 32600391 PMCID: PMC7322716 DOI: 10.1186/s13756-020-00751-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/04/2020] [Indexed: 11/23/2022] Open
Abstract
Background Antimicrobial stewardship (AMS) programs have shown to reduce the emergence of antimicrobial resistance (AMR) and health-care-associated infections (HAIs), and save health-care costs associated with an inappropriate antimicrobial use. The primary objective of this study was to compare the consumption and cost of antimicrobial agents using defined daily dose (DDD) and direct cost of antibiotics before and after the AMS program implementation. Secondary objective was to determine the rate of HAIs [Clostridium difficile (C. difficile), ventilator-associated pneumonia (VAP), and central line-associated bloodstream infection (CLABSI) before and after the AMS program implementation. Methods This is a pre-post quasi-experimental study. Adult inpatients were enrolled in a prospective fashion under the active AMS arm and compared with historical inpatients who were admitted to the same units before the AMS implementation. Study was conducted at four tertiary private hospitals located in two cities in Saudi Arabia. Adult inpatients were enrolled under the pre- AMS arm and post- AMS arm if they were on any of the ten selected restricted broad-spectrum antibiotics (imipenem/cilastatin, piperacillin/tazobactam, colistin, tigecycline, cefepime, meropenem, ciprofloxacin, moxifloxacin, teicoplanin and linezolid). Results A total of 409,403 subjects were recruited, 79,369 in the pre- AMS control and 330,034 in the post- AMS arm. Average DDDs consumption of all targeted broad-spectrum antimicrobials from January 2016 to June 2019 post- AMS launch was lower than the DDDs use of these agents pre- AMS (233 vs 320 DDDs per 1000 patient-days, p = 0.689). Antimicrobial expenditures decreased by 28.45% in the first year of the program and remained relatively stable in subsequent years, with overall cumulative cost savings estimated at S.R. 6,286,929 and negligible expenses of S.R. 505,115 (p = 0.648). Rates of healthcare associated infections involving C. difficile, VAP, and CLABSI all decreased significantly after AMS implementation (incidence of HAIs in 2015 compared to 2019: for C. difficile, 94 vs 13, p = 0.024; for VAP, 24 vs 6, p = 0.001; for CLABSI, 17 vs 1, p = 0.000; respectively). Conclusion Implementation of AMS program at HMG healthcare facilities resulted in reduced antimicrobials use and cost, and lowered incidence of healthcare associated infections.
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Affiliation(s)
- Awad Al-Omari
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia.,Alfaisal University, Riyadh, Saudi Arabia
| | - Abbas Al Mutair
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia. .,Alfaisal University, Riyadh, Saudi Arabia. .,School of Nursing, Wollongong University, Wollongong, Australia.
| | | | - Samer Salih
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Ahmed Alanazi
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Hesham Albarsan
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Maha Abourayan
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
| | - Maha Al Subaie
- Research Center, Dr Sulaiman Al Habib Medical Group, Riyadh, Saudi Arabia
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Impact of a Diagnosis-Centered Antibiotic Stewardship on Incident Clostridioides difficile Infections in Older Inpatients: An Observational Study. Antibiotics (Basel) 2020; 9:antibiotics9060303. [PMID: 32517086 PMCID: PMC7345193 DOI: 10.3390/antibiotics9060303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 05/27/2020] [Accepted: 06/04/2020] [Indexed: 12/17/2022] Open
Abstract
In 2015, a major increase in incident hospital-onset Clostridioides difficile infections (HO-CDI) in a geriatric university hospital led to the implementation of a diagnosis-centered antibiotic stewardship program (ASP). We aimed to evaluate the impact of the ASP on antibiotic consumption and on HO-CDI incidence. The intervention was the arrival of a full-time infectiologist in the acute geriatric unit in May 2015, followed by the implementation of new diagnostic procedures for infections associated with an antibiotic withdrawal policy. Between 2015 and 2018, the ASP was associated with a major reduction in diagnoses for inpatients (23% to 13% for pneumonia, 24% to 13% for urinary tract infection), while median hospital stays and mortality rates remained stable. The reduction in diagnosed bacterial infections was associated with a 45% decrease in antibiotic consumption in the acute geriatric unit. HO-CDI incidence also decreased dramatically from 1.4‰ bed-days to 0.8‰ bed-days in the geriatric rehabilitation unit. The ASP focused on reducing the overdiagnosis of bacterial infections in the acute geriatric unit was successfully associated with both a reduction in antibiotic use and a clear reduction in the incidence of HO-CDI in the geriatric rehabilitation unit.
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Prescriber perceptions of fluoroquinolones, extended-spectrum cephalosporins, and Clostridioides difficile infection. Infect Control Hosp Epidemiol 2020; 41:914-920. [PMID: 32468967 DOI: 10.1017/ice.2020.183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Fluoroquinolones (FQs) and extended-spectrum cephalosporins (ESCs) are associated with higher risk of Clostridioides difficile infection (CDI). Decreasing the unnecessary use of FQs and ESCs is a goal of antimicrobial stewardship. Understanding how prescribers perceive the risks and benefits of FQs and ESCs is needed. METHODS We conducted interviews with clinicians from 4 hospitals. Interviews elicited respondent perceptions about the risk of ESCs, FQs, and CDI. Interviews were audio recorded, transcribed, and analyzed using a flexible coding approach. RESULTS Interviews were conducted with 64 respondents (38 physicians, 7 nurses, 6 advance practice providers, and 13 pharmacists). ESCs and FQs were perceived to have many benefits, including infrequent dosing, breadth of coverage, and greater patient adherence after hospital discharge. Prescribers stated that it was easy to make decisions about these drugs, so they were especially appealing to use in the context of time pressures. They described having difficulty discontinuing these drugs when prescribed by others due to inertia and fear. Prescribers were skeptical about targeting specific drugs as a stewardship approach and felt that the risk of a negative outcome from under treatment of a suspected bacterial infection was a higher priority than the prevention of CDI. CONCLUSIONS Prescribers in this study perceived many advantages to using ESCs and FQs, especially under conditions of time pressure and uncertainty. In making decisions about these drugs, prescribers balance risk and benefit, and they believed that the risk of CDI was acceptable in compared with the risk of undertreatment.
