Impact of Antibiotic Stewardship Rounds in the Intensive Care Setting: a prospective cluster-randomized crossover study

2021 ◽  
Author(s):  
Jessica L Seidelman ◽  
Nicholas A Turner ◽  
Rebekah H Wrenn ◽  
Christina Sarubbi ◽  
Deverick J Anderson ◽  
...  
Keyword(s):  
Intensive Care ◽  
Crossover Study ◽  
Antibiotic Stewardship ◽  
Antibiotic Use ◽  
Baseline Period ◽  
Period Change ◽  
University Hospital ◽  
High Resource ◽  
Cluster Randomized ◽  
Randomized Crossover Study

Abstract Background Few groups have formally studied the effect of dedicated antibiotic stewardship rounds (ASRs) on antibiotic use (AU) in intensive care units (ICUs). Methods We implemented weekly ASRs using a two-arm, cluster-randomized, crossover study in 5 ICUs at Duke University Hospital from 11/2017 to 6/2018. We excluded patients without an active antibiotic order, or if they had a marker of high complexity including an existing infectious disease consult, transplant, ventricular assist device, or ECMO. AU during and following ICU stay for patients with ASRs was compared to the controls. We recorded the number of reviews, recommendations delivered, and responses. We evaluated change in ICU-specific AU during and after the study. Results Our analysis included 4,683 patients: 2330 intervention and 2353 controls. Teams performed 761 reviews during ASRs, which excluded 1569 patients: 60% of patients off antibiotics, and 8% complex patients. Exclusions affected 88% the cardiac surgery ICU (CTICU) patients. AU rate ratio (RR) was 0.97 (0.91-1.04). When CTICU was removed, the RR was 0.93 (0.89-0.98). AU in the post-study period decreased by 16% (95% CI 11-24%) compared to the AU in the baseline period. Change in AU was differential among units: largest in the neurology ICU (-28%) and smallest in the CTICU (-2%). Conclusion Weekly multi-disciplinary ASRs was a high-resource intervention associated with a small AU reduction. The noticeable ICU AU decline over time is possibly due to indirect effects of ASRs. Effects differed among specialty ICUs, emphasizing the importance of customizing ASRs to match unit-specific population, workflow, and culture.

scholarly journals Chlorhexidine versus Tincture of Iodine for Reduction of Blood Culture Contamination Rates: a Prospective Randomized Crossover Study

2016 ◽  
Vol 54 (12) ◽  
pp. 3007-3009 ◽  
Author(s):  
Elizabeth Story-Roller ◽  
Melvin P. Weinstein
Keyword(s):  
Blood Culture ◽  
Crossover Study ◽  
Clinical Care ◽  
Bloodstream Infections ◽  
Antibiotic Use ◽  
University Hospital ◽  
Contamination Rate ◽  
Nursing Unit ◽  
Skin Antisepsis ◽  
Randomized Crossover Study

Blood cultures (BCs) are the standard method for diagnosis of bloodstream infections (BSIs). However, the average BC contamination rate (CR) in U.S. hospitals is 2.9%, potentially resulting in unnecessary antibiotic use and excessive therapy costs. Several studies have compared various skin antisepsis agents without a clear consensus as to which agent is most effective in reducing contamination. A prospective, randomized crossover study directly comparing blood culture contamination rates using chlorhexidine versus iodine tincture for skin antisepsis was performed at Robert Wood Johnson University Hospital (RWJUH). Eight nursing units at RWJUH were provided with blood culture kits containing either chlorhexidine (CH) or iodine tincture (IT) for skin antisepsis prior to all blood culture venipunctures, which were obtained by nurses or clinical care technicians. At quarterly intervals, the antiseptic agent used on each nursing unit was switched. Analyses of positive BCs were performed to distinguish true BSIs from contaminants. Of the 6,095 total BC sets obtained from the participating nursing units, 667 (10.94%) were positive and 238 (3.90%) were judged by the investigators to be contaminated. Of the 3,130 BCs obtained using IT, 340 (10.86%) were positive and 123 (3.93%) were contaminated. Of 2,965 BCs obtained using CH, 327 (11.03%) were positive and 115 (3.88%) were contaminated. The rates of contaminated BCs were not statistically significant between the two antiseptic agents (P= 1.0). We conclude that CH and IT are equivalent agents for blood culture skin antisepsis.

