Assessing the conversion of electronic medical record data into antibiotic stewardship indicators.

BACKGROUND: Measuring the appropriateness of antibiotic use is crucial for antibiotic stewardship (ABS) programmes to identify targets for interventions. OBJECTIVES: To assess the technical feasibility of converting electronic medical record (EMR) data into ABS indicators. METHODS: In this observational feasibility study covering a period of 2 years, the EMRs of patients hospitalized at a large non-university hospital network and receiving at least one dose of a systemic antibiotic were included. ABS indicators measuring steps in the process of antibiotic prescription proposed by the literature were collected and rephrased or defined more specifically to be calculable if needed. Algorithms were programmed in R to convert EMR data into ABS indicators. The indicators were visualized in an interactive dashboard and the plausibility of each output value was assessed. RESULTS: In total, data from 25 337 hospitalizations from 20 723 individual patients were analysed and visualized in an interactive dashboard. Algorithms could be programmed to compute 89% (25/28) of all pre-selected indicators assessing treatment decisions automatically out of EMR data, with good data quality for 46% (13/28) of these indicators. According to the data quality observed, the most important issues were (i) missing or meaningless information on indication (e.g. 'mild infection') and (ii) data processing issues such as insufficiently categorized metadata. CONCLUSIONS: The calculation of indicators assessing treatment decisions from EMRs was feasible. However, better data structure and processing within EMR systems are crucial for improving the validity of the results.

Impact of antibiotic use on carbapenem resistance in Pseudomonas aeruginosa: is there a role for antibiotic diversity?

In this study, we aimed to evaluate the relationship between the rates of resistance of Pseudomonas aeruginosa to carbapenems and the levels and diversity of antibiotic consumption. Data were retrospectively collected from 20 acute care hospitals across 3 regions of Switzerland between 2006 and 2010. The main outcome of the present study was the rate of resistance to carbapenems among P. aeruginosa. Putative predictors included the total antibiotic consumption and carbapenem consumption in defined daily doses per 100 bed days, the proportion of very broad-spectrum antibiotics used, and the Peterson index. The present study confirmed a correlation between carbapenem use and carbapenem resistance rates at the hospital and regional levels. The impact of diversifying the range of antibiotics used against P. aeruginosa resistance was suggested by (i) a positive correlation in multivariate analysis between the above-mentioned resistance and the proportion of consumed antibiotics having a very broad spectrum of activity (coefficient = 1.77; 95% confidence interval, 0.58 to 2.96; P < 0.01) and (ii) a negative correlation between the resistance and diversity of antibiotic use as measured by the Peterson homogeneity index (coefficient = -0.52; P < 0.05). We conclude that promoting heterogeneity plus parsimony in the use of antibiotics appears to be a valuable strategy for minimizing the spread of carbapenem resistance in P. aeruginosa in hospitals.

Changes in the use of broad-spectrum antibiotics after cefepime shortage: a time series analysis.

The original cefepime product was withdrawn from the Swiss market in January 2007 and replaced by a generic 10 months later. The goals of the study were to assess the impact of this cefepime shortage on the use and costs of alternative broad-spectrum antibiotics, on antibiotic policy, and on resistance of Pseudomonas aeruginosa toward carbapenems, ceftazidime, and piperacillin-tazobactam. A generalized regression-based interrupted time series model assessed how much the shortage changed the monthly use and costs of cefepime and of selected alternative broad-spectrum antibiotics (ceftazidime, imipenem-cilastatin, meropenem, piperacillin-tazobactam) in 15 Swiss acute care hospitals from January 2005 to December 2008. Resistance of P. aeruginosa was compared before and after the cefepime shortage. There was a statistically significant increase in the consumption of piperacillin-tazobactam in hospitals with definitive interruption of cefepime supply and of meropenem in hospitals with transient interruption of cefepime supply. Consumption of each alternative antibiotic tended to increase during the cefepime shortage and to decrease when the cefepime generic was released. These shifts were associated with significantly higher overall costs. There was no significant change in hospitals with uninterrupted cefepime supply. The alternative antibiotics for which an increase in consumption showed the strongest association with a progression of resistance were the carbapenems. The use of alternative antibiotics after cefepime withdrawal was associated with a significant increase in piperacillin-tazobactam and meropenem use and in overall costs and with a decrease in susceptibility of P. aeruginosa in hospitals. This warrants caution with regard to shortages and withdrawals of antibiotics.

Temporal and structural patterns of extended-spectrum cephalosporin-resistant Klebsiella pneumoniae incidence in Swiss hospitals.