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25
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Bundling Probiotics With Antimicrobial Stewardship Programs for the Prevention of Clostridiodes difficile Infections in Acute Care Hospitals. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2020. [DOI: 10.1097/ipc.0000000000000853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Kayali O, Icgen B. Untreated HWWs Emerged as Hotpots for ARGs. BULLETIN OF ENVIRONMENTAL CONTAMINATION AND TOXICOLOGY 2020; 104:386-392. [PMID: 31965225 DOI: 10.1007/s00128-020-02792-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/14/2020] [Indexed: 06/10/2023]
Abstract
Hospital wastewaters (HWWs) are reported to be hotspots for antibiotics and antibiotic-resistant bacteria. However, limited information involves the impact of these effluents on dissemination of antibiotic-resistance genes (ARGs). In this study, therefore, seasonally collected HWWs were monitored for overall bacterial load and seven ARGs aadA, tetA, cmlA, sul1, qnrS, ermB and bla CTX-M by using quantitative polymerase chain reaction method. Overall bacterial 16S rRNA copy number was found to be the lowest in winter with 103 copy number/mL, while the highest copy number, with 105 copy number/mL, was observed in both summer and spring. All hospitals tested displayed similar seasonal ARG copy number profile of aadA > tetA > cmlA ≈ sul1 > ermB ≈ qnrS > bla CTX-M. The results indicated that untreated HWWs were hotspots for ARGs and required attention before discharging into public sewer.
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Affiliation(s)
- Osman Kayali
- Department of Biotechnology 06800, Middle East Technical University, Ankara, Turkey
| | - Bulent Icgen
- Department of Biotechnology 06800, Middle East Technical University, Ankara, Turkey.
- Department of Environmental Engineering, Middle East Technical University, 06800, Ankara, Turkey.
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27
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Karp J, Edman-Wallér J, Toepfer M, Lundqvist A, Jacobsson G. Clostridioides difficile incidence related to in-hospital cephalosporin use: a tale of two highly comparable hospitals. J Antimicrob Chemother 2020; 74:182-189. [PMID: 30358837 DOI: 10.1093/jac/dky408] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 09/07/2018] [Indexed: 11/14/2022] Open
Abstract
Background Antibiotic treatment is a well-known risk factor for healthcare facility-associated Clostridioides (Clostridium) difficile infection (HCF-CDI). Antibiotic stewardship programmes (ASPs) targeting high-risk antibiotics have been shown to decrease HCF-CDI incidence. HCF-CDI incidence is high in Nordic countries despite relatively low antibiotic use in hospital. Objectives To determine if HCF-CDI incidence was modified by a hospital ASP that restricted cephalosporin use. Methods The effects of an ASP on HCF-CDI incidence were evaluated in a two-centre setting using a retrospective design. We exploited a strategy of both individual case ascertainment based on chart reviews and aggregated data from the hospitals. Cases were attributed to the antibiotics given prior to disease onset, in proportion to the number of DDDs used. Three periods were studied: 2007 (before the ASP), 2012 and 2015. Results At the ASP hospital, cephalosporin use decreased by 87% and the number of HCF-CDI/1000 hospital admissions decreased significantly from 2.25 (2007) to 1.16 (2015) (P = 0.0014). The corresponding results at the non-ASP hospital showed a non-significant increase from 2.09 to 2.38. A high number of cases could be attributed to cephalosporins at both hospitals. The increased use of other broad-spectrum antibiotics, e.g. piperacillin/tazobactam, at the ASP hospital was not associated with offsetting increases in attributable HCF-CDI cases. Conclusions Decreased use of cephalosporins is an effective strategy to decrease HCF-CDI incidence over time in a setting with high incidence and low antibiotic use.
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Affiliation(s)
- Johan Karp
- Department of Infectious Diseases, Skaraborg Hospital, Lövängsvägen, Skövde, Sweden.,Center for Antibiotic Resistance Research (CARe), Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Jon Edman-Wallér
- Center for Antibiotic Resistance Research (CARe), Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.,Department of Hospital Infection Control, Södra Älvsborg Hospital, Brämhultsvägen, Borås, Sweden
| | - Michael Toepfer
- Clinical Microbiology, Unilabs AB, Rådhusgatan 6, Skövde, Sweden
| | - Anders Lundqvist
- Department of Infectious Diseases, Södra Älvsborg Hospital, Brämhultsvägen 53, Borås, Sweden
| | - Gunnar Jacobsson
- Department of Infectious Diseases, Skaraborg Hospital, Lövängsvägen, Skövde, Sweden.,Center for Antibiotic Resistance Research (CARe), Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
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28
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Bolukcu S, Hakyemez IN, Gultepe BS, Okay G, Durdu B, Koc MM, Aslan T. Clostridium difficile infection: Is there a change in the underlying factors? Inflammatory bowel disease and Clostridium difficile. Saudi J Gastroenterol 2019; 25:384-389. [PMID: 31793457 PMCID: PMC6941457 DOI: 10.4103/sjg.sjg_44_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND / AIMS Clostridium difficile is a Gram-positive, strict anaerobe, spore-forming bacterium. It can cause self-limiting mild diarrhea, severe diarrhea, pseudomembranous colitis, and fatal fulminant colitis. We aimed to investigate the changes in epidemiology and incidence of C. difficile infection in our hospital database. PATIENTS AND METHODS Episodes of C. difficile toxin were identified in hospital database, and data such as age, sex, community versus hospital acquisition, intensive care follow-up, current or previous treatments with antibiotics within the past 3 months, medication with proton pump inhibitors, or immunosuppressive therapies were collected. RESULTS Toxin-positive 78 individuals constituted the patient group. In univariate analyses, independent risk factors for toxin positivity were community versus hospital acquisition [odds ratio (OR), 5.49; 95% confidence interval (CI), 2.52-11.95; P = 0.0001], presence of inflammatory bowel diseases (IBDs) (OR, 21.5; 95% CI, 8.65-53.44; P = 0.0001), proton pump inhibitors' use (OR, 4.53; 95% CI, 1.97-10.43; P = 0.0001), immunosuppressive drug use (OR, 4.1; 95% CI, 2.01-8.3; P = 0.0001), and use of quinolone group of antibiotics (OR, 5.95; 95% CI, 1.92-18.46; P = 0.001). Antibiotic use was a protective risk factor (OR, 0.09; 95% CI, 0.01-0.78; P = 0.01) and presence of IBDs was an independent risk factor (OR, 6.8; 95% CI, 1.5-30.08; P = 0.01) in community-acquired group (OR, 0.09; 95% CI, 0.01-0.78; P = 0.01). CONCLUSION In recent studies, C. difficile infections were demonstrated to be more frequent in younger individuals who did not have a history of hospitalization but had an underlying disease such as IBD. In our study, we showed the change in the epidemiological data with prominence of underlying diseases such as IBDs.
