The Implementation of a Unit-Based Antimicrobial Stewardship Program Using a Consultative Approach to Improve Antibiotic Prescribing Practices

ABSTRACT Introduction As antimicrobial resistance continues to increase and new antimicrobial development stagnates, antimicrobial stewardship programs are being implemented worldwide. The goal of antimicrobial stewardship is to optimize antimicrobial therapy with maximal impact on subsequent development of resistance. Thirty to fifty percent of hospitalized patients receive antimicrobial therapy. Previous data suggest that inappropriate use results in higher mortality rates, longer lengths of stay, and increased medical costs. Antimicrobial stewardship programs (ASPs) reduce the improper use of antimicrobials and improve patient safety. Despite increased awareness about the benefits of these programs, few medical and surgical ASPs exist and fewer comprehensive studies evaluate their effects. Aim To study the antimicrobial stewardship program in a large tertiary care teaching center. Objectives • To study the antibiotic prescribing practices in a tertiary care government hospital • To compare the antibiotic prescribing practices with the standard guidelines available with the hospital • To make recommendation if any for rational use of antibiotics. Materials and methods • Review of literature • Prospective study of 15 days in selected general medicine and general surgery ward in which 5 to 6 reading will be taken in to know the antibiotic prescribed to patients. • Retrospective study of 15 days for study of patient records to know the antibiotic prescribed to patients. • Interaction with faculty and senior residents of general medicine and surgery to know about the pattern of infection and antibiotic prescription. • Interaction with microbiology department and their faculty to know the microbial resistance pattern and possible suggestion which need to be incorporated in antibiotic Stewardship program. Results The present study on antibiotic prescribing practices was undertaken in a super specialty hospital at New Delhi. A sample size of 100 case records was considered. There is no such stewardship program in tertiary care hospital, although it was demanded in various forum and meetings. There are no recommendations available either for patients of renal failure or other such compromised metabolic or immune states in the form of written antibiotic stewardship program of the hospital. The appropriateness of antibiotics prescribed in the case records was examined in light of the antibiotic stewardship program of the hospital. It was found that the overall adherence to antibiotic stewardship program was nil as no existing antibiotic stewardship program is exiting in this hospital. Gautum Dey in a study conducted at this hospital in New Delhi found that in 40.7% preoperative cases and 60.3% postoperative cases two or more than two antibiotics were given. The author has also commented that there was no evidence of adhering to antibiotic stewardship program or utilising culture and sensitivity reports to guide the therapy. The data obtained from the present study on further analysis has shown that in seven cases, the antibiotics prescribed were inadequate in terms of dose and duration. Thus resulting in an apparently lower cost of treatment than what was recommended by the antibiotic stewardship program of the hospital. Although such inappropriate prescription results in increased chances of antibiotic resistance, the immediate or short-term effects are not very conclusive. It is observed that there were 26 (26%) cases in medical and 12 (12%) cases in surgery disciplines in which the initial and final diagnosis was different. Uncertainty about the final diagnosis promotes empirical prescribing practices. Conclusion Antimicrobial stewards are a prominent part of local and national efforts to contain and reverse antimicrobial resistance. A range of intervention options is available with varying levels of resources and can yield substantial improvements in morbidity, mortality, quality of care, and cost. The cost of delivering such programs is dwarfed by the benefits and provides an opportunity for hospital epidemiologists to garner support. This suggests that antimicrobial management programs belong to the rarefied group of truly cost saving quality improvement initiatives. Considering the enormous implications of antibiotic resistance, it is necessary that we act in haste, lest our wonder drugs and magic bullets become ineffectual. Future systems promise greater integration and analysis of data, facilitated delivery of information to the clinician, and rapid and expert decision support that will optimize patient outcomes while minimizing antimicrobial resistance. They may also offer our best hope for avoiding an ‘Antibiotic armageddon’. In addition, the ASP plays an integral role in providing guidance to clinicians and ensures that the appropriate antimicrobial agents are used. How to cite this article Singh MM, Gupta SK, Gupta YK, Sharma DK, Kapil A. To Study the Antimicrobial Stewardship Program in a Large Tertiary Care Teaching Center. Int J Res Foundation Hosp Healthc Adm 2015;3(1):13-24.

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142. Implementing an Antimicrobial Stewardship Program in the Outpatient Setting

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.187 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S82-S82

Author(s):

Travis B Nielsen ◽

Maressa Santarossa ◽

Beatrice D Probst ◽

Laurie Labuszewski ◽

Jenna Lopez ◽

...

