Implementation and outcomes of a hospital-wide computerised antimicrobial stewardship programme in a large medical centre in Taiwan

Antibiotic stewardship is important to address the problem of antimicrobial resistance, but a practical and sustainable strategy to provide stewardship in a large hospital setting is lacking. We developed a hospital-wide computerised antimicrobial approval system (HCAAS) to guide the use of antimicrobial agents in late 2004 in a 3500-bed medical centre in Taiwan. The objective of this study was to evaluate the impacts of HCAAS on the hospital from 2003 to 2009. Following HCAAS deployment, the gradients of consumption over time during the study period of third- and fourth-generation cephalosporins, fluoroquinolones and glycopeptides fell significantly, whilst that of carbapenems increased. The amount and expenditure of antimicrobial use did not increase with the overall healthcare-associated infection rate, and inpatient mortality rate remained stable with a slight decreasing trend. The rate of meticillin-resistant Staphylococcus aureus started to decline in 2002 and continued after HCAAS deployment. There was an increasing isolation of extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae, presumably leading to the increased use of carbapenems. The isolation rate of Clostridium difficile from patients who developed diarrhoea after antimicrobial therapy did not change over the years, with a mean annual rate of 10.0% after the implementation of HCAAS. HCAAS along with strict infection control measures is necessary to reduce the spread of resistant organisms within the hospital. HCAAS is a sustainable system for providing antibiotic stewardship and exerts a positive impact on the hospital by reducing antimicrobial consumption and expenditure whilst not compromising healthcare quality.     

Community pharmacy interventions to improve antibiotic stewardship and implications for pharmacy education: A narrative overview

BackgroundAntibiotic resistance is one of the world's most pressing public health problems, resulting in over 23,000 deaths per year. One of the main contributing factors to antimicrobial resistance is antibiotic misuse and overuse. Community pharmacists can play a role in reducing antibiotic resistance, since they are one of the most accessible healthcare professionals.ObjectiveThe purpose of this paper is to describe community pharmacy interventions and strategies to reduce antibiotic misuse and overuse and to discuss the implications for pharmacy training.MethodsA narrative overview strategy was employed to identify papers on antibiotic stewardship and the role of the community pharmacist. Our review examined potential stewardship strategies and interventions within community pharmacy practice that provide opportunities for pharmacists to engage or lead in the reduction of antimicrobial resistance.ResultsWe describe five promising community pharmacist-led intervention strategies: Collaborative Practice Agreements (CPAs), point-of-care (POC) testing, patient consultations, academic detailing and serving as an advocate for patients and other healthcare providersConclusionsThis review highlights topics that may warrant increased attention in pharmacy school curricula. Pharmacy schools may want to consider modifying their curricula to address the shifts in practice of the community pharmacist – emphasizing the expanded role of the pharmacist in patient care and public health issues such as outpatient antibiotic stewardship.     

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.     

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.     

Impact of Antimicrobial Stewardship Interventions on Antimicrobial Utilization in Asymptomatic Bacteriuria

Background: Antimicrobial therapy for asymptomatic bacteriuria (ASB) is often unnecessary and is a common reason for inappropriate antimicrobial use in hospitalized patients. Unnecessary ASB treatment leads to collateral damage such as resistance, and Clostridium difficile infections. This study evaluated the impact of interdisciplinary antimicrobial stewardship interventions on antimicrobial utilization in ASB. Methods: This was a quasi-experimental institutional review board (IRB)-approved study evaluating the impact of antimicrobial stewardship on antibiotic utilization for ASB in a pilot medical-surgical unit. The control phase was from August-October 2017 and the postintervention phase was from December-March 2018. In the control phase, electronic medical records of patients with positive urine cultures were retrospectively reviewed. Patients were classified as either having ASB or urinary tract infection (UTI) based on the absence or presence of UTI symptoms documented in the medical record. The intervention phase consisted of educational in-services to providers, nurses, and pharmacists. Clinical pharmacists for the pilot unit utilized an electronic real-time surveillance system to identify patients with positive urine cultures. With nurses’ collaboration, clinical pharmacists classified these patients as either having UTI or ASB. Stewardship interventions were made in real-time to discontinue antibiotics in patients with ASB. Results: There were 65 and 77 patients with bacteriuria in the pre- and postintervention phases. Among these, ASB was present in 29 (45%) and 27 (35%) patients, respectively. After excluding those receiving antibiotics for concurrent nonurinary indications, the combination of education with pharmacist and nursing interventions decreased unnecessary ASB treatment from 18 (62%) to 6 (22%) patients (relative risk: 0.36, 95% confidence interval: 0.16-0.72, P = .003). Conclusion: The findings of this study highlight the importance of interdisciplinary interventions in reducing unnecessary antimicrobial therapy for the treatment of ASB. With increasing antimicrobial resistance, healthcare institutions should evaluate the role of these interdisciplinary interventions to reduce unnecessary treatment for ASB.     