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Affiliation(s)
- Sibel Bolukcu
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Istanbul, Turkey,Address for correspondence: Dr. Sibel Bolukcu, Adnan Menderes Bulvarý Vatan Caddesi 34093 Fatih/İstanbul, Turkey. E-mail:
| | - Ismail Necati Hakyemez
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Istanbul, Turkey
| | - Bilge Sumbul Gultepe
- Department of Clinical Microbiology, Bezmialem Vakif University, Istanbul, Turkey
| | - Gulay Okay
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Istanbul, Turkey
| | - Bulent Durdu
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Istanbul, Turkey
| | - Meliha Meric Koc
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Istanbul, Turkey
| | - Turan Aslan
- Department of Infectious Diseases and Clinical Microbiology, Bezmialem Vakif University, Istanbul, Turkey
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McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC, Coffin SE, Dubberke ER, Garey KW, Gould CV, Kelly C, Loo V, Shaklee Sammons J, Sandora TJ, Wilcox MH. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2019; 66:e1-e48. [PMID: 29462280 DOI: 10.1093/cid/cix1085] [Citation(s) in RCA: 1228] [Impact Index Per Article: 245.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
A panel of experts was convened by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to update the 2010 clinical practice guideline on Clostridium difficile infection (CDI) in adults. The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis. Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Moreover, C. difficile has established itself as an important community pathogen. Although the prevalence of the epidemic and virulent ribotype 027 strain has declined markedly along with overall CDI rates in parts of Europe, it remains one of the most commonly identified strains in the United States where it causes a sizable minority of CDIs, especially healthcare-associated CDIs. This guideline updates recommendations regarding epidemiology, diagnosis, treatment, infection prevention, and environmental management.
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Affiliation(s)
| | | | - Stuart Johnson
- Edward Hines Jr Veterans Administration Hospital, Hines.,Loyola University Medical Center, Maywood, Illinois
| | | | - Karen C Carroll
- Johns Hopkins University School of Medicine, Baltimore, Maryl
| | | | - Erik R Dubberke
- Washington University School of Medicine, St Louis, Missouri
| | | | - Carolyn V Gould
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ciaran Kelly
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vivian Loo
- McGill University Health Centre, McGill University, Montréal, Québec, Canada
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30
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Schluger A, Rosenblatt R, Knotts R, Verna EC, Pereira MR. Clostridioides difficile infection and recurrence among 2622 solid organ transplant recipients. Transpl Infect Dis 2019; 21:e13184. [PMID: 31571380 DOI: 10.1111/tid.13184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/22/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is common after solid organ transplant (SOT) and is associated with high morbidity and mortality. METHODS We assessed incidence, risk factors, and outcomes of CDI among SOT patients at a large multi-organ transplant center. Multivariable logistic regression was used to identify risk factors for initial and recurrent CDI. RESULTS A total of 2622 SOT patients were included. 224 (8.5%) had CDI 1 year post-SOT. The highest incidence of CDI was among pancreas recipients (12.5%) followed by lung (11.7%), liver (11.0%), heart (10.8%), and kidney (5.8%). Median time to CDI was 56 days (range 2-354) post-SOT. About 64% of patients had severe CDI. About 56.3% were treated with metronidazole, 13.8% with oral vancomycin, and 28.6% with both. About 28.6% of patients had recurrent CDI. In multivariable modeling, lung transplant recipient status was the only significant predictor of recurrent CDI (OR 4.97, 95% CI 2.11-11.78, P < .001) controlling for age, severe CDI, and pre-SOT CDI. Post-SOT CDI nearly doubled the risk of mortality at one year, in particular among those with severe CDI. CONCLUSIONS In summary, CDI is highly prevalent, occurs early in the post-transplant period, usually severe, with a high rate of recurrence, and associated with increased mortality within 1 year after transplant. The early post-transplant period may be a crucial window to reduce CDI rates.
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Affiliation(s)
- Aaron Schluger
- Department of Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Russell Rosenblatt
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Rita Knotts
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, NY, USA
| | - Marcus R Pereira
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, NY, USA
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Clostridioides difficile-associated diarrhea in surgical service patients in Mexico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2019; 85:227-234. [PMID: 31416629 DOI: 10.1016/j.rgmx.2019.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 05/26/2019] [Accepted: 05/27/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Clostridioides difficile is the first cause of healthcare-associated diarrhea in developed countries. In recent years the incidence of C. difficile infection (CDI) has increased worldwide. There is not much information on the topic in Mexico, and little is known about the risk factors for the infection in patients that are hospitalized in surgical services. MATERIALS AND METHODS A case-control study was conducted that compared the epidemiologic findings and risk factors between surgical patients with PCR-confirmed CDI, surgical patients with diarrhea and a negative PCR test, and surgical patients with no diarrhea. The statistical analysis was carried out using the SPSS version 22.0 program. RESULTS The majority of the surgical patients with CDI belonged to the areas of neurosurgery, cardiac surgery, orthopedics, and general surgery. A total of 53% of the CDI cases were associated with the hypervirulent CD NAP1/027 strain. The presence of mucus in stools (OR: 1.5, P=.001), fever (OR: 1.4, P=.011), leukocytes in stools (OR: 3.2, P<.001), hospitalization within the past 12weeks (OR: 2.0, P<.001), antibiotic use (OR: 1.3, P=.023), and ceftriaxone use (OR: 1.4, P=.01) were independent risk factors for the development of CDI. CONCLUSIONS C. difficile-induced diarrhea in the surgical services is frequent at the Hospital Civil de Guadalajara "Fray Antonio Alcalde".
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32
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Zahn M, Adalja AA, Auwaerter PG, Edelson PJ, Hansen GR, Hynes NA, Jezek A, MacArthur RD, Manabe YC, McGoodwin C, Duchin JS. Infectious Diseases Physicians: Improving and Protecting the Public's Health: Why Equitable Compensation Is Critical. Clin Infect Dis 2019; 69:352-356. [PMID: 30329044 PMCID: PMC7108186 DOI: 10.1093/cid/ciy888] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 10/15/2018] [Indexed: 02/07/2023] Open
Abstract
Infectious diseases (ID) physicians play a crucial role in public health in a variety of settings. Unfortunately, much of this work is undercompensated despite the proven efficacy of public health interventions such as hospital acquired infection prevention, antimicrobial stewardship, disease surveillance, and outbreak response. The lack of compensation makes it difficult to attract the best and the brightest to the field of ID, threatening the future of the ID workforce. Here, we examine compensation data for ID physicians compared to their value in population and public health settings and suggest policy recommendations to address the pay disparities that exist between cognitive and procedural specialties that prevent more medical students and residents from entering the field. All ID physicians should take an active role in promoting the value of the subspecialty to policymakers and influencers as well as trainees.
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Affiliation(s)
- Matthew Zahn
- Epidemiology and Assessment, Orange County Health Care Agency, California
| | - Amesh A Adalja
- Johns Hopkins Center for Health Security, Johns Hopkins University, Baltimore, Maryland
| | - Paul G Auwaerter
- Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paul J Edelson
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, New York
| | | | - Noreen A Hynes
- Schools of Medicine and Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Amanda Jezek
- Public Policy and Government Relations, Infectious Diseases Society of America, Arlington, Virginia
| | - Rodger D MacArthur
- Office of Academic Affairs, Medical College of Georgia at Augusta University
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Colin McGoodwin
- Public Policy and Government Relations, Infectious Diseases Society of America, Arlington, Virginia
| | - Jeffrey S Duchin
- Communicable Disease Epidemiology & Immunization Section, Division of Infectious Diseases, Seattle and King County Public Health Department and University of Washington School of Public Health
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McLeod M, Ahmad R, Shebl NA, Micallef C, Sim F, Holmes A. A whole-health-economy approach to antimicrobial stewardship: Analysis of current models and future direction. PLoS Med 2019; 16:e1002774. [PMID: 30925166 PMCID: PMC6440619 DOI: 10.1371/journal.pmed.1002774] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In a Policy Forum, Alison Holmes and colleagues discuss coordinated approaches to antimicrobial stewardship.