scholarly journals Swallowability of Minitablets among Children Aged 6–23 Months: An Exploratory, Randomized Crossover Study

Pharmaceutics ◽  
2022 ◽  
Vol 14 (1) ◽  
pp. 198
Author(s):  
Nao Mitsui ◽  
Noriko Hida ◽  
Taro Kamiya ◽  
Taigi Yamazaki ◽  
Kazuki Miyazaki ◽  
...  
Keyword(s):  
Crossover Study ◽  
Age Groups ◽  
University Hospital ◽  
Multiple Drug ◽  
Paediatric Department ◽  
Administration Method ◽  
Drug Free ◽  
Randomized Crossover Study ◽  
Paediatric Formulation ◽  
Two Age Groups

Minitablets have garnered interest as a new paediatric formulation that is easier to swallow than liquid formulations. In Japan, besides the latter, fine granules are frequently used for children. We examined the swallowability of multiple drug-free minitablets and compared it with that of fine granules and liquid formulations in 40 children of two age groups (n = 20 each, aged 6–11 and 12–23 months). We compared the percentage of children who could swallow minitablets without chewing with that of children who could swallow fine granules or liquid formulations without leftover. The children who visited the paediatric department of Showa University Hospital were enrolled. Their caregivers were allowed to choose the administration method. In total, 37 out of 40 caregivers dispersed the fine granules in water. Significantly more children (80%, 95% CI: 56–94%) aged 6–11 months could swallow the minitablets than those who could swallow all the dispersed fine granules and liquid formulations (22%, 95% CI: 6–47% and 35%, 95% CI: 15–59%, respectively). No significant differences were observed in children aged 12–23 months. Hence, minitablets may be easier to swallow than dispersed fine granules and liquid formulations in children aged 6–11 months.

scholarly journals 1878. Title: Impact of Antibiotic Stewardship Rounds in the Intensive Care Setting: A Prospective Cluster-Randomized Crossover Study

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S48-S49
Author(s):  
Jessica Seidelman ◽  
Nicholas A Turner ◽  
Rebekah Wrenn ◽  
Christina Sarubbi ◽  
Deverick J Anderson ◽  
...  
Keyword(s):  
Intensive Care ◽  
Usual Care ◽  
Primary Outcome ◽  
Negative Binomial ◽  
University Hospital ◽  
Stewardship Program ◽  
Days Of Therapy ◽  
Intervention Impact ◽  
Cluster Randomized ◽  
The Impact