Keyword(s):

Primary Care ◽

Antimicrobial Stewardship ◽

Inappropriate Prescribing ◽

The United States ◽

Outpatient Setting ◽

Urgent Care ◽

Antibiotic Prescribing ◽

Antimicrobial Stewardship Program ◽

Post Intervention ◽

Stewardship Program

Abstract Background Antimicrobial-resistant infections lead to increased morbidity, mortality, and healthcare costs. Among the most facile modifiable risk factors for developing resistance is inappropriate prescribing. The CDC estimates that 47 million (or ≥30% of) outpatient antibiotic prescriptions in the United States are unnecessary. This has provided impetus for expanding our antimicrobial stewardship program (ASP) into the outpatient setting. Initial goals included the following: continuous evaluation and reporting of antibiotic prescribing compliance; minimize underuse of antibiotics from delayed diagnoses and misdiagnoses; ensure proper drug, dose, and duration; improve the percentage of appropriate prescriptions. Methods To achieve these goals, we first sent a baseline survey to outpatient prescribers, assessing their understanding of stewardship and antimicrobial resistance. Questions were modeled from the Illinois Department of Public Health (IDPH) Precious Drugs & Scary Bugs Campaign. The survey was sent to prescribers at 19 primary care and three immediate/urgent care clinics. Compliance rates for prescribing habits were subsequently tracked via electronic health records and reported to prescribers in accordance with IRB approval. Results Prescribers were highly knowledgeable about what constitutes appropriate prescribing, with verified compliance rates highly concordant with self-reported rates. However, 74% of respondents reported intense pressure from patients to inappropriately prescribe antimicrobials. Compliance rates have been tracked since December 2018 and comparing pre- with post-intervention rates shows improvement in primary care since reporting rates to prescribers in August 2019. Conclusion Reporting compliance rates has been helpful in avoiding inappropriate antimicrobial therapy. However, the survey data reinforce the importance of behavioral interventions to bolster ASP efficacy in the outpatient setting. Going forward, posters modeled off of the IDPH template will be conspicuously exhibited in exam rooms, indicating institutional commitment to the enumerated ASP guidelines. Future studies will allow for comparison of pre- and post-intervention knowledge and prescriber compliance. Disclosures All Authors: No reported disclosures

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Outcomes of an ambulatory care pharmacist-led antimicrobial stewardship program within a family medicine resident clinic

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1275 ◽

2020 ◽

pp. 1-7

Author(s):

Lindsey R. Westerhof ◽

Lisa E. Dumkow ◽

Tarajo L. Hanrahan ◽

Samantha V. McPharlin ◽

Nnaemeka E. Egwuatu

Keyword(s):

Family Medicine ◽

Ambulatory Care ◽

Antimicrobial Stewardship ◽

Antibiotic Prescribing ◽

Antimicrobial Stewardship Program ◽

Upper Respiratory Tract ◽

Family Medicine Residency ◽

Medicine Resident ◽

Stewardship Program ◽

Tract Infections

Abstract Objective: To determine whether an ambulatory care pharmacist (AMCP)-led intervention improved outpatient antibiotic prescribing in a family medicine residency clinic (FMRC) for upper respiratory tract infections (URIs), urinary tract infections (UTIs), and skin and soft-tissue infections (SSTIs). Design: Retrospective, quasi-experimental study comparing guideline-concordant antibiotic prescribing before and after an antimicrobial stewardship program (ASP) intervention. Setting: Family medicine residency clinic affiliated with a community teaching hospital. Participants: Adult and pediatric patients prescribed antibiotics for URI, UTI, or SSTI between November 1, 2017, and April 31, 2018 (pre-ASP group), or October 1, 2018, and March 31, 2019 (ASP group), were eligible for inclusion. Methods: The health-system ASP physician and pharmacist provided live education and pocket cards to FMRC staff with local guidelines as a quick reference. Audit with feedback was delivered every other week by the clinic’s AMCP. Guideline-concordance was determined based on the institution’s outpatient ASP guidelines. Results: Overall, 525 antibiotic prescriptions were audited (pre-ASP n = 90 and ASP n = 435). Total guideline-concordant antibiotic prescribing at baseline was 38.9% (URI, 53.3%; SSTI, 16.7%; UTI, 46.7%) and improved across all 3 infection types to 57.9% (URI, 61.2%; SSTI, 57.6%; UTI, 53.5%; P = .001). Significant improvements were seen in guideline-concordant antibiotic selection (68.9% vs 80.2%; P = .018), dose (76.7% vs 86.2%; P = .023), and duration of therapy (73.3% vs 86.2%; P = .02). Conclusions: An AMCP-led outpatient ASP intervention significantly improved guideline-concordant antibiotic prescribing for common infections within a FMRC.

