A systematic review of inpatient antimicrobial stewardship programmes involving clinical pharmacists in small-to-medium-sized hospitals

Evolution of pharmacist roles in antimicrobial stewardship: A 20-year systematic review

INTRODUCTION

Whilst pharmacists are recognized as key contributors to antimicrobial stewardship (AMS) programs, the extent of their participation varies in different countries. We report a systematic review of pharmacist roles in AMS over 20 years.

METHODS

A systematic review of the literature describing pharmacist-led or driven AMS and its outcomes published in English between January 01, 2000, and June 30, 2020, was conducted across the main databases for research publication.

RESULTS

The analysis included 111 papers, of which 77.5% (86/111) were from high-income countries (HIC) predominantly from the USA. While pharmacist-led or driven AMS interventions were reported only from HICs in the early 2000s, the review found a progressive rise in such studies from all income settings with audit and feedback being the most frequent intervention reported. Between 2016 and 2020, studies on pharmacists-led or driven outpatient AMS and interventions related to beta-lactam or penicillin allergy were reported from HICs. Key outcomes reported include improved appropriateness of antimicrobial therapy and decreased consumption of antimicrobials.

CONCLUSION

Existing evidence demonstrates the positive impact of pharmacists' involvement in AMS. There needs to be a concerted effort in facilitating pharmacist roles in AMS across all countries, irrespective of income setting.

Impact of pharmacist-driven antimicrobial stewardship interventions in a secondary care facility in Japan: A pragmatic quasi-experimental study

BACKGROUND

Efforts to promote antimicrobial stewardship aimed at reducing antimicrobial resistance are necessary regardless of hospital scale owing to delays in new antimicrobial development. We aimed to evaluate the effects of pharmacist-driven interventions on broad-spectrum antimicrobial usage and the prognosis of patients with bacteremia in a medium-sized hospital lacking infectious disease physicians and a microbiology laboratory.

METHODS

This single-center, retrospective, pragmatic, quasi-experimental study was conducted to compare pre- and post-intervention effects at Saiseikai Futsukaichi Hospital. We analyzed the days of therapy (DOT) for carbapenems and days of antibiotic spectrum coverage (DASC) for antimicrobials using an interrupted time series analysis. Cox proportional hazards analysis was performed to assess 30-day mortality using propensity score and inverse probability of treatment weighting in patients with bacteremia.

RESULTS

Pharmacist-driven interventions significantly reduced the DOT (incidence rate ratio [IRR]: 0.53, 95 % confidence intervals [CI]: 0.33-0.81, p = 0.003) and DASC (IRR: 0.87, 95 % CI: 0.78-0.97, p = 0.016). The 30-day mortality due to bacteremia did not significantly differ between pre- and post-intervention in all patients (adjusted hazard ratio [HR]: 0.92, 95 % CI: 0.56-1.51, p = 0.74). Conversely, pharmacist-driven interventions significantly reduced the 30-day mortality owing to bacteremia with Pitt bacteremia score (PBS) ≥4 (adjusted HR: 0.52, 95 % CI: 0.28-0.99, p = 0.047).

CONCLUSIONS

Pharmacist-driven interventions may represent a valuable approach for optimizing antimicrobial treatment and improving prognosis, especially in patients with PBS ≥4, which will potentially benefit patients in similar healthcare environments facing challenges related to antimicrobial stewardship and patient prognosis.

The Impact of Clinical Pharmacist-Driven Weekend Antimicrobial Stewardship Coverage at a Quaternary Hospital

BACKGROUND AND OBJECTIVE

Extending a consistent pharmacy antimicrobial stewardship weekend service was a newly implemented initiative. We sought to evaluate the impact of incorporating an Infectious Diseases (ID)-trained clinical pharmacist into an antimicrobial stewardship program (AMS) during weekends.

RESULTS

The number of documented interventions was 451 on 362 patients compared to 115 interventions on 108 patients during the pre-implementation period (p = 0.04), with interventions primarily targeting Watch antibiotics, as classified by the WHO AWaRe classification. A reduction in the LOS was observed, with a median of 16 days (8-34) during the post-implementation period compared to 27.5 days (10-56) during the pre-implementation period (p = 0.001). The median DOT increased during the post-implementation period to 8 (6-11), versus the increase to 7 (4-11) during the pre-implementation period (p ≤ 0.001). Finally, there was no significant difference observed in healthcare-associated CDI and infection-related readmission.

