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Roger PM, Lesselingue D, Gérard A, Roghi J, Quint P, Un S, Chincholle A, Assi A, Bouchard O, Javaudin V, Denes E. Antibiotic Consumption 2017-2022 in 30 Private Hospitals in France: Impact of Antimicrobial Stewardship Tools and COVID-19 Pandemic. Antibiotics (Basel) 2024; 13:180. [PMID: 38391566 PMCID: PMC10886305 DOI: 10.3390/antibiotics13020180] [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: 01/10/2024] [Revised: 02/02/2024] [Accepted: 02/10/2024] [Indexed: 02/24/2024] Open
Abstract
Our aim was to determine the impact of antimicrobial stewardship tools (ASTs) and the COVID-19 pandemic on antibiotic consumption (AC). We used the national software Consores® to determine AC in DDD/1000 days of hospitalization from 2017 to 2022 in voluntary private hospitals in France. The ASTs considered were: 1. internal guidelines; 2. the list of antibiotics with restricted access; 3. the presence of an antibiotic referent or 4. an ID specialist; and 5. proof of an annual meeting on antimicrobial resistance. Institutions with dedicated units for COVID-19 patients were specified. In 30 institutions, the total AC varied from (means) 390 to 405 DDD/1000 DH from 2017 to 2022. Fluoroquinolones and amoxicillin/clavulanate consumption decreased from 50 to 36 (p = 0.003) and from 112 to 77 (p = 0.025), respectively, but consumption of piperacillin/tazobactam increased from 9 to 21 (p < 0.001). Over the study period, 10 institutions with ≤2 AST had lower AC compared to 20 institutions with ≥3 AST (p < 0.01). COVID-19 units opened in 10 institutions were associated with a trend toward higher macrolide consumption from 15 to 25 from 2017 to 2020 (p = 0.065) and with an acceleration of piperacillin/tazobactam consumption from 2020 to 2022 (p ≤ 0.003). Antibiotic consumption in 30 private hospitals in France was inversely related to the number of AST. The COVID-19 pandemic was associated with limited impact on AC, but special attention should be paid to piperacillin/tazobactam consumption.
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Affiliation(s)
- Pierre-Marie Roger
- Infectiologie, Clinique Les Fleurs, 332 ave F. Mistral, 83110 Ollioules, France
- Cellule Recherche et Enseignement, Groupe Elsan, Territoire Provence Alpes-Côte d'Azur, 83110 Ollioules, France
| | - Diane Lesselingue
- Pharmacie, Clinique Jeanne d'Arc, 7 rue N. Saboly, 13200 Arles, France
| | - Anouk Gérard
- Pharmacie, Clinique Bouchard, 77 rue Dr Escat, 13006 Marseille, France
| | - Jacques Roghi
- Pharmacie, Clinique St Michel, Pl 4 Sept av Orient, 83100 Toulon, France
| | - Pauline Quint
- Pharmacie, Clinique Inkermann, 84 Rte d'Aiffres, 79000 Niort, France
| | - Sophie Un
- Pharmacie, Hôpital Privé Océane, 11 rue Dr J. Audic, 56000 Vannes, France
| | - Agnès Chincholle
- Pharmacie, Centre Médico-Chirurgical du Mans, 28 rue Guetteloup, 72100 Le Mans, France
| | - Assi Assi
- Infectiologie, Clinique Les Fleurs, 332 ave F. Mistral, 83110 Ollioules, France
| | - Odile Bouchard
- Infectiologie, Clinique Rhône Durance, 1750 ch Lavarin, 84000 Avignon, France
| | - Véronique Javaudin
- Hygiène, Centre Chirurgical Montagard, 23 bd Gambetta, 84000 Avignon, France
| | - Eric Denes
- Infectiologie, Polyclinique de Limoges, Site Chénieux, 18 rue du Général Catroux, 87000 Limoges, France
