Consumption In Intensive Care Unit Research Articles

The impact of COVID-19 on microbiological profile and antibiotic consumption in ICU: a retrospective study in an infectious disease hospital in Brazil

BackgroundThe COVID-19 pandemic has triggered crises in the public health sector that have complex and multifaceted interrelationships with antimicrobial resistance. It is important to evaluate the impact of COVID-19 on microbiological profile, antibiotic and alcohol gel consumption in Intensive Care Units (ICU). MethodsThis is a retrospective study undertaken in an infectious disease hospital located in Bahia/Brazil during three periods: from March 2019 to February 2020; from March 2020 to February 2021; and from March 2021 to February 2022. It was evaluated the incidence density of Candida spp and of multidrug-resistant Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species (ESKAPE group) in blood, urine and tracheal secretion isolated 48 h after the patient's admission to the ICU, as well as the use of alcohol gel (in milliliters) and consumption of antibiotics in Defined Daily Dose (DDD) per 1,000 ICU patient-days in the previous year and in the first two years of COVID-19 pandemic. ResultsThere was an increase in Candida spp. (5.81, p < 0.001, IRR = 10.47, 95 % CI 2.57‒42.62) and in carbapenem-resistant A. baumannii in clinical cultures (4.71, p < 0.001, IRR = 8.46, 95 % CI 2.07‒34.60), the latter mainly in tracheal secretions (3.18, p= 0.02, IRR = 11.47, 95 % CI 1.58‒83.39). A rise in the consumption of ceftriaxone and piperacillin-tazobactam, along with an increase in the utilization of alcohol gel were observed. ConclusionThe shifting microbiological profile can be attributed to both the unique characteristics of patients with COVID-19 and the adjustments made to healthcare facilities' structural and work routines. Understanding these changes is essential in addressing the accelerated impact of antimicrobial resistance during the pandemic. Therefore, conducting thorough reviews of institutional practices and routines becomes critical in mitigating the consequences of antimicrobial resistance and its implications for patient care.

Antimicrobial drug utilization pattern in a tertiary level intensive care unit in Northern India: Antimicrobial Stewardship Programme need of the hour

Background: Antimicrobial drugs are the most frequently prescribed drugs in hospital settings with intensive care unit (ICU) patients showing the highest consumption of these drugs. Antimicrobial overuse and misuse is attributed to antimicrobial resistance (AMR). AMR in coming years will emerge as a global pandemic, maiming the modern health-care system. High consumption of antimicrobial drugs is one of leading factors contributing to AMR. Aims and Objectives: This study aimed at evaluating the prescription pattern of antimicrobial drugs in ICU and estimates the burden of inappropriate antimicrobial drug utilization in ICU settings of a tertiary level teaching hospital. Materials and Methods: The current study was conducted on 100 patients over a period of 6 months, admitted in surgical ICU (SICU), and neuro SICU (NICU) of a tertiary level hospital in Jammu and Kashmir, India. Study patients were identified through daily review of pharmacy records and antimicrobial drugs prescribed for the initial 5 days of ICU admission were documented in a well-designed questionnaire consisting all the necessary information regarding antibiotic therapy. Results: Out of the 100 enrolled study subjects, 98% received an empiric therapy. Majority of the patients were given a combination antimicrobial therapy during the initial 5 days of ICU admission. The most common antibiotic prescribed as monotherapy was ceftriaxone during the initial 2 days of ICU stay followed by piperacillin-tazobactam and meropenem in the next 3 days. Amikacin was the most frequently prescribed antibiotic in combination therapy during first 2 days followed by vancomycin in the consecutive days. A total of 27 antimicrobial drugs belonging to 15 classes were prescribed to the study participants during the initial 5 days of ICU admission. Conclusion: The study reports a very high consumption of antimicrobial drugs in ICUs with maximum of antimicrobial therapies prescribed empirically. A robust action plan, consisting of proper protocol for prescribing empiric antimicrobials, regular monitoring of antibiotic consumption in ICUs with a system of prospective audit, and feedback and timely interventions are a keystone of good antibiotic stewardship and should be the focus in ICU and NICU.

