Reduction In Duration Of Therapy Research Articles

Discontinuation of Antibiotics in Patients with Neurological Conditions – A Study on the Impact of an Antimicrobial Stewardship Program (ASP) in a Tertiary Institution

BackgroundUp to 50% of antibiotics are prescribed either unnecessarily or inappropriately in most hospitals worldwide. In the largest tertiary hospital in Singapore, patients with neurological conditions were often initiated on antibiotics for change in mental state or isolated fevers. We hypothesize that Antimicrobial Stewardship Program (ASP) interventions to discontinue empirical antibiotics in neurological patients with no clinical evidence of bacterial infection are safe. The aim of this study was to compare clinical impact and safety outcomes of ASP interventions between accepted and rejected groups. MethodsA retrospective review of the ASP database was conducted for all patients admitted to the neurology department in Singapore General Hospital between January 2014 and December 2017. Interventions were followed up and patients were classified into two intervention groups, the accepted and rejected groups. Demographic data, age-adjusted Charlson co-morbidity index, duration of antibiotic therapy, length of hospital stay post-ASP intervention (PLOS), infection-related readmissions and mortality were compared between the two groups. Data were expressed as mean ± standard deviation for continuous variables, and unpaired Student's t-test was performed to determine intergroup differences between mean values. ResultsThe ASP team recommended 184 interventions, with an overall acceptance rate of 82.6% (152/184). There was no significant difference in demographics and age-adjusted Charlson co-morbidity index between the two groups. The accepted group had a shorter duration of therapy by 1.67 days (4.99±2.50 days vs. 6.66±2.34 days; P<0.01) and a shorter PLOS by 2 days, although this was not statistically significant (22.5±22.2 days vs. 24.5±51.4 days; P=0.83). There were no significant differences between the two groups in 14-day mortality and readmission rates. ConclusionIn neurological patients with no clinical evidence of bacterial infections, ASP interventions to discontinue empirical antibiotics were not associated with increased mortality and readmissions but were associated with significant reduction in duration of therapy.

Impact of an antimicrobial stewardship intervention on appropriateness of prescribing for community-acquired pneumonia in an Australian regional hospital.

Community-acquired pneumonia (CAP) is the second commonest indication for antibiotic use in Australian hospitals and is therefore a frequent target for antimicrobial stewardship. A single-centre prospective study was conducted in a regional referral hospital comparing management of adult patients with CAP before and after an educational intervention. We demonstrated a reduction in duration of therapy and reduced inappropriate use of ceftriaxone-based regimens for non-severe CAP.

Impact of Antimicrobial Stewardship Program (ASP) on Outcomes in Patients with Acute Bacterial Skin and Skin Structure Infections (ABSSSIs) in an Acute-Tertiary Care Hospital

IntroductionAcute bacterial skin and skin structure infections (ABSSSIs) are among the most common infections treated in hospitals, but to date, there has been little information with regards to the implementation of Antimicrobial Stewardship Programs (ASPs) for patients with ABSSSIs. Hence, we aim to evaluate the impact of ASPs on the following outcomes in patients with ABSSSIs: duration of therapy and hospital stay, 14-day reinfection, infection-related readmissions and mortality.MethodsA retrospective review of the ASP database was conducted, focusing on selected outcomes (as above) among all patients in whom the institution’s ASP recommended a change in antibiotic regimen—de-escalation of the antibiotic based on culture results; discontinuation of the antibiotic; narrowing of the empirical coverage; and intravenous-to-oral (i.v.-to-p.o.) switch between September 2009 and December 2012. Data were expressed as mean ± standard deviation for continuous variables, and unpaired Student’s t test was performed to determine intergroup differences between mean values. For categorical variables, data were presented as number and percentage and analyzed using the χ 2 test or Fisher’s exact test, as appropriate.ResultsASP recommended 407 interventions with an overall acceptance rate of 66.8%. ASP interventions significantly reduced median duration of therapy by 2 [from a median (interquartile range, IQR) of 8 (6–12) days to 6 (4–9) days] and median length of stay by 5 days [from median (IQR) of 12 (5–32) days to 7 (3–18) days]. This led to an estimated total cost avoidance of USD 0.7 million. There were no significant differences in the 14-day reinfection, infection-related readmission and mortality rates between patients whose physicians accepted and those who rejected ASP interventions.ConclusionInterventions recommended by the ASP in Singapore General Hospital were safe and associated with a significant reduction in duration of therapy and hospital stay. The results of our study have affirmed the role of ASP in optimizing the care of patients with ABSSSI.

