Inpatient Antimicrobial Stewardship Research Articles

Fluoroquinolone Restriction as an Effective Antimicrobial Stewardship Intervention.

Fluoroquinolones are a commonly prescribed antibiotic class that has come under scrutiny in recent years due to mounting evidence of association between adverse drug events, C. difficile infection and isolation of antibiotic-resistant bacteria. Inpatient antimicrobial stewardship (AMS) programs have a toolbox of potential interventions to curb inappropriate antibiotic use, prevent antibiotic-associated adverse drug events, and avoid unnecessary costs of care. Fluoroquinolone restriction policies in the acute care setting have demonstrated beneficial effects, including decreased rates of C. difficile infection and ESBL-producing Enterobacteriaceae. However, a simple blanket restriction policy may "squeeze the antibiotic balloon" and will likely be insufficient if not implemented in conjunction with other AMS interventions. There is a growing body of evidence to support formulary restriction of fluoroquinolones in the acute care setting to decrease rates of C. difficile infection and development of ESBL-producing organisms. Data on how to best implement these restrictions or how to implement outside of acute care settings is limited.

Potentially Inappropriate Durations of Anti-Infective Therapy at Hospital Discharge Despite Inpatient Antimicrobial Stewardship

BackgroundExcess durations of anti-infective therapy are a common problem that may lead to unintended consequences. Antimicrobial stewardship (AMS) is a growing field that largely focuses on inpatient anti-infective use. For this study, one site was an academic medical center whose AMS uses prospective auditing; the other was a community hospital with pharmacy-driven AMS. Little research has examined durations of anti-infective therapy at hospital discharge.MethodsPatient charts were reviewed and 284 were included in the final analysis. Patients were excluded if discharged on non-oral anti-infectives or only agents for a non-study indication. Patients were included if they were discharged on oral anti-infective therapy for CAP, healthcare-associated pneumonia (HCAP), UTI, cellulitis, and superficial abscess. Evidence-based durations of therapy were utilized to determine the potential inappropriateness of anti-infective therapy. Guidelines from the study period were used. Total duration of therapy was derived from the combination of outpatient therapy plus inpatient therapy beginning with the first day of relevant coverage for the given indication. Descriptive statistics were utilized to compare durations of therapy. Chi-squared tests were utilized to examine differences in expected frequencies. All statistics were performed in SPSS v. 24.ResultsThe average combined duration of therapy was 11.3 days. 190 patients (66.9%) were found to have a potentially inappropriate duration of oral anti-infective therapy at hospital discharge. Only 2 durations were too short. Figure 1 displays the distribution of excess days of therapy. Figure 2 shows the breakdown of potential inappropriateness of duration by diagnosis. Figure 3 displays the percentage of potentially inappropriate cases by site. There were no significant differences in the primary outcome between the sites.ConclusionCAP and cellulitis appear to be areas that are often overtreated. Discharge durations of therapy should be a focus of AMS teams. Many patients receive potentially inappropriate durations of therapy at discharge without any discernible benefit. Further research is needed in this area.Disclosures All authors: No reported disclosures.

Use of the Health Belief Model to Study Patient Perceptions of Antimicrobial Stewardship in the Acute Care Setting.

To identify themes associated with patient perceptions of antibiotic use and the role of patients in inpatient antimicrobial stewardship. We conducted semi-structured interviews with 30 hospitalized patients using the Health Belief Model as the framework for questions and analysis. An academic tertiary care hospital in Madison, Wisconsin. A total of 30 general medicine inpatients receiving at least 1 anti-infective medication were interviewed. Participants recognized antibiotic resistance as a serious public health threat but expressed low perceived susceptibility to being personally affected by antibiotic resistance. Views of susceptibility were influenced by a high degree of trust in physicians and misperceptions regarding the mechanisms underlying resistance. Participants expressed high self-efficacy and a desire to be involved in their health care. Perceived roles for patients in preventing the inappropriate use of antibiotics ranged from asking questions and speaking up about concerns to active involvement in decision making regarding antibiotic treatments. Few participants reported being offered the opportunity to engage in such shared decision making while hospitalized. Our findings suggest an important role for patients in improving antibiotic use in hospitals. However, patient engagement has not been recognized as a critical component of antimicrobial stewardship programs. Our study suggests that the likelihood of patient engagement in stewardship practices is currently limited by low perceived susceptibility and lack of cues to act. Further investigation into how patients may be engaged as good stewards of antibiotics may reveal new ways to improve antibiotic prescribing practices in the inpatient setting.