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Affiliation(s)
- Monsey McLeod
- Centre for Medication Safety and Service Quality, Pharmacy Department, Imperial College Healthcare National Health Service (NHS) Trust, London, United Kingdom
- National Institute for Health Research Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London in partnership with Public Health England, Hammersmith Hospital, London, United Kingdom
| | - Raheelah Ahmad
- National Institute for Health Research Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London in partnership with Public Health England, Hammersmith Hospital, London, United Kingdom
| | - Nada Atef Shebl
- Department of Clinical and Pharmaceutical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Christianne Micallef
- Pharmacy Department, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Fiona Sim
- Institute for Health Research, University of Bedfordshire, Luton, United Kingdom
- NHS England (Midlands & East), United Kingdom
| | - Alison Holmes
- National Institute for Health Research Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London in partnership with Public Health England, Hammersmith Hospital, London, United Kingdom
- * E-mail:
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34
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Patton A, Davey P, Harbarth S, Nathwani D, Sneddon J, Marwick CA. Impact of antimicrobial stewardship interventions on Clostridium difficile infection and clinical outcomes: segmented regression analyses. J Antimicrob Chemother 2019; 73:517-526. [PMID: 29177477 DOI: 10.1093/jac/dkx413] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 10/10/2017] [Indexed: 12/12/2022] Open
Abstract
Background Antimicrobial exposure is associated with increased risk of Clostridium difficile infection (CDI), but the impact of prescribing interventions on CDI and other outcomes is less clear. Objectives To evaluate the effect of an antimicrobial stewardship intervention targeting high-risk antimicrobials (HRA), implemented in October 2008, and to compare the findings with similar studies from a systematic review. Methods All patients admitted to Medicine and Surgery in Ninewells Hospital from October 2006 to September 2010 were included. Intervention effects on HRA use (dispensed DDD), CDI cases and mortality rates, per 1000 admissions per month, were analysed separately in Medicine and Surgery using segmented regression of interrupted time series (ITS) data. Data from comparable published studies were reanalysed using the same method. Results Six months post-intervention, there were relative reductions in HRA use of 33% (95% CI 11-56) in Medicine and 32% (95% CI 19-46) in Surgery. At 12 months, there was an estimated reduction in CDI of 7.0 cases/1000 admissions [relative change -24% (95% CI - 55 to 6)] in Medicine, but no change in Surgery {estimated 0.1 fewer cases/1000 admissions [-2% (95% CI - 116 to 112)]}. Mortality reduced throughout the study period, unaffected by the intervention. In all six comparable studies, HRA use reduced significantly, but reductions in CDI rates were only statistically significant in two and none measured mortality. Pre-intervention CDI rates and trends influenced the intervention effect. Conclusions Despite large reductions in HRA prescribing and reductions in CDI, demonstrating real-world impact of stewardship interventions remains challenging.
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Affiliation(s)
- Andrea Patton
- Population Health Sciences, School of Medicine, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK.,Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Delta House, West Nile Street, Glasgow G1 2NP, UK
| | - Peter Davey
- Population Health Sciences, School of Medicine, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Dilip Nathwani
- Department of Infection and Immunodeficiency, East Block, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
| | - Jacqueline Sneddon
- Scottish Antimicrobial Prescribing Group, Healthcare Improvement Scotland, Delta House, West Nile Street, Glasgow G1 2NP, UK
| | - Charis A Marwick
- Population Health Sciences, School of Medicine, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK.,Department of Infection and Immunodeficiency, East Block, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
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Lambl BB, Altamimi S, Kaufman NE, Rein MS, Freeley M, Duram M, Krauss W, Kurowski J, O'Neill WE, Seeley P, Gagnon MJ, Phillips DE, Rubin MS. Leveraging Quality Improvement Science to Reduce C. difficile Infections in a Community Hospital. Jt Comm J Qual Patient Saf 2018; 45:285-294. [PMID: 30527394 DOI: 10.1016/j.jcjq.2018.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 10/26/2018] [Accepted: 10/26/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The most common infection acquired in US hospitals is Clostridium difficile, which can lead to protracted diarrhea, severe abdominal cramping, and infectious colitis and an attributable mortality of 6.5%. The mortality associated with C. difficile is of major clinical importance. The best strategy to prevent such infections is an open question. METHODS A multiyear quality improvement initiative was performed in our community hospital to determine where hospitals should focus their resources to achieve sustainable reductions in hospital-acquired C. difficile infection (CDI). Quality improvement methodology was used to evaluate the impact of sequential interventions in environmental cleaning, infection prevention, and antibiotic stewardship over time. RESULTS After four years, hospital-acquired CDI declined 55.5%, from 12.2 to 5.4 cases/10,000 patient-days (Poisson rate test, p = 0.002). High-risk antibiotic use declined 88.1%, from 63.7 to 7.6 days on treatment/1,000 patient-days (Student's t-test, p < 0.001). The highest-impact intervention was stewardship on diagnostics and high-risk antibiotics using home-grown decision support tools. CONCLUSION Translating scientific evidence into clinical practice using quality improvement methods led to sustained reductions in C. difficile transmission and identified high-risk antibiotics and diagnostics as key leverage points.
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Trends and Drivers of Inpatient Antibiotic Consumption among 89 China Tertiary General Hospitals from 2011Q1 to 2015Q4. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5968653. [PMID: 30519582 PMCID: PMC6241243 DOI: 10.1155/2018/5968653] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 08/07/2018] [Accepted: 09/06/2018] [Indexed: 11/24/2022]
Abstract
Antibacterial surveillance is an essential measure for strengthening the management of clinical antibiotic use. This study aimed to determine the trends and drivers of inpatient antibiotic consumption in China. A sample of 89 hospitals with complete data from 2011Q1 to 2015Q4 was included. Accumulative defined daily doses (DDDs), antibiotic use density (AUD), and drug variety were calculated to evaluate antibiotic consumption. From 2011Q1 to 2015Q4, the median values of DDDs, AUD, and drug variety dropped by 10.49%, 39.19%, and 27.96%, respectively. Panel regression results showed, for each additional quarter, DDDs reduced by 6.714 DDDs, AUD reduced by 0.013 DDDs per 100 inpatients per day, and drug variety reduced by 0.012 types (p < 0.001). National hospitals were more likely to use antibiotics, with the highest number of DDDs (106 709 DDDs) and AUD (60 DDDs per 100 inpatients per day) and a large number of drug variety (71 types of drug) all reported from national hospitals. Overall, a downward trend of inpatient antibiotic consumption was observed in competitive tertiary general hospitals in China. However, antibiotic use in China, especially in national hospitals, continues to exceed the guidelines set forth by the nationwide antibiotic stewardship program. China must continue to improve surveillance of antibiotic consumption by constructing a more comprehensive, continuous, and targeted stewardship program. Policy interventions in China should be made in consideration of unbalanced regional development and the consequences this may have on antibiotic consumption.
