Persuasive antimicrobial stewardship intervention in the context of a KPC outbreak: a controlled interrupted time series analysis

Nuno Rocha-Pereira,Sofia Correia,João Neves,Carlos Lima Alves,Paulo Figueiredo Dias,José Teixeira,Ana Azevedo,Shirin Shahriari,José Artur Paiva

doi:10.1186/s13756-020-00718-5

Abstract

IntroductionAntimicrobial resistance is a major public health threat. Antimicrobial stewardship (AMS) is one of the key strategies to overcome resistance, but robust evidence on the effect of specific interventions is lacking. We report an interrupted time series (ITS) analysis of a persuasive AMS intervention implemented during a KPC producing Klebsiella pneumoniae outbreak.MethodsA controlled ITS for carbapenem consumption, total antibiotic consumption and antibiotic-free days, between January 2012 and May 2018 was performed, using segmented regression analysis. The AMS intervention was implemented in the Vascular Surgery ward starting on April 2016 in the context of a KPC outbreak. The General Surgery ward was taken as a control group. Data were aggregated by month for both wards, including 51 pre-intervention and 26 intervention points.ResultsThe AMS intervention produced a level change in carbapenem consumption of − 11.14 DDDs/100 patient-days accompanied by a decreasing trend of total antibiotic consumption and stable rate of antibiotic-free days in Vascular Surgery ward. These differences were not apparent in the control group. No differences in mortality or readmission rates between pre-intervention and intervention periods were noticed in any of the groups.ConclusionPersuasive AMS interventions on top of previously implemented restrictive interventions can reduce carbapenem consumption without increasing total antibiotic consumption. Starting persuasive AMS interventions in an outbreak setting does not compromise the sustainability of the intervention.

Highlights

Antimicrobial resistance is a major public health threat
Antimicrobial resistance is a major threat to public health worldwide [1, 2] and there is a global call for action to preserve antibiotics for future generations [3, 4]
Despite having been identified in April 2016, the first case of the outbreak was traced back to January 2016. The identification of this outbreak prompted UPCIRA to act and alongside with infection control and prevention measures, an analysis of the factors that might have contributed to the occurrence of the outbreak identified excessive use of antibiotics and a high proportion of patients under carbapenem therapy; there were no local guidelines for treatment of diabetic foot infections, one of the most common causes of admission to Vascular Surgery ward

Summary

Introduction

Antimicrobial resistance is a major public health threat. Antimicrobial stewardship (AMS) is one of the key strategies to overcome resistance, but robust evidence on the effect of specific interventions is lacking. Different types of interventions can be used, namely restrictive and persuasive interventions The latter includes interventions like audit and feedback, educational outreach and formal or informal local consensus for clinical protocols, all of them aiming at change current behaviours in antibiotic prescription [11, 12]. Both persuasive and restrictive interventions have shown efficacy in reducing antimicrobial consumption [12, 13], duration of therapy, length of stay and in increasing compliance with guidelines [12, 13]. In a pragmatic and realistic approach, the use of interrupted time series (ITS) analysis can be useful to evaluate complex interventions used in AMS programs [3, 9, 15]

Methods

Results

Discussion

Conclusion