Evaluation of antimicrobial therapy orders circumventing an antimicrobial stewardship program: investigating the strategy of "stealth dosing".

OBJECTIVE: Prior-approval antimicrobial stewardship programs (ASPs) improve patient outcomes and decrease antimicrobial resistance. These benefits would be limited if physicians circumvented ASP efforts. We evaluated whether prescribers wait until after the prior-approval period to order restricted antimicrobial therapy that is in conflict with guidelines or unnecessary. DESIGN: A cross-sectional study design and a retrospective cohort study design. SETTING: A tertiary care, academic medical center with a prior-approval ASP that was active between 8 am and 10 pm. METHODS: We evaluated whether there was an increase in the proportion of orders for antimicrobial therapy that involve restricted (vs nonrestricted) antimicrobials during the first hour that the ASP is inactive (ie, the first hour that prior approval is not required), compared with the remainder of the day. We also evaluated whether restricted antimicrobial therapy ordered during this first hour is less likely to be continued when the ASP becomes active the next day, compared with that ordered during the preceding hour. RESULTS: A greater proportion of the antimicrobial therapy orders placed between 10:00 pm and 10:59 pm were for restricted agents, compared with orders placed during other periods (57.0% vs 49.9%; P=.02). Surgical patients for whom antimicrobial therapy orders were placed between 10:00 pm and 10:59 pm were less likely to have that antimicrobial therapy continued, compared with patients whose therapy was ordered between 9:00 pm and 9:59 pm (60.0% vs 98.1%; P<.001). Nonsurgical patients whose therapy orders were placed between 10:00 pm and 10:59 pm were also less likely to have the ordered antimicrobial therapy continued, compared with patients whose therapy was ordered between 9:00 pm and 9:59 pm (70.8% vs 84.2%; P=.01). CONCLUSION: Physicians avoid having to obtain prior approval for therapy involving restricted antimicrobials by waiting until restrictions are no longer active to place orders. Compared with restricted antimicrobial therapy ordered when the ASP is active, these courses of therapy are less often continued by the ASP, suggesting that they are more likely to be in conflict with guidelines or unnecessary.     

Inaccurate communications in telephone calls to an antimicrobial stewardship program.

BACKGROUND: Antimicrobial stewardship programs (ASPs) decrease unnecessary antimicrobial use, decrease antimicrobial resistance, and improve patient outcomes. The effectiveness of a prior approval system--that is, the requirement that approval be obtained from ASP practitioners before certain antimicrobials can be used--depends on the accuracy of the patient data communicated from the primary service. OBJECTIVES: To determine the incidence of inaccurate communication of patient data during ASP interactions, describe examples of inaccurate communications, and identify risk factors for inaccurate communication. DESIGN: We used a retrospective cohort design. We evaluated the communicated patient data for clinically important inaccuracies, using the patients' medical records as the gold standard. SETTING: A tertiary care medical center that has a prior approval system for restricted antimicrobials. PATIENTS: Inpatients discussed in telephone ASP interactions. INTERVENTION: Observational study. RESULTS: Of telephone calls requesting prior approval from ASP practitioners, 39% (95% confidence interval [CI], 31%-48%) contained an inaccuracy in at least 1 type of patient data (eg, current antimicrobial therapy); the incidence varied widely between data types. Examples of inaccuracies are given to demonstrate their clinical relevance. In multivariable analysis, inaccurate communications were more common for telephone calls from surgical services (versus calls from nonsurgical services: odds ratio, 2.1 [95% CI, 1.1-3.9]) and for calls received by Infectious Diseases fellows (versus pharmacists: odds ratio, 2.0 [95% CI, 1.1-3.8]). CONCLUSIONS: A high proportion of ASP calls requesting prior approval included patient data inaccuracies, which have the potential to affect the prescribing of antimicrobials. Although risk factors were identified, these communication errors were common across the different types of ASP interactions. Inaccurate communications may compromise the utility of ASPs that use a prior approval system for optimizing antimicrobial use.     

Effect of communication errors during calls to an antimicrobial stewardship program.

OBJECTIVE: To determine how inaccurate communication of patient data by clinicians in telephone calls to the prior-approval antimicrobial stewardship program (ASP) staff affects the incidence of inappropriate antimicrobial recommendations made by ASP practitioners. DESIGN: A retrospective cohort design was used. The accuracy of the patient data communicated was evaluated against patients' medical records to identify predetermined, clinically significant inaccuracies. Inappropriate antimicrobial recommendations were defined having been made if an expert panel unanimously rated the actual recommendations as inappropriate after reviewing vignettes derived from inpatients' medical records. SETTING: The setting was an academic medical center with a prior-approval ASP. PATIENTS: All inpatient subjects of ASP prior-approval calls were eligible for inclusion. RESULTS: Of 200 ASP telephone calls, the panel agreed about whether or not antimicrobial recommendations were inappropriate for 163 calls (82%); these 163 calls were then used as the basis for further analyses. After controlling for confounders, inaccurate communication was found to be associated with inappropriate antimicrobial recommendations (odds ratio [OR], of 2.2; P=.03). In secondary analyses of specific data types, only inaccuracies in microbiological data were associated with the study outcome (OR, 7.5; P=.002). The most common reason panelists gave for rating a recommendation as inappropriate was that antimicrobial therapy was not indicated. CONCLUSIONS: Inaccurate communication of patient data, particularly microbiological data, during prior-approval calls is associated with an increased risk of inappropriate antimicrobial recommendations from the ASP. Clinicians and ASP practitioners should work to confirm that critical data has been communicated accurately prior to use of that data in prescribing decisions.     

