Expert Consensus on Metrics to Assess the Impact of Patient-Level Antimicrobial Stewardship Interventions in Acute-Care Settings.
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SUBMITTER: Moehring RW
PROVIDER: S-EPMC5241782 | biostudies-literature | 2017 Feb
REPOSITORIES: biostudies-literature
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Expert Consensus on Metrics to Assess the Impact of Patient-Level Antimicrobial Stewardship Interventions in Acute-Care Settings.
Moehring Rebekah W RW Anderson Deverick J DJ Cochran Ronda L RL Hicks Lauri A LA Srinivasan Arjun A Dodds Ashley Elizabeth S ES
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 20161207 3
Antimicrobial stewardship programs (ASPs) positively impact patient care, but metrics to assess ASP impact are poorly defined. We used a modified Delphi approach to select relevant metrics for assessing patient-level interventions in acute-care settings for the purposes of internal program decision making. An expert panel rated 90 candidate metrics on a 9-point Likert scale for association with 4 criteria: improved antimicrobial prescribing, improved patient care, utility in targeting stewardshi ...[more]
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Project description:ObjectivesMonitoring the appropriateness of antibiotic prescriptions with indicators based on reimbursement data is required to guide antibiotic stewardship (AMS) interventions in nursing homes (NHs). Quantity metrics (QMs) monitor the volume of prescriptions while proxy indicators (PIs) reflect the appropriateness of antibiotic use. Our objectives were: (i) to provide a relevant consensual set of indicators to be used in French NHs; and (ii) to assess the feasibility of their implementation at the national and local scale.MethodsNine French professional organizations implicated in AMS in NHs were asked to nominate at least one member to create a national expert panel of 20 physicians. Twenty-one recently published QMs and 11 PIs were assessed by the expert panel. Indicators were evaluated using a RAND-modified Delphi procedure comprising two online surveys and a videoconference meeting. Indicators were kept in the final list if >70% of stakeholders validated their relevance for estimating the volume (QMs) and appropriateness (PIs) of prescriptions.ResultsOf the 21 QM indicators submitted to the panel, 14 were selected, describing the consumption of antibiotics overall (n = 3), broad-spectrum (n = 6) and second-line antibiotics (n = 2). The three remaining QMs evaluated the route of administration (n = 1) and urine culture prescriptions (n = 2). Ten PIs (six modified, two rejected, one new) were selected to assess the appropriateness of prescriptions for urinary tract infections (n = 2), seasonal variations in prescriptions (n = 2), repeated prescriptions of fluoroquinolones (n = 1), cephalosporins' route of administration (n = 1), duration of treatment (n = 1), rate of second-line antibiotics (n = 1), co-prescriptions with non-steroidal anti-inflammatory drugs (n = 1), and flu vaccine coverage (n = 1). The panel was in favour of using these indicators for regional and facility level AMS programmes (91%), feedback to NH prescribers (82%), benchmarking by health authorities (55%) and public reporting at the facility level (9%).ConclusionsThis consensual list of indicators, covering a wide range of frequent clinical situations, may be used as part of the French national AMS strategy for monitoring antibiotic prescriptions in NHs at the national and local levels. Regional AMS networks might manage this selected list to guide personalized action plans with concrete objectives of reducing the quantity and improving the quality of antibiotic prescriptions.
| S-EPMC10064325 | biostudies-literature
Project description:ObjectivesTo identify interventions implemented in hospital electronic prescribing systems and the outcome measures used to monitor their impact.MethodsWe systematically searched CINAHL, EMBASE, Google Scholar and Medline using keywords in three strands: (i) population: hospital inpatient or emergency department; (ii) intervention: electronic prescribing functionality; and (iii) outcome: antimicrobial stewardship. The interventions were grouped into six themes: alerts, order sets, restriction of access, mandated documentation, embedded guidelines and automatic prescription stop. The outcome measures were organized into those that measure the quality or quantity of prescribing or clinical decision support (CDS) activity. The impact of each intervention reported was grouped into a positive, negative or no change.ResultsA total of 28 studies were eligible for inclusion. There were 28 different interventions grouped into the six themes. Alerts visible to the practitioner in the electronic health record (EHR) were most frequently implemented (n = 11/28). Twenty different outcome measures were identified, divided into quality (n = 13/20) and quantity outcomes (n = 4/20) and CDS activity (n = 3/20). One-third of outcomes reported across the 28 studies showed positive change (34.4%, n = 42/122) and 61.4% (n = 75/122) showed no change.ConclusionsThe most frequently implemented interventions were alerts, the majority of which were to influence behaviour or decision-making of the practitioner within the EHR. Quality outcomes were most frequently selected by researchers. The review supports previous research that larger well-designed randomized studies are needed to investigate the impact of interventions on AMS and outcome measures to be standardized.
