1
|
Nicolle LE. Reducing Treatment of Asymptomatic Bacteriuria: What Works? Infect Dis Clin North Am 2024; 38:267-276. [PMID: 38575492 DOI: 10.1016/j.idc.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Asymptomatic bacteriuria is common, but usually benign. Inappropriate antimicrobial treatment of asymptomatic bacteriuria contributes to negative antimicrobial outcomes. Optimizing antimicrobial use for bacteriuria is a component of antimicrobial stewardship programs and includes key practices of dissemination and implementation of guidelines, laboratory practices which support stewardship, and programs to monitor and implement optimal antimicrobial treatment for urinary infection. These activities vary in their effectiveness, costs, and complexity to institute. Stewardship strategies targeting unique populations with a high prevalence of bacteriuria and for whom symptom assessment is not straightforward need to be further developed and evaluated to support optimal stewardship.
Collapse
Affiliation(s)
- Lindsay E Nicolle
- Department of Internal Medicine, GC-443 Health Sciences Centre, University of Manitoba, 820 Sherbrook Street, Winnipeg MB, R3A 1R9' MB, Canada.
| |
Collapse
|
2
|
Grigoryan L, Trautner BW. Antibiotic Stewardship Interventions for Urinary Tract Infections in Outpatient Settings: A Narrative Review. Infect Dis Clin North Am 2024; 38:277-294. [PMID: 38575491 DOI: 10.1016/j.idc.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Inappropriate antibiotic choice or duration of therapy for urinary tract infections (UTIs) in outpatients is common and is a major contributor to antibiotic overuse. Most studies on outpatient antibiotic stewardship for UTIs follow a pre-design or post-design with a multifaceted intervention; these trials generally have found improvement in appropriateness of antibiotic use for UTI. Audit and feedback was one of the most commonly employed strategies across these trials but may not be sustainable. Future research on antibiotic stewardship for UTIs in outpatients should measure both effectiveness and implementation success.
Collapse
Affiliation(s)
- Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, 3701 Kirby Drive, Suite 600, Houston TX 77098, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, IQuESt (152), 2002 Holcombe Boulevard, Houston, TX 77030, USA
| |
Collapse
|
3
|
De Waele JJ, Boelens J. Antimicrobial stewardship and molecular diagnostics: a symbiotic approach to combating resistance in the ED and ICU. Curr Opin Crit Care 2024; 30:231-238. [PMID: 38525881 DOI: 10.1097/mcc.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
PURPOSE OF REVIEW This review aims to evaluate the incorporation of rapid molecular diagnostics (RMD) in antimicrobial stewardship programs (ASPs) in the management of patients in the emergency department (ED) and intensive care unit (ICU), highlighting a shift from conventional microbiological diagnostic tests to RMD strategies to optimize antimicrobial use and improve patient outcomes. RECENT FINDINGS Recent advances in RMD have demonstrated the superior accuracy of RMD in identifying pathogens, combined with shorter turnaround times. RMD allows speeding up of antimicrobial decision making in the ED and facilitates faster escalation when empirical therapy was inappropriate, as well as more efficient de-escalation of empirical therapy later in the course of the treatment. Implementation of RMD however may be challenging. SUMMARY RMD hold great value in simplifying patient management and mitigating antimicrobial exposure, particularly in settings with high levels of antimicrobial resistance where the use of broad-spectrum antimicrobials is high. While the impact on the use of antimicrobials is significant, the impact on patient outcomes is not yet clear. Successful integration of RMD in clinical decision making in the ED and ICU requires a team approach and continued education, and its use should be adapted to the local epidemiology and infrastructure.
Collapse
Affiliation(s)
- Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University
| | - Jerina Boelens
- Department of Medical Microbiology, Ghent University Hospital
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
4
|
Ohashi K, Matsuoka T, Shinoda Y, Takahashi T, Shikano H, Kagajo M, Yagi T, Usami E. Evaluation of long-term pharmacist-led prospective audit and feedback in antimicrobial stewardship: An 8-year study. Am J Infect Control 2024; 52:670-677. [PMID: 38142775 DOI: 10.1016/j.ajic.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Limited research has evaluated the long-term outcomes of prospective audit and feedback (PAF) led by pharmacists. We assessed pharmacist-led PAF processes and outcome measures over 8 years. METHODS This study was conducted at a single public hospital in Japan. Between 2014 and 2021, pharmacists conducted weekday PAFs for hospitalized patients and annually evaluated the process and outcome measures. The endpoints included detection of drug-resistant bacteria, drug susceptibility rates, duration of antimicrobial therapy, and proportion of long-term administration. RESULTS Among inpatients, methicillin-resistant Staphylococcus aureus significantly decreased from 50.9% in 2014 to 32.8% in 2021 (P < .001). The susceptibility rate of Pseudomonas aeruginosa to meropenem significantly increased from 91.2% in 2014 to 94.4% in 2021 (P < .001) and levofloxacin increased from 84.9% in 2014 to 89.3% in 2021 (P < .001). Antimicrobial therapy duration did not differ significantly between 2014 and 2016, but decreased significantly from 2017 onwards (P < .001), except in 2018. The number of patients receiving intravenous antimicrobials for >10 days decreased significantly between 2014 and 2021 (P < .001). CONCLUSIONS Long-term continuous PAF interventions by pharmacists contribute to improving and maintaining process and outcome indicators and prevent the spread of drug-resistant bacteria.
Collapse
Affiliation(s)
- Kengo Ohashi
- Department of Pharmacy, Ogaki Municipal Hospital, Gifu, Japan; The Team for Antimicrobial Stewardship, Ogaki Municipal Hospital, Gifu, Japan.
| | - Tomoko Matsuoka
- Department of Pharmacy, Ogaki Municipal Hospital, Gifu, Japan; The Team for Antimicrobial Stewardship, Ogaki Municipal Hospital, Gifu, Japan
| | - Yasutaka Shinoda
- Department of Pharmacy, Ogaki Municipal Hospital, Gifu, Japan; The Team for Antimicrobial Stewardship, Ogaki Municipal Hospital, Gifu, Japan
| | - Takamasa Takahashi
- The Team for Antimicrobial Stewardship, Ogaki Municipal Hospital, Gifu, Japan; Department of Surgery, Ogaki Municipal Hospital, Gifu, Japan
| | - Hiroaki Shikano
- The Team for Antimicrobial Stewardship, Ogaki Municipal Hospital, Gifu, Japan; Department of Pediatrics, Ogaki Municipal Hospital, Gifu, Japan
| | - Michiko Kagajo
- The Team for Antimicrobial Stewardship, Ogaki Municipal Hospital, Gifu, Japan; Department of Respiratory Medicine, Ogaki Municipal Hospital, Gifu, Japan
| | - Tetsuya Yagi
- The Team for Antimicrobial Stewardship, Ogaki Municipal Hospital, Gifu, Japan; Department of Infectious Diseases, Nagoya, University Hospital, Nagoya, Japan
| | - Eiseki Usami
- Department of Pharmacy, Ogaki Municipal Hospital, Gifu, Japan
| |
Collapse
|
5
|
Abbs SE, Armstrong-Buisseret L, Eastwood K, Granier S, Lane A, Lui M, Metcalfe C, Mitchell P, Muir P, Ridd M, Taylor J, Yardley L, Young G, Hay AD. Rapid respiratory microbiological point-of-care-testing and antibiotic prescribing in primary care: Protocol for the RAPID-TEST randomised controlled trial. PLoS One 2024; 19:e0302302. [PMID: 38768129 PMCID: PMC11104596 DOI: 10.1371/journal.pone.0302302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 03/28/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Antibiotics are prescribed for over 50% of respiratory tract infections in primary care, despite good evidence of there being no benefit to the patient, and evidence of over prescribing driving microbial resistance. The high treatment rates are attributed to uncertainty regarding microbiological cause and clinical prognosis. Point-of-care-tests have been proposed as potential antibiotic stewardship tools, with some providing microbiological results in 15 minutes. However, there is little research on their impact on antibiotic use and clinical outcomes in primary care. METHODS This is a multi-centre, individually randomised controlled trial with mixed-methods investigation of microbial, behavioural and antibiotic mechanisms on outcomes in patients aged 12 months and over presenting to primary care in the UK with a suspected respiratory tract infection, where the clinician and/or patient thinks antibiotic treatment may be, or is, necessary. Once consented, all participants are asked to provide a combined nose and throat swab sample and randomised to have a rapid microbiological point-of-care-test or no point-of-care-test. For intervention patients, clinicians review the result of the test, before contacting the patient to finalise treatment. Treatment decisions are made as per usual care in control group patients. The primary outcome is whether an antibiotic is prescribed at this point. All swab samples are sent to the central laboratory for further testing. Patients are asked to complete a diary to record the severity and duration of symptoms until resolution or day 28, and questionnaires at 2 months about their beliefs and intention to consult for similar future illnesses. Primary care medical records are also reviewed at 6-months to collect further infection consultations, antibiotic prescribing and hospital admissions. The trial aims to recruit 514 patients to achieve 90% power with 5% significance to detect a 15% absolute reduction in antibiotic prescribing. Qualitative interviews are being conducted with approximately 20 clinicians and 30 participants to understand any changes in beliefs and behaviour resulting from the point-of-care-test and generate attributes for clinician and patient discrete choice experiments. DISCUSSION This trial will provide evidence of efficacy, acceptability and mechanisms of action of a rapid microbiological point-of-care test on antibiotic prescribing and patient symptoms in primary care. TRIAL REGISTRATION ISRCTN16039192, prospectively registered on 08/11/2022.
Collapse
Affiliation(s)
- Samantha Elizabeth Abbs
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | | | | | | | - Athene Lane
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Mandy Lui
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Chris Metcalfe
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Paul Mitchell
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Peter Muir
- UKHSA South West Regional Laboratory, Southmead Hospital, Bristol, United Kingdom
| | - Matthew Ridd
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Jodi Taylor
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Lucy Yardley
- School of Psychological Science, University of Bristol, Bristol, United Kingdom
- School of Psychology, University of Southampton, Southampton, United Kingdom
| | - Grace Young
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Alastair D. Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| |
Collapse
|
6
|
Harrigan JJ, Hamilton KW, Cressman L, Bilker WB, Degnan KO, David MZ, Tran D, Pegues DA, Dutcher L. Antibiotic Prescribing Patterns for Respiratory Tract Illnesses Following the Conclusion of an Education and Feedback Intervention in Primary Care. Clin Infect Dis 2024; 78:1120-1127. [PMID: 38271275 DOI: 10.1093/cid/ciad754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND A study previously conducted in primary care practices found that implementation of an educational session and peer comparison feedback was associated with reduced antibiotic prescribing for respiratory tract diagnoses (RTDs). Here, we assess the long-term effects of this intervention on antibiotic prescribing following cessation of feedback. METHODS RTD encounters were grouped into tiers based on antibiotic prescribing appropriateness: tier 1, almost always indicated; tier 2, possibly indicated; and tier 3, rarely indicated. A χ2 test was used to compare prescribing between 3 time periods: pre-intervention, intervention, and post-intervention (14 months following cessation of feedback). A mixed-effects multivariable logistic regression analysis was performed to assess the association between period and prescribing. RESULTS We analyzed 260 900 RTD encounters from 29 practices. Antibiotic prescribing was more frequent in the post-intervention period than in the intervention period (28.9% vs 23.0%, P < .001) but remained lower than the 35.2% pre-intervention rate (P < .001). In multivariable analysis, the odds of prescribing were higher in the post-intervention period than the intervention period for tier 2 (odds ratio [OR], 1.19; 95% confidence interval [CI]: 1.10-1.30; P < .05) and tier 3 (OR, 1.20; 95% CI: 1.12-1.30) indications but was lower compared to the pre-intervention period for each tier (OR, 0.66; 95% CI: 0.59-0.73 tier 2; OR, 0.68; 95% CI: 0.61-0.75 tier 3). CONCLUSIONS The intervention effects appeared to last beyond the intervention period. However, without ongoing provider feedback, there was a trend toward increased prescribing. Future studies are needed to determine optimal strategies to sustain intervention effects.
Collapse
Affiliation(s)
- James J Harrigan
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Keith W Hamilton
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Leigh Cressman
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Warren B Bilker
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kathleen O Degnan
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael Z David
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lauren Dutcher
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
7
|
Datta R, Kiwak E, Fried TR, Benjamin A, Iannone L, Krein SL, Carter W, Cohen AB. Diagnostic uncertainty and decision-making in home-based primary care: A qualitative study of antibiotic prescribing. J Am Geriatr Soc 2024; 72:1468-1475. [PMID: 38241465 PMCID: PMC11090732 DOI: 10.1111/jgs.18778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/19/2023] [Accepted: 12/23/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Evaluating infection in home-based primary care is challenging, and these challenges may impact antibiotic prescribing. A refined understanding of antibiotic decision-making in this setting can inform strategies to promote antibiotic stewardship. This study investigated antibiotic decision-making by exploring the perspectives of clinicians in home-based primary care. METHODS Clinicians from the Department of Veterans Affairs Home-Based Primary Care Program were recruited. Semi-structured interviews were conducted from June 2022 through September 2022 using a discussion guide. Transcripts were analyzed using grounded theory. The constant comparative method was used to develop a coding structure and to identify themes. RESULTS Theoretical saturation was reached after 22 clinicians (physicians, n = 7; physician assistants, n = 2, advanced practice registered nurses, n = 13) from 19 programs were interviewed. Mean age was 48.5 ± 9.3 years, 91% were female, and 59% had ≥6 years of experience in home-based primary care. Participants reported uncertainty about the diagnosis of infection due to the characteristics of homebound patients (atypical presentations of disease, presence of multiple chronic conditions, presence of cognitive impairment) and the challenges of delivering medical care in the home (limited access to diagnostic testing, suboptimal quality of microbiological specimens, barriers to establishing remote access to the electronic health record). When faced with diagnostic uncertainty about infection, participants described many factors that influenced the decision to prescribe antibiotics, including those that promoted prescribing (desire to avoid hospitalization, pressure from caregivers, unreliable plans for follow-up) and those that inhibited prescribing (perceptions of antibiotic-associated harms, willingness to trial non-pharmacological interventions first, presence of caregivers who were trusted by clinicians to monitor symptoms). CONCLUSIONS Clinicians face the difficult task of balancing diagnostic uncertainty with many competing considerations during the treatment of infection in home-based primary care. Recognizing these issues provides insight into strategies to promote antibiotic stewardship in home care settings.