Abstract Background The impact of formalized, interdisciplinary antimicrobial stewardship program (ASP) rounds in the intensive care unit (ICU) setting has not been well described. Methods We performed a two-arm, cluster-randomized, crossover quality improvement study over 8 months to compare the impact of weekly ICU rounds with an ASP team vs. usual care. The primary outcome was antibiotic use (AU) in days of therapy (DOT) per 1,000 days present during and following ICU exposure. Our cohort consisted of ICU patients in 5 ICUs in Duke University Hospital. The unit of randomization was rounding team, which corresponded to half of the ICU beds in each unit. Each team was randomized to the intervention for 4 months followed by usual care for 4 months (or vice versa). The intervention involved multidisciplinary review of eligible patients to discuss antibiotic optimization. Patients not on antibiotics, followed by infectious diseases, post-transplant, on ECMO, or with a ventricular assist device were excluded from review. Intervention impact was assessed with multivariable negative binomial regression rate ratios (RR). AU was assessed over time before and after the study period to assess global and unit-level trends. Results We had 4,683 ICU-exposed patients. Intervention effect was not significant for the primary outcome (table). The intervention order was not significant in the model. Eligible patients were lower in the cardiothoracic ICU (CTICU) compared with other units (table); the intervention led to a significant decrease in AU when the CTICU was removed (RR = 0.93 [0.89–0.98], P = 0.0025). Intervention impact was differential among ICUs, with the greatest effect in surgical and least in CTICU (table). nit-level AU decreased in all ICUs, driven by 4 of the 5 ICUs (table, figure). Conclusion The effect of ASP rounds on AU was mixed for different types of ICUs. The direct effect on AU (intervention vs. control) was small because the analysis addressed the whole ICU population and thus was subject to biases from exposures after an ICU stay, ineligible patients, and lack of blinding. However, we observed an overall decline in AU during the study period, which we believe represents indirect effects of increased ASP activity and awareness. Additional ASP resources to round more than weekly may result in greater effect. Disclosures All Authors: No reported Disclosures.

scholarly journals Stewarding antibiotic stewardship in intensive care units with Bayesian artificial intelligence

2018 ◽  
Vol 3 ◽  
pp. 73 ◽  
Author(s):  
Tavpritesh Sethi ◽  
Shubham Maheshwari ◽  
Aditya Nagori ◽  
Rakesh Lodha
Keyword(s):  
Artificial Intelligence ◽  
Intensive Care ◽  
Intensive Care Units ◽  
Antimicrobial Stewardship ◽  
Antibiotic Stewardship ◽  
Expert Knowledge ◽  
Antibiotic Use ◽  
Ensemble Averaging ◽  
Sensitivity Testing ◽  
Resistance Evolution

Emerging antimicrobial resistance (AMR) is a global threat to life. Injudicious use of antibiotics is the biggest driver of resistance evolution, creating selection pressures on micro-organisms. Intensive care units (ICUs) are the strongest contributors to this pressure, owing to high infection and antibiotic usage rates. Antimicrobial stewardship programs aim to control antibiotic use; however, these are mostly limited to descriptive statistics. Genomic analyses lie at the other extreme of the value-spectrum, and together these factors predispose to siloing of knowledge arising from AMR stewardship. In this study, we bridged the value-gap at a Pediatric ICU by creating Bayesian network (BN) artificial intelligence models with potential impacts on antibiotic stewardship. Methods, actionable insights and an interactive dashboard for BN analysis upon data observed over 3 years at the PICU are described. BNs have several desirable properties for reasoning from data, including interpretability, expert knowledge injection and quantitative inference. Our pipeline leverages best practices of enforcing statistical rigor through bootstrapping, ensemble averaging and Monte Carlo simulations. Competing, shared and independent drug resistances were discovered through the presence of network motifs in BNs. Inferences guided by these visual models are also discussed, such as increasing the sensitivity testing for chloramphenicol as a potential mechanism of avoiding ertapenem overuse in the PICU. Organism, tissue and temporal influences on drug co-resistances are also discussed. While the model represents inferences that are tailored to the site, BNs are excellent tools for building upon pre-learnt structures, hence the model and inferences were wrapped into an interactive dashboard not only deployed at the site, but also made openly available to the community via GitHub. Shared repositories of such models could be a viable alternative to raw-data sharing and could promote partnering, learning across sites and charting a joint course for antimicrobial stewardship programs in the race against AMR.

scholarly journals Effectiveness and Acceptance of Multimodal Antibiotic Stewardship Program: Considering Progressive Implementation and Complementary Strategies

Antibiotics ◽  
2020 ◽  
Vol 9 (12) ◽  
pp. 848
Author(s):  
Flavien Bouchet ◽  
Vincent Le Moing ◽  
Delphine Dirand ◽  
François Cros ◽  
Alexi Lienard ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Infectious Diseases ◽  
Antibiotic Therapy ◽  
Antibiotic Stewardship ◽  
Antibiotic Use ◽  
Stewardship Program ◽  
Microbiological Laboratory ◽  
Combined Actions ◽  
One Year