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Alghamdi S, Shebl NA, Aslanpour Z, Shibl A, Berrou I. Hospital adoption of antimicrobial stewardship programmes in Gulf Cooperation Council countries: A review of existing evidence. J Glob Antimicrob Resist 2018; 15:196-209. [DOI: 10.1016/j.jgar.2018.07.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 07/12/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022] Open
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Schultz K, Sickbert-Bennett E, Marx A, Weber DJ, DiBiase LM, Campbell-Bright S, Bode LE, Baker M, Belhorn T, Buchanan M, Goldbach S, Harden J, Hoke E, Huenniger B, Juliano JJ, Langston M, Ritchie H, Rutala WA, Smith J, Summerlin-Long S, Teal L, Gilligan P. Preventable Patient Harm: a Multidisciplinary, Bundled Approach to Reducing Clostridium difficile Infections While Using a Glutamate Dehydrogenase/Toxin Immunochromatographic Assay/Nucleic Acid Amplification Test Diagnostic Algorithm. J Clin Microbiol 2018; 56:e00625-18. [PMID: 29997201 PMCID: PMC6113472 DOI: 10.1128/jcm.00625-18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/05/2018] [Indexed: 12/18/2022] Open
Abstract
Health care facility-onset Clostridium difficile infections (HO-CDI) are an important national problem, causing increased morbidity and mortality. HO-CDI is an important metric for the Center for Medicare and Medicaid Service's (CMS) performance measures. Hospitals that fall into the worst-performing quartile in preventing hospital-acquired infections, including HO-CDI, may lose millions of dollars in reimbursement. Under pressure to reduce CDI and without a clear optimal method for C. difficile detection, health care facilities are questioning how best to use highly sensitive nucleic acid amplification tests (NAATs) to aid in the diagnosis of CDI. Our institution has used a two-step glutamate dehydrogenase (GDH)/toxin immunochromatographic assay/NAAT algorithm since 2009. In 2016, our institution set an organizational goal to reduce our CDI rates by 10% by July 2017. We achieved a statistically significant reduction of 42.7% in our HO-CDI rate by forming a multidisciplinary group to implement and monitor eight key categories of infection prevention interventions over a period of 13 months. Notably, we achieved this reduction without modifying our laboratory algorithm. Significant reductions in CDI rates can be achieved without altering sensitive laboratory testing methods.
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Affiliation(s)
- Katherine Schultz
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | | | - Ashley Marx
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - David J Weber
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
- Division of Adult Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Lauren M DiBiase
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Stacy Campbell-Bright
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lauren E Bode
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Mike Baker
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Tom Belhorn
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Mark Buchanan
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Sherie Goldbach
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Jacci Harden
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Emily Hoke
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Beth Huenniger
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Jonathan J Juliano
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
- Division of Adult Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Michael Langston
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Heather Ritchie
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - William A Rutala
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Jason Smith
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | | | - Lisa Teal
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Peter Gilligan
- University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
- Clinical Microbiology-Immunology Laboratories, UNC Health Care, Chapel Hill, North Carolina, USA
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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King A, Mullish BH, Williams HRT, Aylin P. Comparative epidemiology of Clostridium difficile infection: England and the USA. Int J Qual Health Care 2018; 29:785-791. [PMID: 29025123 DOI: 10.1093/intqhc/mzx120] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 08/23/2017] [Indexed: 12/18/2022] Open
Abstract
Objective To examine whether there is an epidemiological difference between Clostridium difficile infection (CDI) inpatient populations in England and the United States. Design A cross-sectional study. Setting National administrative inpatient discharge data from England (Hospital Episode Statistics) and the USA (National Inpatient Sample) in 2012. Participants De-identifiable non-obstetric inpatient discharges from the national datasets were used to estimate national CDI incidence in the United States and England using ICD9-CM(008.45) and ICD10(A04.7) respectively. Main outcome measures The rate of CDI was calculated per 100 000 population using national population estimates. Rate per 100 000 inpatient discharges was also calculated separated by primary and secondary diagnosis of CDI. Age, sex and Elixhauser comorbidities profiles were examined. Results The USA had a higher rate of CDI compared to England: 115.1/100 000 vs. 19.3/100 000 population (P < 0.001). CDI age profiles differed between the countries (P < 0.001): in England, patients ≥75 years constitute a larger proportion of CDI cases, whilst those aged 25-70 constitute more cases in the US (P < 0.001). Overall adjusted odds of CDI in females compared to males was elevated in both England (odds ratios (OR) 1.26 95% CI [1.21,1.31] P < 0.001) and the USA (OR 1.20 95% CI [1.18,1.22] P < 0.001). The proportion of CDI patients with comorbidities was greater in the USA compared to England apart from dementia, which was greater in England (9.63% vs. 1.25%, P < 0.0001). Conclusions The 2012 inpatient CDI rate within the USA was much higher than in England. Age and comorbidity profiles also differed between CDI patients in both countries. The reasons for this are likely multi-factorial but may reflect national infection control policy.
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Affiliation(s)
- Alice King
- Dr Foster Unit at Imperial College London, 3 Dorset Rise, London EC4Y 8EN, UK
| | - Benjamin H Mullish
- Division of Digestive Diseases, Department of Surgery and Cancer, Faculty of Medicine, St Mary's Hospital Campus, Imperial College London, South Wharf Road, London W2 1NY, UK
| | - Horace R T Williams
- Division of Digestive Diseases, Department of Surgery and Cancer, Faculty of Medicine, St Mary's Hospital Campus, Imperial College London, South Wharf Road, London W2 1NY, UK
| | - Paul Aylin
- Dr Foster Unit at Imperial College London, 3 Dorset Rise, London EC4Y 8EN, UK
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Abstract
Antibiotic-associated diarrhoea is among the most common adverse events related to antibiotic use. Most cases are mild, but Clostridium difficile infection causes a spectrum of disease, ranging from occasional diarrhoea to colitis, toxic megacolon, and potentially death. Recent developments in our understanding of the biology of the gut microbiota have provided new insights into the pathogenesis of these conditions, and have revealed a role for manipulation of the gut microbiota as a novel therapeutic approach. This review will give an overview of the assessment of these conditions, before focusing on the rapidly developing area of their treatment.
