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Branstetter JW, Barker L, Yarbrough A, Ross S, Stultz JS. Challenges of Antibiotic Stewardship in the Pediatric and Neonatal Intensive Care Units. J Pediatr Pharmacol Ther 2021; 26:659-668. [PMID: 34588929 DOI: 10.5863/1551-6776-26.7.659] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 07/01/2021] [Indexed: 12/14/2022]
Abstract
The goals of antimicrobial stewardship programs (ASPs) are to optimize antimicrobial prescribing habits in order to improve patient outcomes, reduce antimicrobial resistance, and reduce hospital costs. Multiple society-endorsed guidelines and government policies reinforce the importance of ASP implementation. Effective antimicrobial stewardship can impact unique patients, hospitals, and societal antibiotic-resistance burden. The role and subsequent success of these programs has largely been reported in the adult population. Pediatric and neonatal intensive care units present unique challenges for traditional antimicrobial stewardship approaches. The purpose of this review article is to explore the challenges of appropriate antibiotic use in the pediatric and neonatal intensive care units and to summarize strategies ASPs can use to overcome these challenges. These problems include non-specific disease presentations, limited evidence for definitive treatment durations in many pediatric infections, fewer pediatric-trained infectious disease physicians, and applicability of intensive laboratory obtainment, collection, and interpretation. Additionally, many ASP implementation studies evaluating the efficacy of ASPs exclude the PICU and NICU. Areas of focus for pediatric ASPs should likely include appropriate antibiotic initiation, appropriate antibiotic duration, and appropriate antibiotic de-escalation.
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Thomas AA, Korienek PJ, Reid SA, Dierkhising RA, Dababneh AS, Lessard SR. Effect of Pharmacist Audit on Antibiotic Duration for Pneumonia and Urinary Tract Infection. Mayo Clin Proc Innov Qual Outcomes 2021; 5:763-769. [PMID: 34377948 PMCID: PMC8332370 DOI: 10.1016/j.mayocpiqo.2021.06.007] [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] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess the effect of clinical pharmacists in daily audits, under the direction of an antimicrobial stewardship program, of antibiotic treatment durations for the common inpatient disease states of community-acquired pneumonia (CAP) and urinary tract infection (UTI). PATIENTS AND METHODS This was a retrospective single-center cohort study that evaluated the difference in the duration of antibiotic therapy for CAP or non-catheter-associated UTI of hospitalized patients who received a daily audit by clinical pharmacists compared with patients who did not receive a daily audit. Retrospective chart review included randomly selected hospitalized patients diagnosed with CAP or UTI during preaudit and postaudit periods. RESULTS The preaudit group had 64 patients; and the postaudit group, 51 patients. The therapy duration was 7 days in the preaudit group and 6 days in the postaudit group (P=.55). Fluoroquinolone use was reduced in the postaudit group and was significantly less than in the preaudit group (24 [37.5%] vs 7 [13.7%]; P=.007). CONCLUSION The daily audits of clinical pharmacists may be an effective method to reduce the duration of antibiotic therapy and are effective in the reduction of fluoroquinolone use. Additional studies must be done to further investigate the effects of clinical pharmacist antimicrobial stewardship efforts.
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Affiliation(s)
- Ashley A. Thomas
- Pharmacy Services, Mayo Clinic Health System – Southwest Wisconsin Region, La Crosse
| | - Patrick J. Korienek
- Pharmacy Services, Mayo Clinic Health System – Southwest Wisconsin Region, La Crosse
| | - Stacy A. Reid
- Pharmacy Services, Mayo Clinic Health System – Southwest Wisconsin Region, La Crosse
| | | | | | - Sarah R. Lessard
- Pharmacy Services, Mayo Clinic Health System – Southwest Wisconsin Region, La Crosse
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Procopio GL, Jain RP, Tompkins DM, Perez JM, Bicking K. Impact of a pharmacist driven anticoagulation reversal program at a large academic medical center. J Thromb Thrombolysis 2021; 53:158-166. [PMID: 34097227 DOI: 10.1007/s11239-021-02491-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2021] [Indexed: 11/29/2022]
Abstract
In major/life-threatening bleeding, administration of timely and appropriate reversal agents is imperative to reduce morbidity and mortality. Due to complexities associated with the use of reversal agents, a clinical pharmacist-driven anticoagulation reversal program (ARP) was developed. The goal of this program was to ensure appropriateness of reversal agents based on the clinical scenario, optimize selection and avoid unintended consequences. This study describes the impact of a pharmacist-driven anticoagulation program on patient outcomes and cost. A single center retrospective chart review of adult patients whom the ARP was consulted from October 2018 to January 2020 was performed. Patients were included in the efficacy analysis if they were > 18 years of age and presented with acute bleeding. Patients were excluded from the efficacy analysis if the recommended reversal agent was not administered, if a repeat head CT was not available for patients who presented with intracranial hemorrhage (ICH), or if the patient was not bleeding. All patients were included in the economic evaluation. The primary outcome was the percentage of patients who achieved effective hemostasis within 24 h of anticoagulation reversal. Secondary outcomes include incidence of thromboembolic events, in-hospital mortality, and cost avoidance. One hundred twenty-one patients were evaluated by the ARP with 92 patients included in the efficacy analysis. The primary sites of bleeding were ICH in 46% and gastrointestinal (GI) in 29%. Hemostasis was achieved in 84% of patients. Thrombotic events occurred in 7.4% of patients and in-hospital mortality was 26.4%. Total cost avoidance was $1,005,871.78. To our knowledge, this is the first study to evaluate the impact of a pharmacist-driven ARP on clinical and economic outcomes. Implementation of a pharmacist-driven ARP was associated with favorable outcomes and cost savings.
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Affiliation(s)
- Gabrielle L Procopio
- Department of Pharmacy, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ, 07601, USA. .,Department of Emergency Medicine, Hackensack Meridian School of Medicine, Nutley, NJ, 07110, USA.
| | - Ruchi Patel Jain
- Department of Pharmacy, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ, 07601, USA
| | - Danielle M Tompkins
- Department of Pharmacy, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ, 07601, USA.,Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, The State University of NJ, New Brunswick, NJ, 08854, USA
| | - Javier Martin Perez
- Department of Surgery, Hackensack University Medical Center, Hackensack, NJ, 07601, USA
| | - Keri Bicking
- Department of Pharmacy, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ, 07601, USA
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Cuevas C, Batura N, Wulandari LPL, Khan M, Wiseman V. Improving antibiotic use through behaviour change: a systematic review of interventions evaluated in low- and middle-income countries. Health Policy Plan 2021; 36:594-605. [PMID: 33822953 PMCID: PMC8488384 DOI: 10.1093/heapol/czab021] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 01/13/2021] [Accepted: 02/09/2021] [Indexed: 12/12/2022] Open
Abstract
Antibiotic resistance (ABR) has been identified as a critical threat to global health at the highest policy fora. A leading cause of ABR is the inappropriate use of antibiotics by both patients and healthcare providers. Although countries around the world have committed to developing and implementing national action plans to tackle ABR, there is a considerable gap in evidence about effective behaviour change interventions addressing inappropriate use of antibiotics in low- and middle-income countries (LMICs), where ABR is growing at an alarming rate. We conducted a systematic review to synthesize evidence about the effectiveness and cost-effectiveness of behaviour change interventions to reduce inappropriate use of antibiotics in LMICs. Three databases were searched using a set of predefined search terms and exclusion criteria. The search identified 43 relevant articles. A narrative synthesis of results was conducted using the Behaviour Change Wheel framework to categorize intervention components. The majority of the reviewed studies were set in lower-middle-income or low-income countries located in Sub-Saharan Africa or East Asia and the Pacific. Twenty-four articles evaluated multi-faceted interventions over a period of 12 months or less. Despite the widespread use of antibiotics in the community, interventions were primarily implemented in public health facilities, targeting health professionals such as doctors, nurses, and other allied medical staff. Although education for providers was the most widely used strategy for influencing antibiotic use, it was shown to be most effective when used in conjunction with training or other enabling and supportive measures to nudge behaviour. Six articles included an evaluation of costs of interventions and found a reduction in costs in inpatient and outpatient settings, and one article found a training and guidelines implementation-based intervention to be highly cost-effective. However, the small number of articles conducting an economic evaluation highlights the need for such analyses to be conducted more frequently to support priority setting in resource-constrained environments.
