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Huang L, Bao Y, Yi Q, Yu D, Wang H, Wang H, Liu Z, Zhu C, Meng Q, Chen Y, Wang W, Deng J, Liu G, Zheng Y, Yang Y. Molecular characteristics and antimicrobial resistance of invasive pneumococcal isolates from children in the post-13-valent pneumococcal conjugate vaccine era in Shenzhen, China. J Glob Antimicrob Resist 2024; 36:399-406. [PMID: 38266961 DOI: 10.1016/j.jgar.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 12/24/2023] [Accepted: 01/08/2024] [Indexed: 01/26/2024] Open
Abstract
OBJECTIVES This study aimed to evaluate the molecular epidemiology and antimicrobial resistance of invasive pneumococcal isolates from children in Shenzhen, China, in the early stage of the pneumococcal 13-valent conjugated vaccine (PCV-13) era from 2018 to 2020. METHODS Invasive pneumococcal strains were isolated from hospitalized children with invasive pneumococcal diseases (IPDs) from January 2018 to December 2020. The serotype identification, multilocus sequence typing (MLST), and antibiotic susceptibility tests were performed on all culture-confirmed strains. RESULTS Sixty-four invasive strains were isolated mainly from blood (70.3%). Prevalent serotypes were 23F (28.1%), 14 (18.8%), 19F (15.6%), 6A/B (14.1%), and 19A (12.5%), with a serotype coverage rate of 96.9% for PCV13. The most common sequence types (STs) were ST876 (17.1%), ST271 (10.9%), and ST320 (7.8%). Half of the strains were grouped in clonal complexes (CCs): CC271 (21.9%), CC876 (20.3%), and CC90 (14.1%). Meningitis isolates showed a higher resistance rate (90.9% and 45.5%) to penicillin and ceftriaxone than the rate (3.8% and 9.4%) of non-meningitis isolates. The resistance rates for penicillin (oral), cefuroxime, and erythromycin were 53.13%, 73.4%, and 96.9%, respectively. The dual ermB and mefA genotype was found in 81.3% of erythromycin-resistant strains. The elevated minimum inhibitory concentration (MIC) of β-lactam antibiotics and dual-genotype macrolide resistance were related mainly to three major serotype-CC combinations: 19F-CC271, 19A-CC271, and 14-CC876. CONCLUSION Invasive pneumococcus with elevated MICs of β-lactams and increased dual ermB and mefA genotype macrolide resistance were alarming. Expanded PCV13 vaccination is expected to reduce the burden of paediatric IPD and to combat antibiotic-resistant pneumococcus in Shenzhen.
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Affiliation(s)
- Lu Huang
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Laboratory of Infection and Microbiology, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, PR China; Shenzhen Children's Hospital, Guangdong, 518000, PR China
| | - Yanmin Bao
- Shenzhen Children's Hospital, Guangdong, 518000, PR China
| | - Qiuwei Yi
- Shenzhen Children's Hospital, Guangdong, 518000, PR China
| | - Dingle Yu
- Shenzhen Children's Hospital, Guangdong, 518000, PR China
| | - Heping Wang
- Shenzhen Children's Hospital, Guangdong, 518000, PR China
| | - Hongmei Wang
- Shenzhen Children's Hospital, Guangdong, 518000, PR China
| | - Zihao Liu
- Shenzhen Children's Hospital, Guangdong, 518000, PR China
| | - Chunqing Zhu
- Shenzhen Children's Hospital, Guangdong, 518000, PR China
| | - Qing Meng
- Shenzhen Children's Hospital, Guangdong, 518000, PR China
| | - Yunsheng Chen
- Shenzhen Children's Hospital, Guangdong, 518000, PR China
| | - Wenjian Wang
- Shenzhen Children's Hospital, Guangdong, 518000, PR China
| | - Jikui Deng
- Shenzhen Children's Hospital, Guangdong, 518000, PR China
| | - Gang Liu
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Laboratory of Infection and Microbiology, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, PR China
| | - Yuejie Zheng
- Shenzhen Children's Hospital, Guangdong, 518000, PR China.
| | - Yonghong Yang
- Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics, Laboratory of Infection and Microbiology, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, PR China.
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Harun MGD, Sumon SA, Hasan I, Akther FM, Islam MS, Anwar MMU. Barriers, facilitators, perceptions and impact of interventions in implementing antimicrobial stewardship programs in hospitals of low-middle and middle countries: a scoping review. Antimicrob Resist Infect Control 2024; 13:8. [PMID: 38263235 PMCID: PMC10804809 DOI: 10.1186/s13756-024-01369-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/15/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) are pivotal components of the World Health Organization's Global Action Plan to combat antimicrobial resistance (AMR). ASPs advocate rational antibiotic usage to enhance patient-centered outcomes. However, existing evidence on ASPs and their determinants is largely limited to well-equipped hospitals in high-income nations. OBJECTIVE This scoping review aimed to examine the current state of hospital-based ASPs in low- and middle-income countries (LMICs), shedding light on barriers, facilitators, prescribers' perceptions and practices, and the impact of ASP interventions. DESIGN Scoping review on ASP. METHODS Adhering to PRISMA guidelines, we conducted electronic database searches on PubMed, Scopus, and Google Scholar, covering ASP articles published between January 2015 and October 2023. Our review focused on four key domains: barriers to ASP implementation, facilitators for establishing ASP, ASP perceptions and practices of prescribers, and the impact of ASP interventions. Three reviewers separately retrieved relevant data from the included citations using EndNote 21.0. RESULTS Among the 7016 articles searched, 84 met the inclusion criteria, representing 34 LMICs. Notably, 58% (49/84) of these studies were published after 2020. Barriers to ASP implementation, including human-resources shortage, lack of microbiology laboratory support, absence of leadership, and limited governmental support, were reported by 26% (22/84) of the studies. Facilitators for hospital ASP implementation identified in five publications included the availability of antibiotic guidelines, ASP protocol, dedicated multidisciplinary ASP committee, and prompt laboratory support. The majority of the research (63%, 53/84) explored the impacts of ASP intervention on clinical, microbiological, and economic aspects. Key outcomes included increased antibiotic prescription appropriateness, reduced antimicrobial consumption, shorter hospital stays, decreased mortality rate, and reduced antibiotic therapy cost. CONCLUSIONS The published data underscores the imperative need for widespread antimicrobial stewardship in LMIC hospital settings. Substantial ASP success can be achieved through increasing human resources, context-specific interventions, the development of accessible antibiotic usage guidelines, and heightened awareness via training and education.
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Affiliation(s)
- Md Golam Dostogir Harun
- Infectious Diseases Division, icddr, b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh.
| | - Shariful Amin Sumon
- Infectious Diseases Division, icddr, b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Istiaque Hasan
- Infectious Diseases Division, icddr, b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Fairoze Masuda Akther
- Infectious Diseases Division, icddr, b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
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3
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He J, You E, Zhong Q, Huang F. Trends and seasonal variation of antibiotic consumption by community residents in Hefei, China, 2012-2016. Public Health 2023; 220:27-32. [PMID: 37229945 DOI: 10.1016/j.puhe.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/13/2023] [Accepted: 04/19/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the trends and seasonal variations of antibiotic consumption by community residents in Hefei, China, over a 5-year period. STUDY DESIGN This was an ecological study. METHODS Data on antibiotic consumption by community residents in Hefei between 2012 and 2016 were collected from the Hefei Center for Disease Control and Prevention. Statistical analysis was carried out using Microsoft Excel 2021, SPSS 26.0 and R4.1.3. An interrupted time series (ITS) analysis was modelled to assess the impact of policies on antibiotic consumption trends. RESULTS Amoxicillin and cephalosporins accounted for 63.64% and 30.48%, respectively, of the total defined daily dose per 1000 inhabitant-days (DID) of antibiotics in 2016. The total consumption of antibiotics decreased from 6.92 DID in 2012 to 5.61 DID in 2016 (Ptrend = 0.017). Seasonal analysis showed an average of 34.24% antibiotic consumption in the winter over the 5 years. The equation constructed by the ITS analysis was Y = 5.530 + 0.323X1 - 7.574X2 - 0.323X3 + ε. CONCLUSION Between 2012 and 2016, overall antibiotic consumption by community residents in Hefei decreased significantly. The impact of antibiotic policies, implemented between 2011 and 2013, started to appear in 2014 when the consumption of antibiotics decreased. This study has important policy implications for the use of antibiotics at the community level. Further studies on the trends of antibiotic consumption are required, and strategies should be designed to promote appropriate use of antibiotics.
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Affiliation(s)
- J He
- School of Public Health, Anhui Medical University, Hefei, Anhui, PR China
| | - E You
- Hefei Center for Disease Control and Prevention, Hefei, Anhui, PR China
| | - Q Zhong
- School of Public Health, Anhui Medical University, Hefei, Anhui, PR China.
| | - F Huang
- School of Public Health, Anhui Medical University, Hefei, Anhui, PR China.
