A multicenter point-prevalence study: antimicrobial prescription frequencies in hospitalized patients in Turkey

Point prevalence of antibiotic usage in major referral hospital in Turkey

INTRODUCTION

The most important and undesirable consequence of inappropriate antibiotic use is the spread of antibiotic resistance, increased adverse effects, increased mortality and healthcare costs. We aimed to assess antibiotic usage characteristics in inpatient setting in our center.

MATERIALS AND METHODS

A one-day, single center point-prevalence study was carried out on June 9th 2021, in Ankara City Hospital in Turkey. Data of antibiotic consumption, appropriateness of usage and predictors of inappropriate use in adult patients were evaluated.

RESULTS

Out of 2640 adult patients, 893 (33.8%) were receiving at least one antibiotic. A total of 1212 antibiotic prescriptions with an average of 1.44±0.64 were found. Antibiotics were most commonly used for therapeutic purpose (84.7%), followed by surgical prophylaxis (11.6%). Majority of therapeutically used antibiotics were empirical (67.9%). Infectious diseases consultation was present in 68.3% with a compliance rate of 95.7%. Rate of inappropriate use was 20%. The most frequent cause of inappropriateness was unnecessary use (52.5%). Most commonly and most inappropriately used antibiotics were carbapenems (17.5%) and first generation cephalosporins (38.7%), respectively. Most of the inappropriateness observed in first-generation cephalosporins was due to inappropriate longer surgical prophylaxis. While age is an independent risk factor for inappropriate antibiotic use (p = 0.042), COVID-19 unit admission, use for therapeutic purpose and infectious diseases consultation were protective factors (p<0.001, p<0.001, p<0.001).

CONCLUSION

Rate of inappropriate use was low, but inappropriate surgical prophylaxis remains an important problem in surgical units. There is a considerable need to implement an antimicrobial stewardship program that focuses on surgical prophylaxis practices.

Early Stage Risk Identification and Governance of Major Emerging Infectious Diseases: A Double-Case Study Based on the Chinese Context

Purpose

Based on the Chinese context, this study uses severe acute respiratory syndrome (SARS) and coronavirus disease 2019 (COVID-19) outbreaks as examples to identify the risk factors that lead to the major emerging infectious diseases outbreak, and put forward risk governance strategies to improve China's biosecurity risk prevention and control capabilities.

Material and Methods

This study combines grounded theory and WSR methodology, and utilizes the NVivo 12.0 qualitative analysis software to identify the risk factors that led to the major emerging infectious diseases outbreak. The research data was sourced from 168 publicly available official documents, which are highly authoritative and reliable.

Results

This study identified 10 categories of Wuli risk factors, 6 categories of logical Shili risk factors, and 8 categories of human Renli risk factors that contributed to the outbreak of major emerging infectious diseases. These risk factors were distributed across the early stages of the outbreak, and have different mechanisms of action at the macro and micro levels.

Conclusion

This study identified the risk factors that lead to the outbreak of major emerging infectious disease, and discovered the mechanism of the outbreak at the macro and micro levels. At the macro level, Wuli risk factors are the forefront antecedents that lead to the outbreak of the crisis, Renli factors are the intermediate regulatory factors, and Shili risk factors are the back-end posterior factors. At the micro level, there are risk coupling, risk superposition, and risk resonance interactions among various risk factors, leading to the outbreak of the crisis. Based on these interactive relationships, this study proposes risk governance strategies that are helpful for policymakers in dealing with similar crises in the future.

Point prevalence survey of antibiotic utilization in secondary care hospital in the United Arab Emirates

Objectives

The present study was carried out to identify and report the pattern of antibiotics prescribing to determine the adherence to the international empirical and therapeutic guidelines of antibiotic use.

Methods

A point prevalence survey took place at a selected date of January 26, 2020, in which data collection was performed to all the patients present in the hospital who used at least one systemic antibiotic agent as an inpatient from 00:00 am until midnight of that day. This was performed using European Surveillance of Antimicrobial Consumption (ESAC - audit tool). The participated hospital in this point prevalence study represents a major government hospital in the UAE. Descriptive statistics were used and results were expressed using standard statistical methods.

Results

Out of the 125 hospitalized patients, a total of 41 (32.8%) patients were included in the survey and treated with different trends of antibiotics on the date point prevalence survey. The total number prescribed antibiotics was 54 with a higher percentage of treatment indication (70.4%), compared to prophylaxis indication (29.6%). The combinations of penicillin's win in being the most commonly used agents by a percent of 31.5%, including the use of Amoxicillin-clavulanic acid by 22.2% and Piperacillin-tazobactam with 9.3%. The compliance with local/international guidelines accounts for 78.0% of the treated & prophylaxis patients.

Conclusions

Considerable results have been obtained which can assure the quality improvement of the antibiotic use in the studied hospital.

Antimicrobial Usage and Resistance in Makkah Region Hospitals: A Regional Point Prevalence Survey of Public Hospitals

(1) Background: Inappropriate use of antimicrobials and subsequently rise of antimicrobial resistance (AMR) remains a major public health priority. Over-prescribing of broad-spectrum antibiotics is one of the main contributing factors for the emergence of AMR. We sought to describe antimicrobial prescribing trends among patients in public hospitals in Makkah hospitals. (2) Method: We undertook a point prevalence survey (PPS) in six hospitals in Makkah, Saudi Arabia, from January 2019 to July 2019. The survey included all the inpatients receiving antimicrobials on the day of PPS. Data was collected using the Global point prevalence survey (PPS) tool developed by the University of Antwerp, Belgium. (3) Results: Of 710 hospitalized patients, 447 patients (61.9%) were treated with one or more antimicrobials during the study period. The average bed occupancy among six hospitals was 74.4%. The majority of patients received antimicrobials parenterally (90.3%). Of the total prescribed antimicrobials, 415 (53.7%) antimicrobials were used in medical departments, 183 (23.7%) in surgical departments, and 175 (22.6%) in ICUs. Pneumonia (17.3%), skin and soft tissue infections (10.9%), and sepsis (6.6.%) were three common clinical indications. Ceftriaxones were the most commonly used antibiotics that were prescribed in 116 (15%) of patients, followed by piperacillin, with an enzyme inhibitor in 84 (10.9%). (4) Conclusion: There was a high prevalence of antibiotic use in the hospitals of Makkah, which could be a potential risk factor for the incidence of resistant strains, particularly MRSA infection. Public health decision-makers should take these findings into consideration to update national policies for antibiotic use in order to reduce the risks of further increases of AMR.

