The impact of antimicrobial stewardship ward rounds on antimicrobial use and predictors of advice, uptake, and outcomes

OBJECTIVE

To identify the impact of introducing antimicrobial stewardship (AMS) ward rounds.

METHODS

We used an interrupted time-series approach to investigate the impact of implementing AMS ward rounds with in-person feedback from a multidisciplinary team in Hospital-1, also comparing to Hospital-2 in the same city where AMS ward rounds were not yet implemented. Regression models were used to identify predictors of advice given and of whether advice was followed, and associations between advice uptake and length of stay.

RESULTS

Introducing AMS ward rounds was followed by new or accelerated declines in ceftriaxone, ciprofloxacin, amoxicillin-clavulanate, meropenem and piperacillin-tazobactam use at Hospital-1. Except for ceftriaxone, similar declines were not seen at Hospital-2. Half of reviews (3471/6878; 50%) recommended an intervention; 2003/2726 (73%) subsequently evaluated recommendations were implemented. Senior doctors were more likely than pharmacists or specialist doctors in training to recommend de-escalation/stopping antibiotics and to have their advice followed. The more prior AMS reviews completed, the more likely advice was to be followed. Following advice to de-escalate/stop antimicrobials was associated with a 0.58 day [95%CI 0.22-0.94] reduction in hospital stay.

CONCLUSIONS

Multidisciplinary AMS ward rounds reduced antibiotic use and likely reduced length of hospital stay. Senior clinician input and more AMS experience increased advice uptake.

Pharmacist insights into antimicrobial stewardship: A social marketing approach

BACKGROUND

Antimicrobial resistance is a worldwide public health problem. Antimicrobial stewardship programs (ASPs) optimize antimicrobial use within hospitals. The social marketing framework has been used in analyzing systems and devising best practices.

OBJECTIVE

(s): To use the social marketing framework to explore pharmacist experiences and perceptions of structural, behavioral and interventional strategies that support ASPs.

METHODS

A qualitative approach utilizing semi-structured individual interviews was utilized. A purposive sample of hospital pharmacists was invited to participate. An interview guide was constructed to describe participant experience and perceptions regarding ASPs in their institutions based on elements of social marketing: Behavioral goals; Customer Insight; Segmentation and Targeting; Competition; Exchange; and Marketing and Interventional mix. Interviews were recorded digitally and transcribed verbatim. Thematic analysis was conducted using deductive methods. A combination of case-based and code-based approaches allowed individual and holistic analyses respectively. Codes were collated into themes and subthemes.

RESULTS

Saturation of themes occurred with 25 interviews from 17 hospitals. ASP metrics included: consumption of antibiotics using days of therapy and defined daily dose, rates of C. difficile and multidrug resistant organisms, resistance patterns, and provider adherence to the ASP. Active stewardship tools such as preauthorization, and prospective feedback/audit were preferred over passive tools such as order sets and automatic stop orders. A physician champion and a clinical pharmacist with infectious disease training were core elements in the multidisciplinary team. Despite certain areas being considered key for stewardship, participants emphasized a hospital-wide approach including outpatient departments; discharge stewardship emerged as a primary theme. Leadership supported ASPs with finances, rapid and novel diagnostics, Clinical Decision Support Systems, mobile technology, and continuous staff training.

CONCLUSIONS

The social marketing framework has been used to explore pharmacist perceptions that inform successful qualities including metrics, restriction methods, personnel, benefits, barriers, training needs/modes, and promotional avenues that support ASPs in hospitals.

Bloodstream infections in neutropenic and non-neutropenic patients with haematological malignancies: epidemiological trends and clinical outcomes in Queensland, Australia over the last 20 years

Knowledge of the epidemiology of bloodstream infection (BSI) in haematology patients is essential to guide patient management. We investigated the epidemiology of BSI in patients with haematological malignancies in Queensland over the last 20 years (2000-2019), including all episodes diagnosed by the state-wide microbiology service. We identified 7749 BSI in 5159 patients, 58% associated with neutropenia. Gram-negatives were the main causative pathogens (58.3%), more frequent in neutropenic than non-neutropenic patients (3308/5309, 62.3% vs 1932/3678, 52.5%, p < 0.001). Amongst 8987 isolates the most common were E. coli (15.4%) and Pseudomonas spp. (14.2%). Pseudomonas spp. (16.6% vs 10.7%, p < 0.001), Klebsiella spp. (11.6% vs 6.8%, p < 0.001), viridans-group streptococci (4.4% vs 1.2%, p < 0.001) and E. faecium (2.4% vs 0.9%, p < 0.001) were more common in neutropenic than non-neutropenic patients, while S. aureus was less common (5.9% vs 15.6%, p < 0.001). Several antimicrobial resistance rates increased over time and had higher prevalence in neutropenic than non-neutropenic patients, including ciprofloxacin-resistant E. coli (94/758, 12.4% vs 42/506, 8.3%, p = 0.021), trimethoprim-sulfamethoxazole-resistant E. coli (366/764, 47.9% vs 191/517, 36.9%, p < 0.001), penicillin-resistant streptococci (51/236, 21.6% vs 28/260, 10.8%, p < 0.001) and vancomycin-resistant enterococci (46/250, 18.4% vs 9/144, 6.3%, p < 0.001). Carbapenem-resistant Pseudomonas spp. (OR 7.32, 95%CI 2.78-19.32) and fungi, including yeasts and moulds (OR 3.33, 95%CI 2.02-5.48) were associated to the highest odds of 30-day case-fatality at a multivariable logistic regression analysis. Neutropenia was associated with survival (OR 0.66, 95%CI 0.55-0.78). Differences were observed in the BSI epidemiology according to neutropenic status, with an overall increase of resistance over time associated to adverse outcome.