Impact of COVID-19 on healthcare-associated infections: Antimicrobial consumption does not follow antimicrobial resistance

BackgroundThis study aimed to analyze the Healthcare-Associated Infections (HAI) rates and antimicrobial consumption in Intensive Care Units (ICU) in São Paulo city during the COVID-19 pandemic and compare them with the pre-pandemic period. MethodsThis cohort included all hospitals that reported HAI rates (Central-Line-Associated Bloodstream Infection ‒ CLABSI and Ventilator-Associated Pneumonia ‒ VAP), the proportion of microorganisms that caused CLABSI, the proportion of resistant microorganisms, and antimicrobial consumption from January 2017 ‒ December 2020. Hospitals were stratified by the number of beds, Central Venous Catheter (CVC) utilization rate, Mechanical-Ventilation (MV) utilization rate, and type of funding. Statistical analyses were based on time-series plots and regression models. Results220 ICUs were included. The authors observed an abrupt increase in CLABSI rates after the pandemic onset. High CLABSI rates during the pandemic were associated with hospital size, funding (public and non-profit private), and low CVC use (≤ 50%). An increase in VAP rates was associated with public hospitals, and high MV use (> 35%). The susceptibility profile of microorganisms did not differ from that of the pre-pandemic period. polymyxin, glycopeptides, and antifungal use increased, especially in COVID-19 ICUs. ConclusionsHAI increased during COVID-19. The microorganisms’ susceptibility profile did not change with the pandemic, but the authors observed a disproportionate increase in large-spectrum antimicrobial drug use.

Financial Evaluation and Pattern of Antibiotic Consumption in Intensive Care Units of a University Hospital.

Financial Evaluation and Pattern of Antibiotic Consumption in Intensive Care Units of a University Hospital.

Increased Use of Antibiotics in the Intensive Care Unit During Coronavirus Disease (COVID-19) Pandemic in a Brazilian Hospital.

Background: Microbial drug resistance is one of the biggest public health problems. Antibiotic consumption is an essential factor for the emergence and spread of multiresistant bacteria. Therefore, we aimed to analyze the antibiotics consumption in the Intensive Care Unit (ICU), identifying trends in the antibiotics use profile and microbiological isolates throughout the COVID-19 pandemic. Methods: We performed this retrospective observational study in intensive care units of a Brazilian tertiary hospital from January 2019 to December 2020. The primary outcome was antimicrobial consumption in the ICU, measured by defined daily doses (DDDs) per 100 bed-days. As a secondary outcome, bacterial infections (microbiological isolates) were calculated in the same fashion. Outcomes trends were analyzed using Joinpoint regression models, considering constant variance (homoscedasticity) and first-order autocorrelation assumptions. A monthly percent change (MPC) was estimated for each analyzed segment. Results: Seven thousand and nine hundred fifty-three patients had data available on prescribed and received medications and were included in the analyses. Overall, the use of antibiotics increased over time in the ICU. The reserve group (World Health Organization Classification) had an increasing trend (MPC = 7.24) from February to April 2020. The azithromycin consumption (J01FA) increased rapidly, with a MPC of 5.21 from January to April 2020. Polymyxin B showed a relevant increase from March to June 2020 (MPC = 6.93). The peak of the antibiotic consumption of Reserve group did not overlap with the peak of the pathogenic agents they are intended to treat. Conclusion: Overall antimicrobial consumption in ICU has increased in the context of the COVID-19 pandemic. The peaks in the antimicrobial’s use were not associated with the rise of the pathogenic agents they intended to treat, indicating an empirical use, which is especially concerning in the context of treating multidrug-resistant (MDR) infections. This fact may contribute to the depletion of the therapeutic arsenal for MDR treatment.

Antimicrobial resistance and antibiotic consumption in intensive care units, Switzerland, 2009 to 2018.