Collapse
Affiliation(s)
- Rupak Datta
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Eliza Kiwak
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Terri R. Fried
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andrea Benjamin
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lynne Iannone
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sarah L. Krein
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Warren Carter
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andrew B. Cohen
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
8
|
Abel K, Agnew E, Amos J, Armstrong N, Armstrong-James D, Ashfield T, Aston S, Baillie JK, Baldwin S, Barlow G, Bartle V, Bielicki J, Brown C, Carrol E, Clements M, Cooke G, Dane A, Dark P, Day J, de-Soyza A, Dowsey A, Evans S, Eyre D, Felton T, Fowler T, Foy R, Gannon K, Gerada A, Goodman A, Harman T, Hayward G, Holmes A, Hopkins S, Howard P, Howard A, Hsia Y, Knight G, Lemoine N, Koh J, Macgowan A, Marwick C, Moore C, O’Brien S, Oppong R, Peacock S, Pett S, Pouwels K, Queree C, Rahman N, Sculpher M, Shallcross L, Sharland M, Singh J, Stoddart K, Thomas-Jones E, Townsend A, Ustianowski A, Van Staa T, Walker S, White P, Wilson P, Buchan I, Woods B, Bower P, Llewelyn M, Hope W. System-wide approaches to antimicrobial therapy and antimicrobial resistance in the UK: the AMR-X framework. Lancet Microbe 2024; 5:e500-e507. [PMID: 38461831 DOI: 10.1016/s2666-5247(24)00003-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 01/05/2024] [Accepted: 01/05/2024] [Indexed: 03/12/2024]
Abstract
Antimicrobial resistance (AMR) threatens human, animal, and environmental health. Acknowledging the urgency of addressing AMR, an opportunity exists to extend AMR action-focused research beyond the confines of an isolated biomedical paradigm. An AMR learning system, AMR-X, envisions a national network of health systems creating and applying optimal use of antimicrobials on the basis of their data collected from the delivery of routine clinical care. AMR-X integrates traditional AMR discovery, experimental research, and applied research with continuous analysis of pathogens, antimicrobial uses, and clinical outcomes that are routinely disseminated to practitioners, policy makers, patients, and the public to drive changes in practice and outcomes. AMR-X uses connected data-to-action systems to underpin an evaluation framework embedded in routine care, continuously driving implementation of improvements in patient and population health, targeting investment, and incentivising innovation. All stakeholders co-create AMR-X, protecting the public from AMR by adapting to continuously evolving AMR threats and generating the information needed for precision patient and population care.
Collapse
|
9
|
de Lorenzi-Tognon M, Schrenzel J. Simplified Spectrum Score (S 3) app for pathogen-agnostic antimicrobial drug spectrum ranking to assess for antimicrobial de-escalation events. Sci Rep 2024; 14:9776. [PMID: 38684841 PMCID: PMC11059348 DOI: 10.1038/s41598-024-60041-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/18/2024] [Indexed: 05/02/2024] Open
Abstract
Antimicrobial/antibiotic de-escalation (ADE) is a key feature of antimicrobial stewardship programs (ASP) that relies mainly on individual panels for determining ADE events based on subjective ranking of antibiotics' spectrum activity. The lack of consensus among ASP experts leads to reproducibility issues in the measure of this clinical outcome, making difficult to assess its real impact on patient care. The S3 score (Simplified Spectrum Score) app was developed to allow an objective ranking of antibiotics. Ranking was achieved by developing a database harboring pairs of bacteria-antibiotics for which each molecule was assigned a score based on published and clinically validated data from a recognized international committee. S3 score shows a strong correlation relationship and substantial agreement to a clinically validated spectrum score, and its framework enables any person to use it for ADE detection without assuming prior knowledge or training. In addition, its design enables regular updates and sustainability.
Collapse
Affiliation(s)
- Mikaël de Lorenzi-Tognon
- Bacteriology Laboratory, Division of Laboratory Medicine, Department of Diagnostics, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, 1211, Geneva 14, Switzerland.
- Genomic Research Laboratory, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Jacques Schrenzel
- Bacteriology Laboratory, Division of Laboratory Medicine, Department of Diagnostics, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, 1211, Geneva 14, Switzerland
- Genomic Research Laboratory, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Infectious Diseases, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| |
Collapse
|
10
|
Jarab AS, Al-Alawneh TO, Alshogran OY, Heshmeh SA, Mukattash TL, Naser YA, Alefishat E. Knowledge and attitude of healthcare prescribers and pharmacists toward antimicrobial stewardship program and the barriers for its implementation. Antimicrob Resist Infect Control 2024; 13:35. [PMID: 38566242 PMCID: PMC10985862 DOI: 10.1186/s13756-024-01382-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 02/10/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Antimicrobial stewardship (ASP) is considered a key prevention strategy in addressing the worldwide concern of accelerating antimicrobial resistance. Limited research is available regarding healthcare providers' knowledge and attitude toward antimicrobial stewardship and the barriers for its implementation. METHODS The present cross-sectional study was conducted on pharmacists and healthcare prescribers (HCPs) in different hospital sites across Jordan. A validated survey was used to evaluate HCPs and pharmacists' knowledge, and attitudes towards ASP and the barriers for its implementation. Logistic and linear regression were conducted to identify the factors associated with knowledge and attitude toward ASP, respectively. RESULTS A total of 603 participants, 69 (11.4%) pharmacists and 534 (88.6%) HCPs completed the study questionnaire, with a response rate of 80.4%. The overall mean knowledge about ASP was 7.16 out of 10, ranging from 0 to 10 (SD 2.22). Being a pharmacist and increased awareness/familiarity about ASP were associated with improved ASP knowledge. The overall average attitude score was = 3.8 ± 0.49 (range: 1.8-4.8). Results revealed that being a pharmacist and improved knowledge were associated with improved attitude toward ASP. Lack of specialized staff with expertise in ASP and lack of access to education and training programs were the major barriers hinder ASP implementation. CONCLUSION Despite the reasonable knowledge and the positive attitude toward the ASP, several barriers were reported, particularly by the pharmacists. Therefore, promoting the presence of adequately skilled healthcare personnel, creating easily accessible online courses, and establishing a comprehensive database of ASP resources are all suggested approaches to improve the application of ASP in healthcare settings.
Collapse
Affiliation(s)
- Anan S Jarab
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, 22110, Irbid, P.O. Box 3030, Jordan
- College of Pharmacy, AL Ain University, Abu Dhabi, United Arab Emirates
| | - Tasneem O Al-Alawneh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, 22110, Irbid, P.O. Box 3030, Jordan
| | - Osama Y Alshogran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, 22110, Irbid, P.O. Box 3030, Jordan
| | - Shrouq Abu Heshmeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, 22110, Irbid, P.O. Box 3030, Jordan
| | - Tareq L Mukattash
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, 22110, Irbid, P.O. Box 3030, Jordan
| | - Yara A Naser
- School of Pharmacy, Medical Biology Centre, Queen's University Belfast, Northern Ireland, 97 Lisburn Road, BT9 7BL, Belfast, UK
| | - Eman Alefishat
- Department of Medical Sciences, College of Medicine and Health Science, Khalifa University of Science and Technology, 127788, Abu Dhabi, United Arab Emirates.
- Department of Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, 11942, Amman, Jordan.
- Center for Biotechnology, Khalifa University of Science and Technology, 127788, Abu Dhabi, United Arab Emirates.
| |
Collapse
|
11
|
Wang EY, Girotto JE. Approaches to Reduce Use and Duration of Anti-MRSA Agents for Antimicrobial Stewardship Programs: A Review of Recent Literature. J Pharm Pract 2024; 37:448-466. [PMID: 36194825 DOI: 10.1177/08971900221130893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Antimicrobial stewardship programs (ASPs) have the potential to effectively deescalate unnecessary methicillin-resistant Staphylococcus aureus (MRSA) coverage. This review summarizes literature published from 2014 through 2021 describing contemporary ASP methods and their resulting effectiveness at reducing anti-MRSA agent use (ie vancomycin, linezolid, daptomycin, ceftaroline, and clindamycin). This review of the literature examined the following strategies, which had reports of success in either decreasing the use or duration of anti-MRSA agents: prospective review and feedback, antibiotic timeouts, health system or department protocol changes, polymerase chain reaction (PCR) and rapid testing of patient samples. Most of the current literature continue to support most ASP interventions including antibiotic timeouts, pathways, and molecular testing including MRSA nasal PCRs and rapid diagnostic testing can be successful at reducing unnecessary anti-MRSA use.
Collapse
Affiliation(s)
- Ethan Y Wang
- Department of Pharmacy Practice, University of Connecticut, School of Pharmacy, Storrs, CT, USA
| | - Jennifer E Girotto
- Department of Pharmacy Practice, University of Connecticut, School of Pharmacy, Storrs, CT, USA
- Department of Pediatrics, Antimicrobial Stewardship Program Connecticut Children's, Hartford, CT, USA
| |
Collapse
|
12
|
Li X, Wu Y, Jiang T, Chen B, Feng R, Zhang J, Xie X, Ruan Z. China's plan to combat antimicrobial resistance. Science 2024; 383:1424-1425. [PMID: 38547275 DOI: 10.1126/science.ado5186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Xinyang Li
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Hangzhou, China
| | - Yuye Wu
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Hangzhou, China
| | - Tian Jiang
- Department of Clinical Laboratory, Affiliated Wenling Hospital, Wenzhou Medical University, Wenling, China
| | - Bin Chen
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, Hangzhou, China
| | - Rui Feng
- College of Environmental and Resource Sciences, Zhejiang University, Hangzhou, China
| | - Jun Zhang
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Hangzhou, China
| | - Xinyou Xie
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Hangzhou, China
| | - Zhi Ruan
- Department of Clinical Laboratory, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Key Laboratory of Precision Medicine in Diagnosis and Monitoring Research of Zhejiang Province, Hangzhou, China
| |
Collapse
|
13
|
Kolberg L, Khanijau A, van der Velden FJS, Herberg J, De T, Galassini R, Cunnington AJ, Wright VJ, Shah P, Kaforou M, Wilson C, Kuijpers T, Martinón-Torres F, Rivero-Calle I, Moll H, Vermont C, Pokorn M, Kolnik M, Pollard AJ, Agyeman PKA, Schlapbach LJ, Tsolia MN, Yeung S, Zavadska D, Zenz W, Schweintzger NA, van der Flier M, de Groot R, Usuf E, Voice M, Calvo-Bado L, Mallet F, Fidler K, Levin M, Carrol ED, Emonts M, von Both U. Raising AWaRe-ness of Antimicrobial Stewardship Challenges in Pediatric Emergency Care: Results from the PERFORM Study Assessing Consistency and Appropriateness of Antibiotic Prescribing Across Europe. Clin Infect Dis 2024; 78:526-534. [PMID: 37820031 PMCID: PMC10954344 DOI: 10.1093/cid/ciad615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/22/2023] [Accepted: 10/04/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Optimization of antimicrobial stewardship is key to tackling antimicrobial resistance, which is exacerbated by overprescription of antibiotics in pediatric emergency departments (EDs). We described patterns of empiric antibiotic use in European EDs and characterized appropriateness and consistency of prescribing. METHODS Between August 2016 and December 2019, febrile children attending EDs in 9 European countries with suspected infection were recruited into the PERFORM (Personalised Risk Assessment in Febrile Illness to Optimise Real-Life Management) study. Empiric systemic antibiotic use was determined in view of assigned final "bacterial" or "viral" phenotype. Antibiotics were classified according to the World Health Organization (WHO) AWaRe classification. RESULTS Of 2130 febrile episodes (excluding children with nonbacterial/nonviral phenotypes), 1549 (72.7%) were assigned a bacterial and 581 (27.3%) a viral phenotype. A total of 1318 of 1549 episodes (85.1%) with a bacterial and 269 of 581 (46.3%) with a viral phenotype received empiric systemic antibiotics (in the first 2 days of admission). Of those, the majority (87.8% in the bacterial and 87.0% in the viral group) received parenteral antibiotics. The top 3 antibiotics prescribed were third-generation cephalosporins, penicillins, and penicillin/β-lactamase inhibitor combinations. Of those treated with empiric systemic antibiotics in the viral group, 216 of 269 (80.3%) received ≥1 antibiotic in the "Watch" category. CONCLUSIONS Differentiating bacterial from viral etiology in febrile illness on initial ED presentation remains challenging, resulting in a substantial overprescription of antibiotics. A significant proportion of patients with a viral phenotype received systemic antibiotics, predominantly classified as WHO Watch. Rapid and accurate point-of-care tests in the ED differentiating between bacterial and viral etiology could significantly improve antimicrobial stewardship.
Collapse
Affiliation(s)
- Laura Kolberg
- Dr. von Hauner Children's Hospital, Division Pediatric Infectious Diseases, University Hospital, LMU Munich, Munich, Germany
| | - Aakash Khanijau
- Department of Infectious Diseases, Alder Hey Children's Hospital, Liverpool, United Kingdom
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Fabian J S van der Velden
- Pediatric Immunology, Infectious Diseases & Allergy Department, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Jethro Herberg
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Tisham De
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Rachel Galassini
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Aubrey J Cunnington
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Victoria J Wright
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Priyen Shah
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Myrsini Kaforou
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Clare Wilson
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Taco Kuijpers
- Amsterdam University Medical Center, Location Academic Medical Center, Department of Pediatric Immunology, Rheumatology and Infectious Diseases, University of Amsterdam, Amsterdam, The Netherlands
| | - Federico Martinón-Torres
- Translational Pediatrics and Infectious Diseases, Hospital Clinico Universitario de Santiago de Compostela, Santiago De Compostela, Spain
| | - Irene Rivero-Calle
- Translational Pediatrics and Infectious Diseases, Hospital Clinico Universitario de Santiago de Compostela, Santiago De Compostela, Spain
| | - Henriette Moll
- Department of General Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Clementien Vermont
- Department of General Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Pediatrics, Division of Pediatric Infectious Diseases & Immunology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marko Pokorn
- Univerzitetni Klinični Center, Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Mojca Kolnik
- University Medical Center Ljubljana, University Children's Hospital, Ljubljana, Slovenia
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Pediatrics, University of Oxford, Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals Trust, Oxford, United Kingdom
| | - Philipp K A Agyeman
- Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, and Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Maria N Tsolia
- Second Department of Pediatrics, Children's Hospital ‘P. and A. Kyriakou,’ National and Kapodistrian University of Athens, Athens, Greece
| | - Shunmay Yeung
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Dace Zavadska
- Children Clinical University Hospital, Department of Pediatrics, Rīgas Stradina Universitāte, Riga, Latvia
| | - Werner Zenz
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Graz, Austria
| | - Nina A Schweintzger
- Department of Pediatrics and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Graz, Austria
| | - Michiel van der Flier
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
- Wilhelmina Children's Hospital, Pediatric Infectious Diseases and Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ronald de Groot
- Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Effua Usuf
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Marie Voice
- Micropathology Ltd, The Venture Center, University of Warwick Science Park, Coventry, United Kingdom
| | - Leonides Calvo-Bado
- Micropathology Ltd, The Venture Center, University of Warwick Science Park, Coventry, United Kingdom
| | - François Mallet
- Joint Research Unit Hospice Civils de Lyon–bioMérieux, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Katy Fidler
- Academic Department of Pediatrics, Royal Alexandra Children's Hospital, Brighton, United Kingdom
- Brighton and Sussex Medical School, University of Sussex, East Sussex, United Kingdom
| | - Michael Levin
- Section of Pediatric Infectious Disease, Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Enitan D Carrol
- Department of Infectious Diseases, Alder Hey Children's Hospital, Liverpool, United Kingdom
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Marieke Emonts
- Pediatric Immunology, Infectious Diseases & Allergy Department, Great North Children's Hospital, Newcastle Upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
- NIHR Newcastle Biomedical Research Centre, Newcastle Upon Tyne Hospitals NHS Trust and Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Ulrich von Both
- Dr. von Hauner Children's Hospital, Division Pediatric Infectious Diseases, University Hospital, LMU Munich, Munich, Germany
- German Center for Infection Research (DZIF), Partner Site Munich, Munich, Germany
| |
Collapse
|
14
|
Tiwaskar M, Vora A, Saraf A, Bhadade R, Choudhari S, Pawar D, Sharma A. Defeating the Silent Enemy: Antimicrobial Resistance Looming as the Next Global Pandemic. J Assoc Physicians India 2024; 72:66-72. [PMID: 38736120 DOI: 10.59556/japi.72.0487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
Antibiotics are the magic bullets that have saved millions worldwide. Enormous and irresponsible use of antibiotics has led to resistance to antibiotics, which is a matter of global health concern. The superbugs are responsible for life-threatening infections, treatment failure, and high mortality worldwide. The urgent healthcare threat caused by antimicrobial resistance (AMR) to nonfermenting gram-negative bacteria is being increasingly acknowledged worldwide. Antibiotic resistance found in organisms in hospital settings is now increasingly found in the community. Although antimicrobial stewardship requiring a multidisciplinary approach is developing rapidly at the hospital level, it needs more attention at the community level. New therapeutics are certainly required, but the major challenge is rapidly identifying resistant infections and tailoring treatment. This review highlights the crisis that reflects the current scenario of AMR, common resistant pathogens, and the major challenges in the fight against AMR. It also discusses potential methods and strategies to address the intricacies of antibiotic resistance.