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Antimicrobial stewardship experiences in acute-care hospitals of Northern Italy: Assessment of structure, process and outcome indicators, 2017-2019. Am J Infect Control 2023; 51:282-288. [PMID: 35709971 DOI: 10.1016/j.ajic.2022.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Antimicrobial stewardship (AMS) programs are effective strategies for optimizing antimicrobial use. We aimed to assess AMS programs implemented in acute-care trusts of the region of Piedmont, Northern Italy. METHODS AMS programs were investigated via a survey addressing structure, process and outcome indicators. For outcome indicators, annual means for the years 2017-2019 were considered, as well as the percentage change between 2017 and 2019. Outcome indicators were investigated in relation to structure and process scores using Spearman correlation. RESULTS In total, 25 AMS programs were surveyed. Higher scores were achieved for process over structure indicators. Improvements in alcohol-based handrub usage (+30%), total antimicrobial usage (-4%), and percentages of methicillin-resistant Staphylococcus aureus and carbapenem-resistant Enterobacteriaceae over invasive isolates (respectively -16 and -23%) were found between 2017 and 2019. Significant correlations were found between structure score and percentage change in total antimicrobial usage and carbapenem-resistant Enterobacteriaceae over invasive isolates (Spearman's ρ -0.603, P .006 and ρ -0.433, P .044 respectively). DISCUSSION This study identified areas for improvement: accountability, microbiological laboratory quality management and feedback to clinicians. Improving the organization of AMS programs in particular should be prioritized. CONCLUSION Repeated measurements of structure and process indicators will be important to guide continuing quality improvement efforts.
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Kurotschka PK, Tiedemann E, Wolf D, Thier N, Forster J, Liese JG, Gagyor I. Management of Common Infections in German Primary Care: A Cross-Sectional Survey of Knowledge and Confidence among General Practitioners and Outpatient Pediatricians. Antibiotics (Basel) 2021; 10:antibiotics10091131. [PMID: 34572713 PMCID: PMC8466449 DOI: 10.3390/antibiotics10091131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 11/16/2022] Open
Abstract
Outpatient antibiotic use is closely related to antimicrobial resistance and in Germany, almost 70% of antibiotic prescriptions in human health are issued by primary care physicians (PCPs). The aim of this study was to explore PCPs, namely General Practitioners' (GPs) and outpatient pediatricians' (PDs) knowledge of guideline recommendations on rational antimicrobial treatment, the determinants of confidence in treatment decisions and the perceived need for training in this topic in a large sample of PCPs from southern Germany. Out of 3753 reachable PCPs, 1311 completed the survey (overall response rate = 34.9%). Knowledge of guideline recommendations and perceived confidence in making treatment decisions were high in both GPs and PDs. The two highest rated influencing factors on prescribing decisions were reported to be guideline recommendations and own clinical experiences, hence patients' demands and expectations were judged as not influencing treatment decisions. The majority of physicians declared to have attended at least one specific training course on antibiotic use, yet almost all the participating PCPs declared to need more training on this topic. More studies are needed to explore how consultation-related and context-specific factors could influence antibiotic prescriptions in general and pediatric primary care in Germany beyond knowledge. Moreover, efforts should be undertaken to explore the training needs of PCPs in Germany, as this would serve the development of evidence-based educational interventions targeted to the improvement of antibiotic prescribing decisions rather than being focused solely on knowledge of guidelines.
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Affiliation(s)
- Peter Konstantin Kurotschka
- Department of General Practice, University Hospital Würzburg, 97080 Würzburg, Germany; (E.T.); (D.W.); (N.T.); (I.G.)