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Antibiotic Culture: A History of Antibiotic Use in the Second Half of the 20th and Early 21st Century in the People’s Republic of China. Antibiotics (Basel) 2023; 12:antibiotics12030510. [PMID: 36978376 PMCID: PMC10044684 DOI: 10.3390/antibiotics12030510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/26/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
Antimicrobial resistance is now widely regarded as a global public health threat. A growing number of studies suggest that antibiotic resistance is higher in China than in most western countries. Despite the current official regulation prohibiting pharmacies from the unrestricted selling of antibiotics, there is little sign of declining consumer demand. China now ranks as the second largest consumer of antibiotics in the world, after India. Drawing on published historical data, unpublished archival documents, and recently collected oral interviews, this paper provides a historical overview of antibiotic use and abuse in the People’s Republic of China (PRC) from the second half of the 20th century to the present. It demonstrates how the political demand for health improvement, along with the state-sponsored popularization of allopathic medicine, on the one hand, and the lack of access to adequate medical care for the majority of the population, as well as the existing culture of self-medication, on the other hand, are working in tandem to create antibiotic dependency in China. In addition, the privatization and marketization of biomedicine and health care in post-Mao China have helped to build a new and ever-thriving network of production, distribution, and marketing of antibiotics, which has often proven difficult for the authorities to monitor. At the same time, increased purchasing power and easier accessibility created by this new network of production, distribution, and marketing have further contributed to the prevalence of antibiotic overuse in the late 20th and early 21st centuries.
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5
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Shen L, Wei X, Yin J, Haley DR, Sun Q, Lundborg CS. Interventions to optimize the use of antibiotics in China: A scoping review of evidence from humans, animals, and the environment from a One Health perspective. One Health 2022; 14:100388. [PMID: 35686150 PMCID: PMC9171522 DOI: 10.1016/j.onehlt.2022.100388] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 04/02/2022] [Accepted: 04/03/2022] [Indexed: 12/28/2022] Open
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Coope C, Schneider A, Zhang T, Kadetz P, Feng R, Lambert H, Wang D, Oliver I, Michie S, Cabral C. Identifying key influences on antibiotic use in China: a systematic scoping review and narrative synthesis. BMJ Open 2022; 12:e056348. [PMID: 35338063 PMCID: PMC8961142 DOI: 10.1136/bmjopen-2021-056348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 02/15/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The inappropriate use of antibiotics is a key driver of antimicrobial resistance. In China, antibiotic prescribing and consumption exceed recommended levels and are relatively high internationally. Understanding the influences on antibiotic use is essential to informing effective evidence-based interventions. We conducted a scoping review to obtain an overview of empirical research about key behavioural, cultural, economic and social influences on antibiotic use in China. METHODS Searches were conducted in Econlit, Medline, PsycINFO, Social Science citation index and the Cochrane Database of Systematic Reviews for the period 2003 to early 2018. All study types were eligible including observational and intervention, qualitative and quantitative designs based in community and clinical settings. Two authors independently screened studies for inclusion. A data extraction form was developed incorporating details on study design, behaviour related to antibiotic use, influences on behaviour and information on effect (intervention studies only). RESULTS Intervention studies increased markedly from 2014, and largely focused on the impact of national policy and practice directives on antibiotic use in secondary and tertiary healthcare contexts in China. Most studies used pragmatic designs, such as before and after comparisons. Influences on antibiotic use clustered under four themes: antibiotic prescribing; adherence to antibiotics; self-medicating behaviour and over-the-counter sale of antibiotics. Many studies highlighted the use of antibiotics without a prescription for common infections, which was facilitated by availability of left-over medicines and procurement from local pharmacies. CONCLUSIONS Interventions aimed at modifying antibiotic prescribing behaviour show evidence of positive impact, but further research using more robust research designs, such as randomised trials, and incorporating process evaluations is required to better assess outcomes. The effect of national policy at the primary healthcare level needs to be evaluated and further exploration of the influences on antibiotic self-medicating is required to develop interventions that tackle this behaviour.
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Affiliation(s)
- Caroline Coope
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Annegret Schneider
- Population Health Sciences, University of Bristol, Bristol, UK
- Centre for Behaviour Change, University College London, London, UK
| | - Tingting Zhang
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Paul Kadetz
- Queen Margaret University, Institute for Global Health and Development, Edinburgh, UK
| | - Rui Feng
- Library, Anhui Medical University, Hefei, Anhui, China
| | - Helen Lambert
- Population Health Sciences, University of Bristol, Bristol, UK
| | - DeBin Wang
- School of Health Services Management, Anhui Medical University, Hefei, Anhui, China
| | - Isabel Oliver
- Field Service, National Infection Service, Public Health England National Infection Service, Salisbury, UK
| | - Susan Michie
- Centre for Behaviour Change, University College London, London, UK
| | - Christie Cabral
- Population Health Sciences, University of Bristol, Bristol, UK
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Setiawan E, Abdul-Aziz MH, Roberts JA, Cotta MO. Hospital-Based Antimicrobial Stewardship Programs Used in Low- and Middle-Income Countries: A Scoping Review. Microb Drug Resist 2022; 28:566-584. [PMID: 35333607 DOI: 10.1089/mdr.2021.0363] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The burden of antimicrobial resistance (AMR) is considerable in many low- and middle-income countries (LMICs), and it is important to describe the antimicrobial stewardship program (ASP) activities found in these countries and report their impact. Importantly, as these programs target prescribing behavior, the factors influencing prescription of antimicrobials must also be taken into account. This scoping review aimed to (1) describe hospital-based ASP activities, (2) report methods used to measure the impact of ASPs, and (3) explore factors influencing antimicrobial prescribing behavior in LMICs. PubMed was searched from database inception until April 2021. Factors influencing antimicrobial prescribing behavior were canvassed using the Capability-Opportunity-Motivation and Behavior framework. Most of ASP studies in LMICs were predominantly conducted in tertiary care and university-based hospitals. Audit of antimicrobial prescriptions with feedback and restrictive-based strategies was the main reported activity. Total antimicrobial consumption was the main method used to measure the impact of ASPs. Positive outcomes were observed for both clinical and microbiological outcomes; however, these were measured from nonrandomized controlled trials. Dominant factors identified through the behavioral framework were a limited awareness of AMR as a local problem, a perception that overprescription of antimicrobials had limited consequences and was mainly driven by a motivation to help improve patient outcomes. In addition, antimicrobial prescribing practices were largely influenced by existing hierarchy among prescribers. Our scoping review suggests that LMICs need to evaluate antimicrobial appropriateness as an added measure to assess impact. Furthermore, improvements in the access of microbiology and diagnostic facilities and ensuring ASP champions are recruited from senior prescribers will positively influence antimicrobial prescribing behavior, helping improve stewardship of antimicrobials in these countries.
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Affiliation(s)
- Eko Setiawan
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Clinical and Community Pharmacy; and Center for Medicines Information and Pharmaceutical Care (CMIPC), Faculty of Pharmacy, University of Surabaya, Surabaya, Indonesia
| | - Mohd-Hafiz Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Yoon YK, Kwon KT, Jeong SJ, Moon C, Kim B, Kiem S, Kim HS, Heo E, Kim SW. Guidelines on Implementing Antimicrobial Stewardship Programs in Korea. Infect Chemother 2021; 53:617-659. [PMID: 34623784 PMCID: PMC8511380 DOI: 10.3947/ic.2021.0098] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/17/2021] [Indexed: 12/11/2022] Open
Abstract
These guidelines were developed as a part of the 2021 Academic R&D Service Project of the Korea Disease Control and Prevention Agency in response to requests from healthcare professionals in clinical practice for guidance on developing antimicrobial stewardship programs (ASPs). These guidelines were developed by means of a systematic literature review and a summary of recent literature, in which evidence-based intervention methods were used to address key questions about the appropriate use of antimicrobial agents and ASP expansion. These guidelines also provide evidence of the effectiveness of ASPs and describe intervention methods applicable in Korea.