Measurement of Serum Procalcitonin

THE ADVENT OF ANTIBIOTICS LED TO DRAMATIC REductions in mortality and medical complications from bacterial respiratory tract infections. Although the armamentarium of diagnostic and therapeutic approaches has increased exponentially since that time, the effect of these advances on patient outcomes is less dramatic. Nevertheless, the goal of care remains constant: to match the patient’s illness with a treatment approach that optimizes recovery while causing no harm. Harm exists in at least 2 forms: patient-specific, from an adverse event due to a diagnostic test or a treatment, and population-based, from the development of bacterial resistance promoted by the misuse or overuse of antibiotics. Lower respiratory tract infections (LRTIs) are a pervasive public health problem and cause more disease and death in the United States than any other infection. Patients and their physicians share a goal of improving symptoms from LRTIs as quickly as possible, often viewing antibiotics as the most expeditious intervention to achieve this goal. This one-sizefits-all approach for patients with illnesses ranging from acute bronchitis to community-acquired pneumonia (CAP) fails to consider the basic questions of who would benefit (or be harmed) from antibiotic therapy, and if treated, what is the optimal duration. Answering these questions requires an accurate assessment of which patients have bacterial infections and how their illness might progress with or without treatment. Many conventional bacterial detection techniques used in LRTIs, such as sputum Gram stains and cultures, lack sufficient diagnostic accuracy and turnaround time to inform real-time decisions. In the setting of a severe LRTI with evidence of organ derangement, assessing the benefits and risks of treatment often favors empirical antibiotic therapy. However, such clinical scenarios are uncommon; the vast majority of patients have mild to moderate illness, rendering this assessment of cause and response more challenging. Clinical decision rules based on bedside clinical and laboratory data could help physicians improve antibiotic management for such patients and optimize the duration of therapy. The ultimate clinical value of such rules is a function of diagnostic accuracy, effectiveness in changing clinician behavior, safety for patients, and both individual and societal cost. In this issue of JAMA, Schuetz and colleagues build on prior work bystudyingtheeffectivenessandsafetyofusinganovel decision rule to guide antibiotic therapy of patients diagnosed with LRTIs ranging from acute bronchitis to exacerbationofchronicobstructivepulmonarydisease(COPD)toCAP. In their current study, theauthors evaluated1359patientspresenting to emergency departments in 6 tertiary care hospitals who were randomized to receive care guided by evidencebased LRTI guidelines (control group) or by an experimental algorithm that used serum procalcitonin (PCT) to quantify the likelihood of a bacterial infection and gauge the response to therapy. PCT is released in response to bacterial infection and correlates with illness burden and severity; furthermore, it is rarely elevated in patients with viral infection. The algorithm specified 1 of 4 antibiotic treatment recommendations, rangingfromstronglydiscouragetostronglyrecommend,based on the measured PCT levels. For hospitalized patients, repeat PCT measurements guided continuation of antibiotic therapy. In contrast to many effectiveness trials that seek to change clinician behavior through the implementation of decision rules, compliance with treatment recommendations in this trial were commendably high (79.4% in the control group and 90.8% in the PCT group). Overall, the PCT-guided strategy led to reduced antibiotic exposure by an average of 3 days (8.7 vs 5.7 days) and led to 8.2% less antibioticrelated adverse effects (28.1% vs 19.8%), with slightly lower overall adverse event rates in the PCT group (15.4% vs 18.9%). Although similar outcomes were observed for patients with acute bronchitis, COPD exacerbation, and CAP, the paths to reducing antibiotic exposure differed in a predictable fashion. For acute bronchitis, decreased antibiotic exposure was principally from nontreatment, whereas for CAP it was principally from reduction in duration of therapy. Even though this PCT-guided decision rule holds promise for the management of patients with LRTI, several issues must be carefully considered before broadly translating this research into clinical practice. First, the study had a high proportion of patients with pneumonia (68.1%), more than half of whom were considered high risk (pneumonia severity index risk classes IV or V). In such patients, the high likelihood of bacterial disease and high disease acuity render PCT guidance unlikely to alter the decision to initiate antibiotic