Antimicrobial stewardship for inpatient facilities

Ohl, Christopher; Luther, Vera

doi:10.1002/jhm.881

Cited by 90 publications

(77 citation statements)

References 92 publications

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“…Thereby effective antibiotic therapy is the foundation of sepsis management [22]. Over-exposure to antibiotics subjects patients to the risk of adverse drug reactions without any corresponding therapeutic benefit, and increases the likelihood of development of bacterial resistance [23,24]. Physicians are often reluctant to not use or early stop antibiotic therapy based on clinical grounds only.…”

Section: Procalcitonin -A Diagnostic Marker That Improves Antibiotic mentioning

confidence: 99%

Can biomarkers help us to better diagnose and manage sepsis?

Schuetz

Plebani

2015

Diagnosis

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Abstract:The recognition over 25 years ago that the host response plays an exquisite role in sepsis, led to the today still-standard sepsis definition. Unfortunately, the inflammatory response syndrome (SIRS) criteria turned out to be less useful than anticipated, lacking sensitivity, specificity and ease of clinical application. Had novel host-response biomarkers been available by that time, it arguably would have been preferable to white blood cell count as an unspecific and not-sensitive laboratory-based SIRS criterion. Several novel markers have been put forward as sepsis markers with better diagnostic and/or prognostic potential in sepsis including inflammatory markers such as procalcitonin (PCT), presepsin, proadrenomedullin (ProADM), endothelial dysfunction markers such as P-selectin, E-selectin, intercellular cell adhesion molecule [ICAM]-1 and vascular cell adhesion molecule [VCAM]-1 and genetic markers among others. The limitations to using clinical parameters and conventional diagnostic markers for patients with clinical suspicion of sepsis may directly lead to both, under treatment of patients with severe disease needing urgent antibiotic and fluid therapy, and unnecessary and prolonged exposure to antimicrobial agents adversely affecting patient outcomes and increasing antibiotic resistance. The aim of this review is to summarize the current evidence for emerging diagnostic, prognostic, and therapeutic-response sepsis biomarkers in different infections and clinical settings, and discuss the reliability, potential benefit and limitations of these marker when used in clinical routine for sepsis management.

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Section: Procalcitonin -A Diagnostic Marker That Improves Antibiotic mentioning

confidence: 99%

Can biomarkers help us to better diagnose and manage sepsis?

Schuetz

Plebani

2015

Diagnosis

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“…In addition to increased costs, prolonged antibiotic use may have greater implications for antibiotic stewardship and public health, though the consideration of these factors are beyond the scope of this study. 2,12,16 Perhaps the single most compelling and practical finding for clinicians pertains to administration of preoperative antibiotics: the subgroup of patients who missed preoperative antibiotic administration had a significantly higher 6-month surgical infection/complication (rate 27.03%, OR 1.48, p value = 0.021) compared with patients who received the overall AP bundle (rate 20.03%). While our results have multiple avenues for examining quality, this striking finding involving the administration of preoperative antibiotic is directly linked to surgical outcomes and impacts clinical practice.…”

Section: Discussionmentioning

confidence: 99%

“…11 The consequences of inappropriate use of antibiotics have also been reported to increase the risk of antimicrobial resistance and hospital-acquired infections and complications. 2,12,16 For a patient population with chronic healthcare needs, such as children needing ITBP therapy, risk of surgery-related infection as well as overall healthcare burden is high.…”

mentioning

confidence: 99%

Impact of antibiotic prophylaxis for intrathecal baclofen pump surgery in pediatric patients

Pan

Kuo

Luerssen

et al. 2015

FOC

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OBJECT This study explored antibiotic prophylaxis (AP) in pediatric patients undergoing intrathecal baclofen pump (ITBP) surgery and factors associated with perioperative AP compliance with clinical guidelines. METHODS Data were obtained from the Pediatric Health Information System. The study cohort comprised patients who underwent ITBP surgery within 3 days of admission, between July 1, 2004, and March 31, 2014, with a minimum prior screening period and follow-up of 180 days. Exclusion criteria were prior infection, antibiotic use within 30 days of admission, and/or missing financial data. Chi-square tests and multivariate logistic regressions were used to determine factors associated with compliance with AP guidelines in ITBP surgeries. RESULTS A total of 1,534 patients met the inclusion criteria; 91.5% received AP and 37.6% received dual coverage or more. Overall bundled compliance comprised 2 components: 1) perioperative antibiotic administration and 2) < 24-hour postoperative antibiotic course. The most frequently used antibiotics in surgery were cefazolin (n = 873, 62.2%) and vancomycin (n = 351, 25%). Documented bundled AP compliance rates were 70.2%, 62.0%, 66.0%, and 55.2% in West, South, Midwest, and Northeast regions of the US, respectively. Compared with surgeries in the Northeast, procedures carried out in the West (OR 2.0, 95% C11.4-2.9, p < 0.001), Midwest (OR 1.6, 95% C11.1-2.3, p = 0.007), and South (OR 1.5, 95% C11.1-2.0, p = 0.021) were more likely to have documented AP compliance. Black (OR 0.74, 95% CI 0.55-1.00, p = 0.05) and Hispanic (OR 0.63, 95% CI 0.47-0.86, p = 0.004) patients were less likely to have documented AP compliance in ITBP surgeries than white patients. There were no significant differences in compliance rate by age, sex, type of insurance, and diagnosis. AP process measures were associated with shorter length of stay, lower hospitalization costs, and lower 6-month rates of surgical infection/complication. One of the 2 noncompliance subgroups, missed preoperative antibiotic administration, was correlated with a significantly higher 6-month surgical complication/infection rate (27.03%) compared with bundled compliance (20.00%, p = 0.021). For the other subgroup, prolonged antibiotic use > 24 hours postoperatively, the rate was insignificantly higher (22.00%, p = 0.368). Thus, of direct relevance to practicing clinicians, missed preoperative antibiotics was associated with 48% higher risk of adverse complication/infection outcome in a 6-month time frame. Adjusted hospitalization costs associated with baclofen pump surgery differed significantly (p < 0.001) with respect to perioperative antibiotic practices: 22.83, 29.10, 37.66 (× 1000 USD) for bundled compliance, missed preoperative antibiotics, and prolonged antibiotic administration, respectively. CONCLUSIONS Significant variation in ITBP antibiotic prophylaxis was found. Documented AP compliance was associated with higher value of care, showing favorable clinical and financial outcomes. Of most impact to clinical outcome, missed preoperative antibiotics was significantly associated with higher risk of 6-month surgical complication/infection. Prolonged antibiotic use was associated with significantly higher hospital costs compared with those with overall bundled antibiotic compliance. Future research is warranted to examine factors associated with practice variation and how AP compliance is associated with outcomes and quality, aiming for improving delivery of care to pediatric patients undergoing ITBP procedures.

