Challenges in the distribution of antimicrobial medications in community dispensaries in Accra, Ghana.

INTRODUCTION: The dispensation of medicines in some low- and middle-income countries is often carried out by private vendors operating under constrained conditions. The aim of this study was to understand the challenges reported by employees of dispensaries, specifically, chemical and herbal shops and pharmacies in Accra, Ghana. Our objectives were twofold: (1) to assess challenges faced by medicine vendors related to dispensing antimicrobials (antibiotic and antimalarial medications), and (2) to identify opportunities for improving their stewardship of antimicrobials. METHODS: Data were collected in 79 dispensaries throughout Accra, in 2021, using a survey questionnaire. We used open-ended questions, grounded on an adapted socioecological model of public health, to analyze these data and determine challenges faced by respondents. RESULTS: We identified multiple, interlocking challenges faced by medicine vendors. Many of these relate to challenges of antimicrobial stewardship (following evidence-based practices when dispensing medicines). Overall, medicine vendors frequently reported challenges at the Customer and Community levels. These included strained interactions with customers and the prohibitive costs of medications. The consequences of these challenges reverberated and manifested through all levels of the socioecological model of public health (Entity, Customer, Community, Global). DISCUSSION: The safe and effective distribution of medications was truncated by strained interactions, often related to the cost of medicines and gaps in knowledge. While addressing these challenges requires multifaceted approaches, we identified several areas that, if intervened upon, could unlock the great potential of antimicrobal stewardship. The effective and efficient implementation of key interventions could facilitate efforts spearheaded by medicine vendors and leverage the benefits of their role as health educators and service providers. CONCLUSION: Addressing barriers faced by medicine vendors would provide an opportunity to significantly improve the provision of medications, and ultimately population health. Such efforts will likely expand access to populations who may otherwise be unable to access medications and treatment in formal institutions of care such as hospitals. Our findings also highlight the broad range of care provided by shopkeepers and vendors at dispensaries. These findings suggest that the meaningful engagement of dispensaries as valued conduits of community health is a promising pathway for interventions aiming to improve antimicrobial stewardship.

Antibiotic management programme in a tertiary intensive care unit: effects of a carbapenem-restricted period on clinical and laboratory parameters and costs of infections.

BACKGROUND: Carbapenems are antibiotics used for serious infections. The consumption of carbapenems has increased worldwide due to increasing microbial resistance. AIM: To investigate the effects of a carbapenem-restricted antimicrobial stewardship programme (ASP) on changes in the resistance profiles of infectious agents, the amount of antibiotics used, length of stay in the intensive care unit (ICU), mortality, and costs. METHODS: Patients hospitalized in ICU between July 1st, 2020 and May 1st, 2021 were divided into two periods: the carbapenem-non-restricted period (CNRP); and the carbapenem-restricted period (CRP) in which alternative antibiotics to carbapenems were preferred during infection. The defined daily dose (DDD) per 100 patient-day methodology was used to calculate the antibiotic consumption. FINDINGS: Of the 572 patients included in the study, 62.2% were male, and mean age was 70.5 years. In the blood culture the most frequently Gram-negative agent was Acinetobacter baumannii (25%). A. baumannii bloodstream infections with multidrug-resistant and extensively drug resistant micro-organisms were significantly different between the two periods (CNRP: 95.6% (N = 22), CRP: 66.6% (N = 8); P = 0.04). There was a gradual decrease in the incidence density and rate of nosocomial infection (P = 0.06), and a significant decrease in meropenem consumption between the two periods (CNRP vs CRP: 21.19 vs 6.37 DDD per 100 patient-days respectively; P = 0.007). ASP yielded US$8,600 of antibiotic cost savings and a total of 14% patient cost savings (P < 0.05) per patient. CONCLUSION: Combining an effective ASP with a comprehensive infection control programme may mitigate the emergence of antimicrobial-resistant bacteria.

Improving antimicrobial treatment in terms of antimicrobial stewardship and health costs by an OPAT service.