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Affiliation(s)
- Young Kyung Yoon
- Division of Infectious Diseases, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea.,Korean Society for Antimicrobial Therapy, Seoul, Korea
| | - Ki Tae Kwon
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Su Jin Jeong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Korean Society of Infectious Diseases, Seoul, Korea
| | - Chisook Moon
- Korean Society of Infectious Diseases, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, Inje University College of Medicine, Busan, Korea
| | - Bongyoung Kim
- Korean Society of Infectious Diseases, Seoul, Korea.,Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sungmin Kiem
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Division of Infectious Diseases, Department of Internal Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyung-Sook Kim
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Eunjeong Heo
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea.,Korean Society of Health-System Pharmacist, Seoul, Korea
| | - Shin-Woo Kim
- Korean Society for Antimicrobial Therapy, Seoul, Korea.,Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
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Qian X, Pan Y, Su D, Gong J, Xu S, Lin Y, Li X. Trends of Antibiotic Use and Expenditure After an Intensified Antimicrobial Stewardship Policy at a 2,200-Bed Teaching Hospital in China. Front Public Health 2021; 9:729778. [PMID: 34621721 PMCID: PMC8490695 DOI: 10.3389/fpubh.2021.729778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aimed to evaluate the effects of intensified Chinese special rectification activity on clinical antibiotic use (CSRA) policy on a tertiary-care teaching hospital. Methods: A 48-month longitudinal dataset involving inpatients, outpatients, and emergency patients were collected. Study period included pre-intervention stage (adopting soft measures like systemic training) and post-intervention stage (applying antibiotic control system to intensify CSRA policy). Antibiotic use was evaluated by antibiotic use rate (AUR) or antibiotic use density (AUD). Economic indicator was evaluated by antibiotic cost in prescription or antibiotic expenditure in hospitalization. Data was analyzed by interrupted time series (ITS) analysis. Results: The medical quality indicators remained stable or improved during the study period. AUR of inpatients (AURI) declined 0.553% per month (P = 0.025) before the intervention and declined 0.354% per month (P = 0.471) after the intensified CSRA policy was implemented. AUD, expressed as defined daily doses per 100 patients per day (DDDs/100PD), decreased by 1.102 DDDs/100PD per month (P = 0.021) before and decreased by 0.597 DDDs/100PD per month (P = 0.323) thereafter. The ratio of antibiotic expenditure to medication expenditure (AE/ME) decreased by 0.510% per month (P = 0.000) before and fell by 0.096% (P = 0.000) per month thereafter. AE per patient decreased by 25.309 yuan per month (P = 0.002) before and decreased by 7.987 yuan per month (P = 0.053) thereafter. AUR of outpatient (AURO) decreased by 0.065% per month before (P = 0.550) and decreased by 0.066% per month (P = 0.994) thereafter. The ratio of antibiotic cost to prescription cost in outpatient (ACO/PCO) decreased by 0.182% per month (P = 0.506) before and decreased by 0.216% per month (P = 0.906) thereafter. AUR of emergency patient (AURE) decreased by 0.400% per month (P = 0.044) before and decreased by 0.092% per month (P = 0.164) thereafter. The ratio of antibiotic cost to prescription cost in emergency patient (ACE/PCE) decreased by 0.616% per month (P < 0.001) before and decreased by 0.151% per month (P < 0.001) thereafter. Conclusions: Implementation of CSRA policy was associated with declining antibiotic use and antibiotic expenditure in inpatients, outpatients, and emergency patients. However, it is also important to note that the declining trend of antibiotic consumption slowed due to the limited capacity for decline in the later stages of CSRA intervention.
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Affiliation(s)
- Xiaodan Qian
- Department of Pharmacy, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, China
| | - Yuyan Pan
- Department of Pharmacy, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, China
| | - Dan Su
- Department of Pharmacy, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, China
| | - Jinhong Gong
- Department of Pharmacy, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, China
| | - Shan Xu
- Department of Pharmacy, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, China
| | - Ying Lin
- Department of Pharmacy, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, China
| | - Xin Li
- Department of Clinical Pharmacy, School of Pharmacy, Nanjing Medical University, Nanjing, China.,Department of Health Policy, School of Health Policy and Management, Nanjing Medical University, Nanjing, China.,Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
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10
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Yiang GT, Tzeng IS, Shui HA, Wu MY, Peng MY, Chan CY, Chan ED, Wu YK, Lan CC, Yang MC, Huang KL, Wu CW, Chang CH, Su WL. Early Screening of Risk for Multidrug-Resistant Organisms in the Emergency Department in Patients With Pneumonia and Early Septic Shock: Single-Center, Retrospective Cohort Study. Shock 2021; 55:198-209. [PMID: 32694392 DOI: 10.1097/shk.0000000000001599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Pneumonia is the fourth leading cause of death globally, with rapid progression during sepsis. Multidrug-resistant organisms (MDROs) are becoming more common with some healthcare-associated pneumonia events. Early detection of MDRO risk improves the outcomes; however, MDROs risk in pneumonia with sepsis is unknown. This study investigated the disease outcomes of pneumonia with septic shock in patients admitted in the emergency department (ED) intensive care unit (ICU), a population with a high prevalence of MDROs, after early screening of MDROs risk. METHODS In this retrospective cohort study, patients with pneumonia and early septic shock (n = 533) admitted to the ED at the Taipei Tzu Chi Hospital from 2013 to 2019 were selected. The study population was divided into four subgroups after the MDROs risk and screening procedure were completed within 1 or 6 h of admission. ICU mortality and multidrug antibiotic therapy were compared. RESULTS The high-risk MDROs groups had higher percentage of P aeruginosa than the low-risk group. Furthermore, the appropriate ED first antibiotics were higher in the 1-h subgroup than in the 6-h subgroup of the high-risk MDROs group. In multivariate analysis, the 6-h high-risk MDROs group had an adjusted odds ratio of 7.191 (95% CI: 2.911-17.767, P < 0.001) and 2.917 (95% CI: 1.456-5.847, P = 0.003) for ICU mortality and multidrug therapy in the ICU, respectively, after adjusting for other confounding factors. CONCLUSIONS MDRO screening within 1 h is recommended following admission of patients with pneumonia and early septic shock in the ED, especially in areas with a high prevalence of MDROs.
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Affiliation(s)
- Giou-Teng Yiang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - I-Shiang Tzeng
- Department of Medical Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Hao-Ai Shui
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Meng-Yu Wu
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ming-Yieh Peng
- Division of Infectious Disease, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chih-Yu Chan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Edward D Chan
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver at Anschutz Medical Center, Denver, Colorado
- Denver Veterans Affairs Medical Center, Denver, Colorado
- Department of Medicine, Division of the Mycobacterial and Respiratory Infections, National Jewish Health, Denver, Colorado
| | - Yao-Kuang Wu
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chou-Chin Lan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Mei-Chen Yang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Kuo-Liang Huang
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chih-Wei Wu
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chia-Hui Chang
- Divisions of Endocrine and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Wen-Lin Su
- School of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
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11
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Liu W, Hassan Gillani A, Xu S, Chen C, Chang J, Yang C, Ji W, Jiang M, Zhao M, Fang Y. Antibiotics (Macrolides and Lincosamides) Consumption Trends and Patterns in China's Healthcare Institutes. Based on a 3 Year Procurement Records, 2015-2017. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010113. [PMID: 33375251 PMCID: PMC7794919 DOI: 10.3390/ijerph18010113] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 02/08/2023]
Abstract
In this study, we investigated the trends and patterns of antibiotic consumption (macrolides and lincosamides) in China’s healthcare institutions from 2015 to 2017. The China Drug Supply Information Platform (CDSIP) was officially launched in 2015. We collected records from this national centralized bidding procurement system between 2015 and 2017. The use of J01F antibiotics (macrolides or lincosamides) was calculated in a defined daily dose per 1000 inhabitants per day (DID).Purchase data from 70,366 national medical facilities included in the CDSIP were collected. The procurement data of 66,007 medical facilities have not changed over 3 years. There is a slight decline in the consumption of J01F antibiotics, which decreased from 3.03 DID in 2015 to 2.91 DID in 2017. Azithromycin (20.6%) was the most commonly used antibiotic in 2017 among all classes, followed by clindamycin (17.9%) and erythromycin (13.7%). Parenteral antibiotics accounted for 32.0% of total antibiotic consumption and 59.6% of total antibiotics expenditure in 2017. The overall consumption of most antibiotics decreased slightly over the 3-yearstudy period. This may be owing to China’s health-related policies in the past few years. A gap still exists in antibiotic use between regions and dosage forms. Further studies are needed to optimize antibiotic prescribing and reduce antibiotic resistance.
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Affiliation(s)
- Wenchen Liu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China; (W.L.); (A.H.G.); (S.X.); (C.C.); (C.Y.); (W.J.); (M.J.); (M.Z.)
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an 710061, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an 710061, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an 710049, China
| | - Ali Hassan Gillani
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China; (W.L.); (A.H.G.); (S.X.); (C.C.); (C.Y.); (W.J.); (M.J.); (M.Z.)
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an 710061, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an 710061, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an 710049, China
| | - Sen Xu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China; (W.L.); (A.H.G.); (S.X.); (C.C.); (C.Y.); (W.J.); (M.J.); (M.Z.)
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an 710061, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an 710061, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an 710049, China
| | - Chen Chen
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China; (W.L.); (A.H.G.); (S.X.); (C.C.); (C.Y.); (W.J.); (M.J.); (M.Z.)
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an 710061, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an 710061, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an 710049, China
| | - Jie Chang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China; (W.L.); (A.H.G.); (S.X.); (C.C.); (C.Y.); (W.J.); (M.J.); (M.Z.)
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an 710061, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an 710061, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an 710049, China
- Correspondence: (J.C.); (Y.F.); Tel.: +86-29-82655132 (J.C. & Y.F.); Fax: +86-29-82655424 (Y.F.)
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China; (W.L.); (A.H.G.); (S.X.); (C.C.); (C.Y.); (W.J.); (M.J.); (M.Z.)