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Affiliation(s)
- Carla Cuevas
- Centre for Global Health Economics, Institute for Global Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
| | - Neha Batura
- Centre for Global Health Economics, Institute for Global Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
| | - Luh Putu Lila Wulandari
- The Kirby Institute, University of New South Wales, Level 6, Wallace Wurth BuildingHigh Street, UNSW Australia. Sydney, New South Wales, 2052, Australia
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Mishal Khan
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
- Aga Khan University, National Stadium Road, Karachi, Pakistan
| | - Virginia Wiseman
- The Kirby Institute, University of New South Wales, Level 6, Wallace Wurth BuildingHigh Street, UNSW Australia. Sydney, New South Wales, 2052, Australia
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
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Evaluation of Antimicrobial Stewardship Programs (ASPs) and their perceived level of success at Makkah region hospitals, Kingdom of Saudi Arabia. Saudi Pharm J 2020; 28:1166-1171. [PMID: 33132709 PMCID: PMC7584782 DOI: 10.1016/j.jsps.2020.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/08/2020] [Indexed: 02/07/2023] Open
Abstract
Antimicrobial stewardship programs (ASPs) are collaborative efforts to optimize antimicrobial use in healthcare institutions through evidence-based quality improvement strategies. The general administration of pharmaceutical care in the Saudi ministry of health (MOH) is putting outstanding efforts in implementing antimicrobial stewardship in Saudi health care settings. Several surveys have been conducted globally and reported many types of antimicrobial stewardship strategies in health institutions and their effectiveness. This study aims to identify ASPs in Makkah region hospitals and their perceived level of success. We administered a regional survey to explore current progress and issues related to the implementation of ASPs in Makkah region hospitals at the pharmacy level (n = 25). Among responding hospitals, 19 (76%) hospitals, the most commonly reported ASP were as following: formulary restrictions (90%) for broad-spectrum antimicrobials and use of prospective feedback on antimicrobial prescribing (68%), use of clinical guidelines and pathways (100%), and use of automatic stop orders (68%) to limit inappropriate antimicrobial therapy. The study outcomes will also be of pivotal importance to devise policies and strategies for antimicrobial stewardship implementation in other non-MOH settings in the Makkah region. Based on our results, all reported institutions have at least one antimicrobial stewardship program in a process with a high success rate. A multidisciplinary ASP approach, active involvement of drug & therapeutic committee, formulary restrictions, and availability of education & training of pharmacists and physicians on ASP are the primary elements for perceived successful antimicrobial stewardship programs in the Makkah region hospitals.
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[Organisational and staff requirements for antimicrobial stewardship activities in hospitals : Position paper of the Commission on Anti-Infectives, Resistance and Therapy (Commission ART) at the Robert Koch Institute, with advice from professional associations]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:749-760. [PMID: 32468301 DOI: 10.1007/s00103-020-03152-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Increased awareness of the rising antimicrobial resistance problem and impending loss of suitable treatment options for infectious diseases have changed patient care. Antimicrobial/antibiotic stewardship (ABS) activities aiming to optimize antimicrobial treatment were specified in international (WHO, ECDC) and national programmes and evidence-based practice guidelines. In Germany, ABS in hospitals is enshrined in the Infection Protection Act §23 and in a national guideline. The position paper presents the goals and tasks of ABS as well as the necessary organisational and staff requirements.Qualified training and education, mandates and support from hospital directors, and the provision of sufficient resources are essential prerequisites for the successful work of the ABS team. The ABS team should work hospital-wide across clinical services. Their main tasks are developing and implementing an ABS programme tailored to local needs and the conditions of the hospital, taking into account anti-infective drug prescribing, the resistance situation and case mix. Their tasks also include drafting and implementing in-house recommendations for diagnosis, prophylaxis and treatment of important infectious diseases. The ABS team should be interdisciplinary and include specially qualified doctors and pharmacists. Doctors commissioned for ABS should support this team and take the department-specific concerns into account. The document specifies a minimum ABS staff of one full-time equivalent (FTE) per 500 beds. Depending on the case mix and specialties, additional staff may be required. It proposes that there should be 0.1 FTE doctors commissioned for ABS per 100 beds.
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Zaha DC, Bungau S, Uivarosan D, Tit DM, Maghiar TA, Maghiar O, Pantis C, Fratila O, Rus M, Vesa CM. Antibiotic Consumption and Microbiological Epidemiology in Surgery Departments: Results from a Single Study Center. Antibiotics (Basel) 2020; 9:antibiotics9020081. [PMID: 32069828 PMCID: PMC7168146 DOI: 10.3390/antibiotics9020081] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/10/2020] [Accepted: 02/10/2020] [Indexed: 02/06/2023] Open
Abstract
The spectrum and antibiotic sensitivity of isolated strains vary between departments, hospitals, countries; the discrepancies are related to the use and dosage of these antibiotics. The purpose of our research was to compare the type of pathogens and the susceptibility of the isolated strains, as well as the use of antibiotics in the surgical departments of the Emergency Clinical County Hospital, Oradea, Romania; for one year, all the patients admitted to the mentioned sections were monitored. Antibiotic sensitivity of isolated strains was expressed using cumulative antibiogram. The total consumption of antibiotics was 479.18 DDD/1000 patient-days in the surgical sections. The most commonly used drugs were cephalosporins third and first generation, and clindamycin. Infections of wounds, urinary tract and fluids were most commonly diagnosed, and the most isolated was Escherichia coli, followed by Staphylococcus aureus and Enterococcus faecalis. The most commonly prescribed antimicrobial was ceftriaxone, but its sensitivity was low. This study revealed that the intake of antimicrobials in the surgical sections is increased and the comparison of antimicrobial prescriptions, sensitivity rates, and the spectrum of isolated pathogens showed differences between antimicrobials.
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Affiliation(s)
- Dana Carmen Zaha
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1 December Sq., 410081 Oradea, Romania; (D.C.Z.); (D.U.); (C.M.V.)
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 29 N. Jiga St., 410028 Oradea, Romania;
- Correspondence: ; Tel.: +40-726-776-588
| | - Diana Uivarosan
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1 December Sq., 410081 Oradea, Romania; (D.C.Z.); (D.U.); (C.M.V.)
| | - Delia Mirela Tit
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 29 N. Jiga St., 410028 Oradea, Romania;
| | - Teodor Andrei Maghiar
- Department of Surgical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1 December Sq., 410081 Oradea, Romania; (T.A.M.); (O.M.); (C.P.)
| | - Octavian Maghiar
- Department of Surgical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1 December Sq., 410081 Oradea, Romania; (T.A.M.); (O.M.); (C.P.)
| | - Carmen Pantis
- Department of Surgical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1 December Sq., 410081 Oradea, Romania; (T.A.M.); (O.M.); (C.P.)
| | - Ovidiu Fratila
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1 December Sq., 410081 Oradea, Romania; (O.F.); (M.R.)
| | - Marius Rus
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1 December Sq., 410081 Oradea, Romania; (O.F.); (M.R.)
| | - Cosmin Mihai Vesa
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 1 December Sq., 410081 Oradea, Romania; (D.C.Z.); (D.U.); (C.M.V.)
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Zaha DC, Bungau S, Aleya S, Tit DM, Vesa CM, Popa AR, Pantis C, Maghiar OA, Bratu OG, Furau C, Moleriu RD, Petre I, Aleya L. What antibiotics for what pathogens? The sensitivity spectrum of isolated strains in an intensive care unit. THE SCIENCE OF THE TOTAL ENVIRONMENT 2019; 687:118-127. [PMID: 31207502 DOI: 10.1016/j.scitotenv.2019.06.076] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 06/09/2023]
Abstract
Antibiotic sensitivity spectrum of isolated strains differs according to hospital departments, the hospitals themselves, and countries. Discrepancies also exist in terms of antibiotic use and dosage. The aim of the present study is to compare the antibacterial agents, the types of infections, the number and type of pathogens, and the sensitivity to antibiotics used in the Intensive Care Unit (ICU) of the Emergency Clinical County Hospital of Oradea, Romania. Over a one-year period, data were gathered from the pharmacy computer system and medical records of inpatients. WHO Anatomical Therapeutic Chemical (ATC)/defined daily doses (DDD) methodology was used to assess drug administration data, and antibiotic use was expressed as DDD/1000 PD (patient days). The antibiotic susceptibility of isolated strains was expressed through the cumulative antibiogram. The overall consumption of antimicrobial agents was 1247.47 DDD/1000 PD. The most common drugs used were cephalosporins and fluoroquinolones (52.97% of the total). Ceftriaxone was the most commonly used, followed by levofloxacin. Infections of the respiratory and urinary tract were the most frequently diagnosed infections. The most commonly isolated bacteria type was Acinetobacter baumannii (22.12% overall), isolated especially from the respiratory tract and resistant to all the β-lactam antibiotics including carbapenems. Antimicrobials intake at the ICU is much higher compared to medical and surgical wards. After we tested the existence of a possible connection between antibiotic consumption and antibiotic resistance of bacteria, it was revealed that on our sample exists a poor positive association.
