A Role for Antimicrobial Stewardship in Clinical Sepsis Pathways

The aim of this study was to evaluate the impact of early infectious diseases (ID) antimicrobial stewardship (AMS) intervention on inpatient sepsis antibiotic management | Infection Control & Hospital Epidemiology

All patients reviewed by an ID Fellow within 24 hours of sepsis pathway trigger underwent case review and clinic file documentation of recommendations. Those not reviewed by an ID Fellow were considered controls and received standard sepsis pathway care. The primary outcome was antibiotic appropriateness 48 hours after sepsis trigger.

In total, 164 patients triggered the sepsis pathway: 6 patients were excluded (previous sepsis trigger); 158 patients were eligible; 106 had ID intervention; and 52 were control cases. Of these 158 patients, 91 (58%) had sepsis, and 15 of these 158 (9.5%) had severe sepsis. Initial antibiotic appropriateness, assessable in 152 of 158 patients, was appropriate in 80 (53%) of these 152 patients and inappropriate in 72 (47%) of these patients. In the intervention arm, 93% of ID Fellow recommendations were followed or partially followed, including 53% of cases in which antibiotics were de-escalated. ID Fellow intervention improved antibiotic appropriateness at 48 hours by 24% (adjusted risk ratio, 1.24; 95% confidence interval, 1.04–1.47; P=.035). The appropriateness agreement among 3 blinded ID staff opinions was 95%. Differences in intervention and control group mortality (13% vs 17%) and median length of stay (13 vs 17.5 days) were not statistically significant.

Sepsis overdiagnosis and delayed antibiotic optimization may reduce sepsis pathway effectiveness. Early ID AMS improved antibiotic management of non-ICU inpatients with suspected sepsis, predominantly by de-escalation.

Full reference: Burston, J. et al. (2017) A Role for Antimicrobial Stewardship in Clinical Sepsis Pathways: a Prospective Interventional Study. Infection Control & Hospital Epidemiology. Vol. 38 (Issue 9) pp. 1032-1038

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Staff nurses as antimicrobial stewards

An integrative literature review | American Journal of Infection Control

Background: Guidelines on antimicrobial stewardship emphasize the importance of an interdisciplinary team, but current practice focuses primarily on defining the role of infectious disease physicians and pharmacists; the role of inpatient staff nurses as antimicrobial stewards is largely unexplored.

Methods: An updated integrative review method guided a systematic appraisal of 13 articles spanning January 2007-June 2016. Quantitative and qualitative peer-reviewed publications including staff nurses and antimicrobial knowledge or stewardship were incorporated into the analysis.

Results: Two predominant themes emerged from this review: (1) nursing knowledge, education, and information needs; and (2) patient safety and organizational factors influencing antibiotic management.

Discussion: Focused consideration to empower and educate staff nurses in antimicrobial management is needed to strengthen collaboration and build an interprofessional stewardship workforce.

Full reference: Monsees, E. et al. (2017) Staff nurses as antimicrobial stewards: An integrative literature review. American Journal of Infection Control. Vol. 45 (no. 8) pp. 917–922

Antimicrobial stewardship program and Clostridium difficile

Institutional antimicrobial stewardship programs seek to decrease the occurrence of C difficile by implementing strategies to address antibiotic usage; however, optimal structure and strategies for accomplishing this remain largely unknown | American Journal of Infection Control

A colour-enhanced scanning electron micrograph image showing a cluster of Clostridium difficile on a surface.

Image source: Annie Cavanagh – Wellcome Images // CC BY-NC-ND 4.0

Image shows a colour-enhanced scanning electron micrograph image showing a cluster of Clostridium difficile on a surface.

Highlights: 

  • More hospitals with non-better Clostridium difficile rank used prospective audit and feedback.
  • More better C difficile rank hospitals used a preauthorization strategy.
  • More better C difficile rank hospitals restricted more high-risk antibiotics.

Full reference: Barlow, G. et al. (2017) Associations between antimicrobial stewardship program elements and Clostridium difficile infection performance. American Journal of Infection Control. Published online: 27 July 2017.

Impact of an antimicrobial stewardship program to optimize antimicrobial use for outpatients at emergency department

Antimicrobial stewardship programs (ASPs) have proven to be effective in optimizing antibiotic use for inpatients. However, Emergency Department (ED)’s fast-paced clinical setting can be challenging for a successful ASP | The Journal of Hospital Infection

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Aim: In April 2015, an ASP was implemented in our ED and we aimed to determine its impact on antimicrobial use for outpatients.

Methods: Monocentric study comparing the quality of antibiotic prescriptions between a one-year period before ASP implementation (November 2012 to October 2013) and a one-year period after its implementation (June 2015 to May 2016).