PURPOSE: Outpatient parenteral antimicrobial therapy (OPAT) is a standard for antimicrobial therapy internationally. With this prospective cohort study, we aimed to assess the impact of an OPAT service as part of antimicrobial stewardship (AMS) and evaluate the safety and efficiency of the program while illuminating the financial benefit for the hospital. METHODS: Socio-demographic data, treatment regimen and outcomes were prospectively recorded for all patients assigned to the program of the OPAT unit of the University Hospital of Zurich between November 2018 and September 2022. RESULTS: In total, we recorded 303 OPAT assignments of which 260 resulted in effective OPAT episodes. The 260 OPAT episodes were further optimized toward the choice of antimicrobial agent (n = 18) and length of therapy (n = 6). Moreover, OPAT resulted in alteration of patient assessment and care led by AMS strategies in 247 of 260 episodes (95%). While the bed days saved per year increased consistently with time, a total of 3934 in-hospital treatment days were saved amounting to a cost saving of 9,835,000 CHF over 47 months. Adverse events were recorded in 46 cases whilst only two of these have been the reason for readmission during OPAT treatment. Clinical cure was noted in 77% (199/260) and was negatively associated with Charlson Comorbidity Index (CCI; OR per 1 unit higher 0.85 (95% CI 0.78-0.93)). CONCLUSION: This study demonstrates the impact of an OPAT service in the framework of AMS as well as its benefits for the hospital whilst preserving safety and efficacy for the patient's parenteral antimicrobial treatment.

Budget impact analysis of using procalcitonin to optimize antimicrobial treatment for patients with suspected sepsis in the intensive care unit and hospitalized lower respiratory tract infections in Argentina.

BACKGROUND: Inappropriate antibiotic use represents a major global threat. Sepsis and bacterial lower respiratory tract infections (LRTIs) have been linked to antimicrobial resistance, carrying important consequences for patients and health systems. Procalcitonin-guided algorithms may represent helpful tools to reduce antibiotic overuse but the financial burden is unclear. The aim of this study was to estimate the healthcare and budget impact in Argentina of using procalcitonin-guided algorithms to guide antibiotic prescription. METHODS: A decision tree was used to model health and cost outcomes for the Argentinean health system, over a one-year duration. Patients with suspected sepsis in the intensive care unit and hospitalized patients with LRTI were included. Model parameters were obtained from a focused, non-systematic, local and international bibliographic search, and validated by a panel of local experts. Deterministic and probabilistic sensitivity analyses were performed to analyze the uncertainty of parameters. RESULTS: The model predicted that using procalcitonin-guided algorithms would result in 734.5 [95% confidence interval (CI): 1,105.2;438.8] thousand fewer antibiotic treatment days, 7.9 [95% CI: 18.5;8.5] thousand antibiotic-resistant cases avoided, and 5.1 [95% CI: 6.7;4.2] thousand fewer Clostridioides difficile cases. In total, this would save $422.4 US dollars (USD) [95% CI: $935;$267] per patient per year, meaning cost savings of $83.0 [95% CI: $183.6;$57.7] million USD for the entire health system and $0.4 [95% CI: $0.9;$0.3] million USD for a healthcare provider with 1,000 cases per year of sepsis and LRTI patients. The sensitivity analysis showed that the probability of cost-saving for the sepsis patient group was lower than for the LRTI patient group (85% vs. 100%). CONCLUSIONS: Healthcare and financial benefits can be obtained by implementing procalcitonin-guided algorithms in Argentina. Although we found results to be robust on an aggregate level, some caution must be used when focusing only on sepsis patients in the intensive care unit.

Effect of pharmacist interventions on antibiotic use in the general pediatric ward.

Antibiotics are widely prescribed and often used irrationally in Chinese hospitals. This study aimed to evaluate the pharmacist's influence on antibiotic use in the pediatric ward. We conducted this pre-to-post intervention study in the pediatrics of a Chinese tertiary hospital. The patients hospitalized from April to June 2018 were assigned to the pre-intervention group and those from April to June 2019 were distributed to post-intervention group. In the post-intervention stage, the pharmacist took measures to promote rational use of antibiotics and their effects were assessed. This study analyzed data of 1408 patients totally, 671 and 737 in the pre-intervention and post-intervention group respectively. The interventions of clinical pharmacist significantly reduced the rate of using antibiotics without indications (from 33.55% to 15.82%, p<0.01), percentage of inappropriate antibiotic choice (from 24.79% to 16.58%, p p<0.01), dose (from 8.55% to 4.34%, p p<0.05), combination (from 11.75% to 5.10%, p p<0.01) and prolonged duration (from 14.53% to 10.46%, p p<0.05). The mean antibiotic cost and cost/patient-day were also significantly reduced after the intervention. The ratio of average antibiotic cost saving to pharmacist time cost was 16.77:1. The pharmacist could play vital roles in optimizing antibiotic use, thus resulting in favorable clinical and economic outcomes in pediatric ward.