Collapse
Affiliation(s)
- Mangesh Tiwaskar
- Consultant Physician and Diabetologist, Department of Diabetology, Shilpa Medical Research Centre, Mumbai, Maharashtra, India
| | - Agam Vora
- Medical Director, Department of Pulmonology, Vora Clinic, Mumbai, Maharashtra, India
| | - Amit Saraf
- Director, Department of Internal Medicine, Jupiter Hospital, Thane, Maharashtra, India
| | - Rakesh Bhadade
- Associate Professor, Department of Medicine, Topiwala National Medical College and Bai Yamunabai Laxman Nair Charitable Hospital, Mumbai, Maharashtra, India
| | - Sachin Choudhari
- Senior Manager, Department of Medical Affairs, Alkem Laboratories Limited, Mumbai, Maharashtra, India, Corresponding Author
| | - Dattatray Pawar
- Head, Department of Medical Affairs, Alkem Laboratories Limited, Mumbai, Maharashtra, India
| | - Akhilesh Sharma
- President, Department of Medical Affairs, Alkem Laboratories Limited, Mumbai, Maharashtra, India
| |
Collapse
|
15
|
Nie X, Lin M, Xu S, Zhang L, Lin X, Huang W. Strategically reducing carbapenem-resistant Acinetobacter baumannii through PDCA cycle-driven antibiotic management. Indian J Med Microbiol 2024; 48:100527. [PMID: 38185209 DOI: 10.1016/j.ijmmb.2024.100527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/13/2023] [Accepted: 01/02/2024] [Indexed: 01/09/2024]
Abstract
PURPOSE With the escalating global challenge of antibiotic resistance, particularly the resistance rate of Acinetobacter baumannii, the need to rationalize carbapenem antibiotic use in clinical settings has become paramount. Our study tapped into a fishbone diagram to uncover the irrationalities in applying these antibiotics and highlight potential influencing factors. METHODS Based on these analyses, we initiated targeted intervention strategies. A PDCA cycle-based scientific management approach was implemented through the combined efforts of our antimicrobial stewardship team and relevant departments. RESULTS Our study showed a significant post-intervention increase in the rational use of carbapenem antibiotics (P < 0.01) and a concurrent decrease in the detection of carbapenem-resistant Acinetobacter baumannii. CONCLUSION Our findings underscore that carbapenem usage can be effectively minimized with the continuous refinements offered by the PDCA cycle, leading to a reduction in multidrug-resistant bacteria, thus fostering rational drug use in healthcare.
Collapse
Affiliation(s)
- Xuekun Nie
- Department of Clinical Pharmacy, Ningde Municipal Hospital of Ningde Normal University, Ningde, Fujian, 352100, China; Collaborative Innovation Center of Active Ingredient Research of She Medicine (2020Z03), Innovation Center of Clinical Pharmacy Service (2023T06), Ningde Normal University, Ningde, Fujian, 352100, China.
| | - Minhua Lin
- Department of Clinical Pharmacy, Ningde Municipal Hospital of Ningde Normal University, Ningde, Fujian, 352100, China; Collaborative Innovation Center of Active Ingredient Research of She Medicine (2020Z03), Innovation Center of Clinical Pharmacy Service (2023T06), Ningde Normal University, Ningde, Fujian, 352100, China.
| | - Shuanglin Xu
- Department of Clinical Pharmacy, Ningde Municipal Hospital of Ningde Normal University, Ningde, Fujian, 352100, China; Collaborative Innovation Center of Active Ingredient Research of She Medicine (2020Z03), Innovation Center of Clinical Pharmacy Service (2023T06), Ningde Normal University, Ningde, Fujian, 352100, China.
| | - Lingling Zhang
- Department of Clinical Pharmacy, Ningde Municipal Hospital of Ningde Normal University, Ningde, Fujian, 352100, China; Collaborative Innovation Center of Active Ingredient Research of She Medicine (2020Z03), Innovation Center of Clinical Pharmacy Service (2023T06), Ningde Normal University, Ningde, Fujian, 352100, China.
| | - Xiaohui Lin
- Department of Clinical Pharmacy, Ningde Municipal Hospital of Ningde Normal University, Ningde, Fujian, 352100, China; Collaborative Innovation Center of Active Ingredient Research of She Medicine (2020Z03), Innovation Center of Clinical Pharmacy Service (2023T06), Ningde Normal University, Ningde, Fujian, 352100, China.
| | - Weiying Huang
- Department of Clinical Pharmacy, Ningde Municipal Hospital of Ningde Normal University, Ningde, Fujian, 352100, China; Collaborative Innovation Center of Active Ingredient Research of She Medicine (2020Z03), Innovation Center of Clinical Pharmacy Service (2023T06), Ningde Normal University, Ningde, Fujian, 352100, China.
| |
Collapse
|
16
|
Ruiz Ramos J, Santolaya Perrín MR, González Del Castillo J, Candel FJ, Quirós AM, López-Contreras González J, Jiménez AJ, Suárez-Lledó Grande A. Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department. Farm Hosp 2024; 48:57-63. [PMID: 37481455 DOI: 10.1016/j.farma.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/24/2023] Open
Abstract
OBJECTIVE To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. METHODS A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritization level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritization order and rated the new indicators in the same manner as in the first round. RESULTS 61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analyzing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. CONCLUSIONS The experts agreed on a panel of ASP indicators adapted to the emergency services prioritized by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.
Collapse
Affiliation(s)
- Jesús Ruiz Ramos
- Servicio de Farmacia, Hospital Santa Creu y San Pau, Barcelona, España.
| | | | | | - Francisco Javier Candel
- Unidad de Enfermedades Infecciosas, Hospital Clínico Universitario San Carlos, Madrid, España
| | | | | | | | | |
Collapse
|
17
|
Ruiz-Ramos J, Santolaya-Perrín MR, González-Del-Castillo J, Candel FJ, Martín-Quirós A, López-Contreras-González J, Julián-Jiménez A, Suárez-Lledó-Grande A. [Translated article] Design of a panel of indicators for antibiotic stewardship programs in the Emergency Department. Farm Hosp 2024; 48:T57-T63. [PMID: 38148256 DOI: 10.1016/j.farma.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 12/28/2023] Open
Abstract
OBJECTIVE To develop a panel of indicators to monitor antimicrobial stewardship programs activity in the emergency department. METHODS A multidisciplinary group consisting of experts in the management of infection in emergency departments and the implementation of antimicrobial stewardship programs (ASP) evaluated a proposal of indicators using a modified Delphi methodology. In the first round, each expert classified the relevance of each proposed indicators in two dimensions (healthcare impact and ease of implementation) and two attributes (prioritisation level and frequency). The second round was conducted based on the modified questionnaire according to the suggestions raised and new indicators suggested. Experts modified the prioritisation order and rated the new indicators in the same manner as in the first round. RESULTS 61 potential indicators divided into four groups were proposed: consumption indicators, microbiological indicators, process indicators, and outcome indicators. After analysing the scores and comments from the first round, 31 indicators were classified as high priority, 25 as intermediate priority, and 5 as low priority. Moreover, 18 new indicators were generated. Following the second round, all 61 initially proposed indicators were retained, and 18 new indicators were incorporated: 11 classified as high priority, 3 as intermediate priority, and 4 as low priority. CONCLUSIONS The experts agreed on a panel of ASP Indicators adapted to the emergency services prioritised by level of relevance. This is as a helpful tool for the development of these programs and will contribute to monitoring the appropriateness of the use of antimicrobials in these units.
Collapse
Affiliation(s)
- Jesús Ruiz-Ramos
- Servicio de Farmacia, Hospital Santa Creu y San Pau, Catalonia, Spain.
| | | | | | - Francisco Javier Candel
- Infectious diseases-Clinical Microbiology, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | | | | | | |
Collapse
|
18
|
Sumon SA, Anwar MMU, Akther FM, Priyanka AS, Tamanna T, Rahman A, Islam MS, Harun MGD. Perceptions of antibiotic stewardship programmes and determinants of antibiotic prescribing patterns among physicians in tertiary hospitals in Bangladesh: implications for future policy and practice. J Hosp Infect 2024; 144:56-65. [PMID: 38070709 DOI: 10.1016/j.jhin.2023.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND The concerning growth of antimicrobial resistance (AMR) renders common infections life-threatening due to irrational antibiotic use and a lack of effective antimicrobial stewardship programmes (ASPs). AIM To investigate the awareness, perceptions and practices of physicians regarding ASPs, AMR and antibiotic prescribing in tertiary care hospitals in Bangladesh. METHODS This hospital-based cross-sectional survey was conducted in 11 tertiary care hospitals across Bangladesh between September 2020 and January 2021. A semi-structured questionnaire was administered through face-to-face interviews for data collection. Descriptive and multi-variate analyses were performed using STATA Version 13. RESULTS In total, 559 physicians were enrolled in this survey. Overall, 40.6% [95% confidence interval (CI) 36.5-44.8] of physicians reported being aware of ASPs, and this figure was higher in public hospitals compared with private hospitals (43.8% vs 27.1%). None of the study hospitals had any ASP initiatives. More than half (55.1%) of the participants were willing to receive feedback from an ASP on their antibiotic selection. Only 30.9% of respondents stated that they wait for the findings of microbiological tests before prescribing antibiotics, although challenges included empiric use of broad-spectrum antibiotics, delayed laboratory results and the existence of drug-resistant patients. In contrast, physicians aware of ASPs were 33% (adjusted odds ratio 0.67, 95% CI 0.45-0.98; P=0.033) less likely to wait for laboratory results before prescribing antibiotics. However, 42.5% of physicians considered patient affordability of purchasing antibiotics when prescribing. CONCLUSIONS Physicians' fundamental knowledge of ASPs and rational antibiotic prescription were found to fall short of the standard. Context-specific and integrated ASP activities, availability and use of guidelines, and improved laboratory facilities are required to battle AMR in Bangladesh.
Collapse
Affiliation(s)
- S A Sumon
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh.
| | - M M U Anwar
- Department of Population Sciences, University of Dhaka, Dhaka, Bangladesh
| | - F M Akther
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - A S Priyanka
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - T Tamanna
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - A Rahman
- Communicable Disease Control, Directorate General of Health Services, Dhaka, Bangladesh
| | - M S Islam
- School of Population Health, University of New South Wales, Sydney, Australia
| | - M G D Harun
- Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| |
Collapse
|
19
|
Patel PK, Watari T, Greene MT, Fowler KE, Ratz D, Saint S, Kasatpibal N, Apisarnthanarak A. The current state of antimicrobial and urine culture stewardship in Thailand: Results from a national survey. Am J Infect Control 2024; 52:191-194. [PMID: 37295675 DOI: 10.1016/j.ajic.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/26/2023] [Accepted: 05/28/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Antimicrobial stewardship in Thailand has made major progress backed by a national strategic plan. The current study aimed to assess the antimicrobial stewardship program (ASP) composition, reach, and breadth, as well as urine culture stewardship in Thai hospitals. METHODS We sent an electronic survey to 100 Thai hospitals between February 1, 2021 and August 31, 2021. This hospital sample represented 20 hospitals in each of Thailand's 5 geographical regions. RESULTS The response rate was 100%. A total of 86 of 100 hospitals had an ASP. These were often multi-disciplinary in nature, with half including infectious disease-trained physicians and pharmacists, infection preventionists, and nursing staff. Urine culture stewardship protocols existed in 51% of hospitals. CONCLUSIONS The national strategic plan in Thailand has allowed the country to stand up robust ASPs. Further research should examine the effectiveness of such programs and ways to expand them into other medical settings, like nursing homes, urgent care, and outpatient while continuing to grow telehealth and urine culture stewardship.
Collapse
Affiliation(s)
- Payal K Patel
- Division of Infectious Diseases, Intermountain Medical Center, Murray, UT.
| | - Takashi Watari
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; General Medicine Center, Shimane University, Izumo, Shimane, Japan
| | - M Todd Greene
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Karen E Fowler
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - David Ratz
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Sanjay Saint
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Nongyao Kasatpibal
- Division of Nursing Science, Chiang Mai University, Mueang Chiang Mai, Chiang Mai, Thailand
| | - Anucha Apisarnthanarak
- Division of Infectious Diseases, Thammasart University Hospital, Khlong Nueng, Pratum Thani, Thailand
| |
Collapse
|
20
|
Aboza Garcia M, Goycochea-Valdivia W, Peñalva G, Falcon Neyra L, Moleón Ruiz M, Rodriguez-Villodres A, Montero Valladares C, Olbrich P, Sánchez-Valderrabanos E, Jiménez F, Molina M, Moreno Madueño G, Valencia Martin R, Gil Navarro MV, Molina J, Neth O, Cisneros JM. Long-term outcomes of an educational paediatric antimicrobial stewardship programme: a quality improvement study. Arch Dis Child 2024; 109:144-151. [PMID: 37940361 DOI: 10.1136/archdischild-2022-323802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 10/17/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Antimicrobial stewardship programmes (ASPs) have resulted in antimicrobial consumption (AMC) reduction and quality of prescription (QOP) improvement. However, evidence of ASP impact in paediatrics is still limited. This study aims to assess a paediatric ASP long-term outcomes. METHODS A quality improvement study assessed by a interrupted time series analysis was conducted in a paediatric tertiary hospital. QOP expressed as proportion of adequate prescriptions, AMC measured by defined daily dose incidence per 1000 occupied bed days, incidence density of bloodstream infections (BSIs) and its related all-cause crude death rate (CDR) were compared between pre (from January 2013 to December 2015) and post (from January 2016 to December 2019) ASP activities intensification, which included a dedicated paediatric infectious diseases physician to actively perform educational interviews with prescribers. RESULTS Inappropriate prescribing showed a significant downward shift associated to the intervention with a -51.4% (-61.2% to -41.8%) reduction with respect to the expected values. Overall AMC showed no trend change after the intervention. For neonatology a28.8% (-36.8% to -20.9%) reduction was observed. Overall anti-pseudomonal cephalosporin use showed a -51.2% (-57.0% to -45.4%) reduction. Decreasing trends were observed for carbapenem use, with a quarterly per cent change (QPC) of -2.4% (-4.3% to -0.4%) and BSI-related CDR (QPC=-3.6%; -5.4% to -1.7%) through the study period. Healthcare-associated multi-drug-resistant BSI remained stable (QPC=2.1; -0.6 to 4.9). CONCLUSIONS Intensification of counselling educational activities within an ASP suggests to improve QOP and to partially reduce AMC in paediatric patients. The decreasing trends in mortality remained unchanged.
