Implementation Of Antimicrobial Stewardship Programs Research Articles

2023. Antimicrobial Resistance and Stewardship Knowledge and Perception among Medical and Pharmacy Students in Nigeria

BackgroundNigeria is the most populous country in Africa and has high rates of antimicrobial resistance (AMR). The practice of antimicrobial stewardship in Nigerian hospitals is very limited and the subject is rarely included in undergraduate medical and pharmacy curriculums. To further acceptance and implementation of antimicrobial stewardship programs (ASP) in Nigeria health system, baseline measurements of the knowledge and perceptions held by graduating medical and pharmacy students was deemed essential. This study evaluated the knowledge and perceptions of a cohort of Nigerian medical and pharmacy students in concepts of AMR and ASP.MethodsThis was a cross-sectional questionnaire-based study of final year medical and pharmacy students from the two largest schools in the southeastern region of Nigeria. A previously published 20-items questionnaire measuring knowledge and perceptions toward AMR and ASP was adopted for the study. Results were expressed as frequencies and percentages.ResultsCompleted questionnaires were received from 79.3% (361 of 455 students), over half (60%) were male, and mostly between 22 and 25 years old (68.7%). More pharmacy students had formal training on ASP compared with medical students (41.3% vs. 27.5%, P < 0.05). Pharmacy students (n = 84.3% and 90.5%) were significantly more knowledgeable of factors that promote the spread of AMR and interventions to combat resistance than medical students (n = 73.9% and 82.3%), P < 0.05, respectively. Interestingly, 23.3% of medical students thought pharmacists should lead ASP teams, while 5.8% of pharmacy students thought doctors should lead ASP. However, both held poor perceptions of each other’s roles in the ASP team.ConclusionKnowledge of AMR and ASP among medical and pharmacy students in Nigeria is lacking. Inter-professional collaboration to change perceptions and drive ASP in urgently needed.Disclosures All authors: No reported disclosures.

2406. Trends of Clostridioides difficile-Associated Diarrhea at a Tertiary Care Center in India

Background Clostridioides difficile has been recognized as a significant cause of morbidity and mortality globally. Its infection can range from asymptomatic carriage to antibiotic-associated diarrhea and colitis. Reports of outbreak with the hypervirulent strain (N1/NAP1 Ribotype 027) has raised the concern on the magnitude and severity of C. difficile infections. This study aimed to determine the prevalence of C. difficile-associated diarrhea (CDAD) among the patients at a tertiary care hospital in India.MethodsA retrospective analysis from January 2015-December 2018 was done to determine the trends of C. difficile infection. ELISA for detection of toxins A and B was performed on stool samples. A diagnosis of CDAD was made in all patients with stool samples positive for toxins A and B.ResultsSamples from 1311 patients were received from January 2015-December 2018 from patients with suspected nosocomial diarrhea. 9/1311 were culture positive for C. difficile, 7/9 were both culture and ELISA positive. A total of 74 patients were positive for ELISA for detection of toxins A and B. The prevalence of CDAD in the years 2015–2018 were as follows: 4.01% (10/249) in 2015, 10.03% (26/259) in 2016, 4.7% (21/446) in 2017 and 5.32% (19/357) in 2018, respectively. Malignancy was found to be the most common underlying pathological condition 15/69. Most common group of antibiotics used in these patients of CDAD were carbapenems 20/64. Amongst 82.6% (57/69) of the patients were hospitalized. Diarrhea was associated with fever in 40.5% (28/69) of the patients.ConclusionOur results show over all variable prevalence of CDAD over the years and was higher in the year 2016. Timely appropriate diagnosis, high index of suspicion in high-risk patients and proper implementation of antimicrobial stewardship programs may help in reducing morbidity and mortality in patients of CDAD.Disclosures All authors: No reported disclosures.