Multiple modes of interventions are available when implementing an antibiotic stewardship program (ASP), however, their complementarity has not yet been assessed. In a 938-bed hospital, we sequentially implemented four combined modes of interventions over one year, centralized by one infectious diseases specialist (IDS): (1) on-request infectious diseases specialist consulting service (IDSCS), (2) participation in intensive care unit meetings, (3) IDS intervention triggered by microbiological laboratory meetings, and (4) IDS intervention triggered by pharmacist alert. We assessed the complementarity of the different cumulative actions through quantitative and qualitative analysis of all interventions traced in the electronic medical record. We observed a quantitative and qualitative complementarity between interventions directly correlating to a decrease in antibiotic use. Quantitatively, the number of interventions has doubled after implementation of IDS intervention triggered by pharmacist alert. Qualitatively, these kinds of interventions led mainly to de-escalation or stopping of antibiotic therapy (63%) as opposed to on-request IDSCS (32%). An overall decrease of 14.6% in antibiotic use was observed (p = 0.03). Progressive implementation of the different interventions showed a concrete complementarity of these actions. Combined actions in ASPs could lead to a significant decrease in antibiotic use, especially regarding critical antibiotic prescriptions, while being well accepted by prescribers.

scholarly journals Determinants and Magnitude of Neonatal Sepsis at Hiwot Fana Comprehensive Specialized University Hospital, Harar, Ethiopia: A Cross-Sectional Study

2021 ◽  
Author(s):  
Astawus Alemayehu Feleke ◽  
Mohammed Yusuf Abdella ◽  
Abebaw Demissie W/mariam
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Neonatal Sepsis ◽  
Birth Asphyxia ◽  
Antibiotic Use ◽  
Cross Sectional Study ◽  
University Hospital ◽  
Sectional Study ◽  
Urban Residence ◽  
Cross Sectional

Introduction: Neonatal sepsis is a serious blood bacterial infection in neonates at the age of equal to or less than 28 days of life, and it's still the major significant cause of death and long-term morbidity in developing countries. Therefore, this study has assessed the prevalence and related factors with neonatal sepsis among new born admitted to the neonatal intensive care unit at Hiwot Fana Comprehensive Specialized University Hospital, Harar, Ethiopia. Methods: An institutional based retrospective cross-sectional study design was conducted among 386 neonates admitted to NICU from September 2017 to August 2019 G.C. A systematic random sampling method was used. Data was analyzed using SPSS V.26. Descriptive summary statistics was done. Bivariate analysis was computed to identify association between dependent and independent variables. Multivariate analysis was used to control possible confounder variables and variables with p-value <0.05 were declared as having statistically significant association. Result: The prevalence of neonatal sepsis was 53.1% and 59.5% were males. Among the total neonates who had sepsis, 67.8% had early neonatal sepsis. Among neonatal factors, preterm neonates (AOR: 8.1, 95%CI: 2.1, 31.2), birth asphyxia (AOR: 4.7, 95%CI: 1.6, 13.6); and among maternal factors, urban residence (AOR: 0.26, 95%CI: 0.1, 0.5), ANC attendance (AOR: 0.32, 95%CI: 0.2, 0.6), SVD (AOR: 0.047, 95%CI: 0.01, 0.2), Maternal antibiotic use (AOR: 0.39; 95%CI: 0.2, 0.8), duration of rupture of membrane < 12 hours (AOR: 0.11; 95%CI: 0.05, 0.2) were found to have significant association with neonatal sepsis. Conclusion: Overall, the magnitude of neonatal sepsis was high. Being preterm, low birth weight and having birth asphyxia were found to significantly increase the odds of neonatal sepsis. Urban residence, having ANC follow up, giving birth by SVD and CS, history of antibiotic use and having rupture of membrane < 18 hours were found to significantly decrease the odds of neonatal sepsis. Key words: Neonatal Sepsis, Intensive Care Unit, Harar

scholarly journals Impact of a Multimodal Antimicrobial Stewardship Program onPseudomonas aeruginosaSusceptibility and Antimicrobial Use in the Intensive Care Unit Setting