Cost Study of a Cluster Randomized Trial on a Clinical Decision Rule Guiding Antibiotic Treatment in Children With Suspected Lower Respiratory Tract Infections in the Emergency Department.

BACKGROUND: Children with fever and respiratory symptoms represent a large patient group at the emergency department (ED). A decision rule-based treatment strategy improved targeting of antibiotics in these children in a recent clinical trial. This study aims to evaluate the impact of the decision rule on healthcare and societal costs, and to describe costs of children with suspected lower respiratory tract infections (RTIs) in the ED in general. METHODS: In a stepped-wedge, cluster randomized trial, we collected cost data of children 1 month to 5 years of age with fever and cough/dyspnea in 8 EDs in The Netherlands (2016-2018). We calculated medical costs and societal costs per patient, during usual care (n = 597), and when antibiotic prescription was guided by the decision rule (n = 402). We calculated cost-of-illness of this patient group and estimated their annual costs at national level. RESULTS: The cost-of-illness of children under 5 years with suspected lower RTIs in the ED was on average &OV0556;2130 per patient. At population level this is &OV0556;15 million per year in The Netherlands (&OV0556;1.7 million/100,000 children under 5). Mean costs per patient in usual care (&OV0556;2300) were reduced to &OV0556;1870 in the intervention phase (P = 0.01). Main cost drivers were hospitalization and lost parental workdays. CONCLUSIONS: Implementation of a decision rule-based treatment strategy in children with suspected lower RTI was cost-saving, due to a reduction in hospitalization and parental absenteeism. Given the high frequency of this disease in children, the decision rule has the potential to result in a considerable cost reduction at population level.

[Impact of an antimicrobial stewardship program in a pediatric third level hospital in Panama]. / Impacto de un programa de optimización de uso de antimicrobianos en un hospital pediátrico de tercer nivel en Panamá.

BACKGROUND: Antimicrobial Stewardship Programs (ASP) focus in the appropriate use of antimicrobials to improve clinical results and minimize risk of adverse events. AIMS: To compare consumption and costs of antimicrobials before and after the establishment of an antimicrobial stewardship program and to describe the resistance proportion of priority bacteria. METHODS: Quasi-experimental, retrospective and prospective, descriptive and analytical study, to compare consumption and costs of antimicrobials in a pre- intervention period (2007-2010) and a post- intervention period (2011-2017). Additionally, a descriptive analysis of bacterial resistance from 2010 was performed. RESULTS: Gentamicin, vancomycin, meropenem, cefotaxime, ceftazidime and imipenem consumption decreased significantly in the post-intervention period compared to the pre-intervention period (p < 0.05) while consumption of amikacin, piperacillin/tazobactam, cefepime and levofloxacin increased significantly in the post-intervention period. The reduction in costs was not significant for gentamicin, vancomycin, meropenem, cefotaxime, ceftazidime and imipenem, meanwhile, costs increased for amikacin, piperacillin/tazobactam, cefepime and levofloxacin, but this was not significant. The isolation of Acinetobacter baumannii, Klebsiella pneumoniae, Staphylococcus aureus and Enterococcus faecalis decreased during the post-intervention period. CONCLUSION: The ASP showed a decrease in consumption and costs of some antimicrobials.

Global Antimicrobial Stewardship with a Focus on Low- and Middle-Income Countries.

Antimicrobial resistance is a global public health crisis. Antimicrobial Stewardship involves adopting systematic measures to optimize antimicrobial use, decrease unnecessary antimicrobial exposure and to decrease the emergence and spread of resistance. Low- and middle-income countries (LMICs) face a disproportionate burden of antimicrobial resistance and also face challenges related to resource availability. Although challenges exist, the World Health Organization has created a practical toolkit for developing Antimicrobial Stewardship Programs (ASPs) that will be summarized in this article.

Clinical and economic effects of an antimicrobial stewardship intervention in a surgical intensive care unit.

