Changes in antibiotic consumption, AMR and Clostridioides difficile infections in a large tertiary-care center following the implementation of institution-specific guidelines for antimicrobial therapy: A nine-year interrupted time series study

Background Institution-specific guidelines (ISGs) within the framework of antimicrobial stewardship programs offer locally tailored decision support taking into account local pathogen and resistance epidemiology as well as national and international guidelines. Objectives To assess the impact of ISGs for antimicrobial therapy on antibiotic consumption and subsequent changes in resistance rates and Clostridioides difficile infections (CDIs). Methods The study was conducted at the Leipzig University Hospital, a 1,451-bed tertiary-care medical center, and covered the years 2012 to 2020. Since 2014, ISGs were provided to optimize empirical therapies, appropriate diagnostics, and antimicrobial prophylaxis. We used interrupted time series analysis (ITSA) and simple linear regression to analyze changes in antimicrobial consumption, resistance and CDIs. Results Over the study period, 1,672,200 defined daily doses (DDD) of antibiotics were dispensed, and 85,645 bacterial isolates as well as 2,576 positive C. difficile cultures were collected. Total antimicrobial consumption decreased by 14% from 2012 to 2020, without clear impact of the deployment of ISGs. However, implementation of ISGs was associated with significant decreases in the use of substances that were rarely recommended (e.g., fluoroquinolones). Over the whole study period, we observed declining resistance rates to most antibiotic classes of up to 25% in Enterobacterales, staphylococci, and Pseudomonas aeruginosa. Switching from ceftriaxone to cefotaxime was associated with reduced resistance to third-generation cephalosporins. The number of CDI cases fell by 65%, from 501 in 2012 to 174 in 2020. Conclusions Well-implemented ISGs can have a significant, immediate, and lasting impact on the prescription behavior. ISGs might thereby contribute to reduce resistance rates and CDI incidences in the hospital setting.

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The Impact of Direct Healthcare Professional Communication on Prescribing Practice in the UK Hospital Setting: An Interrupted Time Series Analysis

Drug Safety ◽

10.1007/s40264-013-0057-3 ◽

2013 ◽

Vol 36 (7) ◽

pp. 557-564 ◽

Cited By ~ 13

Author(s):

Sarah K. Thomas ◽

James Hodson ◽

Graham McIlroy ◽

Annjeet Dhami ◽

Jamie J. Coleman

Keyword(s):

Time Series ◽

Healthcare Professional ◽

Time Series Analysis ◽

Hospital Setting ◽

Interrupted Time Series ◽

Professional Communication ◽

Interrupted Time Series Analysis ◽

Prescribing Practice ◽

The Uk ◽

The Impact

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Impact of cascade reporting of antimicrobial susceptibility on fluoroquinolone and meropenem consumption at a Veterans’ Affairs medical center

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2021.83 ◽

2021 ◽

pp. 1-6

Author(s):

Nicole C. Vissichelli ◽

Christine M. Orndahl ◽

Jane A. Cecil ◽

Emily M. Hill ◽

Matthew M. Hitchcock ◽

...

Keyword(s):

Antimicrobial Susceptibility ◽

Medical Center ◽

Tertiary Care ◽

Interrupted Time Series ◽

Veterans Affairs ◽

Antimicrobial Consumption ◽

Clostridioides Difficile ◽

Days Of Therapy ◽

Before And After ◽

Quasi Experimental

Abstract Objective: To determine whether cascade reporting is associated with a change in meropenem and fluoroquinolone consumption. Design: A quasi-experimental study was conducted using an interrupted time series to compare antimicrobial consumption before and after the implementation of cascade reporting. Setting: A 399-bed, tertiary-care, Veterans’ Affairs medical center. Participants: Antimicrobial consumption data across 8 inpatient units were extracted from the Center for Disease Control and Prevention (CDC) National Health Safety Network (NHSN) antimicrobial use (AU) module from April 2017 through March 2019, reported as antimicrobial days of therapy (DOT) per 1,000 days present (DP). Intervention: Cascade reporting is a strategy of reporting antimicrobial susceptibility test results in which secondary agents are only reported if an organism is resistant to primary, narrow-spectrum agents. A multidisciplinary team developed cascade reporting algorithms for gram-negative bacteria based on local antibiogram and infectious diseases practice guidelines, aimed at restricting the use of fluoroquinolones and carbapenems. The algorithms were implemented in March 2018. Results: Following the implementation of cascade reporting, mean monthly meropenem (P =.005) and piperacillin/tazobactam (P = .002) consumption decreased and cefepime consumption increased (P < .001). Ciprofloxacin consumption decreased by 2.16 DOT per 1,000 DP per month (SE, 0.25; P < .001). Clostridioides difficile rates did not significantly change. Conclusion: Ciprofloxacin consumption significantly decreased after the implementation of cascade reporting. Mean meropenem consumption decreased after cascade reporting was implemented, but we observed no significant change in the slope of consumption. cascade reporting may be a useful strategy to optimize antimicrobial prescribing.