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Affiliation(s)
- Dana Carmen Zaha
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
| | - Simona Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
| | - Selim Aleya
- Faculty of Medicine, Besançon, Chrono-Environnement Laboratory, UMR CNRS 6249, France
| | - Delia Mirela Tit
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
| | - Cosmin Mihai Vesa
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
| | - Amorin Remus Popa
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
| | - Carmen Pantis
- Department of Surgical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
| | - Octavian Adrian Maghiar
- Department of Surgical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
| | - Ovidiu Gabriel Bratu
- Clinical Department 3, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | - Cristian Furau
- Life Sciences Department, Western University "Vasile Goldis" of Arad, Arad, Romania
| | - Radu Dumitru Moleriu
- Department of Mathematics, Faculty of Mathematics and Computer Science, West University of Timisoara, Romania
| | - Izabella Petre
- Department XII of Obstetrics and Gynecology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Lotfi Aleya
- Department XII of Obstetrics and Gynecology, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania; Laboratoire Chrono-environnement, UMR CNRS 6249, Université de Franche-Comté, Besançon, France.
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Ideal and Actual Impact of Rapid Diagnostic Testing and Antibiotic Stewardship on Antibiotic Prescribing and Clinical Outcomes in Children With Positive Blood Cultures. Pediatr Infect Dis J 2019; 38:131-137. [PMID: 29750765 DOI: 10.1097/inf.0000000000002102] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Implementing matrix-assisted laser desorption ionization-time of flight and multiplex polymerase chain reaction has been associated with decreased mortality and hospital length of stay in adults, but the impact in pediatrics is less understood. METHODS This pre-post quasi-experimental study compared antibiotic prescribing for positive blood cultures in patients ≤21 years of age collected in 2012 (preintervention) and in 2015 (after matrix-assisted laser desorption ionization-time of flight/multiplex polymerase chain reaction). Time to effective and optimal antimicrobial therapy was evaluated using Cox proportional hazards regression. Time to ideal optimal therapy was estimated as the earliest potential initiation of optimal therapy. Antibiotic use and clinical outcomes were measured. RESULTS There were 242 and 192 positive monomicrobial blood cultures in 2012 and 2015, respectively. Postintervention, time to optimal therapy (73.8 vs. 48.8 hours; P < 0.001) and organism identification (55.6 vs. 29.5 hours; P < 0.001) were reduced, and patients were more likely to receive optimal therapy by 7 days (hazard ratio, 1.85; P < 0.001). In the ideal scenario in 2015, there was an 8.8-hour delay in initiating optimal therapy based on the time that sufficient microbiologic data were available. Postintervention, time to effective therapy (2.8 vs. 2.7 hours; P = 0.782) and clinical outcomes did not differ. Unnecessary antibiotic duration for probable contaminants (skin flora) (43.1 vs. 29.7 hours; P = 0.027), vancomycin for methicillin-sensitive Staphylococcus aureus (54.0 vs. 41.3 hours; P = 0.008) and nonpenicillin/ampicillin antibiotics for group A Streptococcus, group B Streptococcus and Enterococcus faecalis (87.2 vs. 33.4 hours; P < 0.001) were reduced postintervention. CONCLUSIONS Rapid diagnostics reduced time to optimal antimicrobial therapy and unnecessary antibiotic use without worse clinical outcomes.
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Zhu L, Bai J, Chen Y, Xue D. Effects of a clinical pathway on antibiotic use in patients with community-acquired pneumonia: a multi-site study in China. BMC Infect Dis 2018; 18:471. [PMID: 30231869 PMCID: PMC6146630 DOI: 10.1186/s12879-018-3369-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 08/30/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a common condition with high mortality, morbidity and healthcare costs. This study aimed to determine whether clinical pathway (CP) implementation in different hospitals in China increased antibiotic compliance with the national CP in inpatients with CAP. METHODS Chart reviews of CAP cases were conducted in 18 public hospitals from 3 different regions of China in 2015. Chi-square tests and the t-test were used to compare differences between hospitals that implemented CP (CP group) and those that did not (non-CP group). Multivariate logistic analysis was adopted to test whether CP implementation for CAP in hospitals affected their overall antibiotic use compliance rates with the national CP for CAP. RESULTS The overall compliance rate with the national CP for inpatients with CAP was 43.69%. The compliance rates for timely initial antibiotic use, recommended antibiotic use and use of the recommended combination of antibiotics and the overall compliance rate were substantially higher in the CP group than in the non-CP group. A multivariate logistic model for overall compliance in inpatients with CAP showed that the hospitals in the CP group had greater overall compliance than those in the non-CP group (odds ratio [OR] = 1.76; 95% confidence interval [CI] = 1.16-2.71) after controlling for hospital and inpatient characteristics. CONCLUSION In China, the overall compliance rate with the national CP for inpatients with CAP was low, but inpatients with CAP in the hospitals in the CP group received antibiotics more concordantly with the national CP. Since adherence to evidence-based care has been shown to improve clinical outcomes, internal and external support from hospitals is required to facilitate CP implementation for inpatients with CAP. Additionally, governmental commitment, hospital input and population involvement are required to improve antibiotic utilization.
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Affiliation(s)
- Liping Zhu
- NHC Key Laboratory of Health Technology Assessment (Fudan University), Department of Hospital Management, School of Public Health, Fudan University, Shanghai, People’s Republic of China
| | - Jie Bai
- NHC Key Laboratory of Health Technology Assessment (Fudan University), Department of Hospital Management, School of Public Health, Fudan University, Shanghai, People’s Republic of China
| | - Yongcong Chen
- School of Public Health, Lanzhou University, Lanzhou, People’s Republic of China
| | - Di Xue
- NHC Key Laboratory of Health Technology Assessment (Fudan University), Department of Hospital Management, School of Public Health, Fudan University, Shanghai, People’s Republic of China
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Colbert J, McBane S, Lam M, Blaj A, Zimmers B, Yoon M, Park B, Le T, Dinh H, Wang J. Assessing the Acceptance of the Pay-For-Performance Model in a Segment of California Pharmacists. JOURNAL OF CONTEMPORARY PHARMACY PRACTICE 2018. [DOI: 10.37901/jcphp17-00011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background
Pay-for-performance (P4P) is a payment system in which providers are rewarded financially for the outcome of patient care. This study surveyed pharmacists to gain an overall understanding of their knowledge, experience, and attitude toward P4P. We investigated if having prior experience with P4P influences one's attitude toward and acceptance of this payment model.
Methods
A cross-sectional study was performed where a survey was sent to pharmacists affiliated with the University of California, San Diego (UCSD) School of Pharmacy. Data was collected over a two-week period. Chi-square and odds-ratio (OR) tests were used to assess an association between payment preference and the following factors: management experience, experience with P4P, years of practice, and familiarity with P4P. Six benefits and six problems relating to P4P were evaluated.
Results
Eighty-seven pharmacists participated in our survey. Fifty preferred traditional pay, and thirty-seven preferred P4P. The OR analysis suggests: 1) Pharmacists with P4P experience are 50% more likely to prefer P4P, 2) Pharmacists with management experience are 39% more likely to prefer P4P, and 3) Pharmacists with less than five years of working experience are 12% more likely to prefer P4P. The top perceived benefit of P4P was increased collaboration among healthcare providers. The main perceived challenge was cumbersome billing processes.
Conclusion
Pharmacists with P4P experience held more positive views of the payment system. Pharmacists without experience in the program were less supportive. The positive responses about P4P from those with P4P experience suggest that employers may receive more support for P4P from their staffs by educating them about the benefits of the model.