| S-EPMC9237448 | biostudies-literature
Project description:BackgroundAs meropenem is a restricted antimicrobial, lessons learned from its real-life usage will be applicable to antimicrobial stewardship (AMS) more generally.ObjectivesTo retrospectively evaluate meropenem usage at our institution to identify targets for AMS interventions.MethodsPatients receiving meropenem documented with an 'alert antimicrobial' form at two tertiary care UK hospitals were identified retrospectively. Clinical records and microbiology results were reviewed.ResultsA total of 107 adult inpatients receiving meropenem were identified. This was first-line in 47% and escalation therapy in 53%. Source control was required in 28% of cases after escalation, for predictable reasons. Those ultimately requiring source control had received more prior antimicrobial agents than those who did not (P = 0.03). Meropenem was rationalized in 24% of cases (after median 4 days). Positive microbiology enabled rationalization (OR 12.3, 95% CI 2.7-55.5, P = 0.001) but rates of appropriate sampling varied. In cases with positive microbiology where meropenem was not rationalized, continuation was retrospectively considered clinically and microbiologically necessary in 8/40 cases (0/17 empirical first-line usage). Rationalization was more likely when meropenem susceptibility was not released on the microbiology report (OR 5.2, 95% CI 1.3-20.2, P = 0.02). Input from an infection specialist was associated with a reduced duration of meropenem therapy (P < 0.0001). Early review by an infection specialist has the potential to further facilitate rationalization.ConclusionsIn real-life clinical practice, core aspects of infection management remain tractable targets for AMS interventions: microbiological sampling, source control and infection specialist input. Further targets include supporting rationalization to less familiar carbapenem-sparing antimicrobials, restricting first-line meropenem usage and selectively reporting meropenem susceptibility.
| S-EPMC8210134 | biostudies-literature
Project description:Antimicrobial stewardship programs represent efficacious measures for reducing antibiotic overuse and improving outcomes in different settings. Specific data on pediatric oncology are lacking. We conducted a systematic review on the PubMed and Trip databases according to the PRISMA guidelines, searching for reports regarding antimicrobial stewardship in pediatric oncology and hematology patients. The aim of the study was to summarize the present literature regarding the implementation of antimicrobial stewardship programs or initiatives in this particular population, and provide insights for future investigations. Nine papers were included in the qualitative analysis: three regarding antifungal interventions, five regarding antibacterial interventions, and one regarding both antifungal and antibacterial stewardship interventions. Variable strategies were reported among the included studies. Different parameters were used to evaluate the impact of these interventions, including days of therapy per 1000-patient-days, infections with resistant strains, safety analysis, and costs. We generally observed a reduction in the prescription of broad-spectrum antibiotics and an improved appropriateness, with reduced antibiotic-related side effects and no difference in infection-related mortality. Antibiotic stewardship programs or interventions are effective in reducing antibiotic consumption and improving outcomes in pediatric oncology hematology settings, although stewardship strategies differ substantially in different institutions. A standardized approach needs to be implemented in future studies in order to better elucidate the impact of stewardship programs in this category of patients.