1979. Five-Year Impact of an Antimicrobial Stewardship Program on Nosocomial Candidemia: An Interrupted Time-Series Analysis Study

BackgroundAntimicrobial stewardship programs allow a reduction in antibiotic prescription and, consequently, in the incidence of multidrug-resistance infections. However, the impact on nosocomial candidemia is still unclear.MethodsThe present study is an interrupted time-series (ITS) before-after study, based on an ecological time-trend analysis. Since 2014, an antimicrobial stewardship program (ASP) has been implemented at an Italian tertiary-care hospital. The first objective of the program was to reduce carbapenem consumption, through an active and computerized surveillance of all carbapenem prescriptions, each of which was checked and validated by ID specialists always after audit of the cases with treating physicians. We retrospectively evaluated the changing in the consumption of antimicrobials, carbapenems, and in the incidence of candidemia, during two study periods: before (2007–2013) and after (2014–2018) the implementation of the ASP.ResultsThe implementation of ASP was followed by a significant decrease in antibiotic consumption, which was consistent through the following 5 years. At the end of the study, total antibiotic consumption has decreased by 38.476 DDDs per 100 patient-days (PDs) per quarter (95% CI: −21.784 to −55.168; P < 0.001) and carbapenems decreased by 4.452 DDD per 100 PDs per quarter (95% CI: −3.658 to −5.246; P = 0.001). After 5 years of ASP, incidence of candidemia decreased by 2.034 episodes per 1,000 PDs per quarter (95% CI: −0.738 to −3.330; P = 0.003), decreasing, at the end of 2018, by 53% compared with the expected value if the program had not been implemented.ConclusionAt our Institution, the ASP had a positive impact on the consumption of carbapenems, and antimicrobials. The incidence of candidemia was also favorably affected by the program, reversing the trend after 2014. The ASP, even if not directly targeted to fungal infections, indirectly caused a reduction in the incidence of candidemia, probably reducing the number of patients colonized by Candida spp.Disclosures All authors: No reported disclosures.

1084. A Pre- and Post-Intervention Study to Implement a Successful Antimicrobial Stewardship Program at an Urban Chronic Hemodialysis Center

BackgroundPatients receiving chronic outpatient hemodialysis (CHD) are at high risk for bloodstream and vascular access infections due to the immune-compromised status of patients and repeated vascular access. CHD patients are especially vulnerable to multidrug-resistant organisms due to extensive exposure to antibiotics (ABX). It is estimated that more than 40% of CHD patients receive ≥1 ABX course each year. As data characterizing ABX use and reasons for inappropriate prescribing is still scarce in CHD patients, our objective was to assess ABX use pre- and post-implementation of antimicrobial stewardship program (ASP).MethodsA retrospective cohort study to analyze appropriate ABX use from 2015–2018 in CHD patients was conducted. Starting January 15, 2019, ASP was established at the hemodialysis center and tracked all ABX doses including appropriate indication, dosage, frequency, route, therapeutic drug monitoring (TDM) and duration of therapy. All results are presented as descriptive statistics.ResultsOf the 250 accounts of antibiotics that were assessed retrospectively in all patients from ages 12 to 95 years old, 50% of antibiotics ordered were inappropriately prescribed. The following were the reasons for inappropriateness: indication (59%), duration (14%), culture susceptibility (7%), dose (12%), narrow-spectrum warranted (2%), TDM (6%). Twenty-three accounts were assessed post-implementation phase. ASP implementation led to 100% compliance with regards to the appropriateness of ABX usage (indication, dose, and duration). Additional, ASP interventions included recommendations to obtain blood cultures and conduct TDM in 47% of patients.ConclusionThis study identified inappropriateness of antibiotic usage without an established ASP in CHD patients. Implementation of ASP was associated with a positive impact on all ABX doses prescribed and this can have a significant outcome on optimizing ABX use in CHD patients.Disclosures All authors: No reported disclosures.

2026. A Current Status of Antimicrobial Stewardship Programs in Korean Large Hospitals: A Nationwide Survey in 2018

BackgroundThe aim of this study was to examine the current status of antimicrobial stewardship program (ASP) in large hospitals in South Korea, identifying problems and hurdles for implementation of proper ASP, and providing a reference for the proposal of ASP policies.MethodsThe questionnaire was designed based on the “Seven Core Elements of Hospital Antibiotic Stewardship Programs” from Centers for Diseases Control and Prevention of the U.S. and modified from the questionnaire of the previous survey on ASP in Korea, 2015. The survey targeted all the hospitals with 500 beds or more in South Korea in 2018. The online-based survey using SurveyMonkey® platform was conducted for 3 weeks from June to July 2018. Only one ASP-associated physician per hospital participated in the survey.ResultsThe response rate to the survey was 88.4% (84/95). The median number of medical personnel participating in ASP was 4 [interquartile range (IQR) 2.25–5], most of which were infectious diseases specialists (median 2, IQR 1–2). Besides, some pediatric infectious diseases specialists, pharmacists, etc. were participating in the ASPs. Only 6.0% (5/84) of hospitals had full-time workers for ASP. Restrictive measures for designated antibiotics was a widely accepted ASP strategy among Korean hospitals (88.1%, 74/84) and the median number of designated antibiotic classes was 16 (IQR 11–19). An 11.9% (10/84) of hospitals introduced monitoring and intervention program against inappropriate antibiotic combination therapy. The proportion of hospitals which had interventions for inappropriate long-term antibiotic use and parenteral to oral conversion strategy were 9.5% (8/84) and 1.2% (1/84), respectively. Lack of time, personnel, and appropriate reward were perceived as the major barriers to establishing ASP in Korean hospitals.ConclusionASP in Korean hospitals were mainly carried out by 1–2 infectious diseases specialists and it heavily depended on restrictive measures for designated antibiotics. Supporting manpower and establishment of the appropriate reward system is necessary for improvement of ASP in Korean hospitals. Disclosures All authors: No reported disclosures.

