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Wong JMH, Wooding DJ, Leung SE, Paquette V, Roberts A, Elwood C. Establishing obstetrics-specific metrics and interventions for antimicrobial stewardship. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2023; 8:116-124. [PMID: 38250287 PMCID: PMC10795696 DOI: 10.3138/jammi-2022-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 01/23/2024]
Abstract
Background To describe baseline antimicrobial stewardship (AMS) metrics and apply AMS interventions in an inpatient obstetrical population. Methods From October 2018 to October 2019, our tertiary-care obstetrical center reviewed components of our AMS program, which included: (1) antimicrobial consumption data, (2) point prevalence surveys (PPS), and (3) prospective audit and feedback. We reviewed institutional data for antimicrobial consumption from the pharmacy database. Detailed point prevalence surveys were conducted for all antimicrobial prescriptions on two predefined dates each month. Daily audits and feedback assessed the appropriateness of all non-protocolized antimicrobials. Results Our average antimicrobial length of therapy (LOT) was 12 days per 100 patient-days, where erythromycin (2.33), amoxicillin (2.28), and ampicillin (1.81) were the greatest contributors. Point prevalence surveys revealed that 28.8% of obstetrical inpatients were on antimicrobials, of which 11.2% were inappropriate. Protocolized antimicrobials were 62% less likely (p = 0.027) to be inappropriate. From 565 audited prescriptions, 110 (19.5%) resulted in feedback, where 90% of recommendations were accepted and implemented. The most common reasons for interventions include incorrect dosage, recommending a diagnostic test before continuing antimicrobials, and changing antimicrobials based on specific culture and sensitivity. Conclusions Antimicrobial use in obstetrics is unique compared to general inpatients. We provide a baseline set of metrics for AMS at our obstetrical center intending to lay the groundwork for AMS programming in our discipline. Antimicrobial protocolization, as well as audit and feedback, are feasible interventions to improve antimicrobial prescribing patterns.
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Affiliation(s)
- Jeffrey Man Hay Wong
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Denise J Wooding
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah E Leung
- Department of Pharmacy, Children’s and Women’s Health Centre of BC, Vancouver, British Columbia, Canada
| | - Vanessa Paquette
- Department of Pharmacy, Children’s and Women’s Health Centre of BC, Vancouver, British Columbia, Canada
| | - Ashley Roberts
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Chelsea Elwood
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
- Women’s Health Research Institute, Vancouver, British Columbia, Canada
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Wilde AM, Song M, Moore SE, Bohn BC, Swingler EA, Schulz PS. The Norton Healthcare electronic antimicrobial stewardship program: An opt-out approach to antimicrobial stewardship. Am J Health Syst Pharm 2023; 80:75-82. [PMID: 36194261 DOI: 10.1093/ajhp/zxac285] [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: 10/01/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE To describe the Norton Healthcare electronic antimicrobial stewardship program (E-ASP), a novel prospective audit and feedback approach that leverages the electronic medical record to overcome efficiency barriers. Additionally, to describe an accompanying opt-out antimicrobial stewardship approach that addresses provider nonresponsiveness. SUMMARY Prospective audit and feedback is recommended by antimicrobial stewardship guidelines; however, execution can be difficult due to labor requirements, delays in communication, and provider nonparticipation. The Norton E-ASP was developed to address these issues by reliably identifying target patients, documenting assessments, streamlining recommendation delivery, promoting handoff, and providing automated tracking of recommendation responses. Opt-out stewardship allows recommendations to be implemented if not rejected after 24 hours. CONCLUSION A 25% reduction in target antimicrobial use has been achieved and sustained with the program. Use of the Norton E-ASP, including opt-out antimicrobial stewardship, broadened the reach and furthered the impact of infectious diseases pharmacists. Successes of this program justified addition of 3 full-time infectious diseases pharmacist positions at a large community health system. This strategy may serve as a model for tele-antimicrobial stewardship or other pharmacy recommendations.
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Affiliation(s)
- Ashley M Wilde
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
| | - Matthew Song
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
| | - Sarah E Moore
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
| | - Brian C Bohn
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Elena A Swingler
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
| | - Paul S Schulz
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
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Sine K, Appaneal H, Dosa D, LaPlante KL. Antimicrobial Prescribing in the Telehealth Setting: Framework for Stewardship During a Period of Rapid Acceleration Within Primary Care. Clin Infect Dis 2022; 75:2260-2265. [PMID: 35906829 PMCID: PMC9384578 DOI: 10.1093/cid/ciac598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/12/2022] [Accepted: 07/15/2022] [Indexed: 01/19/2023] Open
Abstract
Antibiotic resistance is a global public health threat. The use of telehealth in primary care presents unique barriers to antimicrobial stewardship, including limited physical examination and changes to the patient-provider relationship. Since the coronavirus disease 2019 (COVID-19) pandemic, there is a need to identify novel antimicrobial stewardship strategies with an explosion in the use of telehealth within primary care. Our review proposes a tailored, sustainable approach to antimicrobial prescribing in the telehealth setting based on the Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship: commitment, action for policy and practice; tracking and reporting; and education and expertise. The rapid growth of telehealth for all types of primary care visits (not just antibiotic use) is outpacing knowledge associated with strategies for antimicrobial stewardship. Improving antibiotic use within primary care settings is critical as telehealth will remain a priority whether the COVID-19 pandemic recedes, particularly within patient populations with limited access to healthcare.
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Affiliation(s)
- Kathryn Sine
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA,Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Haley Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA,Department is College of pharmacy, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - David Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA,Department is College of pharmacy, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA,Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, RI School of Public Health, Brown University, Providence, RI, USA
| | - Kerry L LaPlante
- Correspondence: K. L. LaPlante, University of Rhode Island College of Pharmacy, 7 Greenhouse Road, Suite 255A-C, Kingston, RI 02881, USA ()
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Tandan M, Thapa P, Maharjan P, Bhandari B. Impact of Antimicrobial Stewardship Program on Antimicrobial Resistant and Prescribing in Nursing Home: A Systematic Review and Meta-analysis. J Glob Antimicrob Resist 2022; 29:74-87. [DOI: 10.1016/j.jgar.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/25/2022] [Accepted: 02/06/2022] [Indexed: 11/29/2022] Open
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5
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So M, Hand J, Forrest G, Pouch SM, Te H, Ardura MI, Bartash RM, Dadhania DM, Edelman J, Ince D, Jorgenson MR, Kabbani S, Lease ED, Levine D, Ohler L, Patel G, Pisano J, Spinner ML, Abbo L, Verna EC, Husain S. White paper on antimicrobial stewardship in solid organ transplant recipients. Am J Transplant 2022; 22:96-112. [PMID: 34212491 PMCID: PMC9695237 DOI: 10.1111/ajt.16743] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/17/2021] [Accepted: 06/25/2021] [Indexed: 01/25/2023]
Abstract
Antimicrobial stewardship programs (ASPs) have made immense strides in optimizing antibiotic, antifungal, and antiviral use in clinical settings. However, although ASPs are required institutionally by regulatory agencies in the United States and Canada, they are not mandated for transplant centers or programs specifically. Despite the fact that solid organ transplant recipients in particular are at increased risk of infections from multidrug-resistant organisms, due to host and donor factors and immunosuppressive therapy, there currently are little rigorous data regarding stewardship practices in solid organ transplant populations, and thus, no transplant-specific requirements currently exist. Further complicating matters, transplant patients have a wide range of variability regarding their susceptibility to infection, as factors such as surgery of transplant, intensity of immunosuppression, and presence of drains or catheters in situ may modify the risk of infection. As such, it is not feasible to have a "one-size-fits-all" style of stewardship for this patient population. The objective of this white paper is to identify opportunities, risk factors, and ASP strategies that should be assessed with solid organ transplant recipients to optimize antimicrobial use, while producing an overall improvement in patient outcomes. We hope it may serve as a springboard for development of future guidance and identification of research opportunities.