Evaluation of the initial timing of infection control pharmacist-driven audit and monitoring of vancomycin therapy in patients with infectious diseases: A retrospective observational study

BACKGROUND

Early monitoring and feedback on the treatment of infectious diseases are some of the methods for optimising antimicrobial treatment throughout the treatment period. Prospective audits and feedback interventions have also been shown to improve antimicrobial use and reduce antimicrobial resistance. We examined the appropriate use of antimicrobials by focusing on the initial timing for audits and feedback intervention of antimicrobial prescription by Infection Control Team pharmacists.

METHODS

We conducted a retrospective observational study in a university hospital in Tokyo, Japan from 1 January 2019 to 31 May 2021. We retrospectively enrolled patients with infections and those patients suspected of having an infection, who were administered vancomycin and assessed at our hospital. The definition of primary outcome was the maintenance of target vancomycin trough blood concentrations of 10-20 μg/ml during treatment. Multivariable logistic regression and multivariate linear regression analyses were performed to test the effectiveness of the initial timing of the intervention by Infection Control Team pharmacists as the explanatory variable.

RESULTS

A total of 638 patients were included in this study, with a median age of 69 years (interquartile range: 54-78 years). Multivariable logistic regression revealed that the maintenance of target vancomycin trough concentrations was not associated with the timing of the audit and the initiation of monitoring by Infection Control Team pharmacists (adjusted odds ratio: 0.99, 95% confidence interval: 0.99-1.00, p = 0.990). Multivariate linear regression revealed that the duration of vancomycin administration was significantly correlated with the timing of initiation of monitoring by Infection Control Team pharmacists (adjusted estimate: 0.0227, standard error: 0.0051, p = 0.012).

CONCLUSIONS

Our study showed that early initiation of a comprehensive audit and monitoring by Infection Control Team pharmacists did not affect the maintenance of the target vancomycin trough blood concentration. However, it reduced the duration of vancomycin administration.

Antimicrobial stewardship in Australia: the role of qualitative research in programme development

Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.

Early antimicrobial stewardship team intervention on appropriateness of antimicrobial therapy in suspected sepsis: a randomized controlled trial

Objectives

There has been concern that the imperative to administer rapid antimicrobials in septic patients may result in inappropriate antimicrobial use. We aimed to determine the impact of early antimicrobial stewardship (AMS) team intervention in patients with Medical Emergency Team (MET) calls for suspected sepsis.

Methods

We performed a randomized controlled trial of non-ICU inpatients who had a MET call for suspected sepsis. Patients were randomized to standard care (management of antimicrobial therapy by the treating team) or early targeted intervention (AMS review 48 h post-MET call). The primary outcome was appropriateness of antimicrobial therapy 72 h post-MET call, as determined by a panel of blinded infectious diseases physicians.

Results

In total, 90 patients were enrolled; 45 were randomly allocated to the intervention group, and 45 to the control group. More patients in the AMS intervention group were receiving appropriate antimicrobials 72 h following the MET call (67% versus 44%, P = 0.03). In the intervention group, 27 recommendations were made by the AMS team; 74% of recommendations were accepted, including 30% of cases where antimicrobials were discontinued or de-escalated. There were non-significant differences in total duration of antimicrobial therapy (8.7 versus 10.7 days, P = 0.39), sepsis-related ICU-admission rates (13% versus 18%, P = 0.56) and sepsis-related in-hospital mortality (7% versus 9%, P = 0.71) between intervention and control groups, respectively.

Conclusions

AMS team intervention resulted in significant improvement in appropriateness of antimicrobial therapy following MET calls due to suspected sepsis. Targeted AMS review should be implemented to support early antimicrobial de-escalation and optimization in patients with suspected sepsis.

Building on Antimicrobial Stewardship Programs Through Integration with Electronic Medical Records: The Australian Experience

Antimicrobial stewardship (AMS) is well established in Australian hospitals. Electronic medical record (EMR) implementation has lagged in Australia, with two Healthcare Information and Management Systems Society (HIMSS) Stage 6 hospitals and one Stage 7 hospital as of September 2020. Specific barriers faced by AMS teams with paper-based prescribing and medical records include real-time identification of antimicrobials orders; the ability to prospectively monitor antimicrobial use; and the integration of fundamental point of prescribing AMS principles into routine clinical practice. There are few local guidelines to assist Australian hospitals and AMS teams beyond “out of the box” EMR functionality. EMR implementation has enormous potential to positively impact AMS teams through more efficient workflows and the ability to expand the reach and coverage of AMS activities. There are inevitable limitations associated with EMR implementation that must be considered. In this paper, four Australian hospitals share their experience with EMR roll out, AMS customisation and how they have overcome specific barriers in local AMS practice.

Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review

BACKGROUND

When randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability to control for common biases in healthcare QI. However, there is a potential risk of producing misleading results when this rather robust design is not used appropriately. We performed a methodological systematic review of the literature to investigate the extent to which the use of ITS has followed best practice standards and recommendations in the evaluation of QI interventions.

METHODS

We searched multiple databases from inception to June 2018 to identify QI intervention studies that were evaluated using ITS. There was no restriction on date, language and participants. Data were synthesised narratively using appropriate descriptive statistics. The risk of bias for ITS studies was assessed using the Cochrane Effective Practice and Organisation of Care standard criteria. The systematic review protocol was registered in PROSPERO (registration number: CRD42018094427).

RESULTS

Of 4061 potential studies and 2028 unique records screened for inclusion, 120 eligible studies assessed eight QI strategies and were from 25 countries. Most studies were published since 2010 (86.7%), reported data using monthly interval (71.4%), used ITS without a control (81%) and modelled data using segmented regression (62.5%). Autocorrelation was considered in 55% of studies, seasonality in 20.8% and non-stationarity in 8.3%. Only 49.2% of studies specified the ITS impact model. The risk of bias was high or very high in 72.5% of included studies and did not change significantly over time.