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“…As so few practice guidelines or randomized clinical trials of antibiotic treatment for this population existed, we relied on local epidemiology, practices, and expertise to develop the algorithms. Incorporating local prescribing practices and local antimicrobial stewardship expertise have been shown to be important in CDS tool design and user acceptability [10,18,19].…”

Section: Decision Logic For Recommendations For Antimicrobial Selectionmentioning

confidence: 99%

Developing Clinical Decision Support within a Commercial Electronic Health Record System to Improve Antimicrobial Prescribing in the Neonatal ICU

Hum¹,

Cato²,

Sheehan³

et al. 2014

Appl Clin Inform

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SummaryObjective: To develop and implement a clinical decision support (CDS) tool to improve antibiotic prescribing in neonatal intensive care units (NICUs) and to evaluate user acceptance of the CDS tool. Methods: Following sociotechnical analysis of NICU prescribing processes, a CDS tool for empiric and targeted antimicrobial therapy for healthcare-associated infections (HAIs) was developed and incorporated into a commercial electronic health record (EHR) in two NICUs. User logs were reviewed and NICU prescribers were surveyed for their perceptions of the CDS tool. Results: The CDS tool aggregated selected laboratory results, including culture results, to make treatment recommendations for common clinical scenarios. From July 2010 to May 2012, 1,303 CDS activations for 452 patients occurred representing 22% of patients prescribed antibiotics during this period. While NICU clinicians viewed two culture results per tool activation, prescribing recommendations were viewed during only 15% of activations. Most (63%) survey respondents were aware of the CDS tool, but fewer (37%) used it during their most recent NICU rotation. Respondents considered the most useful features to be summarized culture results (43%) and antibiotic recommendations (48%). Discussion: During the study period, the CDS tool functionality was hindered by EHR upgrades, implementation of a new laboratory information system, and changes to antimicrobial testing methodologies. Loss of functionality may have reduced viewing antibiotic recommendations. In contrast, viewing culture results was frequently performed, likely because this feature was perceived as useful and functionality was preserved. Conclusion: To improve CDS tool visibility and usefulness, we recommend early user and information technology team involvement which would facilitate use and mitigate implementation challenges. Developing Clinical Decision Support within a Commercial Electronic BackgroundInfants in the neonatal intensive care unit (NICU) are at high risk of developing healthcare-associated infections (HAIs), including those caused by multidrug-resistant organisms [1]. Late onset sepsis, meningitis, and necrotizing enterocolitis are clinical scenarios common to all NICUs, but can be caused by pathogens with antimicrobial susceptibility patterns unique to local settings [2][3][4]. Thus, initiation of empiric broad-spectrum antimicrobial therapy, prior to availability of culture results, should be based on local epidemiology as well as the clinical history of individual infants. Optimizing empiric use of antibiotics and then adjusting to targeted therapy when informative culture results are available are recommended clinical practices [5][6][7]. However, as signs and symptoms of sepsis in infants are often non-specific, the practice of initiating and continuing broad-spectrum antibiotics despite negative cultures can lead to overuse of antibiotics with subsequent increases in toxicity, resistance, and healthcare expenditures [8,9]. We have previously reported that approximat...

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Antimicrobial stewardship for inpatient facilities

Cited by 90 publications

References 92 publications

Can biomarkers help us to better diagnose and manage sepsis?

Can biomarkers help us to better diagnose and manage sepsis?

Impact of antibiotic prophylaxis for intrathecal baclofen pump surgery in pediatric patients

Developing Clinical Decision Support within a Commercial Electronic Health Record System to Improve Antimicrobial Prescribing in the Neonatal ICU

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