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Affiliation(s)
- Miranda So
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Jonathan Hand
- Department of Infectious Diseases, Ochsner Medical Center, The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - Graeme Forrest
- Department of Internal Medicine, Division of Infectious Diseases, Rush Medical College, Chicago, Illinois
| | - Stephanie M. Pouch
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Helen Te
- Center for Liver Diseases, The University of Chicago Medicine, Chicago, Illinois
| | - Monica I. Ardura
- Department of Pediatrics, Infectious Diseases and Host Defense, Nationwide Children’s Hospital, The Ohio State University, Columbus, Ohio
| | - Rachel M. Bartash
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Darshana M. Dadhania
- Department of Transplantation Medicine, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Jeffrey Edelman
- Transplant Services at UW Medical Center, Seattle, Washington
| | - Dilek Ince
- Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Health Care, Carver College of Medicine, Iowa City, Iowa
| | | | - Sarah Kabbani
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erika D. Lease
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Deborah Levine
- Division of Pulmonary and Critical Care Medicine and CT Surgery, University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Linda Ohler
- Transplant Institute New York University Langone Health, New York, New York
| | - Gopi Patel
- Icahn Institute for Data Science and Genomic Technology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jennifer Pisano
- Antimicrobial Stewardship and Infection Control, U Chicago Medicine, Chicago, Illinois
| | | | - Lilian Abbo
- Department of Medicine, Miami Transplant Institute, Jackson Health System, University of Miami, Miller School of Medicine, Miami, Florida
| | - Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Medical Center, New York, New York
| | - Shahid Husain
- Sinai Health System-University Health Network Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
- Ajmera Transplant Center, Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
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da Silva RMR, de Mendonça SCB, Leão IN, Dos Santos QN, Batista AM, Melo MS, Xavier MDM, Quintans Júnior LJ, da Silva WB, Lobo IMF. Use of monitoring indicators in hospital management of antimicrobials. BMC Infect Dis 2021; 21:827. [PMID: 34404348 PMCID: PMC8369325 DOI: 10.1186/s12879-021-06542-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background According to the literature, 25% to 50% of antimicrobials prescribed in hospitals are unnecessary or inappropriate, directly impacting antimicrobial resistance. Thus, the present study aimed to evaluate the use of antimicrobials in a university hospital in Northeast Brazil, using days of therapy (DOT) and length of therapy (LOT) indicators in accordance with the latest national and international recommendations for monitoring the use of antimicrobials. Methods This is an observational, prospective analytical study conducted in a teaching hospital, with 94 active beds, distributed between the intensive care unit (ICU), the surgical clinic (SUR), the medical clinic (MED), the pneumology/infectology department (PNE/INF) and pediatrics (PED). The duration of the study was from the beginning of January to the end of December 2018. Results During the study period, a total of 11,634 patient-days were followed up and 50.4% of the patients were found to have received some antimicrobial, with a significant reduction in use of 1% per month throughout the year. Patients were receiving antimicrobial therapy for 376 days in every 1000 days of hospitalization (LOT = 376/1000pd). Overall, the 1st-generation cephalosporins and fluoroquinolones were the most used in respect of the number of prescriptions and the duration of therapy. The calculated global DOT/LOT ratio showed that each patient received an average of 1.5 antimicrobials during the hospital stay. The incidence of antimicrobial resistance, globally, for both methicillin-resistant Staphylococcus aureus (methicillin R), Carbapenem-resistant Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii (Carbapenem R), was 1 per 1000 patient-days. Conclusions The results obtained from the analyses revealed that half of the patients admitted to the hospital who took part in the study were exposed to the use of antimicrobials at some point during their stay. Although moderate, it is noteworthy that there was a decline in the use of antimicrobials throughout the year. The indicators used in this study were found to be very effective for gathering data on the use of antimicrobials, and assessing the results of the initiatives taken as part of the Stewardship program. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06542-5.
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Affiliation(s)
| | | | | | | | | | - Matheus Santos Melo
- Department of Nursing, Federal University of Sergipe, São Cristóvão, Se, Brazil
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Livorsi DJ, Suda KJ, Cunningham Goedken C, Hockett Sherlock S, Balkenende E, Chasco EE, Scherer AM, Goto M, Perencevich EN, Goetz MB, Reisinger HS. The feasibility of implementing antibiotic restrictions for fluoroquinolones and cephalosporins: a mixed-methods study across 15 Veterans Health Administration hospitals. J Antimicrob Chemother 2021; 76:2195-2203. [PMID: 34015115 DOI: 10.1093/jac/dkab138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/06/2021] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION The optimal method for implementing hospital-level restrictions for antibiotics that carry a high risk of Clostridioides difficile infection has not been identified. We aimed to explore barriers and facilitators to implementing restrictions for fluoroquinolones and third/fourth-generation cephalosporins. METHODS This mixed-methods study across a purposeful sample of 15 acute-care, geographically dispersed Veterans Health Administration hospitals included electronic surveys and semi-structured interviews (September 2018 to May 2019). Surveys on stewardship strategies were administered at each hospital and summarized with descriptive statistics. Interviews were performed with 30 antibiotic stewardship programme (ASP) champions across all 15 sites and 19 additional stakeholders at a subset of 5 sites; transcripts were analysed using thematic content analysis. RESULTS The most restricted agent was moxifloxacin, which was restricted at 12 (80%) sites. None of the 15 hospitals restricted ceftriaxone. Interviews identified differing opinions on the feasibility of restricting third/fourth-generation cephalosporins and fluoroquinolones. Some participants felt that restrictions could be implemented in a way that was not burdensome to clinicians and did not interfere with timely antibiotic administration. Others expressed concerns about restricting these agents, particularly through prior approval, given their frequent use, the difficulty of enforcing restrictions and potential unintended consequences of steering clinicians towards non-restricted antibiotics. A variety of stewardship strategies were perceived to be effective at reducing the use of these agents. CONCLUSIONS Across 15 hospitals, there were differing opinions on the feasibility of implementing antibiotic restrictions for third/fourth-generation cephalosporins and fluoroquinolones. While the perceived barrier to implementing restrictions was frequently high, many hospitals were effectively using restrictions and reported few barriers to their use.
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Affiliation(s)
- Daniel J Livorsi
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Health Care System, Pittsburgh, PA, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Cassie Cunningham Goedken
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Stacey Hockett Sherlock
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Erin Balkenende
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Emily E Chasco
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Aaron M Scherer
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michihiko Goto
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Eli N Perencevich
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,David Geffen School of Medicine at the University of California in Los Angeles, CA, USA
| | - Heather Schacht Reisinger
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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8
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Kakkar AK, Shafiq N, Sahni N, Mohindra R, Kaur N, Gamad N, Panditrao A, Kondal D, Malhotra S, Kumar M P, Rohilla R, Bhattacharjee S, Kumar A, Bhandari RK, Pandey AK, Rather I, Mothsara C, Harish C, Belavagi D, Vishwas G. Assessment of Appropriateness of Antimicrobial Therapy in Resource-Constrained Settings: Development and Piloting of a Novel Tool-AmRAT. Antibiotics (Basel) 2021; 10:200. [PMID: 33669509 PMCID: PMC7923130 DOI: 10.3390/antibiotics10020200] [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: 01/09/2021] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 12/04/2022] Open
Abstract
Inappropriate antimicrobial prescribing is considered to be the leading cause of high burden of antimicrobial resistance (AMR) in resource-constrained lower- and middle-income countries. Under its global action plan, the World Health Organization has envisaged tackling the AMR threat through promotion of rational antibiotic use among prescribers. Given the lack of consensus definitions and other associated challenges, we sought to devise and validate an Antimicrobial Rationality Assessment Tool-AmRAT-for standardizing the assessment of appropriateness of antimicrobial prescribing. A consensus algorithm was developed by a multidisciplinary team consisting of intensivists, internal medicine practitioners, clinical pharmacologists, and infectious disease experts. The tool was piloted by 10 raters belonging to three groups of antimicrobial stewardship (AMS) personnel: Master of Pharmacology (M.Sc.) (n = 3, group A), Doctor of Medicine (MD) residents (n = 3, group B), and DM residents in clinical pharmacology (n = 4, group C) using retrospective patient data from 30 audit and feedback forms collected as part of an existing AMS program. Percentage agreement and the kappa (κ) coefficients were used to measure inter-rater agreements amongst themselves and with expert opinion. Sensitivity and specificity estimates were analyzed comparing their assessments against the gold standard. For the overall assessment of rationality, the mean percent agreement with experts was 76.7% for group A, 68.9% for group B, and 77.5% for group C. The kappa values indicated moderate agreement for all raters in group A (κ 0.47-0.57), and fair to moderate in group B (κ 0.22-0.46) as well as group C (κ 0.37-0.60). Sensitivity and specificity for the same were 80% and 68.6%, respectively. Though evaluated by raters with diverse educational background and variable AMS experience in this pilot study, our tool demonstrated high percent agreement and good sensitivity and specificity, assuring confidence in its utility for assessing appropriateness of antimicrobial prescriptions in resource-constrained healthcare environments.