PURPOSE: To study the effects of an Antimicrobial Stewardship (AMS) programme designed as a once-weekly "Prospective Audit with Feedback and Intervention" in a surgical intensive care unit. METHODS: Retrospective, pre-/post-observational comparison of antimicrobial drug use, patient safety, and cost of care. RESULTS: During the 12-month AMS period the consumption of antimicrobials dropped by 18.3%. While the consumption of broad-spectrum antibiotics decreased by 17.4% the consumption of narrow spectrum penicillins increased by 89.9%, reaching 26.3% of the total antibiotic consumption. Treatment outcomes and rates of Clostridioides difficile infections before and during the programme were not significantly different. The reduction in antimicrobial costs of 46,393€ was offset by an expenditure of 8,047€, for both human resources and additional radiological procedures, resulting in a net saving of 38,346€. 92% of the antibiotic related savings were due to the reduced use of tigecycline and linezolid, and decreases in drug retail prices. CONCLUSIONS: AMS programmes can both reduce the consumption of antimicrobials and modify their spectrum in intensive care without negatively affecting treatment outcomes. The resulting cost savings are negligible. The incentive to implement such programmes cannot, therefore, be immediate institutional cost savings, but should be rather the long-term goal of reducing antibiotic resistance, and its consequences, in terms of long-term health care costs.

A persuasive approach to antimicrobial stewardship in Christchurch hospitals produced a sustained decrease in intravenous clarithromycin dosing and expenditure via a switch to azithromycin orally.

AIMS: To assess a persuasive multimodel approach to decreasing unnecessary intravenous (IV) clarithromycin use for community-acquired pneumonia (CAP) in Canterbury District Health Board (CDHB) hospitals. METHODS: In December 2013, CDHB guidelines for empiric treatment of CAP changed to prioritise oral azithromycin over IV clarithromycin. The multimodel approach we used to implement this change included obtaining stakeholder agreement, improved guidelines access, education and pharmacist support. The impact of the intervention was evaluated by comparing macrolide usage and expenditure for the four years pre- and post-intervention. RESULTS: Mean annual clarithromycin IV use decreased by 72% from 6.4 to 1.8 defined daily doses (DDDs) per 1,000 occupied bed days (OBDs) post-intervention, while oral azithromycin increased by 833% (4.2 to 39.2 DDDs per 1,000 OBDs). Concurrently, oral clarithromycin use decreased by 91% (32.9 to 2.9 DDDs per 1,000 OBDs), and roxithromycin by 71% (17.0 to 5.0 DDDs per 1,000 OBDs). Mean annual total macrolide use decreased by 21% (68.2 to 53.9 DDDs per 1,000 OBDs), while expenditure decreased by 69% mainly through avoided IV administration. CONCLUSIONS: A persuasive multimodel approach to support adoption of CAP guidelines produced a sustained decrease in IV clarithromycin use, which may have clinical benefits such as reduced occurrence of catheter-related complications.

Clinical impact of rapid susceptibility testing on Mueller-Hinton Rapid-SIR directly from urine specimens.

Urinary tract infection diagnosis and management generally involves a 48-h microbiological delay to obtain the antibiotic susceptibility test (AST) results. In the context of multidrug resistance, reducing the time to obtain AST results is an essential factor, allowing for more timely appropriate treatment. We conducted a single-centre prospective study on urinary samples meeting two criteria: significant leukocyturia > 50/mm3 and exclusive presence of Gram-negative bacilli on direct examination. AST were performed by direct inoculation on Mueller-Hinton Rapid-SIR (MHR-SIR) agar. We evaluated the time to antibiotic adaptation by the antimicrobial stewardship team according to rapid AST results. Patients were subsequently excluded from the study if asymptomatic bacteria were confirmed, or in the absence of clinical data. Seventy patients were included. Mean age of patients was 68.8 years (± 21.3). Empirical antibiotic treatment were mainly based on third generation cephalosporins (n = 33), fluoroquinolones (n = 15), beta-lactamin/beta-lactamase inhibitors (n = 7), fosfomycin and nitrofurantoin (n = 5, each). The average time to obtain results was 7.2 h (± 1.6 h). Adaptation of therapy following MHR-SIR was performed for 29 patients (41%) with early switch to oral antibiotics, de-escalation or escalation in respectively 72.3%, 30%, and 11% of cases. Time saving of MHR-SIR compared with the standard technique was 42.6 (± 16.7) h. This study showed that rapid antibiotic susceptibility test results, using MHR-SIR method directly from urine, can be obtained 40 h earlier than conventional AST. The study also demonstrated significant clinical impact on the selection and reduction of the antibiotic therapy spectrum.