Opportunities for antimicrobial stewardship among carbapenem-treated patients in 18 North American hospitals

Here we describe the characteristics of carbapenem use at 18 hospitals across North America. Adult inpatients treated with a carbapenem for ≥24 h were included in this multicentre, retrospective, cross-sectional study. Outcomes evaluated included classification of therapy as empirical or definitive, discharge disposition and 30-day re-admission. A total of 621 patients were included in this study. Of these, 467 patients (75.2%) received a carbapenem empirically, among whom negative cultures occurred in 313 (67.0%) and 93% were eligible for de-escalation of therapy. In-hospital mortality occurred in 72 patients (11.6%) and 549 patients (88.4%) were discharged. Of the 549 patients who were discharged, 349 patients (63.6%) went home and 30-day infection-related re-admission occurred in 95 patients (17.3%). This population represents a significant need for carbapenem stewardship. Institutional guidelines should focus on four common disease states (respiratory, genitourinary, intra-abdominal and bloodstream), and diagnostic stewardship should be employed to aid in rapid de-escalation of carbapenem therapy. Additional studies aiming to identify antimicrobial stewardship techniques that may help to optimise carbapenem therapy and increase education about the importance of utilising carbapenem-sparing regimens are required.     

The preparation of orally disintegrating tablets using a hydrophilic waxy binder

The demand for rapidly disintegrating tablets (RDT) has been growing during the last decade especially for elderly and children who have swallowing difficulties. The problem of certain RDT is their low physical resistance and high friability. This work describes a new approach to prepare RDT with sufficient mechanical integrity, involving the use of a hydrophilic waxy binder (Superpolystate, PEG-6-stearate). Superpolystate is a waxy material with a melting point of 33-37 degrees C and an HLB value of 9. So it will not only act as a binder and increase the physical resistance of tablets but will also help the disintegration of the tablets as it melts in the mouth and solublises rapidly leaving no residues. The incorporation of Superpolystate in the formulation of RDT was realised by means of two different granulation methods: wet granulation by using an emulsion of this waxy binder as granulating liquid and melt granulation where the molten form of the binder was used. Granule size distributions of both wet and melt granules of crystallised Paracetamol and D-mannitol were compared using laser light diffractometer. Scanning electron microscopy (SEM) was used to examine their morphological characteristics. The potential of the intragranular addition of croscarmellose sodium as a disintegrating agent was also evaluated. The subsequent step encompassed the preparation and the evaluation of the tablets, including the effect of the extragranular introduction of croscarmellose sodium. An improvement in tablet hardness and friability was observed with both granulation methods where we were able to obtain RDT with a disintegration time of 40 +/- 2 s and a hardness of 47.9 +/- 2.5N.     

临床药师在抗菌药物管理中的作用探讨

本文通过介绍国外抗菌药物的管理程序与感染专业临床药师的工作模式,结合我国临床药师的工作现状,探讨临床药师在抗菌药物管理中的作用.主要内容为美国和英国药师在限制使用药品管理中的作用、我国临床药师参与卫生部抗菌药物临床应用监测网、参与医院抗菌药物品种的评估和基本用药目录的制定、参与处方点评与抗菌药物的主动干预等情况.通过与国外药师工作的比较,认为感染专业临床药师应该在感染性疾病的病房里有自己的工作岗位,不断培训,并通过处方点评和有可监督抗菌药物使用情况的网络系统,在一定程度上直接参与抗菌药物合理应用的干预工作.并提出参与抗菌药物的管理计划,减少药物的不合理使用,优化抗菌药物治疗,同时降低药物带来的不良后果是感染专业临床药师工作的目的和发展方向.     

