Addressing Concerns about Changing the Route of Antimicrobial Administration from Intravenous to Oral in Adult Inpatients

Background:Many health care institutions are in the process of establishing antimicrobial stewardship programs. Changing the route of administration of antimicrobial agents from intravenous to oral (IV to PO) is a simple, well-recognized intervention that is often part of an antimicrobial stewardship program. However, the attending health care team may have concerns about making this switch.Objectives:To provide insights into common concerns related to IV to PO conversion, with the aim of helping antimicrobial stewardship teams to address them.Conclusions:When considering a change to oral therapy, it is important to have a thorough understanding of key aspects of the antimicrobial agent, the patient, and the disease being treated. The antimicrobial stewardship team has an important role in facilitating IV to PO conversion, educating prescribers, and addressing any concerns or reservations that may interfere with timely transition from IV to PO administration.     

Antimicrobial stewardship in the intensive care unit: a focus on potential pitfalls

Patients in the intensive care unit (ICU) have many risk factors for resistant pathogens such as prolonged length of stay, frequent and broad-spectrum antimicrobial therapy, presence of foreign materials, and proximity with other patients. However, of the risk factors associated with acquisition of resistant pathogens, inappropriate use of antimicrobial agents has been the most implicated. Thus, many health care institutions have adopted antimicrobial stewardship programs (ASPs) as a mechanism to ensure more appropriate antimicrobial use. ASPs can have a significant impact in the ICU, leading to improved antimicrobial use and resistance patterns and decreased infection rates and costs, due to the inherent nature of infections encountered and high and often inappropriate antibiotic utilization in this setting. However, certain challenges exist for ASPs in the ICU including issues with infrastructure and personnel, information technology, the core ASP strategy, patient-specific factors, conversion of intravenous to oral therapy, and dose optimization. The combination of comprehensive infection control (IC) and effective antimicrobial stewardship can prevent the emergence of resistance among microorganisms and may decrease the negative consequences associated with antimicrobial misuse.     

A Qualitative Analysis of Implementation of Antimicrobial Stewardship at 3 Academic Hospitals: Understanding the Key Influences on Success

Background:

Inappropriate use of antimicrobials is linked to the development and spread of drug-resistant pathogens and is associated with increased morbidity, mortality, lengths of hospital stay, and health care costs. “Antimicrobial stewardship” is the umbrella term for an evidence-based knowledge translation strategy involving comprehensive quality improvement activities to optimize the use of antimicrobials, improve patient outcomes, reduce the development of antimicrobial resistance and hospital-acquired infections such as Clostridium difficile, and decrease health care costs.

Objective:

To assess the perceptions and experiences of antimicrobial stewardship program leaders in terms of clinicians’ attitudes toward and behaviours related to antimicrobial prescribing.

Methods:

In this qualitative study, semistructured interviews were conducted with 6 antimicrobial stewards (2 physicians and 4 pharmacists) at 3 academic hospitals between June and August 2013.

Results:

The following 3 key themes emerged from the interviews: getting the right people on board, building collegial relationships, and rapidly establishing a track record. The study results elucidated the role and mechanisms that the program leader and other antimicrobial stewards used to influence other clinicians to engage in effective utilization of antimicrobials. The results also highlighted the methods employed by members of the antimicrobial stewardship team to tailor their strategies to the local context and to stakeholders of participating units; to gain credibility by demonstrating the impact of the antimicrobial stewardship program on clinical outcomes and cost; and to engage senior leaders to endorse and invest in the antimicrobial stewardship program, thereby adding to the antimicrobial stewards’ credibility and their ability to influence the uptake of effective antimicrobial use.

Conclusions:

Collectively, these results offer insight into processes and mechanisms of influence employed by antimicrobial stewards to enhance antimicrobial use among clinicians, which can in turn inform future implementation of antimicrobial stewardship and strategies for organizational change in hospitals.     

Antimicrobial stewardship programs as a means to optimize antimicrobial use. Insights from the Society of Infectious Diseases Pharmacists

Each year, approximately 2 million people in the United States contract an infection during a hospital stay. An increasing percentage of these institutionally acquired infections are attributed to antimicrobial-resistant organisms. At the same time, studies and surveys suggest that as much as half of all antimicrobial use is inappropriate. Recommendations for preventing and reducing antimicrobial resistance in hospitals stress the importance of improving antimicrobial use, referred to as antimicrobial stewardship, at the institutional level. Antimicrobial stewardship programs have served as wake-up calls to both clinicians and health care administrators. We review the more recent literature concerning the impact of antimicrobial stewardship programs on costs, outcomes, and resistance and summarize important considerations for implementation of these programs.     