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Affiliation(s)
- Ashish Kumar Kakkar
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Nusrat Shafiq
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Neeru Sahni
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Ritin Mohindra
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Navjot Kaur
- Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi 110029, India;
| | - Nanda Gamad
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Aditi Panditrao
- Adesh Institute of Medical Sciences and Research, Bathinda 151101, India;
| | - Dimple Kondal
- Public Health Foundation of India, Gurugram 122002, India;
| | - Samir Malhotra
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Praveen Kumar M
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Rachna Rohilla
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Samiksha Bhattacharjee
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Ankit Kumar
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Ritika Kondel Bhandari
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Avaneesh Kumar Pandey
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Imraan Rather
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Chakrant Mothsara
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Cvn Harish
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Devaraj Belavagi
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Gopal Vishwas
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
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MacBrayne CE, Williams MC, Levek C, Child J, Pearce K, Birkholz M, Todd JK, Hurst AL, Parker SK. Sustainability of Handshake Stewardship: Extending a Hand Is Effective Years Later. Clin Infect Dis 2021; 70:2325-2332. [PMID: 31584641 DOI: 10.1093/cid/ciz650] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/11/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Children's Hospital Colorado created a unique method of antimicrobial stewardship, called handshake stewardship, that effectively decreased hospital anti-infective use and costs in its pilot year (2013). Handshake stewardship is distinguished by: (1) the lack of prior authorization; (2) a review of all prescribed anti-infectives; (3) a shared review by the physician and the pharmacist; and (4) a daily, rounding-based, in-person approach to supporting providers. We sought to reevaluate the outcomes of the program after 5 years of experience, totaling 8 years of data. METHODS We retrospectively measured anti-infective (antibiotic, antiviral, antifungal) use hospital-wide by unit and by drug for an 8-year period spanning October 2010 to October 2018. Aggregated monthly use was measured in days of therapy per thousand patient days (DOT/1000 PD). The percentage of children admitted ever receiving an anti-infective was also measured, as well as severity-adjusted mortality, readmissions, and lengths of stay. RESULTS Hospital-wide mean anti-infective use significantly decreased, from 891 (95% confidence interval [CI] 859-923) in the pre-implementation phase to 655 (95% CI 637-694) DOT/1000 PD in post-implementation Year 5; in a segmented regression time series analysis, this was a rate of -2.6 DOT/1000 PD (95% CI -4.8 to -0.4). This is largely attributable to decreased antibacterial use, from 704 (95% CI 686-722) to 544 (95% CI 525 -562) DOT/1000 PD. The percentage of children ever receiving an anti-infective during admission likewise declined, from 65% to 52% (95% CI 49-54). There were no detrimental effects on severity adjusted mortality, readmissions, or lengths of stay. CONCLUSIONS The handshake method is an effective and sustainable approach to stewardship.
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Affiliation(s)
- Christine E MacBrayne
- Department of Pharmacy Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Manon C Williams
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Claire Levek
- Department of Pediatrics and Child Health Research Biostatistical Core, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jason Child
- Department of Pharmacy Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Kelly Pearce
- Department of Infection Prevention and Control, Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Meghan Birkholz
- Department of Pediatrics, Section of Pediatric Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - James K Todd
- Department of Pediatrics, Section of Pediatric Infectious Diseases and Department of Infection Prevention and Control, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Amanda L Hurst
- Department of Pharmacy Children's Hospital Colorado, University of Colorado, Aurora, Colorado, USA
| | - Sarah K Parker
- Department of Pediatrics, Section of Pediatric Infectious Diseases and Department of Infection Prevention and Control, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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10
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Chatzopoulou M, Kyriakaki A, Reynolds L. Review of antimicrobial resistance control strategies: low impact of prospective audit with feedback on bacterial antibiotic resistance within hospital settings. Infect Dis (Lond) 2020; 53:159-168. [PMID: 33300825 DOI: 10.1080/23744235.2020.1846777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Antimicrobial stewardship constitutes an essential element of any concerted effort to tackle bacterial resistance, a rising public health threat both in community as well as hospital settings. The term comprises variable strategies which aim to optimise prescribing practices through either antibiotic restrictions or prospective audits of prescriptions with subsequent feedback to clinicians. Although highly debated, the actual effects of the latter on the antimicrobial susceptibility patterns of hospital flora are uncertain. The present study aims to review and evaluate the literature concerning the impact of persuasive stewardship strategies on antimicrobial resistance within hospitals. MATERIALS AND METHODS A literature review covering the period to 1st April 2020 was conducted using the PubMed/Medline, Embase, Global Health and CINAHL Plus databases. RESULTS Fifteen studies were retrieved, including twelve simple before-and-after, and three interrupted time-series studies. Audit frequency and compliance rates varied broadly. The rationale of treatment optimisation is not clear in most cases. Overall, surveillance of sentinel microorganisms through antibiograms indicates ambiguous results, with uncertainty as to whether the few successes are due to a causal effect, random incidence fluctuations, or confounding. The most informative approach targeted solely fluoroquinolones, reporting improvements in relevant Pseudomonas susceptibilities and MRSA, but without sufficient data on other effects of the strategy to assess its overall utility in clinical practice. CONCLUSION Higher standard research is needed to address the actual effects of persuasive stewardship strategies on antimicrobial susceptibility patterns. At present, they seem inadequate to play a decisive role in bacterial resistance control within hospitals.