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The “July Effect” on Antibiotic Prescribing in the Setting of an Antimicrobial Stewardship Program

Open Forum Infectious Diseases ◽

10.1093/ofid/ofv133.70 ◽

2015 ◽

Vol 2 (suppl_1) ◽

Author(s):

Victoria Adams ◽

Patricia Saunders-Hao ◽

Jashvant Poeran ◽

Robert Hiensch ◽

Madhu Mazumdar ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Antibiotic Prescribing ◽

Antimicrobial Stewardship Program ◽

Stewardship Program ◽

July Effect

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Impact of an Education-Based Antimicrobial Stewardship Program on the Appropriateness of Antibiotic Prescribing: Results of a Multicenter Observational Study

Antibiotics ◽

10.3390/antibiotics10030314 ◽

2021 ◽

Vol 10 (3) ◽

pp. 314

Author(s):

Federica Calò ◽

Lorenzo Onorato ◽

Margherita Macera ◽

Giovanni Di Caprio ◽

Caterina Monari ◽

...

Keyword(s):

Observational Study ◽

Antibiotic Therapy ◽

Antimicrobial Stewardship ◽

Case Report Form ◽

Antibiotic Prescribing ◽

Antimicrobial Stewardship Program ◽

Campania Region ◽

Multicenter Observational Study ◽

Stewardship Program ◽

Number Of Patients

To evaluate the effect that an education-based Antimicrobial stewardship program (ASP) implemented in two hospitals in southern Italy had on the quality and appropriateness of antibiotic prescription. We conducted a multicenter observational study in two hospitals in the Campania region. Only some departments of both hospitals were already participating in the ASP. We collected data on all patients admitted on the day of evaluation in antibiotic therapy or prophylaxis through a case report form. The primary outcome was to investigate the difference in the appropriateness of the antibiotic prescriptive practice in the departments that had joined the ASP and in those that had not participated in the project (non-ASP). The total number of patients assessed was 486. Of these, 78 (16.05%) were in antibiotic prophylaxis and 130 (26.7%) in antibiotic therapy. The prescriptive appropriateness was better in the units that had joined ASP than in those that had not, with respectively 65.8% versus 22.7% (p < 0.01). Patients in the non-ASP units more frequently received unnecessary antibiotics (44.9% versus 0%, p = 0.03) and, as surgical prophylaxis, the use of antibiotics not recommended by the guidelines (44.2% versus 0%, p = 0.036). Multivariable analysis of the factors associated with prescriptive appropriateness identified ASP units (p = 0.02) and bloodstream or cardiovascular infections (p = 0.03) as independent predictors of better prescriptive appropriateness. The findings of the present study reinforce the importance of adopting an educational ASP to improve the quality of antimicrobial prescription in clinical practice.

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An antimicrobial stewardship program initiative: a qualitative study on prescribing practices among hospital doctors

Antimicrobial Resistance and Infection Control ◽

10.1186/s13756-015-0065-4 ◽

2015 ◽

Vol 4 (1) ◽

Cited By ~ 25

Author(s):

Brita Skodvin ◽

Karina Aase ◽

Esmita Charani ◽

Alison Holmes ◽

Ingrid Smith

Keyword(s):

Qualitative Study ◽

Antimicrobial Stewardship ◽

Antimicrobial Stewardship Program ◽

Prescribing Practices ◽

Stewardship Program ◽

Hospital Doctors

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Appropriateness of Antibiotic Prescribing in United States Children’s Hospitals: A National Point Prevalence Survey

Clinical Infectious Diseases ◽

10.1093/cid/ciaa036 ◽

2020 ◽

Vol 71 (8) ◽

pp. e226-e234 ◽

Cited By ~ 1

Author(s):

Alison C Tribble ◽

Brian R Lee ◽

Kelly B Flett ◽

Lori K Handy ◽

Jeffrey S Gerber ◽

...