For each period, antimicrobial prescriptions for all adult outpatients (hospitalized for <24hours) were evaluated by an infectious disease specialist (IDS) and an ED physician to assess compliance with local prescribing guidelines. Inappropriate prescriptions were then classified.

Findings: Before and after ASP, 34,671 and 35,925 consultations were registered at our ED, of which 25,470 and 26,208 were outpatients. Antimicrobials were prescribed in 769 (3.0%) and 580 (2.2%) consultations, respectively (p<0.0001). There were 484 (62.9%) and 271 (46.7%) (p<0.0001) instances of non-compliance with guidelines before and after ASP implementation. Non-compliances included unnecessary antimicrobial prescriptions, 197 (25.6%) vs. 101 (17.4%) (p<0.0005); inappropriate spectrum, 108 (14.0%) vs. 54 (9.3%) (p=0.008); excessive treatment duration, 87 (11.3%) vs. 53 (9.1%) (p>0.05); and inappropriate choices, 11 (1.4%) vs. 15 (2.6%) (p>0.05).

Conclusions: The implementation of an ASP dramatically decreased the number of unnecessary antimicrobial prescriptions, but had little impact on most other aspects of inappropriate prescribing.

Full reference: Dinh, A. et al. (2017) Impact of an antimicrobial stewardship program to optimize antimicrobial use for outpatients at emergency department. The Journal of Hospital Infection. Published online: 8th July 2017

How do hospital respiratory clinicians perceive antimicrobial stewardship?

Broom, J. et al. Journal of Hospital Infection | Published online: 5 May 2017

Background: Suboptimal antibiotic use in respiratory infections is widespread both in hospital medicine and primary care. Antimicrobial stewardship (AMS) teams within hospitals, commonly led by infectious diseases physicians, are frequently charged with optimising respiratory antibiotic use, but there is limited information on what drives antibiotic use in this area of clinical medicine, or on how AMS is perceived.

Aim: This study explores the perceptions of hospital respiratory clinicians on AMS in respiratory medicine.

Conclusions: AMS processes are introduced in hospitals with established social structures and knowledge bases. AMS in respiratory medicine is reported by these clinicians to challenge and conflict with many of these dynamics. If the influence of these dynamics is not considered, AMS processes may not be effective in containing antibiotic use in hospital respiratory medicine.

Read the abstract here

Toolkit Offers Framework to Assess, Review and Improve Antibiotic Stewardship

The AAAHC Institute for Quality Improvement has released a new toolkit to enhance antibiotic stewardship programs | Infection Control Today

The AAAHC Institute designed the Antibiotic Stewardship Toolkit to aid ambulatory health facilities in promoting appropriate antibiotic selection while reducing overuse through an overview of illnesses for which inappropriate antibiotic prescriptions are written.

The Centers for Disease Control and Prevention (CDC) define antibiotic stewardship activities as efforts to improve and measure antibiotic prescribing by minimizing inappropriate antibiotic prescribing and overuse, as well as ensuring the right drug, dose and duration are selected when antibiotics are needed.

Providers in ambulatory health care settings use the AAAHC Institute Antibiotic Stewardship Toolkit checklist as both a baseline assessment of policies and practices, and a resource for reviewing and expanding activities on a regular basis.

Read the full news story here

Supporting better decision making for acute infection management in secondary care

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Background

The inappropriate use of antimicrobials drives antimicrobial resistance. We conducted a study to map physician decision-making processes for acute infection management in secondary care to identify potential targets for quality improvement interventions.

Methods

Physicians newly qualified to consultant level participated in semi-structured interviews. Interviews were audio recorded and transcribed verbatim for analysis using NVIVO11.0 software. Grounded theory methodology was applied. Analytical categories were created using constant comparison approach to the data and participants were recruited to the study until thematic saturation was reached.

Results

Twenty physicians were interviewed. The decision pathway for the management of acute infections follows a Bayesian-like step-wise approach, with information processed and systematically added to prior assumptions to guide management. The main emerging themes identified as determinants of the decision-making of individual physicians were (1) perceptions of providing ‘optimal’ care for the patient with infection by providing rapid and often intravenous therapy; (2) perceptions that stopping/de-escalating therapy was a senior doctor decision with junior trainees not expected to contribute; and (3) expectation of interactions with local guidelines and microbiology service advice. Feedback on review of junior doctor prescribing decisions was often lacking, causing frustration and confusion on appropriate practice within this cohort.

Conclusion

Interventions to improve infection management must incorporate mechanisms to promote distribution of responsibility for decisions made. The disparity between expectations of prescribers to start but not review/stop therapy must be urgently addressed with mechanisms to improve communication and feedback to junior prescribers to facilitate their continued development as prudent antimicrobial prescribers.

Full reference: Timothy Miles Rawson, T. M. et al: Mapping the decision pathways of acute infection management in secondary care among UK medical physicians: a qualitative study BMC Medicine 2016 14:208