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1979. Five-Year Impact of an Antimicrobial Stewardship Program on Nosocomial Candidemia: An Interrupted Time-Series Analysis Study

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1659 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S662-S662

Author(s):

Andrea Bedini ◽

Marianna Meschiari ◽

Erica Franceschini ◽

Cristina Mussini

Keyword(s):

Time Series ◽

Antimicrobial Stewardship ◽

Interrupted Time Series ◽

Antibiotic Consumption ◽

Care Hospital ◽

Antimicrobial Stewardship Program ◽

Stewardship Program ◽

Number Of Patients ◽

Nosocomial Candidemia ◽

The Impact

Abstract Background Antimicrobial stewardship programs allow a reduction in antibiotic prescription and, consequently, in the incidence of multidrug-resistance infections. However, the impact on nosocomial candidemia is still unclear. Methods The present study is an interrupted time-series (ITS) before-after study, based on an ecological time-trend analysis. Since 2014, an antimicrobial stewardship program (ASP) has been implemented at an Italian tertiary-care hospital. The first objective of the program was to reduce carbapenem consumption, through an active and computerized surveillance of all carbapenem prescriptions, each of which was checked and validated by ID specialists always after audit of the cases with treating physicians. We retrospectively evaluated the changing in the consumption of antimicrobials, carbapenems, and in the incidence of candidemia, during two study periods: before (2007–2013) and after (2014–2018) the implementation of the ASP. Results The implementation of ASP was followed by a significant decrease in antibiotic consumption, which was consistent through the following 5 years. At the end of the study, total antibiotic consumption has decreased by 38.476 DDDs per 100 patient-days (PDs) per quarter (95% CI: −21.784 to −55.168; P < 0.001) and carbapenems decreased by 4.452 DDD per 100 PDs per quarter (95% CI: −3.658 to −5.246; P = 0.001). After 5 years of ASP, incidence of candidemia decreased by 2.034 episodes per 1,000 PDs per quarter (95% CI: −0.738 to −3.330; P = 0.003), decreasing, at the end of 2018, by 53% compared with the expected value if the program had not been implemented. Conclusion At our Institution, the ASP had a positive impact on the consumption of carbapenems, and antimicrobials. The incidence of candidemia was also favorably affected by the program, reversing the trend after 2014. The ASP, even if not directly targeted to fungal infections, indirectly caused a reduction in the incidence of candidemia, probably reducing the number of patients colonized by Candida spp. Disclosures All authors: No reported disclosures.

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Impact of the coronavirus disease 2019 (COVID-19) pandemic on nosocomial Clostridioides difficile infection

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.454 ◽

2020 ◽

pp. 1-5 ◽

Cited By ~ 3

Author(s):

Manuel Ponce-Alonso ◽

Javier Sáez de la Fuente ◽

Angela Rincón-Carlavilla ◽

Paloma Moreno-Nunez ◽

Laura Martínez-García ◽

...

Keyword(s):

