The use of anti-hyperlipidemia in a private hospital in Yogyakarta during 2013-2019

Background: Lipid modifying agents have an important role in the primary and secondary prevention of cardiovascular diseases such as coronary heart disease and stroke. The use of lipid-modifying agents tends to increase along with the increasing prevalence of these diseases. Objectives: To determine the utilization of lipid modifying agents for hospitalized patients in a private hospital in Yogyakarta during the period of 2013 - 2019 in regard to the agents used and their quantity. Methods: The main data for this study were aggregate data on the use of lipid modifying agents for hospitalized patients during 2013-2019 obtained from the hospital pharmacy department. After identification of the names of lipid modifying agents, the quantities of these drugs were then calculated in units of defined daily dose (DDD) and the final quantity was expressed in DDD/100 bed days (BD). The R2 value from linear regression was used to determine the trend of use of individual agents over the period. Results: There were two pharmacological subgroups of lipid modifying agents used during the period of 2013 – 2019 with an average of total quantity of 14.81 DDD/100 BD. Utilization of statins was approximately 90% of the total use, and utilization of fibrates tended to decrease over the period. Individually, simvastatin use decreased significantly over the period (R2 = 0.885), but atorvastatin use continued to increase (R2 = 0.908) with 10-fold increase from 2013 to 2019. Conclusion: The lipid modifying agents used during the period 2013 - 2019 were predominantly statins, and the utilization of atorvastatin increased significantly during this period. Keywords: lipid modifying agents, ATC/DDD, fibrates, statins

Analysis of lethal cases of pneumonia caused by SARS-CoV-2 virus according to the data of pathology department of Kharkiv Regional Clinical Hospital for the first half of 2021

Background. Given the great medical, social and economic significance of clinical research, pathogenesis and epidemiology of coronavirus infection, it is important to study the epidemiological and pathomorphological features of this infection in Ukraine, especially in fatal cases of this disease. Objective: to analyze the lethal cases of pneumonia caused by SARS-CoV-2 in comparison with lethal cases of pneumonia of other etiologies according to the pathology department of Kharkiv Regional Clinical Hospital for the first half of 2021. Methods. The material of this study was the observation of an autopsy from the archival material the pathology department of Kharkiv Regional Clinical Hospital. The study of autopsy protocols took into account the seasonality of the disease, sex and age of the deceased, the number of bed-days, data of clinical diagnosis and coincidences of pathological diagnosis, as well as the ICD code. 256 protocols of pathological examinations for the first half of 2021 were studied. Results. Of the 256 deaths from pneumonia of various etiologies, 201 (78.52%) were caused by SARS-CoV-2 infection. The highest number of deaths from pneumonia was registered in March, April and May 2021. The number of deaths of patients aged 18-44 years was 4.3% of the total, 45-59 years – 13.28%, 60-74 years – 47.27%, 75-90 years – 35.16%. The study sample among patients died of pneumonia caused by SARS-CoV-2 was dominated by women (57.42%, 147 cases), the number of men was 42.58% (109 cases). The direct causes of death were pulmonary-heart failure, multiple organ failure, acute pulmonary insufficiency, chronic pulmonary insufficiency, and pulmonary embolism. Conclusion. The obtained data can be useful for the analysis of regional features of epidemiology and pathogenesis of coronavirus disease in eastern Ukraine.

Trends in inpatient care for psychiatric disorders in NHS hospitals across England, 1998/99–2019/20: an observational time series analysis

Purpose It is unclear how hospitals are responding to the mental health needs of the population in England, against a backdrop of diminishing resources. We aimed to document patterns in hospital activity by psychiatric disorder and how these have changed over the last 22 years. Methods In this observational time series analysis, we used routinely collected data on all NHS hospitals in England from 1998/99 to 2019/20. Trends in hospital admissions and bed days for psychiatric disorders were smoothed using negative binomial regression models with year as the exposure and rates (per 1000 person-years) as the outcome. When linear trends were not appropriate, we fitted segmented negative binomial regression models with one change-point. We stratified by gender and age group [children (0–14 years); adults (15 years +)]. Results Hospital admission rates and bed days for all psychiatric disorders decreased by 28.4 and 38.3%, respectively. Trends were not uniform across psychiatric disorders or age groups. Admission rates mainly decreased over time, except for anxiety and eating disorders which doubled over the 22-year period, significantly increasing by 2.9% (AAPC = 2.88; 95% CI: 2.61–3.16; p < 0.001) and 3.4% (AAPC = 3.44; 95% CI: 3.04–3.85; p < 0.001) each year. Inpatient hospital activity among children showed more increasing and pronounced trends than adults, including an increase of 212.9% for depression, despite a 63.8% reduction for adults with depression during the same period. Conclusion In the last 22 years, there have been overall reductions in hospital activity for psychiatric disorders. However, some disorders showed pronounced increases, pointing to areas of growing need for inpatient psychiatric care, especially among children.

