Optimizing carbapenem use through a national quality improvement programme

Robson, Siân E.; Cockburn, Alison; Sneddon, Jacqueline; Mohana, Abdulrhman; Bennie, Marion; Mullen, Alexander B.; Malcolm, William; Armstrong, Jennifer; Patton, Andrea; Seaton, R Andrew

doi:10.1093/jac/dky171

Cited by 8 publications

(6 citation statements)

References 10 publications

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“…An additional 15 citations were identified from the grey literature search for a total of 123 publications (figure 1). 13–135 Of the 123 studies, 64 were peer reviewed, 53 were conference proceedings and 6 were online documents (eg, reports).…”

Section: Resultsmentioning

confidence: 99%

Documenting the indication for antimicrobial prescribing: a scoping review

Saini

Leung

et al. 2022

BMJ Qual Saf

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BackgroundDocumenting an indication when prescribing antimicrobials is considered best practice; however, a better understanding of the evidence is needed to support broader implementation of this practice.ObjectivesWe performed a scoping review to evaluate antimicrobial indication documentation as it pertains to its implementation, prevalence, accuracy and impact on clinical and utilisation outcomes in all patient populations.Eligibility criteriaPublished and unpublished literature evaluating the documentation of an indication for antimicrobial prescribing.Sources of evidenceA search was conducted in MEDLINE, Embase, CINAHL and International Pharmaceutical Abstracts in addition to a review of the grey literature.Charting and analysisScreening and extraction was performed by two independent reviewers. Studies were categorised inductively and results were presented descriptively.ResultsWe identified 123 peer-reviewed articles and grey literature documents for inclusion. Most studies took place in a hospital setting (109, 89%). The median prevalence of antimicrobial indication documentation was 75% (range 4%–100%). Studies evaluating the impact of indication documentation on prescribing and patient outcomes most commonly examined appropriateness and identified a benefit to prescribing or patient outcomes in 17 of 19 studies. Qualitative studies evaluating healthcare worker perspectives (n=10) noted the common barriers and facilitators to this practice.ConclusionThere is growing interest in the importance of documenting an indication when prescribing antimicrobials. While antimicrobial indication documentation is not uniformly implemented, several studies have shown that multipronged approaches can be used to improve this practice. Emerging evidence demonstrates that antimicrobial indication documentation is associated with improved prescribing and patient outcomes both in community and hospital settings. But setting-specific and larger trials are needed to provide a more robust evidence base for this practice.

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Section: Resultsmentioning

confidence: 99%

Documenting the indication for antimicrobial prescribing: a scoping review

Saini

Leung

et al. 2022

BMJ Qual Saf

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“…Data were collected from written and electronic medical notes and prescription charts. A data collection tool based on one currently used in Glasgow hospitals, 11 the global PPS tool 12 and bespoke PPS 13 , 14 was used. Data collection was carried out by medical staff, antimicrobial and ward pharmacists and antimicrobial nurses.…”

Section: Methodsmentioning

confidence: 99%

Survey of antibiotic and antifungal prescribing in patients with suspected and confirmed COVID-19 in Scottish hospitals