Health care providers\u2019 perceptions regarding antimicrobial stewardship programs (AMS) implementation\u2014facilitators and challenges: a cross-sectional study in the Eastern province of Saudi Arabia

BackgroundInfections result from invasions of an organism into body tissues leading to diseases and complications that might eventually lead to death. Inappropriate use of antimicrobials has led to development of antimicrobial resistance (AMR) which has been associated with increased mortality, morbidity and health costs. Antimicrobial stewardship (AMS) programs are designed to ensure appropriate selections of an effective antimicrobial drugs and optimizing antibiotic use to minimize antibiotic resistance by implementing certain policies, strategies and guidelines. The aim of this study was to investigate practitioners’ perceptions regarding AMS implementation and to identify challenges and facilitators of these programs execution.MethodsCross-sectional study among health care providers in Eastern province of Saudi Arabia Hospitals. The data was collected using a survey including questions about demographic data and information about clinicians’ (physicians, pharmacists and nurses) previous experience with AMS and prescribing of antibiotics, the level of knowledge and attitudes regarding AMS programs’ implementation.ResultsMore than 50% of clinicians (N = 184) reported lack of awareness of AMS programs and their components, whereas 71.2% do not have previous AMS experience. The majority of clinicians (72.3%) noticed increasing number of AMR infections over the past 5 years and (69.6%) were involved in care of patients with an antibiotic-resistant infection. Around 77.2% of respondents reported that formulary management can be helpful for AMS practice and majority of respondents (79.9%) reported that the availability of pathogens and antimicrobial susceptibility testing can be helpful for AMS. Major barriers to AMS implementation identified were lack of internal policy/guidelines and specialized AMS information resources. Lack of administrative awareness about AMS programs; lack of personnel, time limitation, limited training opportunities, lack of confidence, financial issue or limited funding and lack of specialized AMS information resources were also reported 65.8%, 62.5%, 60.9%, 73.9%, 50%, 54.3 and 74.5%, respectively.ConclusionOur study identified comprehensive education and training needs for health care providers about AMS programs. Furthermore, it appears that internal policy and guidelines need revision to ensure that the health care providers work consistently with AMS. Future research must focus on the benefit of implementing AMS as many hospitals are not implementing AMS as revealed by the clinicians. We recommend policy makers and concerned health authorities to consider the study findings into account to optimize AMS implementation.

Current status of antimicrobial stewardship programmes in Korean hospitals: results of a 2018 nationwide survey

Antimicrobial stewardship programmes (ASPs) are suggested as a vital strategy to address antimicrobial resistance. To examine the current status of ASPs in Korean hospitals, to identify problems and challenges for the implementation of proper ASPs, and to provide a reference for developing more effective ASP policies. A questionnaire based on the 'Seven Core Elements of Hospital Antibiotic Stewardship Programs' from the US Centers for Disease Control and Prevention was developed, modified from the previous questionnaire on ASPs in Korea, 2015. ASP-participating physicians such as infectious disease specialists (IDSs), paediatric IDSs, and directors of infection control departments were targeted. Only one ASP-associated physician per hospital participated in the survey. The survey response rate was 88.4% (84/95). The median number of medical personnel participating in ASPs was 3 (interquartile range (IQR): 1-5), most of whom were IDS (median: 2; IQR: 1-2). Only 6.0% (5/84) of hospitals had full-time workers for ASPs. Whereas restrictive measures for designated antimicrobials were widely implemented among Korean hospitals (88.1%, 74/84), the proportion of hospitals with interventions for inappropriate long-term antimicrobial use and a conversion strategy from parenteral to oral antimicrobial administration was only 9.5% (8/84) and 1.2% (1/84), respectively. Lack of time, personnel, and appropriate compensation was perceived as the major barrier to establishing an ASP in Korean hospitals. ASPs in Korean hospitals were primarily carried out by one or two IDSs, and programmes mostly comprised restrictive measures for designated antimicrobials. National-level support to implement appropriate ASPs in Korean hospitals is necessary.