CONCLUSIONS

The use of ITS in the evaluation of health system QI interventions has increased considerably over the past decade. However, variations in methodological considerations and reporting of ITS in QI remain a concern, warranting a need to develop and reinforce formal reporting guidelines to improve its application in the evaluation of health system QI interventions.

Assessment of Implementation of Antimicrobial Resistance Surveillance and Antimicrobial Stewardship Programs in Tanzanian Health Facilities a Year After Launch of the National Action Plan

Introduction: Antimicrobial resistance (AMR) is a current global health threat and a challenge to the treatment of infectious diseases. The WHO advocates a strategy of antibiotic stewardship programs (ASP) in optimizing antimicrobial use in hospitals. This study aimed at assessing the existence of AMR surveillance and ASP implementation in health facilities in Tanzania in the year following the launch of the National Action Plan (NAP).

Methodology: From December 2017 through July 2018, a descriptive cross-sectional study was conducted using a structured questionnaire administered online. A total of 199 health facilities in Tanzania mainland whose contacts was obtained from the Ministry of Health Community Development Gender Elderly and Children (MoHCDGEC) were reached by phone and thereafter, a survey was sent via text or e-mail to focal persons in the corresponding facilities.

Results: Only 39 (32.5%) responses from contacted facilities were received and analyzed. Thirty (76.9%) of the facilities were government-owned. Of the 39 respondents surveyed, 13 (35.9%) declared to have implemented some sort of coordinated ASP to promote the rational use of antimicrobials at their facilities. The respondents reported the presence of guidelines for the implementation of ASP at variable proportions, whereas the presence of a committee for Infection Prevention and Control was reported by 27 (69.2%). Twenty-four (61.5%) had a Medical and Therapeutic Committee. Although all 39 (100%) respondents were aware of the presence of AMR in Tanzania, only 26 (66.7%) were aware of the presence of the Tanzanian NAP for AMR. Hospital antibiotic policy document was present in 6 (15.4%) facilities. Only 7 (17.9%) facilities conducted prescription auditing; 9 (23.1%) had a hospital formulary; 14 (35.9%) had standard hospital prescription. 9 (23.1%) had software for data storage about AMR. Only 7 (17.9%) facilities conducted microorganisms' susceptibility tests and kept the record of the microorganism susceptibility testing.

Conclusion: Our study found the existence of AMR surveillance activities and ASP implementation in Tanzania, albeit at a low level. The implementation was inconsistent across the surveyed facilities. These data have identified areas of improvement in addressing AMR in Tanzania through the NAP.

Outcomes of an electronic medical record (EMR)-driven intensive care unit (ICU)-antimicrobial stewardship (AMS) ward round: Assessing the "Five Moments of Antimicrobial Prescribing"

OBJECTIVE

The primary objective of this study was to examine the impact of an electronic medical record (EMR)-driven intensive care unit (ICU) antimicrobial stewardship (AMS) service on clinician compliance with face-to-face AMS recommendations. AMS recommendations were defined by an internally developed "5 Moments of Antimicrobial Prescribing" metric: (1) escalation, (2) de-escalation, (3) discontinuation, (4) switch, and (5) optimization. The secondary objectives included measuring the impact of this service on (1) antibiotic appropriateness, and (2) use of high-priority target antimicrobials.

METHODS

A prospective review was undertaken of the implementation and compliance with a new ICU-AMS service that utilized EMR data coupled with face-to-face recommendations. Additional patient data were collected when an AMS recommendation was made. The impact of the ICU-AMS round on antimicrobial appropriateness was evaluated using point-prevalence survey data.

RESULTS

For the 202 patients, 412 recommendations were made in accordance with the "5 Moments" metric. The most common recommendation made by the ICU-AMS team was moment 3 (discontinuation), which comprised 173 of 412 recommendations (42.0%), with an acceptance rate of 83.8% (145 of 173). Data collected for point-prevalence surveys showed an increase in prescribing appropriateness from 21 of 45 (46.7%) preintervention (October 2016) to 30 of 39 (76.9%) during the study period (September 2017).

CONCLUSIONS

The integration of EMR with an ICU-AMS program allowed us to implement a new AMS service, which was associated with high clinician compliance with recommendations and improved antibiotic appropriateness. Our "5 Moments of Antimicrobial Prescribing" metric provides a framework for measuring AMS recommendation compliance.

Effect of physicians' knowledge on antibiotics rational use in China's county hospitals

BACKGROUND

Irrational prescriptions of antibiotics have received significant international attention. In China, previous studies have described the impact of physicians' knowledge on antibiotic use, however, empirical studies of the relationship between physician knowledge and antibiotic prescription behavior are limited.

OBJECTIVE

This study aimed to examine physicians' knowledge of antibiotic and explore the effects of physicians' knowledge on rational antibiotic use in county hospitals in China.

METHOD

A sample of 360 physicians from 60 county hospitals was designed. Questionnaires were used to evaluate the physicians' knowledge of antibiotic use. We assessed the rationality of antibiotic use by evaluating the physicians' prescriptions. Antibiotic prescriptions were evaluated according to percentage of encounters where an antibiotic was prescribed, percentage of encounters with combined antibiotics prescriptions and the percentage of encounters treated in accordance with a standard treatment guideline. General linear model (GLM) was performed to analyze the factors influencing rational antibiotic use.

RESULT

A total of 58,512 valid antibiotic prescriptions by 280 physicians were included in the analysis. The average score of 62.2 The average percentage of encounters with an antibiotic and combined antibiotics prescribed were 70.1% and 40.2%, respectively. 37.9% of antibiotic prescriptions were in accordance with standard treatment guidelines. GLM analysis showed that physicians with scores exceeding 80 used less antibiotics than those who score lower than 60 (P = 0.005). The percentage of combination antibiotic therapies of those who achieved scores above 80 or in the range from 60 to 80 were lower than that of physicians in low score groups (P = 0.002, P = 0.025), and higher compliance with the guidelines than those received a score below 60 (P = 0.001, P = 0.047).

