Applicability of Quality Indicators for Appropriate Antibiotic use in Outpatient Parenteral Antimicrobial Therapy (OPAT): A Point Prevalence Survey.

The ability to measure the quality of antibiotic prescription is a critical element in any antimicrobial stewardship programme. The aim of this study was to evaluate the clinimetric properties of 33 quality indicators (QIs) developed to assess Outpatient Parenteral Antimicrobial Therapy (OPAT) and to identify potential room for improvement in a hospital-at-home (HaH) unit. Study performed in a healthcare district in Barcelona, Spain with 260,657 inhabitants, nine primary healthcare centres, a 400-bed acute care teaching hospital, and an HaH unit. We studied 33 QIs on appropriate antibiotic use and classified them as qualitative or quantitative. Quantitative QIs were further categorized as measurable or non-measurable depending on the availability of data in the patients' medical records. Data from 202 OPAT episodes in 192 patients were assessed. Adherence was found for 22 of the 24 qualitative QIs analyzed; the other two showed room for improvement. Four of the nine quantitative indicators were non-measurable. High adherence rates were achieved for QI-17 "The OPAT plan should be documented" (84.65%), QI-26 "The OPAT treatment plan should include choice, dose, frequency, duration and follow-up plan" (79.70%), and QI-33 "The team should document clinical response" (94.55%). Adverse events were documented in just 1.98% of cases (QI-32) and 92.57% patients were classified as alive on discharge (QI-24). The QIs evaluated were applicable to clinical practice and proved useful for identifying areas with room for improvement in our setting and for guiding the design of future interventions with specific objectives.

Applicability of Outpatient Quality Indicators for Appropriate Antibiotic Use in a Primary Health Care Area: a Point Prevalence Survey.

The ability to measure the quality of antibiotic prescriptions is a critical element in all antimicrobial stewardship programs. The aims of the present study were to evaluate the clinimetric properties of 32 recently developed outpatient quality indicators (OQIs) and to identify potential room for improvement in antibiotic use in a primary health care (PHC) area. The study was performed in a PHC area in Barcelona, Spain with 260,657 inhabitants, nine PHC centers, and a 400-bed acute-care teaching hospital. We selected 9 of the 32 OQIs that were applicable to our PHC area and evaluated them for measurability, adherence, and room for improvement. Nonmeasurable OQIs, OQIs without room for improvement, and OQIs beyond the scope of the PHC antimicrobial stewardship program were excluded. Data from 260,561 registered patients were assessed. Measurability was high for all OQIs except those that required manual recording of the clinical diagnosis (OQIs on group A streptococcal diagnostic testing). Adherence to guidelines was poor for most OQIs, but particularly for the indicator on the avoidance of antibiotics for viral or self-limiting bacterial infections, where we observed more than 60% room for improvement for both acute tonsillitis and sinusitis. The QIs evaluated were applicable to clinical practice and proved useful for identifying areas with room for improvement in our setting and for guiding the design of future interventions with specific objectives.

Impact of a Multifaceted Antimicrobial Stewardship Intervention in a Primary Health Care Area: A Quasi-Experimental Study.

The aim of the study was to evaluate the impact of a multifaceted antimicrobial stewardship intervention on antibiotic consumption in a primary health care (PHC) area in Spain. Quasi-experimental study conducted in a PHC area with nine PHC centers, a 400-bed acute care teaching hospital, and 18 nursing homes serving a population of 260,561. The intervention was based on the 2016 CDC Core Elements of Outpatient Antibiotic Stewardship publication and targeted 130 PHC physicians, 41 PHC pediatricians, 19 emergency physicians, and 18 nursing home physicians. The components were commitment, actions for improving antibiotic prescribing, tracking and feedback, and education and experience. The primary outcome was overall antibiotic consumption. Secondary outcomes were consumption of antibiotics to treat pharyngotonsillitis, acute otitis media, acute sinusitis, acute bronchitis, and urinary tract infection (UTI), percentage of patients treated with specific antibiotics, and dispensing costs. Consumption was measured in defined daily doses per 1,000 inhabitants per day (DID) and compared pre- and postintervention (2016 vs. 2018). Overall antibiotic consumption decreased from 16.01 to 13.31 DID (-16.85%). Consumption of amoxicillin/clavulanic acid and quinolones decreased from 6.04 to 4.72 DID (-21.88%) and 1.64 to 1.23 DID (-25.06%), respectively. The percentage of patients treated with antibiotics decreased from 26.99 to 22.41%. The intervention resulted in cost savings of €72,673. Use of antibiotics to treat pharyngotonsillitis, UTI, and acute otitis media, sinusitis, and bronchitis decreased significantly. Our antimicrobial stewardship program led to a decrease in antibiotic consumption and significantly improved the use of antibiotics for the most prevalent PHC infections.