Implementing antimicrobial stewardship to reduce surgical site infections: Experience and challenges from two tertiary-care hospitals in Mumbai, India.

Surgical site infections (SSIs) contribute significantly to post-surgical morbidity globally. Antimicrobial stewardship programmes (ASPs) are essential to reduce SSI rates and to curb antimicrobial resistance, especially in low-and-middle-income countries. This prospective study aimed to show the reproducibility of ASP implementation and SSI prevention measures in a semi-private institution with high perioperative prophylactic antimicrobial consumption beyond guidelines. The prevalence of SSIs in clean surgeries was analysed in a government hospital adhering to SSI prevention guidelines including antimicrobial prophylaxis (phase 1; n=335) and in a surgical department unit of a semi-private hospital where the same guidelines were subsequently implemented (phase 2; n=235). SSI rates were compared to check the hypothesis that ASPs and infection control policies are reproducible with similar SSI rates. Moreover, antimicrobial prophylaxis costs were compared between units with and without guideline adherence. Among a total of 570 clean surgeries analysed, SSI rates were similar in both phases (6.0% vs. 5.1%; P=0.659). SSI rates were higher in patients aged >50 years in both phases (P=0.0009 and 0.045), whilst there was no difference in SSI rates between diabetics and non-diabetics (P=0.475 and 0.835). The cost of antimicrobial prophylaxis was lower in the guideline-oriented group (US$0.42 vs US$9 per patient; P=0.0042). Implementing SSI prevention guidelines, including proper antimicrobial prophylaxis, is feasible and reproducible among different hospital settings, leading to a significant decrease in prophylaxis costs. SSI rates do not differ following the same international standards.

Assessment of Core Capacities for Antimicrobial Stewardship Practices in Indian Hospitals: Report from a Multicentric Initiative of Global Health Security Agenda

AbstractIntroduction: Antimicrobial-resistant HAI (Healthcare associated infection) are a global challenge due to their impact on patient outcome. Implementation of antimicrobial stewardship programmes (AMSP) is needed at institutional and national levels. Assessment of core capacities for AMSP is an important starting point to initiate nationwide AMSP. We conducted an assessment of the core capacities for AMSP in a network of Indian hospitals, which are part of the Global Health Security Agenda-funded work on capacity building for AMR-HAIs. Subjects and Methods: The Centers for Disease Control and Prevention’s core assessment checklist was modified as per inputs received from the Indian network. The assessment tool was filled by twenty hospitals as a self-administered questionnaire. The results were entered into a database. The cumulative score for each question was generated as average percentage. The scores generated by the database were then used for analysis. Results and Conclusion: The hospitals included a mix of public and private sector hospitals. The network average of positive responses for leadership support was 45%, for accountability; the score was 53% and for key support for AMSP, 58%. Policies to support optimal antibiotic use were present in 59% of respondents, policies for procurement were present in 79% and broad interventions to improve antibiotic use were scored as 33%. A score of 52% was generated for prescription-specific interventions to improve antibiotic use. Written policies for antibiotic use for hospitalised patients and outpatients were present on an average in 72% and 48% conditions, respectively. Presence of process measures and outcome measures was scored at 40% and 49%, respectively, and feedback and education got a score of 53% and 40%, respectively. Thus, Indian hospitals can start with low-hanging fruits such as developing prescription policies, restricting the usage of high antibiotics, enforcing education and ultimately providing the much-needed leadership support.