BackgroundIntensive care units (ICU) constitute a high-risk setting for antimicrobial resistance (AMR).AimWe aimed to describe secular AMR trends including meticillin-resistant Staphylococcus aureus (MRSA), glycopeptide-resistant enterococci (GRE), extended-spectrum cephalosporin-resistant Escherichia coli (ESCR-EC) and Klebsiella pneumoniae (ESCR-KP), carbapenem-resistant Enterobacterales (CRE) and Pseudomonas aeruginosa (CRPA) from Swiss ICU. We assessed time trends of antibiotic consumption and identified factors associated with CRE and CRPA.MethodsWe analysed patient isolate and antibiotic consumption data of Swiss ICU sent to the Swiss Centre for Antibiotic Resistance (2009–2018). Time trends were assessed using linear logistic regression; a mixed-effects logistic regression was used to identify factors associated with CRE and CRPA.ResultsAmong 52 ICU, MRSA decreased from 14% to 6% (p = 0.005; n = 6,465); GRE increased from 1% to 3% (p = 0.011; n = 4,776). ESCR-EC and ESCR-KP increased from 7% to 15% (p < 0.001, n = 10,648) and 5% to 11% (p = 0.002; n = 4,052), respectively. CRE, mostly Enterobacter spp., increased from 1% to 5% (p = 0.008; n = 17,987); CRPA remained stable at 27% (p = 0.759; n = 4,185). Antibiotic consumption in 58 ICU increased from 2009 to 2013 (82.5 to 97.4 defined daily doses (DDD)/100 bed-days) and declined until 2018 (78.3 DDD/100 bed-days). Total institutional antibiotic consumption was associated with detection of CRE in multivariable analysis (odds ratio per DDD: 1.01; 95% confidence interval: 1.0–1.02; p = 0.004).DiscussionIn Swiss ICU, antibiotic-resistant Enterobacterales have been steadily increasing over the last decade. The emergence of CRE, associated with institutional antibiotic consumption, is of particular concern and calls for reinforced surveillance and antibiotic stewardship in this setting.

ПАТОГЕНЕТИЧЕСКИЕ МЕХАНИЗМЫ ФОРМИРОВАНИЯ ГЕНЕТИЧЕСКОЙ УСТОЙЧИВОСТИ К АНТИБИОТИКАМ ПРИ ЛЕЧЕНИИ ТЯЖЕЛЫХ ИНФЕКЦИЙ В ИНТЕНСИВНОЙ ТЕРАПИИ

Background: The dramatic rise in antibiotic consumption in intensive care units is a major public health concern. A widespread use of antibacterial drugs is the main factor in the resistance of pathogenic microorganisms to antibiotics. The increase in the number of resistant bacterial strains is largely due to the formation of new variants of resistance genes. Purpose: To analyze the results of scientific studies confirming the key role of bacterial genetic resistance in the mechanisms of antibiotic resistance development. Material and methods. A qualitative analysis of the Russian-language and English-language literatura sources concerning the aspects of the genetic resistance of microorganisms has been carried out. Results: It has been found out that antibiotic resistance in bacteria achieved by mutations in the chromosomal DNA leads to a significant increase in the number of multidrug-resistant microorganisms that become insensitive to antibiotic therapy. Conclusion: The growing prevalence of multidrug-resistant pathogens presents an urgent medical problem. The genetic mechanisms underlying bacterial resistance are key to antibiotic resistance. Annual research significantly expands knowledge about known and presumably new resistance genes, their mobility and evolutionary history.

Analysis of Antimicrobial Medication Consumption in Intensive Care Unit, North West (Tabuk) Region Hospitals, Saudi Arabia

Analysis of Antimicrobial Medication Consumption in Intensive Care Unit, North West (Tabuk) Region Hospitals, Saudi Arabia

1780. Results of a Successful Implementation of a Antimicrobial Stewardship Program in a Public Hospital in São Paulo, Brazil

BackgroundThe implementation of antimicrobial stewardship program is one of the basis for the control of multidrug-resistant bacteria (MDR) and the reduction of unnecessary costs, especially in public hospitals. The use of a multimodal strategy is fundamental to the success of a stewardship program.MethodsThis is an analysis of antimicrobial consumption in intensive care unit (ICU) of a public hospital in São Paulo, Brazil, before and after the implementation of the antibiotic stewardship program. In the pre-intervention period—January 2014 to December 2015—the rational use of antimicrobials was based only on postprescription authorization by the infectious diseases doctor. Since January 2016 was established an antibiotic stewardship program based on authorization of antimicrobial use, implementation of an empirical antibiotic protocol according to institutional microbiological profile, measurement of adherence to the protocol and feedback to the leadership, pharmaceutical intervention, educational measures for medical staff and leadership engagement to the program. We compared consumption in DDD per 1,000 patient-days (1,000/pd) and mean cost with antimicrobials in the ICU in US dollars.ResultsThe overall antimicrobial consumption reduced from 1,032 DDD/1,000 pd in the preintervention period to 785 DDD/1,000 pd postintervention. Analysis stratified by individual antibiotic was done for the five most commonly used antibiotics. A reduction of 51% consumption for meropenem, 41% for colistin, and 41% for vancomycin was observed. Antibiotic costs were reduced from a monthly median of US$71,176.49 to US$43,772.75 between the two periods. No difference in mortality or mean Apache was observed over the period.ConclusionThe implementation of the antimicrobial stewardship program can lead to a safe reduction in antibiotic use in the ICU, with significant reduction of costs that can be reapplied in the patient care. Further analyzes are needed to assess the impact on clinical patient outcomes.Disclosures All authors: No reported disclosures.