METHODS

This is a retrospective single-center, pre-post quasi-experimental study. Data including the documented pharmacist interventions were collected from the electronic medical record (EMR), the pre-implementation phase was in 2020, and post-implementation was in 2021. The primary outcome was to identify the number of AMS interventions through prospective audit and feedback review analysis. Secondary outcomes included antibiotic days of therapy (DOT), length of hospital stay (LOS), healthcare-associated Clostridioides difficile infection (CDI), and infection-related readmission.

CONCLUSIONS

The pharmacist-driven weekend AMS is an opportunity for pharmacists to intervene and optimize patients' care plans. This initiative demonstrated significant increased AMS-related interventions, promoted judicious antimicrobial use, and contributed to a reduced length of hospital stay. Our findings need to be replicated in a larger prospective study.

Benefits of Accepting Infectious Diseases Pharmacist Recommendations: A 5-Year Outcome Study in a Multihospital System

Background: Infectious diseases (ID) pharmacists are pivotal members of antimicrobial stewardship teams. Prospective audit and feedback is a strong recommendation by The Infectious Diseases Society of America Guidelines for Antimicrobial Stewardship Programs (ASP). Utilizing customized ASP intervention documentation tools known as "ivents" in Epic, we aimed to assess the impact of interventions by measuring outcomes that were accepted compared to those that were rejected in a multihospital health system over 5 years. Methods: A multicenter, retrospective cohort study was conducted to compare clinical outcomes among intensive care unit (ICU) and non-ICU patients with accepted and rejected ASP interventions over 5 years from October 2015 to December 2020. Outcomes measured included antibiotic days of therapy per 1000 patient days (DOT/1000 PD), antibiotic doses per 1000 patient days (doses/1000 PD), hospital length of stay (LOS), in-hospital mortality, hospital-acquired Clostridioides difficile infection (HA-CDI), community-onset C. difficile infection (CO-CDI) within 30 days, and hospital readmission within 30 days. Coarsened exact matching (CEM) was used as a non-parametric matching method to balance covariates between groups and to control for confounding. Results: ASP recommendations by ID pharmacists were well-received by providers in a multihospital system over 5 years as evidenced by an overall acceptance rate of 92%. Acceptance of ASP interventions was associated with substantial reductions in antibiotic utilization without adversely affecting mortality or hospital readmissions. While high-risk C. difficile antibiotic use increased significantly due to frequent de-escalation to ceftriaxone among non-ICU patients with accepted interventions, rates of HA-CDI and CO-CDI within 30 days did not worsen. Furthermore, hospital LOS was notably shorter by an average of 1 day for non-ICU patients with accepted interventions, which resulted in substantial cost avoidance of $7 631 400. Conclusion: Collaboration with ID pharmacists to optimize antimicrobial stewardship was associated with significant reductions in antibiotic utilization, costs, and hospital LOS without worsening patient outcomes.

[Antibiotic stewardship programs in the Spanish emergency services: PROA-URG Study]

OBJECTIVE

Antimicrobial stewardship programs (ASP) have become a key tool in the adaptation of these drugs to the health system. The information available on the application and indicators used in these programs in emergency departments is scarce. The objective of this study is to know the extent of ASP implementation in the emergency departments, as well as the use of antimicrobials in these units.

METHODS

Multicenter retrospective study. An invitation was sent to all participants of the REDFASTER-SEFH emergency pharmacist working group. A questionnaire was used consisting of 21 items, answered by a team made up of a pharmacist, emergency room specialist, infectious disease specialist and microbiologist.

RESULTS

Eighteen hospitals completed the survey. Fourteen (77.8%) had an ASP manager. The DDD value per 1000 admissions ranged between 36.5 and 400.5 (median: 100.4 [IQR:57.2-157.3]). Both carbapenem and macrolide group presented wide variability in use. Six (33.3%) hospitals had an annual report on the specific resistance profile for urine and blood cultures. The percentage of multi-drug resistant strains in urine cultures was 12.5% and in blood cultures 12.2%. The percentage of adequacy in the bacteremia treatment was 81.0% (IQR:74.6-85.0%), while in urinary tract infections was 78.0% (IQR:71.5-88.0).

CONCLUSIONS

Despite the existence of ASP members in emergency services, as well as the training activity and local guidelines is common. knowledge of the use of antimicrobials and resistances is limited. Future activities must be aimed at improving information about the ASP results in these units.