Seaton

Gibbons

Cooper

et al. 2020

Journal of Infection

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Background: Concern regarding bacterial co-infection complicating SARS-CoV-2 has created a challenge for antimicrobial stewardship. Following introduction of national antibiotic recommendations for suspected bacterial respiratory tract infection complicating COVID-19, a point prevalence survey of prescribing was conducted across acute hospitals in Scotland. Methods: Patients in designated COVID-19 units were included and demographic, clinical and antimicrobial data were collected from 15 hospitals on a single day between 20th and 30th April 2020. Comparisons were made between SARS-CoV-2 positive and negative patients and patients on non-critical care and critical care units. Factors associated with antibiotic prescribing in SARS-CoV-2 positive patients were examined using Univariable and multivariable regression analyses. Findings: There were 820 patients were included, 64.8% were SARS-CoV-2 positive and 14.9% were managed in critical care, and 22.1% of SARS-CoV-2 infections were considered probable or definite nosocomial infections. On the survey day, antibiotic prevalence was 45.0% and 73.9% were prescribed for suspected respiratory tract infection. Amoxicillin, doxycycline and co-amoxiclav accounted for over half of all antibiotics in non-critical care wards and meropenem, piperacillin-tazobactam and co-amoxiclav accounted for approximately half prescribed in critical care. Of all SARS-CoV-2 patients, 38.3% were prescribed antibiotics. In a multivariable logistic regression analysis, COPD/chronic lung disease and CRP ≥ 100 mg/l were associated with higher odds and probable or confirmed nosocomial COVID-19, diabetes and management on an elderly care ward had lower odds of an antibiotic prescription. Systemic antifungals were prescribed in 9.8% of critical care patients and commenced a median of 18 days after critical care admission. Interpretation: A relatively low prevalence of antibiotic prescribing in SARS-CoV-2 hospitalised patients and low proportion of broad spectrum antibiotics in non-critical care settings was observed potentially reflecting national antimicrobial stewardship initiatives. Broad spectrum antibiotic and antifungal prescribing in critical care units was observed indicating the importance of infection prevention and control and stewardship initiatives in this setting.

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“…The rapid identification of the TZP-R/3GC-S phenotype could potentially enable de-escalation from TZP to a 3GC [ 51 ], both reducing the likelihood of treatment failure, and preventing overuse of carbapenems, which is key for antimicrobial stewardship [ 52 ]. However, care must be taken in this approach to reduce the risk of treatment failure, as it is unknown whether the mechanisms of TZP-R may readily evolve to confer resistance to 3GCs due to selection pressure during antimicrobial therapy.…”

Section: Discussionmentioning

confidence: 99%

Piperacillin/tazobactam-resistant, cephalosporin-susceptible Escherichia coli bloodstream infections are driven by multiple acquisition of resistance across diverse sequence types

Edwards

Heinz

Aartsen³

et al. 2022

Microbial Genomics

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Resistance to piperacillin/tazobactam (TZP) in Escherichia coli has predominantly been associated with mechanisms that confer resistance to third-generation cephalosporins. Recent reports have identified E. coli strains with phenotypic resistance to piperacillin/tazobactam but susceptibility to third-generation cephalosporins (TZP-R/3GC-S). In this study we sought to determine the genetic diversity of this phenotype in E. coli (n=58) isolated between 2014–2017 at a single tertiary hospital in Liverpool, UK, as well as the associated resistance mechanisms. We compare our findings to a UK-wide collection of invasive E. coli isolates (n=1509) with publicly available phenotypic and genotypic data. These data sets included the TZP-R/3GC-S phenotype (n=68), and piperacillin/tazobactam and third-generation cephalosporin-susceptible (TZP-S/3GC-S, n=1271) phenotypes. The TZP-R/3GC-S phenotype was displayed in a broad range of sequence types, which was mirrored in the same phenotype from the UK-wide collection, and the overall diversity of invasive E. coli isolates. The TZP-R/3GC-S isolates contained a diverse range of plasmids, indicating multiple acquisition events of TZP resistance mechanisms rather than clonal expansion of a particular plasmid or sequence type. The putative resistance mechanisms were equally diverse, including hyperproduction of TEM-1, either via strong promoters or gene amplification, carriage of inhibitor-resistant β-lactamases, and an S133G bla CTX-M-15 mutation detected for the first time in clinical isolates. Several of these mechanisms were present at a lower abundance in the TZP-S/3GC-S isolates from the UK-wide collection, but without the associated phenotypic resistance to TZP. Eleven (19%) of the isolates had no putative mechanism identified from the genomic data. Our findings highlight the complexity of this cryptic phenotype and the need for continued phenotypic monitoring, as well as further investigation to improve detection and prediction of the TZP-R/3GC-S phenotype from genomic data.

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Optimizing carbapenem use through a national quality improvement programme

Cited by 8 publications

References 10 publications

Documenting the indication for antimicrobial prescribing: a scoping review

Documenting the indication for antimicrobial prescribing: a scoping review

Survey of antibiotic and antifungal prescribing in patients with suspected and confirmed COVID-19 in Scottish hospitals

Piperacillin/tazobactam-resistant, cephalosporin-susceptible Escherichia coli bloodstream infections are driven by multiple acquisition of resistance across diverse sequence types

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