Impacto de un programa de optimización de uso de antimicrobianos en un hospital pediátrico de tercer nivel en Panamá / Impact of an antimicrobial stewardship program in a pediatric third level hospital in Panama

Resumen Introducción: Los programas de optimización de uso de antimicrobianos (PROA) se enfocan en el uso apropiado de antimicrobianos para ofrecer mejores resultados clínicos y menores riesgos de eventos adversos. Objetivos: Comparar consumo y costos de antimicrobianos antes y después de instauración de un programa de regulación de antimicrobianos y describir la proporción de resistencia de bacterias prioritarias. Métodos: Estudio cuasi-experimental, retrospectivo y prospectivo, descriptivo y analítico, que comparó el consumo y costo de antimicrobianos en un período pre- intervención (2007-2010) y un período post-intervención (2011-2017). Se realizó análisis descriptivo de resistencias bacterianas prioritarias. Resultados: El consumo de gentamicina, vancomicina, meropenem, cefotaxima, ceftazidima e imipenem disminuyó significativamente en el período post-intervención comparado con el período pre-intervención (p < 0,05), mientras que el consumo de amikacina, piperacilina/tazobactam, cefepime y levofloxacina en el período post-intervención mostró un aumento significativo. La reducción de costos no fue significativa para gentamicina, vancomicina, meropenem, cefotaxima, ceftazidima e imipenem. Para amikacina, cefepime, piperacilina/tazobactam y levofloxacina el aumento de costos no fue significativo. Los aislamientos de Acinetobacter baumannii, Klebsiella pneumoniae, Staphylococcus aureus y Enterococcus faecalis disminuyeron durante el período post-intervención. Conclusión: el PROA demostró disminución en consumo y costos de algunos antimicrobianos.

Abstract Background: Antimicrobial Stewardship Programs (ASP) focus in the appropriate use of antimicrobials to improve clinical results and minimize risk of adverse events. Aims: To compare consumption and costs of antimicrobials before and after the establishment of an antimicrobial stewardship program and to describe the resistance proportion of priority bacteria. Methods: Quasi-experimental, retrospective and prospective, descriptive and analytical study, to compare consumption and costs of antimicrobials in a pre- intervention period (2007-2010) and a post- intervention period (2011-2017). Additionally, a descriptive analysis of bacterial resistance from 2010 was performed. Results: Gentamicin, vancomycin, meropenem, cefotaxime, ceftazidime and imipenem consumption decreased significantly in the post-intervention period compared to the pre-intervention period (p < 0.05) while consumption of amikacin, piperacillin/tazobactam, cefepime and levofloxacin increased significantly in the post-intervention period. The reduction in costs was not significant for gentamicin, vancomycin, meropenem, cefotaxime, ceftazidime and imipenem, meanwhile, costs increased for amikacin, piperacillin/tazobactam, cefepime and levofloxacin, but this was not significant. The isolation of Acinetobacter baumannii, Klebsiella pneumoniae, Staphylococcus aureus and Enterococcus faecalis decreased during the post-intervention period. Conclusion: The ASP showed a decrease in consumption and costs of some antimicrobials.

Implementation and impact of pediatric antimicrobial stewardship programs: a systematic scoping review.

Background: Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods: MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18 years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results: Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions: Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

Implementing antimicrobial stewardship to reduce surgical site infections: Experience and challenges from two tertiary-care hospitals in Mumbai, India.

OBJECTIVES: Surgical site infections (SSIs) contribute significantly to post-surgical morbidity globally. Antimicrobial stewardship programmes (ASPs) are essential to reduce SSI rates and to curb antimicrobial resistance, especially in low-and-middle-income countries. This prospective study aimed to show the reproducibility of ASP implementation and SSI prevention measures in a semi-private institution with high perioperative prophylactic antimicrobial consumption beyond guidelines. METHODS: The prevalence of SSIs in clean surgeries was analysed in a government hospital adhering to SSI prevention guidelines including antimicrobial prophylaxis (phase 1; n=335) and in a surgical department unit of a semi-private hospital where the same guidelines were subsequently implemented (phase 2; n=235). SSI rates were compared to check the hypothesis that ASPs and infection control policies are reproducible with similar SSI rates. Moreover, antimicrobial prophylaxis costs were compared between units with and without guideline adherence. RESULTS: Among a total of 570 clean surgeries analysed, SSI rates were similar in both phases (6.0% vs. 5.1%; P=0.659). SSI rates were higher in patients aged >50 years in both phases (P=0.0009 and 0.045), whilst there was no difference in SSI rates between diabetics and non-diabetics (P=0.475 and 0.835). The cost of antimicrobial prophylaxis was lower in the guideline-oriented group (US$0.42 vs US$9 per patient; P=0.0042). CONCLUSION: Implementing SSI prevention guidelines, including proper antimicrobial prophylaxis, is feasible and reproducible among different hospital settings, leading to a significant decrease in prophylaxis costs. SSI rates do not differ following the same international standards.