Evaluation of Hospital Antimicrobial Stewardship Programs: Implementation, Process, Impact, and Outcomes, Review of Systematic Reviews

Antimicrobial Stewardship Programs (ASP) were introduced in healthcare as a public health priority to promote appropriate prescribing of antimicrobials, to reduce adverse events related to antimicrobials, as well as to control the escalating challenges of antimicrobial resistance. To deliver aimed outcome objectives, ASPs involve multiple connected implementation process measures. A systematic review was conducted to evaluate both concepts of ASPs. Guided by PRISMA frames, published systematic reviews (SR) focusing on ASPs restricted to secondary and tertiary healthcare were evaluated over the past 10 years involving all age groups. Out of 265 identified SR studies, 63 met the inclusion criteria. The majority were conducted in Europe and North America, with limited studies from other regions. In the reviewed studies, all age groups were examined, although they were conducted mainly on adults when compared to children and infants. Both process and outcomes measures of ASPs were examined equally and simultaneously through 25 different concepts, dominated by efficacy, antimicrobial resistance, and economic impact, while information technology as well as role of pharmacy and behavioral factors were equally examined. The main broad conclusions from the review were that, across the globe, ASPs demonstrated effectiveness, proved efficacy, and confirmed efficiency, while focused evaluation advocated that developed countries should target medium- and small-sized hospitals while developing countries should continue rolling ASPs across healthcare facilities. Additionally, the future of ASPs should focus on embracing evolving information technology to bridge the gaps in knowledge, skills, and attitude, as well as to enhance appropriate decision making.

Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department

OBJECTIVE

To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department.

METHODS

A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritization level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritization order and rated the new indicators in the same manner as in the first round.

RESULTS

61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analyzing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority.

CONCLUSIONS

The experts agreed on a panel of ASP indicators adapted to the emergency services prioritized by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.

[Translated article] Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department

OBJECTIVE

To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department.

METHODS

A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritisation level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritisation order and rated the new indicators in the same manner as in the first round.

RESULTS

61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analysing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority.

CONCLUSIONS

The experts agreed on a panel of ASP Indicators adapted to the emergency services prioritised by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.

The Interventions and Challenges of Antimicrobial Stewardship in the Emergency Department

Over the last decades, we have witnessed a constant increase in infections caused by multi-drug-resistant strains in emergency departments. Despite the demonstrated effectiveness of antimicrobial stewardship programs in antibiotic consumption and minimizing multi-drug-resistant bacterium development, the characteristics of emergency departments pose a challenge to their implementation. The inclusion of rapid diagnostic tests, tracking microbiological results upon discharge, conducting audits with feedback, and implementing multimodal educational interventions have proven to be effective tools for optimizing antibiotic use in these units. Nevertheless, future multicenter studies are essential to determine the best way to proceed and measure outcomes in this scenario.

Quality indicators of hospitalized children influenced by clinical pharmacist services: A systematic review

BACKGROUND

Care for children who are hospitalized can be optimized if the pharmacist, in conjunction with the multidisciplinary team, promotes the rational use of medicines. In this sense, the evaluation of the quality of these clinical services through indicators is important in the planning, decision making of pharmacists and managers of these services.

OBJECTIVE

To characterize which health indicators were influenced by the pharmaceutical clinical services for the care of children in hospitals.

METHODS

A systematic review was performed. The search for data was made on the bases: Cochrane, Embase, Lilacs, Pubmed and Web of Science. Then, the search included studies in which evaluated the impact of pharmaceutical clinical services on clinical, economic and humanistic outcomes.

RESULTS

The search resulted in 11 included studies. In this review, four pharmaceutical clinical services were found: pharmacotherapy review, multiprofessional team interventions, antimicrobial stewardship program and pharmaceutical services at discharge hospital. The most influenced outcome indicators were length of hospital stay, with average time in the group that received the pharmacotherapy review service, and interventions multiprofessional team with a 6.45-day vs. 10.83 days in the control group; hospital readmissions with a significant reduction of non-scheduled readmission of 30 days in the ntimicrobial stewardship program; reduction of hospital costs and caregiver satisfaction.

CONCLUSION

In this study, we can highlight that pharmacotherapy review, multiprofessional team interventions and Antimicrobial Stewardship Program that significantly reduced the clinical results of length of hospital stay and hospital readmission, as well as a significant reduction of hospital costs.

Impact of antimicrobial stewardship interventions on days of therapy and guideline adherence: A comparative point-prevalence survey assessment

Background

Antimicrobial stewardship (AMS) is a crucial tool for rationalizing the use of antimicrobial agents and reducing the burden of antimicrobial resistance. We aimed to assess the impact of AMS interventions on antimicrobial utilization and adherence to antimicrobial guidelines.