CONCLUSION

Results confirmed that physicians' knowledge significantly influences rational antibiotic use. Targeted training programs to promote physicians' knowledge of antibiotic especially at county hospitals in the western regions of China are urgently needed.

Outcomes of multisite antimicrobial stewardship programme implementation with a shared clinical decision support system

Background

Studies evaluating antimicrobial stewardship programmes (ASPs) supported by computerized clinical decision support systems (CDSSs) have predominantly been conducted in single site metropolitan hospitals.

Objectives

To examine outcomes of multisite ASP implementation supported by a centrally deployed CDSS.

Methods

An interrupted time series study was conducted across five hospitals in New South Wales, Australia, from 2010 to 2014. Outcomes analysed were: effect of the intervention on targeted antimicrobial use, antimicrobial costs and healthcare-associated Clostridium difficile infection (HCA-CDI) rates. Infection-related length of stay (LOS) and standardized mortality ratios (SMRs) were also assessed.

Results

Post-intervention, antimicrobials targeted for increased use rose from 223 to 293 defined daily doses (DDDs)/1000 occupied bed days (OBDs)/month (+32%, P  <   0.01). Conversely, antimicrobials targeted for decreased use fell from 254 to 196 DDDs/1000 OBDs/month (-23%; P  <   0.01). These effects diminished over time. Antimicrobial costs decreased initially (-AUD$64551/month; P  <   0.01), then increased (+AUD$7273/month; P  <   0.01). HCA-CDI rates decreased post-intervention (-0.2 cases/10 000 OBDs/month; P  <   0.01). Proportional LOS reductions for key infections (respiratory from 4.8 to 4.3 days, P  <   0.01; septicaemia 6.8 to 6.1 days, P  <   0.01) were similar to background LOS reductions (2.1 to 1.9 days). Similarly, infection-related SMRs (observed/expected deaths) decreased (respiratory from 1.1 to 0.75; septicaemia 1.25 to 0.8; background rate 1.19 to 0.90.

Conclusions

Implementation of a collaborative multisite ASP supported by a centrally deployed CDSS was associated with changes in targeted antimicrobial use, decreased antimicrobial costs, decreased HCA-CDI rates, and no observable increase in LOS or mortality. Ongoing targeted interventions are suggested to promote sustainability.

A systematic review of inpatient antimicrobial stewardship programmes involving clinical pharmacists in small-to-medium-sized hospitals

Objective

Antimicrobial stewardship programmes (ASPs) have been widely implemented in large hospitals but little is known regarding small-to-medium-sized hospitals. This literature review evaluates outcomes described for ASPs participated in by clinical pharmacists and implemented in small-to-medium-sized hospitals (<500 beds).

Methods

Following PRISMA principles, PubMed and Cochrane Library databases were searched in early 2016 for English language articles describing implementation and outcomes for inpatient ASPs participated in by clinical pharmacists in small-to-medium-sized hospitals. Each included study was required to include at least one of the following outcomes: microbiological outcomes, quality of care and clinical outcomes or antimicrobial use and cost outcomes.

Results

We included 28 studies from 26 hospitals, mostly American or Canadian. Most cases (23 studies) consisted of time-series comparisons of pre-and post-intervention periods. Of the 28 studies analysed, 8 reported microbiological outcomes, 21 reported quality of care and clinical outcomes, and 27 reported antimicrobial use and cost outcomes. Interventions were not generally associated with significant changes in mortality or readmission rates but were associated with substantial cost savings, mainly due to reduced use of antibiotics or the use of cheaper antibiotics.

Conclusion

As far as we are aware, ours is the first systematic review that evaluates ASPs participated in by clinical pharmacists in small-to-medium-sized hospitals. ASPs appear to be an effective strategy for reducing antimicrobial use and cost. However, the limited association with better microbiological, care quality and clinical outcomes would highlight the need for further studies and for standardised methods for evaluating ASP outcomes.

Nurses as Antibiotic Brokers: Institutionalized Praxis in the Hospital

We are likely moving rapidly toward a post-antibiotic era, as a result of escalating antimicrobial resistance, rapidly declining antibiotic production and profligate overuse. Hitherto research has almost exclusively focused on doctors' prescribing, with nurses' roles in antibiotic use remaining virtually invisible. Drawing on interviews with 30 nurses, we focus on nurses as brokers of doctors' antibiotic decisions, nursing capacity to challenge doctors' decisions, and, "back stage" strategies for circumnavigating organizational constraints. We argue that nurses occupy an essential and conscious position as brokers within the hospital; a subject position that is not neutral, facilitates (short-term) cohesion, and involves the pursuit of particular (preferred) nursing outcomes. Illustrating how authority can be diffuse, mediated by institutionalized praxis, and how professionals evade attempts to govern their practice, we challenge the reification of physician prescribing power, arguing that it may work against the utilization of nurses as important stakeholders in the future of antibiotics.

Changes in antimicrobial prescribing behavior after the introduction of the antimicrobial stewardship program: A pre- and post-intervention survey

The introduction of an antimicrobial stewardship (AMS) program is associated with a change in antimicrobial prescribing behavior. A proposed mechanism for this change is by impacting the prescribing etiquette described in qualitative studies. This study sought to detect a change in prescribing attitudes 12 months after the introduction of AMS and gauge utility of various AMS interventions. Surveys were distributed to doctors in two regional Australian hospitals on a convenience basis 6 months before, and 12 months after, the introduction of AMS. Agreement with 20 statements describing attitudes (cultural, behavioral and knowledge) towards antimicrobial prescribing was assessed on a 4-point Likert scale. Mean response scores were compared using the Wilcoxon Rank sum test. 155 responses were collected before the introduction of AMS, and 144 afterwards. After the introduction of AMS, an increase was observed in knowledge about available resources such as electronic decision support systems (EDSS) and therapeutic guidelines, with raised awareness about the support available through AMS rounds and the process to be followed when prescribing restricted antimicrobials. Additionally, doctors were less likely to rely on pharmacy to ascertain when an antimicrobial was restricted, depend on infectious diseases consultant advice and use past experience to guide antimicrobial prescribing. Responses to this survey indicate that positive changes to the antimicrobial prescribing etiquette may be achieved with the introduction of an AMS program. Use of EDSS and other resources such as evidence-based guidelines are perceived to be important to drive rational antimicrobial prescribing within AMS programs.