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Affiliation(s)
| | | | | | | | | | | | | | - Thu Le
- University of California, San Diego
| | - Han Dinh
- University of California, San Diego
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Monnier AA, Eisenstein BI, Hulscher ME, Gyssens IC. Towards a global definition of responsible antibiotic use: results of an international multidisciplinary consensus procedure. J Antimicrob Chemother 2018; 73:vi3-vi16. [PMID: 29878216 PMCID: PMC5989615 DOI: 10.1093/jac/dky114] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Conducted as part of the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project, this study aimed to identify key elements for a global definition of responsible antibiotic use based on diverse stakeholder input. Methods A three-step RAND-modified Delphi method was applied. First, a systematic review of antibiotic stewardship literature and relevant organization web sites identified definitions and synonyms of responsible use. Identified elements of definitions were presented by questionnaire to a multidisciplinary international stakeholder panel for appraisal of their relevance. Finally, questionnaire results were discussed in a consensus meeting. Results The systematic review and the web site search identified 17 synonyms (e.g. appropriate, correct) and 22 potential elements to include in a definition of responsible use. Elements were grouped into patient-level (e.g. Indication, Documentation) or societal-level elements (e.g. Education, Future Effectiveness). Forty-eight stakeholders with diverse backgrounds [medical community, public health, patients, antibiotic research and development (R&D), regulators, governments] from 18 countries across all continents participated in the questionnaire. Based on relevance scores, 21 elements were retained, 9 were rephrased and 1 was added. Together, the 22 elements and associated best-practice descriptions comprise an exhaustive list of elements to be considered when defining responsible use. Conclusions Combination of concepts from the literature and stakeholder opinion led to an international multidisciplinary consensus on a global definition of responsible antibiotic use. The widely diverging perspectives of stakeholders providing input should ensure the comprehensiveness and relevance of the definition for both individual patients and society. An aspirational goal would be to address all elements.
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Affiliation(s)
- Annelie A Monnier
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
| | | | - Marlies E Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge C Gyssens
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Medicine, Research Group of Immunology and Biochemistry, Hasselt University, Hasselt, Belgium
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Oczkowski S. Antimicrobial stewardship programmes: bedside rationing by another name? JOURNAL OF MEDICAL ETHICS 2017; 43:684-687. [PMID: 28298480 DOI: 10.1136/medethics-2015-102785] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 01/17/2017] [Accepted: 02/13/2017] [Indexed: 06/06/2023]
Abstract
Antimicrobial therapy is a cornerstone of therapy in critically ill patients; however, the wide use of antibiotics has resulted in increased antimicrobial resistance and outbreaks of resistant disease. To counter this, many hospitals have instituted antimicrobial stewardship programmes as a way to reduce the inappropriate use of antibiotics. However, uptake of antimicrobial stewardship programmes has been variable, as many clinicians fear that they may put individual patients at risk of treatment failure. In this paper, I argue that antimicrobial stewardship programmes are indeed a form of bedside rationing, and explore the risks and benefits of such programmes for individual patients in the intensive care unit, and the critically ill population in general. Using Norman Daniels' Accountability for Reasonableness as a framework for evaluating resource allocation policies, I conclude that antimicrobial stewardship programmes are an ethically sound form of bedside rationing.
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Calabrese MJ, Cooke CE, Watson K, de Bittner MR. Emerging roles for pharmacists in performance-based risk-sharing arrangements. Am J Health Syst Pharm 2017; 74:1007-1012. [PMID: 28522641 DOI: 10.2146/ajhp160398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Martin J Calabrese
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD.
| | - Catherine E Cooke
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
| | - Kristin Watson
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
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Yang K, Wu D, Tan F, Shi S, Guo X, Min Q, Zhang X, Cheng H. Attitudes and perceptions regarding antimicrobial use and resistance among medical students in Central China. SPRINGERPLUS 2016; 5:1779. [PMID: 27795921 PMCID: PMC5061672 DOI: 10.1186/s40064-016-3454-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/29/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Senior medical students, who are future doctors, should be prepared to use antimicrobials appropriately and will be important partners in antimicrobial stewardship. This survey was designed to investigate the attitudes and perceptions of senior medical students regarding antimicrobial use and resistance. METHODOLOGY We performed a multi-center survey involving a questionnaire handed out to all fourth year medical students from five representative teaching hospitals in Central China. The survey was completed within 1 month (October to November, 2015). Antimicrobial stewardship programs were taught in all of the teaching hospitals, yet only part of the respondents took part in it. RESULTS A total of 611 out of 728 students completed our survey. The majority of the respondents (92 %) believed that inappropriate use of antimicrobials causes antimicrobial resistance and agreed with the importance of a strong knowledge of antimicrobials in their medical careers. Most students (67 %) rated their education concerning antimicrobial use and resistance as useful or very useful, but only 25 % recalled having courses on this subject. The overall mean number of correct answers on a section of 11 knowledge questions was 3.78 (standard deviation 1.57, P value for score between hospitals <0.001). CONCLUSIONS We should make an effort to optimize curriculum system in Chinese institutions, and this may contribute to making our future doctors better prepared for antimicrobial stewardship and prudent antimicrobial prescribing.
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Affiliation(s)
- Kun Yang
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Dongfang Wu
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
| | - Fei Tan
- The Second Clinical College, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Shaojun Shi
- Department of Pharmacy, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Xianxi Guo
- Department of Pharmacy, Renmin Hospital, Wuhan University, Wuhan, China
| | - Qing Min
- Department of Pharmacy, Hubei University of Science and Technology, Wuhan, China
| | - Xiaolian Zhang
- Department of Immunology, Medical College of Wuhan University, Wuhan, China
| | - Hong Cheng
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, 430071 China
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Abstract
BACKGROUND There is no more challenging a group of pharmaceuticals than antimicrobials. With the antibiotic era came great optimism as countless deaths were prevented from what were previously fatal conditions. Although antimicrobial resistance was quickly identified, the abundance of antibiotics entering the market helped cement attitudes of arrogance as the "battle against pestilence appeared won". Opposite emotions soon followed as many heralded the return of the pre-antibiotic era, suggesting that the "antibiotic pipeline had dried up" and that our existing armament would soon be rendered worthless. DISCUSSION In reality, humans overrate their ecological importance. For millions of years there has been a balance between factors promoting bacterial survival and those disturbing it. The first half century of the "antibiotic era" was characterised by a cavalier attitude disturbing the natural balance; however, recent efforts have been made through several mechanisms to respond and re-strengthen the antimicrobial armament. Such mechanisms include a variety of incentives, educational efforts and negotiations. Today, there are many more "man-made" factors that will determine a new balance or state of ecological harmony. CONCLUSION Antibiotics are not a panacea nor will they ever be inutile. New resistance mechanisms will be identified and new antibiotics will be discovered, but most importantly, we must optimise our application of these extraordinary "biological tools"; therein lays our greatest challenge - creating a society that understands and respects the determinants of the effectiveness of antibiotics.
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Affiliation(s)
- Sze-Ann Woon
- Division of Infectious Diseases, University Medicine Cluster, National University Hospital, Singapore, Singapore
| | - Dale Fisher
- Division of Infectious Diseases, University Medicine Cluster, National University Hospital, Singapore, Singapore. .,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore. .,National University Health System, NUHS Tower Block, 1E Kent Ridge Road, Level 10, Singapore, 119228, Singapore.
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Abstract
OBJECTIVES The objectives of this review are to discuss the prevalence and risk factors associated with the development of hospital-acquired infections in pediatric patients undergoing cardiac surgery and the published antimicrobial prophylaxis regimens and rational approaches to the diagnosis, prevention, and treatment of nosocomial infections in these patients. DATA SOURCE MEDLINE and PubMed. CONCLUSION Hospital-acquired infections remain a significant source of potentially preventable morbidity and mortality in pediatric cardiac surgical patients. Through improved understanding of these conditions and implementation of avoidance strategies, centers caring for these patients may improve outcomes in this vulnerable population.