Benefits of Pharmacist Intervention in the Critical Care Geriatric Patients with Infectious Diseases: A Propensity Score Matching Retrospective Cohort Study

Background The variabilities of the pharmacotherapeutics’ efficacy and safety in the ICU geriatric patients further highlighted the importance of optimization of antimicrobial therapy. The aim of our study was to assess the impacts of clinical pharmacist intervention on antibiotic use, cost outcomes, and clinical benefits of the geriatric patients with infectious diseases in the critical care unit (ICU). Methods A propensity score matching (PSM) retrospective cohort study was undertaken in ICU patients with infectious diseases from 2017 to 2019. Baseline demographic, pharmacists’ activities and clinical outcomes including the patients’ mortality, antibiotic utilization, length of ICU stay (LOS), and costs of the drugs were compared between these two groups. Univariate analysis and bivariate logistic regression were adopted to illustrate the influencing factors on the mortality outcome. Results Of 1523 patients evaluated during the observed period, a total of 102 geriatric ICU patients with infectious diseases were enrolled in each group after PSM matching. Top 5 recommendations occurred by the pharmacist were medication regimen adjustments by diseases on progression, medication regimen adjustments by microbial results, drug withdrawal by full treatment courses, suggestions for TDM and medication regimen adjustments by de-escalation. The antibiotic use density (AUD) of all antibiotics consumed decreased significantly (p=0.018) from 241.91 DDD/100 bed days in the control group to 176.64 DDD/100 bed days in the pharmacist exposed group. AUD proportion was dropped in carbapenems from 23.07% to 14.43% and tetracyclines from 11.56% to 6.26% after pharmacist interventions. Although the mortality or LOS had no statistical difference between these two groups, the total cost of antibiotics was reduced significantly from $836.3 (IQR 426.88, 1682.09) in the control group to $362.15 (IQR 148.23, 1034.4) (p＜0.001) in the pharmacist intervention group, and cost for all the medications were reduced from $2868.18 ($1268.44, $5059.00) to $1941.5 ($1092.89, $3538.97) (p=0.016). Univariate analyses showed that there was no statistically difference in pharmacist intervention between the groups of survival and death (p=0.288) Conclusions The services provided by the critical care pharmacist could promote the rational use of drugs, which benefit both ICU geriatric patient and hospital care.

Expected Evolution of COVID-19 Epidemic in France for Several Combinations of Vaccination Strategies and Barrier Measures

The outbreak of the SARS-CoV-2 virus, enhanced by rapid spreads of variants, has caused a major international health crisis, with serious public health and economic consequences. An agent-based model was designed to simulate the evolution of the epidemic in France over 2021 and the first six months of 2022. The study compares the efficiencies of four theoretical vaccination campaigns (over 6, 9, 12, and 18 months), combined with various non-pharmaceutical interventions. In France, with the emergence of the Alpha variant, without vaccination and despite strict barrier measures, more than 600,000 deaths would be observed. An efficient vaccination campaign (i.e., total coverage of the French population) over six months would divide the death toll by 10. A vaccination campaign of 12, instead of 6, months would slightly increase the disease-related mortality (+6%) but require a 77% increase in ICU bed–days. A campaign over 18 months would increase the disease-related mortality by 17% and require a 244% increase in ICU bed–days. Thus, it seems mandatory to vaccinate the highest possible percentage of the population within 12, or better yet, 9 months. The race against the epidemic and virus variants is really a matter of vaccination strategy.