Impact of Antibiotic Stewardship Program on Prescribing Pattern of Antimicrobials in Patients of Medical Intensive Care Unit

INTRODUCTION

Rising concerns about antimicrobial resistance and inadequate development of effective new anti-infective drugs have stimulated universal efforts to strengthen infection-control interventions. Antimicrobial stewardship is a rational, systematic approach to promote the optimal selection, dosing, and duration of therapy for antimicrobial agents throughout the course of their use in order to improve the outcomes.

AIM

Since in Shree Krishna Hospital (SKH), Antibiotic Stewardship Program (ASP) was first implemented in 2013, this study was planned to assess any change in antimicrobial use before and after implementation of ASP and to study the rate and pattern of antimicrobial use in medical ICU.

MATERIALS AND METHODS

A cross-sectional study was conducted in 12 bedded medical intensive care unit, over a period of two years from October 2014 to October 2016 at SKH. Permission was taken from Institutional Human Research Ethics Committee. Total 150 case files i.e., 75 from year 2012 and 75 from year 2015 were retrieved from medical record section of the hospital. Appropriateness of prescriptions was decided on the basis of appropriateness of choice, dose, frequency and duration of antimicrobial agents. Data were analysed by using descriptive statistics.

RESULTS

There were 68.67% males and the mean (±SD) age was 57.11 (±16.83) years. Majority of the patients were suffering from respiratory conditions. The most common group of drugs prescribed in MICU was β-lactam antibiotics + β-lactamase inhibitors during 2012 as well as 2015. Total 139 patients i.e., 69 (92%) patients in 2012 and 70 (93.33%) patients in 2015 were given antimicrobial for therapeutic purpose. During the year 2015, 67 (89.33%) antimicrobial prescriptions were adhering to antibiotic policy of SKH. Appropriateness of prescriptions had significantly improved in 2015 in MICU (p-value=0.031).

CONCLUSION

In-depth analysis of the study revealed a positive impact of ASP and antibiotic policy. Implementation of ASP in year 2013, brought an effective increase in the appropriate use of antimicrobials.

Antimicrobial stewardship program in a Malaysian district hospital: First year experience

Backgrounds & Objective:

Antimicrobial resistance is an alarming public health threat that requires urgent global solution. Implementation of antimicrobial stewardship program (ASP) is an essential practice element for healthcare institutions in gate-keeping judicious antimicrobial use. This study highlighted the development, first year experience, and result of the implementation of ASP utilizing persuasive and restrictive approaches in a Malaysian district hospital.

Methods:

An observational study was conducted between January 2015 to December 2015 on implementation of ASP among hospitalized inpatients age 12 years old and above.

Results:

Recommendations were provided for 60% of cases (110 patients) with the average acceptance rate of 83.33%. Majority of the interventions were to stop the antimicrobial therapy (30.3%), and the most common audited antimicrobials was Piperacillin/Tazobactam (25.5%), followed by Meropenem (11.82%), Amoxicillin/Clavulanate and Vancomycin (8.18%) respectively. The concordance rate towards authorization policy was increased in 2015 (71.59% of cases) as compared before the implementation of ASP in 2014 (60.6% of cases). Restrictive enforcement under ASP had been shown to improve significantly adherence rate towards antimicrobials authorization policy (p-value: 0.004).

Conclusion:

ASP was successfully implemented in a district hospital. Future studies on its clinical outcomes are important to evaluate its effectiveness as well as focus on the improvement to the pre-existing strategies and measures.

[Antibiotic stewardship: Measures for optimization of antibacterial therapy]

Because the development of resistance is steadily increasing, especially among Gram-negative pathogens and new developments in antibiotics are lacking, a rational antibiotic therapy is necessary now more than ever. A continuing uncritical and non-guideline-conform use of antibiotics leads to selection of multidrug-resistant pathogens, which can colonize patients and as instigators of infections make treatment more difficult. A prerequisite for targeted antibiotic therapy is a critical testing of the suspected infection diagnosis based on a guideline-conform microbiological preanalytical procedure. To promote a guideline-conform antibiotic therapy in hospitals with respect to choice of substance, dosage and duration, in December 2013 so-called antibiotic stewardship (ABS) measures were summarized in a so-called S3-guideline from the Association of the Scientific Medical Societies in Germany (AWMF) under the auspices of the German Society for Infectious Diseases (DGI). With a strategy of targeted antibiotic therapy and infection prevention it is possible to achieve optimum treatment results and to minimize the development of resistance.

The impact of a multidisciplinary antimicrobial stewardship team on the timeliness of antimicrobial therapy in patients with positive blood cultures: a randomized controlled trial

BACKGROUND

Antimicrobial stewardship teams play an important role in assisting with the optimization of antimicrobial use in acute care settings. We aimed to determine whether a rapid review by a multidisciplinary antimicrobial stewardship team would improve the timeliness of optimal antimicrobial therapy for patients with positive blood cultures.

METHODS

This prospective randomized controlled trial was undertaken in two Australian hospitals. Patients received either standard care (a clinical microbiologist, registrar or laboratory scientist communicating the positive blood culture by phone to the treating doctor) or intervention (standard care plus rapid review by a multidisciplinary antimicrobial stewardship team). Outcomes included time to appropriate and/or active antimicrobial therapy and in-hospital mortality. The trial was registered on the Australian New Zealand Clinical Trials Registry (ACTRN12614000258651).