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an 710061, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an 710061, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an 710049, China
| | - Wenjing Ji
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China; (W.L.); (A.H.G.); (S.X.); (C.C.); (C.Y.); (W.J.); (M.J.); (M.Z.)
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an 710061, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an 710061, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an 710049, China
| | - Minghuan Jiang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China; (W.L.); (A.H.G.); (S.X.); (C.C.); (C.Y.); (W.J.); (M.J.); (M.Z.)
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an 710061, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an 710061, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an 710049, China
| | - Mingyue Zhao
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China; (W.L.); (A.H.G.); (S.X.); (C.C.); (C.Y.); (W.J.); (M.J.); (M.Z.)
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an 710061, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an 710061, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an 710049, China
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an 710061, China; (W.L.); (A.H.G.); (S.X.); (C.C.); (C.Y.); (W.J.); (M.J.); (M.Z.)
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an 710061, China
- Shaanxi Center for Health Reform and Development Research, Xi’an Jiaotong University, Xi’an 710061, China
- Research Institute for Drug Safety and Monitoring, Institute of Pharmaceutical Science and Technology, China’s Western Technological Innovation Harbor, Xi’an 710049, China
- Correspondence: (J.C.); (Y.F.); Tel.: +86-29-82655132 (J.C. & Y.F.); Fax: +86-29-82655424 (Y.F.)
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Yan K, Yang C, Zhang H, Ye D, Liu S, Chang J, Jiang M, Zhao M, Fang Y. Impact of the zero-mark-up drug policy on drug-related expenditures and use in public hospitals, 2016-2018: an interrupted time series study in Shaanxi. BMJ Open 2020; 10:e037034. [PMID: 33243788 PMCID: PMC7692976 DOI: 10.1136/bmjopen-2020-037034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE The aim of this study was to measure the impact of zero-mark-up drug policy (ZMDP) on drug-related expenditures and use in urban hospitals. DESIGN This was a retrospective observational study of trends in drug expenses and use in the context of the ZMDP using an interrupted time series analysis. SETTING Twelve hospitals (three tertiary hospitals and nine secondary hospitals) in Xi'an, which is the capital of Shaanxi Province in Western China. DATA AND PARTICIPANTS The prescription information for all outpatients and inpatients in the study hospitals from January 2016 to April 2018 was used in this study. INTERVENTIONS The Chinese government announced the policy intervention measure of the ZMDP, which was implemented in all public hospitals as of 1 April 2017. PRIMARY MEASURES Monthly drug expenditures, monthly medical expenditures, the percentage of drug expenditures among total medical expenditures, the average outpatient drug expenditure per visit, the percentage of prescriptions that include an injection and the percentage of prescriptions that include an antibiotic. RESULTS Monthly total medical expenses increased in both tertiary and secondary hospitals after the ZMDP was implemented. In tertiary hospitals, the average outpatient drug expenditures per visit showed a slow decreasing trend before the intervention and an increasing trend after the intervention, with statistically significant changes in both the level (p<0.001) and the trend (p=0.02). Secondary hospitals showed a slow increasing trend both before and after the policy implementation, with no significant change in the trend (p=0.205). The proportion of prescriptions, including injections, was over 20% in secondary hospitals and less than 20% in tertiary hospitals, with no significant changes to this indicator observed after implementation of ZMDP. CONCLUSIONS The effect of the ZMDP on drug-related expenditures and use in Chinese public hospitals was not substantially evident. Future pharmaceutical reform measures should give more consideration to physician prescription behaviours.
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Affiliation(s)
- Kangkang Yan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
- Department of Pharmacy, Xi'an No. 3 Hospital, the Affiliated Hospital of Northwest University, Xi'an, China
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Hongli Zhang
- Department of Pharmacy, Xi'an Central Hospital, Xi'an, China
| | - Dan Ye
- Department of Pharmacy, Xi'an No. 3 Hospital, the Affiliated Hospital of Northwest University, Xi'an, China
| | - Shengyuan Liu
- Department of Pharmacy, Xi'an No. 3 Hospital, the Affiliated Hospital of Northwest University, Xi'an, China
| | - Jie Chang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Minghuan Jiang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Mingyue Zhao
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
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13
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Li XX, Zheng SQ, Gu JH, Huang T, Liu F, Ge QG, Liu B, Li C, Yi M, Qin YF, Zhao RS, Shi LW. Drug-Related Problems Identified During Pharmacy Intervention and Consultation: Implementation of an Intensive Care Unit Pharmaceutical Care Model. Front Pharmacol 2020; 11:571906. [PMID: 33013415 PMCID: PMC7516263 DOI: 10.3389/fphar.2020.571906] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/20/2020] [Indexed: 12/29/2022] Open
Abstract
Aim To identify common drug-related problems (DRPs) during pharmacy intervention and consultation in an intensive care unit (ICU); to explore the gap between physicians and pharmacists on their understanding of each other’s capabilities and needs. Method We conducted a single-center prospective study in the ICU of a tertiary academic hospital for 21 months. A pharmaceutical care (PC) model was implemented by a pharmacy team, and data were collected during pharmacy intervention and consultation. Data analysis was performed on identified DRPs, causes and their relationships. DRPs’ frequency during intervention and consultation was compared. Problem-level descriptive analysis and network analysis were conducted using R 3.6.3. Result Implementation of PC model greatly improved the efficacy of pharmacists in both interventions proposed to solve DRPs (from 13.6 to 20.1 cases per month) and number of patients being closely monitored (from 7.7 to 16.9 per month). Pharmacists identified 427 DRPs during pharmacy intervention with primarily adverse drug events (ADEs, 34.7%) and effect of treatment not optimal (25.5%), and 245 DRPs during consultation (mainly ADEs, 58.4%). About three-fifths DRPs were caused by antibiotics. Comparing DRPs identified during pharmacy intervention and consultation, physicians consulted pharmacists more on questions related to medication safety, while pharmacists also paid attention to treatment effectiveness, which was consulted less commonly. Conclusion Implementation of PC model is beneficial in guiding pharmacy practice and improving efficacy especially under limited human resources. Physicians and pharmacists shall continue ensuring drug safety and be familiar with the scope of PC and clinical need for a better cooperation.
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Affiliation(s)
- Xiao-Xiao Li
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Si-Qian Zheng
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Jia-Hui Gu
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China.,International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Tao Huang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China.,International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Fang Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Qing-Gang Ge
- Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China
| | - Bin Liu
- Information Management and Big Data Center, Peking University Third Hospital, Beijing, China
| | - Chao Li
- Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China
| | - Min Yi
- Department of Intensive Care Unit, Peking University Third Hospital, Beijing, China
| | - You-Fa Qin
- Department of Clinical Pharmacy, SSL Center Hospital of Dongguan City, Dongguan, China
| | - Rong-Sheng Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing, China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Lu-Wen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China.,International Research Center for Medicinal Administration, Peking University, Beijing, China
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14
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Han M, Zhang X. Impact of medical professionals on Carbapenem-resistant Pseudomonas aeruginosa: moderating effect of workload based on the panel data in China. BMC Health Serv Res 2020; 20:670. [PMID: 32690017 PMCID: PMC7372746 DOI: 10.1186/s12913-020-05535-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 07/13/2020] [Indexed: 12/18/2022] Open
Abstract
Background Antimicrobial resistance (AMR), especially carbapenem-resistant Pseudomonas aeruginosa (CRPA), causes a serious increase in morbidity, mortality and costs. Medical professionals play an important role in curbing AMR. Previous studies overlooked the impact of workload on the relationship between medical professionals and AMR. This study aimed to explore the relationship between medical professionals and the CRPA rate as well as the moderating effect of medical professionals’ workload on this relationship. Methods A provincial-level panel dataset from 2014 to 2017 was constructed. Medical professionals were measured by the numbers of physicians, registered nurses, pharmacists, and clinical microbiologists per 1000 population. Workload was measured by the number of daily physician visits. Fixed effect model and hierarchical regression analysis were performed to explore the moderating effect of workload on medical professionals and the CRPA rate. Results The numbers of physicians, registered nurses, pharmacists and clinical technicians were significantly negative associated with the CRPA rate (coef. = − 0.889, − 0.775, − 1.176, and − 0.822; P = 0.003, 0.003, 0.011, and 0.007, respectively). Workload had a significant and positive moderating effect on physicians, registered nurses, pharmacists, clinical technicians and the CRPA rate (coef. = 1.270, 1.400, 2.210, and 1.634; P = 0.004, 0.001, 0.035, and 0.003, respectively). Conclusions Increasing the number of medical professionals may help curb the CRPA rate. Measures aimed at reducing medical professionals’ workload should be implemented to further improve CRPA performance.
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Affiliation(s)
- Meng Han
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No.13. Hangkong Road, Wuhan, 430030, Hubei Province, China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No.13. Hangkong Road, Wuhan, 430030, Hubei Province, China.
