Half of Prescribed Antibiotics Are Not Needed: A Pharmacist-Led Antimicrobial Stewardship Intervention and Clinical Outcomes in a Referral Hospital in Ethiopia.

Gebremedhin Beedemariam Gebretekle,Wondwossen Amogne Degu,Cedric P Yansouni,Teferi Gedif Fenta,Atalay Mulu Fentie,Damen Haile Mariam,Temesgen Beyene,Tinsae Alemayehu,Makeda Semret,Workeabeba Abebe Taye,Michael Libman

doi:10.3389/fpubh.2020.00109

Gebremedhin Beedemariam Gebretekle, Wondwossen Amogne Degu + Show 9 more

Open Access

https://doi.org/10.3389/fpubh.2020.00109

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Abstract

Intense antibiotic consumption in Low- and Middle-Income Countries (LMICs) is fueled by critical gaps in laboratory infrastructure and entrenched syndromic management of infectious syndromes. Few data inform the achievability and impact of antimicrobial stewardship interventions, particularly in Sub-Saharan Africa. Our goal was to demonstrate the feasibility of a pharmacist-led laboratory-supported intervention at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, and report on antimicrobial use and clinical outcomes associated with the intervention.Methods: This was a single-center prospective quasi-experimental study conducted in two phases: (i) an intervention phase (November 2017 to August 2018), during which we implemented weekly audit and immediate (verbal and written) feedback sessions on antibiotic prescriptions of patients admitted in 2 pediatric and 2 adult medicine wards, and (ii) a post-intervention phase (September 2018 to January 2019) during which we audited antibiotic prescriptions but provided no feedback to the treating teams. The intervention was conducted by an AMS team consisting of 4 clinical pharmacists (one trained in AMS) and one ID specialist. Our primary outcome was antimicrobial utilization (measured as days of therapy (DOT) per 1,000 patient-days and duration of antibiotic treatment courses); secondary outcomes were length of hospital stay and in-hospital all-cause mortality. A multivariable logistic regression model was used to explore factors associated with all-cause in-hospital mortality.Results: We collected data on 1,109 individual patients (707 during the intervention and 402 in the post-intervention periods). Ceftriaxone, vancomycin, cefepime, meropenem, and metronidazole were the most commonly prescribed antibiotics; 96% of the recommendations made by the AMS team were accepted. The AMS team recommended to discontinue antibiotic therapy in 54% of cases during the intervention period. Once the intervention ceased, total antimicrobial use increased by 51.6% and mean duration of treatment by 4.1 days/patient. Mean LOS stay as well as crude mortality also increased significantly in the post-intervention phase (LOS: 24.1 days vs. 19.8 days; in hospital death 14.7 vs. 6.9%). The difference in mortality remained significant after adjusting for potential confounders.Conclusions: A pharmacist-led AMS intervention focused on duration of antibiotic treatment was feasible and had good acceptability in our setting. Cessation of audit-feedback activities was associated with immediate and sustained increases in antibiotic consumption reflecting a rapid return to baseline (pre-intervention) prescribing practices, and worse clinical outcomes (increased length of stay and in-hospital mortality). Pharmacist-led audit-feedback activities can effectively reduce antimicrobial consumption and result in better-quality care, but require organizational leadership's commitment for sustainable benefits.

Highlights

The association between Antimicrobial Resistance (AMR) and antibiotic consumption has been well documented [1,2,3]
The hospital is staffed with 1059 physicians of which 4 had expertise in Infectious Diseases at the time of the study; 80 pharmacists and 7 microbiology laboratory technologists
Guidelines and Cumulative Antibiogram We developed institutional guidelines for the empiric management of the 4 most common indications for antibiotic therapy in the institution: Sepsis, Febrile Neutropenia, Community-Acquired and Hospital-Associated Pneumonia

Summary

Introduction

The association between Antimicrobial Resistance (AMR) and antibiotic consumption has been well documented [1,2,3]. The global increase in antibiotic consumption noted in the past 15 years has predominantly been driven by Low- and Middleincome countries (LMICs) [4], which can least afford the tremendous human and economic costs of AMR [5, 6]. In the first year after implementation, we reported widespread resistance of gram-negative bacteria to locally available antibiotics including carbapenems, a class of antibiotics which had been introduced in Ethiopia only 3 years prior [8]. A national AMR action plan and an antimicrobial stewardship implementation guide were developed for Ethiopia [9, 10], “implementation readiness” in individual hospitals, including in tertiary care urban referral centers, remains extremely low. Gaps in health system processes, lack of sufficiently trained personnel and competing priority initiatives

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