Need for pharmacists to contribute to infection control and building patient safety

With the revisions to the Japanese medical institutions law of April 2006, an improved medical care security system in a medical institution is indispensable. More and more medical institutions are now assigning full-time pharmacists to the task of medical safety. Hospital pharmacy sections are utilizing a valid evaluation system developed by the Japan Council for Quality Health Care. Pharmaceutical specialists who contribute to medical security, such as certified oncology pharmacists and certified infection control pharmacists (CICPha) are much awaited. In addition, the DPC (Diagnosis Procedure Combination) system has now become widespread in Japan, and the call is for pharmaceutical care that can decrease medical costs. It is imperative for health care systems to assure the appropriate use of drugs to decrease medical costs without reducing medical services. CICPha can contribute to the antimicrobial management program, and has also focused on medical care security. Several antimicrobial management programs of broad-spectrum agents, i.e., formulary restriction and prior approval, are gradually being enforced in Japan. The CICPha role is far-reaching, and it should make a concerted effort to prevent the injudicious use of antimicrobial agents resulting in the emergence of drug resistance; this must be handled by infection control doctors and nurses along with microbiological technicians. The CICPha must regulate the appropriate use of these agents, and perform surveillance of antimicrobial use and resistance (AUR). We describe the necessity and evaluation of AUR, and also underscore the necessity of training clinical pharmacists who will contribute to patient safety in days to come.     

Evaluation of Antimicrobial Stewardship Programs (ASPs) and their perceived level of success at Makkah region hospitals,Kingdom of Saudi Arabia

Antimicrobial stewardship programs (ASPs) are collaborative efforts to optimize antimicrobial use in healthcare institutions through evidence-based quality improvement strategies. The general administration of pharmaceutical care in the Saudi ministry of health (MOH) is putting outstanding efforts in implementing antimicrobial stewardship in Saudi health care settings. Several surveys have been conducted globally and reported many types of antimicrobial stewardship strategies in health institutions and their effectiveness. This study aims to identify ASPs in Makkah region hospitals and their perceived level of success. We administered a regional survey to explore current progress and issues related to the implementation of ASPs in Makkah region hospitals at the pharmacy level (n = 25). Among responding hospitals, 19 (76%) hospitals, the most commonly reported ASP were as following: formulary restrictions (90%) for broad-spectrum antimicrobials and use of prospective feedback on antimicrobial prescribing (68%), use of clinical guidelines and pathways (100%), and use of automatic stop orders (68%) to limit inappropriate antimicrobial therapy. The study outcomes will also be of pivotal importance to devise policies and strategies for antimicrobial stewardship implementation in other non-MOH settings in the Makkah region. Based on our results, all reported institutions have at least one antimicrobial stewardship program in a process with a high success rate. A multidisciplinary ASP approach, active involvement of drug & therapeutic committee, formulary restrictions, and availability of education & training of pharmacists and physicians on ASP are the primary elements for perceived successful antimicrobial stewardship programs in the Makkah region hospitals.     

Assessing antibacterial pharmacoeconomics in the intensive care unit

Intensive care units (ICUs) represent areas of high use of antibacterials and other pharmacy goods and services. Many institutions view their ICUs as a target for drug-use surveillance and cost-containment programmes. Economic assessment of antibacterial interventions in the ICU should include all direct costs and patient outcomes. Nonetheless, many of these institutions focus their efforts at reducing antibacterial costs without considering the consequences of these actions. It is possible that devoting more resources to antibacterials can have an overall positive economic impact if more appropriate antibacterial use reduces length of stay, decreases bacterial resistance or lowers frequency of adverse complications. Two consequences of antibacterial use which can result in substantial economic burdens to institutions are drug-induced complications (toxicities and adverse events) and the development of antibacterial-resistant organisms. These events are logical targets for performing pharmacoeconomic studies to evaluate appropriate and inappropriate antibacterial use. Either of these problems can increase length of stay, which is the single most important variable influencing the overall cost of patient care. The primary goal of patient care is to hasten patients' clinical improvement. This will result in decreased antibacterial acquisition costs, decreased lengths of ICU and hospital stays, and ultimately decreased consumption of hospital resources. These can be accomplished by using strategies to guide antibacterial use in order to reduce failures, adverse events, toxicity and antimicrobial resistance.     

Antimicrobial stewardship – can we afford to do without it?

Antimicrobial resistance (AMR) is a rapidly developing and alarming global threat which has been highlighted by national governments and public health bodies including the World Health Organization. The spectre of a ‘post-antibiotic era’ is a real possibility unless curtailing the development and spread of these organisms is given high priority. Numerous studies have shown that AMR is associated with worse outcomes for patients and higher healthcare costs. While clinical data from low and middle income countries is lacking, there is increasing evidence that the problem in these areas is as great, or even greater, than in high income nations. Of the many drivers behind the development of AMR, the most significant is selection pressure caused by antibiotic use. Antimicrobial stewardship programmes are a set of interventions that aim to ensure the judicious use of antimicrobials by preventing their unnecessary use, and by providing targeted and limited therapy in situations where they are warranted. The ultimate goal of these programmes is to provide effective antimicrobial therapy whilst safeguarding their effectiveness for future generations. Whilst they do require an initial investment, they have been shown to be an effective way of controlling antimicrobial use, and have been associated with improved patient outcomes and reduced healthcare costs.     