Implementasi Antimicrobial Stewardship Program di Kawasan Asia: Sebuah Kajian Sistematis

Antimicrobial Stewardship Program (ASP) merupakan salah satu program yang direkomendasikan untuk meningkatkan ketepatan penggunaan antibiotik, khususnya pada setting rumah sakit. Keberhasilan implementasi program tersebut ditentukan oleh banyak faktor, antara lain komunikasi antartenaga kesehatan dan ketersediaan sumber daya manusia maupun sarana-prasarana. Sampai saat ini, bukti penelitian terkait implementasi ASP di Asia khususnya di negara low - dan lower-middle income economies masih terbatas. Tujuan kajian sistematik ini adalah mengidentifikasi jenis strategi ASP yang diimplementasikan di berbagai negara Asia dengan berbagai income status, dan memberikan gambaran dampak dari implementasi ASP terhadap luaran klinis, mikrobiologis, dan finansial. Proses penelusuran pustaka dilakukan dengan menggunakan basis data PUBMED dan kata kunci “ antimicrobial stewardship ” dan “Asia” yang dikombinasikan dengan Boolean operator yaitu “AND”. Total terdapat 28 penelitian dari sembilan negara diikutsertakan dalam kajian akhir. Belum ditemukan bukti penelitian terpublikasi terkait ASP di Indonesia. Hanya terdapat satu penelitian berasal dari negara lower-middle income economies dan penelitian tersebut dilakukan pada institusi kesehatan tersier. Sebagian besar penelitian, yakni 22, berasal dari negara high-middle income economies , dan 18 dari antaranya dilakukan di rumah sakit tersier atau rumah sakit yang berafiliasi pada institusi pendidikan tinggi. Jenis intervensi ASP yang paling banyak diimplementasikan adalah audit peresepan antibiotik secara prospektif dan disertai dengan pemberian umpan balik, dan penerapannya terbukti dapat menghasilkan luaran yang positif baik secara klinis, mikrobiologis, maupun finansial. Dengan mempertimbangkan dampak positif tersebut, sangat diharapkan agar ASP dapat diimplementasikan pada institusi kesehatan di Indonesia dengan memperhatikan ketersediaan sumber daya dan konteks budaya lokal. Kata kunci: Antibiotik, ketepatan penggunaan, program pengendalian resistensi, resistensi antibiotik The Implementation of Antimicrobial Stewardship Program in Asian Region: A Systematic Review Abstract Antimicrobial Stewardship Program (ASP) is one of the recommended programs to optimize the prudent use of antimicrobials, particularly in the hospital settings. The successful ASP implementation is determined by numerous factors, including communication among healthcare workers, and the availability of human resources and facilities. There is limited evidence available regarding the ASP implementation in Asia, particularly in the low- and lower-middle income countries. This systematic review aimed to identify the type of ASP interventions implemented in Asian countries according to the income status and to describe the impact of ASP implementation on the clinical, microbiological, and financial outcomes. The search strategy was undertaken using PUBMED, and the search terms were “antimicrobial stewardship” and “Asia” which were combined with the use of a Boolean operator “AND”. In total, 28 articles from nine countries were included in the final review. No article from Indonesia could be found in this systematic review. There was only an article from a lower-middle income country that was conducted in a tertiary health institution. Most of the articles (22 articles) were from high-middle income countries and 18 of them were conducted either in the tertiary care or university affiliated hospitals. Prospective audit with intervention and feedback was the most frequent ASP used in which positive outcomes on the clinical, microbiological, and financial outcomes have been evidenced. The positive impact of ASP implementation should suggest the needs to initiate the program in the healthcare facilities in Indonesia while taking into account the available resources and the local cultures. Keywords: Antibiotic resistance, antibiotics, prudent use, stewardship program

Essential human resources for antimicrobial stewardship teams in Japan: Estimates from a nationwide survey conducted by the Japanese Society of Chemotherapy

Implementation of antimicrobial stewardship programs (ASPs) with multidisciplinary antimicrobial stewardship teams (ASTs) is critical for appropriate antimicrobial use at healthcare facilities. Although the Japanese medical reimbursement system was revised to allow fees for ASP implementation, several concerns remain, including understaffing and enforcement of the recommendations on ASTs and ASPs in practice. Furthermore, there are no recommendations on full-time equivalents (FTEs) of the core members in ASTs in Japan. This committee report presents our recommendations on ASTs based on an analysis of the nationwide survey on implemented ASPs and staff FTEs at 1358 healthcare facilities conducted by the Japanese Society of Chemotherapy. Our report provides a directive for structural and financial support of ASTs and should aid in planning for the enhancement of AST practices and the organization of new ASTs.