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15
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Increased financial burdens and lengths of stay in patients with healthcare-associated infections due to multidrug-resistant bacteria in intensive care units: A propensity-matched case-control study. PLoS One 2020; 15:e0233265. [PMID: 32421700 PMCID: PMC7233534 DOI: 10.1371/journal.pone.0233265] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 05/03/2020] [Indexed: 12/22/2022] Open
Abstract
Background and objectives Incidence rates of healthcare-associated infections (HAIs) depend upon infection control policy and practices, and the effectiveness of the implementation of antibiotic stewardship. Amongst intensive care unit (ICU) patients with HAIs, a substantial number of pathogens were reported to be multidrug-resistant bacteria (MDRB). However, impacts of ICU HAIs due to MDRB (MDRB-HAIs) remain understudied. Our study aimed to evaluate the negative impacts of MRDB-HAIs versus HAIs due to non-MDRB (non-MRDB-HAIs). Methods Among 60,317 adult patients admitted at ICUs of a 2680-bed medical centre in Taiwan between January 2010 and December 2017, 279 pairs of propensity-score matched MRDB-HAI and non-MRDB-HAI were analyzed. Principal findings Between the MDRB-HAI group and the non-MDRB-HAI group, significant differences were found in overall hospital costs, costs of medical and nursing services, medication, and rooms/beds, and in ICU length-of-stay (LOS). As compared with the non-MDRB-HAI group, the mean of the overall hospital costs of patients in the MDRB-HAI group was increased by 26%; for categorized expenditures, the mean of costs of medical and nursing services of patients in the MDRB-HAI group was increased by 8%, of medication by 26.9%, of rooms/beds by 10.3%. The mean ICU LOS in the MDRB-HAI group was increased by 13%. Mortality rates in both groups did not significantly differ. Conclusions These data clearly demonstrate more negative impacts of MDRB-HAIs in ICUs. The quantified financial burdens will be helpful for hospital/government policymakers in allocating resources to mitigate MDRB-HAIs in ICUs; in case of need for clarification/verification of the medico-economic burdens of MDRB-HAIs in different healthcare systems, this study provides a model to facilitate the evaluations.
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16
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Xin C, Xia Z, Li G. The Impact Of Pharmaceutical Interventions On The Use Of Carbapenems In A Chinese Hospital: A Pre-Post Study. Infect Drug Resist 2019; 12:3567-3573. [PMID: 31814745 PMCID: PMC6863129 DOI: 10.2147/idr.s229009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/10/2019] [Indexed: 11/27/2022] Open
Abstract
Background The challenge of drug resistance to carbapenems is of international concern with leading to increased hospital lengths of stay, costs, and mortality rates. How to get rid of the vicious cycle of drug resistance, new drugs, and re-resistance, and even the emergence of all-drug-resistant bacteria that humans cannot cope with, are the major challenges we face. To date, data about pharmaceutical interventions on the use of carbapenems are currently limited. Patients and methods A retrospective cohort study was conducted to compare pre- and post-intervention in Tongde Hospital of Zhejiang Province. Pharmaceutical interventions were performed in the post-intervention group, including real time monitoring of medication orders, educative group activities, and making interventions to physicians. Intervention acceptance and outcomes, including the length of hospital stay, readmission rates, 30-day mortality, and utilization of carbapenems, which was evaluated by the daily defined doses (DDDs), the days of therapy (DOTs), and the cost of carbapenems, were reviewed. Results During the study, 593 interventions were provided by clinical pharmacists with an average acceptance rate of 82.79%. Compared with the pre-intervention group, prescriptions of carbapenems for pathogen-directed therapy were improved significantly in the post-intervention group (59.27% vs 21.74%, p=0.022). The DDDs decreased from 281.96 to 174.28 and DOTs decreased from 9.19 to 5.18 after pharmaceutical intervention, and the pharmaceutical interventions had significantly lower mean total cost of carbapenems ($13,828.8 vs $8137.1, p=0.004) and length of hospital stay (9.3±1.5 vs 15.9±2.2, p=0.014). There was a significant reduction in 30-day mortality in the post-intervention group (9.46% vs 17.86%, p=0.013) while there were no differences found in the 30-day readmission (20.19% vs 20.66%, p=0.99). Conclusion Implementation of pharmaceutical interventions in our hospital successfully improved the appropriateness of carbapenem prescribing overall, and reduced the DDDs, DOTs, length of hospital day, and cost of carbapenems.
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Affiliation(s)
- Chuanwei Xin
- Department of Pharmacy, Zhejiang Academy of Traditional Chinese Medicine, Tongde Hospital of Zhejiang Province, Hangzhou, People's Republic of China
| | - Zhongni Xia
- Department of Pharmacy, Zhejiang Academy of Traditional Chinese Medicine, Tongde Hospital of Zhejiang Province, Hangzhou, People's Republic of China
| | - Gonghua Li
- Department of Pharmacy, Zhejiang Academy of Traditional Chinese Medicine, Tongde Hospital of Zhejiang Province, Hangzhou, People's Republic of China
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Changes in the resistance and epidemiological characteristics of Pseudomonas aeruginosa during a ten-year period. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2019; 54:261-266. [PMID: 31628088 DOI: 10.1016/j.jmii.2019.08.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 07/05/2019] [Accepted: 08/14/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim of this study was to investigate the changes over a ten-year period in the resistance and epidemiological characteristics of Pseudomonas aeruginosa strains isolated from the Department of Respiratory in Southwest Hospital. METHODS Antimicrobial resistance was detected using the plate double dilution method. PCR amplification and sequencing were performed to evaluate the carbapenemase genes and the oprD gene. Bacterial genotypes were analyzed by multilocus sequence typing (MLST). Quantitative real-time PCR experiments were performed to assess the expression of efflux pump (mexA and mexX) and ampC gene. RESULTS We collected 233 P. aeruginosa isolates in 2006-2007 and 128 isolates in 2016-2017. The resistance rate of P. aeruginosa strains to the tested antibiotics was significantly lower in 2016-2017 than in 2006-2007. The MLST results showed 27 genotypes in 2006-2007 and 18 genotypes in 2016-2017. ST235 was the most prevalent sequence type, and there was no significant change in the genotypes over the ten-year period. Both VIM-2 and IMP-4 genes were found in 2006-2007, whereas only IMP-4 was found in 2016-2017. The oprD mutational inactivation was the main factor responsible for carbapenem resistance, and the overexpression of mexX had a good correlation with aminoglycoside resistance. CONCLUSION These results indicated that the antibiotic resistance of P. aeruginosa in our respiratory department decreased. The loss of oprD gene was the main mechanism of carbapenem resistance, and mexX overexpression was the major contributing factor to aminoglycoside resistance.
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Role of antimicrobial restrictions in bacterial resistance control: a systematic literature review. J Hosp Infect 2019; 104:125-136. [PMID: 31542456 DOI: 10.1016/j.jhin.2019.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 09/13/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Antimicrobial stewardship is considered as one of the most fundamental aspects of bacterial resistance control. Among the multitude of initiatives, restrictive strategies have been widely practiced in hospital settings. However, data concerning their potential effectiveness have not been methodically collected and evaluated to date. AIM To identify, collect and evaluate the available evidence regarding the impact of restrictive policies on bacterial resistance in hospital settings. METHODS A systematic literature review was conducted using the PubMed/Medline, Embase, Global Health and CINAHL Plus databases. FINDINGS In total, 5555 papers were retrieved in the search process, and 29 studies were included in the final analysis. There were no randomized studies, and the inherent limitations of the observational designs employed impede the deduction of safe conclusions. Seemingly beneficial interventions encompass the restriction of broad-spectrum cephalosporins in favour of beta-lactam/lactamase inhibitor combinations as well as the restriction of fluoroquinolones. Antimicrobial restrictions might also play a role in the control of vancomycin-resistant enterococci, while carbapenem stewardship in the form of the preferred use of ertapenem did not produce the anticipated results. Complex restrictions are not offered for informative comparative analyses. Hospital-wide policies could perhaps be superior to those confined to high-risk departments. Carbapenem-resistant Acinetobacter baumannii might be difficult to control through solely formulary interventions. CONCLUSION The presumably effective restrictive strategies rely mainly on inadequately tested hypotheses and low-quality evidence. Therefore, systematic, high-quality research is needed to confirm and expand comprehension of the subject so that the most successful policies are employed in the field.