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Affiliation(s)
| | - Argyrw Kyriakaki
- Department of Haematology and Transfusion Medicine, Nikaia Peiraia Agios Panteleimon, Athens, Greece
| | - Lucy Reynolds
- London School of Hygiene and Tropical Medicine, University of London, London, UK
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11
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Doukas FF, Cheong E, McKew G, Gray T, McLachlan AJ, Gottlieb T. Antimicrobial Stewardship Audit and Feedback rounds: moving beyond the restricted antibiotic list and the impact of electronic systems. Intern Med J 2020; 51:1876-1883. [PMID: 32672887 DOI: 10.1111/imj.14979] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Current methods of antimicrobial usage surveillance have limited efficacy in changing practice due to delayed reporting to clinicians and the inability to stratify by medical specialty. This study was undertaken in a tertiary teaching hospital with a well-established Antimicrobial Stewardship (AMS) programme and electronic medicines management (eMM) system in Sydney, Australia. AIMS The aim was to describe and analyse the implementation of a novel AMS audit and feedback method, in the context of an eMM system. METHODS The AMS team conducted the audit weekly, and the study design was a prospective, observational study. All acute, adult inpatients were included in this intervention. All active systemic antimicrobial prescriptions on the day of the rounds were included. RESULTS The prevalence of patients on antimicrobial therapy was 37%. The median time taken per round was 44 min for eMM compared to 58 min for paper. All key performance indicators improved over the study period. Appropriateness compared to guidelines increased from 55% to 71%, and documentation of an indication increased from 75% to 98%. 1413 recommendations were made with the most common being to cease an antimicrobial agent. The recommendation uptake rate was 47% at 24 h post-round. CONCLUSIONS AMS rounds are an effective tool for auditing and providing feedback on antimicrobial use and should include all antimicrobials rather than solely 'restricted' agents. These rounds had a high uptake rate, improvements in the appropriateness of antimicrobial use, and a planned duration or review date. A benefit of eMM was improvement in the documentation of indication for antimicrobial agents, and reduced time taken to audit. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Fiona F Doukas
- Pharmacy Department, Concord Repatriation General Hospital, Sydney 2139, Australia & Sydney Pharmacy School, The University of Sydney, Sydney, 2050, Australia
| | - Elaine Cheong
- Department of Microbiology and Infectious Diseases, Concord Repatriation General Hospital, Sydney, 2139, Australia
| | - Genevieve McKew
- Department of Microbiology and Infectious Diseases, Concord Repatriation General Hospital, Sydney, 2139, Australia
| | - Timothy Gray
- Department of Microbiology and Infectious Diseases, Concord Repatriation General Hospital, Sydney, 2139, Australia
| | - Andrew J McLachlan
- Sydney Pharmacy School, The University of Sydney, Sydney 2050, Australia & Centre for Education and Research on Ageing, Concord Hospital, Sydney, 2139, Australia
| | - Thomas Gottlieb
- Department of Microbiology and Infectious Diseases, Concord Repatriation General Hospital, Sydney, 2139, Australia
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12
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Zequinao T, Gasparetto J, Oliveira DDS, Silva GT, Telles JP, Tuon FF. A broad-spectrum beta-lactam-sparing stewardship program in a middle-income country public hospital: antibiotic use and expenditure outcomes and antimicrobial susceptibility profiles. Braz J Infect Dis 2020; 24:221-230. [PMID: 32504551 PMCID: PMC9392143 DOI: 10.1016/j.bjid.2020.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 05/03/2020] [Accepted: 05/07/2020] [Indexed: 12/17/2022] Open
Abstract
Background Antimicrobial stewardship programs are an efficient way to reduce inappropriate use of antimicrobials and costs; however, supporting data are scarce in middle-income countries. The aim of this study was to evaluate antibiotic use, bacterial susceptibility profiles, and the economic impact following implementation of a broad-spectrum beta-lactam-sparing antimicrobial stewardship program. Methods An interrupted time-series analysis was performed to evaluate antibiotic use and expenditure over a 24-month period (12 months before the antimicrobial stewardship program and in the 12 months after implementation of the antimicrobial stewardship program). Antibiotics were classified into one of two groups: beta-lactam antibiotics and beta-lactam-sparing antibiotics. We also compared the antimicrobial susceptibility profiles of key pathogens in each period. Results Beta-lactam antibiotics use decreased by 43.04 days of therapy/1000 patient-days (p = 0.04) immediately following antimicrobial stewardship program implementation, whereas beta-lacta-sparing antibiotics use increased during the intervention period (slope change 6.17 days of therapy/1000 patient-days, p < 0.001). Expenditure decreased by $2089.99 (p < 0.001) immediately after intervention and was maintained at this level over the intervention period ($−38.45; p = 0.24). We also observed that a greater proportion of pathogens were susceptible to cephalosporins and aminoglycosides after the antimicrobial stewardship program. Conclusions The antimicrobial stewardship program significantly reduced the use of broad-spectrum beta-lactam-antibiotics associated with a decrease in expenditure and maintenance of the susceptibility profile in Gram-negative bacteria.
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Affiliation(s)
- Tiago Zequinao
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | - Juliano Gasparetto
- School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
| | | | | | - João Paulo Telles
- Laboratory of Emerging Infectious Diseases, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil; AC Camargo Cancer Center, São Paulo, SP, Brazil
| | - Felipe Francisco Tuon
- Laboratory of Emerging Infectious Diseases, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil.
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Impact of an antimicrobial stewardship intervention in India: Evaluation of post-prescription review and feedback as a method of promoting optimal antimicrobial use in the intensive care units of a tertiary-care hospital. Infect Control Hosp Epidemiol 2020; 40:512-519. [PMID: 31084674 DOI: 10.1017/ice.2019.29] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Antimicrobial stewardship programs (ASPs) are effective in developed countries. In this study, we assessed the effectiveness of an infectious disease (ID) physician-driven post-prescription review and feedback as an ASP strategy in India, a low middle-income country (LMIC). DESIGN AND SETTING This prospective cohort study was carried out for 18 months in 2 intensive care units of a tertiary-care hospital, consisting of 3 phases: baseline, intervention, and follow up. Each phase spanned 6 months. PARTICIPANTS Patients aged ≥15 years receiving 48 hours of study antibiotics were recruited for the study. METHODS During the intervention phase, an ID physician reviewed the included cases and gave alternate recommendations if the antibiotic use was inappropriate. Acceptance of the recommendations was measured after 48 hours. The primary outcome of the study was days of therapy (DOT) per 1,000 study patient days (PD). RESULTS Overall, 401 patients were recruited in the baseline phase, 381 patients were recruited in the intervention phase, and 379 patients were recruited in the follow-up phase. Antimicrobial use decreased from 831.5 during the baseline phase to 717 DOT per 1,000 PD in the intervention phase (P < .0001). The effect was sustained in the follow-up phase (713.6 DOT per 1,000 PD). De-escalation according to culture susceptibility improved significantly in the intervention phase versus the baseline phase (42.7% vs 23.6%; P < .0001). Overall, 73.3% of antibiotic prescriptions were inappropriate. Recommendations by the ID team were accepted in 60.7% of the cases. CONCLUSION The ID physician-driven implementation of an ASP was successful in reducing antibiotic utilization in an acute-care setting in India.
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14
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Liao S, Rhodes J, Jandarov R, DeVore Z, Sopirala MM. Out of Sight-Out of Mind: Impact of Cascade Reporting on Antimicrobial Usage. Open Forum Infect Dis 2020; 7:ofaa002. [PMID: 32055636 PMCID: PMC7008474 DOI: 10.1093/ofid/ofaa002] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 01/03/2020] [Indexed: 12/22/2022] Open
Abstract
Background There is a paucity of data evaluating the strategy of suppressing broader-spectrum antibiotic susceptibilities on utilization. Cascade reporting (CR) is a strategy of reporting antimicrobial susceptibility test results in which secondary (eg, broader-spectrum, costlier) agents may only be reported if an organism is resistant to primary agents within a particular drug class. Our objective was to evaluate the impact of ceftriaxone-based cascade reporting on utilization of cefepime and clinical outcomes in patients with ceftriaxone-susceptible Escherichia and Klebsiella clinical cultures. Methods We compared post-CR (July 2014-June 2015) with baseline (July 2013-June 2014), evaluating utilization of cefepime, cefazolin, ceftriaxone, ampicillin derivatives, fluoroquinolones, piperacillin/tazobactam, ertapenem, and meropenem; new Clostridium difficile infection; and length of stay (LOS) after the positive culture, 30-day readmission, and in-hospital all-cause mortality. Results Mean days of therapy (DOT) among patients who received any antibiotic for cefepime decreased from 1.229 days during the baseline period to 0.813 days post-CR (adjusted relative risk, 0.668; P < .0001). Mean DOT of ceftriaxone increased from 0.864 days to 0.962 days, with an adjusted relative risk of 1.113 (P = .004). No significant differences were detected in other antibiotics including ertapenem and meropenem, demonstrating the direct association of the decrease in cefepime utilization with CR based on ceftriaxone susceptibility. Average LOS in the study population decreased from 14.139 days to 10.882 days from baseline to post-CR and was found to be statistically significant (P < .0001). Conclusions In conclusion, we demonstrated significant association of decreased cefepime utilization with the implementation of a CR based on ceftriaxone susceptibility. We demonstrated the safety of deescalation, with LOS being significantly lower during the post-CR period than in the baseline period, with no change in in-hospital mortality.