- Correspondence:
| | - Elena Tiedemann
- Department of General Practice, University Hospital Würzburg, 97080 Würzburg, Germany; (E.T.); (D.W.); (N.T.); (I.G.)
| | - Dominik Wolf
- Department of General Practice, University Hospital Würzburg, 97080 Würzburg, Germany; (E.T.); (D.W.); (N.T.); (I.G.)
| | - Nicola Thier
- Department of General Practice, University Hospital Würzburg, 97080 Würzburg, Germany; (E.T.); (D.W.); (N.T.); (I.G.)
| | - Johannes Forster
- Institute for Hygiene and Microbiology, University of Würzburg, 97080 Würzburg, Germany;
| | - Johannes G. Liese
- Department of Pediatrics, University Hospital Würzburg, 97080 Würzburg, Germany;
| | - Ildiko Gagyor
- Department of General Practice, University Hospital Würzburg, 97080 Würzburg, Germany; (E.T.); (D.W.); (N.T.); (I.G.)
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Scobie A, Budd EL, Harris RJ, Hopkins S, Shetty N. Antimicrobial stewardship: an evaluation of structure and process and their association with antimicrobial prescribing in NHS hospitals in England. J Antimicrob Chemother 2020; 74:1143-1152. [PMID: 30649321 DOI: 10.1093/jac/dky538] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/30/2018] [Accepted: 11/26/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Rigorous antimicrobial stewardship programmes (ASPs) are an essential strategy against antimicrobial resistance. OBJECTIVES To evaluate and score ASPs in acute English NHS hospitals and determine association of ASP scores with antimicrobial prescribing. METHODS ASP structure and process were evaluated through an online survey in 148/152 acute hospitals in 2017. Scores were assigned to quality indicators based on resource- and labour-intensiveness, and their association with total and modified WHO-categorized 'Access', 'Watch' and 'Reserve' (AwaRe) prescribing was analysed. RESULTS The survey response rate was 97% with 78% of trusts submitting antimicrobial prescribing data. Over 80% of ASPs contained stewardship teams, policies and access to outpatient parenteral antimicrobial therapy, whilst less than 50% scored well for leadership or funding. High process performance was observed for antimicrobial pre-authorization, prescribing review and feedback, restricted susceptibility reporting, antimicrobial consumption monitoring, adherence to guidelines and junior doctor training. Low process attainment included education of senior prescribers and lack of resistance surveillance data distribution. Between 2016 and 2017, there was no difference in total trust prescribing (P = 0.117) although carbapenem prescribing fell (incidence rate ratio = 0.93, 95% CI 0.88-0.98) in non-teaching hospitals; 'Watch' prescribing also increased for specialist hospitals (OR = 1.10, 95% CI 1.01-1.20), as did 'Reserve' category prescribing in teaching (OR = 1.58, 95% CI 1.23-3.02) and specialist hospitals (OR = 3.09, 95% CI 2.02-4.74). A high process score was associated with lower 'Reserve' prescribing (OR = 0.82, 95% CI 0.67-1.01). CONCLUSIONS All responding trusts had established ASPs. The association of a scoring system with total and 'AWaRe' prescribing to assess effectiveness of ASPs merits further study.
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Affiliation(s)
- Antonia Scobie
- Reference Microbiology, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Emma L Budd
- Healthcare-Associated Infection & Antimicrobial Resistance Division, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Ross J Harris
- Statistics, Modelling and Economics Department, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Susan Hopkins
- Healthcare-Associated Infection & Antimicrobial Resistance Division, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Nandini Shetty
- Reference Microbiology, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
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The learning hospital: From theory to practice in a hospital infection prevention program. Infect Control Hosp Epidemiol 2020; 41:86-97. [DOI: 10.1017/ice.2019.318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AbstractThe learning hospital is distinguished by ceaseless evolution of erudition, enhancement, and implementation of clinical best practices. We describe a model for the learning hospital within the framework of a hospital infection prevention program and argue that a critical assessment of safety practices is possible without significant grant funding. We reviewed 121 peer-reviewed manuscripts published by the VCU Hospital Infection Prevention Program over 16 years. Publications included quasi-experimental studies, observational studies, surveys, interrupted time series analyses, and editorials. We summarized the articles based on their infection prevention focus, and we provide a brief summary of the findings. We also summarized the involvement of nonfaculty learners in these manuscripts as well as the contributions of grant funding. Despite the absence of significant grant funding, infection prevention programs can critically assess safety strategies under the learning hospital framework by leveraging a diverse collaboration of motivated nonfaculty learners. This model is a valuable adjunct to traditional grant-funded efforts in infection prevention science and is part of a successful horizontal infection control program.
