Opportunities to enhance antibiotic stewardship: colistin use and outcomes in a low-resource setting

Abstract

Background Colistin use is increasing with the rise in MDR Gram-negative infections globally. Effective antibiotic stewardship is essential to preserve this antibiotic of last resort. Objectives This study investigated stewardship and safety errors related to colistin use to identify opportunities for improvement. Patients and methods A prospective descriptive study involving all patients 13 years and older treated with colistin at a tertiary hospital in Cape Town, South Africa, between August 2018 and June 2019. We collected clinical, laboratory and outcome data and assessed provided treatment for stewardship and safety errors. Results We included 44 patients. Treatment errors were identified for 34 (77%) patients (median = 1), most commonly inadequate monitoring of renal function ( N = 16, 32%). We also identified no rational indication for colistin ( N = 9, 20%), loading dose error ( N = 12, 27%); maintenance dose error ( N = 10, 23%); no prior culture ( N = 11, 25%); and failure to de-escalate (2 of 9) or adjust dose to changes in renal function (6 of 15). All cause in-hospital mortality was 47%. Amongst survivors, median ICU stay was 6 days and hospital stay more than 30 days. Eight (18%) patients developed renal injury or failure during treatment. Three (7%) patients in this study were found to have colistin-resistant organisms including two prior to colistin exposure. Conclusions This study has identified opportunities to enhance colistin stewardship and improve efficacy and safety of prescription. The appearance of colistin-resistant organisms reinforces the urgent need to ensure effective and appropriate use of colistin.

Antibiotic Use and Stewardship Indicators in the First- and Second-Level Hospitals in Zambia: Findings and Implications for the Future

“…Similar to D’Arcy and colleagues [ 13 ], encouragingly there was no prescribing of ‘Reserve’ antibiotics among the 10 participating hospitals, unlike other hospitals in Africa [ 36 ]. This is particularly important given that patients from first- and second-level hospitals can be transferred to tertiary hospitals for more specialized care if needed, and inappropriate prescribing of ‘Reserve’ antibiotics outside of specialist hospitals reduces their potential to tackle serious and critical infections [ 36 , 53 ]. Our findings are similar to the low or no prescribing of ‘Reserve’ antibiotics among other African countries in published PPS studies [ 21 , 36 , 42 , 43 , 46 , 48 , 49 , 50 , 51 , 54 ], which is also encouraging.…”

Ongoing Efforts to Improve Antimicrobial Utilization in Hospitals among African Countries and Implications for the Future

“… Empiric prescribing: Continue to develop, update and communicate hospital antibiograms to improve empiric prescribing whilst awaiting CST results. Regularly monitor prescribing activities: Quality improvement programs in hospitals including increased accountability of prescribers with a requirement to justify their treatment approach; Building restrictions for certain antibiotics where necessary based on the WHO AWaRe list and agreed quality indicators [ 56 , 58 , 66 , 231 ]. Communication: Keep working with key stakeholders to enhance adherence to agreed national/local guidelines to improve patient outcomes and reduce AMR.…”

“…Regularly monitor prescribing activities: Quality improvement programs in hospitals including increased accountability of prescribers with a requirement to justify their treatment approach; Building restrictions for certain antibiotics where necessary based on the WHO AWaRe list and agreed quality indicators [ 56 , 58 , 66 , 231 ].…”

“…The ‘Watch’ group have a higher resistance potential and side-effects, with the ‘Reserve’ group only recommended as last resort antibiotics and prioritized for Antimicrobial Stewardship Programs (ASPs) using agreed quality indicators (QIs) ( Figure 1 ) [ 55 , 56 , 57 , 58 , 59 ]. Assessing antimicrobial prescribing against current guidance, and monitoring their use based on the WHO AWaRe list, is increasingly being undertaken across Africa and beyond to improve prescribing given the extent of current prescribing of ‘Watch’ and ‘Reserve’ antibiotics in Africa [ 13 , 15 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 ].…”

The impact of colistin-based regimens on mortality compared to other antimicrobials in patients with carbapenem-resistant Enterobacterales bacteremia in South African hospitals: a cross-sectional study

“…Therapeutic options are therefore limited to a few mainstay drugs such as polymyxins or colistin [13][14][15]. In South Africa, the available treatment options include colistin, tigecycline, carbapenem, and β-lactamase inhibitor combinations (BLICs) such as ceftolozane-tazobactam, and ceftazidime-avibactam, although colistin is the most widely available antimicrobial, particularly in public-sector facilities [16][17][18]. Nonetheless, treatment practices for Gram-negative infections and CREs likely vary owing to conflicting available evidence on optimal treatment and lack of standardised treatment guidelines [16,[18][19][20].…”