PSY140 - DEXMEDETOMIDINE UTILISATION STUDY IN THE INTENSIVE CARE UNIT

To describe the patterns of dexmedetomidine use in the Intensive Care Unit (ICU) in a tertiary hospital and the impact of pharmacy intervention on it. Prospective four-month study (October 2017-January 2018). There was a greater use of dexmedetomidine in November so pharmacists encouraged physicians to consider protocols before prescribing. Dexmedetomidine 1mg/10 ml vial is administered as a solution (4 mcg/ml) by intravenous perfusion at dose range: 0.2-1.4 mcg/kg/hour. Data collected: treatment days with dexmedetomidine or sedative drugs combination, oral clonidine consumption, dexmedetomidine solution used (ml/day), infusion rates used (milliliters/h), RASS level and vials dispensed/month. Thirty-one patients received dexmedetomidine. Median duration of treatment was 1.8 days(maximum 8 days). Two patients(6.5%) received the combination formed by Remifentanil+Propofol+Midazolam+Dexmedetomidine, although it was less than 24 hours. Average dexmedetomidine solution administered/patient: 175 ml/day(48-672); average dexmedetomidine infusion rate: 9.9 ml/h(2-28). RASS level was not recorded any time during dexmedetomidine treatment in 13 patients (41.9%). Seven patients(22.6%) registered a RASS value lower than -3, two of them received treatment with dexmedetomidine during 6 and 7 days of respectively. Dexmedetomidine consumption in ICU was 26, 114, 91 and 76 vials for each month of this study. In three patients(9.7%) dexmedetomidine was replaced by clonidine when possible (clonidine was not prescribed in the first two months; in December and in January it was dispensed 91 and 48 tablets respectively). During the study, two cases of incorrect use were detected(6.5%). Dexmedetomidine consumption has been clearly reduced since the intervention halfway through the study period, and the use of clonidine was favored in its place. In most cases the use of dexmedetomidine was indicated and correctly justified. The importance in these cases lies in the need to establish maximum times from which the combination of dexmedetomidine should not be overcome with several sedatives for own use in deep sedation levels.

Ventilator-Associated Pneumonia (VAP): Are we ready to let go of the old definitions

Background: In 2013 the NHSH implemented major changes in the VAP definition. Reviewing episodes became easier and faster and it eliminated most of the subjective interpretation of data. We started implementing this new definition in January 2017 but continued to use the old definition as well. Objectives: Assess the impact of the new NHSN definitions to calculate the VAP rates in our hospital. Analyze whether the changes in the VAP rates trends are reflected in antibiotic consumption. Methods & Materials: Descriptive Study. Retrospective analysis of the VAP rates in Intensive Care Unit (ICU) and Coronary Care Unit (CCU). Daily data from active surveillance, microbiology reports and electronic medical records review. Antibiotic consumption in ICU and CCU: DDD Defined Daily Dose. D/P: every 100 days/patient Results: VAP Rates (per1000 days ventilator) 2013-2016 old definition and 2017 old and new definition. ICU: 2013: 4.02, 2014 6.27 2015 3.42, 2016 4.12 2017 old 2.65, new:0. CCU: 2013: 12.41, 2014 9.9, 2015 10.23, 2016: 8, 2017 old: 2.8 new: 0. Antibiotic consumption: CCU DDD 2016 D/P 27.4, 2017 39.09. ICU DDD 2016 D/P 91,39 2017 95.43. We observed a statistically significant increase in antibiotic consumption in the ICC from 2016 to 2017(p ≤ 0.001). In the ICU there was there was no significant decrease in antibiotic consumption, with a tendency to rise for this period. Conclusion: Although we observed a decreasing tendency in VAP these years, the abrupt fall in VAP rates after the introduction of the new NHSN definitions seems to reflect a definition biass more than an improvement in the care provided to our patients.We have observed no significant change in antibiotic use to match the changes in VAP rates.It can be a big risk to use a definition that gives us a false sense of security, leading us to more relaxed behaviour in terms of prevention. For the time being, we consider useful to use both definitions to calculate VAP rates and dentify this risk.