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Association between meeting core elements for inpatient antimicrobial stewardship and antibiotic utilization. Infect Control Hosp Epidemiol 2019; 40:1050-1052. [DOI: 10.1017/ice.2019.171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AbstractWe used multivariable analyses to assess whether meeting core elements was associated with antibiotic utilization. Compliance with 7 elements versus not doing so was associated with higher use of broad-spectrum agents for community-acquired infections [days of therapy per 1,000 patient days: 155 (39) vs 133 (29), P = .02] and anti-methicillin-resistant S. aureus agents [days of therapy per 1,000 patient days: 145 (37) vs 124 (30), P = .03].
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Assessing the impact of antibiotic stewardship program elements on antibiotic use across acute-care hospitals: an observational study. Infect Control Hosp Epidemiol 2018; 39:941-946. [PMID: 29893654 DOI: 10.1017/ice.2018.121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Antibiotic use varies widely between hospitals, but the influence of antimicrobial stewardship programs (ASPs) on this variability is not known. We aimed to determine the key structural and strategic aspects of ASPs associated with differences in risk-adjusted antibiotic utilization across facilities. DESIGN Observational study of acute-care hospitals in Ontario, Canada METHODS: A survey was sent to hospitals asking about both structural (8 elements) and strategic (32 elements) components of their ASP. Antibiotic use from hospital purchasing data was acquired for January 1 to December 31, 2014. Crude and adjusted defined daily doses per 1,000 patient days, accounting for hospital and aggregate patient characteristics, were calculated across facilities. Rate ratios (RR) of defined daily doses per 1,000 patient days were compared for hospitals with and without each antimicrobial stewardship element of interest. RESULTS Of 127 eligible hospitals, 73 (57%) participated in the study. There was a 7-fold range in antibiotic use across these facilities (min, 253 defined daily doses per 1,000 patient days; max, 1,872 defined daily doses per 1,000 patient days). The presence of designated funding or resources for the ASP (RRadjusted, 0·87; 95% CI, 0·75-0·99), prospective audit and feedback (RRadjusted, 0·80; 95% CI, 0·67-0·96), and intravenous-to-oral conversion policies (RRadjusted, 0·79; 95% CI, 0·64-0·99) were associated with lower risk-adjusted antibiotic use. CONCLUSIONS Wide variability in antibiotic use across hospitals may be partially explained by both structural and strategic ASP elements. The presence of funding and resources, prospective audit and feedback, and intravenous-to-oral conversion should be considered priority elements of a robust ASP.
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Barlow G, Patterson J, Stultz J, Pakyz AL. Associations between antimicrobial stewardship program elements and Clostridium difficile infection performance. Am J Infect Control 2017; 45:1399-1401. [PMID: 28757087 DOI: 10.1016/j.ajic.2017.06.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 06/21/2017] [Accepted: 06/21/2017] [Indexed: 12/18/2022]
Abstract
Hospitals are categorized as better, no different, or worse at a national level based on their Clostridium difficile infection performance. Institutional antimicrobial stewardship programs seek to decrease the occurrence of C difficile by implementing strategies to address antibiotic usage; however, optimal structure and strategies for accomplishing this remain largely unknown. We found that a higher proportion of hospitals with either a worse or no different rank used a postprescription audit and feedback strategy than hospitals with a better rank.
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Affiliation(s)
- Giulia Barlow
- School of Pharmacy, Virginia Commonwealth University, Richmond, VA
| | | | - Jeremy Stultz
- School of Pharmacy, Virginia Commonwealth University, Richmond, VA
| | - Amy L Pakyz
- School of Pharmacy, Virginia Commonwealth University, Richmond, VA.