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Guo W, Sun F, Liu F, Cao L, Yang J, Chen Y. Antimicrobial resistance surveillance and prediction of Gram-negative bacteria based on antimicrobial consumption in a hospital setting: A 15-year retrospective study. Medicine (Baltimore) 2019; 98:e17157. [PMID: 31517862 PMCID: PMC6750273 DOI: 10.1097/md.0000000000017157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Antimicrobial resistance, a major threat to human health, is mainly driven by the overuse of antimicrobials. The purpose of this study was to further investigate the relationship between antimicrobial use and resistance with a 15-year record in Southwest hospital, one of the largest hospitals in Southwest China and a university affiliated hospital, thus to further predict the antimicrobial resistance in an autoregressive integrated moving average (ARIMA) manner. Kirby-Bauer tests were carried out to figure out the drug sensitivity of Gram-negative bacterial. Antimicrobials (β-lactamase inhibitor complex, aminoglycosides, quinolones, third and fourth-generation cephalosporins, carbapenems, cephamycins, oxacephems, and sulfonamides) consumption were calculated according to World Health Organization (WHO) anatomical therapeutic chemical classification index and expressed as annual defined daily dose (DDD) or DDD per 1000 out patients. Resistance rates of levofloxacin-resistant Escherichia coli, ceftazidime-resistant Klebsiella pneumoniae, amikacin-resistant Bacterium levans, imipenem-resistant Pseudomonas aeruginosa is positively correlated with the usage of aminoglycosides and quinolones; resistance rates of imipenem-resistant Acinetobacter baumanii is positively correlated with the usage of carbapenemes (P-value between the drug resistance of levofloxacin-resistant E. coli, ceftazidime-resistant K. pneumoniae and the usage of aminoglycosides is under .05, the other P-value are under .01); resistance rates of the drug resistance of levofloxacin-resistant E. coli is positively correlated with the usage of oxacephems (P < .01); resistance rates of imipenem-resistant P. aeruginosa is positively correlated with the usage of oxacephems and sulfonamides (P < .01).The present study presents one of the largest and longest retrospective analyses in China between antimicrobial consumption and antimicrobial resistance. Change of the usage of several antibacterial drugs has great influence on the drug resistance of Gram-negative bacterial. Of particular, ARIMA forecasting revealed that carbapenem related bacterial resistance should be closely watched.
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Wang H, Wang H, Yu X, Zhou H, Li B, Chen G, Ye Z, Wang Y, Cui X, Zheng Y, Zhao R, Yang H, Wang Z, Wang P, Yang C, Liu L. Impact of antimicrobial stewardship managed by clinical pharmacists on antibiotic use and drug resistance in a Chinese hospital, 2010-2016: a retrospective observational study. BMJ Open 2019; 9:e026072. [PMID: 31377693 PMCID: PMC6687004 DOI: 10.1136/bmjopen-2018-026072] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES 'National Special Stewardship in the Clinical Use of Antibiotics' was put forward in July 2011 in China. We aimed to retrospectively evaluate the impact of antimicrobial stewardship (AMS) managed by clinical pharmacists on antibiotic utilisation, prophylaxis and antimicrobial resistance (AMR). DESIGN This was a retrospective observational study of trends in antibiotic use and AMR in the context of AMS. SETTING Beijing Chaoyang Hospital, a 1400-bed tertiary hospital, in China. DATA AND PARTICIPANTS Antibiotic prescriptions from 820 doctors included all outpatients (n=17 766 637) and inpatients (n=376 627) during 2010-2016. Bacterial resistance data were from all inpatients (n=350 699) during 2011-2016. INTERVENTIONS Multiaspect intervention measures were implemented by clinical pharmacists (13 persons), for example, formulating the activity programme and performance management, advising on antibacterial prescriptions and training. OUTCOME MEASURES The proportion of antibiotic prescriptions among outpatients and inpatients, intensity of consumption in defined daily dose (DDD)/100 bed-days, antibiotic prophylaxis in type I incision operations and resistance rates of Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa were retrospectively analysed. RESULTS The proportion of antibiotic prescriptions decreased in outpatients (from 19.38% to 13.21%) and in inpatients (from 64.34% to 34.65%), the intensity of consumption dropped from 102.46 to 37.38 DDD/100 bed-days. The proportion of antibiotic prophylaxis decreased from 98.94% to 18.93%. The proportion of rational timing of initial dose increased from 71.11% to 96.74%, the proportion of rational duration rose from 2.84% to 42.63%. Time series analysis demonstrated the resistance rates of E. coli and P. aeruginosa to fluoroquinolones decreased, the incidence rate of methicillin-resistant Staphylococcus aureus also decreased, whereas the resistance rates of E. coli and K. pneumoniae to carbapenems increased. The antibiotic use was partly positively correlated with AMR. CONCLUSIONS AMS had an important role in reducing antibiotic use and surgical antibiotic prophylaxis. The AMR was positively correlated with antibiotic consumption to some extent.
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Affiliation(s)
- Huaguang Wang
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Han Wang
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Xiaojia Yu
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Hong Zhou
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Boyu Li
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Gang Chen
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Zhikang Ye
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Ying Wang
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Xiangli Cui
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Yunying Zheng
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Rui Zhao
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Hui Yang
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Zihui Wang
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Peng Wang
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Chunxia Yang
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
| | - Lihong Liu
- Beijing Chaoyang Hospital, Capital University of Medical Sciences, Beijing, China
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Rogers Van Katwyk S, Grimshaw JM, Nkangu M, Nagi R, Mendelson M, Taljaard M, Hoffman SJ. Government policy interventions to reduce human antimicrobial use: A systematic review and evidence map. PLoS Med 2019; 16:e1002819. [PMID: 31185011 PMCID: PMC6559631 DOI: 10.1371/journal.pmed.1002819] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 05/03/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Growing political attention to antimicrobial resistance (AMR) offers a rare opportunity for achieving meaningful action. Many governments have developed national AMR action plans, but most have not yet implemented policy interventions to reduce antimicrobial overuse. A systematic evidence map can support governments in making evidence-informed decisions about implementing programs to reduce AMR, by identifying, describing, and assessing the full range of evaluated government policy options to reduce antimicrobial use in humans. METHODS AND FINDINGS Seven databases were searched from inception to January 28, 2019, (MEDLINE, CINAHL, EMBASE, PAIS Index, Cochrane Central Register of Controlled Trials, Web of Science, and PubMed). We identified studies that (1) clearly described a government policy intervention aimed at reducing human antimicrobial use, and (2) applied a quantitative design to measure the impact. We found 69 unique evaluations of government policy interventions carried out across 4 of the 6 WHO regions. These evaluations included randomized controlled trials (n = 4), non-randomized controlled trials (n = 3), controlled before-and-after designs (n = 7), interrupted time series designs (n = 25), uncontrolled before-and-after designs (n = 18), descriptive designs (n = 10), and cohort designs (n = 2). From these we identified 17 unique policy options for governments to reduce the human use of antimicrobials. Many studies evaluated public awareness campaigns (n = 17) and antimicrobial guidelines (n = 13); however, others offered different policy options such as professional regulation, restricted reimbursement, pay for performance, and prescription requirements. Identifying these policies can inform the development of future policies and evaluations in different contexts and health systems. Limitations of our study include the possible omission of unpublished initiatives, and that policies not evaluated with respect to antimicrobial use have not been captured in this review. CONCLUSIONS To our knowledge this is the first study to provide policy makers with synthesized evidence on specific government policy interventions addressing AMR. In the future, governments should ensure that AMR policy interventions are evaluated using rigorous study designs and that study results are published. PROTOCOL REGISTRATION PROSPERO CRD42017067514.
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Affiliation(s)
- Susan Rogers Van Katwyk
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School, York University, Toronto, Ontario, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Miriam Nkangu
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Ranjana Nagi
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School, York University, Toronto, Ontario, Canada
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Steven J. Hoffman
- Global Strategy Lab, Dahdaleh Institute for Global Health Research, Faculty of Health and Osgoode Hall Law School, York University, Toronto, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, and McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada
- Department of Global Health & Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
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Wilkinson A, Ebata A, MacGregor H. Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems. Antibiotics (Basel) 2018; 8:antibiotics8010002. [PMID: 30583566 PMCID: PMC6466578 DOI: 10.3390/antibiotics8010002] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/17/2018] [Accepted: 12/18/2018] [Indexed: 01/11/2023] Open
Abstract
This review identifies evidence on supply-side interventions to change the practices of antibiotic prescribers and gatekeepers in low- and middle-income countries (LMICs). A total of 102 studies met the inclusion criteria, of which 70 studies evaluated interventions and 32 provided insight into prescribing contexts. All intervention studies were from human healthcare settings, none were from animal health. Only one context study examined antibiotic use in animal health. The evidence base is uneven, with the strongest evidence on knowledge and stewardship interventions. The review found that multiplex interventions that combine different strategies to influence behaviour tend to have a higher success rate than interventions based on single strategies. Evidence on prescribing contexts highlights interacting influences including health system quality, education, perceptions of patient demand, bureaucratic processes, profit, competition, and cultures of care. Most interventions took place within one health setting. Very few studies targeted interventions across different kinds of providers and settings. Interventions in hospitals were the most commonly evaluated. There is much less evidence on private and informal private providers who play a major role in drug distribution in LMICs. There were no interventions involving drug detailers or the pharmaceutical companies despite their prominent role in the contextual studies.
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Affiliation(s)
- Annie Wilkinson
- Institute of Development Studies, University of Sussex, Brighton BN1 NRE, UK.
| | - Ayako Ebata
- Institute of Development Studies, University of Sussex, Brighton BN1 NRE, UK.
| | - Hayley MacGregor
- Institute of Development Studies, University of Sussex, Brighton BN1 NRE, UK.
