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Giamarellou H, Galani L, Karavasilis T, Ioannidis K, Karaiskos I. Antimicrobial Stewardship in the Hospital Setting: A Narrative Review. Antibiotics (Basel) 2023; 12:1557. [PMID: 37887258 PMCID: PMC10604258 DOI: 10.3390/antibiotics12101557] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
The increasing global threat of antibiotic resistance, which has resulted in countless fatalities due to untreatable infections, underscores the urgent need for a strategic action plan. The acknowledgment that humanity is perilously approaching the "End of the Miracle Drugs" due to the unjustifiable overuse and misuse of antibiotics has prompted a critical reassessment of their usage. In response, numerous relevant medical societies have initiated a concerted effort to combat resistance by implementing antibiotic stewardship programs within healthcare institutions, grounded in evidence-based guidelines and designed to guide antibiotic utilization. Crucial to this initiative is the establishment of multidisciplinary teams within each hospital, led by a dedicated Infectious Diseases physician. This team includes clinical pharmacists, clinical microbiologists, hospital epidemiologists, infection control experts, and specialized nurses who receive intensive training in the field. These teams have evidence-supported strategies aiming to mitigate resistance, such as conducting prospective audits and providing feedback, including the innovative 'Handshake Stewardship' approach, implementing formulary restrictions and preauthorization protocols, disseminating educational materials, promoting antibiotic de-escalation practices, employing rapid diagnostic techniques, and enhancing infection prevention and control measures. While initial outcomes have demonstrated success in reducing resistance rates, ongoing research is imperative to explore novel stewardship interventions.
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Affiliation(s)
- Helen Giamarellou
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Lamprini Galani
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Theodoros Karavasilis
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
| | - Konstantinos Ioannidis
- Clinical Pharmacists, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece;
| | - Ilias Karaiskos
- 1st Department of Internal Medicine-Infectious Diseases, Hygeia General Hospital, 4 Erythrou Stavrou & Kifisias, Marousi, 15123 Athens, Greece; (L.G.); (T.K.); (I.K.)
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Gregory E, Martin C. The Intersection of Antimicrobial Stewardship, the Pharmaceutical Industry, and the Federal Legislature. Open Forum Infect Dis 2022; 9:ofac404. [PMID: 36046701 PMCID: PMC9423378 DOI: 10.1093/ofid/ofac404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/03/2022] [Indexed: 11/17/2022] Open
Abstract
To mitigate the dangers of inappropriate antimicrobial use leading to increased multidrug-resistant organisms and mortality, antimicrobial stewardship programs have become a mainstay in many health systems. Unfortunately, some pharmaceutical manufacturers simultaneously have ended antimicrobial research and development efforts altogether due to suboptimal return on investments. An optimal and sustainable antimicrobial armamentarium requires a broad alliance between antimicrobial stewardship programs, the pharmaceutical industry, the legislature, and federal and state agencies. Public–private relationships such as the Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) and legislative policies creating push and pull incentives, including the Generating Antibiotic Incentives Now (GAIN), Developing an Innovative Strategy for Antimicrobial-Resistant Microorganisms (DISARM), and Pioneering Antimicrobial Subscriptions to End Upsurging Resistance (PASTEUR) Acts, are each a step in the right direction, but more work remains. Understanding these legislative actions is imperative for all clinicians, as is teamwork from those involved in the antimicrobial field to develop and maintain the life cycle of each drug that harbors societal value.