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Affiliation(s)
- Siyun Liao
- Department of Pharmacy, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Judith Rhodes
- Department of Pathology, University of College of Medicine, Cincinnati, Ohio, USA
| | - Roman Jandarov
- Division of Biostatistics and Bioinformatics, Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Zachary DeVore
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Madhuri M Sopirala
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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15
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Fu CJ, Mantell E, Stone PW, Agarwal M. Characteristics of nursing homes with comprehensive antibiotic stewardship programs: Results of a national survey. Am J Infect Control 2020; 48:13-18. [PMID: 31447117 PMCID: PMC6935405 DOI: 10.1016/j.ajic.2019.07.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Antibiotic stewardship in nursing homes (NHs) is a high priority owing to intense antibiotic use and increased risk of adverse events. Updated Centers for Medicare and Medicaid Services regulations required NHs to establish antibiotic stewardship programs (ASPs). This study describes the current state of NH ASPs. METHODS A nationally representative survey of NHs was conducted in 2018. ASP comprehensiveness, infection preventionist (IP) training, participation in Quality Innovation Network-Quality Improvement Organization (QIN-QIO) activities, and facility and staff characteristics were analyzed using weighted descriptive statistics and multinomial regression models. RESULTS Of 861 NHs, 33.2% (6-7) had "comprehensive" ASP policies, 41.1% (4-5) had "moderately comprehensive" ASP policies, and 25.6% (≤ 3) had "not comprehensive" ASP policies. Data collection on antibiotic use was most reported (91.4%), and restricting use of specific antibiotics was least reported (19.0%). Comprehensive ASPs were associated with QIN-QIO involvement; moderate and comprehensive ASPs were associated with IP training and high occupancy. DISCUSSION Immediately following Centers for Medicare and Medicaid Services regulation changes, a majority of NHs had moderately comprehensive or comprehensive ASPs. Rates for each policy and infection control-trained IPs increased from previous studies. CONCLUSIONS NH ASPs are becoming more comprehensive. Infection control training and partnerships with QIN-QIOs can support NHs to increase ASP comprehensiveness.
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Affiliation(s)
| | | | | | - Mansi Agarwal
- Columbia University School of Nursing, New York, NY.
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16
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Association between statewide adoption of the CDC's Core Elements of Hospital Antimicrobial Stewardship Programs and rates of methicillin-resistant Staphylococcus aureus bacteremia and Clostridioides difficile infection in the United States. Infect Control Hosp Epidemiol 2019; 41:430-437. [PMID: 31858919 DOI: 10.1017/ice.2019.352] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To measure the association between statewide adoption of the Centers for Disease Control and Prevention's (CDC's) Core Elements for Hospital Antimicrobial Stewardship Programs (Core Elements) and hospital-associated methicillin-resistant Staphylococcus aureus bacteremia (MRSA) and Clostridioides difficile infection (CDI) rates in the United States. We hypothesized that states with a higher percentage of reported compliance with the Core Elements have significantly lower MRSA and CDI rates. PARTICIPANTS All US states. DESIGN Observational longitudinal study. METHODS We used 2014-2016 data from Hospital Compare, Provider of Service files, Medicare cost reports, and the CDC's Patient Safety Atlas website. Outcomes were MRSA standardized infection ratio (SIR) and CDI SIR. The key explanatory variable was the percentage of hospitals that meet the Core Elements in each state. We estimated state and time fixed-effects models with time-variant controls, and we weighted our analyses for the number of hospitals in the state. RESULTS The percentage of hospitals reporting compliance with the Core Elements between 2014 and 2016 increased in all states. A 1% increase in reported ASP compliance was associated with a 0.3% decrease (P < .01) in CDIs in 2016 relative to 2014. We did not find an association for MRSA infections. CONCLUSIONS Increasing documentation of the Core Elements may be associated with decreases in the CDI SIR. We did not find evidence of such an association for the MRSA SIR, probably due to the short length of the study and variety of stewardship strategies that ASPs may encompass.
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Anthone J, Boldt D, Alexander B, Carroll C, Ased S, Schmidt D, Vivekanandan R, Destache CJ. Implementation of a Health-System Wide Antimicrobial Stewardship Program in Omaha, NE. PHARMACY 2019; 7:E156. [PMID: 31775246 PMCID: PMC6958401 DOI: 10.3390/pharmacy7040156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 11/17/2022] Open
Abstract
The Centers for Medicare and Medicaid Services (CMS) have mandated that acute care and critical access hospitals implement an Antimicrobial Stewardship (AMS) Program. This manuscript describes the process that was implemented to ensure CMS compliance for AMS, across a 14-member health system (eight community hospitals, five critical access hospitals, and an academic medical center) in the Omaha metro area, and surrounding cities. The addition of the AMS program to the 14-member health system increased personnel, with a 0.5 full-time equivalent (FTE) infectious diseases (ID) physician, and 2.5 FTE infectious diseases trained clinical pharmacists to support daily AMS activities. Clinical decision support software had previously been implemented across the health system, which was also key to the success of the program. Overall, in its first year, the AMS program demonstrated a $1.2 million normalized reduction (21% total reduction in antimicrobial purchases) in antimicrobial expenses. The ability to review charts daily for antimicrobial optimization with ID pharmacist and physician support, identify facility specific needs and opportunities, and to collect available data endpoints to determine program effectiveness helped to ensure the success of the program.
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Affiliation(s)
- Jennifer Anthone
- Department of Pharmacy Services, CHI Health, Omaha, NE 68124, USA; (J.A.); (D.B.); (B.A.); (C.C.); (S.A.); (D.S.); (R.V.)
| | - Dayla Boldt
- Department of Pharmacy Services, CHI Health, Omaha, NE 68124, USA; (J.A.); (D.B.); (B.A.); (C.C.); (S.A.); (D.S.); (R.V.)
| | - Bryan Alexander
- Department of Pharmacy Services, CHI Health, Omaha, NE 68124, USA; (J.A.); (D.B.); (B.A.); (C.C.); (S.A.); (D.S.); (R.V.)
| | - Cassara Carroll
- Department of Pharmacy Services, CHI Health, Omaha, NE 68124, USA; (J.A.); (D.B.); (B.A.); (C.C.); (S.A.); (D.S.); (R.V.)
| | - Sumaya Ased
- Department of Pharmacy Services, CHI Health, Omaha, NE 68124, USA; (J.A.); (D.B.); (B.A.); (C.C.); (S.A.); (D.S.); (R.V.)
| | - David Schmidt
- Department of Pharmacy Services, CHI Health, Omaha, NE 68124, USA; (J.A.); (D.B.); (B.A.); (C.C.); (S.A.); (D.S.); (R.V.)
| | - Renuga Vivekanandan
- Department of Pharmacy Services, CHI Health, Omaha, NE 68124, USA; (J.A.); (D.B.); (B.A.); (C.C.); (S.A.); (D.S.); (R.V.)
- School of Medicine, Creighton University, Omaha, NE 68178, USA
| | - Christopher J. Destache
- School of Medicine, Creighton University, Omaha, NE 68178, USA
- School of Pharmacy & Health Professions, Creighton University, Omaha, NE 68178, USA
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High versus low intensity: What is the optimal approach to prospective audit and feedback in an antimicrobial stewardship program? Infect Control Hosp Epidemiol 2019; 40:1344-1347. [PMID: 31637981 DOI: 10.1017/ice.2019.189] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Antimicrobial stewardship program (ASP) interventions, such as prospective audit and feedback (PAF), have been shown to reduce antimicrobial use and improve patient outcomes. However, the optimal approach to PAF is unknown. OBJECTIVE We examined the impact of a high-intensity interdisciplinary rounds-based PAF compared to low-intensity PAF on antimicrobial use on internal medicine wards in a 400-bed community hospital. METHODS Prior to the intervention, ASP pharmacists performed low-intensity PAF with a focus on targeted antibiotics. Recommendations were made directly to the internist for each patient. High-intensity, rounds-based PAF was then introduced sequentially to 5 internal medicine wards. This PAF format included twice-weekly interdisciplinary rounds, with a review of all internal medicine patients receiving any antimicrobial agent. Antibiotic use and clinical outcomes were measured before and after the transition to high-intensity PAF. An interrupted time-series analysis was performed adjusting for seasonal and secular trends. RESULTS With the transition from low-intensity to high-intensity PAF, a reduction in overall usage was seen from 483 defined daily doses (DDD)/1,000 patient days (PD) during the low-intensity phase to 442 DDD/1,000 PD in the high-intensity phase (difference, -42; 95% confidence interval [CI], -74 to -9). The reduction in usage was more pronounced in the adjusted analysis, in the latter half of the high intensity period, and for targeted agents. There were no differences seen in clinical outcomes in the adjusted analysis. CONCLUSIONS High-intensity PAF was associated with a reduction in antibiotic use compared to a low-intensity approach without any adverse impact on patient outcomes. A decision to implement high-intensity PAF approach should be weighed against the increased workload required.