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Bond SE, Chubaty AJ, Adhikari S, Miyakis S, Boutlis CS, Yeo WW, Batterham MJ, Dickson C, McMullan BJ, Mostaghim M, Li-Yan Hui S, Clezy KR, Konecny P. Outcomes of multisite antimicrobial stewardship programme implementation with a shared clinical decision support system. J Antimicrob Chemother 2018; 72:2110-2118. [PMID: 28333302 DOI: 10.1093/jac/dkx080] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 02/21/2017] [Indexed: 01/08/2023] Open
Abstract
Background Studies evaluating antimicrobial stewardship programmes (ASPs) supported by computerized clinical decision support systems (CDSSs) have predominantly been conducted in single site metropolitan hospitals. Objectives To examine outcomes of multisite ASP implementation supported by a centrally deployed CDSS. Methods An interrupted time series study was conducted across five hospitals in New South Wales, Australia, from 2010 to 2014. Outcomes analysed were: effect of the intervention on targeted antimicrobial use, antimicrobial costs and healthcare-associated Clostridium difficile infection (HCA-CDI) rates. Infection-related length of stay (LOS) and standardized mortality ratios (SMRs) were also assessed. Results Post-intervention, antimicrobials targeted for increased use rose from 223 to 293 defined daily doses (DDDs)/1000 occupied bed days (OBDs)/month (+32%, P < 0.01). Conversely, antimicrobials targeted for decreased use fell from 254 to 196 DDDs/1000 OBDs/month (-23%; P < 0.01). These effects diminished over time. Antimicrobial costs decreased initially (-AUD$64551/month; P < 0.01), then increased (+AUD$7273/month; P < 0.01). HCA-CDI rates decreased post-intervention (-0.2 cases/10 000 OBDs/month; P < 0.01). Proportional LOS reductions for key infections (respiratory from 4.8 to 4.3 days, P < 0.01; septicaemia 6.8 to 6.1 days, P < 0.01) were similar to background LOS reductions (2.1 to 1.9 days). Similarly, infection-related SMRs (observed/expected deaths) decreased (respiratory from 1.1 to 0.75; septicaemia 1.25 to 0.8; background rate 1.19 to 0.90. Conclusions Implementation of a collaborative multisite ASP supported by a centrally deployed CDSS was associated with changes in targeted antimicrobial use, decreased antimicrobial costs, decreased HCA-CDI rates, and no observable increase in LOS or mortality. Ongoing targeted interventions are suggested to promote sustainability.
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Affiliation(s)
| | - Adriana J Chubaty
- Department of Pharmacy, Prince of Wales Hospital, South Eastern Sydney Local Health District, Randwick, New South Wales, Australia
| | - Suman Adhikari
- Department of Pharmacy, St George Hospital, South Eastern Sydney Local Health District, Kogarah, New South Wales, Australia.,St George Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Spiros Miyakis
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia.,Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.,Department of Infectious Diseases, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Craig S Boutlis
- Department of Infectious Diseases, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Wilfred W Yeo
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia.,Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.,Division of Medicine, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Marijka J Batterham
- School of Mathematics and Applied Statistics, University of Wollongong, New South Wales, Australia
| | - Cara Dickson
- Performance Unit, South Eastern Sydney Local Health District, Kogarah, New South Wales, Australia
| | - Brendan J McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Mona Mostaghim
- Department of Pharmacy, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Samantha Li-Yan Hui
- Information Management Services Directorate, South Eastern Sydney Local Health District, Randwick, New South Wales, Australia
| | - Kate R Clezy
- Department of Infectious Diseases, Prince of Wales Hospital, South Eastern Sydney Local Health District, Randwick, New South Wales, Australia
| | - Pamela Konecny
- St George Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Department of Infectious Diseases, Immunology & Sexual Health, St George Hospital, South Eastern Sydney Local Health District, Kogarah, New South Wales, Australia
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Claeys KC, Hopkins TL, Vega AD, Heil EL. Fluoroquinolone Restriction as an Effective Antimicrobial Stewardship Intervention. Curr Infect Dis Rep 2018; 20:7. [PMID: 29572691 DOI: 10.1007/s11908-018-0615-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Fluoroquinolones are a commonly prescribed antibiotic class that has come under scrutiny in recent years due to mounting evidence of association between adverse drug events, C. difficile infection and isolation of antibiotic-resistant bacteria. RECENT FINDINGS Inpatient antimicrobial stewardship (AMS) programs have a toolbox of potential interventions to curb inappropriate antibiotic use, prevent antibiotic-associated adverse drug events, and avoid unnecessary costs of care. Fluoroquinolone restriction policies in the acute care setting have demonstrated beneficial effects, including decreased rates of C. difficile infection and ESBL-producing Enterobacteriaceae. However, a simple blanket restriction policy may "squeeze the antibiotic balloon" and will likely be insufficient if not implemented in conjunction with other AMS interventions. There is a growing body of evidence to support formulary restriction of fluoroquinolones in the acute care setting to decrease rates of C. difficile infection and development of ESBL-producing organisms. Data on how to best implement these restrictions or how to implement outside of acute care settings is limited.
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Affiliation(s)
- Kimberly C Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, N423, Baltimore, MD, 21201, USA. .,Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA.
| | - Teri L Hopkins
- Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Ana D Vega
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, N423, Baltimore, MD, 21201, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, N423, Baltimore, MD, 21201, USA.,Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
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Clostridium Difficile Infection in Acute Care Hospitals: Systematic Review and Best Practices for Prevention. Infect Control Hosp Epidemiol 2018; 38:476-482. [PMID: 28300019 DOI: 10.1017/ice.2016.324] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Prevention of Clostridium difficile infection (CDI) in acute-care hospitals is a priority for hospitals and clinicians. We performed a qualitative systematic review to update the evidence on interventions to prevent CDI published since 2009. DESIGN We searched Ovid, MEDLINE, EMBASE, The Cochrane Library, CINAHL, the ISI Web of Knowledge, and grey literature databases from January 1, 2009 to August 1, 2015. SETTING We included studies performed in acute-care hospitals. PATIENTS OR PARTICIPANTS We included studies conducted on hospitalized patients that investigated the impact of specific interventions on CDI rates. INTERVENTIONS We used the QI-Minimum Quality Criteria Set (QI-MQCS) to assess the quality of included studies. Interventions were grouped thematically: environmental disinfection, antimicrobial stewardship, hand hygiene, chlorhexidine bathing, probiotics, bundled approaches, and others. A meta-analysis was performed when possible. RESULTS Of 3,236 articles screened, 261 met the criteria for full-text review and 46 studies were ultimately included. The average quality rating was 82% according to the QI-MQCS. The most effective interventions, resulting in a 45% to 85% reduction in CDI, included daily to twice daily disinfection of high-touch surfaces (including bed rails) and terminal cleaning of patient rooms with chlorine-based products. Bundled interventions and antimicrobial stewardship showed promise for reducing CDI rates. Chlorhexidine bathing and intensified hand-hygiene practices were not effective for reducing CDI rates. CONCLUSIONS Daily and terminal cleaning of patient rooms using chlorine-based products were most effective in reducing CDI rates in hospitals. Further studies are needed to identify the components of bundled interventions that reduce CDI rates. Infect Control Hosp Epidemiol 2017;38:476-482.