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Affiliation(s)
- Eric Gregory
- Department of Pharmacy, University of Kansas Health System , Kansas City, Kansas , USA
| | - Craig Martin
- Department of Pharmacy Practice & Science, University of Kentucky College of Pharmacy , Lexington, Kentucky , USA
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Syndrome-specific versus prospective audit and feedback interventions for reducing use of broad-spectrum antimicrobial agents. Am J Infect Control 2019; 47:1284-1289. [PMID: 31221448 DOI: 10.1016/j.ajic.2019.04.175] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/23/2019] [Accepted: 04/23/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Antimicrobial use (AU) of antipseudomonal β-lactams (APBL) has significantly increased over the past decade in US hospitals. This retrospective cohort study compares 2 common antimicrobial stewardship strategies, syndrome-specific interventions and antimicrobial postprescription prospective audit and feedback (PAF), in reducing AU of APBL at a large community-teaching hospital. METHODS Four antimicrobial stewardship interventions targeting APBL were serially introduced, including 2 syndrome-specific interventions (bloodstream and intra-abdominal infections) and 2 PAF interventions (carbapenems and piperacillin/tazobactam). Multivariable linear regression was used to examine overall AU of APBL and audited antimicrobial agents. RESULTS Overall AU of APBL declined from 92.4-69.1 days of therapy (DOT) per 1,000 patient-days between February 2013 and July 2017 (P < .001). Both syndrome-specific interventions were associated with significant reduction in AU of APBL (-7.7 [95% confidence interval (CI): -11.5, -4.0] and -6.0 [95% CI: -9.7, -2.3] DOT per 1,000 patient-days) for bloodstream and intra-abdominal infections, respectively). No significant change in overall AU of APBL was observed after implementation of PAF interventions for carbapenems (-1.4 [95% CI: -7.4, 4.6] DOT per 1,000 patient-days) or piperacillin/tazobactam (0.9 [95% CI: -3.7, 5.4] DOT per 1,000 patient-days). CONCLUSIONS Implementation of syndrome-specific interventions was followed by significant reduction in AU of APBL in this population. Despite reducing AU of targeted agents, neither PAF intervention contributed to overall observed decline in APBL use, likely due to compensatory increase in using other APBL.
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Al-Hasan MN, Acker EC, Kohn JE, Bookstaver PB, Justo JA. Impact of Penicillin Allergy on Empirical Carbapenem Use in Gram-Negative Bloodstream Infections: An Antimicrobial Stewardship Opportunity. Pharmacotherapy 2017; 38:42-50. [DOI: 10.1002/phar.2054] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Majdi N. Al-Hasan
- University of South Carolina School of Medicine; Columbia South Carolina
- Department of Medicine; Palmetto Health USC Medical Group; Columbia South Carolina
| | - Emily C. Acker
- Department of Pharmacy; Cincinnati Children's Hospital; Cincinnati Ohio
| | - Joseph E. Kohn
- Department of Pharmacy; Palmetto Health Richland; Columbia South Carolina
| | - Paul Brandon Bookstaver
- Department of Pharmacy; Palmetto Health Richland; Columbia South Carolina
- Department of Clinical Pharmacy and Outcomes Sciences; University of South College of Pharmacy; Columbia South Carolina
| | - Julie Ann Justo
- Department of Pharmacy; Palmetto Health Richland; Columbia South Carolina
- Department of Clinical Pharmacy and Outcomes Sciences; University of South College of Pharmacy; Columbia South Carolina
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Shah KB, Rimawi RH, Mazer MA, Cook PP. Can a collaborative subspecialty antimicrobial stewardship intervention have lasting effects? Infection 2017; 45:645-649. [PMID: 28726037 DOI: 10.1007/s15010-017-1047-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 07/12/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We previously demonstrated the benefit of direct, daily collaboration between infectious disease (ID) and critical care practitioners (CCP) on guideline adherence and antibiotic use in the medical intensive care unit (MICU). In this post-intervention review, we sought to establish whether the effect on antibiotic use and guideline adherence was sustainable. DESIGN A retrospective review of 87 patients, admitted to the 24-bed MICU, was done 3 (n = 45) and 6 months (n = 42) after the intervention. MEASUREMENTS Data included demographics, severity indicators, admitting pathology, infectious diagnosis, clinical outcomes [mechanical ventilation days (MVD) and MICU length of stay (LOS), antibiotic days of therapy (DOT), in-hospital mortality], and antibiotic appropriateness based on current guidelines. RESULTS In the 3-month (3-PI) and 6-month post-intervention (6-PI), there were no significant differences in the APACHE II score, MVD, LOS, DOT, or total antibiotic use at 3 (p = 0.59) and 6-PI (p = 0.87). There was no change in the mean use of extended-spectrum penicillins, cephalosporin, and carbapenems. While there were significant differences in vancomycin usage at 3-PI [3.1 DOT vs. 4.3 DOT (p = 0.007)], this finding was not seen after 6 months [3.1 DOT vs. 3.4 DOT (p = 0.08)]. When compared to the intervention period, the inappropriateness of antibiotic use at 3 (p = 1.00) and 6-PI (p = 0.30) did not change significantly. CONCLUSIONS There were no significant differences in either total antibiotic use or inappropriate antibiotic use at the 6-PI time period. Continuous, daily, direct collaboration between ID and CCP, once implemented, can have lasting effects even at 6 months after the interaction has been discontinued.