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Echevarria K, Groppi J, Kelly AA, Morreale AP, Neuhauser MM, Roselle GA. Development and application of an objective staffing calculator for antimicrobial stewardship programs in the Veterans Health Administration. Am J Health Syst Pharm 2017; 74:1785-1790. [PMID: 28947624 DOI: 10.2146/ajhp160825] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The development and validation of a staffing calculator and its use in creating staffing guidance for antimicrobial stewardship programs (ASPs) in Veterans Health Administration (VHA) facilities are described. METHODS The Tools and Resources Work Group of the Antimicrobial Stewardship Task Force and PBM Clinical Pharmacy Practice Office of the Department of Veterans Affairs developed, tested, and validated a staffing calculator to track patient care and ASP management activities needed to maintain a comprehensive ASP. Time spent on activities was based on time-in-motion tracking studies and input from experienced antimicrobial stewards. The staffing calculator was validated across VHA facilities of varying sizes and complexities to determine the number of needed clinical pharmacist full-time equivalents (FTEs) to implement and maintain ASPs per 100 occupied beds. RESULTS A total of 12 facilities completed the staffing calculator for 1 calendar week. The median number of occupied beds was 226. Most facilities had at least 100 occupied beds, and 6 of the 12 were considered high complexity facilities. The median calculated FTE personnel requirement was 2.62, or 1.01 per 100 occupied beds. The majority of FTE time (70%) was spent on patient care activities and 30% on program management activities, including infectious diseases or ASP rounds. The final recommendations indicated that in order to implement and manage a robust ASP, a pharmacist FTE investment of 1.0 per 100 occupied beds would be needed. CONCLUSION A staffing calculator to account for the time needed to implement ASP activities and provide staffing guidance across a large health-care system was validated.
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Affiliation(s)
- Kelly Echevarria
- Department of Pharmacy, South Texas Veterans Health Care System, San Antonio, TX .,University of Texas at Austin College of Pharmacy, Austin, TX.
| | - Julie Groppi
- Clinical Pharmacy Practice Office, Pharmacy Benefits Management Service, Washington, DC
| | - Allison A Kelly
- National Infectious Diseases Services, Veterans Health Administration, Washington, DC.,University of Cincinnati College of Medicine, Cincinnati, OH
| | - Anthony P Morreale
- Clinical Pharmacy Practice Office, Pharmacy Benefits Management Service, Washington, DC
| | | | - Gary A Roselle
- National Infectious Diseases Services, Veterans Health Administration, Washington, DC.,University of Cincinnati College of Medicine, Cincinnati, OH
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Abstract
Clostridium difficile is an anaerobic, Gram-positive, spore-forming, toxin-secreting bacillus that has long been recognized to be the most common etiologic pathogen of antibiotic-associated diarrhea. C. difficile infection (CDI) is now the most common cause of health care-associated infections in the United States and accounts for 12% of these infections (Magill SS et al., N Engl J Med370:1198-1208, 2014). Among emerging pathogens of public health importance in the United States, CDI has the highest population-based incidence, estimated at 147 per 100,000 (Lessa FC et al., N Engl J Med372:825-834, 2015). In a report on antimicrobial resistance, C. difficile has been categorized by the Centers for Disease Control and Prevention as one of three "urgent" threats (http://www.cdc.gov/drugresistance/threat-report-2013/). Although C. difficile was first described in the late 1970s, the past decade has seen the emergence of hypertoxigenic strains that have caused increased morbidity and mortality worldwide. Pathogenic strains, host susceptibility, and other regional factors vary and may influence the clinical manifestation and approach to intervention. In this article, we describe the global epidemiology of CDI featuring the different strains in circulation outside of North America and Europe where strain NAP1/027/BI/III had originally gained prominence. The elderly population in health care settings has been disproportionately affected, but emergence of CDI in children and healthy young adults in community settings has, likewise, been reported. New approaches in management, including fecal microbiota transplantation, are discussed.