Chameleon project: a children’s end-of-life care quality improvement project

In response to there being no specialist paediatric palliative care (PPC) team in a region of England, we undertook a 12-month quality improvement project (funded by National Health Service England’s Marginal Rate Emergency Threshold and Readmission fund) to improve children’s end-of-life care.Improvements were implemented during two plan–do–study–act (PDSA) cycles and included specialist experts, clinical champions, focused education and training, and tools and materials to support identification, care planning and communication. A lead paediatrician with expertise in PPC (10 hours/week) led the project, supported by a PPC nurse (3 days/week) and a network administrator (2 days/week).Children who died an expected death were identified from the child death review teams. Numbers of non-elective hospital admissions, bed days, and costs were identified.Twenty-nine children died an expected death during the 12 months of the project and coincidentally 29 children died an expected death during the previous 12 months. The median number of non-elective admissions in the last 12 months of life was reduced from two per child to one. There was a reduction in specialist hospital (14%) and district general hospital (38%) bed days. The percentage of children who died an expected death who had anticipatory care plans rose from 50% to 72%.The results indicate that a network of clinicians with expertise in PPC working together across a region can improve personalised care planning and reduce admissions and bed days for children in their last year-of-life with reduced bed utilisation costs.

Impact of an electronic alert on prescription patterns of meropenem, voriconazole and caspofungin

Background Antimicrobial stewardship programs promote the appropriate use of antimicrobial substances through the implementation of evidence-based, active and passive interventions. We analyzed the effect of a computer-assisted intervention on antimicrobial use in a tertiary care hospital. Methods Between 2011 and 2016 we introduced an electronic alert for patients being prescribed meropenem, voriconazole and caspofungin. At prescription and at day 3 of treatment, physicians were informed about the risk related to these antimicrobial substances by an electronic alert in the medical records. Physicians were invited to revoke or confirm the prescription and to contact the infectious disease (ID) team. Using interrupted time series regression, the days of therapy (DOTs) and the number of prescriptions before and after the intervention were compared. Results We counted 64,281 DOTs for 5549 prescriptions during 4100 hospital stays. Overall, the DOTs decreased continuously over time. An additional benefit of the alert could not be observed. Similarly, the number of prescriptions decreased over time, without significant effect of the intervention. When considering the three drugs separately, the alert impacted the duration (change in slope of DOTs/1000 bed days; P = 0.0017) as well as the number of prescriptions (change in slope of prescriptions/1000 bed days; P < 0.001) of voriconazole only. Conclusions The introduction of the alert lowered prescriptions of voriconazole only. Thus, self-stewardship alone seems to have a limited impact on electronic prescriptions of anti-infective substances. Additional measures such as face-to-face prompting with ID physicians or audit and feedback are indispensable to optimize antimicrobial use.

O-EGS09 Effect of introducing an ambulatory care service on management of patients requiring acute cholecystectomy

Background Biliary pathology is a large tranche of the emergency surgical take, taking up many bed days, with many patients not receiving definitive management on their primary admission. An Emergency Surgical Ambulatory Care (ESAC) service was established at our hospital in 2019, aiming to provide a streamlined platform for diagnosis and surgical management of patients. Most notably this included patients with symptomatic gallstones which could be managed on a semi-urgent basis without hospital admission. We aim to analyse the efficiency of this novel service in hopes of identifying room for improvement so that we may enhance our patient outcomes. Methods Two time periods were retrospectively assessed; September-December 2018 (pre- ESAC) and September-December 2019 (six months after ESAC started). Patients with Cholelithiasis (ICD-K80) and Cholecystitis (ICD-K81) were identified, and those with either an incidental diagnosis of gallstones without symptoms, with gallstone pancreatitis, severe inflammation (empyema, gangrene, perforation), requiring ERCP or if they were unfit for surgery were excluded. Data was collected on number of admissions, length of stay and rate of cholecystectomy. Patients were divided into 2018 SAU, 2019 SAU and 2019 ESAC to compare the difference in their outcomes. Data are presented as median (range). Results Some 57 patients presented acutely in 2018 compared to 82 in 2019. The median wait to operation of 43.5 days in 2018 was significantly reduced to 7 days in 2019. Conclusions The introduction of an ESAC service in 2019 has allowed a reduction in number of admissions, total length of stay of patients and significantly reduced waiting time for surgery. Use of ESAC has shown to be more efficient in terms of hospital bed occupation and indirectly, utilization of resources. The high surgical success rate also ensures fewer patients re-presenting with the same pathology to the acute take and hence contributes to reducing strain on the on-call team. Further work is being done to reduce the number of patients presenting through the SAU pathway, and preferentially attending through ESAC.