Tertiary Care ◽

Control Period ◽

Hospital Setting ◽

Antibiotic Use ◽

Incidence Density ◽

Care Hospital ◽

Patient Mobility ◽

Clostridioides Difficile ◽

Defined Daily Doses ◽

The Impact

Abstract Objectives: The coronavirus disease 2019 (COVID-19) pandemic has induced a reinforcement of infection control measures in the hospital setting. Here, we assess the impact of the COVID-19 pandemic on the incidence of nosocomial Clostridioides difficile infection (CDI). Methods: We retrospectively compared the incidence density (cases per 10,000 patient days) of healthcare-facility–associated (HCFA) CDI in a tertiary-care hospital in Madrid, Spain, during the maximum incidence of COVID-19 (March 11 to May 11, 2020) with the same period of the previous year (control period). We also assessed the aggregate in-hospital antibiotic use (ie, defined daily doses [DDD] per 100 occupied bed days [BD]) and incidence density (ie, movements per 1,000 patient days) of patient mobility during both periods. Results: In total, 2,337 patients with reverse transcription-polymerase chain reaction–confirmed COVID-19 were admitted to the hospital during the COVID-19 period. Also, 12 HCFA CDI cases were reported at this time (incidence density, 2.68 per 10,000 patient days), whereas 34 HCFA CDI cases were identified during the control period (incidence density, 8.54 per 10,000 patient days) (P = .000257). Antibiotic consumption was slightly higher during the COVID-19 period (89.73 DDD per 100 BD) than during the control period (79.16 DDD per 100 BD). The incidence density of patient movements was 587.61 per 1,000 patient days during the control period and was significantly lower during the COVID-19 period (300.86 per 1,000 patient days) (P < .0001). Conclusions: The observed reduction of ~70% in the incidence density of HCFA CDI in a context of no reduction in antibiotic use supports the importance of reducing nosocomial transmission by healthcare workers and asymptomatic colonized patients, reinforcing cleaning procedures and reducing patient mobility in the epidemiological control of CDI.

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Chasing the rate: An interrupted time series analysis of interventions targeting reported hospital onset Clostridioides difficile, 2013–2018

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.247 ◽

2020 ◽

Vol 41 (10) ◽

pp. 1142-1147

Author(s):

Michelle E. Doll ◽

Jinlei Zhao ◽

Le Kang ◽

Barry Rittmann ◽

Michael Alvarez ◽

...

Keyword(s):

Time Series ◽

Decision Support ◽

Infection Control ◽

Medical Center ◽

Academic Medical Center ◽

Interrupted Time Series ◽

Interrupted Time Series Analysis ◽

Test Volume ◽

Clostridioides Difficile ◽

The Impact

AbstractObjective:To assess the impact of major interventions targeting infection control and diagnostic stewardship in efforts to decrease Clostridioides difficile hospital onset rates over a 6-year period.Design:Interrupted time series.Setting:The study was conducted in an 865-bed academic medical center.Methods:Monthly hospital-onset C. difficile infection (HO-CDI) rates from January 2013 through January 2019 were analyzed around 5 major interventions: (1) a 2-step cleaning process in which an initial quaternary ammonium product was followed with 10% bleach for daily and terminal cleaning of rooms of patients who have tested positive for C. difficile (February 2014), (2) UV-C device for all terminal cleaning of rooms of C. difficile patients (August 2015), (3) “contact plus” isolation precautions (June 2016), (4) sporicidal peroxyacetic acid and hydrogen peroxide cleaning in all patient areas (June 2017), (5) electronic medical record (EMR) decision support tool to facilitate appropriate C. difficile test ordering (March 2018).Results:Environmental cleaning interventions and enhanced “contact plus” isolation did not impact HO-CDI rates. Diagnostic stewardship via EMR decision support decreased the HO-CDI rate by 6.7 per 10,000 patient days (P = .0079). When adjusting rates for test volume, the EMR decision support significance was reduced to a difference of 5.1 case reductions per 10,000 patient days (P = .0470).Conclusion:Multiple aggressively implemented infection control interventions targeting CDI demonstrated a disappointing impact on endemic CDI rates over 6 years. This study adds to existing data that outside of an outbreak situation, traditional infection control guidance for CDI prevention has little impact on endemic rates.

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Impact of restricting procalcitonin measurements in a Swiss tertiary-care hospital on antibiotic use, clinical outcomes, and costs: An interrupted time-series analysis

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1314 ◽

2020 ◽

pp. 1-3

Author(s):

Mohamed Abbas ◽

Nathalie Vernaz ◽

Elodie von Dach ◽

Nicolas Vuilleumier ◽

Stephan J. Harbarth ◽

...

Keyword(s):

Time Series ◽

Time Series Analysis ◽

Tertiary Care Hospital ◽

Tertiary Care ◽

Interrupted Time Series ◽

Antibiotic Use ◽

Care Hospital ◽

Interrupted Time Series Analysis ◽

Series Analysis ◽

The Impact

Abstract We evaluated the impact of a restriction of procalcitonin measurements on antibiotic use, length of stay, mortality, and cost in a Swiss tertiary-care hospital using interrupted time-series analysis. There was no significant change in level or slope for rates of antibiotic consumption, and costs decreased considerably, by ~54,488 CHF (US$55,714) per month.