Antibiotics use and appropriateness in two Jordanian children hospitals: a point prevalence study

Background

Although inappropriate antibiotics prescribing in hospitals is a key factor in accelerating antibiotic resistance, inadequate data are available about antibiotics prescribing rate and appropriateness. Our study aimed to measure antibiotics prescribing rate, indications, appropriateness and predictors.

Methods

The study was conducted in two public children hospitals (five wards) in Jordan using one-week point prevalence survey to prospectively collect the data. Appropriateness of antibiotics therapy was assessed by a multidisciplinary committee and predictors of inappropriate prescribing were studied through multivariate logistic regression.

Key findings

The overall antibiotics prescribing rate was 75.6% (n = 501/663), where the highest rate of antibiotics prescribing was in the Pediatrics ward (82.2%, n = 222/270). However, the lowest rate was in the Pediatric Intensive Care Unit (30.0%, 9/30). The most common antibiotics classes prescribed were: Beta-lactams (57.5%, n = 492/855). The most common underlying condition for antibiotics prescribing was upper respiratory tract infections (25.5%, n = 128/501) followed by pneumonia (20.6%, n = 103/501). Around half of antibiotics were prescribed upon appropriate decision (49.5%, n = 423/855). However, 22.0% (n = 188/855) of antibiotics were wrongly chosen, and 9.5% (n = 81/855) were wrongly applied. Initially inappropriate decision for prescription occurred in 15.3% (n = 131/855) of antibiotics. Ceftriaxone (OR 3.1; 95% CI 2.6–4.1; P = 0.03) and patients with ≥3 medication orders (OR 2.6; 95% CI 1.7–3.5; P = 0.001) significantly predicted inappropriate antibiotics prescribing.

Conclusions

The incidence of antibiotics prescribing in Jordanian children hospitals was high compared to other countries. Further multi-centric studies are required to enhance the generalisability of results and better develop effective and efficient antibiotic stewardship programmes.

Implications of human activities for (re)emerging infectious diseases, including COVID-19

Since 1980, the world has been threatened by different waves of emerging disease epidemics. In the twenty-first century, these diseases have become an increasing global concern because of their health and economic impacts in both developed and resource-constrained countries. It is difficult to stop the occurrence of new pathogens in the future due to the interconnection among humans, animals, and the environment. However, it is possible to face a new disease or to reduce the risk of its spread by implementing better early warning systems and effective disease control and prevention, e.g., effective global surveillance, development of technology for better diagnostics, effective treatments, and vaccines, the global political will to respond to any threats and multidisciplinary collaboration involving all sectors in charge of good health maintenance. In this review, we generally describe some factors related to human activities and show how they can play a role in the transmission and spread of infectious diseases by using some diseases as examples. Additionally, we describe and discuss major factors that are facilitating the spread of the new pandemic known as COVID-19 worldwide.

Point prevalence surveys of antimicrobial use: a systematic review and the implications

Introduction: In view of increasing concerns with antimicrobial resistance (AMR), the World Health Organization (WHO) instituted a Global Action Plan (GAP) to address this. Area covered: One of the strategies to achieve the goals of GAP is to conduct regular surveillance of antimicrobial use through point prevalence surveys (PPS). In this review, PubMed, EBSCO, Proquest, Cinahl, and Scopus were searched for PPS of antimicrobial use published in English between January 2000 and December 2019. After systematic database screening of 2,893 articles, 60 PPS met the inclusion criteria and consequently were incorporated in this systematic review. Expert opinion: This review highlighted that most of the PPS were conducted in upper-middle and high-income countries. Prevalence of antimicrobial use was significantly higher in non-European hospitals compared with European hospitals. The domination of third-generation cephalosporin and fluoroquinolones use across all the regions suggests substantial use of broad-spectrum antimicrobials across countries. Among all identified regions around the world, India was the region where the highest use of antimicrobials was observed. Although PPS is a useful tool to assess the pattern of antimicrobial use and provides a robust baseline; however, a standardized surveillance method is needed. In order to optimize antimicrobial use, more efforts are required to improve antimicrobial use.

It Is Time to Revitalize the Antibiotic Pipeline: Systems Ecology Can Help

Antimicrobials have been known for millennia, but innovative antibiotics are currently in short supply. New antimicrobial discoveries are being threatened by planetary scale loss of biodiversity that has important impacts on species and ecosystems. This expert review underscores that microorganisms in nature and their diversity are essential cornerstones to revitalize the antibiotic innovation and discovery pipeline. The recent rise of systems ecology and planetary health offers new and actionable potentials in this regard. Without a systems scale focus and appreciation of systems ecology, the global threats to human and planetary health from inappropriate use of antibiotics and antimicrobial resistance will continue to escalate with serious consequences to all life on the planet. With acutely pressing research and development needs to revitalize antibiotic treatment and novel diagnostic tools for personalized medicine, national health systems ought to work across knowledge silos not only within but also across the ministries, for example, health, agriculture, environment, economy, trade, and social services ministries that collectively impact on systems ecology and by extension on health innovations including the antibiotic discovery pipeline. Such systems vision can also help to revitalize antibiotic discovery pipeline as most antibiotics have natural origins or have designs inspired or based on molecules in the environment and microorganisms that produce antibiotics. Above all, our audience and responsibility include every person who has an interest in his or her own health, in the health of his or her fellow human beings and all life on the planet, and in the health of future generations.