RESULTS

A total of 160 patients were enrolled in this study: 81 in the standard care arm and 79 in the intervention arm. Patients in the intervention arm were commenced earlier on active (HR 8.02, 95% CI: 2.15-29.91) and appropriate antimicrobials (HR 1.95, 95% CI: 1.13-3.38), with a higher proportion of patients allocated to the intervention arm receiving active therapy at 48 h (96% versus 82%) and appropriate therapy at 72 h (70% versus 54%). The majority of patients where the blood culture was a contaminant were not started on antimicrobial therapy, and there were no significant differences in time to cessation of antimicrobial therapy.

CONCLUSIONS

Antimicrobial stewardship team review of patients with pathogenic positive blood cultures improved the time to both active and appropriate antimicrobial therapy.

Systematic Review and Meta-analysis of Clinical and Economic Outcomes from the Implementation of Hospital-Based Antimicrobial Stewardship Programs

The implementation of antimicrobial stewardship programs (ASPs) is a promising strategy to help address the problem of antimicrobial resistance. We sought to determine the efficacy of ASPs and their effect on clinical and economic parameters. We searched PubMed, EMBASE, and Google Scholar looking for studies on the efficacy of ASPs in hospitals. Based on 26 studies (extracted from 24,917 citations) with pre- and postimplementation periods from 6 months to 3 years, the pooled percentage change of total antimicrobial consumption after the implementation of ASPs was -19.1% (95% confidence interval [CI] = -30.1 to -7.5), and the use of restricted antimicrobial agents decreased by -26.6% (95% CI = -52.3 to -0.8). Interestingly, in intensive care units, the decrease in antimicrobial consumption was -39.5% (95% CI = -72.5 to -6.4). The use of broad-spectrum antibiotics (-18.5% [95% CI = -32 to -5.0] for carbapenems and -14.7% [95% CI = -27.7 to -1.7] for glycopeptides), the overall antimicrobial cost (-33.9% [95% CI = -42.0 to -25.9]), and the hospital length of stay (-8.9% [95% CI = -12.8 to -5]) decreased. Among hospital pathogens, the implementation of ASPs was associated with a decrease in infections due to methicillin-resistant Staphylococcus aureus (risk difference [RD] = -0.017 [95% CI = -0.029 to -0.005]), imipenem-resistant Pseudomonas aeruginosa (RD = -0.079 [95% CI = -0.114 to -0.040]), and extended-spectrum beta-lactamase Klebsiella spp. (RD = -0.104 [95% CI = -0.153 to -0.055]). Notably, these improvements were not associated with adverse outcomes, since the all-cause, infection-related 30-day mortality and infection rates were not significantly different after implementation of an ASP (RD = -0.001 [95% CI = -0.009 to 0.006], RD = -0.005 [95% CI = -0.016 to 0.007], and RD = -0.045% [95% CI = -0.241 to 0.150], respectively). Hospital ASPs result in significant decreases in antimicrobial consumption and cost, and the benefit is higher in the critical care setting. Infections due to specific antimicrobial-resistant pathogens and the overall hospital length of stay are improved as well. Future studies should focus on the sustainability of these outcomes and evaluate potential beneficial long-term effects of ASPs in mortality and infection rates.

A qualitative study of hospital pharmacists and antibiotic governance: negotiating interprofessional responsibilities, expertise and resource constraints

BACKGROUND

Antibiotic treatment options for common infections are diminishing due to the proliferation of antimicrobial resistance (AMR). The impact of Antimicrobial Stewardship (AMS) programs seeking to preserve viable antibiotic drugs by governing their use in hospitals has hitherto been limited. Pharmacists have been delegated a critical role in antibiotic governance in AMS teams within hospitals but the experience of pharmacists in influencing antibiotic use has received limited attention. In this study we explore the experiences of pharmacists in antibiotic decision-making in two Australian hospitals.

METHODS

We conducted 19 semi-structured interviews to explore hospital-based pharmacists' perceptions and experiences of antibiotic use and governance. The analysis was conducted with NVivo10 software, utilising the framework approach.

RESULTS

Three major themes emerged in the pharmacist interviews including (1) the responsibilities of pharmacy in optimising antibiotic use and the interprofessional challenges therein; (2) the importance of antibiotic streamlining and the constraints placed on pharmacists in achieving this; and (3) the potential, but often under-utilised expertise, pharmacists bring to antibiotic optimisation.

CONCLUSIONS

Pharmacists have a critical role in AMS teams but their capacity to enact change is limited by entrenched interprofessional dynamics. Identifying how hospital pharmacy's antibiotic gatekeeping is embedded in the interprofessional nature of clinical decision-making and limited by organisational environment has important implications for the implementation of hospital policies seeking to streamline antibiotic use. Resource constraints (i.e. time limitation and task prioritisation) in particular limit the capacity of pharmacists to overcome the interprofessional barriers through development of stronger collaborative relationships. The results of this study suggest that to enact change in antibiotic use in hospitals, pharmacists must be supported in their negotiations with doctors, have increased presence on hospital wards, and must be given opportunities to pass on specialist knowledge within multidisciplinary clinical teams.

What role do pharmacists play in mediating antibiotic use in hospitals? A qualitative study

OBJECTIVE

To understand Australian hospital pharmacists' accounts of antibiotic use, and the potential role of pharmacy in antibiotic optimisation within a tertiary hospital setting.

DESIGN, SETTING AND PARTICIPANTS

Qualitative study, utilising semistructured interviews with 19 pharmacists in two hospitals in Queensland, Australia in 2014. Data was analysed using the framework approach and supported by NVivo10 qualitative data analysis software.