Impact of Pharmacist-led Antimicrobial Stewardship in the Intensive Care Unit: One Year Pre- and Post-Implementation

• Inpatient antimicrobial stewardship programs (ASPs) within acute care hospitals have been shown to improve patient outcomes, shorten length of stay, reduce antimicrobial resistance, and are cost effective • ASPs initiated in the ICU have shown to decrease antimicrobial utilization, length of stay, and cost and are prime targets for ASP intervention due to the high rate of antimicrobial use Primary objective • To assess the impact of a pharmacist-led inpatient antimicrobial stewardship program in a community teaching hospital ICU one year following program implementation.

Inpatient Antimicrobial Stewardship in Pediatrics: A Systematic Review.

The clinical and economic outcomes associated with pediatric antimicrobial stewardship programs (ASPs) and other supplemental antimicrobial stewardship (AS) interventions have not been well described or reviewed. We performed a systematic review using PubMed to identify studies with any of the following terms in the title or abstract: "antimicrobial stewardship," "antimicrobial control," "antibiotic control," or "antibiotic stewardship." Studies were further limited to inpatient studies in the United States that contained the terms: "child," "children," "pediatric*" ("*" includes all terms with the same stem), "paediatric,*" "newborn," "infant," or "neonat,*" in the title or abstract. Clinical and economic outcomes from each relevant study were summarized. Nine original studies reported outcomes related to formal pediatric ASPs. An additional 8 studies focused on specific AS interventions; 3 on management of community-acquired pneumonia, 2 on vancomycin-specific initiatives, and 1 each on clinical support, antibiotic restriction, and antibiotic rotation. Reported outcomes include decreases in antimicrobial utilization (11 studies), prescribing errors (3 studies), and drug costs (3 studies). Five studies assessed the potential adverse effects of AS interventions on patient safety and found none. Data to support an association between pediatric AS interventions and antimicrobial resistance are limited. A small number of pediatric studies evaluating ASPs or other AS strategies have been published. These studies demonstrate reductions in antimicrobial utilization, cost, and prescribing errors with no apparent negative impact on patient safety. Although the studies are promising, the current evidence base is limited. Additional studies focusing on the appropriateness and outcomes of antimicrobial prescribing practices as well as more formalized economic evaluations are needed.

Antimicrobial stewardship programs in inpatient hospital settings: a systematic review.

Evaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes. Systematic review. Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel. Few intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence of Clostridium difficile infection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed. Numerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.

Antimicrobial Stewardship Programs in Inpatient Hospital Settings: A Systematic Review

ObjectiveEvaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes.DesignSystematic review.MethodsSearch of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel.ResultsFew intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence ofClostridium difficileinfection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed.ConclusionsNumerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.

Implementation and Outcome Assessment of an Inpatient Antimicrobial Stewardship Program

Background An antimicrobial stewardship program (ASP), aiming to optimize antimicrobial usage, was implemented at a Veterans Affairs Health Care System (VA HCS). Objective The main objective of this study was to compare antimicrobial usage before and after implementation of an ASP and to assess ASP interventions. Method This retrospective study was conducted at the Fargo VA HCS. A total of 1,017 inpatient charts were reviewed for 2 distinct time periods, February through September 2008 (pre ASP) and February through September 2010 (post ASP). The data that were collected and analyzed included the number of hospitalized patients prescribed antimicrobials, antimicrobial therapy duration, duration of hospital stay, and inpatient antimicrobial costs. Subgroup analyses were performed on the top 5 antimicrobials and the top 6 indications. The number, types of, and overall acceptance rate of ASP interventions were also assessed. Results When the pre- to post-ASP periods were compared, the percentage of patients on antimicrobial therapy decreased from 36.8% to 25% ( P < .001), the median duration of antimicrobial therapy significantly decreased ( P = .02), and the defined daily dose (DDD) per 1,000 patient bed days was reduced for piperacillin/tazobactam, vancomycin, and ciprofloxacin. In addition, the total inpatient antimicrobial costs decreased by $48,044 (25%). The overall ASP intervention acceptance rate was 81.6% (315 out of 386 total interventions). Conclusion The results of this study show that ASP implementation has been highly accepted by providers and has been associated with a reduction in the number of patients prescribed antimicrobials, median duration of antimicrobial therapy, and antimicrobial inpatient costs.