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Graber CJ, Jones MM, Chou AF, Zhang Y, Goetz MB, Madaras-Kelly K, Samore MH, Glassman PA. Association of Inpatient Antimicrobial Utilization Measures with Antimicrobial Stewardship Activities and Facility Characteristics of Veterans Affairs Medical Centers. J Hosp Med 2017; 12:301-309. [PMID: 28459897 DOI: 10.12788/jhm.2730] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) have been advocated to improve antimicrobial utilization, but program implementation is variable. Antimicrobial stewardship programs (ASPs) have been advocated to improve antimicrobial utilization, but program implementation is variable. OBJECTIVE To determine associations between ASPs and facility characteristics, and inpatient antimicrobial utilization measures in the Veterans Affairs (VA) system in 2012. DESIGN In 2012, VA administered a survey on antimicrobial stewardship practices to designated ASP contacts at VA acute care hospitals. From the survey, we identified 34 variables across 3 domains (evidence, organizational context, and facilitation) that were assessed using multivariable least absolute shrinkage and selection operator regression against 4 antimicrobial utilization measures from 2012: aggregate acute care antimicrobial use, antimicrobial use in patients with non-infectious primary discharge diagnoses, missed opportunities to convert from parenteral to oral antimicrobial therapy, and double anaerobic coverage. SETTING All 130 VA facilities with acute care services. RESULTS Variables associated with at least 3 favorable changes in antimicrobial utilization included presence of postgraduate physician/pharmacy training programs, number of antimicrobial-specific order sets, frequency of systematic de-escalation review, presence of pharmacists and/or infectious diseases (ID) attendings on acute care ward teams, and formal ID training of the lead ASP pharmacist. Variables associated with 2 unfavorable measures included bed size, the level of engagement with VA Antimicrobial Stewardship Task Force online resources, and utilization of antimicrobial stop orders. CONCLUSIONS Formalization of ASP processes and presence of pharmacy and ID expertise are associated with favorable utilization. Systematic de-escalation review and order set establishment may be high-yield interventions. Journal of Hospital Medicine 2017;12:301-309.
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Affiliation(s)
- Christopher J Graber
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, CA; David Geffen School of Medicine at the University of California, Los Angeles, CA
| | - Makoto M Jones
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, UT; Department of Medicine, University of Utah, Salt Lake City, UT; Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Ann F Chou
- Department of Family and Preventive Medicine, College of Medicine, University of Oklahoma, Oklahoma City, OK
| | - Yue Zhang
- Department of Medicine, University of Utah, Salt Lake City, UT; Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT
| | - Matthew Bidwell Goetz
- Infectious Diseases Section, VA Greater Los Angeles Healthcare System, Los Angeles, CA; David Geffen School of Medicine at the University of California, Los Angeles, CA
| | - Karl Madaras-Kelly
- VA Medical Center, Boise, Idaho and College of Pharmacy, Idaho State University, Meridian, ID
| | - Matthew H Samore
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, UT; Department of Medicine, University of Utah, Salt Lake City, UT; Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Peter A Glassman
- David Geffen School of Medicine at the University of California, Los Angeles, CA; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA
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Van Parys J, Stevens MP, Moczygemba LR, Pakyz AL. Antimicrobial Stewardship Program Members' Perspectives on Program Goals and National Metrics. Clin Ther 2016; 38:1914-9. [PMID: 27392717 DOI: 10.1016/j.clinthera.2016.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/27/2016] [Accepted: 06/08/2016] [Indexed: 01/14/2023]
Abstract
PURPOSE This study compares antimicrobial stewardship program (ASP)-stated goals and outcomes collected as well as opinions regarding national metric establishment. METHODS Twenty-one ASP members underwent telephone interviews answering open-ended questions about ASP goals, outcomes collected, and opinions about national metrics. Content analysis was used to code responses into predefined ASP-metric categories. FINDINGS The most common ASP goal was antimicrobial appropriateness (76%), outcomes tracked were use and microbial outcomes (both 71%), and desired national metric was use (67%). IMPLICATIONS Stated-goals, outcomes tracked, and opinions regarding national metric establishment did not fully align. With ASP-related regulations looming, it is important that alignment is increased.