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Yan K, Xue M, Ye D, Yang C, Chang J, Jiang M, Zhao M, Zhang H, Fang Y. Antibiotic prescribing practices in secondary and tertiary hospitals in Shaanxi province, western China, 2013-2015. PLoS One 2018; 13:e0207229. [PMID: 30540753 PMCID: PMC6291232 DOI: 10.1371/journal.pone.0207229] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 10/26/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction The irrational use of antibiotics is a major driver of antimicrobial resistance. This study aimed to explore how antibiotics were used in secondary and tertiary hospitals in Shaanxi Province, western China from 2013 to 2015. Method A retrospective study was conducted with a sample of 16 hospitals in Shaanxi Province (2 tertiary and 14 secondary hospitals; 8 public and 8 private hospitals) using a stratified random sampling method. All of the macro data from these hospitals from 2013 to 2015 were analyzed. All collected data were double-entered and analyzed using Excel 2007. Results The percentage of injectable antibiotic prescriptions was 26.6% of all of the antibiotic prescriptions in the secondary hospitals and 14.2% in the tertiary hospitals. Injectable antibiotic prescriptions in private tertiary hospitals (enter %) were more than two times that of public tertiary hospitals (enter %). In both tertiary and secondary hospitals, the percentage of antibiotic prescriptions for outpatients, emergency patients and inpatients were within the scope of the national standards, while the intensity of antibiotic use was higher than the national standard of 40 DDD/100 bed-days. The prophylactic antibiotic use rate in clean surgery was 40.4% in tertiary hospitals and 60.7% in secondary hospitals, which were both higher than the national standard of 30%. The preventive use rate of antibiotics in private tertiary hospitals (55.00%) was more than two times that of public tertiary hospitals (25.90%), and the rate was also higher in private secondary hospitals (61.50%) than in public secondary hospitals (59.70%). Conclusions Substantial antibiotic abuse occurred in the sample Chinese hospitals, especially in secondary hospitals. The government should continue to strengthen the administration of antimicrobial use in hospitals. At the same time, medical professional training and interventions for physicians should be conducted to fundamentally reduce the irrational use of antibiotics.
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Affiliation(s)
- Kangkang Yan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China
- Shaanxi Center for Health Reform and Development Research, Xi’an, China
- Department of Pharmacy, Xi’an No. 3 Hospital, Xi’an, China
| | - Meiling Xue
- Department of Drug and Equipment, No. 521 Hospital of Ordnance Industry, Xi’an, China
| | - Dan Ye
- Department of Pharmacy, Xi’an No. 3 Hospital, Xi’an, China
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China
- Shaanxi Center for Health Reform and Development Research, Xi’an, China
| | - Jie Chang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China
- Shaanxi Center for Health Reform and Development Research, Xi’an, China
| | - Minghuan Jiang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China
- Shaanxi Center for Health Reform and Development Research, Xi’an, China
| | - Mingyue Zhao
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China
- Shaanxi Center for Health Reform and Development Research, Xi’an, China
| | - Hongli Zhang
- Department of Pharmacy, Xi’an Central Hospital, Xi’an, China
| | - Yu Fang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong University, Xi’an, China
- Center for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China
- Shaanxi Center for Health Reform and Development Research, Xi’an, China
- * E-mail:
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Molina J, Peñalva G, Gil-Navarro MV, Praena J, Lepe JA, Pérez-Moreno MA, Ferrándiz C, Aldabó T, Aguilar M, Olbrich P, Jiménez-Mejías ME, Gascón ML, Amaya-Villar R, Neth O, Rodríguez-Hernández MJ, Gutiérrez-Pizarraya A, Garnacho-Montero J, Montero C, Cano J, Palomino J, Valencia R, Álvarez R, Cordero E, Herrero M, Cisneros JM. Long-Term Impact of an Educational Antimicrobial Stewardship Program on Hospital-Acquired Candidemia and Multidrug-Resistant Bloodstream Infections: A Quasi-Experimental Study of Interrupted Time-Series Analysis. Clin Infect Dis 2018; 65:1992-1999. [PMID: 29020166 DOI: 10.1093/cid/cix692] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/03/2017] [Indexed: 01/08/2023] Open
Abstract
Background The global crisis of bacterial resistance urges the scientific community to implement intervention programs in healthcare facilities to promote an appropriate use of antibiotics. However, the clinical benefits or the impact on resistance of these interventions has not been definitively proved. Methods We designed a quasi-experimental intervention study with an interrupted time-series analysis. A multidisciplinary team conducted a multifaceted educational intervention in our tertiary-care hospital over a 5-year period. The main activity of the program consisted of peer-to-peer educational interviews between counselors and prescribers from all departments to reinforce the principles of the proper use of antibiotics. We assessed antibiotic consumption, incidence density of Candida and multidrug-resistant (MDR) bacteria bloodstream infections (BSIs) and their crude death rate per 1000 occupied bed days (OBDs). Results A quick and intense reduction in antibiotic consumption occurred 6 months after the implementation of the intervention (change in level, -216.8 defined daily doses per 1000 OBDs; 95% confidence interval, -347.5 to -86.1), and was sustained during subsequent years (average reduction, -19,9%). In addition, the increasing trend observed in the preintervention period for the incidence density of candidemia and MDR BSI (+0.018 cases per 1000 OBDs per quarter; 95% confidence interval, -.003 to .039) reverted toward a decreasing trend of -0.130 per quarter (change in slope, -0.029; -.051 to -.008), and so did the mortality rate (change in slope, -0.015; -.021 to -.008). Conclusions This education-based antimicrobial stewardship program was effective in decreasing the incidence and mortality rate of hospital-acquired candidemia and MDR BSI through sustained reduction in antibiotic use.
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Affiliation(s)
- José Molina
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - Germán Peñalva
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | | | | | - José A Lepe
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | | | | | | | - Manuela Aguilar
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - Peter Olbrich
- Pediatric Infectious Diseases and Immunodeficiency, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spanish National Research Council, University of Seville
| | | | | | | | - Olaf Neth
- Pediatric Infectious Diseases and Immunodeficiency, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spanish National Research Council, University of Seville
| | | | | | - José Garnacho-Montero
- Department of Critical Care, University Hospital Virgen Macarena, University of Seville
| | - Cristina Montero
- Department of Pediatric Critical Care and Emergency, University Hospital Virgen del Rocio, Seville, Spain
| | - Josefina Cano
- Department of Pediatric Critical Care and Emergency, University Hospital Virgen del Rocio, Seville, Spain
| | - Julián Palomino
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - Raquel Valencia
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - Rocío Álvarez
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - Elisa Cordero
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - Marta Herrero
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
| | - José M Cisneros
- Departments of Infectious Diseases, Microbiology and Preventive Medicine
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Liu J, Yin C, Liu C, Tang Y, Zhang X. Modeling a Production Function to Evaluate the Effect of Medical Staffing on Antimicrobial Stewardship Performance in China, 2009-2016: Static and Dynamic Panel Data Analyses. Front Pharmacol 2018; 9:775. [PMID: 30072897 PMCID: PMC6060732 DOI: 10.3389/fphar.2018.00775] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 06/26/2018] [Indexed: 12/19/2022] Open
Abstract
Background: Antimicrobial resistance (AMR) is an international problem. Emergence and spread of AMR are strongly associated with overuse or inappropriate use of antimicrobials. Antimicrobial stewardship ensures the appropriate use of antimicrobials, and is an effective approach to control AMR. This study aims to understand the relationship between medical staffing and antimicrobial stewardship performance in China. Methods: A provincial-level panel dataset from 2009 to 2016 is used. A macro production function is used to quantify the relationship. The output, antimicrobial stewardship performance, is measured by changes in methicillin resistance rates of Staphylococcus. aureus (S. aureus) and coagulase-negative staphylococci (CoNS). The labor input is measured by the numbers of infectious diseases physicians, pharmacists, clinical microbiologists, and nurses in hospitals per 100,000 populations, whereas the capital input is represented by the number of hospital beds per 100,000 populations. The technology is captured by the time index. Both static and dynamic panel data approaches are employed. Results: The increasing number of clinical microbiologists is a significant predictor of lower resistance of CoNS according to dynamic models (Coef. = -0.191, -0.351; p = 0.070, 0.004, respectively). However, a larger number of nurses is significantly associated with higher resistance of S. aureus (Coef. = 0.648; p = 0.044). In addition, the numbers of the other two groups of medical professionals exhibit no significant associations with stewardship performance. Conclusions: The study demonstrates the crucial role of clinical microbiologists in antimicrobial stewardship. The predicted increased risk of resistance with the higher number of nurses may be attributable to their lack of related knowledge and their unrecognized functions in antimicrobial stewardship.