Assessment of Quality Indicators for Appropriate Antibiotic Use.

One of the critical elements of antimicrobial stewardship programs is the ability to measure the quality of antibiotic prescriptions. The aims of the present study were to evaluate the performance properties of a set of previously developed quality indicators (QIs) and to identify the potential room for improvement in antibiotic use in our setting. A monthly cross-sectional point prevalence survey was conducted in a 400-bed acute care teaching hospital, from June to November 2015. All adult patients treated for ≥24 hours with antibiotic therapy for a suspected hospital- or community-acquired bacterial infection were included. Performance scores (adherence, room for improvement, interobserver reliability, and applicability) were calculated for 8 QIs. A total of 362 patients were evaluated. Adherence to the whole set of QIs was accomplished for 14.1% of evaluable patients. The QIs with greater room for improvement were adequate request for blood cultures (60.6%), therapeutic drug monitoring (TDM) (59.1%), sequential antibiotic therapy within 72 hours (48.2%), and empirical antibiotic therapy according to local guidelines (30.4%). The percentage of patients receiving unnecessary antibiotic treatment in the absence of clinical or microbiological evidence of infection after 5 days was 12.2%. All indicators scored kappa values of ≥0.6, suggesting good interobserver reliability. Low applicability (6.1% of reviewed patients) was found only for the TDM QI. The QIs analyzed were found to be applicable, showed good interobserver reliability, and were useful tools to identify areas with potential room for improvement in antibiotic use.

Protocolo informático de manejo integral de la sepsis. Descripción de un sistema de identificación precoz / Computerised sepsis protocol management. Description of an early warning system

Introducción: Es preciso desarrollar nuevas estrategias que permitan una identificación precoz y una inmediata instauración de medidas efectivas en el abordaje de la sepsis. La unidad multidisciplinar de sepsis (UMS) desarrolló una herramienta: el Protocolo Informático de Manejo Integral de la Sepsis (PIMIS). El objetivo de este estudio es evaluar la intervención de la UMS y la utilidad del PIMIS. Métodos: Se analizaron las intervenciones según fueran realizadas por consulta directamente solicitada (activación de PIMIS o consulta telefónica) o no solicitada (aislamientos microbiológicos y el Sistema Informático de Detección de Constantes Vitales [SIDCV]), los servicios, el tipo de infección, la recomendación de cambio de antibiótico y el grado de aceptación. Resultados: De las 1.581 consultas, el 65,1% se solicitaron directamente: un 84,1% por activación del PIMIS por el médico responsable y un 15,9% por contacto telefónico directo. Entre las consultas no solicitadas, el 95,2% procedían de microbiología y el 4,8% del SIDCV. Las consultas directamente solicitadas se realizaron más precozmente que las no solicitadas (5,63días vs. 8,47días; p<0,001) y la frecuencia fue mayor en los servicios médicos frente a los quirúrgicos (73,0% vs. 39,1%; p<0,001). Se recomendó un cambio de antibiótico en el 32% de las primeras consultas y se aceptó en el 78,1% de los casos. Conclusiones: La elevada proporción de consultas directamente solicitadas y aceptación de las recomendaciones demuestra que la intervención de la UMS es valorada y respetada. El PIMIS es el principal mecanismo de consulta, lo que lo convierte en una herramienta útil y conveniente para la identificación precoz y el abordaje de la sepsis (AU)