RESULTS

The results demonstrate that (1) pharmacists' attitudes are ambivalent towards the significance of antibiotic resistance with optimising antibiotic use perceived as low priority; (2) pharmacists' current capacity to influence antibiotic decision-making is limited by the prescribing power of doctors and the perception of antibiotic use as a medical responsibility; and, (3) interprofessional and organisational barriers exist that prevent change in the hospital setting including medical hierarchies, limited contact with senior doctors and resource constraints resulting in insufficient pharmacy staffing to foster collaborative relationships and facilitate the uptake of their advice.

DISCUSSION

While pharmacy is playing an increasingly important role in enhanced antibiotic governance and is a vital component of antimicrobial stewardship in Australia, role-based limitations, interprofessional dynamics and organisational/resource constraints in hospitals, if not urgently addressed, will continue to significantly limit the ability of pharmacy to influence antibiotic prescribing.

Differential outcome of an antimicrobial stewardship audit and feedback program in two intensive care units: a controlled interrupted time series study

BACKGROUND

Antimicrobial decision making in intensive care units (ICUs) is challenging. Unnecessary antimicrobials contribute to the development of resistant pathogens, Clostridium difficile infection and drug related adverse events. However, inadequate antimicrobial therapy is associated with mortality in critically ill patients. Antimicrobial stewardship programs are increasingly being implemented to improve antimicrobial prescribing, but the optimal approach in the ICU setting is unknown. We assessed the impact of an audit and feedback antimicrobial stewardship intervention on antimicrobial use, antimicrobial costs, clinical outcomes and microbiologic outcomes in two ICUs with different patient populations.

METHODS

The audit and feedback intervention was implemented in a trauma and neurosurgery ICU (TNICU) and a medical surgical ICU (MSICU) at a 465-bed teaching hospital in Toronto, Canada. ICU patients were reviewed Monday to Friday by a physician and pharmacist with infectious diseases training. Recommendations related to appropriate antimicrobial use were presented to ICU teams during a dedicated daily meeting. A controlled interrupted time series analysis was used to compare outcomes in the 12 months before and after the intervention. Cardiovascular and coronary care ICUs served as control units.

RESULTS

Mean total monthly antimicrobial use in defined daily doses (DDD) per 1000 patient days was reduced 28% in the TNICU (1433 vs. 1037) but increased 14% in the MSICU (1705 vs. 1936). In the time series analysis, total monthly antimicrobial use in the TNICU decreased by 375 DDD per 1000 patient days (p < 0.0009) immediately following the intervention, followed by a non-significant downward trend in use of -9 DDD per 1000 patient days (p = 0.56). No significant changes in antimicrobial use were identified in the MSICU. Antimicrobial use temporarily increased in one control unit and remained unchanged in the other. There were no changes in mortality, length of stay, readmission rate, incidence of C. difficile infection or resistance patterns of E. coli and P. aeruginosa in either intervention unit.

CONCLUSIONS

Audit and feedback antimicrobial stewardship programs can lead to significant reductions in total antimicrobial use in the ICU setting. However, this effect may be context-dependent and further work is needed to determine the ingredients necessary for success.

Antimicrobial Stewardship in Australian Hospitals and Other Settings

Australia’s model of antimicrobial stewardship (AMS) has evolved significantly over recent years, from a long-standing national approach of antimicrobial prescribing guidelines and antimicrobial prescribing restrictions to recent advances including the first National Antimicrobial Resistance Strategy and incorporating mandatory AMS as part of hospital accreditation standards. AMS programs are most commonly found in the hospital setting. Various models are used throughout the country based on the local context and resources available. Programs implemented at Alfred Health and the Royal Brisbane and Women’s Hospital represent two successful models in tertiary referral settings that accommodate a general ward setting as well as specialized areas with a high infection burden. Measurement of outcomes related to AMS activities remains poorly standardized, with process indicators such as antimicrobial utilization forming a large proportion of outcome measurement. Presently there is no requirement for any AMS outcome measurements to be reported externally. Point prevalence surveys of appropriateness of prescribing and compliance with prescribing guidelines are widely used at a national level. Despite this, there is still a paucity of published Australian data to support the effect of AMS on patient clinical outcomes. Private hospitals, the community, veterinary medicine and aged care sectors represent an important area for future AMS expansion within Australia. The AMS focus has traditionally been on prescribing restrictions (through the Commonwealth funding agencies); however, recent work has described other areas for improvement and development in both settings. AMS in Australia continues to evolve. The recent development of an Australian strategic plan to link antimicrobial utilization and resistance surveillance with policy represents an important step forward for the future of AMS in Australia.

Agreement on the prescription of antimicrobial drugs

BACKGROUND

There is universal awareness of the difficulties faced by doctors when prescribing antimicrobials.

METHODS

Over a six-month period patients hospitalized in the ICU and under treatment with antibiotics and/or antifungals were eligible to participate in the study. The data were assessed by two infectious diseases specialists. Once completed, all case forms were sent independently to both evaluators (TZSC and ARM) by e-mail. Based on the data received, the evaluator completed a form automatically generated on the e-mail and returned it to the original mailbox for further analysis. We assessed the level of agreement between infectious disease specialists and the physicians directly responsible for the decision to begin antimicrobial therapy, as well as to assess the appropriateness of the regimen prescribed.

RESULTS

Among the antimicrobial regimens prescribed to the 177 patients, 36% were considered inappropriate by specialist #1 and 38% were considered inappropriate by specialist #2. We found 78% agreement by at least one of the infectious disease specialists with the prescribed antimicrobial regimen, and in 49% of cases both specialists agreed with the prescribed regimen. Both disagreed with the prescribed regimen in 22% of the cases and they disagreed between themselves in 29% of the cases.

CONCLUSION

This study highlights the difficulties in prescribing effective empirical antimicrobial therapy--they are of such magnitude that even two specialists in infectious diseases, well acquainted with our hospital's resistance patterns and our patients' profiles have considerable disagreement.