Study of Antimicrobial Utilization and Cost of Therapy in Medicine Intensive Care Unit of a Tertiary Care Hospital in Eastern India

Introduction

High utilization of antimicrobial agent (AMA) and inappropriate usage in an intensive care unit (ICU) intensifies resistant organism, morbidity, mortality, and treatment cost. Prescription audit and active feedback are a proven method to check the irrational prescription. To analyze and compare the utilization of drugs, the World Health Organization (WHO) proposed daily defined dose (DDD)/100 patient days and days of therapy (DOT)/100 patient days to measure utilization of AMAs. Data of AMAs utilization are required for planning an antibiotic policy and for follow-up of intervention strategies.

Materials and methods

A prospective observational study was conducted for 1 year from July 2018 to June 2019 and the data obtained from ICU of a tertiary care hospital. The demographic data, the disease data, and the utilization of different classes of AMAs [WHO-Anatomical Therapeutic Chemical (ATC) classification] as well as their cost were recorded. Total number of patient days, DDD, DDD/100 patient days, and DOT/100 patient days were calculated as proposed by the WHO. Statistical analysis was performed using statistical software SPSS version 25.0. The descriptive analysis was performed using summary statistics median [interquartile range (IQR)].

Results

A total 939 patients were included, out of them 332 (35.4%) were female. The median age of the total patients was 58 (45-70). The median length of stay in ICU was 3 days. Mortality rate during our study period was 38.6%. The highly utilized AMAs in our study was ceftriaxone (36.95 DDD/100 patient days) followed by piperacillin/tazobactam (31.57), meropenem (26.4), doxycycline (21.53), and polymyxin B (21.38). The association between APACHE II and SOFA score with use of restricted antibiotics found to be statistical significant (p value 0.018 and 0.000, respectively). The cost of antibiotics per patient and patient days were $449.97 and $93.77, respectively, while median value of total cost was $2,343.26.

Conclusion

Ceftriaxone was the highest utilized AMA. The risk of receiving restricted antibiotics intensified with increasing prevalence of multidrug resistance bacteria and associated comorbidities. High treatment cost is responsible for higher utilization of restricted antibiotics in ICU.

How to cite this article

Patra SK, Mishra SB, Rath A, Samal S, Iqbal SN. Study of Antimicrobial Utilization and Cost of Therapy in Medicine Intensive Care Unit of a Tertiary Care Hospital in Eastern India. Indian J Crit Care Med 2020;24(10):938-942.

Restricting high-end antibiotics usage - challenge accepted!

Objectives:

Antimicrobial resistance (AMR) leads to increased morbidity, mortality, and healthcare expenditure. The rate of development of AMR is accelerated by the use and misuse of antimicrobials. Preauthorization and restricted use of high-end antibiotics are the key modalities of antimicrobial stewardship. Hence, choosing the right antibiotics is the key to better clinical outcomes and preventing resistance in hospitals as well as communities. The present study was done to assess the judicious usage of high-end antibiotics among inpatients treated at our hospital.

Materials and Methods:

A prospective observational study was conducted on high-end antibiotic usage using a structured proforma among inpatients treated at our hospital for a 3 month period. Department wise educational intervention was done and feedbacks were provided, after which reassessment was done.

Results and Analysis:

Meropenem was the most commonly used high-end antibiotics. After the feedback and intervention, there was 51.2% reduction in the unjustified antibiotic usage. The appropriateness of the usage increased from 77% observed during preintervention to 88% postintervention.

Conclusion:

The increasing compliance of judicious usage of high-end antibiotics needs to be sustained. Therefore, continuous strengthening of antimicrobial stewardship practices are crucial.

Utilization of antimicrobial agents in patients on ventilator in medical Intensive Care Unit at a tertiary care teaching hospital: A prospective study

Background

The burden of bacterial infections is huge and grossly underrepresented in the current health-care system. Inappropriate use of antimicrobial agents (AMAs) poses a potential hazard to patients by causing antibiotic resistance. In addition, the field of antimicrobials is witnessing constant development and introduction of new drugs for which holistic utilization, effectiveness, and side-effects studies are the need of the hour. The current study aims at studying the prescription pattern of AMAs in patients on ventilator and focuses on their prescribing trends.

Methodology

A prospective, observational study was conducted in Medical Intensive Care Unit (ICU) of a tertiary care hospital of Western India for 6 months. Prescription pattern of AMAs was analyzed using predesigned format.

Statistical Analysis

Descriptive statistics was used being an observational study.

Results

Five-hundred and twenty patients who were on ventilator and were prescribed one or more AMAs were enrolled in the study with a mean patient age of 40.7 years. The intended purpose of the use of AMAs was prophylactic in 59% of patients. Empirical therapy was given in 92% of patients. β-lactams group of AMAs along with metronidazole were most frequently used. 73% required concurrent use of two or more AMAs. 9% of the patients required addition or substitution of one or more other AMAs on the basis of culture and sensitivity report or inadequate clinical response and expert opinion. The outcome of therapy with AMAs showed infection was effectively prevented in 34% of the patients.

Conclusion

This study provides a baseline data for improving the utilization of AMAs in ICU settings by rationalizing their use and also carrying out further studies on prescribing pattern of AMAs in a tertiary care unit.

A multicenter point prevalence survey of antibiotic use in Punjab, Pakistan: findings and implications

OBJECTIVES

In line with the recent global action plan for antimicrobial resistance, this is the first time such a comprehensive antimicrobial point prevalence survey has been undertaken in Pakistan, the sixth most populous country.

METHODS

This point prevalence survey (PPS) was conducted in 13 hospitals among 7 different cities of Pakistan. The survey included all inpatients receiving an antibiotic on the day of PPS. A web-based application was used for data entry, validation, and reporting as designed by the University of Antwerp (www.global-pps.com).