Collapse
Affiliation(s)
- Marta Aboza Garcia
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, UniversityHospital Virgen del Rocío, Institute of Biomedicine of Seville (IBIS)/ Universidad deSevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica, Seville, Spain
| | - Walter Goycochea-Valdivia
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, UniversityHospital Virgen del Rocío, Institute of Biomedicine of Seville (IBIS)/ Universidad deSevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica, Seville, Spain
| | - Germán Peñalva
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spanish National Research Council, University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Lola Falcon Neyra
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, UniversityHospital Virgen del Rocío, Institute of Biomedicine of Seville (IBIS)/ Universidad deSevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica, Seville, Spain
| | - Marta Moleón Ruiz
- Department of Pharmacy, Hospital Universitario Virgen del Rocio, Seville, Spain
| | - Angel Rodriguez-Villodres
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spanish National Research Council, University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Peter Olbrich
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, UniversityHospital Virgen del Rocío, Institute of Biomedicine of Seville (IBIS)/ Universidad deSevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica, Seville, Spain
| | | | - Francisco Jiménez
- Department of Neonatology, University Hospital Virgen del Rocío, Seville, Spain
| | - Maria Molina
- Department of Paediatric Surgery, University Hospital Virgen del Rocío, Seville, Spain
| | | | | | - Maria Victoria Gil Navarro
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Department of Pharmacy, Hospital Universitario Virgen del Rocio, Seville, Spain
| | - Jose Molina
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spanish National Research Council, University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Olaf Neth
- Paediatric Infectious Diseases, Rheumatology and Immunology Unit, UniversityHospital Virgen del Rocío, Institute of Biomedicine of Seville (IBIS)/ Universidad deSevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica, Seville, Spain
| | - Jose Miguel Cisneros
- Department of Infectious Diseases, Microbiology and Parasitology, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, Spanish National Research Council, University of Seville, Seville, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
21
|
Chukwu EE, Abuh D, Idigbe IE, Osuolale KA, Chuka-Ebene V, Awoderu O, Audu RA, Ogunsola FT. Implementation of antimicrobial stewardship programs: A study of prescribers' perspective of facilitators and barriers. PLoS One 2024; 19:e0297472. [PMID: 38241406 PMCID: PMC10798493 DOI: 10.1371/journal.pone.0297472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 01/06/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Despite promising signs of the benefits associated with Antimicrobial Stewardship Programs (ASPs), there remains limited knowledge on how to implement ASPs in peculiar settings for a more elaborate impact. This study explored prescriber experiences and perceptions of the usefulness, and feasibility of strategies employed for the implementation of antimicrobial stewardship (AMS) interventions as well as challenges encountered. METHODS This is a cross-sectional mixed-method survey of prescribers' perspective of the facilitators and barriers of implementing ASP. The quantitative approach comprised of a semi-structured questionnaire and data collected were analyzed using SPSS version 26 while the qualitative approach used focus group discussions followed by content analysis. RESULTS Out of the thirty people that participated in the workshop, twenty-five completed the questionnaires which were analyzed. The respondents included 15 (60.0%) medical doctors and 10 (40.0%) pharmacists. The mean age of the respondents was 36.39±7.23 years with mean year of practice of 9.48±6.01 years. Majority of them (84.0%) were in a position to provide input on the implementation of AMS in their facilities, although their managements had the final decision. The pharmacists (100%) were more likely to agree that antibiotic resistance was a problem for their practice than the medical doctors (78.6%) while equal number (80.0%) of respondents (pharmacists and medical doctors) believed that inappropriate prescribing was a problem. Having a specialized and dedicated team with effective monitoring was recognized as crucial for effective ASP while inadequate personnel was identified as a major barrier. We identified stakeholder's engagement, policies and regulation, as well as education as themes for improving AMS in the country. CONCLUSION The results gave insight into the prescribers' perspective on the facilitators and barriers to antimicrobial stewardship; challenges and possible solutions to implementing ASPs in health facilities in Lagos State. We further identified pertinent contextual factors that need to be addressed when developing ASPs in healthcare facilities in a resource-poor setting.
Collapse
Affiliation(s)
- Emelda E. Chukwu
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Dennis Abuh
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Ifeoma E. Idigbe
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Kazeem A. Osuolale
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Vivian Chuka-Ebene
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
- Pharmacy Department, Lagos University Teaching Hospital, Lagos, Lagos State, Nigeria
| | - Oluwatoyin Awoderu
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Rosemary A. Audu
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
| | - Folasade T. Ogunsola
- Antimicrobial Resistance Research group, Nigerian Institute of Medical Research, Yaba, Lagos State, Nigeria
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Lagos, Nigeria
| |
Collapse
|
22
|
Hitchcock MM, Gomez CA, Pozdol J, Banaei N. Effective Approaches to Diagnostic Stewardship of Syndromic Molecular Panels. J Appl Lab Med 2024; 9:104-115. [PMID: 38167764 DOI: 10.1093/jalm/jfad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/08/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Syndromic molecular panels for the diagnosis of gastroenteritis, meningitis/encephalitis, and pneumonia are becoming routinely used for patient care throughout the world. CONTENT These rapid, sample-to-answer assays have great potential to improve patient care, infection control, and antimicrobial stewardship. However, diagnostic stewardship is essential for their optimal use and accuracy, and interventions can be applied at all phases of the diagnostic process. SUMMARY The aim of this review article is to describe effective approaches to diagnostic stewardship for syndromic molecular panels to ensure appropriate test utilization and quality assured results.
Collapse
Affiliation(s)
- Matthew M Hitchcock
- Department of Medicine, Division of Infectious Diseases, Central Virginia VA Health Care System, Richmond, VA, United States
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University School of Medicine, Richmond, VA, United States
| | - Carlos A Gomez
- Department of Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, United States
| | - Joseph Pozdol
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
- Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, CA, United States
| | - Niaz Banaei
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, United States
- Clinical Microbiology Laboratory, Stanford University Medical Center, Palo Alto, CA, United States
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, United States
| |
Collapse
|
23
|
Martin JS, Botta CJ, Bowman S, Giliberti D. Pragmatic Expansion of a Neonatal Antibiotic Stewardship Program in a Community Health Care System. Pediatrics 2024; 153:e2022056356. [PMID: 38093660 DOI: 10.1542/peds.2022-056356] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 01/02/2024] Open
Abstract
BACKGROUND Previously published neonatal antibiotic stewardship efforts have been primarily implemented in single centers. Piedmont Athens Regional began work to decrease antibiotic use in the NICU with spread to the newborn nursery (NBN) and, subsequently, 13 other NICUs and NBNs throughout a health care system over a 4-year period. METHODS This quality improvement initiative was conducted in the context of a multicenter learning collaborative from 2016 to 2019. The primary aim was a 10% reduction in antibiotic days per 1000 patient days (antibiotic utilization rate [AUR]) among newborns in the NICU and NBN at each hospital by December 2018. Change ideas were implemented by using plan-do-study-act cycles. The primary outcome measure was AUR with a balancing measure of antibiotic restarts. RESULTS Piedmont Athens Regional decreased the NICU AUR by 46% and NBN AUR by 83%. Piedmont Healthcare decreased the NICU AUR by 40% and NBN AUR by 74%. Seven of 8 NICUs and 5 of 7 NBNs achieved a >10% reduction in AUR and 8 of 8 intervention hospitals showed a sustained drop in AUR in the NBN, NICU, or both during the 1.5-year postobservation period. Decreases in antibiotic initiation resulted in 335 fewer antibiotic courses in the NICU and 189 fewer infants started on antibiotics in the NBN in 2020 versus 2017. CONCLUSIONS This initiative achieved reductions in AUR across multiple hospitals in the network. The system-wide approach facilitated information technology (IT) and electronic health record modifications. Common drivers of NICU improvement were involvement for at least 2 years, multidisciplinary teams, and the highest baseline AUR. The common driver of nursery improvement was the implementation of a neonatal sepsis risk calculator.
Collapse
Affiliation(s)
- Julie S Martin
- Piedmont Athens Regional, Athens, Georgia
- Augusta University/University of Georgia Medical Partnership, Athens, Georgia
| | - Caleb J Botta
- Augusta University/University of Georgia Medical Partnership, Athens, Georgia
| | - Sarah Bowman
- Augusta University/University of Georgia Medical Partnership, Athens, Georgia
| | | |
Collapse
|
24
|
Alemkere G, Tadeg H, Getahun W, Shewarega W, Agalu A, Joshi MP, Konduri N. Optimizing prophylactic antibiotic use among surgery patients in Ethiopian hospitals. J Infect Public Health 2023; 16 Suppl 1:82-89. [PMID: 37935605 DOI: 10.1016/j.jiph.2023.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Since 2018, the Ethiopian Ministry of Health (MOH) has been working to institutionalize antimicrobial stewardship (AMS) programs across the country. The US Agency for International Development Medicines, Technologies, and Pharmaceutical Services Program supported Ethiopia's multipronged One Health approach to combat AMR. The objective of this paper was to evaluate the effect of a quality improvement intervention to optimize the use of antimicrobials for surgical prophylaxis. METHODS Basic AMS interventions were introduced in five hospitals from January to May 2023. The AMS committees and multidisciplinary teams working at the surgical wards were trained and provided on-site support to implement surgical antibiotic prophylaxis (SAP) interventions. A before-after comparison was made for 206 medical records at baseline and 213 during the intervention phase. Qualitative data were gathered through discussions during experience-sharing workshops to supplement the quantitative results. RESULT There were improvements in the presurgery dose of the prophylactic antibiotic and its timing: the doses within the recommended range increased from 11.2 % to 61.0 % (p < 0.001) and the optimal timing increased from 68 % to 82.6 % (p < 0.001). The hospitals also demonstrated some nonsignificant improvement in the duration of prophylactic antibiotic use (from 35 % to 44.6 % [p = 0.106]), with change in practice hampered by practitioners' resistance to early discontinuation for fear of infection due to perceived weaknesses in infection prevention and control practices. Nonavailability of the recommended antibiotic of choice for surgical prophylaxis was another major challenge in addressing all the elements of SAP. The intervention demonstrated a significant antibiotic-related average cost saving, 51.8 Ethiopian birr (∼1 US dollar) per patient (p = 0.028). CONCLUSION Short-term investments with basic AMS interventions can help to improve SAP use in surgical wards. However, comprehensive success requires complementing AMS interventions with concurrent attention to proper supply chain and infection prevention and control.
Collapse
Affiliation(s)
- Getachew Alemkere
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Addis Ababa, Ethiopia
| | - Hailu Tadeg
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Addis Ababa, Ethiopia
| | - Workineh Getahun
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Addis Ababa, Ethiopia
| | - Wendosen Shewarega
- Pharmaceuticals and Medical Devices Lead Executive Office, Ministry of Health, Addis Ababa, Ethiopia
| | - Asrat Agalu
- Department of Pharmacy, Bahir Dar University, Bahir Dar, Ethiopia
| | - Mohan P Joshi
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Arlington, VA, USA
| | - Niranjan Konduri
- USAID Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program, Management Sciences for Health, Arlington, VA, USA.
| |
Collapse
|
25
|
Claeys KC, Weston LE, Pineles L, Morgan DJ, Krein SL. Implementing diagnostic stewardship to improve diagnosis of urinary tract infections across three medical centers: A qualitative assessment. Infect Control Hosp Epidemiol 2023; 44:1932-1941. [PMID: 37424224 PMCID: PMC10776821 DOI: 10.1017/ice.2023.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
BACKGROUND Urine-culture diagnostic stewardship aims to decrease misdiagnosis of urinary tract infections (UTIs); however, these interventions are not widely adopted. We examined UTI diagnosis and management practices to identify barriers to and facilitators of diagnostic stewardship implementation. METHODS Using a qualitative descriptive design, we conducted semistructured interviews at 3 Veterans' Affairs medical centers. Interviews were conducted between November 2021 and May 2022 via Zoom videoconferencing using an interview guide and visual prototypes of proposed interventions. Interviewees were asked about current practices and thoughts on proposed interventions for urine-culture ordering, processing, and reporting. We used a rapid analysis matrix approach to summarize key interview findings and compare practices and perceptions across sites. RESULTS We interviewed 31 stakeholders and end users. All sites had an antimicrobial stewardship program but limited initiatives targeting appropriate diagnosis and management of UTIs. The majority of those interviewed identified the importance of diagnostic stewardship. Perceptions of specific interventions ranged widely by site. For urine-culture ordering, all 3 sites agreed that documentation of symptomology would improve culturing practices but did not want it to interrupt workflow. Representatives at 2 sites expressed interest in conditional urine-culture processing and 1 was opposed. All sites had similar mechanisms to report culture results but varied in perceptions of the proposed interventions. Feedback from end users was used to develop a general diagnostic stewardship implementation checklist. CONCLUSION Interviewees thought diagnostic stewardship was important. Qualitative assessment involving key stakeholders in the UTI diagnostic process improved understanding of site-specific beliefs and practices to better implement interventions for urine-culture ordering, processing, and reporting.
Collapse
Affiliation(s)
- Kimberly C. Claeys
- department of Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Lauren E. Weston
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Arbor, Michigan
| | - Lisa Pineles
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel J. Morgan
- VA Maryland Healthcare System, Department of Epidemiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sarah L. Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Arbor, Michigan
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| |
Collapse
|
26
|
Silva JT, Montoro J, Pérez-Jacoiste Asín MA, Fernández-Ruiz M, Polanco N, González E, Caro-Teller JM, Andrés A, Aguado JM, López-Medrano F. A joint program of antimicrobial stewardship and hospital-acquired infection control to reduce healthcare-associated infections after kidney transplantation: The Hipomenes study. Am J Transplant 2023; 23:1949-1960. [PMID: 37479034 DOI: 10.1016/j.ajt.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/28/2023] [Accepted: 07/13/2023] [Indexed: 07/23/2023]
Abstract
Infection is a common complication in kidney transplant recipients (KTRs). The usefulness of antimicrobial stewardship programs (ASP) and hospital-acquired infection control (HAIC) initiatives in the general inpatient population is well established. We performed a quasi-experimental study to evaluate a joint ASP/HAIC initiative focused on KTRs. A dedicated ASP team optimized antimicrobial prescriptions in consecutive KTRs during the intervention period (June 2015-March 2016). A multifaceted, evidence-based HAIC program was concurrently implemented. Results were compared with the preceding period (June 2014-March 2015). We included 96 and 100 KTRs in the intervention and preintervention periods, respectively. There was a reduction in the consumption of meropenem (rate ratio [RR]: 0.63; 95% confidence interval [CI]: 0.53-0.75; P <.0001), ceftazidime (RR: 0.31; 95% CI: 0.21-0.45; P <.0001), vancomycin (RR: 0.65; 95% CI: 0.53-0.8; P <.0001), and ciprofloxacin (RR: 0.66; 95% CI: 0.55-0.81; P <.0001) and an increase of fosfomycin (RR: 1.80; 95% CI: 1.17-2.76; P =.008) during the intervention period. The incidence of cystitis (RR: 0.30; 95% CI: 0.28-0.33; P <.001) and upper urinary tract infection (RR: 0.56; 95% CI: 0.33-0.95; P =.04) decreased. A specific ASP/HAIC initiative was effective in optimizing antimicrobial use and reducing the incidence of common bacterial infections among KTRs.