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Patel V, Doyen S. Evaluating a Pharmacy-Driven 72-Hour Antibiotic Monitoring Program Implemented in a Community Hospital. Hosp Pharm 2019; 56:88-94. [PMID: 33790483 DOI: 10.1177/0018578719867661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Antimicrobial stewardship programs commonly utilize infectious diseases pharmacists to guide appropriate utilization of broad-spectrum antimicrobials. Strategies should be developed to increase staff pharmacist's participation in decreasing broad-spectrum antibiotic use. Objective: The purpose of this study was to determine the effectiveness of a pharmacy-driven 72-hour antimicrobial stewardship initiative. Methods: A pharmacy-driven 72-hour antibiotic review policy was implemented at a community hospital. Targeted antibiotics included ertapenem, meropenem, and daptomycin. The hospital's infectious diseases pharmacist provided policy education to staff pharmacists. All pharmacists provided prospective audit and feedback to physicians. Preimplementation and postimplementation data were collected through a retrospective chart review to analyze the impact of the initiative. Results: There were a total of 570 targeted antibiotic orders for review, of which 155 antibiotic orders met criteria for inclusion; 97 in the preimplementation group and 58 in the postimplementation group. Targeted antibiotic orders decreased postimplementation during the study period. Days of therapy per 1000 patient days decreased between the 2 groups, although this was statistically significant neither for the pooled targeted antibiotics nor for each individual antibiotic. There was a statistically significant increase in the number of appropriately prescribed targeted antibiotics from preimplementation compared to postimplementation (from 35% to 64%, P < .01). Pharmacist interventions documented for patients receiving the targeted antibiotics increased significantly during the intervention period (P < .01). In addition, there was a total of $28 795.96 in cost avoidance based on the difference in antibiotic use between the 2 groups. Conclusion: Implementation of a pharmacy-driven 72-hour broad-spectrum antibiotic review in a large community-based hospital resulted in a reduction in utilization and hospital spending and a significant increase in appropriate use of targeted antibiotics, while also increasing pharmacist engagement with antimicrobial stewardship.
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Rennert-May E, Conly J, Chen G, Dalton B. Clinical outcomes in patients admitted to a hospitalist service exposed to an antimicrobial stewardship program - a retrospective matched cohort study. Antimicrob Resist Infect Control 2019; 8:85. [PMID: 31149332 PMCID: PMC6534861 DOI: 10.1186/s13756-019-0542-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 05/17/2019] [Indexed: 12/16/2022] Open
Abstract
Background Given global issues with antimicrobial resistance and a need to optimize antimicrobial usage, antimicrobial stewardship (AS) programs are becoming a necessary component of hospitals and are increasingly mandated worldwide. It is important to evaluate these programs with respect to relevant clinical outcomes. Methods An AS program with a prospective audit and feedback service (PAF) of antimicrobial usage was initiated May 11, 2015 at our tertiary care center, for patients admitted under the hospitalist service. We conducted a retrospective matched cohort study. Patients assessed during the first year of this PAF were considered to be the exposed cohort and were compared to unexposed controls matched on gender, age and infectious diagnosis selected from patients who had been admitted under the hospitalist service prior to initiation of the PAF. Descriptive analysis was completed and a multivariate conditional logistic regression was performed to analyze differences between the exposed and control groups in terms of a composite endpoint of 30 day mortality, 30 day post hospital discharge mortality and hospital re-admission. Results A total of 348 patients were assessed and received PAF suggestions during the first year were compared to 827 matched control patients who did not receive PAF suggestions. Of 707 PAF suggestions made, the most common was to stop an antimicrobial (23%). A significantly lower (20.7% vs 28.8%, p = 0.008) composite endpoint was found in the group exposed to the PAF (OR 0.71 95%CI 0.52–0.97). This difference persisted when only patients with PAF suggestions that were completely or partially accepted were considered (18.6% vs 28.5%, p = 0.001) but was no longer significant when patients who had their ASP suggestions declined were analyzed (30.2% vs 26.7%, p = 0.610). Conclusions In this retrospective cohort study, patient admissions in which PAF recommendations were accepted had better clinical outcomes than matched historical controls managed in the absence of this AS service.
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Affiliation(s)
- E Rennert-May
- 1Department of Medicine, Cumming School of Medicine, University of Calgary, and Alberta Health Services, AGW5 Ground Floor SSB, Foothills Medical Centre, 1403 29 St NW, Calgary, AB T2N 2T9 Canada
| | - J Conly
- 2Department of Medicine, Department of Pathology & Laboratory Medicine, Department of Microbiology, Immunology and Infectious Diseases, Cumming School of Medicine, University of Calgary, Alberta Health Services, O'Brien Institute for Public Health, and Snyder Institute for Chronic Diseases, Calgary, AB Canada
| | - G Chen
- 3Community Health Sciences, Cumming School of Medicine, University of Calgary and Research Facilitation, Alberta Health Services, Calgary, AB Canada
| | - B Dalton
- 4Pharmacy Services, Alberta Health Services, and O'Brien Institute for Public Health, Calgary, AB Canada
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Hurst AL, Child J, Parker SK. Intervention and Acceptance Rates Support Handshake-Stewardship Strategy. J Pediatric Infect Dis Soc 2019; 8:162-165. [PMID: 29912364 DOI: 10.1093/jpids/piy054] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 05/30/2018] [Indexed: 12/21/2022]
Abstract
We instituted a new antimicrobial stewardship approach that involves review of all antimicrobial agents and communication of interventions in person by a pharmacist-physician team termed handshake stewardship. The acceptance rate in this study was 86%, intervention rates were higher with a physician, and interventions on antibiotics not reviewed by other strategies were made frequently.
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Affiliation(s)
- Amanda L Hurst
- Department of Pharmacy, Children's Hospital Colorado, Highlands Ranch
| | - Jason Child
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Sarah K Parker
- Section of Pediatric Infectious Diseases and Epidemiology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora
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22
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Garau J, Bassetti M. Role of pharmacists in antimicrobial stewardship programmes. Int J Clin Pharm 2018; 40:948-952. [PMID: 30242589 DOI: 10.1007/s11096-018-0675-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/14/2018] [Indexed: 11/26/2022]
Abstract
Antimicrobial resistance is a growing public health problem of global concern and, unless action is taken, the burden of death could reach 10 million per year by 2050. Resistance has been associated with increasing mortality, treatment failure and healthcare costs. In order to help combat this, antimicrobial stewardship programmes, have been implemented in many countries. These stewardship programmes can help, reduce inappropriate prescription and broad-spectrum use of antimicrobials, improve, clinical outcomes for the population as a whole, slow down the emergence of antimicrobial resistance and conserve healthcare resources. Pharmacists are an integral part of the stewardship team and have an important role in tackling antimicrobial resistance. This article aims to review the role of pharmacists within antimicrobial stewardship programmes and the opportunities for pharmacist-driven antimicrobial stewardship strategies in hospital and community settings.
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Affiliation(s)
- Javier Garau
- Department of Medicine, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain.