Methods

We conducted a prospective quasi-experimental study at a major tertiary hospital in the United Arab Emirates. Using standardized World Health Organization’s methodology, point-prevalence surveys (PPS) were performed in November 2019 and January 2022. Core AMS interventions consisted of proactive bloodstream infection service, proactive and reactive infectious diseases consult service, prospective audit and feedback by clinical pharmacists, development of antimicrobial guidelines based on cumulative antibiograms, and implementation of induction programs for new clinical staff. Days of therapy (DOT) per 1000 patient days present and rate of compliance with antimicrobial guidelines were compared before and after the core interventions. Multiple logistic regression analysis was carried out to adjust for the potential confounding effects of age, gender, hospitalization within 90 days, central or peripheral line insertion, urinary catheterization, and mechanical ventilation. P-value<0.05 was considered statistically significant.

Results

Pre- and post-intervention PPSs included 292 and 370 patients, respectively. Both had similar age and gender distribution. Patients receiving antimicrobials were 51% (149/292) in 2019 and 45% (166/370) in 2022 (p 0.12). Univariate analysis showed a reduced post-intervention DOT per 1000 patients present (6.1 +/- 16.2 vs 2.4 +/-5.1, p<0.01) and an improved post-intervention guideline compliance (59% vs 67%, p 0.23). Following multiple logistic regression, the reduction in post-intervention DOT remained statistically significant (co-efficient -0.17 (95% CI -8.58 to -1.94, p<0.01), and the improvement in guideline adherence became statistically significant (adjusted odds ratio 1.91 (95% CI 1.05 to 3.45, p 0.03).

Conclusion

Coordinated and sustained AMS interventions have a significant impact on improving antimicrobial utilisation and adherence to guidelines.

Impact of medical and pharmaceutical interventions on anti-infective prescriptions: an observational study

Appropriate prescribing of anti-infectives is a public health challenge. In our hospital, clinical microbiologists (clinical microbiology mobile unit, UMMc) and clinical pharmacists (clinical pharmacy, PHAc) carry out interventions on anti-infective prescriptions to improve practices. Our main objective was to evaluate the acceptance of UMMc and PHAc interventions on anti-infective prescriptions by quantifying the rate of prescription change 24 h after intervention. The secondary objective was to characterize the type of intervention and associate the rate of change for each. All prescriptions are computerized, and interventions traced via DxCare® software, which feeds a local data warehouse (HEGP-CDW). This descriptive, retrospective, single-center, uncontrolled study was conducted from January 2015 to December 2018. The data were extracted over this period from the data warehouse and analyzed using R software. UMMc interventions were accepted 72.2% of the time and PHA interventions 87.3%. The types of interventions found were mostly dose adjustments (61.1% for the UMMc and 54.2% for the PHAc) and proposals to change or stop a drug. Interventions have an impact on anti-infective prescriptions and are generally followed by clinicians. For the category "discontinuation of a molecule", almost half of the advice from the UMMc was refused. The collaboration between the UMMc and PHAc should be reinforced to improve acceptance.

Effectiveness of Educational Interventions for Health Workers on Antibiotic Prescribing in Outpatient Settings in China: A Systematic Review and Meta-Analysis

Educational interventions are considered an important component of antibiotic stewardship, but their effect has not been systematically evaluated in outpatient settings in China. This research aims to evaluate the effectiveness of educational interventions for health workers on antibiotic prescribing rates in Chinese outpatient settings. Eight databases were searched for relevant randomized clinical trials, non-randomized trials, controlled before–after studies and interrupted time-series studies from January 2001 to July 2021. A total of 16 studies were included in the systematic review and 12 in the meta-analysis. The results showed that educational interventions overall reduced the antibiotic prescription rate significantly (relative risk, RR 0.72, 95% confidence interval, CI 0.61 to 0.84). Subgroup analysis demonstrated that certain features of education interventions had a significant effect on antibiotic prescription rate reduction: (1) combined with compulsory administrative regulations (RR With: 0.65 vs. Without: 0.78); (2) combined with financial incentives (RR With: 0.51 vs. Without: 0.77). Educational interventions can also significantly reduce antibiotic injection rates (RR 0.83, 95% CI 0.74 to 0.94) and the inappropriate use of antibiotics (RR 0.61, 95% CI 0.51 to 0.73). The limited number of high-quality studies limits the validity and reliability of the results. More high-quality educational interventions targeting the reduction of antibiotic prescribing rates are needed.