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Affiliation(s)
- Kaushal B Shah
- Division of Infectious Diseases, Department of Internal Medicine, The Brody School of Medicine at East Carolina University, Doctor's Park 6A, Mail Stop 715, Greenville, NC, 27834, USA.
| | - Ramzy H Rimawi
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, East Carolina University, Brody School of Medicine, Greenville, NC, 27834, USA
| | - Mark A Mazer
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, East Carolina University, Brody School of Medicine, Greenville, NC, 27834, USA
| | - Paul P Cook
- Division of Infectious Diseases, Department of Internal Medicine, The Brody School of Medicine at East Carolina University, Doctor's Park 6A, Mail Stop 715, Greenville, NC, 27834, USA
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Dodds Ashley ES, Kaye KS, DePestel DD, Hermsen ED. Antimicrobial stewardship: philosophy versus practice. Clin Infect Dis 2015; 59 Suppl 3:S112-21. [PMID: 25261538 DOI: 10.1093/cid/ciu546] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
To promote the judicious use of antimicrobials and preserve their usefulness in the setting of growing resistance, a number of policy-making bodies and professional societies have advocated the development of antimicrobial stewardship programs. Although these programs have been implemented at many institutions in the United States, their impact has been difficult to measure. Current recommendations advocate the use of both outcome and process measures as metrics for antimicrobial stewardship. Although patient outcome metrics have the greatest impact on the quality of care, the literature shows that antimicrobial use and costs are the indicators measured most frequently by institutions to justify the effectiveness of antimicrobial stewardship programs. The measurement of more meaningful outcomes has been constrained by difficulties inherent to these measures, lack of funding and resources, and inadequate study designs. Antimicrobial stewardship can be made more credible by refocusing the antimicrobial review process to target specific disease states, reassessing the usefulness of current metrics, and integrating antimicrobial stewardship program initiatives into institutional quality and safety efforts.
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Affiliation(s)
| | - Keith S Kaye
- Division of Infectious Diseases, Wayne State University School of Medicine and Detroit Medical Center, Michigan
| | - Daryl D DePestel
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts
| | - Elizabeth D Hermsen
- Global Medical Affairs, Cubist Pharmaceuticals, Lexington, Massachusetts Department of Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha
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Koning SI, Rhodes J, Rofe OC, Sundararajan V, O'Reilly M, Koning SI. Antimicrobial Prescribing in a Rapid Assessment Medical Unit - A Multi-Phase Pilot Study. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2013. [DOI: 10.1002/j.2055-2335.2013.tb00270.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Jessica Rhodes
- Faculty of Pharmacy and Pharmaceutical Sciences; Monash University
| | | | - Vijaya Sundararajan
- Department of Medicine, St Vincent's Hospital, Department of Medicine, Southern Clinical School; University of Melbourne, Monash University
| | - Mary O'Reilly
- Infectious Diseases and Infection Prevention and Control, Eastern Health, Faculty of Medicine, Nursing and Health Sciences; Monash University; Clayton Victoria
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Antworth A, Collins CD, Kunapuli A, Klein K, Carver P, Gandhi T, Washer L, Nagel JL. Impact of an antimicrobial stewardship program comprehensive care bundle on management of candidemia. Pharmacotherapy 2013; 33:137-43. [PMID: 23355283 DOI: 10.1002/phar.1186] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY OBJECTIVE To analyze the impact of a comprehensive care bundle directed by an antimicrobial stewardship team (AST) on the management of candidemia. DESIGN Single-center, quasi-experimental study. SETTING A 930-bed academic hospital. PATIENTS Seventy-eight patients with candidemia were evaluated; 41 patients received the candidemia care bundle (AST group), and 37 did not (historical control group). MEASUREMENTS AND MAIN RESULTS A candidemia care bundle was developed by an interdisciplinary AST, incorporating key elements from the Infectious