RESULTS

Out of 1954 patients, 1516 (77.6%) were treated with antibiotics. The top three most reported indications for antibiotic use were prophylaxis for obstetrics or gynaecological indications (16.5%), gastrointestinal indications (12.6%) and lower respiratory tract infections (12.0%). The top three most commonly prescribed antibiotics were ceftriaxone (35.0%), metronidazole (16.0%) and ciprofloxacin (6.0%). Out of the total indications, 34.2% of antibiotics were prescribed for community-acquired infections (CAI), 5.9% for healthcare-associated infections (HAI), and 57.4% for either surgical or medical prophylaxis. Of the total use for surgical prophylaxis, 97.4% of antibiotics were given for more than one day.

CONCLUSIONS

Unnecessary prophylactic antibiotic use is extremely high, and broad-spectrum prescribing is common among hospitals in Pakistan. There is an urgent need to work on the  national action plan of Pakistan on antibiotic resistance to address this.

Comparative point prevalence survey of antimicrobial consumption between a hospital in Northern Ireland and a hospital in Jordan

Background

To assess antimicrobial prescribing in a Northern Ireland hospital (Antrim Area Hospital (AAH)) and compare them with those of a hospital in Jordan (Specialty Hospital).

Methods

Using the Global-PPS approach, the present study surveyed patients admitted to the hospital in 2015, the prescribed antibiotics, and a set of quality control indicators related to antibiotics.

Results

Ultimately, 444 and 112 inpatients in the AAH and the Specialty Hospital, respectively, were surveyed. For the medical group, 165 inpatients were prescribed 239 antibiotics in the AAH, while 44 patients in the Specialty Hospital were prescribed 65 antibiotics. In relation to the surgical group, 34 inpatients treated for infection were prescribed 66 antibiotics in the AAH, while 41 patients in the Specialty Hospital treated for infection were prescribed 56 antibiotics. For the medical patients, the most frequently prescribed antibiotics in the AAH were a combination of penicillins (18.8%) and penicillins with extended spectrum (18.8%). For the surgical patients, the most frequently prescribed antibiotics in the AAH were imidazole derivatives (24.2%). For the medical and surgical patients in the Specialty Hospital, the most frequently prescribed antibiotics were third-generation cephalosporins (26.2 and 37.5%, respectively). In medical patients, compliance to guidelines was 92.2% in the Specialty Hospital compared to 72.0% in the AAH (p < 0.001). In surgical patients, compliance to guidelines was 92.7% in the Specialty Hospital compared to 81.8% in the AAH (p = 0.012).

Conclusions

The present study highlighted differences in the utilisation of antimicrobials between two hospitals in two distinct regions and benchmarked antibiotic prescriptions across two hospitals.

Longitudinal point prevalence survey of antibacterial use in Northern Ireland using the European Surveillance of Antimicrobial Consumption (ESAC) PPS and Global-PPS tool

Antimicrobial resistance is a limiting factor for the success of the treatment of infectious diseases and is associated with increased morbidity and cost. The present study aims to evaluate prescribing patterns of antimicrobials and quantify progress in relation to targets for quality improvement in the prescription of antimicrobials in Northern Ireland's secondary care sector using three repetitive point prevalence surveys (PPS) over a 6-year period: the European Surveillance of Antimicrobial Consumption (ESAC-PPS) in 2009 and 2011 and the Global-PPS on Antimicrobial Consumption and Resistance in 2015. Out of 3605 patients surveyed over the three time points, 1239 (34.4%) were treated with an antibiotic, the most frequently prescribed antibiotic groups were a combination of penicillins, including β-lactamase inhibitors. Compliance with hospital antibiotic policies in 2009, 2011 and 2015 were 54.5%, 71.5% and 79.9%, respectively. Likewise, an indication for treatment was recorded in patient notes 88.5%, 87.7% and 90.6% in 2009, 2011 and 2015, respectively, and surgical prophylactic antibiotic prescriptions for >24 h was 3.9%, 3.2% and 0.7% in 2009, 2011 and 2015, respectively. Treatment based on biomarker data was used in 61.5% of cases. In conclusion, a general trend in the improvement of key antimicrobial-related quality indicators was noted. The PPS tool provided a convenient, inexpensive surveillance system of antimicrobial consumption and should be considered an essential component to establish and maintain informed antibiotic stewardship in hospitals.

The threat of antimicrobial resistance in developing countries: causes and control strategies

The causes of antimicrobial resistance (AMR) in developing countries are complex and may be rooted in practices of health care professionals and patients' behavior towards the use of antimicrobials as well as supply chains of antimicrobials in the population. Some of these factors may include inappropriate prescription practices, inadequate patient education, limited diagnostic facilities, unauthorized sale of antimicrobials, lack of appropriate functioning drug regulatory mechanisms, and non-human use of antimicrobials such as in animal production. Considering that these factors in developing countries may vary from those in developed countries, intervention efforts in developing countries need to address the context and focus on the root causes specific to this part of the world. Here, we describe these health-seeking behaviors that lead to the threat of AMR and healthcare practices that drive the development of AMR in developing countries and we discuss alternatives for disease prevention as well as other treatment options worth exploring.

The threat of antimicrobial resistance in developing countries: causes and control strategies

The causes of antimicrobial resistance (AMR) in developing countries are complex and may be rooted in practices of health care professionals and patients’ behavior towards the use of antimicrobials as well as supply chains of antimicrobials in the population. Some of these factors may include inappropriate prescription practices, inadequate patient education, limited diagnostic facilities, unauthorized sale of antimicrobials, lack of appropriate functioning drug regulatory mechanisms, and non-human use of antimicrobials such as in animal production. Considering that these factors in developing countries may vary from those in developed countries, intervention efforts in developing countries need to address the context and focus on the root causes specific to this part of the world. Here, we describe these health-seeking behaviors that lead to the threat of AMR and healthcare practices that drive the development of AMR in developing countries and we discuss alternatives for disease prevention as well as other treatment options worth exploring.