Real-World Antimicrobial Stewardship Experience in a Large Academic Medical Center: Using Statistical and Machine Learning Approaches to Identify Intervention “Hotspots” in an Antibiotic Audit and Feedback Program

Background

Prospective audit with feedback (PAF) is an impactful strategy for antimicrobial stewardship program (ASP) activities. However, because PAF requires reviewing large numbers of antimicrobial orders on a case-by-case basis, PAF programs are highly resource-intensive. The current study aimed to identify predictors of ASP intervention (i.e., feedback), and to build models to identify orders that can be safely bypassed from review, to make PAF programs more efficient.

Methods

We performed a retrospective cross-sectional study of inpatient antimicrobial orders reviewed by the University of Maryland Medical Center’s PAF program between 2017–2019. We evaluated the relationship between antimicrobial and patient characteristics with ASP intervention using multivariable logistic regression models. Separately, we built prediction models for ASP intervention using statistical and machine learning approaches and evaluated performance on held-out data.

Results

Across 17,503 PAF reviews, 4,219 (24%) resulted in intervention. In adjusted analyses, a clinical pharmacist on the ordering unit or receipt of an ID consult were associated with 17% and 56% lower intervention odds, respectively (aORs 0.83 and 0.44, P values ≤ 0.001). Fluoroquinolones had the highest adjusted intervention odds (aOR 3.22, 95% CI: 2.63–3.96). A machine learning classifier (C-statistic 0.76) reduced reviews by 49% while achieving 78% sensitivity. A “workflow simplified” regression model that restricted to antimicrobial class and clinical indication variables, two strong machine-learning-identified predictors, reduced reviews by one-third while achieving 81% sensitivity.

Conclusions

Prediction models substantially reduced PAF review caseloads while maintaining high sensitivities. Our results and approach may offer a blueprint for other ASPs.

Pharmacist-led antimicrobial stewardship programme in a small hospital without infectious diseases physicians

Pharmacists may be tasked to lead antibiotic stewardship programmes (ASP) implementation in small hospitals in absence of infectious diseases (ID) physicians. The objectives are to evaluate the effectiveness of a pharmacist-led ASP in a hospital without ID physician support, with special focus on indicators of the hospital use of antimicrobial agents based on consumption and asess the potential clinical and economic impact of pharmacist interventions (PIs) through the CLEO tool. A prospective quasi-experimental study to implement an ASP in a 194-bed hospital. We evaluated changes in antimicrobial use measured as mean defined daily doses per 1000 patient-days (AUD) for intervention versus preintervention period. A total of 847 antimicrobial PIs were proposed, being 88.3% accepted. Discontinuation due to excessive duration was the most frequently performed PI (23.4%). Most of PIs was classified as major or moderate clinical impact, 41.7% and 37.8% respectively. The global consumption of antimicrobial was reduced from 907.1 to 693.8 AUD, with a signifcant drop in carbapenems and quinolones. Direct expenditure of antibiotics decreased significantly. Pharmacist-led ASP has being effective in reducing consumption of antibiotics. In the absence of ID physician´s support and oversight, pharmacists could lead the improvement of the use of antimicrobials.

Characteristics of antimicrobial stewardship programmes in hospitals of Uganda

While interest in antimicrobial stewardship programmes (ASPs) is growing in most low- and middle-income countries (LMICs), there is a paucity of information on their adoption or implementation in Africa, particularly Uganda. The study assessed the presence and characteristics of ASPs, implemented antimicrobial stewardship (AMS) strategies and the challenges to their implementation in hospitals in Uganda. We conducted a cross-sectional study among heads of infection prevention committees (IPCs) in regional referral hospitals, general hospitals, and private-not-for-profit (PNFP) hospitals from November 2019 to February 2020. An interviewer-administered questionnaire was used to collect data. We analysed data using descriptive statistics. A total of 32 heads of IPCs were enrolled in the study. Of these, eight were from regional referral hospitals, 21 were from general hospitals, and three were from PNFPs. Most heads of IPC were pharmacists (17/32, 53.1%) with a mean age and standard deviation (sd) of 36.1 (±1.1) years. A formal ASP was adopted or implemented in 14 out of the 32 (44%, 95% CI 26-62) studied hospitals. Thirty out of 32 hospitals implemented at least one type of AMS strategy. Sixty-eight percent (22/32) of the hospitals implemented pre-authorisation and approval as their primary AMS core strategy to optimise antibacterial use. The most commonly reported challenges to the implementation of ASP across all 32 hospitals (with or without ASP) were lack of time for the ASP team (29/32, 90.6%) and lack of allocated funding for antimicrobial stewardship team (29/32, 90.6%). In this study, most hospitals in Uganda implemented at least one AMS strategy despite the low implementation of ASPs in hospitals. The ministry of health needs to sensitise and support the establishment of ASP in hospitals across the country.