Collapse
Affiliation(s)
- José Tiago Silva
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Antimicrobial Stewardship Team in Hospitalized Patients, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | - Juan Montoro
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | | | - Mario Fernández-Ruiz
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; School of Medicine, Universidad Complutense, Madrid, Spain
| | - Natalia Polanco
- Department of Nephrology, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | - Esther González
- Department of Nephrology, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | - José Manuel Caro-Teller
- Antimicrobial Stewardship Team in Hospitalized Patients, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Department of Pharmacy, University Hospital "12 de Octubre", Madrid, Spain
| | - Amado Andrés
- School of Medicine, Universidad Complutense, Madrid, Spain; Department of Nephrology, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain
| | - José María Aguado
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; School of Medicine, Universidad Complutense, Madrid, Spain
| | - Francisco López-Medrano
- Unit of Infectious Diseases, Instituto de Investigación Hospital "12 de Octubre", University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain; School of Medicine, Universidad Complutense, Madrid, Spain.
| |
Collapse
|
27
|
Hermes VC, Loureiro AP, Assis MP, Balbinot F, Frighetto I, Ziembowicz H, Menezes RM, Carneiro M. Pharmacoeconomic and antimicrobial stewardship analysis in waste management: Beyond switching drug administration route. Am J Infect Control 2023; 51:1334-1338. [PMID: 37295674 DOI: 10.1016/j.ajic.2023.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/02/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of switch therapy of antimicrobials on cost reduction (pharmacoeconomic analysis) and hospital waste generation by switching from intravenous to oral therapy. This is a cross-sectional, observational, and retrospective study. METHODS Data from 2019, 2020, and 2021, provided by the clinical pharmacy service of a teaching hospital in the interior of Rio Grande do Sul, were analyzed. The variables analyzed were intravenous and oral antimicrobials, frequency, duration of use, and total treatment time according to the institutional protocols. An estimate of the amount of waste not generated from the change of administration route was calculated by weighing the kits using a precision balance in grams. RESULTS During the analyzed period, 275 switch therapy of antimicrobials were performed, resulting in US$ 55,256.00 of savings. The main antimicrobial classes that underwent changes were cephalosporins (25.1%), penicillins (22.55%), and quinolones (17.45%). Changing from intravenous to oral therapy avoided the generation of 170,631 g of waste, including needles, syringes, infusion bags, equipment, reconstituted solution bottles, and medication. CONCLUSIONS The change from intravenous to the oral route of antimicrobials is safe for the patient, economically effective, and significantly reduces waste generation.
Collapse
Affiliation(s)
- Vanessa C Hermes
- Núcleo de Gerenciamento de Antimicrobianos - Hospital Santa Cruz, Brasil
| | - Adália P Loureiro
- Núcleo de Gerenciamento de Antimicrobianos - Hospital Santa Cruz, Brasil
| | - Mariana P Assis
- Núcleo de Gerenciamento de Antimicrobianos - Hospital Santa Cruz, Brasil
| | - Fábio Balbinot
- Department Ciência da Vida - Universidade de Santa Cruz, Brasil
| | | | | | - Rochele M Menezes
- Núcleo de Gerenciamento de Antimicrobianos - Hospital Santa Cruz, Brasil
| | - Marcelo Carneiro
- Núcleo de Gerenciamento de Antimicrobianos - Hospital Santa Cruz, Brasil.
| |
Collapse
|
28
|
Ausman SE, Mara KC, Brown CS, Epps KL, Kooda K, Mendez J, Rivera CG. CLinician and patient characteristics effect on Antimicrobial Stewardship Interventions (CLASI) study. Infect Control Hosp Epidemiol 2023; 44:2002-2008. [PMID: 37222155 DOI: 10.1017/ice.2023.93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE To determine whether the gender of clinicians making antimicrobial stewardship recommendations has an impact on intervention acceptance rate. DESIGN A retrospective, multivariable analysis of antimicrobial stewardship prospective audit and feedback outcomes. SETTING A multisite healthcare system including Mayo Clinic Rochester (MN), Mayo Clinic Arizona, Mayo Clinic Florida and 17 health-system hospital sites, where prospective audit and feedback is performed and documented within an electronic tool embedded in the medical record. PARTICIPANTS The study included 143 Mayo Clinic clinicians (84 cisfemales and 59 cismales). METHODS Outcomes were analyzed from July 1, 2017, to June 30, 2022, for intervention rates, communication methods, and intervention acceptance by clinician gender, profession, patient age, and intensive care unit (ICU) status of patient. RESULTS Of 81,927 rules, 71,729 rules met study inclusion. There were 18,175 (25%) rules associated with an intervention. Most of the rules were reviewed by pharmacists (86.2%) and stewardship staff (85.5%). Of 10,363 interventions with an outcome documented, 8,829 (85.2%) were accepted and 1,534 (14.8%) were rejected. Female clinicians had 6,782 (86.5%) of 7,843 interventions accepted, and male clinicians had 2,047 (81.2%) of 2,520 interventions accepted (P = .19). Female patients had more interventions than male patients (female vs male: 25.9% vs 24.9%; OR, 1.04; 95% CI, 1.02-1.08; P = .001). Patients in the ICU had a significantly lower intervention acceptance rate (ICU vs non-ICU: 78.2% vs 86.7%; OR, 0.56; 95% CI, 0.45-0.7; P < .001). CONCLUSIONS Female and male clinicians were equally effective at prospective audit and feedback in a multisite antimicrobial stewardship program. Patients in the ICU were less likely to have stewardship interventions accepted.
Collapse
Affiliation(s)
- Sara E Ausman
- Department of Pharmacy, Mayo Clinic Health System, Eau Claire, Wisconsin
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin L Epps
- Department of Pharmacy, Mayo Clinic, Jacksonville, Florida
| | - Kirstin Kooda
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Julio Mendez
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, Florida
| | | |
Collapse
|
29
|
Nelson GE, Narayanan N, Onguti S, Stanley K, Newland JG, Doernberg SB. Principles and Practice of Antimicrobial Stewardship Program Resource Allocation. Infect Dis Clin North Am 2023; 37:683-714. [PMID: 37735012 DOI: 10.1016/j.idc.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Antimicrobial Stewardship Programs (ASP) improve individual patient outcomes and clinical care processes while reducing antimicrobial-associated adverse events, optimizing operational priorities, and providing institutional cost savings. ASP composition, resources required, and priority focuses are influenced by myriad factors. Despite robust evidence and broad national support, individual ASPs still face challenges in obtaining appropriate resources. Though understanding the current landscape of ASP resource allocation, factors influencing staffing needs, and strategies required to obtain desired resources is important, acceptance of recommended staffing levels and appropriate ASP resource allocation are much needed to facilitate ASP sustainability and growth across the complex and diverse health care continuum.
Collapse
Affiliation(s)
- George E Nelson
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, 1161 21st Avenue South, A2200 MCN, Nashville, TN 37232-2582, USA.
| | - Navaneeth Narayanan
- Department of Pharmacy Practice and Administration, Rutgers University Ernest Mario School of Pharmacy, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Sharon Onguti
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, 1161 21st Avenue South, A2200 MCN, Nashville, TN 37232-2582, USA
| | - Kim Stanley
- Department of Quality and Patient Safety, Division of Hospital Epidemiology and Infection Prevention, University of San Francisco, California, San Francisco, CA, USA
| | - Jason G Newland
- Department of Pediatrics, Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Sarah B Doernberg
- Department of Medicine, Division of Infectious Diseases, University of San Francisco, California, 513 Parnassus Avenue, Box 0654, San Francisco, CA 94143, USA
| |
Collapse
|
30
|
Bloomfield M, Todd S, van der Werff K, Blackmore T, Balm M. Post-report antibiotic initiation following community non-sterile-site microbiology results: an opportunity for labs to lead stewardship? J Antimicrob Chemother 2023; 78:2715-2722. [PMID: 37712940 DOI: 10.1093/jac/dkad288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVES Positive culture results from non-sterile sites (NSSs) are poorly predictive of clinical infection. Despite this, these results are often interpreted as an indication for antibiotics, even in patients with limited signs of infection. We sought to quantify the influence of NSS culture results on post-report antibiotic initiation (PRAI) in patients who had not been started on antibiotics pre-report. METHODS All community wound/skin swab and sputum cultures were matched to antibiotic dispensing records from February 2017 to July 2022. Prescribing behaviour was assessed pre- and post-report. Sampling without treatment pre-report was termed 'test-and-wait' (TaW). Following TaW, PRAI was identified if antibiotics were started within 5 days post-report. RESULTS There were 65 480 wound/skin swabs and 8126 sputum samples, with TaW occurring in 21 740 (35.1%) and 4185 (54.4%), respectively. Following a TaW approach PRAI occurred in 43.3% when an organism was reported, versus 10.8% (P < 0.01) for a 'no growth' report for wound/skin swabs. For the same comparison with sputum, PRAI occurred in 47.9% versus 10.8% (P < 0.01). On multivariate analysis reporting an organism remained strongly associated with PRAI. CONCLUSIONS Reporting an organism in those not already on antibiotics was strongly associated with PRAI. We hypothesize that for many patients TaW suggests limited evidence of infection (i.e. insufficient to justify antibiotic treatment at time of sampling), meaning positive NSS results may be driving a considerable volume of potentially unnecessary antibiotic use. Further study on this topic is required, but strategies to reduce PRAI may offer laboratories an opportunity to meaningfully impact antimicrobial stewardship efforts.
Collapse
Affiliation(s)
- Max Bloomfield
- Department of Microbiology, Wellington Southern Community Laboratories, Wellington, New Zealand
- Department of Infection Services, Wellington Regional Hospital, Wellington, New Zealand
- Antimicrobial Stewardship Committee, Te Whatu Ora-Capital, Coast and Hutt Valley, Wellington, New Zealand
| | - Sue Todd
- Antimicrobial Stewardship Committee, Te Whatu Ora-Capital, Coast and Hutt Valley, Wellington, New Zealand
- Ora Toa Cannons Creek General Practice, Porirua, New Zealand
| | - Koen van der Werff
- Department of Microbiology, Wellington Southern Community Laboratories, Wellington, New Zealand
| | - Tim Blackmore
- Department of Microbiology, Wellington Southern Community Laboratories, Wellington, New Zealand
- Department of Infection Services, Wellington Regional Hospital, Wellington, New Zealand
| | - Michelle Balm
- Department of Microbiology, Wellington Southern Community Laboratories, Wellington, New Zealand
- Department of Infection Services, Wellington Regional Hospital, Wellington, New Zealand
- Antimicrobial Stewardship Committee, Te Whatu Ora-Capital, Coast and Hutt Valley, Wellington, New Zealand
| |
Collapse
|
31
|
Asai Y, Konishi T, Yamamoto T, Chikazawa K, Nakano M, Kinoshita E, Yamada K, Ibata H. Impact of antimicrobial stewardship program-driven educational intervention for vancomycin loading dose on mortality. J Infect Chemother 2023; 29:1023-1032. [PMID: 37451618 DOI: 10.1016/j.jiac.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/21/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Although the loading dose (LD) of vancomycin (VCM) contributes to its efficacy, it may not be conducted adequately. Herein, the objective was to evaluate the effect of LD on patient prognosis using therapeutic drug monitoring by pharmacists and elucidate the impact of an antimicrobial stewardship program (ASP)-driven educational intervention on the LD implementation rate and patient prognosis. MATERIALS AND METHODS First, a retrospective cohort study was conducted involving 121 adult patients administered with VCM and compared with 28-day mortality in LD and non-LD groups. To avoid confounding, the propensity score method was employed. Second, post-training with ASP-driven lectures, a questionnaire survey was conducted for healthcare workers, including physicians, nurses, and pharmacists. The rates of VCM LD implementation and 28-day mortality were compared during a period of one year and 9 months between the pre-ASP (n = 38) and post-ASP (n = 33) groups. RESULTS After propensity score matching, the 28-day mortality in the LD group was significantly improved, suggesting that the early increase in blood levels of VCM due to an LD is an important factor influencing patient prognosis. After the lecture, a questionnaire survey revealed that the understanding rates of "well" and "slightly well" for educational lectures exceeded 80% of all healthcare workers. The rate of LD implementation significantly increased to 63.6% (21/33) in the post-ASP group compared with 31.6% (12/38) in the pre-ASP group (p = 0.007), and the 28-day mortality declined from 23.7% (9/38) to 6.1% (2/33) (p = 0.041). CONCLUSION This method of ASP-driven educational intervention would facilitate LD implementation, improving patient prognosis.
Collapse
Affiliation(s)
- Yuki Asai
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojin, Tsu, Mie, 514-1101, Japan.
| | - Tomomi Konishi
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojin, Tsu, Mie, 514-1101, Japan
| | - Takanori Yamamoto
- Pharmacy, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojin, Tsu, Mie, 514-1101, Japan
| | - Kaori Chikazawa
- Nursing Department, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojin, Tsu, Mie, 514-1101, Japan
| | - Manabu Nakano
- Department of Clinical Laboratory, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojin, Tsu, Mie, 514-1101, Japan
| | - Eri Kinoshita
- Department of Clinical Laboratory, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojin, Tsu, Mie, 514-1101, Japan
| | - Kenichi Yamada
- Department of Clinical Laboratory, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojin, Tsu, Mie, 514-1101, Japan
| | - Hidenori Ibata
- Department of Pulmonary Medicine, National Hospital Organization Mie Chuo Medical Center, 2158-5 Hisaimyojin, Tsu, Mie, 514-1101, Japan
| |
Collapse
|
32
|
Park SY, Kim YC, Moon SM, Kim B, Lee R, Kim HB. Developing a framework for regular and sustainable qualitative assessment of antibiotic use in Korean medical institutions: a Delphi study. Antimicrob Resist Infect Control 2023; 12:114. [PMID: 37853455 PMCID: PMC10585816 DOI: 10.1186/s13756-023-01319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND We aimed to develop a roadmap for conducting regular, sustainable, and strategic qualitative assessments of antibiotic use in medical institutions within the Republic of Korea. METHODS A literature review on the current state of qualitative antibiotic assessments was conducted, followed by one open round to collect ideas, two scoring rounds to establish consensus, and one panel meeting between them. The expert panel comprised 20 experts in infectious disease or antibiotic stewardship. RESULTS The response rate for all three surveys was 95% (19/20), while the panel meeting attendance rate was 90% (18/20). The following long-term goals were defined to assess the annual use of antibacterial and antifungal agents in all medical institutions, including clinics. The panel agreed that random sampling of antibiotic prescriptions was the most suitable method of selecting antibiotics for qualitative assessment, with the additional possibility of evaluating specific antibiotics or infectious diseases that warrant closer evaluation for promoting appropriate antibiotic use. The plan for utilization of results from evaluation involves providing feedback while maintaining anonymity and disclosure. It includes a quantitative assessment of antibiotic prescriptions and resistance rates to compare against institutional benchmarks. Furthermore, it was agreed to link the evaluation findings to the national antibiotic stewardship programme, enabling policy and institutional approaches to address frequently misused items, identified during the evaluation. CONCLUSION This study provides a framework for establishing a qualitative assessment of antimicrobial use for medical institutions at a national level in the Republic of Korea.