PHP58 - Trends of Antibiotic Consumption in Intensive Care Units of Colombia, 2010-2016

Antibiotics, especially those of broad-spectrum, are frequently used in intensive care units (ICU). Their usage and resistance profile may vary over time. The objective was to describe the trends in the prescription of antibiotics in a population of patients treated in ICUs of Colombia. Descriptive study. The consumption of antibiotics was analyzed from a systematized drug dispensing database in 11 ICUs with a mean of 157 beds/year in seven cities from Colombia. We included patients older than 18 years who received antibiotics in the period January-2010 to December-2016. Usage was analyzed per patient and by therapy, defined as continuous use of any antibiotic. Demographic, pharmacological and cost variables were evaluated. R Statistics Software version 3.2 was used for the data analysis. A total of 26,625 ICU patients were treated with antibiotics during the study period, accounting for 34,549 therapies and 221,791 dispensations. Mean age was 60.0±19.8 years and 50.6% were male. Therapies had a mean of 1,79 antibiotics and the median therapy duration was 2 days (interquartile range: 1-6). The most used antibiotics were piperacillin-tazobactam (24,8%), ampicillin-sulbactam (22,3%), vancomycin (20,6%), meropenem (18,7%) and cefazoline (17,0%). The defined daily dose per 100-beds-day of cefepime increased the most, from 5.8 in 2010 to 16.02 in 2016, followed by meropenem (14.9 to 17.0) and piperacillin-tazobactam (9.5 to 11.0). By contrast, consumption of ciprofloxacin, oxacillin, ceftriaxone and clarithromycin decreased over time. The mean cost per day of treatment decreased between 2010 and 2016 for most antibiotics; 64.1% for linezolid, 63.1% for meropenem and 61.8% for piperacillin-tazobactam. There was an increase in the use of piperacillin-tazobactam, carbapenems and vancomycin. The changes in the prescription patterns might be indicators of growing antibiotic resistance. In general, the mean cost per day of treatment decreased over time.

Higher third-generation cephalosporin prescription proportion is associated with lower probability of reducing carbapenem use: a nationwide retrospective study

BackgroundThe ongoing extended spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) pandemic has led to an increasing carbapenem use, requiring release of guidelines for carbapenem usage in France in late 2010. We sought to determine factors associated with changes in carbapenem use in intensive care units (ICUs), medical and surgical wards between 2009 and 2013.MethodsThis ward-level multicentre retrospective study was based on data from French antibiotic and multidrug-resistant bacteria surveillance networks in healthcare facilities. Antibiotic use was expressed in defined daily doses per 1000 patient-days. Factors associated with the reduction in carbapenem use (yes/no) over the study period were determined from random-effects logistic regression model (493 wards nested within 259 healthcare facilities): ward characteristics (type, size…), ward antibiotic use (initial antibiotic use [i.e., consumption of a given antibiotic in 2009], initial antibiotic prescribing profile [i.e., proportion of a given antibiotic in the overall antibiotic consumption in 2009] and reduction in the use of a given antibiotic between 2009 and 2013) and regional ESBL-PE incidence rate in acute care settings in 2011.ResultsOver the study period, carbapenem consumption in ICUs (n = 85), medical (n = 227) and surgical wards (n = 181) was equal to 73.4, 6.2 and 5.4 defined daily doses per 1000 patient-days, respectively. Release of guidelines was followed by a significant decrease in carbapenem use within ICUs and medical wards, and a slowdown in use within surgical wards. The following factors were independently associated with a higher probability of reducing carbapenem use: location in Eastern France, higher initial carbapenem prescribing profile and reductions in consumption of fluoroquinolones, glycopeptides and piperacillin/tazobactam. In parallel, factors independently associated with a lower probability of reducing carbapenem use were ICUs, ward size increase, wards of cancer centres, higher initial third-generation cephalosporin (3GC) prescribing profile and location in high-risk regions for ESBL-PE.ConclusionsOur study suggests that a decrease in 3GCs in the overall antibiotic use and the continuation of reduction in fluoroquinolone use, could allow reducing carbapenem use, given the well-demonstrated role of 3GCs and fluoroquinolones in the occurrence of ESBL-PE. Thus, antibiotic stewardship programs should target wards with higher 3GC prescription proportions to reduce them.