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Chen AWJ, Khumra S, Eaton V, Kong DCM. Snapshot of Barriers to and Indicators for Antimicrobial Stewardship in Australian Hospitals. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2011.tb00064.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | | | - David CM Kong
- Department of Pharmacy Practice, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesMonash University Parkville Victoria
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Lee YJF, Levy R, Bajorek BV. Restricted Antimicrobial Use at Transitions of Care at an Australian Hospital. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2011.tb00105.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Yi JF Lee
- Faculty of PharmacyThe University of Queensland
| | | | - Beata V Bajorek
- School of PharmacyUniversity of Technology Sydney, and Northern Local Health District St Leonards New South Wales
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Howard P, Pulcini C, Levy Hara G, West RM, Gould IM, Harbarth S, Nathwani D. An international cross-sectional survey of antimicrobial stewardship programmes in hospitals. J Antimicrob Chemother 2014; 70:1245-55. [PMID: 25527272 DOI: 10.1093/jac/dku497] [Citation(s) in RCA: 165] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To report the extent and components of global efforts in antimicrobial stewardship (AMS) in hospitals. METHODS An Internet-based survey comprising 43 questions was disseminated worldwide in 2012. RESULTS Responses were received from 660 hospitals in 67 countries: Africa, 44; Asia, 50; Europe, 361; North America, 72; Oceania, 30; and South and Central America, 103. National AMS standards existed in 52% of countries, 4% were planning them and 58% had an AMS programme. The main barriers to implementing AMS programmes were perceived to be a lack of funding or personnel, a lack of information technology and prescriber opposition. In hospitals with an existing AMS programme, AMS rounds existed in 64%; 81% restricted antimicrobials (carbapenems, 74.3%; quinolones, 64%; and cephalosporins, 58%); and 85% reported antimicrobial usage, with 55% linking data to resistance rates and 49% linking data to infection rates. Only 20% had electronic prescribing for all patients. A total of 89% of programmes educated their medical, nursing and pharmacy staff on AMS. Of the hospitals, 38% had formally reviewed their AMS programme: reductions were reported by 96% of hospitals for inappropriate prescribing, 86% for broad-spectrum antibiotic use, 80% for expenditure, 71% for healthcare-acquired infections, 65% for length of stay or mortality and 58% for bacterial resistance. CONCLUSIONS The worldwide development and implementation of AMS programmes varies considerably. Our results should inform and encourage the further evaluation of this with a view to promoting a worldwide stewardship framework. The prospective measurement of well-defined outcomes of the impact of these programmes remains a significant challenge.
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Affiliation(s)
- P Howard
- Leeds Teaching Hospitals NHS Trust, Leeds LS1 3EX, UK
| | - C Pulcini
- CHU de Nancy, Service de Maladies Infectieuses, Nancy, France Université de Lorraine, Université Paris Descartes, EA 4360 Apemac, Nancy, France
| | - G Levy Hara
- Infectious Diseases Unit, Hospital Carlos G Durand, Buenos Aires, Argentina
| | - R M West
- Leeds Institute for Health Sciences, University of Leeds, Leeds LS2 9LJ, UK
| | - I M Gould
- Microbiology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK
| | - S Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - D Nathwani
- Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
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Ng TM, Liew YX, Teng CB, Ling LM, Ang B, Lye DC. An interactive, point-of-care, computerised antibiotic prescription decision support system and quality of antibiotic prescription in the management of complicated urinary tract infection. J Glob Antimicrob Resist 2014; 2:127-128. [PMID: 27873592 DOI: 10.1016/j.jgar.2014.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Revised: 01/03/2014] [Accepted: 03/06/2014] [Indexed: 11/15/2022] Open
Affiliation(s)
- Tat Ming Ng
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore.
| | - Yi Xin Liew
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Christine B Teng
- Department of Pharmacy, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore
| | - Li Min Ling
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
| | - Brenda Ang
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore
| | - David C Lye
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Zhanel GG, Karlowsky JA, Rubinstein E, Hoban DJ. Tigecycline: a novel glycylcycline antibiotic. Expert Rev Anti Infect Ther 2014; 4:9-25. [PMID: 16441206 DOI: 10.1586/14787210.4.1.9] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Tigecycline, the first-in-class glycylcycline, was developed to recapture the broad spectrum of activity of the tetracycline class and to treat patients with difficult-to-treat bacterial infections. Tigecycline's in vitro spectrum of activity encompasses aerobic, facultative and anaerobic Gram-positive and -negative bacteria, including antimicrobial-resistant bacteria such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus faecalis and Enterococcus faecium, and extended-spectrum beta-lactamase-producing Enterobacteriaceae. Clinical trials involving patients with complicated skin and skin-structure infections and complicated intra-abdominal infections, including patients infected with methicillin-resistant S. aureus, demonstrated that tigecycline was bacteriologically and clinically effective with mild-to-moderate gastrointestinal adverse events (i.e., nausea, vomiting and diarrhea) the most commonly reported. Tigecycline is a promising new broad-spectrum parenteral monotherapy for the treatment of patients with Gram-positive and -negative bacterial infections.
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Affiliation(s)
- George G Zhanel
- Department of Medical Microbiology, Faculty of Medicine, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada.
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Montesinos-Sanchis E, Moraga-Llop FA, Soler-Palacín P, Oliveras-Arenas M, Larrosa Escartín MN, Martínez Gómez X, Figueras-Nadal C. [Carbapenem antibiotics in hospitalised paediatric patients. Adherence to a therapeutic protocol]. Enferm Infecc Microbiol Clin 2013; 32:647-53. [PMID: 24355607 DOI: 10.1016/j.eimc.2013.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 10/06/2013] [Accepted: 10/16/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To describe the use of carbapenems in children hospitalised outside intensive care and onco-haematology units, and assess adherence to a therapeutic protocol. PATIENTS AND METHODS A retrospective observational study was conducted on the use of carbapenems between January 2009 and December 2010. The study included children with a community-acquired infectious disease or a health care-associated infectious disease, and who were admitted to paediatric areas of the Vall d'Hebron University Hospital (Barcelona, Spain), other than intensive care, neonatology and onco-haematology units. Clinical data were collected and antibiotic consumption data were provided by the Pharmacy Department. RESULTS A total of 51 episodes fulfilled the inclusion criteria. Carbapenem as initial empirical treatment was indicated in 31.4%, and applied as rescue therapy in the remainder. The instructions of the protocol were adhered to in 70.6% of the empirical and 87.5% of the targeted prescriptions (77.6% overall). A better match was found for empirical carbapenem in patients with a previous admission or underlying condition. Factors such as diagnosis, age or antibiotic use prior to admission did not affect the empirical indication of carbapenem. CONCLUSIONS The establishment of a treatment protocol with carbapenem indications in our centre since 2007 has yielded significantly better results on the appropriateness of the prescription than those obtained in other studies.
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Affiliation(s)
- Elena Montesinos-Sanchis
- Unidad de Patología Infecciosa e Inmunodeficiencias de Pediatría, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - Fernando A Moraga-Llop
- Unidad de Patología Infecciosa e Inmunodeficiencias de Pediatría, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España.
| | - Pere Soler-Palacín
- Unidad de Patología Infecciosa e Inmunodeficiencias de Pediatría, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - María Oliveras-Arenas
- Servicio de Farmacia, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - M Nieves Larrosa Escartín
- Servicio de Microbiología, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - Xavier Martínez Gómez
- Servicio de Medicina Preventiva y Epidemiología, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
| | - Concepción Figueras-Nadal
- Unidad de Patología Infecciosa e Inmunodeficiencias de Pediatría, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, España
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Selection of hospital antimicrobial prescribing quality indicators: a consensus among German antibiotic stewardship (ABS) networkers. Infection 2013; 42:351-62. [PMID: 24326986 DOI: 10.1007/s15010-013-0559-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Accepted: 11/05/2013] [Indexed: 12/31/2022]
Abstract
PURPOSE Simple, valid, and evidence-based indicators to measure the quality of antimicrobial prescribing in acute-care hospitals are urgently needed and increasingly requested by policymakers. The aim of this study was to develop new consensus quality indicators (QIs) for hospital antibiotic stewardship (ABS) and infection management which will be further evaluated for internal quality management and external quality assessment in Germany. METHODS Based on an extensive literature review, the Austrian-German hospital ABS Guideline Committee and selected members of the German ABS Expert Network discussed and drafted a list of 99 potential indicators for hospitals that reflect structural prerequisites for ABS (35 items), ABS core activities (18 items), additional ABS measures (5 items), and process of care indicators (both generic and disease-specific-12 and 29 items, respectively). Questionnaires were mailed to German ABS experts and healthcare professionals with further education in ABS. Participants scored (on a nine-point Likert scale) relevance (clinical, ecological/resistance, economical/expenses) and presumed practicability (six categories: clarity of definition, effort to collect data, barrier to implementation, verifiability, suitability for external quality assessment, quality gap), taking into account their local work environment. The scores were processed according to the RAND/UCLA appropriateness method, and QIs were judged relevant if the median (clinical + ecological and/or economical) scores were >6. The indicators thus assessed to be potentially relevant were then filtered according to their practicability. Highly relevant QIs with borderline practicability scores and items with disagreements and overlapping areas were re-discussed in a final multidisciplinary panel consensus workshop convened in November 2012. RESULTS Of the 340 questionnaires that were mailed, 75 questionnaires were completed and returned. Of 99 initially proposed items, 32 were excluded due to insufficient scores. Of the remaining 67 items, 21 structural and 21 process of care QIs were finally selected, including four QIs with high clinical and ecological but limited economical relevance, and three QIs with high clinical and economical but limited ecological relevance. Among the selected QIs, efforts to collect data and implementation barriers were scored as suboptimal in many cases. CONCLUSIONS A catalog of consensus structural and process of care ABS-QIs was established. These should undergo further pilot and feasibility studies in the German hospital healthcare sector. The panelists were most critical regarding resource use/complexity issues and presumed implementation barriers. How this may limit applicability of QIs remains to be determined.