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Affiliation(s)
- Jacob Van Parys
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Michael P Stevens
- Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Leticia R Moczygemba
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
| | - Amy L Pakyz
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
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Evaluating the Effectiveness of an Antimicrobial Stewardship Program on Reducing the Incidence Rate of Healthcare-Associated Clostridium difficile Infection: A Non-Randomized, Stepped Wedge, Single-Site, Observational Study. PLoS One 2016; 11:e0157671. [PMID: 27309536 PMCID: PMC4910981 DOI: 10.1371/journal.pone.0157671] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/02/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The incidence rate of healthcare-associated Clostridium difficile infection (HA-CDI) is estimated at 1 in 100 patients. Antibiotic exposure is the most consistently reported risk factor for HA-CDI. Strategies to reduce the risk of HA-CDI have focused on reducing antibiotic utilization. Prospective audit and feedback is a commonly used antimicrobial stewardship intervention (ASi). The impact of this ASi on risk of HA-CDI is equivocal. This study examines the effectiveness of a prospective audit and feedback ASi on reducing the risk of HA-CDI. METHODS Single-site, 339 bed community-hospital in Barrie, Ontario, Canada. Primary outcome is HA-CDI incidence rate. Daily prospective and audit ASi is the exposure variable. ASi implemented across 6 wards in a non-randomized, stepped wedge design. Criteria for ASi; any intravenous antibiotic use for ≥ 48 hrs, any oral fluoroquinolone or oral second generation cephalosporin use for ≥ 48 hrs, or any antimicrobial use for ≥ 5 days. HA-CDI cases and model covariates were aggregated by ward, year and month starting September 2008 and ending February 2016. Multi-level mixed effect negative binomial regression analysis was used to model the primary outcome, with intercept and slope coefficients for ward-level random effects estimated. Other covariates tested for inclusion in the final model were derived from previously published risk factors. Deviance residuals were used to assess the model's goodness-of-fit. FINDINGS The dataset included 486 observation periods, of which 350 were control periods and 136 were intervention periods. After accounting for all other model covariates, the estimated overall ASi incidence rate ratio (IRR) was 0.48 (95% 0.30, 0.79). The ASi effect was independent of antimicrobial utilization. The ASi did not seem to reduce the risk of Clostridium difficile infection on the surgery wards (IRR 0.87, 95% CI 0.45, 1.69) compared to the medicine wards (IRR 0.42, 95% CI 0.28, 0.63). The ward-level burden of Clostridium difficile as measured by the ward's previous month's total CDI cases (CDI Lag) and the ward's current month's community-associated CDI cases (CA-CDI) was significantly associated with an increased risk of HA-CDI, with the estimated CDI Lag IRR of 1.21 (95% 1.15, 1.28) and the estimated CA-CDI IRR of 1.10 (95% CI 1.01, 1.20). The ward-level random intercept and slope coefficients were not significant. The final model demonstrated good fit. CONCLUSIONS In this study, a daily prospective audit and feedback ASi resulted in a significant reduction in the risk of HA-CDI on the medicine wards, however, this effect was independent of an overall reduction in antibiotic utilization. In addition, the ward-level burden of Clostridium difficile was shown to significantly increase the risk of HA-CDI, reinforcing the importance of the environment as a source of HA-CDI.
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Audit and Feedback Processes Among Antimicrobial Stewardship Programs: A Survey of the Society for Healthcare Epidemiology of America Research Network. Infect Control Hosp Epidemiol 2016; 37:704-6. [PMID: 26961763 DOI: 10.1017/ice.2016.57] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Optimal implementation of audit-and-feedback is an important part of advancing antimicrobial stewardship programs. Our survey demonstrated variability in how 61 programs approach audit-and-feedback. The median (interquartile range) number of recommendations per week was 9 (5-19) per 100 hospital-beds. A major perceived barrier to more comprehensive stewardship was lack of resources. Infect Control Hosp Epidemiol 2016;37:704-706.