Implementation of a pharmacist-led antimicrobial management team in a community teaching hospital: use of pharmacy residents and pharmacy students in a prospective audit and feedback approach

Antimicrobial stewardship is an important process proven to combat antimicrobial resistance, improve patient outcomes, and reduce costs. The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have provided guidelines for the provision of antimicrobial stewardship. According to these recommendations, antimicrobial stewardship teams should be multidisciplinary in nature, with core members consisting of an infectious disease physician and an infectious disease-trained clinical pharmacist. Due to limited resources, our institution chose to implement a pharmacist-led antimicrobial stewardship service on 1 medical/surgical ward, with the existing clinical pharmacist and 3 infectious disease physicians as core members. This clinical pharmacist was not trained in infectious disease specialty, and stewardship activities were only one part of his daily activities. Pharmacy residents and students were extensively utilized to assist in the stewardship process. Approximately two thirds of stewardship recommendations were accepted using primarily a prospective audit and feedback approach.     

Determination of the in vitro disintegration profile of rapidly disintegrating tablets and correlation with oral disintegration

The assessment of the in vitro disintegration profile of rapidly disintegrating tablets (RDT) is very important in the evaluation and the development of new formulations of this type. So far neither the US Pharmacopoeia nor the European Pharmacopoeia has defined a specific disintegration test for RDT; currently, it is only possible to refer to the tests on dispersible or effervescent tablets for the evaluation of RDT's disintegration capacity. In the present study, we have evaluated the disintegration profile of RDT manufactured by main commercialised technologies, using the texture analyser (TA). In order to simulate as much as possible the oral disintegration of these dosage forms, a new operating structure was developed. This structure mimics the situation in the patient's mouth and provides a gradual elimination of the detached particles during the disintegration process. The obtained time-distance profiles or disintegration profiles enabled the calculation of certain quantitative values as the disintegration onset (t1) and the total disintegration time (t2). These values were used in the characterisation of the effect of test variables as the disintegration medium and temperature on the disintegration time of RDT. Moreover, the oral disintegration time of the same products was evaluated by 14 healthy volunteers. Results obtained when artificial saliva at 37 degrees C was employed as disintegration medium were used to correlate the in vitro (t2) and oral disintegration times. Excellent correlation was found and in addition, we were able to achieve a qualitative measure of the mouthfeel by comparing the thickness of the tablets and the penetration distance obtained from the disintegration profile. This method also permitted the discrimination between different RDT, where differences in the disintegration mechanism were reflected on the disintegration profile achieved for each tablet.     

Alveolar permeability to protein in rats differentially susceptible to ozone

Sprague-Dawley rats susceptible (DS) to NaCl-induced hypertension suffer higher mortality when exposed daily to 2.0 ppm ozone than do hypertension-resistant (DR) rats, independent of salt in the diet or systemic blood pressure. To investigate one possible contribution to this differential sensitivity to ozone, alveolar permeabilities to serum albumin were measured both in ozone-exposed and in control DS and DR rats. Female rats aged 5-7 weeks maintained on a low-salt (0.4% NaCl) diet were injected intravenously with 125I-bovine serum albumin and were then exposed to either 2.0 ppm ozone or air for 5 h. After pentobarbital anesthesia, the rats were exsanguinated and their lungs were lavaged in situ with saline. Lavage fluids and blood samples were measured for radioactivity using a NaI-well gamma counter. The results indicated that while DS and DR control rats have similar pulmonary permeabilities to 125I-albumin, the lungs of the ozone-exposed DS animals were 63% (p less than 0.02) more permeable than those of DR rats exposed to ozone. Sloughing of epithelial tissue, mucous formation and an accumulation of macrophages in the end-airways were more pronounced among ozone-exposed DS animals than in DR-ozone-exposed rats. This increased damage among DS rats correlated well with the increased protein permeability levels. In similar studies, Sprague-Dawley (D) rats were more variable in their response to ozone than either inbred strain. However, the results appeared generally more like those of the DS animals, suggesting that the trait selected by inbreeding may have been resistance rather than sensitivity to ozone-induced lung injury.     

Considerations in the treatment of anxiety disorders: a pharmacoeconomic review

Anxiety disorders are a group of common mental disorders that impose a significant economic burden on the healthcare system and society. For this review of published literature on the pharmacoeconomics of treating anxiety disorders, various studies of the cost, resource use and the economic outcomes of pharmacological treatment were examined. Numerous studies have been published that document how the excessive costs associated with anxiety disorders, especially panic disorder, result from a combination of factors including under-recognition and misdiagnosis of the problem by primary healthcare providers, high medical resource utilisation including unnecessary or inappropriate diagnostic tests and high levels of medical help-seeking behaviour by patients. Little information has been available on the economic effects of pharmacotherapy for anxiety disorders but recent studies have shown that selective serotonin re-uptake inhibitors (SSRIs) are associated with a shift in medical resource utilisation (lower rates of emergency department and laboratory visits) which can potentially result in decreased healthcare expenditures. Facilitating an increased awareness among primary healthcare providers of the anxiety disorders and utilising appropriate diagnostic and treatment strategies can benefit patients while providing more efficient and effective healthcare spending leading to an overall reduction in the burden of disease.     