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Abbo LM, Cosgrove SE, Pottinger PS, Pereyra M, Sinkowitz-Cochran R, Srinivasan A, Webb DJ, Hooton TM. Medical students' perceptions and knowledge about antimicrobial stewardship: how are we educating our future prescribers? Clin Infect Dis 2013; 57:631-8. [PMID: 23728148 DOI: 10.1093/cid/cit370] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Better understanding of medical students' perceptions, attitudes, and knowledge about antimicrobial prescribing practices could facilitate more effective education of these future prescribers. METHODS A 24-item electronic survey on antimicrobial prescribing and education was administered to fourth-year medical students at the University of Miami, the Johns Hopkins University, and the University of Washington (January-March 2012). RESULTS Three hundred seventeen of 519 (61%) students completed the survey; 92% of respondents agreed that strong knowledge of antimicrobials is important in their careers, and 90% said that they would like more education on appropriate use of antimicrobials. Mean correct knowledge score (11 items) was 51%, with statistically significant differences between study sites and sources of information used to learn about antimicrobials. Only 15% had completed a clinical infectious diseases rotation during medical school; those who had done so rated the quality of their antimicrobial education significantly higher compared to those who had not (mean, 3.93 vs 3.44, on a 5-point scale; P = .0003). There were no statistically significant associations between knowledge scores and having had an infectious diseases clinical elective. Only one-third of respondents perceived their preparedness to be adequate in some fundamental principles of antimicrobial use. CONCLUSIONS Differences exist between medical schools in educational resources used, perceived preparedness, and knowledge about antimicrobial use. Variability in formative education could frame behaviors and prescribing practices in future patient care. To help address the growing problem of antimicrobial resistance, efforts should be undertaken to ensure that our future doctors are well educated in the principles and practices of appropriate use of antibiotics and antimicrobial stewardship.
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Affiliation(s)
- Lilian M Abbo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Florida 33136, USA.
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García-Vázquez E, Moral-Escudero E, Hernández-Torres A, Canteras M, Gómez J, Ruiz J. What is the impact of a rapid diagnostic E-test in the treatment of patients with Gram-negative bacteraemia? ACTA ACUST UNITED AC 2013; 45:623-8. [PMID: 23596976 DOI: 10.3109/00365548.2013.782102] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To evaluate the influence of a rapid diagnostic test (RDT) in antibiotic therapeutic decisions in non-paediatric patients with Gram-negative bacteraemia (GNB). PATIENTS AND METHODS A RDT consisting of a direct antibiogram was used on blood isolates of GNB. GNB were also identified and sensitivity tests were performed according to standard criteria. Information on empirical treatment was registered (T1), as well as the antibiotic administered once the results of the RDT were available (T2). Finally, we noted the ideal antibiotic that the infectious diseases specialist (IDS) would have prescribed (T3). The decision regarding T2 was always taken by the patient's physician or the physician on duty. RESULTS A RDT was performed for 248 patients. The most frequently isolated bacterium was Escherichia coli (13% producing extended-spectrum beta-lactamase). T1 was considered appropriate in 74% and appropriate but optimizable in 43%. T2 was considered appropriate in 95%, appropriate but optimizable in 36%, and inappropriate in 5%. The cost of the optimizable treatment (T2) was € 2210, while the cost of the ideal treatment would have been € 416; the saving in antibiotic cost of 1 day of treatment would have been € 1694. CONCLUSIONS Treatment prescribed by a non-IDS after a RDT was inappropriate in 5% and optimizable in 36%. It is our recommendation that information provided by a RDT should be interpreted by an IDS to make the information more beneficial both economically and 'ecologically'.
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Affiliation(s)
- Elisa García-Vázquez
- From the Infectious Diseases - Internal Medicine Service, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.
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Nowak MA, Nelson RE, Breidenbach JL, Thompson PA, Carson PJ. Clinical and economic outcomes of a prospective antimicrobial stewardship program. Am J Health Syst Pharm 2013; 69:1500-8. [PMID: 22899745 DOI: 10.2146/ajhp110603] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
PURPOSE A pre-post analysis of an antimicrobial stewardship program (ASP) involving the use of data-mining software to prospectively identify cases for ASP intervention was conducted. METHODS The investigators evaluated clinical outcomes and cost metrics before and after implementation of the ASP, which entailed daily physician review of summary reports on all adult inpatients receiving antimicrobial therapy. The primary outcome measures were annual antimicrobial expenditures and rates of infections due to common nosocomial pathogens; secondary outcome measures included patient survival and length of stay (LOS) in cases involving the indicator diagnoses of pneumonia and abdominal sepsis. RESULTS Antimicrobial expenditures, which had increased by an average of 14.4% annually in the years preceding ASP implementation, decreased by 9.75% in the first year of the program and remained relatively stable in subsequent years, with overall cumulative cost savings estimated at $1.7 million. Rates of nosocomial infections involving Clostridium difficile, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci all decreased after ASP implementation. A pre-post comparison of survival and LOS in patients with pneumonia (n = 2186) or abdominal sepsis (n = 225) showed no significant differences in those outcomes in either patient group, possibly due to the hospital's initiation of other, concurrent infection-control programs during the study period. CONCLUSION A prospective collaborative ASP employed automated reports to efficiently identify key data for ASP review. After ASP implementation, antimicrobial expenditures and rates of nosocomial infections caused by resistant pathogens dropped without significant changes in patient survival, LOS, and readmissions for the two studied illness categories.
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Affiliation(s)
- Michael A Nowak
- College of Pharmacy, California Northstate University, Rancho Cordova, 95670, USA.
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Abstract
The judicious use of antibiotics is an important means to limit the emergence of antibiotic-resistant organisms. Although specific guidelines for neonates are often lacking, antibiotic stewardship principles can be applied to the neonatal intensive care unit. Principles include accurately identifying patients who need antibiotic therapy, using local epidemiology to guide the selection of empiric therapy, avoiding agents with overlapping activity, adjusting antibiotics when culture results become available, monitoring for toxicity, and optimizing the dose, route, and duration of therapy. Neonatal intensive care units should develop interdisciplinary antimicrobial stewardship teams with the support of their institutions. Prescriber audit and feedback, as well as preauthorization and formulary restriction of selected antibiotics, are recommended antimicrobial stewardship interventions. Ancillary strategies include education and computerized decision support. Metrics to evaluate antimicrobial stewardship programs should include measurements of patient safety and quality, such as rates of adverse drug events, and appropriate dosing and timing of perioperative prophylaxis.
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Affiliation(s)
- Sameer J. Patel
- Assistant Professor of Pediatrics, Department of Pediatrics, Columbia University, New York, NY
| | - Lisa Saiman
- Professor of Clinical Pediatrics, Department of Pediatrics, Columbia University, New York, NY
- Hospital Epidemiologist, Department of Infection Prevention & Control, Morgan Stanley Children’s Hospital of New York-Presbyterian, New York, NYFrom: Children’s Hospital of New York-Presbyterian
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Boothe D, Smaha T, Carpenter DM, Shaheen B, Hatchcock T. Antimicrobial resistance and pharmacodynamics of canine and feline pathogenic E. coli in the United States. J Am Anim Hosp Assoc 2012; 48:379-89. [PMID: 23033458 DOI: 10.5326/jaaha-ms-5805] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Percent resistance and minimum inhibitory concentrations (MIC) were described for canine (n = 301) and feline (n = 75) pathogenic Escherichia coli (E. coli) isolates solicited during May 2005 to Sep 2005 from the Clinical Pharmacology Laboratory at Auburn University (n = 165) or commercial diagnostic laboratories ([CDL]; n = 211) from four regions in the USA. Drugs tested were amoxicillin (AMX), amoxicillin trihydrate/clavulanate potassium (AMXC), cefpodoxime (CFP), doxycycline (DXY), enrofloxacin (ENR), gentamicin (GM) and trimethoprim-sulfamethoxazole (TMS). Urinary isolates were most common (n = 174). Percent resistance was greatest for isolates from the respiratory tract, urine, and skin compared with the ear. Resistance was also greatest for samples sent from the south and central states compared with the western states (P ≤ 0.001). Percent resistance by drug was AMX (46 ± 2.6%) > AMXC (37 ± 2.5%) > CFP (21.8 ± 2%) = DXY (22 ± 2.1%) = ENR (20 ± 2.1%) = TMS (19 ± 2%) > GM (12 ± 1.7%). There was a significant difference in resistance between the different antibiotic drugs (P ≤ 0.001). Population MIC distributions were bimodal, and MICs were highest in samples from the southern states (P ≤ 0.001). E. coli resistance may limit its empirical treatment. For susceptible isolates, AMX and AMXC may be least effective and TMS most effective.