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National epidemiology of initial and recurrent Clostridium difficile infection in the Veterans Health Administration from 2003 to 2014. PLoS One 2017; 12:e0189227. [PMID: 29216276 PMCID: PMC5720754 DOI: 10.1371/journal.pone.0189227] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/21/2017] [Indexed: 12/15/2022] Open
Abstract
Introduction Prior studies demonstrated marked increases in Clostridium difficile infection (CDI) in the United States (U.S.) in recent years. The objective of this study was to describe the epidemiology of initial and recurrent CDI in a national Veterans Health Administration (VHA) cohort over a 12-year period. Methods This was a retrospective cohort study of all adult VHA beneficiaries with CDI (ICD-9-CM code 008.45) plus a positive CDI stool test between October 1, 2002 and September 30, 2014. Data were obtained from the VA Informatics and Computing Infrastructure. Recurrence was defined as a second ICD-9-CM code plus a new course of CDI therapy following a minimum three-day gap after the initial therapy was completed. CDI incidence and outcomes were presented descriptively and longitudinally. Results Overall, 30,326 patients met study inclusion criteria. CDI incidence increased from FY 2003 (1.6 per 10,000) to FY 2013 (5.1 per 10,000). Thereafter, CDI incidence decreased through FY 2014 (4.6 per 10,000). A total of 5,011 patients (17%) experienced a first recurrence and, of those, 1,713 (34%) experienced a second recurrence. Recurrence incidence increased 10-fold over the study period, from (0.1 per 10,000) in FY 2003, to (1.0 per 10,000) in FY 2014. Overall, 30-day mortality and median hospital length of stay (LOS) decreased among initial episodes over the study period. Mortality was higher for initial episodes (21%) compared to first recurrences (11%) and second recurrences (7%). Median hospital LOS was longer for first episodes (13 days) compared to first (9 days) and second recurrences (8 days). Conclusions Initial and recurrent CDI episodes increased among veterans over a 12-year period. Outcomes, such as mortality and hospital LOS improved in recent years; both of these outcomes are worse for initial CDI episodes than recurrent episodes.
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Chrysou K, Zarkotou O, Kalofolia S, Papagiannakopoulou P, Chrysos G, Themeli-Digalaki K, Tsakris A, Pournaras S. First-year results of an antibiotic stewardship program in a Greek tertiary care hospital. Eur J Clin Microbiol Infect Dis 2017; 37:333-337. [PMID: 29152678 DOI: 10.1007/s10096-017-3137-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/06/2017] [Indexed: 12/18/2022]
Abstract
The aim of this study was to investigate the effect of the implementation of an antibiotic stewardship program (ASP) on antibiotic consumption in our 428-bed hospital. The Infection Control Committee implemented an ASP beginning in January 2016, aiming to reduce inappropriate antibiotic use through improved prescribing practices. The ASP included both pre-authorization and prospective audit and feedback strategies. We collected pharmacy and hospital data for the years 2015 (pre-intervention) and 2016 (post-intervention). Consumption data were expressed as daily defined doses (DDDs) per 100 patient-days (PD) and the significance of the differences between 2015 and 2016 was assessed by paired t-test. Antibiotic resistance rates for the most important hospital pathogens were monitored for 2015-2016. The ASP effectively reduced consumption of most antimicrobials; total antibiotic use decreased by 16.7% (from 104.3 in 2015 to 86.9 DDDs/100 patient-days in 2016, p < 0.001) owing to reduction of 19.1% for non-restricted and 13.8% for restricted antibiotics. Important restricted antimicrobials, such as colistin, carbapenems, quinolones and tigecycline showed significantly decreased usage post-intervention. Significant changes in the resistance rates were not observed, except a decreasing trend for colistin and tigecycline (Acinetobacter baumannii and Klebsiella pneumoniae) and also vancomycin (enterococci). The ASP was successful in terms of reducing the antibiotic consumption for the first year of its implementation. Interestingly, antimicrobials requiring pre-authorization exhibited a lower reduction than other antibiotics. Potential effects of the ASP in reducing resistance rates remain to be shown.
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Affiliation(s)
- K Chrysou
- Department of Microbiology, National and Kapodistrian University of Athens, 75 Mikras Asias Street, PC 11527, Athens, Greece
| | - O Zarkotou
- Department of Clinical Microbiology, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - S Kalofolia
- Hospital Pharmacy, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - P Papagiannakopoulou
- Department of Clinical Microbiology, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - G Chrysos
- 2nd Department of Medicine and Infectious Diseases Unit, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - K Themeli-Digalaki
- Department of Clinical Microbiology, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - A Tsakris
- Department of Microbiology, National and Kapodistrian University of Athens, 75 Mikras Asias Street, PC 11527, Athens, Greece
| | - S Pournaras
- Department of Microbiology, National and Kapodistrian University of Athens, 75 Mikras Asias Street, PC 11527, Athens, Greece.
- Laboratory of Clinical Microbiology, ATTIKON Hospital, National and Kapodistrian University of Athens, Athens, Greece.
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Hiensch R, Poeran J, Saunders-Hao P, Adams V, Powell CA, Glasser A, Mazumdar M, Patel G. Impact of an electronic sepsis initiative on antibiotic use and health care facility-onset Clostridium difficile infection rates. Am J Infect Control 2017; 45:1091-1100. [PMID: 28602274 DOI: 10.1016/j.ajic.2017.04.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 04/05/2017] [Accepted: 04/05/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although integrated, electronic sepsis screening and treatment protocols are thought to improve patient outcomes, less is known about their unintended consequences. We aimed to determine if the introduction of a sepsis initiative coincided with increases in broad-spectrum antibiotic use and health care facility-onset (HCFO) Clostridium difficile infection (CDI) rates. METHODS We used interrupted time series data from a large, tertiary, urban academic medical center including all adult inpatients on 4 medicine wards (June 2011-July 2014). The main exposure was implementation of the sepsis screening program; the main outcomes were the use of broad-spectrum antibiotics (including 3 that were part of an order set designed for the sepsis initiative) and HCFO CDI rates. Segmented regression analyses compared outcomes in 3 time segments: before (11 months), during (14 months), and after (12 months) implementation of a sepsis initiative. RESULTS Antibiotic use and HFCO CDI rates increased during the period of implementation and the period after implementation compared with baseline; these increases were highest in the period after implementation (level change, 50.4 days of therapy per 1,000 patient days for overall antibiotic use and 10.8 HCFO CDIs per 10,000 patient days; P < .05). Remarkably, the main drivers of overall antibiotic use were not those included in the sepsis order set. CONCLUSIONS The implementation of an electronic sepsis screening and treatment protocol coincided with increased broad-spectrum antibiotic use and HCFO CDIs. Because these protocols are increasingly used, further study of their unintended consequences is warranted.