Advances in Rapid Molecular Blood Culture Diagnostics: Healthcare Impact, Laboratory Implications, and Multiplex Technologies.

BACKGROUND: For far too long, the diagnosis of bloodstream infections has relied on time-consuming blood cultures coupled with traditional organism identification and susceptibility testing. Technologies to define the culprit in bloodstream infections have gained sophistication in recent years, notably by application of molecular methods. CONTENT: In this review, we summarize the tests available to clinical laboratories for molecular rapid identification and resistance marker detection in blood culture bottles that have flagged positive. We explore the cost-benefit ratio of such assays, covering aspects that include performance characteristics, effect on patient care, and relevance to antibiotic stewardship initiatives. SUMMARY: Rapid blood culture diagnostics represent an advance in the care of patients with bloodstream infections, particularly those infected with resistant organisms. These diagnostics are relatively easy to implement and appear to have a positive cost-benefit balance, particularly when fully incorporated into a hospital's antimicrobial stewardship program.

Antimicrobial stewardship in children: more shadows than lights?

Introduction: The aim of this review is to evaluate the effectiveness of antimicrobial stewardship (AMS) programmes in the pediatric population in improving clinical outcomes, altering prescribing behavior, controlling antimicrobial resistance and measuring the cost-effectiveness.Areas covered: Medline Ovid MEDLINE(R), Embase, and Cochrane Library were searched on 30 September 2018 combining MeSH and free terms for 'antimicrobial stewardship', 'clinical outcomes', 'antimicrobial resistance', 'cost-effectiveness' and 'prescribing behavior'. Several studies have been conducted on the impact of antimicrobial stewardship programmes (ASPs) in children, which showed a positive impact on length of hospital stay and days of therapy. Together with ASP bundles, the introduction of fast microbiology and point-of-care tests showed a positive impact in terms of rapid identification of the pathogen, time to optimal antimicrobial therapy and reduction of antibiotic use, without worsening clinical outcomes. These improvements turned out to be limited over time. Conflicting results were observed regarding the impact of ASPs on antimicrobial resistance and on cost-effectiveness and cost-benefits, due to the lack of homogeneity between studies.Expert opinion: Evidence regarding the impact of ASPs in children is limited to single center studies, with different study designs, making it impossible to draw unequivocal conclusions. High quality studies are needed. More feasable approaches should be designed both for inpatients and outpatients and for critical patients.

Penicillin allergy skin testing as an antibiotic stewardship intervention reduces alternative antibiotic exposures in hematopoietic stem cell transplant recipients.

BACKGROUND: Antibiotic allergy de-labeling using penicillin allergy skin testing (PAST) can reduce the use and cost of alternative, non-ß-lactam antibiotics in general inpatient populations. This strategy's role in hematopoietic stem cell transplant (HSCT) recipients is unclear. METHODS: This study aimed to determine the effect of a pre-transplant PAST protocol on antibiotic use, days of therapy (DOT), and cost in an immunocompromised population at a single center from 7/1/2010-2/1/2019. Patients who received chimeric antigen receptor (CAR) T-cell therapy and those who underwent transplantation in the outpatient setting were excluded. RESULTS: Of 1560 patients who underwent inpatient HSCT during the study period, 208 reported ß-lactam allergy (136/844 [16%] pre- and 72/716 [10%] post-implementation; P < .001). PAST was performed on 7% and 54% of HSCT recipients pre- and post-implementation, respectively. Only two positive PAST were noted. There were no adverse reactions to PAST. There were no significant differences in the disease and transplant characteristics between the two groups. Days of therapy and cost of alternative antibiotics significantly decreased post-implementation (mean 788 vs 627 days, P = .01; mean $24 425 vs $17 518, P = .009). CONCLUSION: Penicillin allergy skin testing adjudicates reported ß-lactam allergy in HSCT recipients, lowering use, DOT, and cost of alternative antibiotics and promoting effective formulary agents to treat immunocompromised HSCT recipients.

Developing an antimicrobial stewardship program across a rural health system: The Avera Health experience.