Expert clinical decision support systems to enhance antimicrobial stewardship programs: insights from the society of infectious diseases pharmacists

Health care-associated infections (HAIs) are a leading cause of in-hospital mortality and adverse events such as antimicrobial resistance. These infections place tremendous burdens on the health care system and create situations for misuse of antimicrobial drugs. Recognition of these factors has led professional societies, clinicians, and hospitals to develop programs to improve the management of HAIs and the use of antimicrobial drugs. The clinical literature is replete with examples of these programs, often referred to as antimicrobial stewardship. Traditionally, antimicrobial stewardship programs have relied on manual methods combined with clinical oversight and intervention. The advent of modern health care information technology offers the opportunity to expand the breadth and depth of these programs. Expert clinical decision support systems are the most promising of these information technology advances.     

Indications for home intravenous antibiotic therapy in The Netherlands

Advances in technology, such as new antimicrobial drugs and new equipment, have led to an increased interest in home intravenous antibiotic therapy (HIVAT) in The Netherlands. The aim of this study was to evaluate HIVAT in terms of costs, effectiveness and patient experience. Seventy-five patients with an infectious disease were treated by a transmural intravenous antibiotic therapy (TIVAT) programme at home for approximately 2000 days. An individual protocol and training was given to each patient and the care givers so that patients could perform the home treatment themselves with, in most cases, the help of family and friends. Optimal use was made of existing health care structures like hospital facilities, pharmacies and the general practitioner. TIVAT is an example of intensive home care. Preliminary data show that it seems safe, effective and cost-efficient with positive patient experiences. A once-daily dosage regimen of the antimicrobial agent was preferable.     

Development of an Antimicrobial Stewardship-based Infectious Diseases Elective that Incorporates Human Patient Simulation Technology

Objective. To design an elective for pharmacy students that facilitates antimicrobial stewardship awareness, knowledge, and skill development by solving clinical cases, using human patient simulation technology.Design. The elective was designed for PharmD students to describe principles and functions of stewardship programs, select, evaluate, refine, or redesign patient-specific plans for infectious diseases in the context of antimicrobial stewardship, and propose criteria and stewardship management strategies for an antimicrobial class at a health care institution. Teaching methods included active learning and lectures. Cases of bacterial endocarditis and cryptococcal meningitis were developed that incorporated human patient simulation technology.Assessment. Forty-five pharmacy students completed an antimicrobial stewardship elective between 2010 and 2013. Outcomes were assessed using student perceptions of and performance on rubric-graded assignments.Conclusion. A PharmD elective using active learning, including novel cases conducted with human patient simulation technology, enabled outcomes consistent with those desired of pharmacists assisting in antimicrobial stewardship programs.     

A multidisciplinary approach to antimicrobial stewardship: evolution into the 21st century

In the 21st century, we face the problems of escalating antibiotic resistance, difficult-to-treat infections and slowed new drug development. Healthcare practitioners are increasingly recognising the importance of good antimicrobial stewardship. Various strategies such as formulary management, prior approval, clinical pathways, post-prescribing evaluation and intravenous to oral conversion have been used singly or in combination to improve prescribing and reduce costs. Combining a multifaceted approach with a full-time dedicated multidisciplinary team appears to be capable of yielding satisfactory clinical and economic outcomes and most importantly, sustaining efforts of antimicrobial stewardship. The multidisciplinary approach to antibiotic management should be tailored to fit the individual needs of an institution. More data are needed to document effects on curbing resistance.     

关节置换术后感染的药物治疗

髋和膝等关节置换术后的人工关节感染6个月内发生率较高,其致病菌主要为凝固酶阴性葡萄球菌、金葡菌、链球菌属、革兰阴性杆菌、厌氧菌等,多采用以静脉或口服高生物利用度的抗感染药物或联合治疗以控制其感染的治疗方案。综述国内外近年来在关节置换术后控制感染的药物治疗的研究进展文献,并对其作了分析与论述。     

社区卫生服务机构门诊抗菌药物应用情况分析

目的回顾性分析2010年我市社区卫生服务机构门诊处方抗菌药物应用情况,为合理使用抗菌药物提供参考。方法随机抽取我市5个社区卫生服务机构2010年1~10月6000张使用抗菌药物的处方。分析抗菌药物使用情况。结果被调查的社区卫生服务机构门诊患者抗菌药物使用不合格率为48.5%。结论应加强干预和管理,促进安全合理使用抗菌药物。     