Role of the hospital pharmacist in an Italian antimicrobial stewardship programme

The inappropriate use of antimicrobial agents is contributing to an increasing phenomenon of bacterial resistance. For this reason, there is a growing interest in 'antimicrobial stewardship', a series of coordinated and multidisciplinary interventions aimed to promote the safe and appropriate use of antimicrobials in which the pharmacist's contribution is necessary for the optimal choice of drug, dose, duration of therapy and the implementation of cost containment strategies.

AIM OF THE STUDY

We wanted to create a reference model and a specific training manual on antibiotic stewardship to introduce the role of the department pharmacist with specific infection disease skills in the Italian health system hospitals.

METHODS

This study was conducted in six Italian hospitals for 24 months. It was divided into three phases: definition of indicators (as defined daily doses/100 days of hospitalisation, switches from intravenous (IV) to oral and from empirical to targeted therapies, etc) elaboration of research protocol; sharing, application and detection of the indicators and selection of centres involved; analysis and sharing of results and subsequent drafting and distribution of the training manual.Statistical analysis focused on possible differences between the frequencies of the aforementioned switches. Differences were analysed comparing the values recorded in the first quarter with those of the third quarter trough a χ² test. Statistical significance was set at p<0.05.

RESULTS

The pharmacist's work showed a statistically significant increase in the conversion from IV to oral antibiotic therapy (χ² (1.496)=9112 ; p=0.0025; df=1). It was also detected a 5% improvement in appropriate dosing, 34% reduction in drug stocks, 4% increase in allergy reports and 275% increase in the number of adverse drug reactions reported.

CONCLUSIONS

In this study, the interventions of the antibiotic stewardship pharmacist led to an improvement in quality of care, resource efficiency and healthcare professional awareness.

Indonesian healthcare providers' perceptions and attitude on antimicrobial resistance, prescription and stewardship programs

Background: A successful antimicrobial stewardship program (ASP) is sustained through improving antimicrobial prescribing by changing prescribing behavior. This requires a better understanding of hospital stakeholders' views regarding antimicrobial resistance (AMR), antimicrobial use and participation in ASP activities. Objectives: Identify perceptions and attitudes among physicians and pharmacists in a public hospital toward AMR, prescription and ASP. Methods: A questionnaire consisting of 45 items was distributed to physicians and pharmacists in a 320-bed public hospital. All responses were formatted into the Likert scale. Results: A total of 78 respondents (73% response rate) completed the questionnaire. The majority of the respondents perceived AMR within hospital as less of a severe problem, and factors outside hospital were considered to be greater contributors to AMR. In addition, interprofessional conflict was identified as a serious concern in relation to implementing ASP. Conclusion: This finding indicates the need to address existing perceptions and attitudes toward ASP activities that may hamper its successful implementation in Indonesia.

Antimicrobial stewardship programs in emergency departments: how do we measure antimicrobial use? A systematic review

OBJECTIVE

The implementation of antimicrobial stewardship programs (ASPs) has become a usual practice in hospital settings. However, the method for monitoring antimicrobial use in accident and emergency departments (ED) is not yet adequately defined. Thus, the objective of this review is to describe antimicrobial use indicators used by ASPs implemented in ED.

METHODS

A systematic review was performed based on studies found in the following academic research databases: MEDLINE, EMBASE, Web of Science, and Scopus (Period: January 2000 to December 2019). Controlled clinical trials, before-and-after studies, interrupted time series, and repeated measures studies assessing the impact of ASPs on antimicrobial use in ED were included; studies published in languages other than English or Spanish were excluded from this review.

RESULTS

Twenty-six studies met the inclusion criteria and were included in this systematic review. In total, 15 (62.5%) studies described the ASP team members who collaborated with the ED staff. Most (21; 80.8%) studies used the percentage of patients with an antibiotic prescription as an indicator. Four (15.4%) studies included defined daily dose data. The antibiotic treatment duration was reported in four (15.4%) studies. Only two studies assessed the impact of the ASP using microbiological indicators, both of which used the incidence of infection with Clostridioides difficile as the indicator.

CONCLUSIONS

The reports of experiences in implementing ASPs in ED show heterogeneous antimicrobial use indicators, which makes it difficult to compare results. Therefore, antimicrobial use indicators for ASPs must be standardised between hospital units.