Antimicrobial prophylaxis outside the operating theatre, an audit in a university hospital

BACKGROUND

The prophylactic use of antimicrobial agents to prevent infections in non-surgical situations has hardly been investigated. We investigate the extent, indications and appropriateness of antimicrobial prophylaxis given outside the operating room in a tertiary care hospital.

METHODS

Four point-prevalence surveys were conducted in which all inpatients on that day were screened for the use of prophylactic antimicrobials: medical prophylaxis, prophylaxis around non-surgical interventions and surgical prophylaxis given on the ward. The primary endpoint was the extent of prophylaxis relative to the total number of antimicrobial prescriptions. We also investigated per prescription the presence of a (local) protocol and adherence to these protocols.

RESULTS

We registered in total 1020 antimicrobial prescriptions, of which 317 (31.1%) were given as prophylaxis. 827/1020 were antibiotic prescriptions. Of these antibiotic prescriptions, 17.0% was medical prophylaxis, 2.7% prophylaxis around non-surgical interventions and 6.9% surgical prophylaxis administered on a ward. For medical antibiotic prophylaxis, a protocol was present in 125 of 141 prescriptions (88.7%); the protocol was followed in 118 cases (94.4%). For prophylaxis around non-surgical interventions and surgical prophylaxis on the wards, protocol presence and adherence rates were 59.1% and 92.3%, and 73.3% and 97.6% respectively. Of the 96 antiviral and 97 antifungal prescriptions, 42.7% and 57.8%, respectively, were medical prophylaxis, of which 95.1 and 96.3% were prescribed according to protocols respectively.

CONCLUSIONS

Antimicrobial prophylaxis outside the operating theatre is responsible for a considerable part of total in-hospital antimicrobial use. For most prescriptions there was a protocol and adherence to the protocols was high. The main targets for improvement were prophylaxis around non-surgical interventions and surgical prophylaxis given on the ward.

Antimicrobial agents' utilization and cost pattern in an Intensive Care Unit of a Teaching Hospital in South India

Background and Aims:

High utilization and inappropriate usage of antimicrobial agents (AMAs) in an Intensive Care Unit (ICU) increases resistant organisms, morbidity, mortality, and treatment cost. Prescription audit and active feedback are a proven method to check the irrational prescription. Measuring drug utilization in DDD/100 bed-days is proposed by the WHO to analyze and compare the utilization of drugs. Data of AMAs utilization are required for planning an antibiotic policy and for follow-up of intervention strategies. Hence, in this study, we proposed to evaluate the utilization pattern and cost analysis of AMA used in the ICU.

Methodology:

A prospective observational study was conducted for 1 year from January 1, 2014, to December 31, 2014, and the data were obtained from the ICU of a tertiary care hospital. The demographic data, disease data, relevant investigation, the utilization of different classes of AMAs (WHO-ATC classification) as well as individual drugs and their costs were recorded.

Results:

One thousand eight hundred and sixty-two prescriptions of AMAs were recorded during the study period with an average of 1.73 ± 0.04 prescriptions/patient. About 80.4% patients were prescribed AMAs during admission. Ceftriaxone (22.77%) was the most commonly prescribed AMA followed by piperacillin/tazobactam (15.79%), metronidazole (12%), amoxicillin/clavulanic acid (6.44%), and azithromycin (4.34%). Ceftriaxone, piperacillin/tazobactam, metronidazole, and linezolid were the five maximally utilized AMAs with 38.52, 19.22, 14.34, 8.76, and 8.16 DDD/100 bed-days respectively. An average cost of AMAs used per patient was 2213 Indian rupees (INR).

Conclusion:

A high utilization of AMAs and a high cost of treatment were noticed which was comparable to other published data, though an increased use of newer AMAs such as linezolid, clindamycin, meropenem, colistin was noticed.

Antibiotic consumption in Turkish hospitals; a multi-centre point prevalence study

This multi-centre study aimed to determine the antibiotic consumption in Turkish hospitals by point prevalence. Antibiotic consumption of 14 centres was determined using the DDD method. Among hospitalized patients, 44.8% were using antibiotics and the total antibiotic consumption was 674.5 DDD/1000 patient-days (DPD). 189.6 (28%) DPD of the antibiotic consumption was restricted while 484.9 (72%) DPD was unrestricted. Carbapenems (24%) and beta lactam/beta lactamase inhibitors (ampicillin-sulbactam or amoxicillin-clavulanate; 22%) were the most commonly used restricted and unrestricted antibiotics. Antibiotics were most commonly used in intensive care units (1307.7 DPD). Almost half of the hospitalized patients in our hospitals were using at least one antibiotic. Moreover, among these antibiotics, the most commonly used ones were carbapenems, quinolones and cephalosporins, which are known to cause collateral damage. We think that antibiotic resistance, which is seen at considerably high rates in our hospitals, is associated with this level of consumption.

Antimicrobial resistance of Staphylococcus aureus isolated from skin infections and its implications in various clinical conditions in Korea

BACKGROUND

Periodic investigations into patterns of antimicrobial resistance can help to optimize the efficacy of treatment and limit the development of resistance.

OBJECTIVES

The aim of this study was to update information on patterns of antimicrobial resistance in Staphylococcus aureus isolated from skin infections in South Korea.

METHODS

We retrospectively analyzed clinical information and in vitro antimicrobial resistance data for 965 clinical S. aureus isolates obtained from skin infections during 2010-2013 in a university hospital in South Korea.

RESULTS

The rate of resistance to oxacillin (methicillin-resistant S. aureus [MRSA]) was 47.4%. Similar rates of resistance to erythromycin (45.6%), fusidic acid (44.0%), and clindamycin (42.3%) were noted. The rate of resistance to mupirocin was 8.4%. Overall, 4.9% of isolates were resistant to both fusidic acid and mupirocin. None of the isolates showed resistance to habekacin, synercid, teicoplanin, or vancomycin. Generally, antimicrobial resistance rates did not increase from 2010 to 2013 except with reference to a few agents such as mupirocin and rifampin. Isolates from surgical patients, inpatients, non-dermatology outpatients, and adult patients showed relatively high rates of resistance to multiple antimicrobials. Resistance to mupirocin was not only lower than that to fusidic acid but was consistent across clinical contexts.