Practice of prophylactic antibiotic and timing of administration in two common elective surgeries in Pakistan: An audit-based study

Antibiotic prophylaxis usage is one of the main actions to prevent and reduce rate of surgical site infections. Antimicrobial stewardship programme is also focused on audit of surgical antibiotic prophylaxis (SAP). The objective of study was to evaluate the appropriateness of SAP and their pattern of utilization in two tertiary-care teaching hospitals in Islamabad (Pakistan). A total of 965 elective surgeries were performed during the 9 months study period. The two most common elective surgical procedures were Laparoscopic cholecystectomy and Direct right inguinal hernia, that were performed on 443 patients. Adherence to the Standard International Guidelines (CDC, 2017) about appropriate use of antibiotic and timing of administration were main outcomes. The mean age of patients was 43.5±16.3 years. SAP was appropriate according to guidelines in only 5% (n=22) of cases. Appropriate use of SAP was greater in direct right inguinal hernia (10%) than laparoscopic cholecystectomy (1.2%) surgery; P = 0.001. The drug of choice cefazolin was only prescribed to 4.2% (19 out of 443) of patients. Timing of administration was appropriate in 50.8% (225 out of 443) of the procedures. Compliance with timing was significantly lower in Hospital GH (32%) as compared to Hospital PH (71%); P < 0.001. Length of stay was significantly different (P = 0.001) between surgical procedures. The most common antibiotics used inappropriately were ceftriaxone and Cefuroxime. Present study found an overall low adherence to SAP mainly regarding choice and timing of administration. Educational intervention and urgent need for implementation of antimicrobial stewardship programme are required.

Distribution and molecular characterization of beta-lactamases in Gram-negative bacteria in Colombia, 2001-2016

Beta-lactamases are enzymes with hydrolytic activity over beta-lactam antibiotics and they are the main resistance mechanism in Gram-negative bacteria. Extended-spectrum beta-lactamases (ESBL), AmpC, and carbapenemases have the greatest clinical and epidemiological impact in hospital settings. The increasing frequency and worldwide spread of these enzymes have limited the therapeutic options in hospital-acquired infections and those originating in the community. In Colombia, surveillance networks and research groups began studying them in the late 90s. Different variants of these enzymes have been molecularly characterized and their high prevalence and dissemination in medium and high complexity hospitals, along with a high clinical impact, have been reported. Furthermore, many studies in Colombia have evidenced high endemicity for some of these beta-lactamases, which requires an urgent implementation of antimicrobial stewardship programs in order to preserve the few therapeutic options and infection control strategies to prevent and limit their dissemination. In this publication, we carried out a review of the different enzyme variants, geographic distribution, and molecular characterization of these beta-lactamases in Colombia. Additionally, we describe the available information in the literature regarding studies conducted between the late 1990s and 2016, which provide an overview of the beta-lactamases circulating in different regions of Colombia, their increase over time, and their clinical implications.

Perspective of Pakistani Physicians towards Hospital Antimicrobial Stewardship Programs: A Multisite Exploratory Qualitative Study.

Background: Antimicrobial resistance (AMR) is a global threat and the antimicrobial stewardship program (ASP) is a globally used tool to combat AMR. There is little information on the views among Pakistani physicians regarding AMR and the benefits of hospital antimicrobial stewardship implementation. This study was designed to explore the physicians’ views about ASP. Methods: Qualitative face-to-face and telephonic interviews were conducted by using purposive sampling method with 22 physicians working in seven tertiary care public hospitals of Punjab, Pakistan. All interviews were audio recorded and transcribed verbatim. Qualitative software was used, and a thematic analysis was conducted. Results: Three broad themes were identified: (1) the growing concern of antimicrobial resistance in Pakistan, (2) the role(s) of healthcare professionals in antibiotic prescribing, and (3) managing antibiotic resistance in hospitals. Inadequate resources, poor healthcare facilities, and insufficiently trained medical staff were the major hurdles in ASP implementation in Pakistan. Conclusions: Our study found a poor familiarity of hospital ASP among physicians working in public sector tertiary care teaching hospitals, and a number of distinct themes emerged during this study that could be helpful in establishing the concept of hospital ASP in Pakistan. Overall, physicians showed a positive attitude towards the enforcement of ASP in all healthcare settings, including teaching hospitals.

Attitudes and beliefs of Australian emergency department clinicians on antimicrobial stewardship in the emergency department: A qualitative study.

