An antibiotic stewardship program in a surgical ICU of a resource-limited country: financial impact with improved clinical outcomes

Abstract

Background Antibiotic resistance (ABX-R) is alarming in lower/middle-income countries (LMICs). Nonadherence to antibiotic guidelines and inappropriate prescribing are significant contributing factors to ABX-R. This study determined the clinical and economic impacts of antibiotic stewardship program (ASP) in surgical intensive care units (SICU) of LMIC. Method We conducted this pre and post-test analysis in adult SICU of Aga Khan University Hospital, Pakistan, and compared pre-ASP (September–December 2017) and post-ASP data (April–July 2018). January–March 2018 as an implementation/training phase, for designing standard operating procedures and training the team. We enrolled all the patients admitted to adult SICU and prescribed any antibiotic. ASP-team daily reviewed antibiotics prescription for its appropriateness. Through prospective-audit and feedback-mechanism changes were made and recorded. Outcome measures included antibiotic defined daily dose (DDDs)/1000 patient-days, prescription appropriateness, antibiotic duration, readmission, mortality, and cost-effectiveness. Result 123 and 125 patients were enrolled in pre-ASP and post-ASP periods. DDDs/1000 patient-days of all the antibiotics reduced in the post-ASP period, ceftriaxone, cefazolin, metronidazole, piperacillin/tazobactam, and vancomycin showed statistically significant (p < 0.01) reduction. The duration of all antibiotics use reduced significantly (p < 0.01). Length of SICU stays, mortality, and readmission reduced in the post-ASP period. ID-pharmacist interventions and source-control-documentation were observed in 62% and 50% cases respectively. Guidelines adherence improved significantly (p < 0.01). Net cost saving is 6360US$ yearly, mainly through reduced antibiotics consumption, around US$ 18,000 (PKR 2.8 million) yearly. Conclusion ASP implementation with supplemental efforts can improve the appropriateness of antibiotic prescriptions and the optimum duration of use. The approach is cost-effective mainly due to the reduced cost of antibiotics with rational use. Better source-control-documentation may further minimize the ABX-R in SICU.

Barriers, facilitators, perceptions and impact of interventions in implementing antimicrobial stewardship programs in hospitals of low-middle and middle countries: a scoping review

“…Most studies (79%, 42/53) primarily documented a decrease in antibiotic consumption and an improvement in rational antibiotic use after ASP implementation in hospitals [ 39 , 46 , 62 , 64 , 66 – 69 , 71 , 73 , 76 – 104 ]. Metrics for evaluating antibiotic consumption included defined daily doses (DDDs) or days of therapy (DOT) per 1,000 patient-days [ 62 – 64 , 68 , 72 , 77 , 79 – 81 , 84 – 86 , 88 , 100 , 104 , 105 ] while some studies used defined daily doses (DDDs) per 100 patient-days or Days of therapy/DOT per 100 patient-days [ 66 , 67 , 76 , 90 , 97 , 102 ].…”

“…To assess the impact of ASP interventions, 24 studies (45%, 24/53) assessed clinical or patient-centered outcomes [ 62 – 64 , 66 , 67 , 69 , 73 – 75 , 77 , 79 – 81 , 86 – 88 , 97 , 100 – 104 , 106 – 108 ]. Metrics used to evaluate the intervention included length of stay in hospital (LOS) in specific units (e.g., ICU) [ 46 , 62 , 68 , 69 , 73 , 74 , 76 , 77 , 81 , 86 , 88 , 96 , 101 – 103 ], hospital mortality [ 62 , 76 , 77 , 80 , 86 , 100 – 102 , 106 ], rehospitalization [ 77 , 81 , 83 , 86 , 104 ], hospital-acquired infections [ 63 , 64 , 67 , 81 , 97 , 107 , 109 ], and device-associated infections [ 64 ]. ASPs brought about positive clinical outcomes in hospital inpatients in most cases.…”

Implementation of a hospital antimicrobial stewardship program to improve vancomycin use in Cyprus: Challenges and opportunity

“…“in absence of line-associated bloodstream infection, this could be a skin contaminant”). It appears that the implementation of ASP and guidelines have a favourable impact on vancomycin consumption [ 14 , 15 ].…”

Evaluations of training and education interventions for improved infectious disease management in low-income and middle-income countries: a systematic literature review

“…30 41 43-49 Interventions targeting the physician were mainly focused on the promotion of adequate use of antimicrobial drug therapy by physicians. [50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68] In addition, physiciantargeted interventions aimed to improve adequate use of antifungal therapy 69 and improved management of infectious diseases. [70][71][72][73] Four studies described interventions that targeted drug retail locations (eg, pharmacies, shopkeepers) that play a vital role in appropriate drug use.…”