Impact of statewide program to promote appropriate antimicrobial drug use

The Wisconsin Antibiotic Resistance Network (WARN) was launched in 1999 to educate physicians and the public about judicious antimicrobial drug use. Public education included radio and television advertisements, posters, pamphlets, and presentations at childcare centers. Physician education included mailings, susceptibility reports, practice guidelines, satellite conferences, and presentations. We analyzed antimicrobial prescribing data for primary care physicians in Wisconsin and Minnesota (control state). Antimicrobial prescribing declined 19.8% in Minnesota and 20.4% in Wisconsin from 1998 to 2003. Prescribing by internists declined significantly more in Wisconsin than Minnesota, but the opposite was true for pediatricians. We conclude that the secular trend of declining antimicrobial drug use continued through 2003, but a large-scale educational program did not generate greater reductions in Wisconsin despite improved knowledge. State and local organizations should consider a balanced approach that includes limited statewide educational activities with increasing emphasis on local, provider-level interventions and policy development to promote careful antimicrobial drug use.     

Show me the money: long-term financial impact of an antimicrobial stewardship program

The financial impact of an antimicrobial stewardship program in operation for more than 11 years was determined by calculating the reduction in antimicrobial expenditures minus program labor costs. Depending on the method of inflation adjustment used, the program was associated with average cost savings of $920,070 to $2,064,441 per year.     

特殊级抗菌药物科学化管理在重症监护病房中的应用

目的 评价抗菌药物科学化管理(ASP)在重症监护病房(ICU)中对碳青霉烯类抗生素的管理效果。方法 回顾性分析2018年4月1日—2020年3月31日某院ICU住院患者的临床资料,2019年4月1日开始实施ASP,以碳青霉烯类抗生素使用频度(DDDs)和使用强度(AUD)作为ASP评价标准。结果 ASP实施前后患者一般资料比较、感染患者和非感染患者的ICU住院日数及病死率比较,差异均无统计学意义(均P>0.05)。ASP实施后,碳青霉烯类抗生素DDDs从2 101.25下降至1 862.25,差异无统计学意义(P>0.05);碳青霉烯类抗生素AUD从43.34 DDDs/100例·d下降至31.32 DDDs/100例·d,差异有统计学意义(P<0.05)。鲍曼不动杆菌、肺炎克雷伯菌对碳青霉烯类抗生素的耐药率分别从实施前的90.00%、20.41%下降至实施后的73.21%、10.14%,差异具有统计学意义(均P<0.05)。结论 以ICU为中心实施ASP可降低碳青霉烯类抗生素DDDs和AUD,降低细菌对碳青霉烯类抗生素的耐药率,但不增加患者的ICU住院日数及病...     

Intervention to discontinue parenteral antimicrobial therapy in patients hospitalized with pulmonary infections: effect on shortening patient stay.

OBJECTIVES: Current efforts to contain anti-microbial costs in hospitals are based on restricting drugs. We explored the effects of unsolicited case-specific recommendations to physicians to discontinue parenteral antimicrobial therapy in medically stable patients with pneumonia, in order to shorten hospital length of stay. METHODS: A nurse-interventionist, working as an emissary of an appropriate committee in 3 nonteaching community hospitals, presented randomly assigned physicians with nonconfrontational suggestions to substitute comparable oral antimicrobials for parenteral antimicrobials. Blinded observers evaluated in-hospital and 30-day postdischarge courses of patients of physicians who had been contacted by the nurse (cases) and those who had not (controls). RESULTS: Eighty-two patient episodes (47 physicians) met study criteria. There were 53 cases and 29 controls. In 42 of 53 (79%) case episodes, physicians discontinued parenteral antimicrobials; patients' mean length of stay was 2.4 days less than for 29 control episodes (estimated cost savings was $884/patient). In 11 (21%) episodes, case physicians continued parenteral therapy; patients' mean length of stay was 1.9 days longer than for controls (estimated cost excess was $704/patient). Education, training and practice characteristics were comparable in physician groups. Severity of illness indicators and postdischarge outcomes were comparable in patient groups. CONCLUSIONS: The major cost-saving potential for shifting from parenteral to oral antimicrobial therapy is shortened length of stay. Timely information about alternative drug therapies, offered on a patient-specific basis, appears to modify the treating behavior of physicians. The program as currently conducted is cost-effective, with an estimated net savings of $50,000 per 100 interventions.     