2011 ◽  
Vol 2011 ◽  
pp. 1-5 ◽  
Author(s):  
Douglas Slain ◽  
Arif R. Sarwari ◽  
Karen O. Petros ◽  
Richard L. McKnight ◽  
Renee B. Sager ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Antimicrobial Stewardship ◽  
Antibiotic Stewardship ◽  
Antibiotic Use ◽  
Resistance Rate ◽  
Defined Daily Doses ◽  
Stewardship Program ◽  
Resistance Patterns ◽  
The Impact

Objective. To study the impact of our multimodal antibiotic stewardship program onPseudomonas aeruginosasusceptibility and antibiotic use in the intensive care unit (ICU) setting.Methods. Our stewardship program employed the key tenants of published antimicrobial stewardship guidelines. These included prospective audits with intervention and feedback, formulary restriction with preauthorization, educational conferences, guidelines for use, antimicrobial cycling, and de-escalation of therapy. ICU antibiotic use was measured and expressed as defined daily doses (DDD) per 1,000 patient-days.Results. Certain temporal relationships between antibiotic use and ICU resistance patterns appeared to be affected by our antibiotic stewardship program. In particular, the ICU use of intravenous ciprofloxacin and ceftazidime declined from 148 and 62.5 DDD/1,000 patient-days to 40.0 and 24.5, respectively, during 2004 to 2007. An increase in the use of these agents and resistance to these agents was witnessed during 2008–2010. Despite variability in antibiotic usage from the stewardship efforts, we were overall unable to show statistical relationships withP. aeruginosaresistance rate.Conclusion. Antibiotic resistance in the ICU setting is complex. Multimodal stewardship efforts attempt to prevent resistance, but such programs clearly have their limits.

scholarly journals Dynamics of the microbiological scope and antibiotic susceptibility in intensive care unit patients

2020 ◽  
Vol 7 (7) ◽  
pp. 3860-3864
Author(s):  
Kostiv Olga ◽  
Yakymchuk Elena ◽  
Kostiv Sviatoslav ◽  
Dmytriiev Dmytro ◽  
Dmytriiev Kostiantyn
Keyword(s):  
Intensive Care Unit ◽  
Antibiotic Resistance ◽  
Intensive Care ◽  
Antibiotic Use ◽  
Infectious Complications ◽  
University Hospital ◽  
Antibacterial Drugs ◽  
And Control ◽  
Rational Antibiotic Use ◽  
Prevention Plan

Introduction: This study addresses and evaluates the decrease of antibiotic resistance after introduction of a proposed prevention plan and control complex in the intensive care unit (ICU). Methods: Data from 1,111 bacteriological analyses, taken from patients who received treatment in the ICU of Ternopil University Hospital from January to August 2015 (group 1) and the same period of 2018 (group II), were included in the study. The complex included measures for the prevention of antibiotic resistance spread and for rational antibiotic use. Results: We found that resistance to imipenem changed more than other antibacterial drugs, increased by 60% (р ≤ 0.05), which was conditioned predominantly by Pseudomonas aeruginosa isolates for 100%. A decrease in 39% of polyresistant clinical isolates of Klebsiella pneumoniae in patients of groups I and II showed important prognostic value. Conclusion: A complex of the proposed measures included the division of patients in blocks according to the risk of infectious complications, control of antibiotics administration, adherence to sanitary norms by ICU staff, use of sodium hypochlorite resulting in decrease of pathogenic isolates, and level of antibiotic resistance to specific groups of antibacterial drugs.

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