Collapse
Affiliation(s)
- Se Yoon Park
- Department of Internal Medicine, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seondong-gu, Seoul, 04763, Republic of Korea
| | - Yong Chan Kim
- Division of Infectious Diseases, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin, Republic of Korea
| | - Song Mi Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, 13620, Republic of Korea.
| | - Bongyoung Kim
- Department of Internal Medicine, Hanyang University College of Medicine, 222-1, Wangsimni-ro, Seondong-gu, Seoul, 04763, Republic of Korea.
| | - Raeseok Lee
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, 13620, Republic of Korea
| |
Collapse
|
33
|
Catho G. [Computerized support to improve antimicrobial prescribing: myth or reality?]. Rev Med Suisse 2023; 19:1846-1850. [PMID: 37819182 DOI: 10.53738/revmed.2023.19.845.1846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Antimicrobial stewardship programmes aim to improve antimicrobial prescribing with the final aim to improve patient care, while limiting the emergence and spread of resistant bacteria. Two main categories of digital tools are currently available in this area: stand-alone mobile applications and tools directly integrated into electronic health records. The former are easy to implement and less costly, but offer limited support as they do not take into account individual patient data. Their impact depends on the clinician's willingness to use them regularly. Integrated systems are based on more sophisticated, individualised algorithms and offer the possibility of intervening with a variety of techniques (restriction, reassessment, feedback, alerts), sometimes before the prescription occurs. They are costly and complex to implement and require an appropriate IT infrastructure. Both systems, as in other areas of digital medicine, have a low level of evidence regarding their clinical impact. In this review we examine the two types of tools, the benefits and challenges associated with each, and the available data on effectiveness.
Collapse
Affiliation(s)
- Gaud Catho
- Service des maladies infectieuses, Hôpital du Valais, 1951 Sion
- Service de prévention et contrôle de l'infection, Hôpitaux universitaires de Genève, 1211 Genève 14
| |
Collapse
|
34
|
Sharma P, Singh M, Chauhan K, Robinson M, Patil N, Singh P, Mehta Y, Trehan N. The feasibility of using of a comprehensive unit-based safety program (CUSP) for improving antimicrobial stewardship at a tertiary care hospital in national capital region of India: A prospective quasi experimental study. Indian J Med Microbiol 2023; 45:100385. [PMID: 37573053 DOI: 10.1016/j.ijmmb.2023.100385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 08/14/2023]
Abstract
PURPOSE To examine the feasibility of Comprehensive Unit-based Safety Program (CUSP) as a strategy tool to improve antibiotic stewardship in low and middle income countries (LMIC) in resource limited setting. The primary outcome measure is identification of inappropriate prescriptions. The secondary outcome parameters are App adoption trends and antimicrobial prescription pattern and practices. MATERIAL AND METHODS A prospective quasi-experimental design was used to operationalizing the CUSP intervention. The project considered the data of 482 patients from two mixed Medical ICUs admitted during June 2019 to April 2020. The information was collected on antimicrobials prescription pattern and practices for identification of inappropriate use as well as app adoption trend with respect to Electronic Medical Record (EMR) Orders Placed, Clinical Notes and Checklist Filled. The intervention in the study comprised of development of an antibiotic monitoring stewardship (AMS) data collection app for ease of use and for Clinical Decision Support System (CDSS) to identify the cases of inappropriate use of antibiotics. RESULTS Data of patients was reviewed to create algorithms for empirical and directed antibiotic therapy as well as to create a CDSS app. Out of 793 prescriptions initially during July-September 2019, 19 (2.4%) were inappropriate antimicrobial prescription. The continuous monitoring of antimicrobial prescription helped in reducing the irrational use and bring it to level zero at the end. CONCLUSION It requires commitment from the management, and seamless communication within Clinical, Microbiology, Pharmacology and data management teams to create and run a successful CUSP program towards Antimicrobial Resistance. Tools such as the CDSS can smoothen the process.
Collapse
Affiliation(s)
- Pooja Sharma
- Research & Clinical Studies, Medanta Institute of Education and Research (MIER), Gurgaon, Haryana, India.
| | - Manish Singh
- Research & Clinical Studies, Medanta Institute of Education and Research (MIER), Gurgaon, Haryana, India.
| | - Kuldeep Chauhan
- Research & Clinical Studies, Medanta Institute of Education and Research (MIER), Gurgaon, Haryana, India.
| | - Matt Robinson
- Division of Infectious Disease, John Hopkins University, School of Medicine, Baltimore, India.
| | - Nipun Patil
- Clinical Pharmacy, Medanta the Medicity, Gurgaon, Haryana, India.
| | - Padam Singh
- Research & Clinical Studies, Medanta Institute of Education and Research (MIER), Gurgaon, Haryana, India.
| | - Yatin Mehta
- Institute of Critical Care & Anesthesia, The Medicity, Gurgaon, Haryana, India.
| | - Naresh Trehan
- The American Board of Cardiothoracic, The Medicity, Gurgaon, Haryana, India.
| |
Collapse
|
35
|
Hawkins R, Michael P, Byrne-Davis L, Bull E, Skone-James R, Hart J. The behaviours identified and the behaviour change techniques planned in health partnerships for antimicrobial stewardship. Appl Psychol Health Well Being 2023; 15:983-998. [PMID: 36433921 DOI: 10.1111/aphw.12421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/14/2022] [Indexed: 11/27/2022]
Abstract
Antimicrobial stewardship (AMS) interventions promote optimised use of antimicrobials by healthcare professionals. In 2019-2020, the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) supported 12 global health partnerships in low- and middle-income countries to co-develop education and training interventions to improve AMS practices amongst hospital staff. This study aimed to describe six of the CwPAMS health partnerships' target behaviours and behaviour change techniques (BCTs) within their planned AMS interventions. Content analysis extracted behaviours and BCTs from partnership materials. Techniques used by partnerships with (n = 2) and without (n = 4) an embedded behavioural scientist were compared, to understand their added value. Nineteen AMS related behaviours for hospital staff were targeted; most commonly hand hygiene and antibiotic prescribing behaviours. Twenty-three BCTs were coded, with instructing participants on how to perform the behaviours the most prominent across all, including partnerships with a behavioural scientist. Intervention materials did not always report the context of the intervention being delivered, including who was delivering it and the target. Behaviours for change were also often not specified. Partnerships varied in reporting their content and specific behaviours, impacting replicability of their interventions, and limiting knowledge exchange. An AMS behaviour change intervention resource is recommended to support clear specification of prospective AMS interventions.
Collapse
Affiliation(s)
- Rachel Hawkins
- Faculty of Biology, Medicine and Health, Manchester, The University of Manchester, Manchester, UK
| | - Panayiotis Michael
- Faculty of Biology, Medicine and Health, Manchester, The University of Manchester, Manchester, UK
| | - Lucie Byrne-Davis
- Faculty of Biology, Medicine and Health, Manchester, The University of Manchester, Manchester, UK
| | - Eleanor Bull
- Faculty of Biology, Medicine and Health, Manchester, The University of Manchester, Manchester, UK
| | | | - Jo Hart
- Faculty of Biology, Medicine and Health, Manchester, The University of Manchester, Manchester, UK
| |
Collapse
|
36
|
Essmann L, Wirz Y, Gregoriano C, Schuetz P. One biomarker does not fit all: tailoring anti-infective therapy through utilization of procalcitonin and other specific biomarkers. Expert Rev Mol Diagn 2023; 23:739-752. [PMID: 37505928 DOI: 10.1080/14737159.2023.2242782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/05/2023] [Accepted: 07/27/2023] [Indexed: 07/30/2023]
Abstract
INTRODUCTION Considering the ongoing increase in antibiotic resistance, the importance of judicious use of antibiotics through reduction of exposure is crucial. Adding procalcitonin (PCT) and other biomarkers to pathogen-specific tests may help to further improve antibiotic therapy algorithms and advance antibiotic stewardship programs to achieve these goals. AREAS COVERED In recent years, several trials have investigated the inclusion of biomarkers such as PCT into clinical decision-making algorithms. For adult patients, findings demonstrated improvements in the individualization of antibiotic treatment, particularly for patients with respiratory tract infections and sepsis. While most trials were performed in hospitals with central laboratories, point-of-care testing might further advance the field by providing a cost-effective and rapid diagnostic tool in upcoming years. Furthermore, novel biomarkers including CD-64, presepsin, Pancreatic stone and sTREM-1, have all shown promising results for increased accuracy of sepsis diagnosis. Availability of these markers however is currently still limited and there is insufficient evidence for their routine use in clinical care. EXPERT OPINION In addition to new host-response markers, combining such biomarkers with pathogen-directed diagnostics present a promising strategy to increase algorithm accuracy in differentiating between bacterial and viral infections. Recent advances in microbiologic testing using PCR or nucleic amplification tests may further improve the diagnostic yield and promote more targeted pathogen-specific antibiotic therapy.
Collapse
Affiliation(s)
- Lennart Essmann
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | - Yannick Wirz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Philipp Schuetz
- Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland
| |
Collapse
|
37
|
Hassan SK, Dahmash EZ, Madi T, Tarawneh O, Jomhawi T, Alkhob W, Ghanem R, Halasa Z. Four years after the implementation of antimicrobial stewardship program in Jordan: evaluation of program's core elements. Front Public Health 2023; 11:1078596. [PMID: 37325334 PMCID: PMC10262748 DOI: 10.3389/fpubh.2023.1078596] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 05/09/2023] [Indexed: 06/17/2023] Open
Abstract
Objectives To combat antimicrobial resistance, the World Health Organization (WHO) urged healthcare organizations in Low- and Middle-Income Countries (LMICs) to implement the core elements of the antimicrobial stewardship (AMS) programs. In response, Jordan took action and developed a national antimicrobial resistance action plan (NAP) in 2017 and commenced the AMS program in all healthcare facilities. It is paramount to evaluate the efforts to implement the AMS programs and understand the challenges of implementing a sustainable and effective program, in Low-Middle Income Country (LMIC) contexts. Therefore, the aim of this study was to appraise the compliance of public hospitals in Jordan to the WHO core elements of effective AMS programs after 4 years of commencement. Methods A cross-sectional study in public hospitals in Jordan, using the WHO AMS program core elements for LMICs was carried out. The questionnaire comprised 30 questions that covered the program's six core elements: leadership commitment, accountability and responsibility, AMS actions, education and training, monitoring, and evaluation, and reporting and feedback. A five-point Likert scale was employed for each question. Results A total of 27 public hospitals participated, with a response rate of 84.4%. Adherence to core elements ranged from (53%) in the leadership commitment domain to (72%) for AMS procedure application (actions). Based on the mean score, there was no significant difference between hospitals according to location, size, and specialty. The most neglected core elements that emerged as top priority areas were the provision of financial support, collaboration, access, as well as monitoring and evaluation. Conclusion The current results revealed significant shortcomings in the AMS program in public hospitals despite 4 years of implementation and policy support. Most of the core elements of the AMS program were below average, which requires hospital leadership commitment, and multifaceted collaborative actions from the concerned stakeholders in Jordan.
Collapse
Affiliation(s)
- Samar Khaled Hassan
- Department of Accreditation, Healthcare Accreditation Council, Amman, Jordan
| | - Eman Zmaily Dahmash
- Department of Chemical and Pharmaceutical Sciences, School of Life Sciences, Pharmacy and Chemistry, Kingston University London, Kingston upon Thames, United Kingdom
| | - Thaira Madi
- Department of Accreditation, Healthcare Accreditation Council, Amman, Jordan
| | - Omar Tarawneh
- Department of Consultation, Healthcare Accreditation Council, Amman, Jordan
| | - Tuqa Jomhawi
- Department of Accreditation, Healthcare Accreditation Council, Amman, Jordan
| | - Worood Alkhob
- Department of Accreditation, Healthcare Accreditation Council, Amman, Jordan
| | - Rola Ghanem
- Laboratory Directorate, Ministry of Health, Amman, Jordan
| | - Zina Halasa
- Clinical Pharmacy Directorate, Ministry of Health, Amman, Jordan
| |
Collapse
|
38
|
Janković R, Stojanović M, Božov H, Domi R, Ivančan V, Karišik M, Mojsova Mijovska M, Jakupović Smajić J, Šoštarič M. PROCALCITONIN GUIDED ANTIBIOTIC STEWARDSHIP: A BALKAN EXPERT CONSENSUS STATEMENT. Acta Clin Croat 2023; 62:36-44. [PMID: 38304372 PMCID: PMC10829966 DOI: 10.20471/acc.2023.62.01.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 02/22/2023] [Indexed: 02/03/2024] Open
Abstract
Sepsis as a consequence of infection is a frequent cause of death among critically ill patients. The most common sites of infection are lover respiratory tract, abdominal, urinary tract and catheter-associated blood stream infections. Early empiric, broad-spectrum therapy in those with severe sepsis and/or shock with the aim of reducing mortality may lead to antibiotic overuse, resistance and increased costs. Among numerous serum biomarkers, procalcitonin (PCT) has proved to be one of the most reliable ones in the diagnosis of sepsis. An important means of limiting antibiotic resistance is the antibiotic stewardship program, especially in intensive care units with critically ill patients and prevalence of multiple drug-resistant pathogens. The PCT-guided antibiotic stewardship was first started in Western Europe and Asia-Pacific countries, as well as in the United States. Considering that this method has proven to be effective in reducing antibiotic consumption while improving clinical outcome, a group of experts from the Balkan region decided to make their own recommendations and PCT protocol. When creating this protocol for initiation and duration of antibiotic treatment, they especially reviewed the literature for lower respiratory tract infection and sepsis. In the protocol, they have included the severity of illness, clinical assessment, and PCT levels. Developing a consensus on the clinical algorithm by eminent experts/specialists in various fields of medicine should enable clinicians to use PCT for initiation of antibiotic therapy and monitoring PCT to stop antibiotics earlier. It is crucial that the PCT-guided algorithm becomes an integral part of institutional stewardship program.
Collapse
Affiliation(s)
- Radmilo Janković
- University Clinical Center Niš, Department of Anesthesia and Intensive Therapy, Faculty of Medicine, University of Niš, Niš, Serbia
| | - Milena Stojanović
- University Clinical Center Niš, Department of Anesthesia and Intensive Therapy, Faculty of Medicine, University of Niš, Niš, Serbia
| | - Hristo Božov
- Department of Anesthesiology, Maritime and Intensive Medicine, Naval Hospital, Varna, Bulgaria
| | - Rudin Domi
- University of Medicine, Tirana Faculty of Medicine, Tirana, Albania
| | | | - Marijana Karišik
- Department of Anesthesiology and Intensive Care, Institute for Children’s Disease, Clinical Center of Montenegro, Podgorica, Montenegro
| | - Maja Mojsova Mijovska
- Department of Anesthesia, Resuscitation and Intensive Care (KARIL), Skopje, North Macedonia
| | - Jasmina Jakupović Smajić
- Tuzla University Clinical Center, Tuzla University, Medical Faculty, Tuzla, Bosnia and Herzegovina
| | - Maja Šoštarič
- Ljubljana University Medical Center, University of Ljubljana, Ljubljana, Slovenia
| |
Collapse
|
39
|
Scott J, Trevi L, McNeil H, Ewen T, Mawson P, McDonald D, Filby A, Lall R, Booth K, Boschman G, Melkebeek V, Perkins G, McMullan R, McAuley DF, McCullagh IJ, Walsh T, Rostron A, Shankar-Hari M, Dark P, Simpson AJ, Conway Morris A, Hellyer TP. Role of immunosuppression in an antibiotic stewardship intervention and its association with clinical outcomes and antibiotic use: protocol for an observational study (RISC-sepsis). BMJ Open 2022; 12:e068321. [PMID: 36600326 PMCID: PMC9743405 DOI: 10.1136/bmjopen-2022-068321] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Sepsis is characterised by a dysregulated immune response to infection, with exaggerated pro-inflammatory and anti-inflammatory responses. A predominant immunosuppressive profile affecting both innate and adaptive immune responses is associated with increased hospital-acquired infection and reduced infection-free survival. While hospital-acquired infection leads to additional antibiotic use, the role of the immunosuppressive phenotype in guiding complex decisions, such as those affecting antibiotic stewardship, is uncertain. This study is a mechanistic substudy embedded within a multicentre clinical and cost-effectiveness trial of biomarker-guided antibiotic stewardship. This mechanistic study aims to determine the effect of sepsis-associated immunosuppression on the trial outcome measures. METHODS AND ANALYSIS RISC-sepsis is a prospective, multicentre, exploratory, observational study embedded within the ADAPT-sepsis trial. A subgroup of 180 participants with antibiotics commenced for suspected sepsis, enrolled in the ADAPT-sepsis trial, will be recruited. Blood samples will be collected on alternate days until day 7. At each time point, blood will be collected for flow cytometric analysis into cell preservation tubes. Immunophenotyping will be performed at a central testing hub by flow cytometry. The primary outcome measures are monocyte human leucocyte antigen-DR; neutrophil CD88; programmed cell death-1 on monocytes, neutrophils and T lymphocytes and the percentage of regulatory T cells. Secondary outcome measures will link to trial outcomes from the ADAPT-sepsis trial including antibiotic days; occurrence of hospital-acquired infection and length of ICU-stay and hospital-stay. ETHICS AND DISSEMINATION Ethical approval has been granted (IRAS 209815) and RISC-sepsis is registered with the ISRCTN (86837685). Study results will be disseminated by peer-reviewed publications, presentations at scientific meetings and via patient and public participation groups and social media.