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Affiliation(s)
- Dawn Boothe
- Department of Anatomy, Physiology and Pharmacology, Auburn University, AL, USA.
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A review of the effect of immunization programs on antimicrobial utilization. Vaccine 2012; 30:6509-14. [DOI: 10.1016/j.vaccine.2012.08.031] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 08/02/2012] [Accepted: 08/15/2012] [Indexed: 11/22/2022]
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Gagliardo C, Saiman L. What is the Evidence Behind Recommendations for Infection Control? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 719:163-9. [DOI: 10.1007/978-1-4614-0204-6_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Yeo CL, Chan DSG, Earnest A, Wu TS, Yeoh SF, Lim R, Jureen R, Fisher D, Hsu LY. Prospective audit and feedback on antibiotic prescription in an adult hematology-oncology unit in Singapore. Eur J Clin Microbiol Infect Dis 2011; 31:583-90. [PMID: 21845470 DOI: 10.1007/s10096-011-1351-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 07/02/2011] [Indexed: 11/28/2022]
Abstract
We evaluated the impact of a prospective audit and feedback antimicrobial stewardship program (ASP) on antibiotic prescription and resistance trends in a hematology-oncology unit in a university hospital (National University Cancer Institute, Singapore [NCIS]). A prospective interrupted time-series study comprising 11-month pre-intervention (PIP) and intervention evaluation phases (IEP) flanking a one-month implementation phase was carried out. Outcome measures included defined daily dose per 100 (DDD/100) inpatient-days of ASP-audited and all antibiotics (encompassing audited and non-audited antibiotics), and the incidence-density of antibiotic-resistant microorganisms at the NCIS. Internal and external controls were DDD/100 inpatient-days of paracetamol at the NCIS and DDD/100 inpatient-days of antibiotics prescribed in the rest of the hospital. There were 580 ASP recommendations from 1,276 audits, with a mean monthly compliance of 86.9%. Significant reversal of prescription trends towards reduced prescription of audited (coefficient = -2.621; 95% confidence interval [CI]: -4.923, -0.319; p = 0.026) and all evaluated antibiotics (coefficient = -4.069; 95% CI: -8.075, -0.063; p = 0.046) was observed. No changes were seen for both internal and external controls, except for the reversal of prescription trends for cephalosporins hospital-wide. Antimicrobial resistance did not change over the time period of the study. Adverse outcomes-the majority unavoidable-occurred following 5.5% of accepted ASP recommendations. Safe and effective ASPs can be implemented in the complex setting of hematology-oncology inpatients.
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Affiliation(s)
- C-L Yeo
- Department of Pharmacy, National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228, Singapore
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Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: Prescribing and transcribing—2010. Am J Health Syst Pharm 2011; 68:669-88. [DOI: 10.2146/ajhp100711] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Philip J. Schneider
- University of Arizona, College of Pharmacy at the Phoenix Biomedical Campus, Phoenix
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Grill E, Weber A, Lohmann S, Vetter-Kerkhoff C, Strobl R, Jauch KW. Effects of pharmaceutical counselling on antimicrobial use in surgical wards: intervention study with historical control group. Pharmacoepidemiol Drug Saf 2011; 20:739-46. [PMID: 21452339 DOI: 10.1002/pds.2126] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 01/24/2011] [Accepted: 01/25/2011] [Indexed: 01/12/2023]
Abstract
PURPOSE The objective of this study was to assess the impact of pharmaceutical consulting on the quality of antimicrobial use in a surgical hospital department in a prospective controlled intervention study. METHODS Patients receiving pharmaceutical intervention (intervention group, IG, n = 317) were compared with a historical control group (control group, CG, n = 321). During the control period, antimicrobial use was monitored without intervention. During the subsequent intervention period, a clinical pharmacist reviewed the prescriptions and gave advice on medication. RESULTS Intervention reduced the length of antimicrobial courses (IG = 10 days, CG = 11 days, incidence rate ratio for i.v. versus o.p. = 0.88, 95% confidence interval 0.84 to 0.93) and shortened i.v. administration (IG = 8 days, CG = 10 days, hazard rate = 1.76 in favour of switch from i.v. to p.o., 95% confidence interval 1.23 to 2.52). Intervention also helped to avoid useless combination therapy and reduced total costs for antimicrobials. CONCLUSIONS A clinical pharmacist who reviews prescriptions can promote an increase in efficiency, for example, by shortening the course of treatment. Counselling by ward-based clinical pharmacists was shown to be effective to streamline antimicrobial therapy in surgical units and to increase drug safety.
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Affiliation(s)
- Eva Grill
- Institute for Health and Rehabilitation Sciences, Ludwig Maximilians University, Munich, Germany
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Deuster S, Roten I, Muehlebach S. Implementation of treatment guidelines to support judicious use of antibiotic therapy. J Clin Pharm Ther 2010; 35:71-8. [PMID: 20175814 DOI: 10.1111/j.1365-2710.2009.01045.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Judicious use of antibiotics is essential considering the growth of antimicrobial resistance and escalating costs in health care. This intervention study used treatment guidelines to improve antibiotic therapy by changing prescribing practice. METHODS A before-after intervention study was performed in a 550-bed tertiary care teaching hospital in Switzerland, with an additional follow-up analysis 1 year later. The pre-intervention phase included chart analysis of current antibiotic use in 100 consecutive patients from the representative medical and surgical wards included in the study. Treatment guidelines were defined, taking into account published guidelines, the local antibacterial sensitivity of the pathogens, and the hospital antibiotic formulary defined by the drug and therapeutics committee. The guidelines were presented to the medical residents on a pocket card. They were informed and educated by the pharmacist (intervention). In the post-intervention phase immediately after the instruction, and in the follow-up phase 1 year later, a prospective analysis of antibiotic prescription was performed by chart review of 100 antibacterial treatments in consecutive patients to detect changes in antibiotic prescribing (treatment) and to determine whether these changes were sustained. RESULTS The pre-intervention review of antibiotic use showed the need for therapy improvements in urinary tract infections (UTI) and hospital-acquired pneumonia (HAP). In the post-intervention phase 100% of UTI were treated as recommended, compared to 30% before the intervention (P < 0.001). The follow-up analysis showed a decrease in guideline adherence to 39% in patients with UTI. Before implementation of the clinical guidelines, HAP was inappropriately treated like community-acquired pneumonia (CAP). Immediately after the intervention, 50% of HAP patients were treated as recommended, and 1 year later (follow-up phase) 56% of HAP patients received the recommended antibiotic medication. This change in prescription practice was significant (P < 0.05). CONCLUSION Antibiotic treatment guidelines for the infections most commonly occurring in hospitalized patients resulted in a significant increase in appropriate antibiotic use. The program was successful in changing prescription practice and achieved a sustained optimization of HAP therapy. Implementing, teaching and monitoring treatment guidelines can have a major impact on patient care.
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Affiliation(s)
- S Deuster
- Division of Pharmacy, University Hospital Basel, Basel, Switzerland.
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Njoku JC, Hermsen ED. Antimicrobial Stewardship in the Intensive Care Unit: A Focus on Potential Pitfalls. J Pharm Pract 2010; 23:50-60. [DOI: 10.1177/0897190009356554] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients in the intensive care unit (ICU) have many risk factors for resistant pathogens such as prolonged length of stay, frequent and broad-spectrum antimicrobial therapy, presence of foreign materials, and proximity with other patients. However, of the risk factors associated with acquisition of resistant pathogens, inappropriate use of antimicrobial agents has been the most implicated. Thus, many health care institutions have adopted antimicrobial stewardship programs (ASPs) as a mechanism to ensure more appropriate antimicrobial use. ASPs can have a significant impact in the ICU, leading to improved antimicrobial use and resistance patterns and decreased infection rates and costs, due to the inherent nature of infections encountered and high and often inappropriate antibiotic utilization in this setting. However, certain challenges exist for ASPs in the ICU including issues with infrastructure and personnel, information technology, the core ASP strategy, patient-specific factors, conversion of intravenous to oral therapy, and dose optimization. The combination of comprehensive infection control (IC) and effective antimicrobial stewardship can prevent the emergence of resistance among microorganisms and may decrease the negative consequences associated with antimicrobial misuse.