Evaluating Adherence of Health-Care Team to Standard Guideline of Colistin Use at Intensive Care Units of a Referral Hospital in Shiraz, Southwest of Iran.

Purpose: To evaluate colistin use according to global standard drug consumption in intensive care units of a referral hospital in Shiraz, IranMethods: A prospective, interventional study was performed during an 11 month period on 100 patients admitted to ICUs of a teaching hospital being treated with colistin for at least 3 subsequent doses. Required demographic, clinical, and paraclinical data were gathered by a pharmacist. Fifteen indexes were considered to evaluate colistin use. A clinical pharmacist reviewed indication and dose of colistin at the time of prescribing this agent.Results: In our study population, pneumonia (69%) was the main indication of colistin. In 87% of patients, colistin administration was based on microbiological laboratory evidence. Continuation of therapy was inappropriate in 5% of cases. By the intervention of the clinical pharmacist, colistin was discontinued in all patients in whom empirical therapy was continued incorrectly. None of the patients received loading dose of colistin. The maintenance dose, dose interval, and duration of treatment of colistin were appropriate in 76%, 71%, and 100% of patients, respectively. For none of the patients, the pharmacokinetic dosing method was used. In all patients, serum creatinine and WBC count were evaluated on daily basis. The sum indexes of colistin use were relevant to standard guidelines in 67.33% of the cases.Conclusion: The results of this study highlight the necessity of the pharmaceutical care team participation in all stages of treatment with antibiotics. After pharmacist interventions, some criteria of colistin utilization were corrected and brought closer to standard values.

Antibiotics Use Patterns in Intensive Care Units of Five Hospitals in Tehran During 2011 - 2012

Background: Inappropriate use of antibiotics is one the most important challenges for health systems. In the hospital setting, intensive care unit (ICU) is a unique place in generating antibiotic-resistant pathogens. Irrational use of antibiotics is one of the main reasons of increasing the resistance of pathogens. Objectives: In this study, we aimed to evaluate antibiotics use pattern in ICUs of five hospitals in Tehran, Iran. Materials and Methods: This observational cross-sectional research aimed to evaluate antibiotic use patterns in ICUs of five hospitals in Tehran, Iran. Retrospectively, data related to antibiotic consumption in ICUs of five Military General Hospitals were collected from 20 March 2011 to 20 March 2012. The Anatomical Therapeutic Chemical classification system and the Defined Daily Dose used to evaluate consumption of antibiotics and drug use 90% was determined for all ICUs antibiotic consumption. Data was analyzed by SPSS software version 16 using one way ANOVA and Tukey post hoc tests to compare antibiotic consumption in ICUs between different hospitals. Results: Antibiotic use in ICU2 ward of hospital C was significantly higher than hospitals A, D, E and ICU-Open Heart (ICUOH) of hospital C (P value ≤ 0.001). Use of antibiotic in ICU1 ward of hospital C was also higher significantly compared to hospitals D, E and ICUOH of hospital C (P value ≤ 0.001). Drug use 90% profile of hospitals’ ICUs showed that Beta-lactams, Cephalosporin and Vancomycin were the most antibiotics used in these wards. Conclusions: Use of antibiotics was higher than expected in the studied ICU wards and the antibiotics use pattern was different from other countries. This problem should be addressed to correct the use pattern of antibiotics in ICUs. Implementation of antibiotic use and microbial resistance monitoring programs, continuous medical education for physicians and compilation of clinical practice guidelines and protocols could be effective in reduction of antibiotic use in hospitals.