PURPOSE: The stages of development of a health system-wide antimicrobial stewardship program (ASP) using existing personnel and technology are described. SUMMARY: Small hospitals with limited resources may struggle to meet ASP requirements, particularly facilities without onsite infectious disease physicians and/or experienced infectious disease pharmacists. Strategies for ASP development employed by Avera Health, a 33-hospital health system in the Midwest, included identifying relevant drug utilization and resistance patterns, education and pathway development, and implementation of Web-based conferencing to provide pharmacists throughout the system with access to infectious disease expertise on a daily basis. These efforts resulted in an evolving single-system ASP that has leveraged existing resources to overcome some system barriers. Program outcomes to date include a reduction in the use of a targeted agent, improved pathogen susceptibility trends, and rates of hospital-associated Clostridium difficile infection below national benchmarks. CONCLUSION: The Avera Health ASP grew from a collaborative project targeting levofloxacin overuse and resistance among key bacteria to a formal, health system-wide ASP in a rural setting. This program used existing personnel to provide standardized processes, educational campaigns, and antimicrobial expertise through the use of technology. This ASP program may provide helpful examples of ASP strategies for other rural health systems with similar resources.

Time to clinical response in sepsis associated with an algorithm for blood-culture pathogen identification using matrix-assisted laser desorption ionization time-of-flight mass spectroscopy.

PURPOSE: Antimicrobial stewardship programs (ASPs) can be aided by using rapid diagnostics (RDT). However, there are limited data evaluating the impact of ASPs and RDT on sepsis outcomes in the setting of the new Sepsis-3 guidelines. This study evaluates the impact of a low-resource method for ASPs with RDT on sepsis outcomes. METHODS: This was a prospective, quasi-experimental study with a retrospective double pretest. Patients ≥ 18 years old with sepsis and concurrent bacteremia or fungemia were included; patients who were pregnant, had polymicrobial septicemia or who were transferred from an outside hospital were excluded. In the first pretest (O1), polymerase chain reaction was used to identify Staphylococcal species from positive blood cultures, and traditional laboratory techniques were used to identify other species. Matrix-assisted laser desorption ionization time-of-flight mass spectroscopy and FilmArray were implemented in the second pretest (O2), and twice daily blood culture review was implemented in the posttest (O3). RESULTS: A total of 394 patients (157 in O1, 176 in O2, 61 in O3) were enrolled. Clinical response was 73.2%, 83.5%, and 88.5% in O1, O2, and O3, respectively, p = 0.013. By Cox regression, the O3 was associated with improved time to clinical response (hazard ratio, 1.388; 95% confidence interval, 1.004-1.919) as compared with O1. Mortality, hospital length of stay, and intensive care unit length of stay were unchanged between groups. CONCLUSION: Twice-daily blood culture review may be useful for implementing rapid diagnostics within low-resource ASPs. Further research is needed to identify the optimal method of blood culture follow-up within low-resource settings.

Leading Practices in Antimicrobial Stewardship: Conference Summary.

The Joint Commission's hospital antimicrobial stewardship (AS) standards became effective in January 2017. Surveyors' experience to date suggests that almost all hospitals have established AS leadership commitment and organized structures. Thus, The Joint Commission sought to examine advances in AS interventions and measures that hospitals could implement to strengthen their existing AS programs. METHODS: The Joint Commission and Pew Charitable Trusts sponsored a meeting to bring together experts and key stakeholder organizations from around the country to identify leading practices for AS interventions and measurement. Presenters were asked to summarize the AS activities they thought were most important for the success of their own AS program and leading practices that all hospitals should be able to implement. RESULTS: The panel highlighted two interventions as leading practices that go beyond current guidelines and established practices (that is, preauthorization and prospective audit and feedback). The first is diagnostic stewardship. This type of intervention addresses errors in diagnostic decision making that lead to inappropriate antibiotic prescribing. The second is handshake stewardship, a method of engaging frontline providers on a regular basis for education and discussions about barriers to AS from the clinician's perspective. The panel identified days of therapy (or defined daily dose, when days of therapy is not possible), Clostridioides difficile rates, and adherence to facility-specific guidelines as the preferred measures for assessing stewardship activities. CONCLUSION: The practices highlighted should be given greater emphasis by The Joint Commission in their efforts to improve hospital AS, and the Centers for Disease Control and Prevention will be updating the Core Elements of Hospital Antibiotic Stewardship Programs.