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Time Series Analysis as a Tool To Predict the Impact of Antimicrobial Restriction in Antibiotic Stewardship Programs Using the Example of Multidrug-Resistant Pseudomonas aeruginosa

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.02142-12 ◽

2013 ◽

Vol 57 (4) ◽

pp. 1797-1803 ◽

Cited By ~ 13

Author(s):

Matthias Willmann ◽

Matthias Marschal ◽

Florian Hölzl ◽

Klaus Schröppel ◽

Ingo B. Autenrieth ◽

...

Keyword(s):

Time Series ◽

Pseudomonas Aeruginosa ◽

Time Series Analysis ◽

Antibiotic Stewardship ◽

Multidrug Resistant ◽

Antimicrobial Consumption ◽

Content Type ◽

Series Analysis ◽

Resistance Rates ◽

The Impact

ABSTRACTThe association between antimicrobial consumption and resistance in nonfermentative Gram-negative bacteria is well-known. Antimicrobial restriction, implemented in clinical routines by antibiotic stewardship programs (ASPs), is considered a means to reduce resistance rates. Whether and how antimicrobial restriction can accomplish this goal is still unknown though. This leads to an element of uncertainty when designing strategies for ASPs. From January 2002 until December 2011, an observational study was performed at the University Hospital Tübingen, Tübingen, Germany, to investigate the association between antimicrobial use and resistance rates inPseudomonas aeruginosa. Transfer function models were used to determine such associations and to simulate antimicrobial restriction strategies. Various positive associations between antimicrobial consumption and resistance were observed in our setting. Surprisingly, impact estimations of different antimicrobial restriction strategies revealed relatively low intervention expenses to effectively attenuate the observed increase in resistance. For example, a simulated intervention of an annual 4% reduction in the use of meropenem over 3 years from 2009 until 2011 yielded a 62.5% attenuation (95% confidence interval, 15% to 110%) in the rising trend of multidrug-resistantPseudomonas aeruginosa(three- and four-class-resistantP. aeruginosa[34MRGN-PA]). Time series analysis models derived from past data may be a tool to predict the outcome of antimicrobial restriction strategies, and could be used to design ASPs.

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Impact of Generic Entry on Hospital Antimicrobial Use: A Retrospective Quasi-Experimental Interrupted Time Series Analysis

Antibiotics ◽

10.3390/antibiotics10101149 ◽

2021 ◽

Vol 10 (10) ◽

pp. 1149

Author(s):

Mercè Espona ◽

Daniel Echeverria-Esnal ◽

Sergi Hernandez ◽

Alexander Almendral ◽

Silvia Inés Gómez-Zorrilla ◽

...

Keyword(s):

Time Series ◽

Time Series Analysis ◽

Economic Benefit ◽

Interrupted Time Series ◽

Antimicrobial Consumption ◽

Interrupted Time Series Analysis ◽

Generic Entry ◽

Series Analysis ◽

Quasi Experimental ◽

The Impact

Background: The impact of antimicrobials generic entry (GE) is controversial. Their introduction could provide an economic benefit yet may also increase their consumption, leading to a higher risk of resistance. Our aim was to analyze the impact of GE on trends of antimicrobial consumption in an acute-care hospital. Methods: A retrospective quasi-experimental interrupted time series analysis was conducted at a 400-bed tertiary hospital in Barcelona, Spain. All antimicrobials for systemic use for which a generic product entered the hospital from January 2000 to December 2019 were included. Antimicrobial consumption was expressed as DDD/100 bed days. Results: After GE, the consumption of cefotaxime (0.09, p < 0.001), meropenem (0.54, p < 0.001), and piperacillin-tazobactam (0.13, p < 0.001) increased, whereas the use of clindamycin (−0.03, p < 0.001) and itraconazole (−0.02, p = 0.01) was reduced. An alarming rise in cefepime (0.004), daptomycin (1.02), and cloxacillin (0.05) prescriptions was observed, despite not achieving statistical significance. On the contrary, the use of amoxicillin (−0.07), ampicillin (−0.02), cefixime (−0.06), fluconazole (−0.13), imipenem–cilastatin (−0.50) and levofloxacin (−0.35) decreased. These effects were noticed beyond the first year post GE. Conclusions: GE led to an increase in the consumption of broad-spectrum molecules. The potential economic benefit of generic antibiotics could be diluted by an increase in resistance. Antimicrobial stewardship should continue to monitor these molecules despite GE.

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