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Affiliation(s)
- Jessica C. Njoku
- Pharmacy Relations & Clinical Decision Support, The Nebraska Medical Center, Omaha, NE, USA
- University of Nebraska Medical Center, College of Pharmacy, Department of Pharmacy Practice, Omaha, NE, USA
| | - Elizabeth D. Hermsen
- Pharmacy Relations & Clinical Decision Support, The Nebraska Medical Center, Omaha, NE, USA
- University of Nebraska Medical Center, College of Pharmacy, Department of Pharmacy Practice, Omaha, NE, USA
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Abstract
Critical-care units can be barometers for appropriate antimicrobial use. There, life and death hang on empirical antimicrobial therapy for treatment of infectious diseases. With increasing therapeutic empiricism, triple-drug, broad-spectrum regimens are often necessary, but cannot be continued without fear of the double-edged sword: a life-saving intervention or loss of life following Clostridium difficile infection, infection from a resistant organism, nephrotoxicity, cardiac toxicity, and so on. While broadened initial empirical therapy is considered a standard, it must be necessary, dosed according to pharmacokinetic-pharmacodynamic principles, and stopped when no longer needed. Antimicrobial stewardship interventions shepherd these considerations in antimicrobial therapy. With pharmacists and physicians trained in infectious disease and critical care, clear-cut interventions can be focused on beginning or growing a stewardship program, or proposing future studies.
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Affiliation(s)
- Robert C Owens
- Department of Clinical Pharmacy Services and Division of Infectious Diseases, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102, USA.
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Waagsbø B, Sundøy A, Quist Paulsen E. Reduction of unnecessary IV antibiotic days using general criteria for antibiotic switch. ACTA ACUST UNITED AC 2009; 40:468-73. [DOI: 10.1080/00365540701837134] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Owens RC, Shorr AF, Deschambeault AL. Antimicrobial stewardship: Shepherding precious resources. Am J Health Syst Pharm 2009; 66:S15-22. [DOI: 10.2146/090087c] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Robert C. Owens
- Antimicrobial Stewardship Program, Department of Pharmacy, and Clinical Pharmacy Specialist, Infectious Diseases, Division of Infectious Diseases, Maine Medical Center, Portland, ME
| | - Andrew F. Shorr
- Pulmonary Critical Care, Department of Medicine, Washington Hospital Center, Washington, DC
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Ernst EJ, Klepser ME, Bosso JA, Rybak MJ, Hermsen ED, Segarra-Newnham M, Drew RH. Recommendations for training and certification for pharmacists practicing, mentoring, and educating in infectious diseases pharmacotherapy. Pharmacotherapy 2009; 29:482-8. [PMID: 19323625 DOI: 10.1592/phco.29.4.482] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Recently created guidelines for the development of institutional antimicrobial stewardship programs recommend that a pharmacist with infectious diseases training be included as a core member of the antimicrobial stewardship team. However, training and certification requirements for infectious diseases-trained clinical pharmacists have not been established. Although pharmacists have nurtured their interest in infectious diseases by self-directed learning or on-the-job experiences, this mode of training is not considered feasible or sufficient for reliable training of future clinical specialists in infectious diseases. This document, therefore, is forward looking and provides overarching recommendations for future training and certification of pharmacists practicing, mentoring, and educating in infectious diseases pharmacotherapy, with the recognition that full implementation may take several years. We recommend that future pharmacists wishing to obtain a clinical position as an infectious diseases-trained pharmacist should complete a postgraduate year (PGY) 1 residency and a PGY2 residency in infectious diseases, that practitioners become board-certified pharmacotherapy specialists, that a certification examination in infectious diseases be developed, that practitioners maintain a portfolio of educational experiences to maintain qualifications, that current nonaccredited training programs seek accreditation, and that employers and academicians recognize the desirability of these qualifications in hiring decisions.
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Affiliation(s)
- Erika J Ernst
- College of Pharmacy, University of Iowa, Iowa City, Iowa 52242, USA.
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Drew RH, White R, MacDougall C, Hermsen ED, Owens RC. Insights from the Society of Infectious Diseases Pharmacists on Antimicrobial Stewardship Guidelines from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Pharmacotherapy 2009; 29:593-607. [DOI: 10.1592/phco.29.5.593] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Scheetz MH, Bolon MK, Postelnick M, Noskin GA, Lee TA. Cost-effectiveness analysis of an antimicrobial stewardship team on bloodstream infections: a probabilistic analysis. J Antimicrob Chemother 2009; 63:816-25. [PMID: 19202150 DOI: 10.1093/jac/dkp004] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We sought to determine the cost-effectiveness of Antimicrobial Stewardship Teams (ASTs) on the reduction of morbidity and mortality associated with nosocomial bacteraemia. METHODS A decision analytic model compared costs and outcomes of bacteraemic patients receiving standard treatment with or without an AST consult. Patients with a bacteraemic event during their hospital admission were included in the model. Effectiveness was estimated as quality-adjusted life years (QALYs) over the lifetime of patients. Model variables and costs, along with their distributions, were obtained from the literature and expert opinion. Incremental cost-effectiveness ratios (ICERs) were calculated to estimate the cost per QALY gained from the hospital perspective. Uncertainty in ICERs was evaluated with probabilistic sensitivity analyses. The cost-effectiveness of clinical decision support systems was evaluated as a secondary analysis. RESULTS Implementing an AST for bacteraemia review cost $39,737 (95% CI $27,272-53, 017) and standard treatment cost $39,563 (95% CI $27,164-52,797). The difference in effectiveness between the two strategies was 0.08 QALYs, and the base case ICER from the probabilistic analysis was $2367 per QALY gained [95% CI dominant (less costly, more effective) to $24,379]. Results from the probabilistic sensitivity analysis demonstrated there was more than a 90% likelihood that an AST would be cost-effective at a level of $10,000 per QALY. CONCLUSIONS Maintaining an AST to improve care for bacteraemia is cost-effective from the hospital perspective. The estimate of $2367 per QALY gained for the AST intervention compares favourably with many currently funded healthcare interventions and services.
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Affiliation(s)
- Marc H Scheetz
- Department of Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA.
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Miliani K, L'Heriteau F, Alfandari S, Arnaud I, Costa Y, Deliere E, Carbonne A, Astagneau P. Specific control measures for antibiotic prescription are related to lower consumption in hospitals: results from a French multicentre pilot study. J Antimicrob Chemother 2008; 62:823-9. [DOI: 10.1093/jac/dkn277] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Antimicrobial optimisation in secondary care: the pharmacist as part of a multidisciplinary antimicrobial programme—a literature review. Int J Antimicrob Agents 2008; 31:511-7. [DOI: 10.1016/j.ijantimicag.2008.01.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Accepted: 01/15/2008] [Indexed: 11/22/2022]
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Owens RC. Antimicrobial stewardship: concepts and strategies in the 21st century. Diagn Microbiol Infect Dis 2008; 61:110-28. [DOI: 10.1016/j.diagmicrobio.2008.02.012] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Accepted: 02/25/2008] [Indexed: 01/12/2023]
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Young J, Stevenson KB. Real-time surveillance and decision support: Optimizing infection control and antimicrobial choices at the point of care. Am J Infect Control 2008. [DOI: 10.1016/j.ajic.2007.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
In response to the global antibiotic resistance crisis, antimicrobial stewardship programs have emerged throughout the United States. Effective programs integrate several strategic methods, including evaluation and feedback regarding the necessity and appropriateness of antimicrobial therapy, staff education, and formulary restrictions. Multidisciplinary teams as well as institutional support are needed to form effective subcommittees to monitor national and local surveillance reports and resistance patterns, and to update antibiograms. Computerized decision support programs have been effective and successful methods of antimicrobial stewardship and can be a powerful tool in stewardship programs. Successful programs have reduced not only institutional resistance rates, but also morbidity, mortality, and cost.
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Affiliation(s)
- Michael J Rybak
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan 48201, USA
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Lautenbach E, Polk RE. Resistant gram-negative bacilli: A neglected healthcare crisis? Am J Health Syst Pharm 2007; 64:S3-21; quiz S22-4. [DOI: 10.2146/ajhp070477] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Ebbing Lautenbach
- University of Pennsylvania School of Medicine, 825 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021
| | - Ron E. Polk
- Department of Pharmacy, School of Pharmacy, Virginia Commonwealth University/Medical College of Virginia Campus, 410 North 12th Street, PO Box 980533, Richmond, VA 23298-0533
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