ASP对胸外科围手术期抗菌药物选择和感染发病率的影响

目的评价抗菌药物管理项目(ASP)对胸外科围手术期抗菌药物选择和患者术后感染发病率的影响。方法选取2015—2016年于某院胸外科进行肺或食管手术且术前无感染的患者。2015年的患者设为对照组(干预前),2016年的患者设为试验组(干预后)。2016年开展ASP,临床药师、感染科医生对使用碳青霉烯类药物和氟喹诺酮类药物的医嘱实时干预,规范抗菌药物的使用。比较实施ASP前后胸外科围手术期抗菌药物选择的规范程度和手术部位感染发生情况。结果干预前(2015年)纳入患者953例;干预后(2016年)纳入患者1 061例。食管或肺部手术患者手术部位感染发病率干预前、干预后分别为1. 57%、1. 70%,两者比较差异无统计学意义(χ~2=0. 047,P=0. 829)。使用推荐抗菌药物(头孢呋辛或头孢美唑)预防手术部位感染的比率从干预前的37. 15%(354/953)上升至干预后的69. 75%(740/1 061),干预前后比较差异有统计学意义(χ~2=215. 025,P=0. 000)。干预前、干预后胸外科抗菌药物AUD情况比较,厄他培南的AUD下降52. 46%(8. 12 VS 3. 86);头孢呋辛(7. 49 VS14. 83)和头孢美唑(4. 98 VS 9. 72)的AUD分别增加98. 00%、95. 18%;头孢曲松的使用强度下降85. 29%(12. 03VS 1. 77)。结论实施ASP,降低了胸外科厄他培南和头孢曲松的使用量,规范了胸外科手术预防用药,且不会引起肺和食管手术手术部位感染发病率的变化。     

抗感染治疗和抗菌药物管理-ASHP 2019年中会议综述

 美国卫生系统药师协会年中会议（ASHP Midyear）作为全球规模最大的药师会议之一,以发布国际前沿的临床用药研究闻名,针对医院药学领域的热点、难点提出创新和科学建议。在2019年12月召开的最近一次ASHP Midyear上,抗菌治疗和抗菌药物管理依然是关注重点,同时针对菌血症、耐甲氧西林金黄色葡萄球菌、艰难梭菌、青霉素过敏、医疗机构抗菌药物管理项目（ASP）等均发布了颇有意义的内容,以上内容同时也是国内医院抗感染领域关注的热点问题。本文就参会的启示和感想作一分享,并对笔者所在医院开展的ASP项目作一介绍。     

Impact of concurrent antimicrobial therapy on catheter-associated urinary tract infection.

Results of a survey in two Dutch district hospitals which investigated the impact of concurrent administration of antibiotics on the incidence of catheter-associated urinary tract infection (UTI), showed that 61% of catheterized patients received antibiotics at some stage during bladder drainage. The use of antibiotics within 48 hours prior to catheter removal reduced the risk of bacteriuria fivefold. Multivariate analysis of patients who were catheterized for 3-14 days indicated that, apart from the duration of catheter employment, the use of antibiotics was the only variable significantly and independently associated with the development of bacteriuria. The power of this association varied inversely with increasing duration of catheterization but remained significant throughout the 3-14-day interval. Patients with bacteriuria at the time of catheter removal were more likely to have a febrile illness compared to those who remained free of catheter-associated UTI.     

感染控制与抗菌药物管理齐头并进有效遏制细菌耐药

细菌耐药(A MR)已经成为全球公共卫生安全危机,世界卫生组织要求全球各国积极行动,采取系统性措施遏制细菌耐药.此文从耐药细菌发生过程、危险因素和控制策略等方面进行阐述,表明A MR的发生和传播与抗菌药物使用、感染控制息息相关,提示控制A MR必须同时开展抗菌药物临床应用管理和感染控制,两者相互协同才能取得成功.     

政策干预对综合医院抗菌药物日使用率的影响

目的评价抗菌药物管理措施对某院住院患者抗菌药物日使用率的影响。方法采用横断面调查方法,对该院2010-2012年某日住院患者抗菌药物使用情况进行调查分析。结果2010-2012年抗菌药物日使用率分别为65.40%、42.09%和26.74%,病原学送检率分别为22.53%、35.74%和41.74%,差异均有统计学意义（χ2trend值分别为266.42、29.02,均P＜0.01）。2010-2012年抗菌药物单一用药率分别为83.72%、80.27%和93.41%,各年均以单一用药为主;二联和≥三联用药比例下降。2010-2012年消化内科、心血管内科、血液肿瘤科、神经内科、普通外科、神经外科、骨科、产科、儿科及眼科各科室抗菌药物使用率呈下降趋势,差异均有统计学意义（均P＜0.01）。结论抗菌药物政策干预降低了该院抗菌药物日使用率,提高了病原学送检率。