Diseases Society of America's Clinical Practice Guidelines for the Management of Candidemia. The AST made prospective recommendations in accordance with the care bundle. Bundle elements were utilization of appropriate antifungal agents with appropriate duration of use, removal of intravenous catheters, repeat blood cultures, monitoring of time until clearance of candidemia, and performance of ophthalmologic examinations. Compliance with all candidemia care bundle elements was significantly higher in the AST group versus the control group (78.0% vs 40.5%, p=0.0016). Implementation of the care bundle significantly improved rates of ophthalmologic examination (97.6% vs 75.7%, p=0.0108), selection of appropriate antifungal therapy (100% vs 86.5%, p=0.0488), and compliance with an appropriate duration of therapy (97.6% vs 67.7%, p=0.0012). In addition, the AST group had fewer excess total days of therapy beyond the recommended duration than the control group (5 vs 83 total antifungal days). Length of hospitalization (20 vs 21 days, p=0.9184), time until clearance of candidemia (3 vs 3 days p=0.610), rate of persistent candidemia (22% vs 40.5%, p=0.126), and rate of recurrent candidemia (4.9% vs 5.4%, p=0.916) were similar in the AST group versus the control group. CONCLUSION A comprehensive candidemia care bundle directed by our institution's AST improved the management of patients with candidemia. We encourage further exploration into the use of care bundles by ASTs as part of their multifaceted approach to promoting appropriate antimicrobial utilization and optimizing the management of patients with infectious diseases.
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Affiliation(s)
- Allen Antworth
- Department of Pharmacy, University of Michigan Hospital and Health Systems, Ann Arbor, MI 48109, USA
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Reed EE, Stevenson KB, West JE, Bauer KA, Goff DA. Impact of formulary restriction with prior authorization by an antimicrobial stewardship program. Virulence 2012; 4:158-62. [PMID: 23154323 PMCID: PMC3654616 DOI: 10.4161/viru.21657] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
In an era of increasing antimicrobial resistance and few antimicrobials in the developmental pipeline, many institutions have developed antimicrobial stewardship programs (ASPs) to help implement evidence-based (EB) strategies for ensuring appropriate utilization of these agents. EB strategies for accomplishing this include formulary restriction with prior authorization. Potential limitations to this particular strategy include delays in therapy, prescriber pushback, and unintended increases in use of un-restricted antimicrobials; however, our ASP found that implementing prior authorization for select antimicrobials along with making a significant effort to educate clinicians on criteria for use ensured more appropriate prescribing of these agents, hopefully helping to preserve their utility for years to come.
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Affiliation(s)
- Erica E Reed
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Newland JG, Banerjee R, Gerber JS, Hersh AL, Steinke L, Weissman SJ. Antimicrobial Stewardship in Pediatric Care: Strategies and Future Directions. Pharmacotherapy 2012; 32:735-43. [DOI: 10.1002/j.1875-9114.2012.01155.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jason G. Newland
- Section of Infectious Diseases; Department of Pediatrics; University of Missouri-Kansas City; Children's Mercy Hospitals & Clinics; Kansas City; Missouri
| | - Ritu Banerjee
- Division of Pediatric Infectious Diseases; Department of Pediatrics and Adolescent Medicine; Mayo Clinic College of Medicine; Mayo Children's Hospital; Rochester; Minnesota
| | - Jeffrey S. Gerber
- Division of Infectious Diseases; Department of Pediatrics; University of Pennsylvania School of Medicine; Children's Hospital of Philadelphia; Philadelphia; Pennsylvania
| | - Adam L. Hersh
- Division of Infectious Diseases; Department of Pediatrics; University of Utah; Primary Children's Medical Center; Salt Lake City; Utah
| | - Leah Steinke
- Department of Pharmacy; Children's Hospital of Michigan; Detroit Medical Center; Detroit; Michigan
| | - Scott J. Weissman
- Division of Infectious Diseases; Department of Pediatrics; University of Washington Medical Center; Seattle Children's Hospital; Seattle; Washington
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