Collapse
Affiliation(s)
- Jonathan Scott
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Loredana Trevi
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hannah McNeil
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Tom Ewen
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Phil Mawson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - David McDonald
- Flow Cytometry Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Filby
- Flow Cytometry Core Facility, Newcastle University, Newcastle upon Tyne, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Katie Booth
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | | | - Gavin Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- Critical Care Department, Birmingham Heartlands Hospital, Birmingham, UK
| | - Ronan McMullan
- Department of Medical Microbiology, Royal Victoria Hospital, Belfast, UK
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Daniel F McAuley
- Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
- Regional Intensive Care Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Iain J McCullagh
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Perioperative Medicine, Freeman Hospital, Newcastle upon Tyne, UK
| | - Timothy Walsh
- Intensive Care Unit, Edinburgh Royal Infirmary, Edinburgh, UK
- The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Anthony Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Integrated Critical Care Unit, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Manu Shankar-Hari
- Intensive Care Unit, Edinburgh Royal Infirmary, Edinburgh, UK
- The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| | - Paul Dark
- Division of Immunology, University of Manchester, Salford, Greater Manchester, UK
- Critical Care Department, Salford Care Organisation, Greater Manchester, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Andrew Conway Morris
- JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge, UK
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
- Division of Immunology, University of Cambridge, Cambridge, UK
| | - Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Department of Critical Care Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, Newcastle upon Tyne, UK
| |
Collapse
|
40
|
Thomas CM, Peterson J, Ahiskali A, Hamid L, Butts J, Czachura J, Alpern JD. Hospital pharmacy acquisition of nonstocked antimicrobials-current processes and areas for improvement. J Am Pharm Assoc (2003) 2022; 62:1848-1854. [PMID: 36068143 PMCID: PMC9637775 DOI: 10.1016/j.japh.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The delivery of prompt and appropriate antimicrobial therapy for life-threatening infections is an important antimicrobial stewardship measure and a priority for hospitals. OBJECTIVES To better understand U.S. hospital pharmacy stocking processes and acquisition of nonstocked antimicrobials and to identify strategies for improving this process. METHODS This mixed-methods study recruited infectious diseases and antimicrobial stewardship pharmacists. Semistructured interviews with pharmacists in Minnesota were conducted via video conferencing software from January 21, 2021, to March 17, 2021. Audio recordings of the interviews guided survey development and were also transcribed, coded, and qualitatively analyzed. Surveys were distributed throughout the United States via an e-mail listserv, and responses were collected between August 5, 2021, and September 15, 2021. RESULTS Ten interviews and 78 surveys were included in the analysis. Formulary and stocking practices varied based on institution. Stocking decisions were most frequently based on the frequency of use, clinical utility, and cost of antimicrobials. Nonstocked antimicrobials were often ordered from the wholesale distributor but, if needed urgently, acquired from another local institution. Antibacterial agents were the most frequently needed nonstocked antimicrobials, especially those targeting multidrug-resistant gram-negative bacteria. When acquiring nonstocked antimicrobials, barriers include process inefficiencies, cost, availability, and safety concerns. Improved information sharing between local institutions may help improve this process. CONCLUSION In this exploratory study, antimicrobial stocking practices varied within U.S. hospitals. Acquisition of nonstocked, urgently needed antimicrobials from neighboring hospitals may be common; however, this process lacks guidance and is often inefficient. Establishing better mechanisms for information sharing may improve this process and should be explored.
Collapse
Affiliation(s)
- Christine M. Thomas
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN
| | | | | | - Lina Hamid
- M Health Fairview, University of Minnesota Medical Center, Minneapolis, MN
| | - Jessica Butts
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Jennifer Czachura
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Jonathan D. Alpern
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN; and Clinical Research Investigator, HealthPartners Institute, Bloomington, MN
| |
Collapse
|
41
|
Gorsline CA, Afghan AK, Stone CA, Phillips EJ, Satyanarayana G. Safety and value of pretransplant antibiotic allergy delabeling in a quaternary transplant center. Transpl Infect Dis 2022; 24:e13885. [PMID: 35765165 PMCID: PMC9588656 DOI: 10.1111/tid.13885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/23/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Self-reported antibiotic allergies, also known as antibiotic allergy labels, are common and may lead to worse patient outcomes. Within immunocompromized patients, antibiotic allergy labels can lead to inappropriate use of antimicrobials and may limit options for prophylactic and therapeutic options in the posttransplant period. While antibiotic allergy delabeling is considered an important aspect of antibiotic stewardship protocols, evidence and awareness of its application in transplant recipients is limited. METHODS We describe our experience with an antibiotic allergy delabeling intervention in the pretransplant evaluation period and its impact on posttransplant antimicrobial utilization. This was a retrospective analysis of patients with an antibiotic allergy label who underwent evaluation for solid organ or stem cell transplantation between 2015 and 2020. Patients included in this analysis were those who completed pretransplant antibiotic allergy delabeling through our Drug Allergy Clinic and were retained in care for 6 months after transplant. RESULTS Twenty-six of 27 patients underwent pretransplant antibiotic allergy delabeling and safely received the delabeled antibiotic posttransplant. There were no reported side effects to the delabeled antibiotic within 6 months posttransplant. Specific examination of sulfonamide (sulfa)-antibiotic delabeling showed cost savings of $254 to $2910 per patient in the posttransplant period compared to the use of alternative antibiotics for prophylaxis protocol. CONCLUSION Antibiotic allergy delabeling prior to transplant is safe, is of high value, and should be considered in the pretransplant evaluation period. More resources are needed for the development of delabeling guidelines and support for broad implementation of pretransplant antibiotic allergy delabeling programs.
Collapse
Affiliation(s)
- Chelsea A Gorsline
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Abaseen K Afghan
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gowri Satyanarayana
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
42
|
Lanckohr C, Bracht H. Antimicrobial stewardship. Curr Opin Crit Care 2022; 28:551-556. [PMID: 35942707 DOI: 10.1097/mcc.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The optimal use of antimicrobials is necessary to slow resistance development and improve patient outcomes. Antimicrobial stewardship (AMS) is a bundle of interventions aimed at promoting the responsible use of antiinfectives. The ICU is an important field of activity for AMS because of high rates of antimicrobial use, high prevalence of resistant pathogens and complex pharmacology. This review discusses aims and interventions of AMS with special emphasis on the ICU. RECENT FINDINGS AMS-interventions can improve the quality and quantity of antimicrobial prescribing in the ICU without compromising patient outcomes. The de-escalation of empiric therapy according to microbiology results and the limitation of treatment duration are important steps to reduce resistance pressure. Owing to the complex nature of critical illness, the pharmacological optimization of antimicrobial therapy is an important goal in the ICU. AMS-objectives and strategies are also applicable to patients with sepsis. This is reflected in the most recent guidelines by the Surviving Sepsis Campaign. AMS-interventions need to be adapted to their respective setting and be mindful of local prescribing cultures and prescribers' attitudes. SUMMARY AMS in the ICU is effective and safe. Intensivists should be actively involved in AMS-programs and propagate responsible use of antimicrobials.
Collapse
Affiliation(s)
- Christian Lanckohr
- Antibiotic Stewardship Team, Institute of Hygiene, University Hospital Münster, Münster
| | - Hendrik Bracht
- Central Emergency Services, University Hospital Ulm, Ulm, Germany
| |
Collapse
|
43
|
Vu HTL, Hamers RL, Limato R, Limmathurotsakul D, Karkey A, Dodds Ashley E, Anderson D, Patel PK, Patel TS, Lessa FC, van Doorn HR. Identifying context-specific domains for assessing antimicrobial stewardship programmes in Asia: protocol for a scoping review. BMJ Open 2022; 12:e061286. [PMID: 36109025 PMCID: PMC9478836 DOI: 10.1136/bmjopen-2022-061286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Antimicrobial stewardship (AMS) is an important strategy to control antimicrobial resistance. Resources are available to provide guidance for design and implementation of AMS programmes, however these may have limited applicability in resource-limited settings including those in Asia. This scoping review aims to identify context-specific domains and items for the development of a healthcare facility (HCF)-level tool to guide AMS implementation in Asia. METHODS AND ANALYSIS This review is the first step in a larger project to assess AMS implementation, needs and gaps in Asia. We will employ a deductive qualitative approach to identify locally appropriate domains and items of AMS implementation guided by Nilsen and Bernhardsson's contextual dimensions. This process is also informed by discussions from a technical advisory group coordinated by the US Centers for Disease Control and Prevention to develop an AMS HCF-level assessment tool for low-income and middle-income countries. We will review English-language documents that discuss HCF-level implementation, including those describing frameworks, components/elements or recommendations for design, implementation or assessment globally and specific to Asia. We have performed the search in August-September 2021 including general electronic databases (MEDLINE, Embase, Web of Science and Google Scholar), region-specific databases, national action plans, grey literature sources and reference lists to identify eligible documents. Country-specific documents will be restricted to countries in three subregions: South Asia, East Asia and Southeast Asia. Codes and themes will be derived through a content analysis, classified following the predefined context dimensions and used for developing domains and items of the assessment tool. ETHICS AND DISSEMINATION Results from this review will feed into our stepwise process for developing a context-specific HCF-level assessment tool for AMS programmes to assess the implementation status, identify intervention opportunities and monitor progress over time. The process will be done in consultation with local stakeholders, the end-users of the generated knowledge.
Collapse
Affiliation(s)
| | - Raph L Hamers
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Ralalicia Limato
- Eijkman-Oxford Clinical Research Unit, Jakarta, Indonesia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Direk Limmathurotsakul
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Abhilasha Karkey
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
- Oxford University Clinical Research Unit - Nepal, Kathmandu, Nepal
| | - Elizabeth Dodds Ashley
- Duke Antimicrobial Stewardship Outreach Network, Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University, Durham, North Carolina, USA
| | - Deverick Anderson
- Duke Antimicrobial Stewardship Outreach Network, Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University, Durham, North Carolina, USA
| | - Payal K Patel
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Twisha S Patel
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Fernanda C Lessa
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - H Rogier van Doorn
- Oxford University Clinical Research Unit, Ha Noi, Viet Nam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| |
Collapse
|
44
|
Yamaguchi R, Yamamoto T, Okamoto K, Tatsuno K, Ikeda M, Tanaka T, Wakabayashi Y, Sato T, Okugawa S, Moriya K, Suzuki H. Prospective audit and feedback implementation by a multidisciplinary antimicrobial stewardship team shortens the time to de-escalation of anti-MRSA agents. PLoS One 2022; 17:e0271812. [PMID: 35905080 PMCID: PMC9337637 DOI: 10.1371/journal.pone.0271812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/07/2022] [Indexed: 11/18/2022] Open
Abstract
Prospective audit and feedback (PAF) is considered an effective procedure for appropriate antibiotic use. However, its effect on the time to de-escalation is unclear. We aimed to evaluate the effect of daily PAF implementation, focusing on the time to de-escalation of anti-methicillin‐resistant Staphylococcus aureus (MRSA) agents as an outcome measure. To this end, a single-center, retrospective, quasi-experimental study including patients treated with intravenous anti-MRSA agents during pre-PAF (April 1, 2014 to March 31, 2015) and post-PAF (April 1, 2015 to March 31, 2016) periods was conducted. The time to de-escalation was estimated using the Kaplan–Meier method, and Cox proportional hazard analysis was performed to assess the effect of daily PAF implementation on the time to de-escalation. Interrupted time series analysis was used to evaluate the relationship between daily PAF implementation and anti-MRSA agent utilization data converted to defined daily dose (DDD) and days of therapy (DOT) per 1,000 patient days. The median time to de-escalation was significantly shorter in the post-PAF period than in the pre-PAF period (6 days vs. 7 days, P < 0.001). According to multivariate analysis, PAF implementation was independently associated with a shorter time to de-escalation (hazard ratio [HR], 1.18; 95% confidence interval [CI], 1.02 to 1.35). There were no significant differences in hospital mortality, 30-day mortality, and length of stay between the two periods. Interrupted time series analysis showed significant reductions in the trends of DDD (trend change, –0.65; 95% CI, –1.20 to –0.11) and DOT (trend change, –0.74; 95% CI, –1.33 to –0.15) between the pre-PAF and post-PAF periods. Daily PAF implementation for patients treated with intravenous anti-MRSA agents led to a shorter time to de-escalation and lower consumption of anti-MRSA agents without worsening the clinically important outcomes.
Collapse
Affiliation(s)
- Ryo Yamaguchi
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
- * E-mail:
| | - Takehito Yamamoto
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
- The Education Center for Clinical Pharmacy, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Koh Okamoto
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Keita Tatsuno
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Mahoko Ikeda
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Takehiro Tanaka
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Tomoaki Sato
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
| | - Shu Okugawa
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Kyoji Moriya
- Department of Infection Control and Prevention, The University of Tokyo Hospital, Tokyo, Japan
- Department of Infectious Diseases, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Suzuki
- Department of Pharmacy, The University of Tokyo Hospital, Tokyo, Japan
| |
Collapse
|
45
|
Nasr ZG, Moustafa DAH, Dahmani S, Wilby KJ. Investigating pharmacy students' therapeutic decision-making with respect to antimicrobial stewardship cases. BMC Med Educ 2022; 22:467. [PMID: 35710400 PMCID: PMC9203133 DOI: 10.1186/s12909-022-03542-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 06/07/2022] [Indexed: 05/13/2023]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) play a big role in minimizing antimicrobial resistance. Pharmacists are essential members of the health care team and in order for them to fulfill roles on ASP teams and become antimicrobial stewards, they must be prepared adequately by pharmacy schools prior to entry into actual practice. Although programming has been implemented into entry-to-practice programs worldwide, little is known about how students interpret antimicrobial stewardship (AMS) data and arrive at clinical decisions. We aimed to explore students' cognitive processes and determine how they formulate therapeutic decisions when presented with AMS cases. METHODS This was a qualitative study conducted using a case study approach, in which a sample (n=20) of pharmacy students was recruited to interpret AMS cases. Semi-structured 1-on-1 interviews were arranged with each participant. A think-aloud procedure with verbal protocol analysis was adopted to determine students' decision-making processes. Thematic analysis was used to interpret themes from the interview data. RESULTS Two themes were interpreted from the data: students' focus and students' approach to case interpretation. Students' focus relates to external factors students consider when interpreting AMS case data and use to make and justify therapeutic decisions including patient-centered factors, drug-related factors, AMS interventions, and pharmacist's role. Students' clinical reasoning describes the approach that students use to interpret the data and the decision-making processes they employ to arrive at a clinical decision including a systematic approach versus non-systematic approach. CONCLUSIONS Students vary in their focus and the cognitive strategies used to interpret AMS cases. Findings support the notion that clinical reasoning and decision-making should be explicitly taught in pharmacy curricula, in order to help students become aware of their own cognitive processes and decision-making abilities.