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria della Misericordia University Hospital, University of Udine, Udine, Italy
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23
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Bertollo LG, Lutkemeyer DS, Levin AS. Are antimicrobial stewardship programs effective strategies for preventing antibiotic resistance? A systematic review. Am J Infect Control 2018; 46:824-836. [PMID: 29472107 DOI: 10.1016/j.ajic.2018.01.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/05/2018] [Accepted: 01/05/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) have been proposed as a solution for the global burden of antibiotic resistance, despite the lack of evidence on the subject. OBJECTIVE To analyze the role of ASPs in reducing bacterial resistance to antibiotics in hospital settings. DATA SOURCES A review in PubMed, Scopus, LILACS, and SciELO databases was performed. The period analyzed was January 1, 2012-January 4, 2017. ELIGIBILITY CRITERIA Studies that related ASPs to bacterial resistance. DATA EXTRACTION All studies that did not focus on ASPs were removed. Antifungal and antiviral programs were excluded. RESULTS Only 8 studies had quasi-experimental designs, and none were controlled trials. ASP strategies and microorganism-antibiotic pairs evaluated varied widely. Seven studies were classified as presenting clearly positive results, 3 had limited positive results, 7 had doubtful results, 4 had negative results, and 5 had noninterpretable results. The implementation of new infection control practices occurred in 7 studies. LIMITATIONS There are yet few studies on this matter, and most of them have inadequate study designs. Great heterogeneity between study features was detrimental to drawing evidence-based conclusions. CONCLUSIONS There is no solid evidence that ASPs are effective in reducing antibiotic resistance in hospital settings. We uphold the need for more studies with appropriate study designs, standardized ASP interventions targeting common microorganism-antibiotic pairs, and avoiding simultaneous implementation of infection control practices.
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Affiliation(s)
- Leandro G Bertollo
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
| | - Diego S Lutkemeyer
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Anna S Levin
- Department of Infectious Diseases and Infection Control, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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24
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Parker SK, Hurst AL, Thurm C, Millard M, Jenkins TC, Child J, Dugan C. Anti-infective Acquisition Costs for a Stewardship Program: Getting to the Bottom Line. Clin Infect Dis 2018; 65:1632-1637. [PMID: 29020143 DOI: 10.1093/cid/cix631] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/18/2017] [Indexed: 01/12/2023] Open
Abstract
Background Though antimicrobial stewardship programs (ASPs) are in place for patient safety, financial justification is often required. In 2016, the Infectious Diseases Society of America (IDSA) recommended that anti-infective costs be measured by patient-level administration data normalized for patient census. Few publications use this methodology. Here, we aim to compare 3 methods of drug cost analysis during 3 phases of an ASP as an example of this recommendation's implementation. Methods At a freestanding pediatric hospital, we retrospectively assessed anti-infective cost using pharmacy purchasing data, patient-level administration data from the electronic medical record (EMR), and patient-level administration data from the Pediatric Hospital Information Systems (PHIS) database, all normalized to patient census. Costs pre-ASP, while planning the ASP, and post-ASP were then compared for each method. Results Significant differences in costs between the methods were observed. Pharmacy purchasing endorsed minimal financial benefit (decrease planning to post-ASP of $590 dollars per 1000 patient-days), while the EMR and PHIS data endorsed a decrease of $12785 and $21380 per 1000 patient-days, respectively, for a total yearly cost savings of $54656 for pharmacy purchasing data, $1184336 for EMR data, and $2117522 for PHIS data. Conclusions Pharmacy purchasing data underestimated cost savings compared with EMR and PHIS data, while EMR and PHIS data were comparable in magnitude of savings. At Children's Hospital Colorado, savings justified the full cost of the ASP. EMR patient-level administration data, normalized to patient census, offers a readily available and standardized measure of anti-infective costs over time.
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Affiliation(s)
- Sarah K Parker
- Department of Pediatrics, Division of Pediatric Infectious Diseases and Epidemiology, University of Colorado School of Medicine
| | - Amanda L Hurst
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kansas
| | - Matthew Millard
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Timothy C Jenkins
- Department of Medicine, Division of Infectious Diseases, University of Colorado Hospital, University of Colorado School of Medicine, Aurora.,Denver Health, Colorado
| | - Jason Child
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Casey Dugan
- Department of Pharmacy, Children's Hospital Colorado, Aurora
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25
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Truong WR, Yamaki J. The Hospital Antimicrobial Use Process: From Beginning to End. Open Forum Infect Dis 2018; 5:ofy098. [PMID: 29977958 PMCID: PMC6016413 DOI: 10.1093/ofid/ofy098] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 04/27/2018] [Indexed: 11/14/2022] Open
Abstract
Hospital antimicrobial stewardship (AMS) programs are responsible for ensuring that all antimicrobials are utilized in the most appropriate and safe manner to improve patient outcomes, prevent adverse drug reactions, and prevent the development of antimicrobial resistance. This Perspectives article outlines the hospital antimicrobial use process (AUP), the foundational system that ensures that all antimicrobials are utilized in the most appropriate and safe manner. The AUP consists of the following steps: antimicrobial ordering, order verification, preparation and delivery, administration, monitoring, and discharge prescribing. AMS programs should determine how each step contributes to how an antimicrobial is used appropriately or inappropriately at their institution. Through this understanding, AMS programs can integrate stewardship activities at each step to ensure that every opportunity is taken to optimize antimicrobial use during a patient's treatment course. Hence, approaching AMS through the framework of a hospital's AUP is essential to improving appropriate antimicrobial use.
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Affiliation(s)
| | - Jason Yamaki
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, California
- Department of Pharmacy, Hoag Memorial Hospital Presbyterian, Newport Beach, California
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26
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Exploring the Role of the Bedside Nurse in Antimicrobial Stewardship: Survey Results From Five Acute-Care Hospitals. Infect Control Hosp Epidemiol 2018; 39:360-362. [DOI: 10.1017/ice.2017.255] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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27
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Katz MJ, Gurses AP, Tamma PD, Cosgrove SE, Miller MA, Jump RLP. Implementing Antimicrobial Stewardship in Long-term Care Settings: An Integrative Review Using a Human Factors Approach. Clin Infect Dis 2017; 65:1943-1951. [PMID: 29020290 PMCID: PMC5850640 DOI: 10.1093/cid/cix566] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Implementing effective antimicrobial stewardship in long-term care facilities (LTCFs) is associated with challenges distinct from those faced by hospitals. LTCFs generally care for elderly populations who are vulnerable to infection, have prescribers who are often off-site, and have limited access to timely diagnostic testing. Identification of feasible interventions in LTCFs is important, particularly given the new requirement for stewardship programs by the Centers for Medicare and Medicaid Services (CMS). In this integrative review, we analyzed published evidence in the context of a human factors engineering approach as well as educational interventions to understand aspects of multimodal interventions associated with the implementation of successful stewardship programs in LTCFs. The outcomes indicate that effective antimicrobial stewardship in long-term care is supported by incorporating multidisciplinary education, tools integrated into the workflow of nurses and prescribers that facilitate review of antibiotic use, and involvement of infectious disease consultants.
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Affiliation(s)
- Morgan J Katz
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine
| | - Ayse P Gurses
- Armstrong Institute for Patient Safety and Quality, School of Medicine, Bloomberg School of Public Health, Whiting School of Engineering
| | - Pranita D Tamma
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine
| | - Melissa A Miller
- Division of Healthcare-Associated Infections, Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland Veterans Affairs Medical Center
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University, Cleveland, Ohio
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28
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Timbrook TT, Caffrey AR, Ovalle A, Beganovic M, Curioso W, Gaitanis M, LaPlante KL. Assessments of Opportunities to Improve Antibiotic Prescribing in an Emergency Department: A Period Prevalence Survey. Infect Dis Ther 2017; 6:497-505. [PMID: 29052109 PMCID: PMC5700895 DOI: 10.1007/s40121-017-0175-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction Approximately 30% of all outpatient antimicrobials are inappropriately prescribed. Currently, antimicrobial prescribing patterns in emergency departments (ED) are not well described. Determining inappropriate antimicrobial prescribing patterns and opportunities for interventions by antimicrobial stewardship programs (ASP) are needed. Methods A retrospective chart review was performed among a random sample of non-admitted, adult patients who received an antimicrobial prescription in the ED from January 1 to December 31, 2015. Appropriateness was measured using the Medication Appropriateness Index, and was based on provider adherence to local guidelines. Additional information collected included patient characteristics, initial diagnoses, and other chronic medication use. Results Of 1579 ED antibiotic prescriptions in 2015, we reviewed a total of 159 (10.1%) prescription records. The most frequently prescribed antimicrobial classes included penicillins (22.6%), macrolides (20.8%), cephalosporins (17.6%), and fluoroquinolones (17.0%). The most common indications for antibiotics were bronchitis or upper respiratory tract infection (URTI) (35.1%), followed by skin and soft tissue infection (SSTI) (25.0%), both of which were the most common reason for unnecessary prescribing (28.9% of bronchitis/URTIs, 25.6% of SSTIs). Of the antimicrobial prescriptions reviewed, 39% met criteria for inappropriateness. Among 78 prescriptions with a consensus on appropriate indications, 13.8% had inappropriate dosing, duration, or expense. Conclusion Consistent with national outpatient prescribing, inappropriate antibiotic prescribing in the ED occurred in 39% of cases with the highest rates observed among patients with bronchitis, URTI, and SSTI. Antimicrobial stewardship programs may benefit by focusing on initiatives for these conditions among ED patients. Moreover, creation of local guideline pocketbooks for these and other conditions may serve to improve prescribing practices and meet the Core Elements of Outpatient Stewardship recommended by the Centers for Disease Control and Prevention.