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Affiliation(s)
- Junjie Liu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chun Yin
- The Center for Modern Chinese City Studies & School of Urban and Regional Science, East China Normal University, Shanghai, China
| | - Chenxi Liu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuqing Tang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Introducing an antibiotic stewardship program in a pediatric center in China. World J Pediatr 2018; 14:274-279. [PMID: 29508365 DOI: 10.1007/s12519-018-0133-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/03/2017] [Accepted: 03/05/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND This study aimed to investigate the effect of antibiotic stewardship programs (ASP) on reducing antimicrobial resistance rate, antibiotics consumption and multi-drug resistance bacterial infections in the pediatric patients. METHODS This study was carried out in the Pediatric Center of a tertiary hospital of Shandong Province, China. The study duration was separated into two periods according to introduction of ASP (began from April 2011). Before intervention: from April 2009 to March 2011; after intervention: from April 2012 to March 2014. The consumption of antibiotics, defined daily dose (DDD), isolation of multidrug-resistant organisms (MDRO) and resistance rate of antibiotics were analyzed and compared between the two study periods. RESULTS Total antibiotics consumption (DDDs) reduced from 56,725 in 2011 to 31,380 in 2014; antibiotic use density (AUD) reduced from 93.8 to 43.5; mean (± SD) antibiotic costs per patient (per quarter) decreased from 637 (± 29) RMB to 462 (± 49) RMB; and the mean total drug consumption (g)/DDD (DDDs) for inpatients decreased from 90.4 (± 3.3) to 56.4 (± 9.5). Multidrug-resistant microorganisms isolation reduced significantly from 463 (20.0) to 216 (6.9%). Resistance rate of general spectrum antibiotics reduced remarkably after intervention. The proportion of patients colonized or infected with Carbapenems-resistant Acinetobacter baumannii was correlated with DDDs of carbapenem. CONCLUSIONS Implementation of ASP leads to reduced medical expense, decrease of improper and abuse of antibiotics, and reduced antibiotics resistance rate and MDRO isolation. Continuous efforts to improve antibiotic use are required.
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Wushouer H, Tian Y, Guan XD, Han S, Shi LW. Trends and patterns of antibiotic consumption in China's tertiary hospitals: Based on a 5 year surveillance with sales records, 2011-2015. PLoS One 2017; 12:e0190314. [PMID: 29281716 PMCID: PMC5744988 DOI: 10.1371/journal.pone.0190314] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 12/12/2017] [Indexed: 01/21/2023] Open
Abstract
The consumption of antibiotics is a major driver in the development of antimicrobial resistance. This study aims to identify the trends and patterns of the total antibiotic consumption in China's tertiary hospitals from 2011 to 2015 by retrospectively analyzing aggregated monthly surveillance data on antibiotic sales made to 468 hospitals from 28 provinces. Antibiotic consumption was expressed in DDD per 1,000 inhabitants per day (DID). We compared population weighted antibiotic consumption patterns in China with European countries using indicators from the European Surveillance of Antimicrobial Consumption (ESAC). Total antibiotic consumption, including all the specific antibiotic class except for aminoglycoside antibacterials, were significantly increased during the study period from an average of 7.97 DID in 2011 to 10.08 DID in 2015. In 2015, the eastern regions of China consumed the most antibiotics using population denominator while the western regions consumed the most using inpatient denominator. Cephalosporins accounted for 28.6% of total DID, followed by beta-lactam-beta-lactamase inhibitor combinations (20.0%), macrolides (17.4%), and fluoroquinolones (10.5%). Antibiotic in parenteral form accounted for nearly half of all antibiotics. Although over the past few years major efforts had been made to reduce the risks of excessive antibiotic use through antibiotic stewardship, total antibiotic consumption showed a significant upward trend during the study period. A consistent preference for cephalosporins, macrolides, beta-lactam-beta-lactamase inhibitor combinations, as well as parenteral preparations was observed.
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Affiliation(s)
- Haishaerjiang Wushouer
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
| | - Ye Tian
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
| | - Xiao-Dong Guan
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
- International Research Center for Medicinal Administration (IRCMA), Peking University, Beijing, China
| | - Sheng Han
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
- International Research Center for Medicinal Administration (IRCMA), Peking University, Beijing, China
| | - Lu-Wen Shi
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
- International Research Center for Medicinal Administration (IRCMA), Peking University, Beijing, China
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Ruiz J, Ramirez P, Gordon M, Villarreal E, Frasquet J, Poveda-Andres JL, Salavert-Lletí M, Catellanos A. Antimicrobial stewardship programme in critical care medicine: A prospective interventional study. Med Intensiva 2017; 42:266-273. [PMID: 28882325 DOI: 10.1016/j.medin.2017.07.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/06/2017] [Accepted: 07/14/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Hospital antimicrobial stewardship programmes have achieved savings and a more rational use of antimicrobial treatments in general wards. The purpose of this report is to evaluate the experience of an antimicrobial stewardship programme in an intensive care unit (ICU). DESIGN Prospective interventional, before-and-after study. SCOPE 24-bed medical ICU in a tertiary hospital. INTERVENTION Prospective audit and feedback antimicrobial stewardship programme. ENDPOINTS Antimicrobial consumption, antimicrobial related costs, multi-drug resistant microorganisms (MDRM) prevalence, nosocomial infections incidence, ICU length of stay, and ICU mortality rates were compared before and after one-year intervention. RESULTS A total of 218 antimicrobial episodes of 182 patients were evaluated in 61 team meetings. Antimicrobial stewardship suggestions were accepted in 91.5% of the cases. Total antimicrobial DDD/100 patient-days consumption was reduced from 380.6 to 295.2 (-22.4%; p=0.037). Antimicrobial stewardship programme was associated with a significant decrease in the prescription of penicillins plus b-lactamase inhibitors, linezolid, cephalosporins, and aminoglycosides. Overall antimicrobial spending was reduced by €119,636. MDRM isolation and nosocomial infections per 100 patient-days did not change after the intervention period. No changes in length of stay or mortality rate were observed. CONCLUSIONS An ICU antimicrobial stewardship programme significantly reduced antimicrobial use without affecting inpatient mortality and length of stay. Our results further support the implementation of an antimicrobial stewardship programme in critical care units.
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Affiliation(s)
- J Ruiz
- Intensive Care Unit, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - P Ramirez
- Intensive Care Unit, Hospital Universitario y Politecnico La Fe, Valencia, Spain.
| | - M Gordon
- Intensive Care Unit, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - E Villarreal
- Intensive Care Unit, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - J Frasquet
- Microbiology Department, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - J L Poveda-Andres
- Pharmacy Department, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - M Salavert-Lletí
- Infectious Disease Department, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | - A Catellanos
- Intensive Care Unit, Hospital Universitario y Politecnico La Fe, Valencia, Spain
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Ruiz-Ramos J, Frasquet J, Romá E, Poveda-Andres JL, Salavert-Leti M, Castellanos A, Ramirez P. Cost-effectiveness analysis of implementing an antimicrobial stewardship program in critical care units. J Med Econ 2017; 20:652-659. [PMID: 28345481 DOI: 10.1080/13696998.2017.1311903] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIMS To evaluate the cost-effectiveness of antimicrobial stewardship (AS) program implementation focused on critical care units based on assumptions for the Spanish setting. MATERIALS AND METHODS A decision model comparing costs and outcomes of sepsis, community-acquired pneumonia, and nosocomial infections (including catheter-related bacteremia, urinary tract infection, and ventilator-associated pneumonia) in critical care units with or without an AS was designed. Model variables and costs, along with their distributions, were obtained from the literature. The study was performed from the Spanish National Health System (NHS) perspective, including only direct costs. The Incremental Cost-Effectiveness Ratio (ICER) was analysed regarding the ability of the program to reduce multi-drug resistant bacteria. Uncertainty in ICERs was evaluated with probabilistic sensitivity analyses. RESULTS In the short-term, implementing an AS reduces the consumption of antimicrobials with a net benefit of €71,738. In the long-term, the maintenance of the program involves an additional cost to the system of €107,569. Cost per avoided resistance was €7,342, and cost-per-life-years gained (LYG) was €9,788. Results from the probabilistic sensitivity analysis showed that there was a more than 90% likelihood that an AS would be cost-effective at a level of €8,000 per LYG. LIMITATIONS Wide variability of economic results obtained from the implementation of this type of AS program and short information on their impact on patient evolution and any resistance avoided. CONCLUSIONS Implementing an AS focusing on critical care patients is a long-term cost-effective tool. Implementation costs are amortized by reducing antimicrobial consumption to prevent infection by multidrug-resistant pathogens.
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Affiliation(s)
- Jesus Ruiz-Ramos
- a Intensive Care Unit , Hospital Universitario y Politecnico La Fe , Valencia , Spain
| | - Juan Frasquet
- b Microbiology Department , Hospital Universitario y Politecnico La Fe , Valencia , Spain
| | - Eva Romá
- c Pharmacy Department , Hospital Universitario y Politecnico La Fe , Valencia , Spain
| | | | - Miguel Salavert-Leti
- d Infectious Disease Unit , Hospital Universitario y Politecnico La Fe , Valencia , Spain
| | - Alvaro Castellanos
- a Intensive Care Unit , Hospital Universitario y Politecnico La Fe , Valencia , Spain
| | - Paula Ramirez
- a Intensive Care Unit , Hospital Universitario y Politecnico La Fe , Valencia , Spain
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