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Characteristics of Antimicrobial Stewardship Programs at Veterans Affairs Hospitals: Results of a Nationwide Survey. Infect Control Hosp Epidemiol 2016; 37:647-54. [PMID: 26905338 DOI: 10.1017/ice.2016.26] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) are variably implemented. OBJECTIVE To characterize variations of antimicrobial stewardship structure and practices across all inpatient Veterans Affairs facilities in 2012 and correlate key characteristics with antimicrobial usage. DESIGN A web-based survey regarding stewardship activities was administered to each facility's designated contact. Bivariate associations between facility characteristics and inpatient antimicrobial use during 2012 were determined. SETTING Total of 130 Veterans Affairs facilities with inpatient services. RESULTS Of 130 responding facilities, 29 (22%) had a formal policy establishing an ASP, and 12 (9%) had an approved ASP business plan. Antimicrobial stewardship teams were present in 49 facilities (38%); 34 teams included a clinical pharmacist with formal infectious diseases (ID) training. Stewardship activities varied across facilities, including development of yearly antibiograms (122 [94%]), formulary restrictions (120 [92%]), stop orders for antimicrobial duration (98 [75%]), and written clinical pathways for specific conditions (96 [74%]). Decreased antimicrobial usage was associated with having at least 1 full-time ID physician (P=.03), an ID fellowship program (P=.003), and a clinical pharmacist with formal ID training (P=.006) as well as frequency of systematic patient-level reviews of antimicrobial use (P=.01) and having a policy to address antimicrobial use in the context of Clostridium difficile infection (P=.01). Stop orders for antimicrobial duration were associated with increased use (P=.03). CONCLUSIONS ASP-related activities varied considerably. Decreased antibiotic use appeared related to ID presence and certain select practices. Further statistical assessments may help optimize antimicrobial practices. Infect Control Hosp Epidemiol 2016;37:647-654.
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Crnich CJ, Jump R, Trautner B, Sloane PD, Mody L. Optimizing Antibiotic Stewardship in Nursing Homes: A Narrative Review and Recommendations for Improvement. Drugs Aging 2015; 32:699-716. [PMID: 26316294 PMCID: PMC4579247 DOI: 10.1007/s40266-015-0292-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
The emerging crisis in antibiotic resistance and concern that we now sit on the precipice of a post-antibiotic era have given rise to advocacy at the highest levels for widespread adoption of programmes that promote judicious use of antibiotics. These antibiotic stewardship programmes, which seek to optimize antibiotic choice when clinically indicated and discourage antibiotic use when clinically unnecessary, are being implemented in an increasing number of acute care facilities, but their adoption has been slower in nursing homes. The antibiotic prescribing process in nursing homes is fundamentally different from that observed in hospital and clinic settings, with formidable challenges to implementation of effective antibiotic stewardship. Nevertheless, an emerging body of research points towards ways to improve antibiotic prescribing practices in nursing homes. This review summarizes the findings of this research and presents ways in which antibiotic stewardship can be implemented and optimized in the nursing home setting.
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Affiliation(s)
- Christopher J Crnich
- School of Medicine and Public Health, University of Wisconsin, 1685 Highland Avenue, MFCB 5217, Madison, WI, 53705, USA.
- William S. Middleton Veterans Affairs Hospital, Madison, WI, USA.
| | - Robin Jump
- Geriatric Research, Education and Clinical Center, Division of Internal Medicine, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA
- Division of Infectious Disease, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Barbara Trautner
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lona Mody
- Division of Geriatric and Palliative Care Medicine, University of Michigan, Ann Arbor, MI, USA
- Geriatric Research Education and Clinical Center, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
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