[Role of a Pharmacist in AST Activity and Pharmaceutical Education in a Mid-sized Japanese Community Hospital]

At small or mid-sized medical institutions, such as Japanese community hospitals, adequate infectious disease physicians (IDP) are lacking, mainly due to shortages of full-time pharmacists and IDPs who support antimicrobial stewardship team (AST) activities. With our hospital AST, we developed a multidisciplinary approach based on the interim reports of culture results or detected resistant bacteria for physicians, which are written by pharmacists and clinical laboratory technicians. At the AST conference, a pharmacist works as a chairman and reviews abstracts of cases which need to be discussed. We performed a retrospective analysis of the process and outcome of AST implementation, and introduced the use of reduction data for our hospital, obtained from Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE). This program is important for pharmacists to promote the diagnostic process and comprehensive judgment necessary for bedside practice with infectious disease cases. We offer opportunities for pharmacy students to participate in the AST conference to learn how pharmacists consult with doctors about diagnosis and treatment. At present, the cooperation between AS and diagnostic stewardship (DS) has been emphasized, and improvements in a pharmacist's overall judgment regarding infectious disease cases are required to appropriate antimicrobial use. In addition, improving communication skills is essential for building a multidisciplinary approach. Regardless of the size of the facility, the role of pharmacists in AST should be implemented for the guidance of pharmacy students, which will help develop and secure future human resources at the facility.

Impact of an antimicrobial stewardship in a 126-bed community hospital with close communication between pharmacists working on post-prescription audit, ward pharmacists, and the antimicrobial stewardship team

Background

Antimicrobial stewardship (AS) is defined as coordinated interventions to improve and measure the appropriate use of antimicrobial agents. However, available resources for AS differ depending on the size of the clinical setting. Therefore, AS programs based on guidelines need to be selected in order to implement AS in small- to medium-sized hospitals. The present study compared the impact of AS in a 126-bed community hospital between pre- and post-AS periods.

Methods

The present study was retrospectively performed by selecting data on eligible patients from electronic medical records stored in the central database of the hospital. The roles of the AS team included weekly rounds and recommendations on the appropriate use of antimicrobials, and pharmacists working on post-prescription audits and pharmaceutical care at the bedside closely communicated with the AS team to assist with its implementation. As process measurements, the order rate of culture examinations, the conducting rate of de-escalation, antimicrobial use density (AUD), days of therapy (DOT), and the AUD/DOT ratio of carbapenems and tazobactam-piperacillin (TAZ/PIPC) were measured. Thirty-day mortality and recurrence rates were examined as clinical outcomes.

Results

A total of 535 patients (288 in the pre-AS period and 247 in the post-AS period) were enrolled in the present study. The recommendation rate to prescribers significantly increased (p < 0.01) from 10.4% in the pre-AS period to 21.1% in the post-AS period. The order rate of culture examinations increased from 56.3 to 73.3% (p < 0.01). The conducting rate of de-escalation increased from 10.2 to 30.8% (p < 0.05). The AUD of carbapenems and TAZ/PIPC significantly decreased (p < 0.05). The DOT of carbapenems (p < 0.01) and TAZ/PIPC (p < 0.05) also significantly decreased. The AUD/DOT ratio of carbapenem significantly increased from 0.37 to 0.60 (p < 0.01). Thirty-day mortality rates were 11.2 and 14.2%, respectively, and were not significantly different. The 30-day recurrence rate significantly decreased (p < 0.05) from 14.7 to 7.5%.

Conclusions

The implementation of AS in this hospital improved the appropriate use of antimicrobials without negatively affecting clinical outcomes. These results may be attributed to close communication between pharmacists working on post-prescription audits and pharmaceutical care at the bedside and the AS team.

Clinical and Cost Implications of Clinical Pharmacist Interventions on Antimicrobial Use at Sultan Qaboos University Hospital in Oman

OBJECTIVE

To evaluate the clinical and financial impact of clinical pharmacists' interventions (CPIs) on antimicrobial use at a 500-bed multidisciplinary tertiary care hospital in Oman.

METHODS

A retrospective analysis of CPIs related to antimicrobials use at Sultan Qaboos University Hospital (SQUH) from January to December 2018. Interventions were recorded using an electronic CPI form and were reviewed by two independent CPs. Data on the type and clinical significance of the interventions were extracted. Cost analysis was done using a previously defined cost avoidance model in addition to direct cost reduction estimation. Descriptive data were used to describe the results.

RESULTS

In 2018, 26% of CPIs were related to antimicrobial use, with more than 60% of these interventions done on intensive care unit patients. The most common intervention type was adjusting the dosing regimen (42% of the total interventions), followed by deletion of the antimicrobial order in 34% of the cases. The most common clinical impact of CPIs was improving efficacy in 45% of the interventions, followed by preventing unnecessary exposure to the antimicrobials in around 30% of the interventions. The interventions were of major significance in 64% of the cases. This translated into a projected net cost saving of approximately $200,000 USD/year.

