No abstract

What is known and objective Implementation of an antifungal stewardship programme is a recognized need. However, there is insufficient information to confirm the impact of antifungal stewardship interventions. Further, few studies have evaluated the clinical effects of an antifungal stewardship intervention using 1‐3, β‐D‐glucan (βDG) testing. The aim of the present study was to evaluate the impact of implementing an antifungal stewardship with monitoring of βDG values on antifungal use and clinical outcomes. Methods A single institutional prospective cohort study was conducted to evaluate the impact of implementing daily reviews of antifungal agents and monitoring patients who measured βDG values since August 2013. Antifungal consumption and clinical outcomes in patients with Candida bloodstream infection were compared before and after the intervention. Results After implementation of the programme, parental antifungal use was significantly reduced compared to that before intervention (P = 0.006). In the after‐intervention group, the rate of 60‐day clinical failure in patients with Candida bloodstream infection was significantly reduced, from 80.0% (28/35) to 36.4% (8/22) (P < 0.001), and the rate of 60‐day mortality associated with Candida bloodstream infection tended to be reduced, from 42.9% (15/35) to 18.2% (4/22) (P = 0.081) compared to the before‐intervention group. The incidence of adverse events associated with antifungal agents was significantly lower in the after‐intervention group than in the before‐intervention group (51.4% [18/35] vs 13.6% [3/22], P = 0.004). What is new and conclusion Our findings suggest that daily review of the use of antifungal agents and monitoring of measured βDG values was highly effective in reducing antifungal consumption and improving the clinical outcomes of patients with Candida bloodstream infection.

No abstract

Summary Background Matrix‐assisted laser desorption ionization‐time of flight mass spectrometry (MALDI‐TOF MS) has the potential to permit early organism identification and optimization of antibiotic therapy. However, MALDI‐TOF MS combined with antimicrobial stewardship is available at only a limited number of institutions. Here, we evaluated the clinical impact of implementing MALDI‐TOF MS combined with antimicrobial stewardship intervention in patients with bloodstream infections. Methods We conducted a single‐centre, prospective cohort study to evaluate the clinical impact of implementing MALDI‐TOF MS combined with antimicrobial stewardship intervention in patients with bloodstream infections. Processes and clinical outcomes in patients with bloodstream infections were compared before and after implementation of MALDI‐TOF MS. Results Compared with the conventional identification method, MALDI‐TOF MS combined with antimicrobial stewardship intervention significantly decreased the time to organism identification (48.6 ± 46.0 hours vs 78.1 ± 38.9 hours, P < 0.001), effective antimicrobial therapy (12.9 ± 19.0 hours vs 26.2 ± 44.8 hours, P < 0.001) and optimal antimicrobial therapy (53.3 ± 55.0 hours vs 91.7 ± 88.7 hours, P < 0.001. Moreover, the rate of clinical failure (14.0% vs 33.3%, P < 0.001) and incidence of adverse events (7.5% vs 23.9%, P < 0.001) was lower in the MALDI‐TOF MS group than in the conventional identification group. A multivariate Cox proportional hazard analysis indicated that implementation of MALDI‐TOF MS was a protective factor against clinical failure in patients with bloodstream infections (hazard ratio, 0.61; 95% confidence interval, 0.38‐0.99; P = 0.047). Conclusions Implementation of the MALDI‐TOF MS combined with antimicrobial stewardship intervention facilitated early optimization of antimicrobial therapy with a remarkable concomitant reduction in clinical failure and adverse events in patients with bloodstream infections.

Insufficient information is available to confirm the beneficial effects of implementing an antimicrobial stewardship program in reducing mortality of patients with bloodstream infections. A single institutional cohort study was conducted to evaluate clinical outcomes after implementation of a daily review of antimicrobials used to treat patients with bloodstream infections. Subjects were allocated to groups receiving either intervention or nonintervention. After implementation of an antimicrobial stewardship program, the day from the onset of infection required to administer effective intravenous antimicrobial treatment was significantly shortened (p 0.022), and the rate of de-escalation was significantly elevated (p<0.001) compared with the nonintervention group. Further, the rate of 30-d death associated with bloodstream infection was siginificantly reduced from 11.4 to 5.4% (p 0.030) compared with the nonintervention group. The incidence of adverse events was significantly lower in the intervention group than in the nonintervention group (7.7 vs. 28.0%, p<0.001). Our present findings suggest that daily review of the use of antimicrobials was highly effective for optimizing early antimicrobial therapy and improved clinical outcomes of patients with bloodstream infections. Key words daily review; antimicrobial use; adverse event; mortality; bloodstream infectionBacteremia is a serious clinical condition associated with high mortality. A multicenter retrospective cohort study conducted in the United States found that the median rate of bloodstream infection in hospital is 3.5 bloodstream infections per 1000 patient days, and the in-hospital mortality rate is 18%.1) The study further indicated that, for patients with bacteremia, timely and appropriate antimicrobial treatment is crucial.2) However, the inappropriate use of antibiotics in hospitals ranges from 26 to 57%.3-5) Therefore, implementation of antimicrobial stewardship is required to ensure appropriate use of antimicrobials.The guidelines of the Infectious Disease Society of America and the Society for Healthcare Epidemiology of America propose the core strategies for implementing antimicrobial stewardship designated "formulary restriction and pre-authorization" and "prospective audit with intervention and feedback." 6) Evidence indicates that the latter strategy is effective when implemented within 72 h of the initiation of antibiotic therapy. 7) In August 2009, we implemented a hospital-wide, multidisciplinary intervention program based on this strategy to optimize antibiotic use within 24 h after onset of therapy, which was unique in targeting all patients received intravenous antimicrobials, and found it highly effective in decreasing inappropriate use of antibiotics, reducing the length of hospitalization, reducing the rate of appearance of methicillin-resistant Staphylococcus aureus (MRSA), and reducing medical expenses. 8)Improved patient outcomes are an important benefit of implementing antimicrobial stewardship; however, limited data are availabl...