To explore the attitudes and beliefs of Australian ED clinicians towards antimicrobial stewardship in the ED. Semi-structured one-to-one interviews were conducted with ED clinicians between March and October 2015. Participants were identified via purposive and snowball sampling. Questionnaires were developed using the literature. Interviews were audio-recorded, transcribed and analysed using thematic analysis via the framework approach. Two researchers coded independently, with one using QSR International's NVivo 10 software and the other manually. Emergent themes were identified and classified. Twenty-two clinicians (eight doctors, eight nurses and six pharmacists) from seven institutions participated. Participants were aware and concerned about antimicrobial resistance. Clinicians were divided based on their opinion on whether antimicrobials are prescribed appropriately and judiciously in the ED, with many perceiving prescribing to be inappropriate. Prior knowledge of the term 'Antimicrobial Stewardship' was demonstrated by doctors and pharmacists, with a relative lack of awareness by nurses. Four main themes were identified as both barriers and facilitators to antimicrobial stewardship in the ED: individual healthcare provider, resource, organisational and cultural. Uncertainty of diagnosis, time and resource pressures, reliance on previous experience and lack of access to expert opinion were perceived barriers. To facilitate appropriate prescribing, clinicians emphasised the need for routine education and feedback, adequate staffing, robust guidelines, senior medical clinician advocacy and multidisciplinary support. Australian ED clinicians were aware of antimicrobial resistance. Many perceive injudicious antimicrobial use as problematic. Consideration of ED clinicians' perceived barriers and facilitators might enhance implementation of antimicrobial stewardship programmes in EDs.

Effectiveness of antibiotic stewardship programmes in primary health care settings in developing countries.

Despite the implementation of antimicrobial stewardship programmes (AMS), antibiotic resistance are a rising a major global concern, and the burden is estimated increase. Little is known about program effectiveness, particularly in primary care and in developing nations. To assess the effectiveness of antimicrobial stewardship programmes in primary health care. A case study assessed the effectiveness of implementation of antimicrobial stewardship at 10 primary health care facilities in Windhoek. From 1 to 31 October 2018, a SWOT analysis of each health facility was conducted through an audit and interview of infection control focal persons to assess the level of compliance to good antimicrobial stewardship practices and policies. Of the 10 facilities, 90% of the focal persons were aware of systems and polices for good AMS practice. The level of compliance at hospital-based primary health centers was 30.8% compared to clinics (9.1%-36.4%). The main challenge is lack of policies and systems specific to antimicrobial use as well as commitment of financial and human resources to implement AMS programmes in primary health care. The implementation of antimicrobial stewardship programmes in primary health care is suboptimal. This negatively affects the global efforts to control antimicrobial resistance. There is a need to institutionalise national guidelines for AMS in primary health care.

Trends in antimicrobial susceptibility patterns in King Fahad Medical City, Riyadh, Saudi Arabia

Objectives:To describe and interpret local antibiograms from a single tertiary care center to monitor the trends of antimicrobial resistance (AMR) patterns and establish baseline data for further surveillance.Methods:We performed a retrospective descriptive review of antibiograms data between January 2010 and December 2015 from King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.Results:A total of 51,491 isolates were identified, and most were gram-negative (76.2%). Escherichia coli was the most frequently isolated organism (36.8%), followed by Coagulase-negative Staphylococcus (28.4%) and Staphylococcus aureus (27.5%). The detection of antibiotic-resistant organisms, especially extended-spectrum beta-lactamase-producing Escherichia coli (31%-41%), increased over time. The sensitivity of Streptococcus pneumoniae to penicillin improved from 66% to 100% (p<0.001). Gram-negative isolates had excellent overall susceptibility to amikacin, variable susceptibility to piperacillin-tazobactam and carbapenems, and declining susceptibility to ceftazidime, ciprofloxacin, and cefepime.Conclusion:Streptococcus pneumoniae susceptibility to penicillin significantly improved over time, which might be because of the introduction of the pneumococcal vaccine. Conversely, the upward trend in resistant gram-negative organisms is worrisome and warrants the implementation of antimicrobial stewardship programs.