PIN4 The Impact of Pharmacist-Led Antimicrobial Stewardship in Intensive Care Units in a Regional Hospital in Taiwan

Large antimicrobial consumption in intensive care units (ICUs) contributes heavy health care burden in Taiwan. This study evaluates the short term influence of pharmacist-led antimicrobial stewardship (PLAS) in ICUs. A prospective PLAS program was implemented in medical and surgical ICUs, including dose optimization (renal dose monitoring and therapeutic drug monitoring), streamlining or de-escalation of therapy, antimicrobial order forms, and antimicrobial treatment duration review, which any antimicrobial duration over 7days was reviewed. Data collection was from October 19, 2011 to December 2, 2011. Patients who admitted to ICU and received at least one parenteral antimicrobial were included. Outcomes included suggestion implementation rate of pharmacist interventions and cost that saving from dose optimization. Feedbacks of non-accepted suggestions were also addressed. Sixty-two (21%) of study population received 88 suggestions. Sixty-two (70.5%) suggestions were implemented. The majority of suggestions is duration review (30.7%) followed by streamlining or de-escalation of therapy (30.6%) and dose optimization (27.3%). There was 76,238 NTDs saving from renal dose monitoring. Further efforts we can make are found from reasons of non-accepted suggestion. For example, education on prophylactic antibiotics and antimicrobial renal dosage adjustment should be provided. Since, we found that prolonged (>3days) post-operation antimicrobial prophylaxis until inserted drainage lumen removed and refusing dose increasing because impaired renal function was expected by doctors. Involvement in multidisciplinary specialists is required due to denials from no recommendation from infectious disease physicians. A PLAS efforts rationale antimicrobial utilization and leads to potential reduction in both the incidence of adverse effects and the burden of health care. Through feedback from refused suggestion, however, we found that antimicrobial stewardship should include a multidisciplinary team, especially incorporating with infectious disease physicians.

Procalcitonin usefulness for the initiation of antibiotic treatment in intensive care unit patients*

To test the usefulness of procalcitonin serum level for the reduction of antibiotic consumption in intensive care unit patients. Single-center, prospective, randomized controlled study. Five intensive care units from a tertiary teaching hospital. All consecutive adult patients hospitalized for >48 hrs in the intensive care unit during a 9-month period. Procalcitonin serum level was obtained for all consecutive patients suspected of developing infection either on admission or during intensive care unit stay. The use of antibiotics was more or less strongly discouraged or recommended according to the Muller classification. Patients were randomized into two groups: one using the procalcitonin results (procalcitonin group) and one being blinded to the procalcitonin results (control group). The primary end point was the reduction of antibiotic use expressed as a proportion of treatment days and of daily defined dose per 100 intensive care unit days using a procalcitonin-guided approach. Secondary end points included: a posteriori assessment of the accuracy of the infectious diagnosis when using procalcitonin in the intensive care unit and of the diagnostic concordance between the intensive care unit physician and the infectious-disease specialist. There were 258 patients in the procalcitonin group and 251 patients in the control group. A significantly higher amount of withheld treatment was observed in the procalcitonin group of patients classified by the intensive care unit clinicians as having possible infection. This, however, did not result in a reduction of antibiotic consumption. The treatment days represented 62.6±34.4% and 57.7±34.4% of the intensive care unit stays in the procalcitonin and control groups, respectively (p=.11). According to the infectious-disease specialist, 33.8% of the cases in which no infection was confirmed, had a procalcitonin value>1µg/L and 14.9% of the cases with confirmed infection had procalcitonin levels<0.25 µg/L. The ability of procalcitonin to differentiate between certain or probable infection and possible or no infection, upon initiation of antibiotic treatment was low, as confirmed by the receiving operating curve analysis (area under the curve=0.69). Finally, procalcitonin did not help improve concordance between the diagnostic confidence of the infectious-disease specialist and the ICU physician. Procalcitonin measuring for the initiation of antimicrobials did not appear to be helpful in a strategy aiming at decreasing the antibiotic consumption in intensive care unit patients.