CONCLUSIONS

The prevalence of MRSA in skin infections in South Korea did not increase during 2010-2013. Isolates from dermatology outpatients showed relatively lower rates of resistance to multiple antimicrobials than isolates from non-dermatology outpatients. Among topical antimicrobials, resistance to mupirocin was relatively low regardless of clinical condition.

Point prevalence survey of antimicrobial utilization in a Canadian tertiary-care teaching hospital

Objectives: Inappropriate antimicrobial use can promote antimicrobial resistance, which is associated with increased patient morbidity and mortality. Identifying the pattern of antimicrobial use can provide data from which targeted antimicrobial stewardship interventions can be made. The primary objective was to identify the prevalence of antimicrobial use at a tertiary care teaching hospital with both acute and long-term care patients.

Methods: A point prevalence study was conducted on July 19th, 2012. Data on antimicrobial utilization, indication for prescribing, duration of therapy, and frequency of infectious disease or antimicrobial stewardship consultations were collected using a customized integrated stewardship database (SPIRIT) and prospective chart review.

Results: One or more antimicrobial agents were ordered in 31% and 4% of acute care and long-term care patients, respectively. Respiratory and urinary tract infections were the most common indication for antimicrobial therapy in both acute and long-term care. About 25% of surgical prophylaxis orders were prescribed for greater than 24 h.

Conclusion: This prospective point prevalence survey provided important baseline information on antimicrobial use within a large tertiary care teaching hospital and identified potential targets for future antimicrobial stewardship initiatives. A multi-center point prevalence survey should be considered to identify patterns of antimicrobial use in Canada and to establish the first steps toward international antimicrobial surveillance.

Point prevalence survey on antibiotic use in a Croatian Infectious Disease Hospital

Antibiotic use is the driving force for increasing antibiotic resistance. A large proportion of antibiotics in hospitals are used inadequately. The objective of this study was to evaluate antibiotic use at the Hospital for Infectious Diseases through point-prevalence surveys conducted in 2006, 2008, and 2009. Point prevalence surveys were part of the European Surveillance on Antimicrobial Consumption (ESAC) Hospital Care Subproject and patients' data were collected following ESAC protocol. Additionally, the adequacy of antimicrobial therapy and administration of the first line antibiotic according to the local guidelines were assessed by an infectious disease doctor and a clinical microbiologist. In the study period among the 599 patients admitted to hospital, 352 (58·8%) received antibiotics. Out of 448 antimicrobial treatments, 313 (69·9%) were administered parenterally and 135 (30·1%) orally. Altogether in years 2006, 2008, and 2009 the most commonly prescribed antibiotics were ceftriaxone (19·9%), co-amoxiclav (15·4%), ciprofloxacin (12·3%), narrow spectrum penicillins (6·5%), and penicillinase resistant penicillins (5·6%). Most (82·6%) of the treated infections were community acquired infections. The predominating diagnoses were urinary tract infections and infections with no primary site defined, followed by skin, soft tissue and bone and joint infections. The overall adequacy of antimicrobial therapy was 82% and the first line antibiotic according to the local guidelines was administered with high frequency for central nervous system and cardiovascular infections (100%), and low for ear, nose, and throat infections, urinary tract infections, lower respiratory tract and bone and joint infections (23·0%, 51·6%, 52·5%, 65·0%, respectively) which indicates a significant overuse of antibiotics for diagnoses listed. The results of an individual point prevalence survey provided reliable and representative data for the hospital. Point-prevalence surveys proved to be a valuable method for detecting targets for antibiotic prescribing improvement and they clearly showed that our local hospital guidelines offered too many choices of antibiotic treatment for each clinical indication and needed revision.

Application of ATC/DDD methodology to evaluate of antibiotic use in a general hospital in Turkey

Background

The aim of this study is to evaluate in-house antibiotic use in a state hospital in Turkey with its cost, using the ATC/DDD index, which is an accepted standard method.

Methods

This study was performed as a point prevalence study in a state hospital with 372 beds. All in-house patients using antibiotics on July 19, 2011 were included in the study. Indications for antibiotic use and information about the patients were recorded on special forms. Antibiotic use and cost analysis were evaluated using the ATC/DDD index, which is also suggested by the WHO to be used in similar studies.

Findings

147 patients out of 308 patients who were in-house were identified to use antibiotics with appropriate indications for prophylaxis or treatment in 61% of the patients. The rate of appropriate antibiotic use was identified to be in 78%, while this rate was 38.9% in surgical clinics. The daily cost of the antibiotics consumed on the date of the study was calculated as 4104.79 TL (=2476.80 USD).

Discussion

The rate of inappropriate use of antibiotics seems to be high in our hospital. This will result in both increased costs and also increased nosocomial infection rates with resistant species. Infectious disease specialists should take more active roles in the in-house antibiotic use, hospitals should prepare and implement their own principles of antibiotic use, and microbiology laboratories should be used more effectively. These measures would decrease the conspicuous shortcomings in the antibiotic use.

Point prevalence survey of antimicrobial utilization in the cardiac and pediatric critical care unit

OBJECTIVES

To determine the rate of documented infections and prevalence of antimicrobial use among pediatric patients admitted to the PICU. To assess the appropriateness of antimicrobial prescribing according to clinical and microbiological findings, Infectious Disease Consult recommendations, and formulary guidelines.

DESIGN

Prospective point prevalence study.

SETTING

Cardiac and medical-surgical critical care units (CCCU-PICU) in a tertiary care pediatric teaching hospital in Toronto, Canada.