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47
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Kufel WD, Devanathan AS, Marx AH, Weber DJ, Daniels LM. Bezlotoxumab: A Novel Agent for the Prevention of Recurrent Clostridium difficile Infection. Pharmacotherapy 2017; 37:1298-1308. [PMID: 28730660 DOI: 10.1002/phar.1990] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
During the past decade, the incidence and severity of Clostridium difficile infection (CDI) have significantly increased, leading to a rise in CDI-associated hospitalizations, health care costs, and mortality. Although treatment options exist for CDI, recurrence is frequent following treatment. Furthermore, patients with at least one CDI recurrence are at an increased risk of developing additional recurrences. A novel approach to the prevention of recurrent CDI is the use of monoclonal antibodies directed against the toxins responsible for CDI as an adjunct to antibiotic treatment. Bezlotoxumab, a human monoclonal antibody that binds and neutralizes C. difficile toxin B, is the first therapeutic agent to receive United States Food and Drug Administration approval for the prevention of CDI recurrence. Clinical studies have demonstrated superior efficacy of bezlotoxumab in adults receiving antibiotic therapy for CDI compared with antibiotic therapy alone for the prevention of CDI recurrence. Bezlotoxumab was well tolerated in clinical trials, with the most common adverse effects being nausea, vomiting, fatigue, pyrexia, headache, and diarrhea. The demonstrated efficacy, safety, and characteristics of bezlotoxumab present an advance in prevention of CDI recurrence.
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Affiliation(s)
- Wesley D Kufel
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina.,Department of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Aaron S Devanathan
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina.,Department of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Ashley H Marx
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina.,Department of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - David J Weber
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lindsay M Daniels
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina.,Department of Practice Advancement and Clinical Education, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
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48
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Lambl BB, Kaufman N, Kurowski J, O’Neill W, Buckley Jr F, Duram M, Swartz B, Phillips D, Rein M, Rubin M. Does electronic stewardship work? J Am Med Inform Assoc 2017; 24:981-985. [PMID: 28371928 PMCID: PMC7651978 DOI: 10.1093/jamia/ocx024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 12/21/2016] [Accepted: 03/15/2017] [Indexed: 02/04/2023] Open
Abstract
Faced with national requirements to promote antimicrobial stewardship and reduce drug-resistant infections, community hospitals are challenged to make the best use of existing resources. Eighteen months after building antibiotic decision support into our electronic order platform, high-risk antibiotic use decreased by 83% (P < .001) at our community hospital. Hospital-acquired Clostridium difficile infections declined 24% (P = .07).
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Affiliation(s)
- Barbara B Lambl
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - Nathan Kaufman
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - Janice Kurowski
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - W O’Neill
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | | | - Maureen Duram
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - Barbara Swartz
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - Duncan Phillips
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - Mitchell Rein
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
| | - Marc Rubin
- North Shore Medical Center, Partners Health Care, Salem, MA, USA
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49
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Abstract
C. difficile infections (CDI) have been a challenging disease to treat, much less to prevent, for decades. Efforts for primary prevention have mainly focused on improving infection control practices, but CDI outbreaks continue to plague healthcare facilities. Areas covered: A literature search from 1970-December 2016 found 13 facility-level and 2 patient-level strategies that were evidence-based. The aim of this manuscript is to assess the current state of the literature on primary prevention of CDI and offer insights into which strategies may be more effective. Expert commentary: The strongest evidence for primary prevention is based on multi-faceted infection control bundles, while there is promising moderate evidence involving facility-wide use of specific probiotics. Moderate-level evidence was found for patient-level use of specific probiotics and low level evidence for vaccines. Future suggestions include use of consistent outcome metrics, measurements of implementation compliance and program sustainability.
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Affiliation(s)
- Lynne V McFarland
- a Medicinal Chemistry , University of Washington, Puget Sound VA HCS , Seattle , WA , USA
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50
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Campbell TJ, Decloe M, Gill S, Ho G, McCready J, Powis J. Every antibiotic, every day: Maximizing the impact of prospective audit and feedback on total antibiotic use. PLoS One 2017; 12:e0178434. [PMID: 28562638 PMCID: PMC5451052 DOI: 10.1371/journal.pone.0178434] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 05/12/2017] [Indexed: 11/18/2022] Open
Abstract
Background The success of antimicrobial stewardship is dependent on how often it is completed and which antimicrobials are targeted. We evaluated the impact of an antimicrobial stewardship program (ASP) in three non-ICU settings where all systemic antibiotics, regardless of spectrum, were targeted on the first weekday after initiation. Methods Prospective audit and feedback (PAAF) was initiated on the surgical, respiratory, and medical wards of a community hospital on July 1, 2010, October 1, 2010, and April 1, 2012, respectively. We evaluated rates of total antibiotic use, measured in days on therapy (DOTs), among all patients admitted to the wards before and after PAAF initiation using an interrupted time series analysis. Changes in antibiotic costs, rates of C. difficile infection (CDI), mortality, readmission, and length of stay were evaluated using univariate analyses. Results Time series modelling demonstrated that total antibiotic use decreased (± standard error) by 100 ± 51 DOTs/1,000 patient-days on the surgical wards (p = 0.049), 100 ± 46 DOTs/1,000 patient-days on the respiratory ward (p = 0.029), and 91 ± 33 DOTs/1,000 patient-days on the medical wards (p = 0.006) immediately following PAAF initiation. Reductions in antibiotic use were sustained up to 50 months after intervention initiation, and were accompanied by decreases in antibiotic costs. There were no significant changes to patient outcomes on the surgical and respiratory wards following intervention initiation. On the medical wards, however, readmission increased from 4.6 to 5.6 per 1,000 patient-days (p = 0.043), while mortality decreased from 7.4 to 5.0 per 1,000 patient-days (p = 0.001). CDI rates showed a non-significant declining trend after PAAF initiation. Conclusions ASPs can lead to cost-effective, sustained reductions in total antibiotic use when interventions are conducted early in the course of therapy and target all antibiotics. Shifting to such a model may help strengthen the effectiveness of ASPs in non-ICU settings.
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Affiliation(s)
- Tonya J. Campbell
- Division of Infectious Diseases, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Melissa Decloe
- Division of Infectious Diseases, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Suzanne Gill
- Division of Infectious Diseases, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Grace Ho
- Division of Infectious Diseases, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Janine McCready
- Division of Infectious Diseases, Michael Garron Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeff Powis
- Division of Infectious Diseases, Michael Garron Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
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