Antimicrobial Stewardship Programs in Inpatient Hospital Settings: A Systematic Review

Objective

Evaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes.

Design

Systematic review.

Methods

Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel.

Results

Few intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence ofClostridium difficileinfection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed.

Conclusions

Numerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.

Implementation of a multidisciplinary infectious diseases team in a tertiary hospital within an Antimicrobial Stewardship Program

BACKGROUND

In January 2011, as part of an antimicrobial stewardship program the Antimicrobial Management Team (AMT) at the Ghent University Hospital initiated a multidisciplinary Infectious Diseases Team (MIT) consisting of infectious diseases physicians, clinical microbiologists, and clinical pharmacists. The aim of this study is to describe the type and acceptance rate of recommendations provided by the MIT.

METHOD

Prospective, observational study in a tertiary care, university teaching hospital with 1062 beds in non-consecutive hospitalized adult patients, excluding intensive care units and paediatrics.

RESULTS

The MIT communicated 432 recommendations in 87 days observed. Of the 293 patients for whom a recommendation was made, the median age was 57 years (range: 16-91 years) and 169 (57·7%) were male. Skin or soft tissue infections (14%), respiratory tract infections (13%), infections without known focus (11%), abdominal infections (11%), and bone infections (8%) were most common. Recommendations were made to perform additional clinical investigation(s) [N = 137 (27%)], to adjust the dose of an antimicrobial drug [N = 42 (8%)], to stop an antimicrobial drug [N = 104 (21%)], to switch from a parenteral to an oral drug [N = 39 (8%)] or to initiate an antimicrobial drug [N = 178 (36%)], with an acceptance rate of 73·0%, 83·3%, 81·7%, 76·9%, and 84·0%, respectively.

CONCLUSIONS

The MIT formulated about five recommendations a day primarily focusing on pharmacotherapy, but also on clinical investigations. In both fields, a high acceptance rate was observed.

Antimicrobial stewardship programs in inpatient hospital settings: a systematic review

OBJECTIVE

Evaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes.

DESIGN

Systematic review.

METHODS

Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel.

RESULTS

Few intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence of Clostridium difficile infection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed.

CONCLUSIONS

Numerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.

Audit and feedback of antibiotic use: utilising electronic prescription data

BACKGROUND

There is now little doubt that improving antimicrobial use is necessary for the containment of resistance.

OBJECTIVE

To determine whether providing individualised feedback to doctors about their recent compliance with the hospital's antibiotic policy improves compliance with the policy.

METHODS

This study was conducted at a teaching hospital in Sydney, Australia. Computerised alerts integrated into the electronic prescribing system (ePS) inform prescribers of the local antibiotic policy. We utilised prescribing data extracted from the ePS for 'audit and feedback'. Thirty-six prescribers were sent feedback letters via email. We also interviewed doctors who had received letters to explore their views of the feedback and the policy in general.

RESULTS

There was no significant change in compliance with the policy following implementation of the feedback intervention (0% compliant vs 11.9%; p = 0.07). Several problems with the policy and the approval process were identified by researchers during auditing and by prescribers during interviews. Some problems identified made it difficult to accurately assess compliance and for doctors to comply with the policy.

CONCLUSION

Our intervention did not result in improved compliance with the antibiotic policy but revealed practical problems with the policy and approval process that had not been identified prior to the trial. Greater support for the policy by senior doctors and the assignment of more clearly defined roles and responsibilities associated with antibiotic use and approval may result in improved compliance. Harnessing the full potential of technology would streamline the antimicrobial approval process and allow more efficient and reliable monitoring of antibiotic use and compliance. Many of the problems we identified are generic issues of importance to all organisations seeking to integrate antimicrobial stewardship into ePS.

Antimicrobial stewardship program implementation in a medical intensive care unit at a tertiary care hospital in Saudi Arabia

BACKGROUND AND OBJECTIVES

Antimicrobial stewardship programs (ASPs) have shown to prevent the emergence of antimicrobial resistance associated with an inappropriate antimicrobial use. The primary objective of this study was to compare the prescribing appropriateness rate of the empirical antibiotic therapy before and after the ASP implementation in a tertiary care hospital. Secondary objectives include the rate of Clostridium difficile-associated diarrhea (CDAD), physicians' acceptance rate, patient's intensive care unit (ICU) course, total utilization using defined daily dose, and total direct cost of antibiotics.

DESIGN AND SETTINGS

This is a comparative, historically controlled study. Adult medical ICU patients were enrolled in a prospective fashion under the active ASP arm and compared with historical patients who were admitted to the same unit before the ASP implementation. This study was approved by the institutional review board, and the need for informed consent was waived because the interventions and recommendations were evidence based and considered the standard of care. The study was conducted at KFSHRC, Riyadh.

METHODS

Adult medical ICU patients were enrolled under the active ASP arm if they were on any of the 5 targeted antibiotics (piperacillin/tazobactam, imipenem/cilastatin, meropenem, vancomycin, tigecycline), and had no official infectious disease consultation. The interventions were conducted via prospective audit and feedback.

RESULTS

A total of 73 subjects were recruited, 49 in historical control and 24 in the active arm. The appropriateness of empirical antibiotics was improved from 30.6% (15/49) in the historical control arm to 100% (24/24) in the proactive ASP arm (P value < .05). For the ASP group, initially 79.1% (19/24) of the antibiotic uses were inappropriate and diminished by ASPs to 0% on the recommendations implementation. A total of 27 interventions were made with an acceptance rate of 96.3%. The rate of CDAD did not differ between the groups. A reduction in antibiotics utilization and direct cost were also noticed in the ASP arm.

CONCLUSION

A proactive ASP is a vital approach in optimizing the appropriate empirical antibiotics utilization in an ICU setting in tertiary care hospitals. This study highlights the importance of such a program and may serve as a foundation for further ASP initiatives particularly in our region.