Evaluation of the Effectiveness of Clinical Pharmacists’ Consultation in the Treatment of Infectious Diseases: A Single-Arm, Prospective Cohort Study

Background: With the implementation of Antimicrobial Stewardship Program, clinical pharmacists’ consultation (CPC) for infectious diseases (ID) is gradually adopted by many hospitals in China. We conducted a cohort study to evaluate the effectiveness of CPC in ID treatment on patient outcomes and potential determinants.Methods: Based on a registry database, a prospective cohort study was conducted in Guizhou Provincial People’s Hospital. The main exposure factor was whether clinician adopted the suggestion from clinical pharmacist. The outcome was effective response rate (ERR) of ID patients. The variables associated with the outcome (e.g., age, gender, severity of infection, liver function, and kidney function) were also prospectively recorded. A multilevel model was performed to analyze the factors related to ERR.Results: A total of 733 ID inpatients were included in the final analysis according to the predesigned inclusion and exclusion criteria. The proportion of clinical pharmacists’ suggestions adopted by clinicians and ERR were 88.13 and 69.03%, respectively. Significant data aggregation (P < 0.05) for individuals at the level of department was observed. According to the two-level variance component model, liver dysfunction (Adjusted Odds Ratio (AOR) = 0.649, 95%Credible Interval (CI): 0.432–0.976), severity of infection (AOR = 0.602, 95%CI: 0.464–0.781), and adopting the suggestion from pharmacist (AOR = 1.738, 95%CI: 1.028–2.940) had significant association with ERR.Conclusion: Our study suggests that the effect of CPC on ID treatment is significant. The policy/decision makers or hospital managers should be cognizant of the critical value of clinical pharmacists in ID treatment.

Barriers to implementing antimicrobial stewardship programmes in three Saudi hospitals: Evidence from a qualitative study.

This study explored antimicrobial stewardship programme (ASP) team members' perspectives regarding factors influencing the adoption and implementation of these programmes in Saudi hospitals. This was a qualitative study based on face-to-face semistructured interviews with healthcare professionals involved in ASPs and activities across three Ministry of Health (MoH) hospitals in Saudi Arabia (n = 18). Interviews were also conducted with two representatives of a General Directorate of Health Affairs in a Saudi region and two representatives of the Saudi MoH (n = 4) between January-February 2017. Despite the existence of a national strategy to implement ASPs in Saudi MoH hospitals, their adoption and implementation remains low. Hospitals have their own antimicrobial stewardship policies, but adherence to these is poor. ASP team members highlight that lack of enforcement of policies and guidelines from the MoH and hospital administration is a significant barrier to ASP adoption and implementation. Other barriers include disintegration of teams, poor communication, lack of recruitment/shortage of ASP team members, lack of education and training, and lack of health information technology (IT). Physicians' fears and concerns in relation to liability are also a barrier to their adoption of ASPs. This is the first qualitative study exploring barriers to ASP adoption and implementation in Saudi hospitals from the perspective of ASP team members. Formal endorsement of ASPs from the MoH as well as hospital enforcement of policies and provision of human and health IT resources would improve the adoption and implementation of ASPs in Saudi hospitals.

Prevalence of extended-spectrum β-lactamase-producing Klebsiella pneumoniae: First systematic review and meta-analysis from Iran.

Extended-spectrum β-lactamase-producing Klebsiella pneumoniae (ESBL-KP) have emerged as an important pathogen causing severe infections worldwide. Infections due to ESBL-KP are associated with high morbidity and mortality, especially in developing countries such as Iran. The aim of this study was to assess the pooled prevalence of ESBL-KP with different gene variants in Iran. A literature search of Medline (via PubMed), Embase, Web of Science and Iranian Database was performed. A meta-analysis was conducted using Comprehensive Meta-Analysis Software (version 2.2, Biostat). A fixed- or random-effects model was used based on the heterogeneity test. Publication bias was determined using Begg's rank correlation and Egger's weighted regression methods. Among 783 articles identified, 43 studies met the eligibility criteria. The pooled prevalence of ESBL-KP was 43.5% (95% CI 39.3-47.9%) among clinical K. pneumoniae isolates. Among genes encoding ESBLs during 2000-2009, SHV, CTX-M and TEM were found with prevalences of 23.3%, 15.2% and 12.3%, respectively, whilst the prevalences of SHV, CTX-M, TEM and VEB were 24%, 28.1%, 25.2% and 8.3%, respectively, during the period 2010-2018. The prevalence of ESBL-KP has increased steadily in recent years among clinical K. pneumoniae isolates in Iran. Thus, initial identification of ESBL-KP according to Clinical and Laboratory Standards Institute (CLSI) guidelines, proper molecular approaches, and implementation of antimicrobial stewardship programmes in Iranian hospitals together with comprehensive infection control measures are urgently needed to control the dissemination of these strains.