Drug-usage evaluation: traditional versus outcome-based approaches

The use of outcome assessment with DUE can provide more detailed information on the impact of drug therapy on the overall health status of the patient, rather than just the narrow view of the drug-prescribing process within the institution. These studies may justify additional pharmacists to help in the selection of drugs and their potential to affect overall quality patient care. In addition, the Joint Commission is recommending that measurement of health outcomes is important in QA. The Joint Commission has stated in their Agenda for Change program "that patient outcomes are influenced by all activities of a health care program." The Joint Commission plans to develop standards that "describe in functional terms what the key jobs are that need to be done to produce good patient outcomes." The major problem with adding outcome measures in the assessment of DUE programs is the evolutionary nature of the available technology to measure these patient outcomes. Incorporation of outcome measures into DUE programs can provide measures of the impact of drug therapy on the patients' HQOL. This HQOL is potentially a better reflection of patient outcomes and the assessment of quality of care.     

Managed care is utilization review

The role of utilization review (UR) as a form of managed care is described. As technology has advanced, the use of diagnostic and therapeutic services has increased and care delivery has shifted to outpatient settings, but the increase in healthcare costs has not slowed. The shift to delivery of medical care outside the hospital setting has increased the need for effective UR in both inpatient and outpatient settings. UR is performed not only by private UR organizations and through external review programs of insurance carriers but also through care-providers' internal programs. UR has been driven by increased medical costs and by redesign of insurance benefit plans to include financial incentives and penalties and copayments. UR has attempted to control the use of hospital services through preadmission certification and concurrent review, requirements for second surgical opinions, and medical case management, which is the identification before or during hospitalization of patients who could safely receive treatment outside the hospital. In-patient mental health and substance-abuse programs have been the subject of intensive review because of high expenditures for such services. Practice indicators are being developed that will be used for prospective determination of treatment plans. As UR techniques improve, management of care in all organized health-care settings will intensify.     

Healthcare costs and prescription adherence with introduction of thiazolidinedione therapy in Medicaid type 2 diabetic patients: a retrospective data analysis

OBJECTIVES: Outcomes in patients with type 2 diabetes may vary depending on the antidiabetic medication used. Observational studies of outcomes of diabetes pharmacotherapy are needed to understand the implications of choice of controller in different populations. This study compared differences in total health care costs, medication adherence, and persistence in patients with type 2 diabetes enrolled in the North Carolina Medicaid Program that were newly started on thiazolidinedione (TZD) therapy with patients starting other oral antidiabetics during the same period. In addition differences among the TZDs with respect to these outcomes were examined. METHODS: A total of 1774 patients newly starting TZD therapy between July 2001 and June 2002 were compared to 1709 patients starting other oral antidiabetic medication (metformin or sulfonylureas) for health care costs and outcomes in the post-medication start year. In addition, a sub-group analysis of health care costs in patients starting either TZD (pioglitazone [n = 1086] versus rosiglitazone [N = 688]) was compared. All included patients had complete enrollment for the 24 months of follow-up. Multivariate techniques incorporating health care utilization in the year prior to start of new therapy were utilized to determine the cost impact of one therapy versus another. RESULTS: Results of multiple regression analyses suggest that patients starting TZD have better treatment adherence and persistence in the post-medication start year compared to patients starting other oral antidiabetics (13% increase in Medication Possession Ratios, and 10% increase in therapy persistence index, both p < 0.001). In addition, patients starting TZDs had 16.1% lower total annual health care costs (p < 0.01) compared to patients starting other oral antidiabetics. There were no differences in adherence and cost outcomes between the 2 TZDs. CONCLUSIONS: Introduction of thiazolidinedione therapy in a Medicaid-enrolled type 2 diabetic population was associated with significantly improved treatment adherence, persistence, and lower annual health care costs in the post-start year compared to patients starting other oral antidiabetics.     

The role of the pharmacist in home health care

Home infusion services, a new facet of home health care (HHC) delivery, have created many new opportunities for hospital pharmacists to participate more actively in patient care. These opportunities can create new roles for the pharmacist as an educator, clinician, and administrator. Early efforts must be made to educate hospital administrators, physicians, and other allied health personnel regarding the advantages and disadvantages of providing HHC--from the perspective of both patients and institutions. The pharmacist can also collect data to assist in determining the extent to which the institution should participate in HHC delivery, and should coordinate the hospital's efforts to initiate home infusion services. Pharmacists should play an active role in screening, selecting, and training patients for HHC before discharge. The input of pharmacists in drug product selection and assistance in product compounding can ensure optimal patient outcomes and minimize costs. Clinical monitoring activities conducted by the pharmacist can include telephone interviews with patients at home and assessment of clinical progress during scheduled return visits to the clinic.