| S-EPMC9369733 | biostudies-literature
Project description:ImportanceThe feasibility of core Infectious Diseases Society of America-recommended antimicrobial stewardship interventions in community hospitals is unknown.ObjectiveTo determine the feasibility and results of implementing 2 core stewardship intervention strategies in community hospitals.Design, setting, and participantsThree-stage, multicenter, prospective nonrandomized clinical trial with crossover design. The setting was 4 community hospitals in North Carolina (median bed size, 305; range, 102-425). Participants were all patients receiving targeted study antibacterial agents or alternative, nonstudy antibacterial agents. The study dates were October 2014 through October 2015. All statistical analyses were completed as of October 2016.InterventionsTwo antimicrobial stewardship strategies targeted vancomycin hydrochloride, piperacillin-tazobactam, and the antipseudomonal carbapenems on formulary at the study hospitals: (1) modified preauthorization (PA), in which the prescriber had to receive pharmacist approval for continued use of the antibiotic after the first dose, and (2) postprescription audit and review (PPR), in which the pharmacist would engage the prescriber about antibiotic appropriateness after 72 hours of therapy. Two hospitals performed modified PA for 6 months, then PPR for 6 months after a 1-month washout. The other 2 hospitals performed the reverse.Main outcomes and measuresThe primary outcome was the feasibility of implementing the interventions, determined by (1) approval by hospital administration and committees at each study hospital; (2) completion of pharmacist training; (3) initiation and implementation as determined by number, type, and outcomes of interventions performed; and (4) time required for interventions. Secondary outcomes included antimicrobial use (days of therapy) compared with matched historical periods and length of hospitalization.ResultsA total of 2692 patients (median age, 65 years; interquartile range, 53-76 years) underwent a study intervention; 1413 (52.5%) were female, 1323 (49.1%) were white, and 1047 (38.9%) were African American. Intervention approvals took a median of 95 days (range, 56-119 days); during these discussions, strict PA was deemed not feasible. Instead, the modified PA intervention was used throughout the study. Pharmacists performed 1456 modified PA interventions (median per hospital, 350 [range, 129-628]) and 1236 PPR interventions (median per hospital, 298 [range, 273-366]). Study antimicrobials were determined to be inappropriate 2 times as often during the PPR period (41.0% [435 of 1060] vs 20.4% [253 of 1243]; P < .001). Pharmacists recommended dose change more often during the modified PA intervention (15.9% [232 of 1456] vs 9.6% [119 of 1236]; P < .001) and de-escalation during PPR (29.1% [360 of 1236] vs 13.0% [190 of 1456]; P < .001). The median time dedicated to the stewardship interventions varied by hospital (range of median hours per week, 5-19). Overall antibiotic use decreased during PPR compared with historical controls (mean [SD] days of therapy per 1000 patient-days, 925.2 [109.8] vs 965.3 [109.4]; mean difference, -40.1; 95% CI, -71.7 to -8.6), but not during modified PA (mean [SD] days of therapy per 1000 patient-days, 931.0 [102.0] vs 926.6 [89.7]; mean difference, 4.4; 95% CI, -55.8 to 64.7).Conclusions and relevanceStrict PA was not feasible in the study hospitals. In contrast, PPR was a feasible and effective strategy for antimicrobial stewardship in settings with limited resources and expertise.Trial registrationClinicalTrials.gov identifier: NCT02212808.
| S-EPMC6704742 | biostudies-literature
Project description:Antimicrobial stewardship interventions are targeted efforts by healthcare organizations to optimize antimicrobial use in clinical practice. The study aimed to explore effective interventions in improving antimicrobial use in hospitals. Literature was systemically searched for interventional studies through PubMed, CINAHL, and Scopus databases that were published in the period between January 2010 to April 2022. A random-effects model was used to pool and evaluate data from eligible studies that reported antimicrobial stewardship (AMS) interventions in outpatient and inpatient settings. Pooled estimates presented as proportions and standardized mean differences. Forty-eight articles were included in this review: 32 in inpatient and 16 in outpatient settings. Seventeen interventions have been identified, and eight outcomes have been targeted. AMS interventions improved clinical, microbiological, and cost outcomes in most studies. When comparing non-intervention with intervention groups using meta-analysis, there was an insignificant reduction in length of stay (MD: -0.99; 95% CI: -2.38, 0.39) and a significant reduction in antibiotics' days of therapy (MD: -2.73; 95% CI: -3.92, -1.54). There were noticeable reductions in readmissions, mortality rates, and antibiotic prescriptions post antimicrobial stewardship multi-disciplinary team (AMS-MDT) interventions. Studies that involved a pharmacist as part of the AMS-MDT showed more significant improvement in measured outcomes than the studies that did not involve a pharmacist.