CONCLUSIONS

CPs interventions on antimicrobial use had a positive impact on both the clinical and financial outcomes.

Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health

Antimicrobial resistance (AMR) is a serious threat to global public health. It increases morbidity and mortality, and is associated with high economic costs due to its health care burden. Infections with multidrug-resistant (MDR) bacteria also have substantial implications on clinical and economic outcomes. Moreover, increased indiscriminate use of antibiotics during the COVID-19 pandemic will heighten bacterial resistance and ultimately lead to more deaths. This review highlights AMR's scale and consequences, the importance, and implications of an antimicrobial stewardship program (ASP) to fight resistance and protect global health. Antimicrobial stewardship (AMS), an organizational or system-wide health-care strategy, is designed to promote, improve, monitor, and evaluate the rational use of antimicrobials to preserve their future effectiveness, along with the promotion and protection of public health. ASP has been very successful in promoting antimicrobials' appropriate use by implementing evidence-based interventions. The "One Health" approach, a holistic and multisectoral approach, is also needed to address AMR's rising threat. AMS practices, principles, and interventions are critical steps towards containing and mitigating AMR. Evidence-based policies must guide the "One Health" approach, vaccination protocols, health professionals' education, and the public's awareness about AMR.

[Prevention and control of antimicrobial stewardship: a review of evidenceGestión de las intervenciones en materia de prevención y control de la resistencia a los antimicrobianos en los hospitales: revisión de la evidencia]

Objective

To identify effective interventions to manage antimicrobial resistance in hospital settings and potential barriers to their implementation.

Method

A synthesis of evidence for health policy was performed using SUPPORT tools. Literature searches were performed in November and December 2018 in 14 databases. A face-to-face deliberative dialogue workshop to identify implementation barriers was performed with 23 participants (manager, researchers, and health care professionals) and 14 listeners divided into three groups. Researchers with experience in deliberative dialogue acted as facilitators.

Results

Twenty-seven systematic reviews focusing on antimicrobial stewardship using combined or individual strategies were identified. The interventions included education, electronic systems, use of biomarkers, and several strategies of antimicrobial management. The main barriers to the implementation of interventions, identified in the literature and deliberative dialogue workshop, were poor infrastructure and insufficient human resources, patient complaints regarding the treatment received, cultural differences within the multidisciplinary team, work overload, and lack of financing/planning.

Conclusion

Most of the strategies identified were effective for antimicrobial stewardship in hospital settings. The reliability of results may be strengthened with the performance of additional research of higher methodological quality.

A survey of Chinese pharmacists participating in anti-infective therapy and its related information technology support

WHAT IS KNOWN AND OBJECTIVE

Anti-infective therapy is the major daily work for most clinical pharmacists in China, and information technology (IT) support for them is very important. However, the current situation of pharmacists' roles in anti-infective therapy and related IT support are seldom reported. The aim of the study was to investigate the current situation of pharmacists participating in anti-infective therapy and the corresponding hospital IT support, which may help identify and solve related problems and facilitate pharmacists to play better roles.

METHODS

A 15-item questionnaire was distributed online to clinical pharmacists from Chinese hospitals. Pharmacists answered the questions on the WeChat platform. Data were analysed using descriptive statistics.

RESULTS AND DISCUSSION

A total of 272 valid questionnaires were returned, and the respondents were from 27 provinces (or autonomous regions or municipalities) of China covering over 15 specialties. Most of the respondents (76.1%) were from tertiary hospitals and 72.4% of all the respondents participated in anti-infective therapy. They mainly performed drug selection (95.4%), dose adjustment (88.8%) and adverse drug reaction monitoring (84.8%) for anti-infective therapy, in ways such as consultation (71.1%), drug consult (86.3%) and prescription evaluation (88.8%). Most pharmacists (93.0%) thought that the modules of anti-infective therapy in hospital IT system needed to be advanced, in the aspects of doctor-pharmacist interaction, convenience for pharmacists to control drug expenses and integration of multi-functions for anti-infective therapy.

WHAT IS NEW AND CONCLUSION

The roles of Chinese clinical pharmacists in anti-infective therapy are becoming increasingly clear, and establishing smart, pharmacist-friendly and highly-integrated electronic interfaces will facilitate the establishment of pharmacist-driven anti-infective therapy team, thus improving work efficiency and user experience.