Hospital antibiotic consumption in Switzerland: comparison of a multicultural country with Europe

The consumption of antibiotics in the inpatient setting of Switzerland was assessed to determine possible differences between linguistic regions, and to compare these results with European results. Data on antibiotic consumption were obtained from a sentinel network representing 54% of the national acute care hospitals, and from a private drug market monitoring company. Aggregated data were converted into defined daily doses (DDD). The total consumption density in Switzerland was close to the median consumption reported in European surveys. Between 2004 and 2008, the total consumption of systemic antibiotics rose from 46.1 to 54.0 DDD per 100 occupied bed-days in the entire hospitals, and from 101.6 to 114.3 DDD per 100 occupied bed-days in the intensive care units. Regional differences were observed for total consumption and among antibiotic classes. Hospitals in the Italian-speaking region showed a significantly higher consumption density, followed by the French- and German-speaking regions. Hospitals in the Italian-speaking region also had a higher consumption of fluoroquinolones, in line with the reported differences between Italy, Germany and France. Antibiotic consumption in acute care hospitals in Switzerland is close to the European median with a relatively low consumption in intensive care units. Some of the patterns of variation in consumption levels noticed among European countries are also observed among the cultural regions of Switzerland.

Antimicrobial utilisation in South Australian hospitals 2002-2004

The South Australian statewide antimicrobial utilisation surveillance programme collects and reports on in-hospital antimicrobial usage data from South Australian metropolitan hospitals. Antimicrobial usage rates over the period of January 2002 – December 2004 are reported.There has been a 3% increase in total annual usage over the period, with monthly analysis suggesting a small upward trend in total antimicrobial consumption. Antimicrobial consumption in intensive care units (ICUs) has shown a reduction of 14% over the 3 year surveillance period; however, monthly data demonstrates variable usage, making assessment of trends difficult. Changes in usage patterns for fluoroquinolones and third generation cephalosporins have occurred, and should be the focus of antibiotic stewardship efforts. Comparison to international data shows that South Australian antimicrobial usage rates are high and efforts to optimise use of these agents should be encouraged.

Methicillin-ResistantStaphylococcus aureusin German Intensive Care Units During 2000-2003: Data from Project SARI (Surveillance of Antimicrobial Use and Antimicrobial Resistance in Intensive Care Units)

The objective of this study was to analyze methicillin-resistant Staphylococcus aureus (MRSA) percentages (defined as the percentage of S. aureus isolates that are resistant to methicillin) and antimicrobial consumption in intensive care units (ICUs) participating in Project SARI (Surveillance of Antimicrobial Use and Antimicrobial Resistance in Intensive Care Units), to look for temporal changes in MRSA percentages and antimicrobial consumption in individual ICUs as an indicator of the impact of an active surveillance system, and to investigate the differences between ICUs with increased MRSA percentages versus those with decreased percentages during a period of 3 years (2001-2003). This was a prospective, ICU-based and laboratory-based surveillance study involving 38 German ICUs during 2000-2003. Antimicrobial use was reported in terms of defined daily doses (DDDs) per 1,000 patient-days. Temporal changes in the MRSA percentage and antimicrobial use in individual ICUs were calculated by means of the Wilcoxon signed rank test. The incidence density of nosocomial MRSA infection was defined as the number of nosocomial MRSA infections per 1,000 patient-days. From February 2000 through December 2003, a total of 38 ICUs reported data on 499,694 patient-days and 9,552 S. aureus isolates, including 2,249 MRSA isolates and 660,029 DDDs of antimicrobials. Cumulative MRSA percentages ranged from 0% to 64.4%, with a mean of 23.6%. The MRSA incidence density ranged from 0 to 38.2 isolates per 1,000 patient-days, with a mean of 2.77 isolates per 1,000 patient-days. There was a positive correlation between MRSA percentage and imipenem and ciprofloxacin use (P<.05). Overall, comparison of data from 2001 with data from 2003 showed that MRSA percentages increased in 18 ICUs (median increase, 13.2% [range, 1.6%-38.4%]) and decreased in 14 ICUs (median decrease, 12% [range, 1.0%-48.4%]). Increased use of third-generation cephalosporins, glycopeptides, or aminoglycosides correlated significantly with an increase in the MRSA percentage (P<.05). The cumulative nosocomial MRSA infection incidence density for 141 ICUs that did not participate in SARI and, therefore, did not receive feedback increased from 0.26 to 0.35 infections per 1,000 patient-days during a 3-year period, whereas the rate in SARI ICUs decreased from 0.63 to 0.40 infections per 1,000 patient-days. The MRSA situation in German ICUs is still heterogeneous. Because MRSA percentages range from 0% to 64.4%, further studies are required to confirm findings that no change in the MRSA percentage and a decrease in the nosocomial MRSA infection incidence density in SARI ICUs reflect the impact of an active surveillance system.