Introduction: New strategies need to be developed for the early recognition and rapid response for the management of sepsis. To achieve this purpose, the Multidisciplinary Sepsis Team (MST) developed the Computerised Sepsis Protocol Management (PIMIS). The aim of this study was to evaluate the convenience of using PIMIS, as well as the activity of the MST. Methods: An analysis was performed on the data collected from solicited MST consultations (direct activation of PIMIS by attending physician or telephone request) and unsolicited ones (by referral from the microbiology laboratory or an automatic referral via the hospital vital signs recording software [SIDCV]), as well as the hospital department, source of infection, treatment recommendation, and acceptance of this. Results: Of the 1,581 first consultations, 65.1% were solicited consultations (84.1% activation of PIMIS and 15.9% by telephone). The majority of unsolicited consultations were generated by the microbiology laboratory (95.2%), and 4.8% from the SIDCV. Referral from solicited consultations were generated sooner (5.63days vs 8.47days; P<.001) and came from clinical specialties rather than from the surgical ward (73.0% vs 39.1%; P<.001). A recommendation was made for antimicrobial prescription change in 32% of first consultations. The treating physician accepted 78.1% of recommendations. Conclusions: The high rate of solicited consultations and acceptance of recommended prescription changes suggest that a MST is seen as a helpful resource, and that PIMIS software is perceived to be useful and convenient to use, as it is the main source of referral (AU)

Computerised sepsis protocol management. Description of an early warning system. / Protocolo informático de manejo integral de la sepsis. Descripción de un sistema de identificación precoz.

INTRODUCTION: New strategies need to be developed for the early recognition and rapid response for the management of sepsis. To achieve this purpose, the Multidisciplinary Sepsis Team (MST) developed the Computerised Sepsis Protocol Management (PIMIS). The aim of this study was to evaluate the convenience of using PIMIS, as well as the activity of the MST. METHODS: An analysis was performed on the data collected from solicited MST consultations (direct activation of PIMIS by attending physician or telephone request) and unsolicited ones (by referral from the microbiology laboratory or an automatic referral via the hospital vital signs recording software [SIDCV]), as well as the hospital department, source of infection, treatment recommendation, and acceptance of this. RESULTS: Of the 1,581 first consultations, 65.1% were solicited consultations (84.1% activation of PIMIS and 15.9% by telephone). The majority of unsolicited consultations were generated by the microbiology laboratory (95.2%), and 4.8% from the SIDCV. Referral from solicited consultations were generated sooner (5.63days vs 8.47days; P<.001) and came from clinical specialties rather than from the surgical ward (73.0% vs 39.1%; P<.001). A recommendation was made for antimicrobial prescription change in 32% of first consultations. The treating physician accepted 78.1% of recommendations. CONCLUSIONS: The high rate of solicited consultations and acceptance of recommended prescription changes suggest that a MST is seen as a helpful resource, and that PIMIS software is perceived to be useful and convenient to use, as it is the main source of referral.

How to measure and monitor antimicrobial consumption and resistance.

Collateral damage caused by antibiotic use includes resistance, which could be reduced if the global inappropriate use of antibiotics, especially in low-income countries, could be prevented. Surveillance of antimicrobial consumption can identify and target practice areas for quality improvement, both in the community and in healthcare institutions. The defined daily dose, the usual adult dose of an antimicrobial for treating one patient for one day, has been considered useful for measuring antimicrobial prescribing trends within a hospital. Various denominators from hospital activity including beds, admissions and discharges have been used to obtain some standard ratios for comparing antibiotic consumption between hospitals and countries. Laboratory information systems in Clinical Microbiology Services are the primary resource for preparing cumulative reports on susceptibility testing results. This information is useful for planning empirical treatment and for adopting infection control measures. Among the supranational initiatives on resistance surveillance, the EARS-Net provides information about trends on antimicrobial resistance in Europe. Resistance is the consequence of the selective pressure of antibiotics, although in some cases these agents also promote resistance by favouring the emergence of mutations that are subsequently selected. Multiple studies have shown a relationship between antimicrobial use and emergence or resistance. While in some cases a decrease in antibiotic use was associated with a reduction in resistance rates, in many other situations this has not been the case, due to co-resistance and/or the low biological cost of the resistance mechanisms involved. New antimicrobial agents are urgently needed, which coupled with infection control measures will help to control the current problem of antimicrobial resistance.