Keyword(s):

United States ◽

Antimicrobial Stewardship ◽

Inappropriate Prescribing ◽

The United States ◽

Antibiotic Prescribing ◽

Hospitalized Children ◽

Prescribing Practices ◽

Children's Hospitals ◽

Stewardship Program ◽

Children’S Hospitals

Abstract Background Studies estimate that 30%–50% of antibiotics prescribed for hospitalized patients are inappropriate, but pediatric data are limited. Characterization of inappropriate prescribing practices for children is needed to guide pediatric antimicrobial stewardship. Methods Cross-sectional analysis of antibiotic prescribing at 32 children’s hospitals in the United States. Subjects included hospitalized children with ≥ 1 antibiotic order at 8:00 am on 1 day per calendar quarter, over 6 quarters (quarter 3 2016–quarter 4 2017). Antimicrobial stewardship program (ASP) physicians and/or pharmacists used a standardized survey to collect data on antibiotic orders and evaluate appropriateness. The primary outcome was the percentage of antibiotics prescribed for infectious use that were classified as suboptimal, defined as inappropriate or needing modification. Results Of 34 927 children hospitalized on survey days, 12 213 (35.0%) had ≥ 1 active antibiotic order. Among 11 784 patients receiving antibiotics for infectious use, 25.9% were prescribed ≥ 1 suboptimal antibiotic. Of the 17 110 antibiotic orders prescribed for infectious use, 21.0% were considered suboptimal. Most common reasons for inappropriate use were bug–drug mismatch (27.7%), surgical prophylaxis > 24 hours (17.7%), overly broad empiric therapy (11.2%), and unnecessary treatment (11.0%). The majority of recommended modifications were to stop (44.7%) or narrow (19.7%) the drug. ASPs would not have routinely reviewed 46.1% of suboptimal orders. Conclusions Across 32 children’s hospitals, approximately 1 in 3 hospitalized children are receiving 1 or more antibiotics at any given time. One-quarter of these children are receiving suboptimal therapy, and nearly half of suboptimal use is not captured by current ASP practices.

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Evaluation of an Antimicrobial Stewardship Program for Wound and Burn Care in Three Hospitals in Nepal

Antibiotics ◽

10.3390/antibiotics9120914 ◽

2020 ◽

Vol 9 (12) ◽

pp. 914

Author(s):

Varidhi Nauriyal ◽

Shankar Man Rai ◽

Rajesh Dhoj Joshi ◽

Buddhi Bahadur Thapa ◽

Linda Kaljee ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Program Implementation ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Post Intervention ◽

Middle Income ◽

Burn Care ◽

Stewardship Program ◽

Days Of Therapy ◽

Henry Ford

Antimicrobial stewardship (AMS) programs can decrease non-optimal use of antibiotics in hospital settings. There are limited data on AMS programs in burn and chronic wound centers in low- and middle-income countries (LMIC). A post-prescription review and feedback (PPRF) program was implemented in three hospitals in Nepal with a focus on wound and burn care. A total of 241 baseline and 236 post-intervention patient chart data were collected from three hospitals. There was a significant decrease in utilizing days of therapy per 1000 patient days (DOT/1000 PD) of penicillin (p = 0.02), aminoglycoside (p < 0.001), and cephalosporin (p = 0.04). Increases in DOT/1000 PD at post-intervention were significant for metronidazole (p < 0.001), quinolone (p = 0.01), and other antibiotics (p < 0.001). Changes in use of antibiotics varied across hospitals, e.g., cephalosporin use decreased significantly at Kirtipur Hospital (p < 0.001) and Pokhara Academy of Health Sciences (p = 0.02), but not at Kathmandu Model Hospital (p = 0.59). An independent review conducted by infectious disease specialists at the Henry Ford Health System revealed significant changes in antibiotic prescribing practices both overall and by hospital. There was a decrease in mean number of intravenous antibiotic days between baseline (10.1 (SD 8.8)) and post-intervention (8.8 (SD 6.5)) (t = 3.56; p < 0.001), but no difference for oral antibiotics. Compared to baseline, over the 6-month post-intervention period, we found an increase in justified use of antibiotics (p < 0.001), de-escalation (p < 0.001), accurate documentation (p < 0.001), and adherence to the study antibiotic prescribing guidelines at 72 h (p < 0.001) and after diagnoses (p < 0.001). The evaluation data presented provide evidence that PPRF training and program implementation can contribute to hospital-based antibiotic stewardship for wound and burn care in Nepal.

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