PATIENTS

All patients admitted to the CCCU-PICU during the week of October 27, 2008 (period A) and February 9, 2009 (period B) were followed until completion of their antimicrobial course(s). Data were collected on infection types and indications, frequency, and types of antimicrobials used. Appropriateness of antimicrobial prescribing was assessed according to predefined criteria by four blinded clinician assessors.

MEASUREMENT AND MAIN RESULTS

Forty-two of 60 patients (70%) received antimicrobials in period A and 42 of 53 patients (79%) received antimicrobials in period B. Of the patients on antimicrobials, 45% in period A and 52% in period B had a definitive diagnosis of infection. Pneumonia and sepsis were the most common infections in period A, whereas pneumonia and other respiratory tract infections were the most common in period B. Antimicrobials were commonly prescribed for documented infection (38%) during period A and empiric therapy (47%) during period B. Cefazolin, cefuroxime, vancomycin, and gentamicin were the commonly used antimicrobials during both periods. Inappropriate antimicrobial use ranged from 16.7% to 61.9%, depending on assessors and surveillance period. The most common reasons for inappropriate use were overly broad spectrum, wrong dosage, and unwarranted overlap of spectrum.

CONCLUSIONS

There was a high prevalence of antimicrobial use in CCCU-PICU patients. Because a significant proportion of antimicrobial use was deemed inappropriate, interventions are required to optimize antimicrobial use in critically ill children.

Healthcare expenditures and increasing antimicrobial consumption in Turkey

OBJECTIVES

The aim of this study was to assess the trend in antimicrobial consumption in Turkey between 2007 and 2010.

METHODS

Antimicrobial consumption data were obtained from Intercontinental Medical Statistics Turkey office. The total antimicrobial consumption data were calculated as Defined Daily Dose (DDD)/1000 inhabitant-days. The correlation between the previous five-year period and association with the main indicators of economy and healthcare services of the country were assessed.

RESULTS

Total utilization of antibiotics increased from 33.7 to 38.8 DDD/1000 inhabitant-days between 2007 and 2010. A steady increase took place during the study period. When this period was compared with the previous period (between 2001 and 2006), a similar trend was found. Turkey's total healthcare expenditure 2001 to 2010 increased from 4.5 billion Turkish Liras to 32 billion Turkish Liras.

CONCLUSION

In Turkey, antibiotic consumption increased steadily in recent years, with a close relation to government healthcare support policy, rising health expenditures and other economical indicators.

Infection control practice in countries with limited resources

Nosocomial infections and their control are a world-wide challenge. The prevalence of nosocomial infections is generally higher in developing countries with limited resources than industrialized countries. In this paper we aimed to further explain the differences with regard to infection control challenges between Turkey, a country with "limited" resources, and the Netherlands, a country with "reasonable" resources. Infrastructure of hospitals, low compliance of hand hygiene, understaffing, overcrowding, heavy workload, misuse of personal protective equipments, late establishment of infection control programme are major problems in limited-resources countries. These problems cause high infection rates and spread of multi-drug resistant pathogens. To improve the control and prevention of infections in countries with limited resources, a multi-facet approach is needed.

European Surveillance of Antimicrobial Consumption (ESAC): value of a point-prevalence survey of antimicrobial use across Europe

All 27 EU member states and another seven countries participate in the European Surveillance of Antimicrobial Consumption (ESAC) project. ESAC carried out three hospital point-prevalence surveys on antimicrobial use. Point-prevalence surveys linked antimicrobial use to indication and also assessed dosing using a standardized methodology for data collection and online data submission with feedback capability using a dedicated web-based tool. The objectives of the ESAC hospital point-prevalence surveys were to first determine the feasibility of a pan-European survey and identify targets for quality improvement. Hospitals were voluntarily selected by the lead national or hospital representatives for each country. The WHO Anatomical Therapeutic Chemical Classification of drugs was used for classification of antimicrobials. The three surveys were carried out during a maximum of 2 weeks in the second quarter of 2006, 2008 and 2009. Each department had to be surveyed in 1 day. All systemic antibacterials (J01), rifampicin (J04AB), oral vancomycin (A07AA) and oral/rectal metronidazole (P01AB) were the antimicrobials surveyed, including the prescribed regimen. The number of participating hospitals increased from 20 to 172 from 2006 to 2009. The patient demographics and indications for treatment were similar throughout the three point-prevalence surveys. 'Reason in notes' and 'surgical prophylaxis >24 hours' were also similar. Guideline compliance (51%) was only introduced in the 2009 point-prevalence survey, replacing 'sample for culture and sensitivity' (<50% in 2006 and 2008) since samples were either not taken or no information was available for the majority (>50%) of patients. The use of combination therapy, although exhibiting a wide range within each category, was related to hospital type, with teaching and tertiary hospitals having a significantly higher use of combination therapy (teaching : non-teaching hospitals [p < 0.0001]; and primary : tertiary hospitals [p < 0.0001]). Point-prevalence surveys are useful when time and resources do not allow for continuous surveillance. Repeated point-prevalence surveys within the same institution(s) can be used to monitor trends and effectiveness of antimicrobial-stewardship initiatives. Targets should be set as quality indicators for the individual hospital(s) and effectiveness of any intervention monitored through repeated point-prevalence surveys. Spin-off initiatives, such as the Antibiotic Resistance and Prescribing in European Children, and the European Centre for Disease Prevention and Control point-prevalence survey on healthcare-associated infections and antimicrobial use, will utilize adapted versions of WebPPS, the point-prevalence survey software developed by ESAC. WebPPS will also be made available for non-commercial use to third parties. Interest has been shown from three continents outside Europe, namely North America, Australia and Africa.

Factors associated with the prevalence of antibiotic use for the treatment of hospital-acquired infections at 393 French hospitals: a regional variation analysis

OBJECTIVE

The present study investigated regional variations in antibiotic use for the treatment of hospital-acquired infections (HAIs) in France by means of a multilevel analysis, to identify targets for quality improvement.