How to measure and monitor antimicrobial consumption and resistance / Medición y monitorización del consumo de antibióticos y resistencias bacterianas

Collateral damage caused by antibiotic use includes resistance, which could be reduced if the global inappropriate use of antibiotics, especially in low-income countries, could be prevented. Surveillance of antimicrobial consumption can identify and target practice areas for quality improvement, both in the community and in healthcare institutions. The defined daily dose, the usual adult dose of an antimicrobial for treating one patient for one day, has been considered useful for measuring antimicrobial prescribing trends within a hospital. Various denominators from hospital activity including beds, admissions and discharges have been used to obtain some standard ratios for comparing antibiotic consumption between hospitals and countries. Laboratory information systems in Clinical Microbiology Services are the primary resource for preparing cumulative reports on susceptibility testing results. This information is useful for planning empirical treatment and for adopting infection control measures. Among the supranational initiatives on resistance surveillance, the EARS-Net provides information about trends on antimicrobial resistance in Europe. Resistance is the consequence of the selective pressure of antibiotics, although in some cases these agents also promote resistance by favouring the emergence of mutations that are subsequently selected. Multiple studies have shown a relationship between antimicrobial use and emergence or resistance. While in some cases a decrease in antibiotic use was associated with a reduction in resistance rates, in many other situations this has not been the case, due to co-resistance and/or the low biological cost of the resistance mechanisms involved. New antimicrobial agents are urgently needed, which coupled with infection control measures will help to control the current problem of antimicrobial resistance

El daño colateral más importante derivado del uso de los antibióticos es la aparición de resistencias bacterianas. La prescripción inadecuada de los antibióticos está íntimamente relacionada con este efecto, observado globalmente a nivel mundial, pero principalmente en países con recursos económicos limitados. La estrecha vigilancia del consumo de los antibióticos puede ser de gran ayuda para identificar cuáles son los problemas relacionados con la prescripción de estos fármacos e introducir las estrategias necesarias para evitarlos, tanto en el ámbito ambulatorio como en el hospitalario. La dosis diaria definida, referida a la dosis usual de un antimicrobiano concreto, destinada al tratamiento diario de un paciente, se ha considerado útil para el estudio de las tendencias de consumo de los antibióticos en el hospital. Esta unidad se ha introducido en diversas fórmulas que incluyen diversos denominadores correspondientes a la actividad hospitalaria, entre ellos el número de camas, ingresos y altas. Todo ello, con el objetivo de obtener una serie de indicadores estandarizados que se utilizan para efectuar comparaciones sobre el uso de antibióticos entre distintos hospitales y países. Los sistemas de información del laboratorio son las fuentes primarias de datos para la preparación de informes acumulados de sensibilidad. Esta información es útil para planificar tratamientos empíricos y adoptar medidas de control de infección. Entre las iniciativas supranacionales de vigilancia de la resistencia, la red EARS-Net proporciona información acerca de las tendencias de resistencia en Europa. La resistencia es consecuencia de la presión selectiva de los antimicrobianos, aunque en ocasiones estos agentes también promueven la resistencia al favorecer la aparición de mutaciones seleccionadas posteriormente. Múltiples estudios indican la relación entre el uso de antimicrobianos y la aparición de resistencias. Aunque en algunos casos una disminución del uso de un antimicrobiano se asocia a una reducción en las tasas de resistencia a este, en muchas otras situaciones no sucede así, debido a la corresistencia o al bajo coste biológico del mecanismo implicado. Son necesarios nuevos antimicrobianos, que junto con medidas de control de infección ayudarán a paliar el problema de la resistencia