Reducing the development of antibiotic resistance in critical care units

Bacteria becoming resistant to an increasing number of antibiotic classes are a major problem at hospitals including critical care units worldwide. Awareness of this problem and the need to prevent the development of antibiotic resistance are very important, especially since very few new antibiotics will become available in the near future. This article gives an overview of the mechanisms of antibacterial resistance and actual resistance data worldwide of the most prevalent Gram positive (MRSA, VISA/VRSE and VRE) and Gram negative bacteria (Pseudomonas aeruginosa, Acinetobacter spp., ESBL producing Enterobacteriaceae and Stenotrophomonas maltophilia). Furthermore, strategies to reduce antibiotic resistance are reviewed. Most important is institution of infection control policies including guidelines on surveillance, isolation of colonized patients and contact precautions, hand hygiene, decolonization measures and environmental decontamination. Antimicrobial stewardship, or striking the balance between an optimal antibiotic treatment for a patient and a minimal risk of development of antibiotic resistance, is another important strategy. Finally, optimizing of antibiotic dosage regimens and thus avoiding underdosage is essential to avoid selection of the most resistant subpopulation of bacteria during antibiotic treatment. Intensive care units with knowledge of local epidemiology of resistance, an effective infection control program and antimicrobial stewardship policy tailored to their specific needs, and using optimal antibiotic dosing regimens have both locally decreased the risk of an outbreak with multi-resistant bacteria, and maybe even more important help to reduce the development of antibiotic resistance.     

Considerations in the treatment of anxiety disorders: a pharmacoeconomic review

Anxiety disorders are a group of common mental disorders that impose a significant economic burden on the healthcare system and society. For this review of published literature on the pharmacoeconomics of treating anxiety disorders, various studies of the cost, resource use and the economic outcomes of pharmacological treatment were examined. Numerous studies have been published that document how the excessive costs associated with anxiety disorders, especially panic disorder, result from a combination of factors including under-recognition and misdiagnosis of the problem by primary healthcare providers, high medical resource utilisation including unnecessary or inappropriate diagnostic tests and high levels of medical help-seeking behaviour by patients. Little information has been available on the economic effects of pharmacotherapy for anxiety disorders but recent studies have shown that selective serotonin re-uptake inhibitors (SSRIs) are associated with a shift in medical resource utilisation (lower rates of emergency department and laboratory visits) which can potentially result in decreased healthcare expenditures. Facilitating an increased awareness among primary healthcare providers of the anxiety disorders and utilising appropriate diagnostic and treatment strategies can benefit patients while providing more efficient and effective healthcare spending leading to an overall reduction in the burden of disease.     

厄他培南应用对医院革兰阴性菌耐药性影响的系统综述

目的：探讨厄他培南应用对于医院革兰阴性菌耐药性的影响,为医院抗菌药物管理提供决策支持。方法：对相关中、英文数据库中关于厄他培南对医院革兰阴性菌耐药性影响的文献进行系统综述。结果：经计算机系统检索到4098篇文献,进一步筛选得到17篇符合入选和排除标准的文献。所纳入文献研究的菌种主要为院内感染常见的铜绿假单胞菌（Pseudomonas aeruginosa,Pae）,鲍曼不动杆菌（Acinetobacter baumannii,Aba）、大肠埃希菌（Escherichia coli,Eco）及肺炎克雷伯菌（Klebsiella pneumoniae,Kpn）,研究周期从24个月至132个月不等,研究方法主要为时间序列分析法。由于研究环境,研究周期以及研究方法不完全相同,各文献的研究结果也不完全一致。对于Pae和Aba耐药性的影响主要有3种结果,即正向,负向和无影响;对于厄他培南抗菌谱可以覆盖的肠杆菌科细菌如Eco,Kpn的研究结果有两种即负向的影响和无影响。结论：厄他培南对于医院常见革兰阴性菌的耐药性并无明显的不利影响,有其适应证时可优先选用,但是各家医院有条件仍需进行持续性的耐药监测,以指导临床实践和抗菌药物管理。     

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.