METHODS

Data were obtained from the 2001 and 2006 French national point-prevalence surveys of HAIs and antibiotic use. The present study was conducted using data from 393 nonteaching public hospitals. Data included patient characteristics calculated at the hospital level (mean age and proportion of patients with the following: HAI, presence of a vascular catheter, presence of a urinary catheter, surgical procedure, and immunodeficiency) and hospital characteristics (size and presence of an intensive care unit). The regional effect was measured using a random intercept on a regional variable.

RESULTS

Overall, the prevalence of antibiotic use was 5.35% for both study years. The most commonly used antibiotics for HAIs were fluoroquinolones (2001, 1.33%; 2006, 1.35%) and combinations of penicillins with a β-lactamase inhibitor (2001, 0.92%; 2006, 1.02%). Mapping of antibiotic use showed wide variation between regions. The regional effect explained 3% of antibiotic variation in the unadjusted analysis. In the multivariable analysis, hospital size, high prevalence of patients with immunodeficiency, and infection characteristics explained 45% of the variability in antibiotic use. The regional effect was not retained in the final model.

CONCLUSION

The pattern of antibiotic use for HAIs differed over time, and regional variations were mostly explained by patient characteristics; there was no regional effect. Models that take data hierarchy into account are essential to better approach antibiotic use and develop relevant strategies for improvement.

Prescribing patterns and utilization of antimicrobial drugs in a tertiary care teaching hospital of a Caribbean developing country

This study aimed to evaluate the prescribing practices and utilization of antimicrobials in a tertiary care teaching hospital of a Caribbean developing country. A prospective observational cohort study was undertaken for a period of 12 weeks in the general wards and the intensive care unit (ICU) of the hospital. Demographic data, diagnoses on admission, antimicrobials prescribed, dosage and duration, route of administration, leukocyte count and microbiological culture and sensitivity reports were recorded. Hospital length of stay and final outcome were recorded. The usage was determined in terms of prescribed daily dose and the total costs of antimicrobials were calculated. Of 889 patients admitted, 335 (37.7%) received 22 different antimicrobial drugs. Overall, 67% of the prescriptions adhered to the hospital protocol. Median length of stay in the hospital was 7 days. Skin and soft tissue infections were the most common diagnoses for which antimicrobials were prescribed. Amoxicillin-clavulanate was the most common (32%) antimicrobial used. Eighty-nine percent of the antimicrobials were given through the intravenous route. Sixty percent of the patients received two antimicrobials, 26% received three, and 14% of patients were prescribed four or more antimicrobials during their stay at the hospital. There was significantly higher inappropriate choice of antimicrobials in ICU when compared with general wards (Mantel-Haenszel Odds Ratio 3.3; 95% Confidence Intervals 1.4, 7.7). Prescribing patterns did not strictly adhere to the hospital antimicrobial protocol. There is a need for monitoring and control of antimicrobial prescription.

Accuracy of consultations performed by infectious diseases trainees and factors associated with adherence to them

OBJECTIVES

Infectious diseases (ID) trainees should be familiar with duties relevant to consultation practice. In this study we aimed to analyze the ID trainee night/weekend shift consultation process in terms of consultant characteristics, types of recommendations, and compliance with recommendations.

METHODS

All consultations performed by ID trainees on the night shift and at the weekends between 10 June and 10 August 2004 were recorded prospectively on standardized forms. Infectious diseases specialists assessed the appropriateness of recommendations the day after each consultation. Recommendations were considered complied with if they were carried out within 72 hours of the consultation.

RESULTS

Of 440 consultations, 163 were for a clinically diagnosed infection (without specific antibiotic request) and 79 were for treatment continuation. Overall, 152 consultations were for requesting specific antibiotic(s), and 327 antibiotics were recommended or approved in 270 consultations. Eight of these recommendations were inappropriate. Overall compliance to ID recommendations was 75.3% (418/555). In univariate analysis, the compliance rate to non-treatment recommendations (microbiologic cultures, radiology, biochemistry, etc.) was found to be lower than the rate of compliance to antibiotic recommendations (186/308 vs. 232/247, p<0.05). In addition, compliance to recommendations made by the first-year trainees was lower than to the recommendations made by the other trainees. In logistic regression analysis only recommendations including antibiotic treatment was associated with higher compliance (p=0.0001, odds ratio=10.2, 95% CI=5.7-18.3).

CONCLUSIONS

ID trainees are capable of evaluating patients and recommending appropriate antibiotics. Methodologies to improve the compliance to non-treatment-based recommendations and optimizing antibiotic selection seem to be necessary.

Short-term effect of antibiotic control policy on the usage patterns and cost of antimicrobials, mortality, nosocomial infection rates and antibacterial resistance

OBJECTIVES

In 2003 Turkish government released a new budget application instruction for regulating the usage of parenteral antibiotics inside and outside of the hospitals. In this study it was aimed to evaluate the effect of this instruction on the overall usage of restricted antibiotics, their cost, overall mortality, bacterial resistance patterns and nosocomial infection rates in intensive care units (ICUs) of our setting for March-October 2002 and March-October 2003 periods.

METHODS AND RESULTS

Overall daily defined dose/1000 patients/day of restricted drugs decreased, whereas unrestricted drugs increased significantly after the instruction. The cost of all analysed drugs in 2003 period was 540,303USD (-19.6%) less than 2002 period. Nosocomial infection rates in ICUs decreased significantly (p<0.05). When all microbiologically confirmed nosocomial bacteremia cases during the study period were analysed, amoxycilline/clavulanate, ciprofloxacin, cefuroxime, cefotaxime, piperacilline/tazobactam resistance and ESBL rate in Klebsiella pneumoniae decreased significantly (p<0.05). Amikacin resistance in Escherichia coli and Acinetobacter baumannii increased significantly (p<0.05).

CONCLUSION

Antibiotic control is one of the most important and significant ways to save money, and to prevent antibacterial resistance.