Cost and consequences of using 7.1 % chlorhexidine gel for newborn umbilical cord care in Kenya

Background Omphalitis is an important contributor to neonatal mortality in Kenya. Chlorhexidine digluconate 7.1 % w/w (CHX; equivalent to 4 % w/w chlorhexidine) was identified as a life-saving commodity for newborn cord care by the United Nations and is included on World Health Organization and Kenyan Essential Medicines Lists. This pilot study assessed the potential resource savings and breakeven price of implementing CHX for neonatal umbilical cord care versus dry cord care (DCC) in Kenya. Methods We employed a cost-consequence model in a Kenyan birth cohort. Firstly, the number of omphalitis cases and cases avoided by healthcare sector were estimated. Incidence rates and treatment effect inputs were calculated from a Cochrane meta-analysis of randomised clinical trials (RCTs) (base case) and 2 other RCTs. Economic outcomes associated with omphalitis cases avoided were determined, including direct, indirect and total cost of care associated with omphalitis, resource use (outpatient visits and bed days) and societal impact (caregiver workdays lost). Costs and other inputs were sourced from literature and supplemented by expert clinical opinion/informed inputs, making necessary assumptions. Results The model estimated that, over 1 year, ~ 23,000 omphalitis cases per 500,000 births could be avoided through CHX application versus DCC, circumventing ~ 13,000 outpatient visits, ~ 43,000 bed days and preserving ~ 114,000 workdays. CHX was associated with annual direct cost savings of ~ 590,000 US dollars (USD) versus DCC (not including drug-acquisition cost), increasing to ~ 2.5 million USD after including indirect costs (productivity, notional salary loss). The most-influential model parameter was relative risk of omphalitis with CHX versus DCC. Breakeven analysis identified a budget-neutral price for CHX use of 1.18 USD/course when accounting for direct cost savings only, and 5.43 USD/course when including indirect cost savings. The estimated breakeven price was robust to parameter input changes. DCC does not necessarily represent standard of care in Kenya; other, potentially harmful, approaches may be used, meaning cost savings may be understated. Conclusions Estimated healthcare cost savings and potential health benefits provide compelling evidence to implement CHX for umbilical cord care in Kenya. We encourage comprehensive data collection to make future models and estimates of impacts of upscaling CHX use more robust.

Antimicrobial resistance and antibiotic consumption in intensive care units, Switzerland, 2009 to 2018

Background Intensive care units (ICU) constitute a high-risk setting for antimicrobial resistance (AMR). Aim We aimed to describe secular AMR trends including meticillin-resistant Staphylococcus aureus (MRSA), glycopeptide-resistant enterococci (GRE), extended-spectrum cephalosporin-resistant Escherichia coli (ESCR-EC) and Klebsiella pneumoniae (ESCR-KP), carbapenem-resistant Enterobacterales (CRE) and Pseudomonas aeruginosa (CRPA) from Swiss ICU. We assessed time trends of antibiotic consumption and identified factors associated with CRE and CRPA. Methods We analysed patient isolate and antibiotic consumption data of Swiss ICU sent to the Swiss Centre for Antibiotic Resistance (2009–2018). Time trends were assessed using linear logistic regression; a mixed-effects logistic regression was used to identify factors associated with CRE and CRPA. Results Among 52 ICU, MRSA decreased from 14% to 6% (p = 0.005; n = 6,465); GRE increased from 1% to 3% (p = 0.011; n = 4,776). ESCR-EC and ESCR-KP increased from 7% to 15% (p < 0.001, n = 10,648) and 5% to 11% (p = 0.002; n = 4,052), respectively. CRE, mostly Enterobacter spp., increased from 1% to 5% (p = 0.008; n = 17,987); CRPA remained stable at 27% (p = 0.759; n = 4,185). Antibiotic consumption in 58 ICU increased from 2009 to 2013 (82.5 to 97.4 defined daily doses (DDD)/100 bed-days) and declined until 2018 (78.3 DDD/100 bed-days). Total institutional antibiotic consumption was associated with detection of CRE in multivariable analysis (odds ratio per DDD: 1.01; 95% confidence interval: 1.0–1.02; p = 0.004). Discussion In Swiss ICU, antibiotic-resistant Enterobacterales have been steadily increasing over the last decade. The emergence of CRE, associated with institutional antibiotic consumption, is of particular concern and calls for reinforced surveillance and antibiotic stewardship in this setting.