Collapse
Affiliation(s)
- Ziad G. Nasr
- College of Pharmacy, QU Health, Qatar University, PO Box 2713, Doha, Qatar
| | | | - Sara Dahmani
- College of Pharmacy, QU Health, Qatar University, PO Box 2713, Doha, Qatar
| | - Kyle J. Wilby
- College of Pharmacy, Dalhousie University, Halifax, Canada
| |
Collapse
|
46
|
Seymann GB, Bevins N, Wu C, Fitzgerald R. Prevalence of Discordant Procalcitonin Use at an Academic Medical Center. Am J Clin Pathol 2022; 157:890-898. [PMID: 34894127 PMCID: PMC9171572 DOI: 10.1093/ajcp/aqab201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 10/22/2021] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Despite multiple trials demonstrating that procalcitonin (PCT) is an effective tool for antibiotic stewardship, inconsistent application in real-world settings continues to fuel controversy regarding its clinical utility. We sought to determine rates of concordance between PCT results and antibiotic prescribing in hospitalized patients. METHODS We performed a retrospective review of all inpatient encounters at an academic tertiary care health system with a PCT result between February 2017 and October 2019. Concordant prescribing was defined as starting or continuing antibiotics following an elevated PCT (>0.5 ng/mL) finding and withholding or stopping antibiotics following a low PCT (< 0.1 ng/mL) finding. RESULTS Antibiotic prescribing decisions were discordant from the PCT level in 32.5% of our sample. Among patients not receiving antibiotics at the time of testing, 25.9% (430 of 1,662) were prescribed antibiotics despite a low PCT result. Among patients already receiving antibiotics, treatment was continued despite a low PCT level in 80.4% (728 of 906) of cases. Enhanced decision support tools introduced during the study period had no impact on PCT use for antibiotic decisions. CONCLUSIONS Overall concordance between PCT results and antibiotic use is relatively low in a real-world setting. The potential value of PCT for antibiotic stewardship may not be fully realized.
Collapse
Affiliation(s)
- Gregory B Seymann
- Division of Hospital Medicine, Department of Medicine, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Nicholas Bevins
- Department of Pathology, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Christina Wu
- Department of Medicine, University of California San Diego School of Medicine, San Diego, CA, USA
- Department of Hospital Medicine, Scripps Memorial Hospital, Encinitas, CA, USA
| | - Robert Fitzgerald
- Department of Pathology, University of California San Diego School of Medicine, San Diego, CA, USA
| |
Collapse
|
47
|
Baier RR, Jump RLP, Zhang T, Kabbani S, Gifford DR, Gravenstein S. Feasibility of a Nursing Home Antibiotic Stewardship Intervention. J Am Med Dir Assoc 2022; 23:1025-1030. [PMID: 34506771 PMCID: PMC10951856 DOI: 10.1016/j.jamda.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 08/10/2021] [Accepted: 08/15/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate a bundled electronic intervention to improve antibiotic prescribing practices in US nursing homes. DESIGN Prospective mixed-methods quality improvement intervention. SETTING AND PARTICIPANTS Nursing staff and residents in 13 nursing homes, and residents in 8 matched-control facilities (n = 21 facilities total, from 2 corporations). METHODS This study involved a 2-month design period (n = 5 facilities) focused on the acceptability and feasibility of a bundled electronic intervention consisting of 3 tools, followed by a 15-month implementation period (n = 8 facilities) during which we used rapid-cycle quality improvement methods to refine and add to the bundle. We used mixed-methods data from providers, intervention tools, and health records to assess feasibility and conduct a difference-in-difference analysis among the 8 intervention sites and 8 pair-matched controls. RESULTS Nurses at 5 pilot sites reported that initial versions of the electronic tools were acceptable and feasible, but barriers emerged when 8 different facilities began implementing the tools, prompting iterative revisions to the training and bundle. The final bundle consisted of 3 electronic tools and training that standardized digital documentation to document and track a change in resident condition, infections, antibiotic prescribing, and antibiotic follow-up. By the end of the implementation phase, all 8 facilities were using at least 1 of the 3 tools. Early antibiotic discontinuation increased 10.5% among intervention sites, but decreased 10.8% among control sites. CONCLUSIONS AND IMPLICATIONS The 3 tools in our bundled electronic intervention capture clinical and prescribing data necessary to assess changes in antibiotic use and were feasible for nurses to adopt. Achieving this required modifying the tools and training before the intervention reached its final form. Comparisons of rates of antibiotic use at intervention and control facilities showed promising improvement in antibiotic discontinuation, demonstrating that the intervention could be evaluated using secondary electronic health record data.
Collapse
Affiliation(s)
- Rosa R Baier
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC) at the VA Northeast Ohio Healthcare System, Cleveland, OH, USA; Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Population & Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Tingting Zhang
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - David R Gifford
- American Health Care Association/National Center for Assisted Living, Washington, DC, USA
| | - Stefan Gravenstein
- Center for Long-Term Care Quality & Innovation, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Division of Geriatrics and Palliative Medicine, Alpert Medical School of Brown University, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports (LTSS-COIN), Providence Veterans Affairs Medical Center, Providence, RI, USA.
| |
Collapse
|
48
|
Falconer N, Paterson DL, Peel N, Welch A, Freeman C, Burkett E, Hubbard R, Comans T, Hanjani LS, Pascoe E, Hawley C, Gray L. A multimodal intervention to optimise antimicrobial use in residential aged care facilities (ENGAGEMENT): protocol for a stepped-wedge cluster randomised trial. Trials 2022; 23:427. [PMID: 35597993 PMCID: PMC9123829 DOI: 10.1186/s13063-022-06323-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic use can cause harm and promote antimicrobial resistance, which has been declared a major health challenge by the World Health Organization. In Australian residential aged care facilities (RACFs), the most common indications for antibiotic prescribing are for infections of the urinary tract, respiratory tract and skin and soft tissue. Studies indicate that a high proportion of these prescriptions are non-compliant with best prescribing guidelines. To date, a variety of interventions have been reported to address inappropriate prescribing and overuse of antibiotics but with mixed outcomes. This study aims to identify the impact of a set of sustainable, multimodal interventions in residential aged care targeting three common infection types. METHODS This protocol details a 20-month stepped-wedge cluster-randomised trial conducted across 18 RACFs (as 18 clusters). A multimodal multi-disciplinary set of interventions, the 'AMS ENGAGEMENT bundle', will be tailored to meet the identified needs of participating RACFs. The key elements of the intervention bundle include education for nurses and general practitioners, telehealth support and formation of an antimicrobial stewardship team in each facility. Prior to the randomised sequential introduction of the intervention, each site will act as its own control in relation to usual care processes for antibiotic use and stewardship. The primary outcome for this study will be antibiotic consumption measured using defined daily doses (DDDs). Cluster-level rates will be calculated using total occupied bed numbers within each RACF during the observation period as the denominator. Results will be expressed as rates per 1000 occupied bed days. An economic analysis will be conducted to compare the costs associated with the intervention to that of usual care. A comprehensive process evaluation will be conducted using the REAIM Framework, to enable learnings from the trial to inform sustainable improvements in this field. DISCUSSION A structured AMS model of care, incorporating targeted interventions to optimise antimicrobial use in the RACF setting, is urgently needed and will be delivered by our trial. The trial will aim to empower clinicians, residents and families by providing a robust AMS programme to improve antibiotic-related health outcomes. TRIAL REGISTRATION US National Library of Medicine Clinical Trials.gov ( NCT04705259 ). Prospectively registered in 12th of January 2021.
Collapse
Affiliation(s)
- Nazanin Falconer
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia.
- Department of Pharmacy, Princess Alexandra Hospital, Metro South Health, Brisbane, QLD, 4102, Australia.
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia.
| | - David L Paterson
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital Campus, Brisbane, Australia
- Royal Brisbane and Women's Hospital, Metro North Health, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia
| | - Nancye Peel
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Alyssa Welch
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Christopher Freeman
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Ellen Burkett
- Department of Emergency Medicine, Princess Alexandra Hospital, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Ruth Hubbard
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
- Princess Alexandra Hospital Southside Clinical Unit, Faculty of Medicine, The University of Queensland, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Tracy Comans
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Leila Shafiee Hanjani
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Elaine Pascoe
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| | - Carmel Hawley
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
- Princess Alexandra Hospital Southside Clinical Unit, Faculty of Medicine, The University of Queensland, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Leonard Gray
- UQ Centre for Health Services Research, Faculty of Medicine, The University of Queensland, The University of Queensland, Brisbane, QLD, 4102, Australia
| |
Collapse
|
49
|
Baudet A, Agrinier N, Charmillon A, Pulcini C, Lozniewski A, Aissa N, Lizon J, Thilly N, Demoré B, Florentin A. Evaluating antibiotic stewardship and healthcare-associated infections surveillance assisted by computer: protocol for an interrupted time series study. BMJ Open 2022; 12:e056125. [PMID: 35383069 PMCID: PMC8984051 DOI: 10.1136/bmjopen-2021-056125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Antibiotic resistance is one of the most pressing health threats that mankind faces now and in the coming decades. Antibiotic resistance leads to longer hospital stays, higher medical costs and increased mortality. In order to tackle antibiotic resistance, we will implement in our tertiary care university hospital a computerised-decision support system (CDSS) facilitating antibiotic stewardship and an electronic surveillance software (ESS) facilitating infection prevention and control activities. We describe the protocol to evaluate the impact of the CDSS/ESS combination in adult inpatients. METHODS AND ANALYSIS We conduct a pragmatic, prospective, single-centre, before-after uncontrolled study with an interrupted time-series analysis 12 months before and 12 months after the introduction of the CDSS for antibiotic stewardship (APSS) and ESS for infection surveillance (ZINC). APSS and ZINC will assist, respectively, the antibiotic stewardship and the infection prevention and control teams of Nancy University Hospital (France). We will evaluate the impact of the CDSS/ESS on the antibiotic use in adult (≥18 years) inpatients (hospitalised ≥48 hours). The primary outcome is the prescription rate by all healthcare professionals from the hospital of all systemic antibiotics expressed in defined daily doses/1000 patients/month. Concurrently, we will assess the safety of the intervention, its impact on the appropriateness of antibiotic prescriptions and on additional precautions (isolation precautions) as recommended in guidelines, and on bacterial epidemiology (multidrug-resistant bacteria and Clostridioides difficile infections) in the hospital. Finally, we will evaluate the users' satisfaction and the cost of this intervention from the hospital perspective. ETHICS AND DISSEMINATION The protocol has been approved by the Ethics Committee of Nancy University Hospital and registered on the ClinicalTrials platform. Results will be disseminated through conferences' presentations and publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04976829.
Collapse
Affiliation(s)
- Alexandre Baudet
- APEMAC, Université de Lorraine, Nancy, France
- Service d'odontologie, CHRU de Nancy, Nancy, France
| | - Nelly Agrinier
- APEMAC, Université de Lorraine, Nancy, France
- CIC, Epidémiologie Clinique, CHRU de Nancy, Nancy, France
| | | | - Céline Pulcini
- APEMAC, Université de Lorraine, Nancy, France
- Service des maladies infectieuses, CHRU de Nancy, Nancy, France
| | - Alain Lozniewski
- Service de microbiologie, CHRU de Nancy, Nancy, France
- Stress Immunity Pathogens unit (SIMPA) EA 7300, Université de Lorraine, Nancy, France
| | - Nejla Aissa
- Service de microbiologie, CHRU de Nancy, Nancy, France
| | - Julie Lizon
- Département territorial d'hygiène et prévention du risque infectieux, CHRU de Nancy, Nancy, France
| | - Nathalie Thilly
- APEMAC, Université de Lorraine, Nancy, France
- Département Méthodologie, Promotion, Investigation, CHRU de Nancy, Nancy, France
| | - Béatrice Demoré
- APEMAC, Université de Lorraine, Nancy, France
- Pharmacie, CHRU de Nancy, Nancy, France
| | - Arnaud Florentin
- APEMAC, Université de Lorraine, Nancy, France
- Département territorial d'hygiène et prévention du risque infectieux, CHRU de Nancy, Nancy, France
| |
Collapse
|
50
|
El Masri M, Haddad N, Saad T, Rizk NA, Zakhour R, Kanj SS, Zeenny RM. Evaluation of Carbapenem Use Before and After Implementation of an Antimicrobial Stewardship-Led Carbapenem-Sparing Strategy in a Lebanese Tertiary Hospital: A Retrospective Study. Front Cell Infect Microbiol 2022; 12:729491. [PMID: 35402313 PMCID: PMC8990088 DOI: 10.3389/fcimb.2022.729491] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 01/13/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose The use of carbapenem before and after implementation of an antimicrobial stewardship-led carbapenem-sparing strategy at a tertiary care center in Lebanon was evaluated. Methods A retrospective, observational chart review was performed on all hospitalized pediatric and adult patients who received carbapenem therapy during January 2019 and January 2020. Patients who started their regimen before January or received carbapenems for less than 24 hours were excluded. Primary outcomes included the appropriateness of physician prescribing patterns and pharmacists’ interventions, as well as appropriateness and response rates of the latter. Secondary outcomes included the carbapenem defined daily dose (DDD) and days of therapy (DOT). Descriptive statistics were used in the analysis and a p-value < 0.05 was considered to be statistically significant. Results A total of 157 and 150 patients charts were reviewed in January 2019 and January 2020, respectively. There was no difference in baseline characteristics except for inpatient services and rates of isolated multidrug-resistant organisms. When comparing the two timelines, the appropriateness of physicians’ prescribing patterns increased in terms of empirical therapy, targeted therapy, and duration of therapy but the results were not statistically significant. Pharmacists’ interventions significantly increased with regards to the duration of therapy (p= <0.001), dose adjustment (p<0.001), de-escalation to a narrower spectrum antibiotic (p=0.007), and use of extended infusion (p=0.042). The DDD and DOT were higher for ertapenem and lower for anti-pseudomonal carbapenems in January 2020. Conclusion The carbapenem-sparing strategy adopted by the antimicrobial stewardship program contributed to an increase in the number of interventions made by pharmacists on carbapenem therapy, including their appropriateness, and response rate. Despite an improvement in the physician-prescribing patterns, more awareness and education may be needed to achieve a better impact.
Collapse
Affiliation(s)
- Mira El Masri
- Department of Pharmacy, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nisrine Haddad
- Department of Pharmacy, American University of Beirut Medical Center, Beirut, Lebanon
| | - Therese Saad
- Department of Pharmacy, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nesrine A. Rizk
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ramia Zakhour
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Souha S. Kanj
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rony M. Zeenny
- Department of Pharmacy, American University of Beirut Medical Center, Beirut, Lebanon
- *Correspondence: Rony M. Zeenny,
| |
Collapse
|