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Affiliation(s)
- Tristan T Timbrook
- Veterans Affairs Medical Center, Providence, RI, USA.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Aisling R Caffrey
- Veterans Affairs Medical Center, Providence, RI, USA.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Brown University School of Public Health, Providence, RI, USA
| | - Anais Ovalle
- Veterans Affairs Medical Center, Providence, RI, USA
| | - Maya Beganovic
- Veterans Affairs Medical Center, Providence, RI, USA.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | | | | | - Kerry L LaPlante
- Veterans Affairs Medical Center, Providence, RI, USA. .,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA. .,Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI, USA.
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29
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Clinical impact of non-antibiotic recommendations by a multi-disciplinary antimicrobial stewardship team. Int J Antimicrob Agents 2017. [PMID: 28625717 DOI: 10.1016/j.ijantimicag.2017.01.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The multi-disciplinary antimicrobial stewardship team at the study hospital conducts prospective review and feedback on all inpatient orders of piperacillin-tazobactam and carbapenems. In addition, the team provides non-antibiotic recommendations (i.e. additional investigations and infectious disease reviews). This study aimed to describe the impact of these recommendations on patient outcomes. METHODS Patients on carbapenem and piperacillin-tazobactam who received at least one non-antibiotic recommendation between January 2012 and August 2014 were included in this study. Acceptance and rejection of non-antibiotic recommendations by the managing physician were compared. The primary outcome was 30-d mortality. RESULTS Non-antibiotic recommendations were made in 166 patients. There were no differences in baseline characteristics between patients for whom recommendations were accepted and patients for whom recommendations were rejected. Thirty-day mortality (18.0% vs. 34.5%, P = 0.02) was significantly lower in patients who had at least one non-antibiotic recommendation accepted. Multi-variate analysis found that Charlson's comorbidity score [odds ratio (OR) 1.20, 95% confidence interval (CI) 1.03-1.42, P = 0.03], APACHE II score (OR 1.10, 95% CI 1.01-1.19, P < 0.01), hepatobiliary source of infection (OR 10.19, 95% CI 1.44-72.13, P = 0.02) and acceptance of at least one non-antibiotic recommendation (OR 0.39, 95% CI 0.17-0.88, P = 0.02) were independently associated with 30-d mortality. CONCLUSIONS During prospective review and feedback of piperacillin-tazobactam and carbapenems, acceptance of non-antibiotic recommendations was found to be associated with a reduction in 30-d mortality.
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30
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Roger PM, Demonchy E, Risso K, Courjon J, Leroux S, Leroux E, Cua É. Medical table: A major tool for antimicrobial stewardship policy. Med Mal Infect 2017; 47:311-318. [PMID: 28457702 DOI: 10.1016/j.medmal.2017.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 09/27/2016] [Accepted: 03/24/2017] [Indexed: 11/20/2022]
Abstract
Infectious diseases are unpredictable, with heterogeneous clinical presentations, diverse pathogens, and various susceptibility rates to anti-infective agents. These features lead to a wide variety of clinical practices, which in turn strongly limits their evaluation. We have been using a medical table since 2005 to monitor the medical activity in our department. The observation of heterogeneous therapeutic practices led to drafting up our own antibiotic guidelines and to implementing a continuous evaluation of their observance and impact on morbidity and mortality associated with infectious diseases, including adverse effects of antibiotics, duration of hospital stay, use of intensive care, and deaths. The 10-year analysis of medical practices using the medical table is based on more than 10,000 hospitalizations. It shows simplified antibiotic therapies and a reduction in infection-related morbidity and mortality. The medical table is a major tool for antimicrobial stewardship, leading to constant benefits for patients.
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Affiliation(s)
- P-M Roger
- Infectiologie, université de Nice Sophia-Antipolis, hôpital de l'Archet, centre hospitalier universitaire de Nice, 151, route de St-Antoine, 06202 Nice, France.
| | - E Demonchy
- Infectiologie, université de Nice Sophia-Antipolis, hôpital de l'Archet, centre hospitalier universitaire de Nice, 151, route de St-Antoine, 06202 Nice, France
| | - K Risso
- Infectiologie, université de Nice Sophia-Antipolis, hôpital de l'Archet, centre hospitalier universitaire de Nice, 151, route de St-Antoine, 06202 Nice, France
| | - J Courjon
- Infectiologie, université de Nice Sophia-Antipolis, hôpital de l'Archet, centre hospitalier universitaire de Nice, 151, route de St-Antoine, 06202 Nice, France
| | - S Leroux
- Infectiologie, université de Nice Sophia-Antipolis, hôpital de l'Archet, centre hospitalier universitaire de Nice, 151, route de St-Antoine, 06202 Nice, France
| | - E Leroux
- Infectiologie, université de Nice Sophia-Antipolis, hôpital de l'Archet, centre hospitalier universitaire de Nice, 151, route de St-Antoine, 06202 Nice, France
| | - É Cua
- Infectiologie, université de Nice Sophia-Antipolis, hôpital de l'Archet, centre hospitalier universitaire de Nice, 151, route de St-Antoine, 06202 Nice, France
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31
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Parente DM, Timbrook TT, Caffrey AR, LaPlante KL. Inappropriate prescribing in outpatient healthcare: an evaluation of respiratory infection visits among veterans in teaching versus non-teaching primary care clinics. Antimicrob Resist Infect Control 2017; 6:33. [PMID: 28360995 PMCID: PMC5371270 DOI: 10.1186/s13756-017-0190-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 03/17/2017] [Indexed: 11/25/2022] Open
Abstract
A recent study led by the Centers for Disease Control and Prevention (CDC) revealed at least 30% of antibiotic prescriptions in the outpatient setting were inappropriate. In this study of all ages, among adult patients, results were similar to the overall population, with the majority of inappropriate prescribing relating to respiratory infections. We applied the same methodology to investigate rates of antibiotic prescribing for respiratory tract infections in outpatient primary care clinics at the Providence Veterans Affairs Medical Center. The results of our evaluation reflected comparable rates of inappropriate prescribing, but when stratified by teaching versus non-teaching primary care clinics, inappropriate prescribing was significantly higher in non-teaching clinics (17.6% vs 44.0%, p < .0001). Respiratory infection visits in non-teaching outpatient clinics may be a pragmatic target for antimicrobial stewardship programs.
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Affiliation(s)
- Diane M Parente
- Rhode Island Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI 02908 USA.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI 02881 USA
| | - Tristan T Timbrook
- Rhode Island Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI 02908 USA.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI 02881 USA
| | - Aisling R Caffrey
- Rhode Island Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI 02908 USA.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI 02881 USA.,Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI 02908 USA
| | - Kerry L LaPlante
- Rhode Island Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI 02908 USA.,Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI 02881 USA.,Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI 02908 USA.,Infectious Diseases Division, Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903 USA
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