BACKGROUND: Routine surveillance data revealed increasing rates of invasive extended-spectrum cephalosporin-resistant Klebsiella pneumoniae (ESCR-KP) in Switzerland, from 1.3% in 2004 to 8.5% in 2019. AIM: The main aim of this study was to understand the causes of this recent trend, specifically to identify predictors affecting the incidence of invasive ESCR-KP infections in Switzerland. METHODS: A retrospective observational multi-centre study was conducted in 21 Swiss hospitals over a period of 11 years (2009-2019). Potential predictor variables for the incidence of invasive ESCR-KP infections were studied with a multiple linear regression model. In an additional analysis, the overall ESCR-KP incidence (all sample sites) was investigated. FINDINGS: An increasing incidence of invasive ESCR-KP infections from 0.01 to 0.04 patients per 1000 bed-days was observed between 2009 and 2019 and confirmed by multiple linear regression analysis (P < 0.01). ESCR-KP incidence was higher in university hospitals (P < 0.01) and in the French-speaking region than in the German-speaking region (P < 0.01). There was no association with antibiotic consumption. Analysing the overall ESCR-KP incidence (all sample sites) revealed high variability between university hospitals, mainly due to a high proportion of patients with screening isolates at Geneva University Hospital (50% of patients with ESCR-KP). CONCLUSION: The incidence of invasive ESCR-KP infections increased in Switzerland between 2009 and 2019 and was not associated with antibiotic consumption. Our findings indicate that, in this low-incidence setting, structural factors such as the hospital type and the linguistic region play a more important role in relation to ESCR-KP incidence than the hospital's antibiotic consumption.

Consumption of anti-meticillin-resistant Staphylococcus aureus antibiotics in Swiss hospitals is associated with antibiotic stewardship measures.

BACKGROUND: Consumption of antibiotics active against meticillin-resistant Staphylococcus aureus (MRSA) has been described in numerous European studies. However, the underlying predictors of consumption are still poorly understood. AIM: To describe the consumption of anti-MRSA antibiotics (daptomycin, intravenous glycopeptides, linezolid) in Switzerland over time and to identify underlying predictor variables. METHODS: A retrospective observational multi-centre study was conducted in 21 Swiss hospitals over a period of 11 years (2009-2019). Multiple linear regression models were built to identify regional and hospital-specific predictor variables affecting the consumption of anti-MRSA antibiotics. FINDINGS: Consumption of anti-MRSA antibiotics increased between 2009 and 2019 from 12.7 to 24.5 defined daily doses per 1000 bed-days (+93%). In the first model presented, which includes data of the whole study period, the following variables were associated with higher anti-MRSA antibiotic consumption: number of MRSA cases (P < 0.01), year (P < 0.01), hospital type (tertiary care university hospitals vs others, P < 0.01), hospital department (intensive care unit vs others, P < 0.01) and linguistic region (French vs German and German vs Italian, P < 0.01). In a second model including data from a query on hospital policies in place in 2019, the presence of an antibiotic stewardship group (P < 0.01) and prescription restrictions (P < 0.01) were associated with consumption of anti-MRSA antibiotics. CONCLUSION: Our study shows that both the presence of an antibiotic stewardship group and the implementation of prescription restrictions, i.e. factors that can be controlled by the hospital itself, were associated with a lower consumption of anti-MRSA antibiotics.

Comparison of hospital-wide and unit-specific cumulative antibiograms in hospital- and community-acquired infection.

BACKGROUND: Empirical antibacterial therapy in hospitals is usually guided by local epidemiologic features reflected by institutional cumulative antibiograms. We investigated additional information inferred by aggregating cumulative antibiograms by type of unit or according to the place of acquisition (i.e. community vs. hospital) of the bacteria. MATERIALS AND METHODS: Antimicrobial susceptibility rates of selected pathogens were collected over a 4-year period in an university-affiliated hospital. Hospital-wide antibiograms were compared with those selected by type of unit and sampling time (<48 or >48 h after hospital admission). RESULTS: Strains isolated >48 h after admission were less susceptible than those presumably arising from the community (<48 h). The comparison of units revealed significant differences among strains isolated >48 h after admission. When compared to hospital-wide antibiograms, susceptibility rates were lower in the ICU and surgical units for Escherichia coli to amoxicillin-clavulanate, enterococci to penicillin, and Pseudomonas aeruginosa to anti-pseudomonal beta-lactams, and in medical units for Staphylococcus aureus to oxacillin. In contrast, few differences were observed among strains isolated within 48 h of admission. CONCLUSIONS: Hospital-wide antibiograms reflect the susceptibility pattern for a specific unit with respect to community-acquired, but not to hospital-acquired strains. Antibiograms adjusted to these parameters may be useful in guiding the choice of empirical antibacterial therapy.

Hospital antibiotic consumption in Switzerland: comparison of a multicultural country with Europe.

The consumption of antibiotics in the inpatient setting of Switzerland was assessed to determine possible differences between linguistic regions, and to compare these results with European results. Data on antibiotic consumption were obtained from a sentinel network representing 54% of the national acute care hospitals, and from a private drug market monitoring company. Aggregated data were converted into defined daily doses (DDD). The total consumption density in Switzerland was close to the median consumption reported in European surveys. Between 2004 and 2008, the total consumption of systemic antibiotics rose from 46.1 to 54.0 DDD per 100 occupied bed-days in the entire hospitals, and from 101.6 to 114.3 DDD per 100 occupied bed-days in the intensive care units. Regional differences were observed for total consumption and among antibiotic classes. Hospitals in the Italian-speaking region showed a significantly higher consumption density, followed by the French- and German-speaking regions. Hospitals in the Italian-speaking region also had a higher consumption of fluoroquinolones, in line with the reported differences between Italy, Germany and France. Antibiotic consumption in acute care hospitals in Switzerland is close to the European median with a relatively low consumption in intensive care units. Some of the patterns of variation in consumption levels noticed among European countries are also observed among the cultural regions of Switzerland.