| S-EPMC9598859 | biostudies-literature
Project description:BackgroundIn the UK there is limited coverage of antimicrobial stewardship across postgraduate curricula and evidence that final year medical students have insufficient and inconsistent antimicrobial stewardship teaching. A national undergraduate curriculum for antimicrobial resistance and stewardship is required to standardize an adequate level of understanding for all future doctors.ObjectivesTo provide a UK national consensus on competencies for antimicrobial resistance and stewardship for undergraduate medical education.MethodsUsing the modified Delphi method over two online survey rounds, an expert panel comprising leads for infection teaching from 25 UK medical schools reviewed competency descriptors for antimicrobial resistance and stewardship education.ResultsThere was a response rate of 100% with all 28 experts who agreed to take part completing both survey rounds. Following the first-round survey, of the initial 55 descriptors, 43 reached consensus (78%). The second-round survey included the 12 descriptors from the first round in which agreement had not been reached, four amended descriptors and 12 new descriptors following qualitative feedback from the panel members. Following the second-round survey, a total of 58 consensus-based competency descriptors within six overarching domains were identified.ConclusionsThe consensus-based competency descriptors defined here can be used to inform standards, design curricula, develop assessment tools and direct UK undergraduate medical education.
| S-EPMC8210211 | biostudies-literature
Project description: Not available
| S-EPMC8209994 | biostudies-literature
Project description:BackgroundOveruse of antibiotics is frequent in nursing homes (NHs) leading to adverse events and selection of resistant bacteria. Antimicrobial stewardship interventions showed heterogeneous effects on reducing inappropriate use of antimicrobials in NHs.ObjectivesThis study aimed (1) to analyze antimicrobial prescribing determinants in NHs; (2) to identify which resources for antimicrobial prescribing are used by NHs' physicians (3) understand which antimicrobial stewardship interventions are required and how they should be implemented in NHs.MethodsWe conducted individual semi-directed interviews with NHs' prescribing physicians in Ile-de-France, France. A thematic content analysis was conducted iteratively.ResultsThirteen interviews were conducted. Participants were mostly women, with a median age of 48 years and a median professional experience in NHs of three years. Participants included medical coordinators, general practitioners and salaried physicians. Main determinants of antimicrobial prescribing in NHs were the perceived risk of infectious complications and discomfort in residents, the difficulty in obtaining microbiological samples and the lack of healthcare professionals to monitor patients. Most participants reported using national guidelines and electronic decision support systems to guide their antimicrobial prescribing. Institutional constraints accentuate situations of doubt and prompt physicians to prescribe antimicrobials "just in case" despite the will to follow guidelines and the known risks of antimicrobial misuse. Physicians stated that proper antimicrobial use in NHs would require a major effort but was not judged a priority as compared to other medical issues. Producing guidelines tailored to the NH's context, performing good practice audits with feedback on antimicrobial prescribing, and reinforcing multidisciplinary relationships and discussions between city and hospital professionals were cited as potential interventions. The role of the medical coordinator was described as central. According to physicians, collaboration among stakeholders, providing support and training during the process might prove effective strategies to ensure successful implementation.ConclusionAntimicrobial prescribing is a complex decision-making process involving different factors and actors in NHs. Tailored guidelines, good practice audits, strengthened multidisciplinary collaboration were proposed as key AMS interventions. Physicians emphasized the central role of the medical coordinator supported by stakeholder engagement, collaboration, training and ongoing support for successful implementation.
| S-EPMC11600803 | biostudies-literature
Project description:Antimicrobial resistance is escalating and triggers clinical decision-making challenges when treating infections in patients admitted to intensive care units (ICU). Antimicrobial stewardship (AMS) may help combat this problem, but it can be difficult to implement in critical care settings. The implementation of multidisciplinary AMS in ICUs could be more challenging than what is currently suggested in the literature. Our main goal was to analyze the reduction in duration of treatment (DOT) for the most commonly used antibacterial and antifungal agents during the first six months of 2014, and during the same period two years later (2016). A total of 426 and 424 patient encounters, respectively, were documented and collected from the intensive care unit's electronic patient record system. Daily multidisciplinary ward rounds were conducted for approximately 30?40 min, with the goal of optimizing antimicrobial therapy in order to analyze the feasibility of implementing AMS. The only antimicrobial agent which showed a significant reduction in the number of prescriptions and in the duration of treatment during the second audit was vancomycin, while linezolid showed an increase in the number of prescriptions with no significant prolongation of the duration of treatment. A trend of reduction was also seen in the DOT for co-amoxiclavulanate and in the number of prescriptions of anidulafungin without any corresponding increases being observed for other broad-spectrum anti-infective agents (p-values of 0.07 and 0.05, respectively).
| S-EPMC6024547 | biostudies-literature